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9

w

ftnSBURGH, PH,

A

DICTIONARY

PRACTICAL MEDICINE:

COMPRISIXG

GENERAL PATHOLOGY,
THE NATURE AND TREATMENT OF DISEASES,

MORBID STRUCTURES,

AND THE DISORDERS ESPECIALLY INCIDENTAL TO CLIMATES, TO THE SEX,
AND TO THE DIFFERENT EPOCHS OP LIFE ;

WITH

iEumtrous prescriptions for tj^e JWEbicinES rccommenlJcU,

A CLASSIFICATION OF DISEASES ACCORDING TO PATHOLOGICAL PRINCIPLES,
A COPIOUS BIBLIOGRAPHY, WITH REFERENCES ;

AND

AN APPENDIX OF APPROVED FORMUL/E :

THE WHOLE FORMING A LIBRARY OF PATHOLOGY AND PRACTICAL MEDICINE, AND A
DIGEST OF MEDICAL LITERATURE.

JAMES COPLAND, M.D. F.E.S.

FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS ;

CONSULTING PHYSICIAN TO QUEEN CHARLOTTE'S LYING-IN HOSPITAL ;

CONSULTING, AND. LATE SENIOR, PHYSICIAN TO THE ROYAL INFIRMARY FOR DISEASES

OF CHILDREN ;

FORMERLY SENIOR PHYSICIAN TO THE SOUTH LONDON DISPENSARY ;

FELLOW OF THE ROYAL MEDICAt ^AnD CHIRURGICAL SOCIETIES OF LONDON AND BERLIN,

AND OF THE ROYAL ACADEMY OF MEDICINE OF BELGIUM, ETC.

Wi^^^ S^km of MeiiMir

:i."S..feS:|f'7ifc2^EE VOLUMES.

LONDON: '^

LONGMAN, BROWN, GREEN, AND LONGMANS,

PATERNOSTER-ROW.

1844.

\^

\

London :

Printed by A. Siottiswoode,

New- Street- Sijiiare.

L^\ ^^— -^ ><: 1^^ ^

CONTENTS

THE FIRST VOLUME.

Page

ABDOMEN — External Examinalion of, in Disease 1

ABORTION - . - - .5

ABSCESS - ~ - - - 12
ABSORPTION — In relation to the Causation,

Continuance, and the Removal of Disease - 23

ABSTINENCE — Its Morbid Effects - - 26

ACNE - - - . .27

ADHESIONS— Reparative and Morbid . - 32

ADIPOSE TISSUE— Its Morbid States. - 36

AFTER PAINS - - - - 37

AGE — Considered with Relation to the Nature and

Treatment of Diseases - - - 38

Of the early Periods of Age - . - 39

Of the advanced Periods of Age . - 44

AMAUROSIS . . - .50

ANGINA PECTORIS - - - 62

ANTIPATHY - . . .70

AORTA— Nervous Pulsation of the - .70

Inflammation of the . - - 71

Aneurism of the . - - - 72

APOPLEXY — Forms of - - - 79

Pathology, &c., of -' . - 87

Treatment of . . . - 98

Of New-born Infants - . . 107

APPETITE — Insatiable — Bulimia . - 107

Vitiated — Pica - - - .110

ARTERIES — Diseases of .' . .Ill

Nervous Affection of . . . 112

Inflammation of - . - . 112

Morbid Structures of - . .116

Aneurisms, &c. - . . - 117

ARTS AND EMPLOYMENTS— In Relation to

Disease . - . . - 122

ASPHYXY . - . . .128
Of New-born Infants ... 134

ASTHMA - - . - .135

ATROPHY . . - - .154

AUSCULTATION . - . - 156

BARRIERS - . - - .163

BERIBERI . - - - - 164

BLOOD — Its States in Health - . - 166

Exuberance of — Plethora - .168

Local Determinations of . . . 171

Deficiency of — Anaemia . - .173

Morbid Effects of its Loss . . .175

Alterations of, in Diseases - .180

Contamination of the, &c. . - 192

Nervous Influence on the - - 193

Aclions of Poisons on — Various Morbid

Slates of — Signs and Treatment of, &c. 194

BLUE DISEASE - - - - 199

BRAIN— Alterations of its Membranes . -201

Alterations of its Sinuses and Vessels - 208

Alterations of its Substance . -209

Abscess of tlie .... 210

Softening — Hsemorrhage — Hypertrophy —

Atrophy — Induration, &c. . - 214
Tumours in the, &c. . . .221
Cerebral Plethora - - - 226
Congestion ol the . - - 227
Inflammation of its Membranes . .228
Inflammation of its Substance . -'230
Inflammation of its Membranes and Sub-
stance - - - - 232

Paee
BRAIN — Softening of the . .241

Bibliography and References . - 24"

BRONCHI AND AIR PASSAGES— Alterations

of their Structure

Congestion of the -

Inflammations of the — Acute and Chronic

Treatment of -
BRONCHIAL FLUX — Bronchorrhcea -
BRONCHOCELE
BULLAE ....

- 244

- 248

- 249

- So7

- 267

- 269

- 271

CACHEXY . - . . .272

African - - - . . 273

CjECUM — Diseases of the - - .274

Functional Disorders of the - -275

Inflammation of the ... 277

of its Appendix, &c. ." . 278

CANCER - . . . ' .282

CATALEPSY - - . -290

CATALEPTIC ECSTASY - - - £91

CATARRH - - . . - 293

CELLULAR TISSUE— Alterations of - - 298

Diffusive Inflammation of the - -299

Induration of the - - . - gu6

CHEST — External Examination of the - -309

Deformities of the . - - -310

CHICKEN-POX - - - -312

CHLOROSIS - - . - - 315

CHOLERA - - . - - 318

CHOLORIC FEVER OF INFANTS . . 325

CHOREA AND RELATED AFFECTIONS . 327
CLIMACTERIC DECAY . . - 336

CLIMATE— Its Physical Relations - - 338

Its influence on the Human Constitution . 342

in the Cure of Disease - - 349

COLD — Its Pathological Effects - - 354

Its Remedial Operations - - . 358

COLIC — Forms depending on Functional Disorder 360

Bilious — Hepatic — Madrid, or West Indian 362

From the Poison of Lead, &c. - - 364

COLIC AND ILEUS — From Change of Structure
and Relative Position of the Bowels — Comprising
Introsusceptions, &c. - - - - 266

Treatment, &c. - - - - 371

COLON — Nature and Treatment of its Morbid

States - . - - - 382

COMA AND LETHARGY - - - 387

CONCRETIONS, BILIARY - - - 392

CONCRETIONS, INTESTINAL - . 397

CONGESTION OF BLOOD - - - 401

CONSTIPATION - - - - 405

CONVULSIONS — Partial and General - .412

Infantile - - - - 417

Puerperal - . . - 4I8

COUGH - - - - - 436

CRANIUM AND EN VELOPES — Their Lesions 439
CRETINISM - - - - - 441

CRISIS AND CRITICAL CHANGES - - 443

CRITICAL DAYS - - - - 448

CROUP - - . - - 449

Its Varieties .... 452

"^AVb

CONTENTS.

CROUP— Its Complications, &c.
Its Treatment

Page

- 454

- 462

DEBILITY — Its General States, &c. - - 473

Its Special Manifestations, Effects, and Rela-
tions - - . . 477
Its Treatment - - - - 481

DEGLUTITION, DIFFICULT - . 486

DELIRIUM - - . - .490

DELIRIUM WITH TREMOR - - 497

And Excited Vascular Action - - 497

And Exhausted Nervous Power (Delirium

Tremens) - - - 497

DENTITION, DIFFICULT - . - 504

DIABETES— Pathology, &c., of - -506

Treatment of - - - - 513

DIAPHRAGM— Inflammation of - .519

Organic and Functional Lesions of - 521

DIARRHOEA — Symptoms and Varieties . 522

Of Infants, &c. - - - - 525

Its Treatment, &c. ... 528

DIGESTIVE CANAL— Its Functional Disorders 536
Its Lesions of Circulation . . 540

Hypertrophy, &c. of its Tissues ■■ -542

Softening of its Coats . - -544

Ulceration and Perforation of - - 545

Adventitious Formations in - - 550

Changes of Capacity and Situation - - 552

DISEASE — The Causation and Doctrine of - 556

Causation of — ilCtiology - - . 558

From Diet — Dietetics - - 566

Its principal and primary States — Pathogeny 572
Dynamic States of — Debility, Excitement, and

Exhaustion - . - . 572

Perverted or alienated Vital Power - - 578

Of the Fluids and Solids, originating in the
foregoing .... 580

Of the Exhalations and Secretions - -580

Of Nutrition .... 585

Of both Secretion and Nutrition, and their

adventitious Products ... 58S
With Destruction of Parts . - 593

Of the Fluids and Solids — their Connection 593
The Procession of ... 594

The Terminations of . . . 596

The Relations, Successions, and Complica.

tions of - . . . 597

Of the Metastasis of . . .599

Circumstances modifying, &c. - - 601

DROPSY— Its Pathology r - -603

Its Treatment . . - -613

Various Remedies recommended in, &c. - 617

DROPSY OF THE ABDOMEN — Ascites - 627

In the Puerperal States ... 633

DROPSY OF THE AMNION . - .634

DROPSY OF THE CELLULAR TISSUE . 635

Local — Oidema . - . - 635

General . - - . . 635

DROPSY OF THE CHEST . . - 641

DROPSY OF THE PERICARDIUM — The Fluid

effused into the Pericardium - - . 641

DROPSY OF THE PLEURAL CAVITIES - 645

The Fluid effused into the Pleurae — Hydro-
thorax .... 646

DROPSY, CONGENITAL, OF THE HEAD - 649
DROPSY, CONGENITAL OF THE SPINE . 650
DROPSY, CONGENITAL, OF THE ABDO.
MEN, CHEST, &c. - - - - 651

DROPSY, ENCYSTED .... 652

DROPSY, ENCYSTED, OF THE OVARIUM . 654
DROPSY OF THE WOMB, TUBES, &c. 657

DROPSY, EN(JYSTED, OF THE PERITO.
NEUM ..... 658

DROPSY, ENCYSTED, OF THE LIVER, KID-
NEY, &c. ..... 659

DROPSy, ACUTE, ANDSUB-ACUTE, IN THE
HEAD ..... 660

DROPSY, CHRONIC, IN THE HEAD . 676

DRUNKENNESS .... 685

DUODENUM — Its Diseases . - .689

DYSEN'J'ERV .... 693

Acute ..... 695

Asthenic .... 698

Chronic ..... 7(17

Treatment .... 717

EAR— Nervous Affections of . . .735
EAR-ACHE . . •- . 736
EAR— Inflammation of - - -737
ECTHYMA - - - - - 742
ECZEMA . . - . - 745
t EDUCATION, PHYSICAL . - - 749
I ELEPHANTIASIS . . - - 750
I EMPHYSEMA - - - .752
ENDEMIC INFLUENCES AND DISEASES . 756
EPHELIS - - - . - 765
! EPIDEMICS, AND EPIDEMIC CONSTITU-
TIONS - - - . .767
EPIGASTRIUM— States of - - -782
Concussions of . - - - 784
EPILEPSY - - . - - 785
Varieties and Complications - - 794
Treatment - - - - 799
ERECTILE TISSUE - . - - 816
ERETHISM - - - . - 816
Mercurial - - - - 817
ERGOTISM - - - - 817
ERYSIPELAS - - - - 818
Varieties and Complications - - 821
Treatment - . . - 828
ERYSIPELAS OF INFANTS - - .835
ERYTHEMA- - . - -836
EXANTHEMATOUS DISEASES - - 839
EXCRETION AND EXCRETIONS . . 840
EXPECTORATION - - . .846
EYE— Diseases of the . . . .848
Inflammation of its Conjunctiva - -850
Purulent Ophthalmia in Infants - - 852
Purulent Ophthalmia of Adults - . 856
Gonorrhoea! Ophthalmia - - - 861
Scrofulous Ophthalmia - . - 863
Exanthem.itous Ophthalmia - - - 865
-Hnflammation of Sclerotic Coat of - - 865
Rheumatic and Arthritic Ophthalmia . 8fi8
Inflammation of the Cornea - - 869
Inflammation of Anterior Chamber . - 870
Inflammation of the Iris . . -871
Inflammation of the Internal Coats - - 875
Inflammation of the whole- . .877

FAINTING AND SWOONING - - 879

FEIGNING DISEASE . - •■ 884

FEVER — GENERAL VIEW OF . . 892

Course and Stages of . - - 899

Types and Forms of . . . 902

Pathology, &c. of - . . . 907

General Treatment of - . - 920

FEVER, INTERMITTENT . - .934

Treatment of Intermittents - -940

FEVER, REMITTENT . . .946

FEVER— Treatment of Remittents - -952

Chronic Remittents ... 9,155

FEVER— Remittent of Children . .957

Treatment of Infantile Remittent . ■ 959

FEVER, HECTIC .... 962

FEVER, CONTINUED ■ . - 967

FEVER, ARDENT . . - 972

FEVEH, INFLAMMATORY - - - 973

FEVER, BILIO-GASTRIC . . - 983

FEVER, MUCOUS OR PITUITOUS . - 988

FEVER, SWEATING . . .990

FEVER, SYNOCHOID . . . 993

FEVER, TYPHOID .... 1001

FEVER, MILD, TYPHOID, OR NERVOUS - 1002

FEVER, COMPLICATED TYPHOID . 1003

FEVER, TYPHOID, WITH PUTKOADYNA-

MIA ..... 1006

FEVER. TYPHOID, WITH EXANTHEMA.

TOUS ERUP'IION . . . 1009
FEVERS, TYPHOID — Terminations and Struc-
tural Lesions in, Sc. .... 1013
Treatuu-nt of .... 1017

Various Modes of Treatment of, &c. . 1028

Bibliography and References - . 1038

FIBROUS TISSUE— Diseases of - -1040

FLATULENCY - - . . 1043

F(ETUS— Diseases of the - - -1047

FUNGOID DISEASES - - - 1048

FURUNCULAR ERUPTIONS - . 10 3

DICTIONARY

OF

PRACTICAL MEDICINE.

ABDOMEN. Syn. Vetitre, Fr. Unterleib,
Bauch, Ger. Ventre, Pancia, Ital. Belly, Eng.
External Examination of the Abdomen in
Disease.

Classification. — Pathology. Semewlogu,
or Si/mplpmatology ; Diagnosis.

1. The abdomen may be considered as the
fundamental part of the frame, inasmuch as it is
never wanting in monstrous foetuses ; and as it
contains parts which are the first formed in the
embryo, and are the centres and sources of or-
ganic life. The number and importance of the
viscera contained in its cavity ; the number, the
diversity, the extreme frequency and complica-
tion, of tlie maladies to which tliese viscera are
liable, are circumstances which pressingly urge
upon tiie practitioner a careful exauiination of
the parietes of this cavity, in order to ascertain
the nature and extent of disease. Aluch, how-
ever, will depend upon the manner in which the
examination is made, in respect both of acquir-
ing information as to the existing state of disease,
and of drawing inferences as to its origin, and the
best means of lemoving it.

2. Pathologists have generally divided the ab-
domen into ceitain Regions, with the view of
describing with more accuracy the seat of morbid
actions. J hese regions are marked out by means
of imaginary lines, drawn in horizontal and ver
tical directions. The horizontal lines, four in
number, divide this cavity into three zones. The
highest of these lines passes over the xiphoid carti-
lage ; the second, by the margin of the tenth nb ;
the tiiird, by the anterior and superior spine of the
ilia ; and the fourtii, by the superior margin of the
pubis ; thus giving three zones, the epigastric, the
umbilical, and the hypogastric.

3. For the sake of additional precision, each of
these zones is divided into segments by vertical
lines, also four in number, drawn from ihe acro-
mial extremity of the right and left clavicles to
the insertion of the ligaments of Poupart ; and
from the posterior margins of the axillas, over the
most exterior part of the crests of the ilia, to the
large trochanters. The spinous processes of the
vertebrae may likewise be considered as forming a
fifth line of demarcation; as we cannot overlook
the posterior parts of the body in our investigation
of many of the diseases affecting the abdominal
organs. The vertical lines now enumerated, di-
viding the horizontal lines very nearly at right
angles, give us nine regions on the anterior and
lateral aspects of the abdomen, and six posterior
regions. The anterior regions are the epigastric,
umbilical, hypogastric, and right and left inguinal ;

Vol. I.

j the lateral regions are the right and left hypo-
chondriac and right and left iliac; the dorsal
regions are inferior dorsal — right and left, the
right and left lumbar, and the right and left glu-
teal regions.

4. It does not belong to the scope of this work
to enumerate the anatomical boundaries of the
abdomen ; the parts forming its parietes ; or the
viscera contained in each region. These are
matters which are, or ought to be, familiar to all
who peruse this work. 15ut it is necessary to
remind the reader, that organs which, in the
healthy state, are always situate in a particular
region, will be so changed in form and bulk by
disease as frequently to extend to adjoining regions,
where they will often be detected upon a careful
examination ; or they will be altogetiier displaced,
either by the specific gravity of their contents, or
by tumours developed in their structure. The
former phenomenon is often remarked in respect
of the liver, spleen, kidneys, ovarium, uterus, &c.;
the latter, in the stomach, pylorus, gall-bladder,
colon, &c.

5. This change of the position of the abdominal
viscera is chiefly observed, in the more chronic
kinds of organic diseases, and is pointed out in
the articles in which they are described : it is ge-
nerally more manifest in one posture of the body
than in others ; and is to be ascertained, with the
other maladies to which these viscera are liable,
by the modes of examining the abdomen about to
be explained, assisted by other rational or infer-
ential symptoms. These modes may be made the
source of much information as to all the relations
of abdominal diseases ; but attention, rejjeated
observations, and much natural discernment, are
required to obtain from them all the knowledge
they are capable of conveying. I shall discuss
this subject, in the brief manner to which I am
neces'iarily driven, by noticing — I. Inspection;
II. Manual ejumination ; III. Percussion; and
IV. Auscultation of the abdomen.

6. I. Inspection by the senso of sight merely,
although the best mode of ac(juiring an idea of the
form, size, and motions of the abdomen, is chiefly
valuable as a means of investigating the diseases
of its viscera in conjunction with the other modes
just enumerated : yet simple inspection furnishes
us with the most imponant infoimation in many
diseases, particularly in those of infancy and
childhood, as well as in many acute and chronic
maladies occurring in adul'.s. The form of the
abdomen, although neces-arily in some measure
changed by marked variation of its bulk, may,
neverthe'ess, be much altered without any decided

li

ABDOMEN — Investigation of, in Disease.

difference in its size. Thus, it is somewhat changed 1
in severe diseases of the respiratory passages, when
the entrance of air into the lungs is obstructed ; the
epigastrium and hypochondria being then pressed
inwards and upwaids: whilst in some morbid
states of the liver and gall-bladder, of the spleen,
and of the ovaria, an unusual prominence in
their respective regions is frequently observed.
But the most remarkable changes in the form of
the abdomen is met with when the size of the ca-
vity is also altered. It is scarcely necessary to
allude to examples; but, in all those diseases at-
tended with enlargement or diminution of the bulk
of this important part of the body, either in one of
its regions, in several of them, or in all, inspection
should always be performed : it gives greater pre-
cision to manual examination ; enables us to com-
pare the bulk of a region with the corresponding
region on the other side, and with others in its
vicinity ; and impresses upon the memory the
changes which the part may experience during
the progress of disease. It should, therefore,
never be neglected in all the forms of abdominal
dropsy ; in peritonitis, chronic or acute ; in in-
flammation of the stomach, liver, spleen, and
bowels; in the different kinds of colic, in fevers,
in uterine and ovarian diseases; in afiections of
the kidneys and urinary organs ; in all disorders
accompanied with obstruction to the excretions;
and, in short, in all ciironic maladies. It ought
never to be ovei looked in the diseases of infancy
and childhood, of whatever nature they may be.

7. Besides, however, attending in those diseases
to the form and size of the abdomen merely, the
motions which it presents ought not to be neglected.
When rightly interpreted, they often furnish im-
portant diagnostic and therapeutic hints. But
they require to be viewed in connection with the
motions of the thorax, and state of the heart's ac-
tion. In diaphragmitis, peritonitis, gastritis, enter-
itis, and certain states of hepatitis, the motions of
the abdomen are slight or obscure, whilst the ac-
tions of the thorax are increased. On the other
hand, in several severe diseases of the respiratory
organs, p.irticularly in croup, laryngiti-!, bronchi-
tis, several varieties of asthma, pleuritis, pneu-
monia, Sic, tiie parietes of the chest are nearly
motionless ; whilst the niovements of the abdomen,
especially at the epigastrium, in croup and asthma,
are remarkably increased, or laborious. The
motions of the abdomen, also, are often not li-
mited to those caused by respiration ; but in some
cases, particularly in organic changesof the heart,
pericardium, aovta, &c.,and even in certain nerv-
ous di^orde^s implicating these organs, comprise
those occasioned by the action of the heart, in-
creased by the state of the large abdominal vessels,
and by the emaciation or other morbid conditions
of the patient.

8. II. IManual Examination of tiie abdo-
men is one of the most important means of dia-
gnosis we possess : but it furnishes information in
proportion to the perfection of manner in which
It is made. In this very retjuisile mode of inves-
tigation, the temperature of the hand of the prac-
titioner at ilietiiue of making it should be attended
to, in the great majority of diseases; both ns a
moderate warmth of the hand is necessary to the
greatest delicacy atul accuracy of touch, and as
its ap])tication to the surface of the abdomen will
not in that state occasion any disturbance or con-

traction of the muscular parietes. In entering
upon tlie examination, care should be taken not to
excite the alarm of the patient. The hand ought
to be applied at first in the gentlest manner pos-
sible. By observing this, three very important
objects wdl be best obtained ; namely, a know-
ledge of the form, of the temperature, and of the
sensibility of the surface of the abdomen,

9. As much more information than this is
required from manual examination, the patient
should be directed to place himself in a favour-
able position for a more general and complete
investigation. He should be placed on his back,
with the head and shoulders slightly and com-
fortably elevated, and the thighs drawn nearly to
a right angle with the trunk. If the bladder be
full, it should be emptied. When proceeding to
examine, the patient should be told to lelax all
the muscles, particularly the abdominal muscles.
Commencing, therefore, with the utmost gentle-
ness, and passing the hand slightly over the ab-
domen, we should slowly increase the pressure,
with the view of ascertaining the following con-
ditions : — 1st, Its temperature ; 2d, Its form and
size ; 3d, Its sensibility ; 4th, Its degree of ten-
sion and firmness ; 5th, The existence of enlarge-
ments, tumours, &c. ; 6th, The presence of effused
fluids; 7th, The probable existence of accumu-
lated secretions and faecal matters ; 8tli, Hernial
protrusions and displacements. On each of these
I proceed to offer a few remarks.

10. 1st, The temperature o( the abdomen fur-
nishes most important indications as to the nature
of disease. It is generally always higher than
natural in diseases of increased action ; and is also
often higher when the patient is actually com-
plaining of cold, particularly at the commence-
ment of fevers. In many feveis and inflammations
of the abdominal viscera, particularly those of a
dangerous or malignant character, the increased
temperature is accompanied with a peculiar acrid
pungency to the sensation of the examiner; a
phenomenon which indicates the utmost risk of
rapidly supervening disorganisation. Diminished
temperature of the abdomen is met with in the
period of depression, or cold stage at the com-
mencement of fevers, but very seldom at their
termination, even in death, unless in the most
malignant or liquescent forms. It is also met
with after injuries of the abdomen, particularly
blows on the epigastrium, in anasmia, chlorosis,
and other disordeis of debility.

11. 2d, The form and si^ze of the abdomen nre
frequently altered, as already noticed (§6, 7.);
but, in order to ascertain the nature of the alter-
ation, various means of investigation are generally
required, particularly those >vhich remain to be
considered. When proceeding- with the manual
examination of the abdomen, it is necessary very
gently to increase the pressure, and, when acute
pain is not complained of, to make it in various
directions, — laterally, downwards, upwards, and
backwards to the spine, — so that if altered sensi-
bility of any of the contained viscera exist, it may
not escape detection, but be accurately ascer-
tained and estimated ; and the examination should
always be made with a careful observ.ntion of its
effects upon the expression of the countenance of
the patient. Jt will also often be reijuisiie to per-
form the manual examination, now with the points
of several hngers, now with the whole of one, or

abdomi:n-

• Investigation of, in Disease.

even of both hands ; and occasionally, at the
same time that a full inspiration is being made.
But it should always be performed with attention
to the sensations of the patient, particularly as
expressed by the countenance, and to the feelings
and ideas it may excite in our own minds. Even
the slate of action in which the abdominal muscles
are often thrown by the examination ; the degree
of pressure occasioning such action ; and the cir-
cumstance of tension of those muscles preceding
the examination, or being excited by it, as well as
the continuance of their contractions, and the pe-
riods and occasions of their relaxation, are all im-
portant matters in our estimate of the state of the
viscera underneath, — more particularly in the
various states of inflammation seated in the peri-
toneum, in the alimentary canal, &:c.

12. 3.1, The sensibilitii of the parietes of the
abdomen is most intimately associated with that
of the contained organs, botii in health and dis-
ease. 'I'he sensibility of the epigastric region
varies most widely in different persons It is fre-
quently, even in tolerable health, very great in
delicate and thin females. It is always so in
inflammation of the viscera, more particularly
when the serous membranes are affected ; and
the more superficial the inflammation, the more
tender is the surface. In order to obtain an ac-
curate idea of the state of the sensibility of the
abdomen, pressure should be commenced in the
gentlest manner, and with the fingers and palm
of the open hand. When the patient cannot
endure the slightest touch, the disease is then
commonly in the parietes, or in the serous mem-
brane reflected over them. When the cause exists
more deeply, the tenderness is less acute, and the
muscles are almost instinctively brought into
action, even before pressure is made, in order to
protect the diseased viscera from it.

13. When superficial tenderness is absent, the
examination may be made with increased pres-
sure, in order to ascertain the presence of tender-
ness, pain, or soreness, in any degree or at any
part. But cauiion in thus iiicrea-ing the pressure
is always necessary when the parenchyma of an
organ, particularly of the liver or spleen, is enlarged
or otherwise affected ; for many such aflTeciions
may be very serious, and yet the sensibility of the
diseased part not much mcreased. 1 have known
rupture of an enlarged and softened spleen occa-
sioned by the rudeness of the examination; and
writers have mentioned similar accidents to have
occurred to the liver.

14. 4lh, The tensim and firmness of the abdo-
men requii'e attention, and due estimation of their
actual amount; and in connection with the other
diagnostic indications furnished by the examin-
ation. Thus, when the tension is associated with
increased temperature and sensibility, inflamma-
tion of one or more organs underneath, particularly
of the peritoneum, may be predicated. The tu-
mefaction, degree of sensibility, position of the
patient, &c. will fuither prove the accuracy of
the diagnosis. Tension and firmness are always
present in the difl^erent forms of peritonitis and
inflammations of the subjacent viscera, but not
uniformly throughout all their stages. Even in
the worst or most malignant forms of peritonitis,
as those met with in puerperal females, these
symptoms are often either almost altogether want-
ing, or they exist for a short time only. \\ hen

eflfusion of a serous or sero-purulent matter occurs
in peritonitis, or when suppuration has followed
inflammation of the enveloped viscera, tension as
well as firmness disappear. They are generally,
however, both present even when the sensibility
of the paiietes is not much greater than natural,
in chronic peritonitis with the formation of false
membranes, or the agglutination of the opposin<r
surfaces of the viscera.

15. 5th, The presence of tumours or other mor-
bid growths, or the lact of their absence, lias also
to be ascertained by a manual examination. This
information can be obtained only by this mode of
investigation, carefully conducted. If we detect
any degree of unusual tuinefaciion or hardness,
we should endeavour to ascertain its exact site ; its
form, size, connections ; its consistence, degree of
sensibility ; and whether it is fixed or moveable,
soft and yielding, or hard ; pulsatile or not. The
situation of the tumour; its size, form, and degree
of fixedness, will enable us to form an idea of the
part afl^ected : whilst the absence or presence of
morbid sensibility in it, of fluctuation and puls-
ation, and the manner in which the nearest parts
of the abdominal parietes are affected by it, will
furnish important indications of its nature. AVlien
tumours or unusual circumscribed indurations are
detected in any part of ihe abdomen, we should
bear in mind that their sources and kinds are nu-
merous : that they maybe formed in the liver,
pancreas, spleen, stomach, pylorus, mesentery,
omentum, caecum, kidneys, uterine organs, &;c. ;
that their nature may be extremely various; and
that they may consist either of accumulations of
some fluid contained in a cyst, or infiltrated in the
substance of an organ, or enclosed in its natural
cavity, the outlet of which has been obstructed ;
or of a deposition of some morbid structure, the
nature of which can only be known by a com-
parison of numerous symptoms, and the history
of the disease. Care should be also taken that
the accumulations of facal matters occasionally
formed in the caecum, and in various parts of the
colon, or that an unusual anterior protuberance
or curvature of the inferior dorsal or lumbar ver-
tebras, be not mistaken, as have sometimes hap-
pened, for morbid growths; and that unusually
large collections of the natural secr-etions in their
C)sts, as of the liile and urine, owing to temporary
obstruction to their discharge, be not treated as
morbid formations of a very difl'erent kind. I have
known ca-es in which distention of the gall-blad-
der, from great accumulation of the cystic bile,
was mistaken for abscess of the liver; and an
enormously distended urinary bladder was viewed
as dropsv.

16. 6th, The presence of fluids effused into
the peritoneal sac is best ascertained by placing
the patient in the erect posture. 1( this cannot
be done, and if he cannot even sit up, the
shoulders and limbs should be placed low ; and,
whether in the erect or recumbent postur,, the
palm of one hand laid with a gentle pressure
upon one sid ■ of the abdomen, vv hilst we tap,
somewhat smaitly, with the other hand, on the
opposite side. The impulse occasioned by the
stroke will occasion, if fluid be efl'used, a vibratory
undulation or shock which will be felt by the
other hand, and which constitutes the diagnostic
symptom in diseases of the abdomen attended
with effusion.

B 2

ABDOMEN — Investigaton of, in Disease.

17. 7th, Acciimulaiion of f meal matlers in the
bowels are not infrequently mistaken for Munours.
These matters usually collect and harden in the
caecum, or in some part of the colon. They
seldom accumulate iu the small intestines, unless
they consist of certain kinds of intestinal concretions
(see the art.) ; which are with difficulty dis-
tinguished from tumours seated in some one of
the abdominal viscera. It is indispensably re-
quisite to examine the abdomen carefully in all
cases of habitual or occasional constipation, par-
ticularly in the region of the caecum and course
of the colon; as, when conducted with an expe-
rienced tact and discrimination, these collections
will generally be ascertained : and when the
history of the case, and numerous contingent
rational symptoms, are taken into account, little
risk will be run of confounding them with morbid
growths. The accumulation of secretions in the
gall-bladder, and in the urinary bladder, are chiefly,
particularly the latter, ascertained by manual
examination. The diagnosis of those disorders is
fully pointed out in another place.

18. 8lh, Protiusion of some part of the abdo-
minal contents, giving rise to any either of the more
common kinds of Hernia-, or of those which are
unusual, should never be overlooked. Inguinal,
femoral, and umbilical herniaj are so fre(|ueiit,
and, when either incarcerated or strangulated,
occasion so serious effects, that in all cases where
severe symptoms are referred to any of (he viscera
contained in the abdominal cavity, or in its vici-
nity, or when the functions of the bowels are
obstructed, this source of mischief should be par-
ticularly inquired into.

19. 1 may observe generally, in respect of
manual examination of the abdomen, that it fu>"-
nishes valuable means of diagnosis in very many
diseases, particularly when estimated in due con-
nection with those derived from other sources; but
I should add, — what I shall often have to prove
herealter, — that it does not always give us exactly
the same kind of information that is slated in
several, and even in some very recent, works.
Thus it is said to be the most certain means of
ascertaining the presence of enlarged mesenteric
glands, and by actually feeling these glands en-
larged, A'ow this is nut the case, and I slate it
from an experience of many hundred cases : for
there are comparatively but few instances in
which these enlarged glands can be satisfactorily
detected, by the most careful manual examination.
Hut this mode of inve-^tigation furnishes certain
indications of their presence of a different kind
from that which writers have laid down. It may
also be remarked, that a manual examination of
the abdomen is generally much more successfully
made in lean subjects, in females than in males,
and in children than in adults; whilst in muscu-
lar men, and in fat persons, it furnishes much less
information, owing to the muscularity and thick-
ness of ihe abdominal parieles.

20. HI, Peiicussion has been employed as
a means of diagnosis in diseases of the abdomen,
from a very early period of medical knowledge,
but chiefly with a view of recoijnising tympanitic
alFections, or unu-ual accumulations of air, and
dropsical efl'u-ioiis ; and ii was not until very
lately that altenlion was directed to it as a means
of investigation in a very large proportion of other
diseases of the ab lominal viscera. Percussion

of the abdomen, as well as of the thorax, is either
direct or mediate : the former is that which was
first ably insisted on by Auenbrugger, and
brought into notice by Cokvisart, chiefly in the
investigation of thoracic diseases ; the latter, both
in its application to abdominal and thoracic affec-
tions, is the invention of JM. Piounv, who has
paid great attention to its perfection, and has
written ably on it as a means of diagnosis.

21. Direct percussion consists of simply striking
the parts, somewhat smartly, with the points of
two or more fingers united and brought to the
same plane, and attending to tlie sounds elicited.
Mediate percussion is performing the same with
a thin plate of ivory, box wood, or any other
hard elastic body, placed over the part to be thus
examined, and striking upon it. The advantages
derived from having such a body interpo-ed be-
tween the surface and the fingers are, 1st, The
part is protected in a great measure from the
stroke, which, although slight, yet is frequently
unpleasant to delicate and sensitive persons; 2d,
It assists in the production of the sound for the
obtaining which percussion is employed. (See
art. Peucussiox.) The body on which the per-
cussion is thus made usually consists of a small
ivory plate of about 2^ or 3 inches in diameter ;
M. PioiiRV calls it the plc.iimeter, or measure of
percussion. In all cases in which we wish to
examine the abdomen by percussion, it will be
necessary to use the pleximeter. The information
it conveys varies according to the state of the
parts underneath. If we place it over the liver,
percussion gives out a dull sound; from the cir-
cumstance of a dense body lying beneath that
part of the abdominal parietes : if it be moved in
the course of the stomach and colon, a sound
will be elicited clear in proportion to the quantity
of air contained in these viscera.

22. During our investigation of the abdominal
contents with the aid of mediate percussion, it
will be necessary to attend to certain facts : — 1st,
That the pleximeter will furnish, in the same
person, a sound varying from dull to tympanitic
as the parts over which it may be placed differ in
density and the (juantity of air they may enclose;
2d, I'hat in situations of the abdomen where,
owing to the quantity of air usually contained in
the bowels, mediate percussion generally gives
a tympanitic sound when the plate is placed
lightly on the surface, it will give a much duller,
or even a dead sound, when pressed inwards so as
to displace the air from underneath it, and to
approach nearer to some solid body, or to bring
the parts nearer to that condition by the pressure ;
3d, That the stomach and whole tract of the in-
testinal canal always contain a certain (piantity
of air or gaseous fluid, particularly the large
bowels ; and that they approach more nearly to
the abdominal paiietes in pro|)ortion to their dis-
tension, whether with air, or with fluid, or more or
less solid contents ; and, 4tli, The quantity of air
contained in the digestive tube, especially the
stomach an'l large bowels, is great in pro])ortion
to the deficiency of its vital energy, and the degree
of inflammatory action affecting it.

23. These facts being attended to in our in-
vestigations of abdominal diseases by means of
percussion, mediate or diiect, the extent of the
liver may be distinctly traced by its means ; and
the d gree of inflation of the bowels, or stoniacii.

ABORTION — Causes of.

may be ascertained witli tolerable certainty. When
the slomacli is nearly empty (for it always con-
tains some air secreted from its internal surface),
it retracts backwards, and recedes from the abdo-
minal parietes towards the centre of the trunk ;
having then the colon, more or less distended witii
gas, placed before it. As it becomes filled with
air or the ordinary ingesta, it extends to the left
hypochondrium, and approaches the left and an-
terior parietes of the upper Eone of the abdomen.
In proportion to the quantity of air it contains,
percussion gives out a clear sound, which is dull
or dead as it is filled with fluid or solid ingesta,
and as the air is displaced. When we know that
the stomach must be empty of food, and yet find
that a dull sound is emitted, on percussion, we
should always suspect organic disea e. In these
cases air is often secreted with great rapidity from
its internal surface, but is immediately expelled,
owing to the irritable state of its muscular coats,
without being retained, and before any very
material distension of the viscus is occasioned by it.

24. The small intestines generally contain air;
although, I believe, much less than is usually
found in the large bowels. In a state of health,
particularly a few hours after a meal, when the
chymous matter is passing along them, percussion
over them, — that is, over the umbilical region, and
the immediately adjoining parts of tlie surround-
ing regions, — generally yields a dull sound ; which
becomes clear in proportion to the quantity of
air they contain, excepting in very fat persons.
In a great majority of abdominal diseases, the
quantity of air contained in the small intestine-;
is increased much beyond what exists in health :
this is particularly the case in several diseases of
debility, as chlorosis, indigestions, colicky affec-
tions, torpid states of the liver, constipation, cer-
tain states of fever, hysteria, &c. ; and stdl more
so in inflammatory states of portions of the diges-
tive tul)e, in peritonitis, in puerperal fevers, &c.

25. When the mucous surface of the bowels
or of the stomach is irritated or inflamed, the
quantity of air secreted is often very great ; but,
excepting in the slighter states of such diseases,
it is seldom retained within the sphere of the in-
flammation so as to occasion that degree of dis-
tension which may be detected by percussion,
although it is often retained in adjoining parts of
the tube, occasioning distension, great pain, tor-
mina, &c. This disposition to expel the morbid
collection of air arises from the irritability of the
muscular fibres of that part of the intestines, the
mucous surface of which is in a state of irritation ;
the morbid action of these fibres propelling it
either upwards or downwards, where it may accu-
mulate or be evacuated, but most commonly into
the large bowels, or into the duodenum and
stomach, where it may he detected by percu-sion.
In diseases which paralyse the contractile actions
of the muscular coats of the bowels, as malig-
nant puerperal peritonitis, the last stages of ente-
ritis, rabies cnnina, and the advanced states of
adynamic fevers, the quantity of air which is
secreted and accumulated in the whole digestive
tube, and the consequent distension, are often
enormous. The sound on percussion, in these
cases, generally becomes quite tympanitic long
before death, indicating the cause, as well as the
lost tone of the mu-cular coat of the canal.

2(5. The phenomena now noticed to occur in

respect of the small intestiries afTect, in a still
more marked manner, the large bowels ; flatulent
distension of these being rt adily traced by mediate,
or even direct percussion, paiticularly in the
course of the colon, even when the small intes-
tines are comparatively free from it.

27. It is not merely the presence of accuinu-
lated air in the difl^erent parts of the digestive tube,
and the important pathological and therapeutic in-
dications to which the knowledge of tlii-^ fact natu-
rally leads, that render percussion of the abdomen
a valuable means of investigation, but it is also the
information it conveys of the existence of mote
solid formations — of fluid collections, and morbid
productions. Unu-ual distension of the bladder;
all the forms of abdominal dropsy ; ovarian dis-
eases ; purulent collections in, or enlargenents of,
the liver; tumours of every kind, particularly
when they reach a considerable size ; enlarge-
ments of the spleen or kidneys, &c. ; are more
readily and earlier detected by means of mediate
percussion than without this aid : and, in all
these, the sound emitted is dead over the diseased
part, and becomes clear as the boundary of dis-
ease is passed, and when the plate is placed over
the hollow viscera.

28. IV'. Auscultation, mediate or direct, par-
ticularly the former, is often necessary in abdo-
minal diseases, particularly in ascertaining whether
or not the large vessels are affected ; and even in
tracing disease of the right side of the heart and
of the pericardium. It may also be useful iti
those diseases of the liver which extend to the
lungs through the diaphragm, particularly abscess,
or hydatidic cysts of the liver breaking into the
lungs. Auscultation of the abdomen has been
resorted (o by M. KiiRGAnADKC to a-certain the
existence of pregnancy; and by JNI. Lisfkanc, to
determine the presence of stone in the bladder,
when the sound is imperfectly heard to strike
against it.

Bibliography. — BurUvi, Prax. Med. lib. iv. c. 9 —
Double, Semeiolosie Generale, t. i. p. 3H3. — Criiveilhicr,
Dictionnaire de Med. el Chinirg. Piat.t. i. — P/uny, De
la Perc\ission Mediate, Pans, 1828 ; et Precede Oferatoire
dansrExploratioiidesOrgane!; par la l^ercussioii Mediate,
Paris, 1830._i^oj-6f4-, Cyclop, of Pract. Med. vol. i. p. I.

ABORTION. SvN. Abortus, Abmsus, Affluxio.
Ata<pdopa., 'E.KTp'jifj.a, EKTpcjafxos, Arist. A/x-
€\ofj.a, E^a/xSAaiffis, Hip. AvortemPiit, Fr.
Ahorto, Ital. Fatche Gelmrt, Fehlgeburt, Ger.
Miscarriage, Eng.

Classif. — 5. Class, Diseases of the Sexual
Function ; 3. Order, Afl^ecting Impreg-
nation {Good). I. Class; V. Ohder
(Author, see Preface).

1. Defin. The eipiilsion of an emliryo or fa: t us
which is either already dead, or is at a too early
period, offvtal existence to live,

2. This definition will distinguish abortion from
premature labour, which latter is applicable to
delivery after the sixth month, when the foetus
may live ; and from false delivery, which sig-
nifies the expulsion of a mole, or false germ,
instead of an embryo. Under this term I also
include expulsion of the ovum before the sixth
week, commonly called miscarriage.

3. I. Causes. — These may be divided into such
as act primarily upon the mother, or depend
upon her ; and into those which are connected
with the product of conception, and are owing
to di=ea=es of the foetus and its appendages.

B 3

ABORTION — Causes of.

(Duces.) Or they may be divided into the pre-
disposing, exciting, and efficient causes. It will
he necessary to consider the causes with some
relation to thefe distinctions.

4. i. rredis}}osiiig causes. — The disposition to
abortion is, in some females, so strong that the
slightest exciting cause will produce it ; in other
females the most serious injuries, and the most
violent mental and moral impressions, are insuffi-
cient to occasion it. Some of the predisposing
causes are referable to the mother, others to the
foetus and its appendages.

5. A. The predisposing causes referable to the
mother are numerous, and consist of certam states
of the uterus, and particular conditions of the
habit and constitution, influencing either the
uterus or the embryo itself.

6. The conditions of the uterus favouring abor-
tion are great rigidity of its fibres, and an un-
yielding state of its parietes, opposing too great
a resistance to the dilatation which the organ
must necessarily experience ; too great sensibihty
and contractiliiy of the uterus, in the former of
which states the other orguns of getieraiion often
also participate; too great a flow of blood to (lie
uterus and ovaria, either pioceeding constitution-
ally, or from causes which excite the nerves of
these organs or parts adjoining ; feebleness and
relaxation of the neck of the uterus — a condition
of the parts which INI. Desormeaux states he has
freqiienily ascertained to exist in females subject
to abortion ; and atony of the uterus itself, either
from original constitution or long-continued leu-
corrhoea, or from a severe or proiracled labour,
a cause which may be conjoined with the one pre-
ceding it. The foregoing causes are chiefly pro-
ductive of thoifC aboitions which occur at the same
period of pregnancy, and which have been called
periodic by some authors.

7. J'o the above may be added, as strictly re-
ferable, a condition of the organ called by Peu
immoderate heat of the uterus, which is attribut-
able to an excited condition of the nerves of the
organ, and a chronic inflammatory or irritative
state of its vessels; also sciirhus, fibrous, fleshy,
sreatomatous tumours of the uterus ; polypus,
dropsy, the presence of several children, and the
too rapid or too great dilation of the organ thereby
occasioned ; tumours of, and fluid efl^usions into,
tlie sub-itance of the ovaria ; and inflammation of
the ovaria and parts adjoining.

8. The causes chiefly referable to the consti-
tution and habit of the mother are certain states
of tlie atmosjjhere, to which only can be attributed
tho-e freciuerit abortions sometimes observed,
which have even assumed an epidemic form, and
of which lIii'i'ociiAi Es, FiscHEK, Tessier, Desor-
BiEAUx, and others, have made mention ; the san-
guine and irritable temperament ; plethoric habit ;
a constitutional disposition to haemorrhage inde-
pendently of, or connected with, the foregoing
Slates ; habitual menorrhagia ; irregular menstru-
ation ; gieal debility of body ; excessive sensibi-
lity, susceptibility, and mobility of the nervous
and muscular systems; hysterical states of the
nervous system ; the syphilitic and the mercurial
poisons; a cachectic condition of the frame ; pain-
ful and chronic diseases ; addiction to masturb-
.'ition in early life ; curvatures of the spine; mal-
formations of the spine and pelvis; hereditary
di-jposition ; an arquired disj)Osition arising Irom

previous abortions caused by accidental circum-
stances; marriage or impregnation late in life;
deficient or improper nourishment ; too close
cinctures of the body ; worms in the intestinal
canal ; conception at a too early period afier
delivery, or alter a previous abortion; the atonic
state of plethora generated by luxuiious indul-
gences, by sleeping m soft and too warm beds, by
indolence, a too full diet, &c. ; local plethora,
or excitement of the uterine organs, occasioned
and kept up by sensual gratifications ; and the
constitutional and local commotion occasioned
by infectious, exanthematous, pestilential, and
febrile diseases.

10. B. The causes which depend upon the foetus
are referable either to the foetus itself or to its
appendages. J hey operate either by favouring
the death of the foetus, which acts then as a
foreign body in the uterus, exciting the organ to
expei it; or by impeding its growth, so that it does
not consume, or does not aflbrd a readv circula-
tion to, tlie blood sent to the uterus ; thus occasion-
ing an accumulation of this fluid in the uterine
vessels, and consequently congesiion, terminating
in haamorrhage and the expulsion of the embryo.
Owing to these circumstances, abortion is favoured
by debility, or imperfect development of the
foetus; by monstrous conformation, and disease
aifecting it at some period of its early growth ;
by the imperfect adhesion of the placenta to the
surface of the womb, or its implantation over the
neck of the organ ; by disease of the placenta,
as inflammation, apoplectic ha;morrhage into its
substance, calcareous deposits, fatly degenera-
tion, scirrhous or cartilaginous induration ; the
formation of serous cysts, of hydatids, aneurism,
or varices of this organ ; by atrophy, hypertrophy,
or disproportionate size of the placenta ; by a too
short or a too long umbilical cord ; by twisting
of the chord around the neck or one of the limbs
of the loetus ; by diseased structure of the chord
itself, as extreme tensity or softness, the formation
of tumours or hydatids in it, by knots or adhe-
sions preventing or impeding the circulation
through it; great tenderness of the membranes of
the ovum ; inflammation, thickening, opacity, and
irregularity of the membranes ; the presence of
too much or too little amniotic fluid, and collec-
tions of serum, or of a sanguineous fluid, be-
tween the chorion and amnion; adhesions formed
between the placenta and parts of the surface of
the foetus; and, in the more advanced periods
of gestation, constitutional diseases, particularly
eruptive and infectious diseases, or continued
fevers, extending from the mother to the embryo.
10. ii. The occasional excitin;^ causes are ex-
tremely numerous. It may be even said that there
is scarcely an occurrence in life winch may not
be occasionally concerned in producing abortion.
( JJesohmeaux.) I'he chief causes of this class
are acute diseases ; such as fevers, scarlatina,
nieiisles, small-pox, and inflammations, piirticu-
lai'ly of the uterus, ovaria, pelvic peiitoiieum,
colon, iS:c. ; the irritation of adjoining viscera ;
diarrhoea, dysentery, tenesmus, colic, constipation,
hjuniorrho'ds ; hysterical and e|)ile|)iic convul-
sions; sy[)hilis ; violent pain ; disappointment and
anxiety of n-iind ; anger, fright, excessive joy;
the imi)ression of various odours ; threatened as-
plivxia, particularly from the va()our of carbon;
violent exertions and tiitiguej dancing; riding on

ABORTION — Si MPiojis of.

horseback, or in an uneasy carriage, or on a
roughly paved road; excessive venereal indul-
gence ; severe coughs ; hiccup ; immoderate laugh-
ter ; vomitings; seasickness; injuries on the
loins or abdomen ; any sudden shock ; even the
extraction of a tooth ; tiie use of irritating or
drastic purgatives, or of emmenagogues ; pedi-
luvia; hot baths; large blood-lettings, particularly
troni the feet ; convulsive movements of the foetus ;
rupture of the umbilical cord or of the mem-
branes ; adhesions formed between the serous
surface of the fundus of the uterus and the ad-
joining viscera, preventing the dilatation or the
ascent of the womb, and occasioning its reaction
on its contents.

11. The foregoing causes act variously in
producing abortion. Some of them may produce
directly a separation of the placenta from the
surface of the uterus, particularly when the pla-

. cental mass is very considerable ; but this is a
rare occurrence, and can only be inferred to exist
when uterine haemorrhage follows immediately
upon the application of the exciting cause. A
violent shock, injury, fall, compression of the
uterine region, riding, dancing, coition, &lC. may
iiave the immediate tiTect, or they may occasion
rupture of the cord or of the membranes ; but
more frequently these, and, in a still more par-
ticular manner, the other exciting causes, produce
certain intermediate effects, as congestion of the
vessels of the womb, which is soon followed by
hasmorrhage and by separation of the. placenta ;
or they occasion contractions of the uterus, owing
to the excitement and irritation of Us nerves, or of
the nerves of adjoining or sympathising parts, the
separation of the placenta, and expulsion of the
foetus.

12. Klein and many other authors have re-
marked that the causes of abortion generally have
a more marked effect at the period at which the
menses would have returned in the unimpregnated
state. The molimen, or tendency to congestion
in, and haemorrhage from, the uterus, which then
may be supposed to exist, renders it more suscep-
tible of bemg injuriously impressed by the occa-
sional causes of the disease ; and, where other
predisposing causes are already in existence, has
a direct influence in separating the placenta, and
inducing uterine contraction and abortion ; several
of the causes produce spasmodic or convulsive
actions, which are sympathetically transmitted to
the uteius, whilst others seem to act primarily on
the foetus. The direct action of certain of the
exciting causes on the fcetus may be doubted ; but
every experienced and observing practitioner must
have remarked the very frequent and immediate
effect of strong passions of the mind of the mo-
ther upon the motions of the foetus, inducing con-
vulsive actions, painfully and distinctly fell, and
sometimes followed by its death. Amongst the
most common exciting causes of abortion are
those means which, from their osccaional action
in this way, have been called abortives, and which
the practitioner should be acquainted with, so
as to enable him the better to counteract their
effects.

13. The production of abortion is a felonious
act, and one which the practitioner never will
resort to, except in the case of irreducible retro-
version of the uterus. The means usually re-
sorted to by females themselves, or by persons

who criminally usurp the medical character, and
employ feloniously the little empirical knowledge
they may have acquired, either surreptitiously or
otherwise, are, large bleeding from the feet ; pedi-
luvia; violent emetics ; drastic purgatives, particu-
larly those which act upon the colon and rectum ;
active emmenagogues, as savine, ergot of rye^
juniper, hellebore, &c. ; and stimulating injections
into the vagina: also various mechanical means
employed to break the membranes, or to procure
the discharge of the amniotic fluid. IMany of
the foregoing, or all of them excepting the last,
will often fail of producing the desired effect.
They frequently also succeed, and sometimes
they occasion the death of both mother and foetus.
MAunicEAu, De la Motte, Boer, Desormeaux,
Duces, Burns, Hamilton, Ryan, &c. have
satisfactorily shown the uncertainty of those
means, and have met with nunrerous instances in
which they had been carried to the utmost extent
without acting in the way desired ; but had occa-
sioned enteritis, dysentery, peritonitis, metritis,
and other dangerous diseases. JNlany cases are
also on record where attempts had been made to
produce abortion by puncturing the membranes ;
and the uterus itself had been penetrated, and the
death of the mother thereby occasioned. It is a
matter of the utmost difficulty, even to the most
expert surgeon, to puncture the membranes at
that period of pregnancy when it is usually at-
tempted by ignorant persons; the only persons,
indeed, who would make he attempt.

14. II. The Symptoms of abortion varv re-
markably with the period of pregnancy at which
it takes place: also with the cause producin^r it.
They do not, therefore, admit of being divided into
piecursoiy and essential symptoms: the former
being frequently wanting. In the two first months
of pregnancy the ovum, which is then small, is
sometimes expelled without any remarkable pain
or haemorrhage ; but more frequently there are
pains, accompanied with coagula, in which the
ovum is generally enveloped, and where it often
escapes observation. This is particularly the case
when, the membranes being broken, the embryo
escapes without the placenta. At this early period
females often suppose that they have been the
subject merely of an interruption of the menses,
followed by a more abundant and painful returu
of them than usual, instead of a true abortion or
miscarriage.

15. As the period of utero-gestation advances,
and the size of the foetus increases, the pains and
haemorrhage accompanying abortion are augment-
ed ; the haemorrhage being generally more con-
siderable than that attending delivery at the regular
period.

The abortions which proceed from chronic dis-
eases, or from causes acting slowly, and particu-
larly those which are occasioned by morbid states
of the embryo, or of its membranes, are generally
preceded by horripilations or rigors, followed by
febrile movements, by heat, want of appetite,
nausea, thirst, pain in the loins, lassitude, leipo-
thymia, syncope, coldness of the extremities, pal-
pitations, lowness of the spirits, paleness of coun-
tenance, tumefaction or lividity of the eyelids,
deficient brightness of the eyes, fcetor of the
breath ; a feeling of weakness in the abdomen, or
of cold about the pubis ; of weight about the anus
and vagina ; flaccidity and diminished size of tlie
B 4

ABORTION — DjAGNOsis of.

breasts, sometimes with aslight discharge of serum ;
a flow of a sanious, then of a sanguineous, fluid,
and afterwards of blood, either in a fluid or gru-
mous stale, from the vulva ; diminished motion of
the child, soon afterwards followed by perfect
cessation of motion ; lessened bulk, of the abdo-
men or of the hypogastrium ; uterine pains, which
become more and more frequent and severe , pro-
gressive dilation of the uterine orifice, and pro-
minence of the membranes ; and, lastly, expulsion
of the amniotic fluid and foetus, followed, at an
indefinite time, by the placenta. JNIost frequently
the discharge of blood does not cease until the
placenta is expelled. (Desormeaux.)

16. Abortion proceeding from the more ener-
getic exciting causes is sometimes preceded by
pains, and an unusual sense of weight in the
loins and at the lower part of the vagina ; by
horripilations or rigors, by general uneasiness, and
cardialgia or nausea. From the first there is often
an appearance of blood, followed by the discharge
of a sanguitieous serum, which soon passes into
serious haemorrhage. In other cases the action
of the cause is instantly followed by a large
effusion of blood, which continues until after the
expulsion of the foetus and its appendages. Fre-
quent lancinating pains dart through the abdo-
men, chiefly in the direction of the umbilicus and
vulva • the uterus makes efl'orts at expulsion, and
the fcEtus is expelled. The more advanced the
term of pregnancy, the nearer do the symptoms
approach to those of delivery at the full time;
and the nearer also do its consequences assimi-
late to those following upon a natural confine-
ment, as the lochial discharge, after pains, milk-
fever, &c.

17. It is sometimes observed, even up to the
middle period of utero-gestation, that the foetus is
expelled enveloped in its membranes. But it
sometimes also occurs in the first months, that,
after the rupture of the membranes, the foetus and
placenta are retained, decomposed, and discharged,
in the form of a brown foetid sanies. In other
cases the placenta is not expelled until several
weeks alter the foetus, either in the state now de-
scribed, or in that of a putrid mass. It occa-
sionally is ot)served that the placenta continues
attached to the uterus, and is nourished, increas-
ing in size, and assuming the appearance of a
fleshy mas<, in which are sometimes found simple
cysts, or cysts containing hydatids. This latter
occurrence takes place either when the foetus had
been expelled, or had died at an early period of
its formation ; and, whilst it was yet small and
nearly gelatinous, being dissolved during the pro-
cess of decay in the amniotic fluid, or preserved
in it.

18. This change in the placenta forms what
has bef-n called by Desohmeaux and others the
mule oj' generatinii ; the chief character of which
is that it possesses a cavity lined with a smooth
membrane, the reniains of the amnion. Fre-
quently, at the more advanced periods at which
abortion takes place, the foetus is expelled alive ;
but the duration of its life subsequently clc])en(.'s
upon its age, and the circumstances attending its
uborticn. It sometimes also is dead before it is
expelled, occasionally for a considerable time ;
allhou;^h it may have reached the a^e of several
months. Its death does not necessarily lead,
although it does generally, to its expulsion. In

some cases it is retained even up to the full period
of utero-gestation, and is then thrown out in a
state of peculiar softening and maceration, but
without putrefaction : this only occurs when the
membranes have remained entire, and air been
excluded from the interior of the uterus. In other
instances it is converted into a substance resem-
bling adipocere, or the fatty substances generated
during the decomposition of animal matter. In
rarer cases the foetus and envelopes become hard-
ened, and even converted into a bony or petrous
state, and retained till the natural death of the
mother ; or, in the course of some months, or even
years, occasion inflammation of the uterus, and
suppuration. Sometimes, in cases of this latter
description, a portion of the uterus forms adhesions
to the parts opposite ; the abscess which is formed
extending in that direction, and opening on the
surface of the abdomen, or in the interior of the
intestinal canal, or into the vagina, and giving
issue to purulent matter, mixed with a foetid sanies,
and portions of bones arising from the decompo-
sition of the textures of the embryo. But these
latter consequences of abortion are rarely met
with unless in cases of rupture of the womb, or
extra-uterine impregnation.

19. In some cases of abortion the haemorrhage
from the uterus continues to a serious extent lor
several days. This may be the case at various
epochs of pregnancy ; and may result from the
detachment, partial or general, of the placenta,
and its retention along with the foetus in the ute-
rine cavity, owing to imperfect action of the uterus
to eject it. It may also proceed from the expul-
sion of the foetus, and the reti ntion of the placenta,
either altogether or paitly separated from the ute-
rus. In some cases the presence of the placenta,
or of a portion of the membranes in the womb, or
in the os uteri and upper part of the vagina, by
the irritation thereby occasioned, may have the
effect of keeping up a constant and exhausting
hemorrhage. In a case of abortion to which 1
was recently called, the practitioner in attendance
stated ihe foetus to have come away two or three
days previously. Upon inquiring as to the dis-
charge of the appendages, I was led to recommend
an examination per vaginarn ; when they were
found lodged partly in the vagina and os uteri.
After their removal the patient rapidly recovered.

20. III. Diagnosis. — Tht diagnosis of abortion
should be directed to three objects : 1st, its cause ;
2dly, to the possibility of prevtnting its occur-
rence ; and, 3dly, to asceitaining Ihe stage or
development of the process. The causes ol abor-
tion are generally readily recognised, and admit
of an easy explanation. There arc two, however,
to which I'lofessor Desoiimeaux has particularly
directed attention; namely, rigulity of the fibres
of the fundus and body of the uterus, and laxity
of its neck. The former of those is generally con-
nected with a siiTiilar state of the whole system,
and accompanied with scanty or jjainful men-
struation. In the first inijiTegnations aboition
takes place at an eaily period ; but in subse-
quent impregnations the period of gestation ap-
proaches more nearly the natural epoch, the
female at last beaiing children to the full time.
When the abortion is referable chiefly to laxity
of the neck of the uterus, a result contrary to the
foregoing takes i)lace ; the period of abortion ap-
proaching nearer, in successive conceptions, to

ABORTION — Treatment of.

9

the time of impregnation. Examination per va-
ginam discloses this state of the cervix uteri, which
sometimes permits the escape of the ovum with-
out much pain. 'I'he presumed existence of either
of the foregoing states, particularly if any of the
symptoms enumerated as characterising abortion
be present, should lead us to suspect its ap-
proaching occurrence. And it may be considered
as commenced if pains occur at regular intervals,
which become of shorter duration, and are di-
rected from the umbilicus to the 05 coccygis ;
if the OS uteri dilates, if the membranes become
prominent during the pains, and if the amniotic
fluid escape. IM. Desormevux, however, has
detailed instances where, notwithstanding the
above phenomena, the patient was not delivered
for several weeks afterwards ; but these are ex-
tremely rare.

21. In cases where more than one child is
contained in the uterus, or where this organ is
double, one of the fcetuses may be expelled in
the course of gestation, and tiie other may still
remain and arrive at the full period of foetal life.
The eminent author whom 1 have now quoted
mentions the case of a female, pregnant for the
first time at the age of forty years, who expe-
rienced abortion at two months and a half: the
symptoms of pregnancy, however, continued, and
the motions of the fcetus were felt at tiie usual
time. At the'seventh month, a severe fright was
immediately followed by symptoms indicating the
death of the child ; however, the motions of the
child were still felt in the uterus : at last, after
two months, and at the usual period of gestation,
this female was delivered of a dead child, and of
another which had arrived at the full period, and
was living and healthy. IVI. Roi'pset has also
related a similar case {Traite de rHysterotokie).
When aboriion occurs during the first two months,
we can often only distinguish it from excessive
menstruation by the coagulating of the blood.
Cases, however, sometimes are met with where
coagula form during menstruation, but seldom or
never during healthy menstruation. Abortion is
most frequent during the first three months of
pregnancy.

22. IV^. Prognosis.- — Abortion has been con-
sidered of moreseiious import than delivery at the
full time, by HippocRATEe, .Txius, jNIauriceau,
and others. 'The prognosis will, however, entirely
depend upon the nature of the causes producing
abortion ; the period of gestation at which it takes
place ; and the symptoms accompanying it. It
may be stated generally, that the danger increases
in proportion as it approaches the full period of
gestation; inasmuch as the haemorrhage is
{.reater, the expulsion of the foetus and ap-
pendages more difficult, and the milk-fever more
violent, the longer the period of utero-gestation.
The abortion which occurs from accidental, or
active exciting causes, is generally more danger-
ous than that which follows the predisposing
causes ; this is more particularly the case, the
more violent the cause, the more prompt its
effects, and when it acts upon females not pre-
disposed to abortion. The most dangerous abor-
tions are those which are procured by substances
of an irritating nature taken internally, and by
attempts to excite the uterus, or to puncture the
membranes per vaginam.

23. On the other hand, when abortion takes

place spontaneously, and wiihout any very mani-
fest or sufficient cause, it, is often unattended by
pain or difficulty, leaving behind it scarcely any
unpleasant consequences; but this form of abor-
tion is most liable to recur ; and its repeated
occurrence often gives origin to a number of ail-
ments, some of them of serious moment, such as
irregular menstruation, chronic metritis, organic
lesions of the uterus and ovaria, irritable uterus,
hysteria, and a debilitated and cachectic habit of
body.

24. Abortion is chiefly dangerous from the
hemorrhage attending it; and hence the risk is
proportionate to the extent of this effusion. Abor-
tion, accompanied by convulsions, diarrhoea, dy-
seniery, or supervening in the course of fevers,
inflammations, or of eruptive diseases, are seldom
devoid of danger, which, under certain circum-
stances, is even great. Infliimmation of the womb
of great severity, endangering the life of the pa-
tient, or causing adhesions of the Fallopian tubes
orof the ovaria to the serous surface of the uterus,
and consequent steiility, is not an infrequent
consequence of abortion.

25. On the other hand, it may be productive
of certain advantages, according to Mauriceau,
Desormeaux, and some others, who have, in rare
cases, observed abortion occurring before the
third month to be followed by a more regular
state of the catamenia, in those who had been
irregular previously, and by an improved state of
health ; even fecundity taking the place of former
sterility.

26. V. 'Treatment. — The treatment of abortion
is divided into, 1st, the preservative ; 2d, the pal-
liative ; and, 3d, the remedial. On each of these
I shall offer a few remarks.

27. i. The Preservative treatment comprises the
following objects ; viz. to remove the predispos-
ing causes as far as tliii may be accomplished ; to
repress all undue action whenever it may appear ;
and to prevent, as well as to counteract, the effects
of the exciting causes. These ends are to be kept
in view, and applied to individual cases, appro-
priately to the causes an<l circumstances by which
they are characterised. Where plethora, general
or local, exists, it should be reduced by general
or local depletion, in very moderate quantity, and
repeated at short intervals; but more prefeiably
by a low and antiphlogistic diet and regimen,
acidulous and cooling beverages, the recumbent
posture, and tranquillity of mind. la cases cha-
racterised by relaxation of the system and of the
reproductive organs, an opposite, or a tonic and
invigorating, regimen is required. In every in-
stance the preservative treatment must be based
upon our views respecting the pathological state
of the uterus, and of the whole frame at the time
of prescribing it.

28. When the horizontal posture is considered
necessary, the patient will be more benehted by
reclining on a mattress, than on a soft, hot bed.
Iler apartment should be cheerful, large, and
airy; the bed-clothes light; and all anxiety of
mind respecting the issue, and depression of spirits,
prevented ; a confiding and cheerful state of fetl-
ing will materially conduce to a favourable result.
The diet, under ordinary circumstances, ought to
be light and digestible, and varied according to
the particular circumstances of the case. The
beverage should be mild, and, in cases of local or

10

ABORTION — Treatment of.

general plethora or excitement, rather cooling
than otherwise, and such as may promote, ratiier
than retard, the natural actions of' the bowels.
Lemonade, imperial, barley-water, toast-water,
&c., are amongst the best in this class of cases.

29. JMucli will depend upon the perseverance
with which this plan may be followed, particu-
larly in cases of habitual or precedent abortions ;
where it ought to be rigorously enforced and con-
tinued for months, or, at least, for a long time
after the period of gestation at which the former
abortion occurred. If the threatened abortion be
accompanied with pains, or by any degree of
discharge, an opiate should be given at bed-time ;
and, In every case where we have conceived it
requisite to abstract blood, either generally or
locally, even as a preventive measure, the oper-
ation should be followed by a dose of opium.

30. Attention to the bowels is indispensable ;
but great discrimination is necessary in the choice of
laxatives when the bowels are constipated. These
should be of the most cooling and gentle descrip-
tion. The soluble tartar, and cream of tartar in
the form of electuary, or with confection of senna,
particularly in cases of plethora, are very eligible.
Castor oil, with a very few drops of laudanum,
which will not retard its operation ;. or small
doses of the bi-sulphate of potash, are also suitable
laxatives.

31. When, from our knowledge of the state of
the ovum, in previous abortion, we suspect a
repetition of it, we may endeavour to prevent if,
by using those means which are most successful
in imparting energy to the constitution, and,
through it, to the generative functions ; so that ihe
process of foetation may proceed to a successful
issue. This is, perhaps, best accomplished by
change of air ; the use of the tonic mineral
waters, both internally and in the form of baths;
but the mineral acids given in the infusions of bit-
ter tonics, or with the solutions of the salts of iron :
as the tinctura ferri sesquichloridi ; the tinctura ferri
aetherea (see Appendix) ; by the sulphate of zinc,
with the compound infusion of roses ; by the ex-
hibition of the various balsamic and terebinthinate
medicines, combined with the pulvis cinchonas,
or the pulvis rhei, and the carbonates of the
alkalies, or magnesia ; and by attention to the
state of the bowels, to diet, and gentle but regular
exercise. The balsams most serviceable in cases
of this description, as well as in all those cha-
racterised by weak and imperfect uterine function,
are the balsams of Peru, of Canada, of Chio,
and of copaiba; the terebinthina vulgaris, and
T. Veneta. SrEnoi.D recommends the balsamuni
vitae Jloll'inanni ( F. 317.), a medicine which
enjoys great leputation on the ('oiitinent in many
diseases of debility. The loins may be rubbed
night and mortiing, for some time, with the lini-
metitum saponis et camphors comp. (F.306.), the
linimentum terebintliiniC comjjositum (F. 311.),
or the liniment, anodynuin ( F. 298.). The ap[)li-
cation of the emplaslrum cumini, the emplaslrum
picis composiluni, or the emplaslrum roborans
( F. 118. ). to the loins will also prove of service.

32. When diarihoea occurs during the period
of utero-gesiHtion, and more especially if it be
accornpnnieil with tenesmus, in delicate females,
or in those who \mve experienced previous abor-
tions, it should be immediilely checked or lessened.
lo these cases disorder is chiefly confined to the

colon and rectum, which should be soothed by
small emollient and anodyne enemata, or by the
use of suppositories of lead plaster, and opium.
VVhilst, however, we thus prevent the irritation
from being extended from the large bowels to the
uterus, we should take care to prevent the reten-
lion of hardened faeces in the cells of the colon,
by which irritation will be perpetuated ; and to
remove them, when we suspect their presence, by
the use of gentle laxatives, and emollient and
aperient injections, avoiding the use of saline
purgatives and cathartics.

33. In cases of threatened abortion in debili-
tated constitutions, the mineral acids, particularly
the sulphuric, either with or without small doses
of laudanum, or combined with small doses of
colchicum, or of digitalis, are extremely useful.
Where the circumstances of the case permit the
horizontal posture to be dispensed with, the pa-
tient may be allowed very gentle exercise, for
short periods, in the open air, avoiding all exer-
tion and local excitement. She should live ab-
stemiously, yet not too low. In many cases of
this description a glass or two of light wine may
be allowed daily, and in several a still more tonic
treatment is required. When this is the case, the
infusion of calumba, or of quassia, with the car-
bonate of soda, and tincture of hyoscyamus, has
seemed to me very serviceable ; and the patient
has been allowed the occasional use of the swing,
or a gentle ride in a carriage. The tepid and
cold hip-bath, particularly with sea-water, are
often of use in cases of this description, as well
as the treatment recommended in a preceding pa-
ragraph. The necessity of abstaining from sexual
intercourse, in all cases of threatened abortion,
is most evident.

34. In cases accompanied with incipient dis-
charge, either the cold hip-bath, or sponging the
hips, thighs, and lower parts, of the trunk with
cold water and vinegar ; or by squeezing a large
sponge filled with cold water, so that its contents
may fall in a scattered stream from some height
upon the hips and pelvis; will sometimes be ser-
viceable. Injections of cold or iced water, or cold
astringent solutions per vaginam, or a lavement of
cold water, will sometimes arrest the accession of
luBiiiorrhage.

35. It will occasionally hz observed that weak,
nervous, and delicate females are often irritable'and
dispirited from a tedious confinement, during gesta-
tion, andeven abort owing to this cause ; obviously,
in many cases, from the effect produced upon the
uterus, and upon the nutrition and health of the
embryo. This should be anticipated, and pre-
vented by a timely relaxation of the plan, and by
allowing the patient as much exercise, amusement,
&c., and by adopting as much of the treatment
recommended above (§33.), as may be consistent
with the accomplishment of our end. When, in
these cases, the nervous symptoms predominate,
the use of antispasmodics, with anodynes, and
their combinations with vegetable bitters, clialy-
beates, &c., are often required. The diet should
also be nutritious; but easy of digestion, and not
too heating and stimulating.

36. The foregoing plan will often succeed in
preserving the infant, unless the discharge con-
tinues or becomes more copious; the uterine
pains, with the other symptoms of commencing
abortion, still persist or increiise ; and the woman

ABORTION — Treatment or.

11

■be advanced in pregnancy ; when little advan-
tage will be obtained, particularly if the orifice of
the womb dilate. When this is the case, attempts
at preservation will entirely fail, and we must
adopt the'second intention.

37. ii. The palliative measures now required
consist, in addition to those recommended (^ 34.),
of cold applications to the genital fissure and in-
sides of the thighs, and the tampon, or plug, as
recommended by a number of authors, and sanc-
tioned l)y Denman, Hamilton, Burns, JMeriu-
MAN, Dewees, Rvan, &c. 'J'hese are especially
requisite where the hjemorrhage is great, particu-
larly when the abortion takes place between the
third and sixth month. Opium, with the acetate
of lead, given in a very large dose at the first, and
repeated according to circumstances, should also
be exhibited. Opium, as well as plugging the
vagina, are chiefly serviceable where the liaimor-
rhage continues after the expulsion of the embryo.
The plug recommended by Dr. Dewees is a
sponge squeezed out of vinegar. Dr. Ryan ad-
vises either old linen or a sponge to be wetted with
a saturated solution of alum, and smeared with
some oleaginous matter, to be passed up the vagina,
so as completely to fill it. Dr. Bi.undell dnects
a scruple of alum, dissolved in a pint of water, to
be injected into the uterine cavity.

38. The practitioner should in every instance
be satisfied as to the expulsion of the embryo and
the whole of its appendages, for he may be de-
ceived in this matter (§ 19.) ; a small remnant of
the placenta or of the membranes, vvhen still left
in the cavity of the uterus, or even lodged in its
orifice, being often sufficient to keep up an ex-
hausting, or even dangerous, discharge. When the
embryo only is expelled, the appendages being still
retained, or when the hsmorihage is great, the
entire ovum still remaining in the uterus, the ergot
of rye will often prove of inestimable service ; and
when given in the form of decoction, with as much
borax as it will dissolve, will selilom disappoint
our expectations. When a portion of the append-
ages remain at the orifice of the womb, it may be
drawn down by the finger, or by a curved dress-
ing forceps. In cases of great haemorrhage in the
early months of pregnancy, the ovum being re-
tained. Dr. BunNS advises the use of smart clys-
ters, and plugging the vagina. In every case of
haemorrhage from abortion, as well as after deli-
very at the full period, but particularly when the
ha;morrhage proceeds from inefficient contraction
of the uterus, and retention of the ovum, or some
poition of the appendages of the embryo, I have
prescribed with complete success, an enema, with
from one to two ounces of the oleum terebinthinse
in a pint of water-gruel.

39. The injection of water into the rectum, or
a solution of acetate of lead and opium, has
been advised by Dr. Dewees and Dr. Conquest.
When the haemorrhage occurs in robust and
plethoric females, and the discharge has not pro-
duced much exhaustion, venaesection nr.ay be tried.
In cases of this description, tincture of digitalis, in
half-drachm doses, has been recommended : but,
owing to the loss of blood, the efTect, although not
produced with the necessary celerity, will often
be too violent and unmanageable, and will so en-
danger the patient as not to justify its use unless
under very peculiar circumstances. I once pre-
fcribed colchicum in large doses in a case of hae-

moptysis, with violent paroxysms of cough and
threatened abortion, occurring in a plethoric lady
at the fourth month of pregnancy. Full venae-
section was performed, chietly on account of the
severity of the pulmonary disease ; the colchicum
was directed with an anodyne ; and the patient
left under the care of the family practitioner.
Abortion took place, and was attributed chiefly to
the sickness, retching, and depression occasioned
by the colchicum ; it having been unremittingly
administered until my next visit, on the third day
from that on which it had been prescribed, not-
withstanding the discretionary power with which
the practitioner had been invested. (See also, on
this subject, the Treatment of H.t.morrhage from
the Uterus.)

40. iii. The remedial treatment of abortions is
next to be considered. It occasionally happens
that the retention of the ovum, or of a portion of
the appendages of the embryo, produces much
constitutional disturbance, particularly nervous
symptoms and irritative fever, which sometimes
assume serious features, with disorder of the
bowels, typhoid or ataxic signs, and an offensive
vaginal discharge. The decoction of cinchona
and hydrochloric acid, or this decoction with the
liquor of the acetate of ammonia, or the following,
will prove extremely serviceable : —

No. I. BIVIist.Camphoia?3j.; Liq. Amnion. Acpt. Sijss.:
Acidi Acetici Pyrolignei }X[ xxv. ; Syrup. Zingiberis,
5ss. M. Fiat Haustus tcr quaterve in die sumendus.

No. 2. R Campliorae rasae gr. ij.— iij.; Extr. Cinclion.
Resin, gr. iij.— v.; Conserv. Itos. q. s. ut fiant Pilulee ij.,
ter die capienda;.

In cases of this description a turpentine enema,
administered every second or third day, is ex-
tremely beneficial ; and advantage will be derived
from injections of a solution of the chloruret of
lime, or of Labarraque's liquor, per vaginam.

No. 3. R Liq.SodaeChlorinatae3jss.;Mist. CamphorjB,
5vij>s. M. Fiat Injectio.

41. When troublesome, diarrhoea is present, in
cases of this description, the cliloiuret of lime,
either in the form of pill or solution, is extremely
efficaciou--. I have prescribed it as follows: —

No. 4.R ChloruretiCalcisgr. viij xvij.; Pulv.Traga-

canth. Comp. Sj^s.; Syrup, q. s. M. Fiant Pilula xxiv.,
qaaruni capiat binas ter quaterve in die.

No. .5. R Ctilorureti Calcis, gt. vj.—xij.; Tinct.CaIumb<p
3 iij.; Aq. Menth. Virid., vel Aq. Carui, vel Aq. Anetlii,
5vj. — 3 vijss. Fiat Mist, cujus sumat coch. j. vel ij.
larga ter quaterve quotidie.

The chloruret of lime may also be administered
in water-gruel, as an enema, in doses of viij. to
xij. grains, once or twice daily.

42. The debility occasioned by abortions requires
the use of tonics, with mineral acids, nourishing
but light diet, a wholesome air, gentle exercise,
and the tepid or cold salt- water bath : — the mi-
neral waters of Bath, Bareges, or Tunbndge;
those of Ems, Spa, Pyrmont, and Geilnau °or
the artificial mineral waters of the last-named
places, are also beneficial. When nervous or
hysterical symptoms supervene, the exhibition of
antispasmodics, with gentle tonics, and the occa-
sional use of cooling aperients, are required. The
treatment of the efifects of abortion is, in every
respect, the same as that recommended in the
articles on Hemorrhage from the Uterus, iii
the unimpregnated and puerperal states.

Bibliography. — F. Albinus, Diss, de Abortu. Franc.
4to. 1099 — StuM^ Dss. de Abonu et Fcetu Mortuo. Hals'
1704 _ Vide Holier, Disser. Collect, t. iv. No. 139. -1
Stall, De Abortu, in Diss. Med. edit, ligerel, t. iv. —
Del/iardmg, De Fcetus immatuii Exclusione. Host. 1718.

12

ABSCESS — Pathological DocTniNE of.

~~ Jassen'ni, De Abortu. Vien. 1777 Mayer, Aphorismi

de Causis Abortum provocantibus, 4tn. Franc. 1780. —
Becker, De Abortu. Got. 179H.— Gccg-w/nj, De Hvdrope

Uteri et Hydatidibus, Hal. 1795 Le Roy , Unt \e% Pertes

de Sang pendant la Grossesse, et sur les lausses Couches.
Paris, 1801. — Stewart, On the Causes whicli destroy the
Foeiusin Utero,in Medical and Chirurgical Transactions,
vol. V. p. 1J4. — El. r. Siebold, Von den Fruhgeburttn in
desst'U Handb. zur Erkenntnijs und Heilungder Fraupu-
zimmer krankheiten, ii. b. u. 2. Frank. 182:!. — Desor-
meaux, art. Avorfemrnt, Diction, de Medecine, t. iii.
p. 177.; et art. (Enf, Ibid. t. w. — Blundfll, Lectures
on Midwifery, &c. Lancet, vol. xiii. — Good, Study of
Medicine, vol. v. p. 17-1. — Els. v. Siebotd, art. Abortus,
Encyclopadisches Wdrterbuch der Medicinischen Wis-
senschaften. &c. erster Band, Berlin, 1828. — Ryan,

Manual of Midwifery, 12mo. Lond. 1831. ;id ed Duges,

in Revue Medicale, 1824, t. iii. p. 74 ; et Manuel des
Accouchemens. Paris, 1830. — Audry, Sur les Maladies du
Foetus et ses Anne.xes, in Journ. des Progres des Scien.
Med. 2d ser. t. i. p. J2C. — Detvecs, in Cyc. of Pract.
Med. and Surg, edit by J. Hays, Part i. Pbiladelph. 8vo.
183.). _ /f. Lee, in Cvc. of Prait. Med. Part i. Loud. 8vo.
1832.— £>K^t-», in Diet, de Med. et de Chirurg. Prat,
torn. iii. Paris, 8vo. 1829. — Brit, and For. Med. Rev.
vol. vi. p. 81.

ABSCESS. Syn. Abscessiis (from ahscedere, to
depart, to separate), Apnsteina, Abscessio, Vo-
mica, Imposthuma, Auct. Lat, ATroa-rufA-a,
Gr. Abces, Fr. Die Eiterbeule, Ger. Edder-
byld, Dan. Bidning, Swed. Ettergezwel, Dut.
Ascesso, Ital. Abscesso, Span. Abscesso, Port.
Abscess, Impostinane, Eng.

Classif. — See Inflammation.

1. Defin. a collection of purulent malter formed
or deposited in the structure of an organ or ]>art.

2. An abscess is never an original disease, but
is constantly the effect or termination of inflam-
matory aciion, in some form or grade, or of irri-
tation of the part in which it is seated. This may
not seem to be in accordance with certain phe-
nomena connected with the formation of purulent
collections, in parts at a distance from ihose in
whicli inflammatory action originates, and where
pus is originally formed: but I shall iiave occa-
sion to show that it is not oppO'^ed to sound views
as to tiiis topic, or, at least, that the exceptions to
it are few.

3. Without noticing further than to enumerate
them, the older distinctions of abscesses into the
warm, phlegmonous, or inflammatory, the cold
or congestive, and the acute and the clironic, 1
shall have to show that, instead of proceeding
from difl^erent sources, they are equally the result
of a certain state of inflammatory action, modified
into a variety of forms according to the degrees
of vital energy and aciion of the part, and of the
system generally, the organisation of the part af-
fected, and the peculiarity of constitution and
diathesis. In the present article, a general view
will be taken of the patliologif and medical treat-
ment of ahscess, the consideration of the difl^erent
kinds of absce-s : their vaiious seals, and lelaiioiis
to other diseases, fail under different heads, where
tiiey are more adrantugeously discussed.

4. I. Of the Patiiologicai (^iiahacteks of
Abscess. — 1st, Of abscess proceeding from acute
injlammation, with integritxi of the constitutional
energi/. — When a part becomes inflamed, liie vi-
tality of which has not been previously injured,
as respects either its in<lividual state, or constitu-
tional relations, its temperature becomes increased,
and its v(ssels are injected with a greater (|uantity
of the circulating fluid than in health, and gene-
rally in proportion to the violence of the irritation
upon which this afflux of fluid depends. At first
llie fluid does not extend beyond the vessels in

which it has passed ; but, in proportion as it dis-
tends them so as to exhaust their tone and power
of reaction, and as the vital cohesion of their
extremities, and of the tissues which they supply,
is weakened, a portion of the more fluid consti-
tuents of their contents escapes into the texture
of the part affected ; infiltrates, and combines
with, its constituent elements, and renders it, at
first, more compact and dense. But, at the same
time that the inflamed part undergoes this change,
it loses its vital elasticity, is more friable or la-
cerable, so as to break down more readily from
foreign pressure, or upon the application of a
firm lioature.

5. If the inflammatory action stops not here,
the tissues affected by it undergo further changes.
They pass, more or less rapidly, from a dense but
friable state to that of softening ; and this quickly
but insensibly assumes a pulpy condition, owing
to its continued and increasing infiltration with
the more fluid parts of the blood, and even with
more or less of its colouring particles ; the mole-
cules composing the tissues of the part being so
combined with, and separated by, the infiltrated
fluid, that all distinct traces of proper organisation
are lo^t. From this pulpy state, to which the
central portion of the inflamed structure is re-
duced, the transition to pus proceeds rapidly. But
it is not to be understood that the tissues them-
selves are converted into this fluid. The fluid
poured out from the extreme capillaries gradually
distends the surrounding parts, and partially dis-
solves the softened and disorganized tissues in
which it is effused. The coagulable lymph, which
the tonic or unexhausted vital energy of the ad-
joining vessels form in the surrounding texture,
confines the effused fluid, and prevents it from
extending beyond the barrier it opprses ; whilst
the impaction of the cellular tissue, occasioned
by the increasing quantity of purulent effusion,
and the pressure it produces in all directi< ns, with
the thickening, and the continued deposition of
lymph in the parietes of the abscess, tend still
further to fulfil this end, and thus to limit the
mischief, and to prevent the contamination and
disorganisation of the adjoining structures ; con-
sequences which not infrequently supervene, when
the vital energies of the frame and the state of
local action are insuflii'ient to admit of the form-
ation of coagulable lymph, and to throw up this
barrier against the extension of disease.

6. The first step of the suppurative process is
the dissemination, particularly in the softest, in the
first and most intensely inflamed part, of minute
collections of a sero-albuminous or sero-sangui-
neous matter. By degrees, thi< fluid become s more
abundant. These minute collections enlarge, ap-
proach each other, and, at last, the parlitions of
softened tissue between them are altogether dis-
organised and disappear; the whole, at last,
forming only one cavity of variable extent. As
this process advances, the effused fluid changes
from a thin albuminous lymph into pus ; which
becomes more thoroughly eliib( rated, losing its
colouring mutter which it had derived from the
blood, and dissolving the shreds or di'bris of the
disorganised tissues in which it had formed : and
when the suppurative procc-s is matured, the pus
forms an homogeneous fluid, presenting certain
characters distinguishing it from all other animal
fluids.

ABSCESS — Acute, its Pathology.

13

7. Pus, taken from a matured abscess of the
description now exliibited, is generally a whitish
or cream-like fluid; friable, homogeneous, soft,
and smooth to the touch ; somewhat heavier than
water, in which it is only partially soluble ; with-
out any disagreeable smell, and producing of itself
no irritating effects upon the tissues enclosing it,
as long as it is excluded fiom the action of the
atmosphere. Upon a closer examination, it is
found to consist of minute colourless globules,
resembling the colourless globules found in the
blood, floating in a thin albuminous fluid.

8. It is often a matter of importance to distin-
guish pus from the mucus secreted by a mucous
membrane in a state of irritation ; and accord-
ingly, various attempts have been made to esta-
blish some specific character. 'J'he circumstance
of pus sinking in and partially mixing with water,
wliil-t mucus remains at its surface, has been
taken as a common test ; and in many cases will
be sufficient, with the history of the disease, and
various concomitant phenomena, to enable us to
decide : but it should be recollected that the mu-
cus, which is frequently secreted in great ab.n-
dance by the internal surface of the bladder, and
which is very remote from pus in its characters,
always sinks in water. Besides, mucous surfaces,
when in a state of inflammation, secrete a fluid
varying from a tiiin watery or frothy matter ; and
in some cases, from a thick albuminous and vis-
cous mucus to a friable cream-like pus : but most
commonly, a muco-purulent liquid, which pre-
sents more or less of the characters of both pus
and mucus. The appearance exhibited by pus,
when pressed between two plates of glass, which
are afterwards sepaiated, is often distinctive : this
fluid attaching itself to their surfaces, without the
viscous adhesion of mucous and paitly consisting
of small globules. The viscous elasticity of mu-
cus, of which character pus is entiiely deprived,
distinguishes the one from the other more com-
pletely, and in a more intelligible manner, to the
practised eye, than any other feature they present.
In addition, however, to this, it may be adde<l that,
when water is added to a solution of pus in dilute
sulphuric acid, a more or less abundant precipi-
tate is formed ; whilst, with a solution of mucus
in the same acid, whitish filaments form on the
suiface upon the addition of water.

9. As the partitions of softened tissue placed
between the incipient purulent collections, in a
part undergoing the early process of suppuration,
lose their vitality, and become broken down in
the eff"used fluid, the vessels and nerves, as well
as the more solid tissues passing through the part,
continue to resist the disorganising process for a
longer period, so as to form isolated bridles, and
communications between the separated parietes of
the abscess.

10. The interior of the parietes of the cavity is
generally more or less reddened, tomentous, and
very close in its texture, owing to the impaction
or distending power exercised by the accumu-
lated fluid and the effusion of lymph ; so that the
fluid contained by them is completely isolated
from the surrounding structures. I'he membrane
thus formed presents all the characters of a mu-
cous surface, particularly when the greyish pellicle
which usually covers it is removed. Its inteiior
surface is in contact with the purulent collection;
whilst, externally, it adheres intimately to the

surrounding tissues, and is confounded insensibly
with them. It approaches more nearly to the cir-
cumference of the inflamed part, the more com-
plete the softening of the tissues, and the moie
the abscess has advanced to maturity. Its dens-
ity and thickness are generally in proportion to the
slowness of its formation and the length of lime it
has existed.

11. In parts abundantly supplied with cellular
tissue, the membrane proper to abscesses acquires
a great degree of resistance and density, forming
thick cijsts ; whilst in very soft organs, or in those
but scantily provided with cellular tissue, as in
the brain, it remains long in the state of a vas-
cular pellicle, scarcely distinct from the healthy
structure with which it is connected. It is in
general rare that we find a thick or firm cyst in
the acute abscess now under consideration ; for it
forms too rapidly to admit of the thickening and
condensation usually occasioned by inflammatory
action of some duration. In some very acute
abscesses, as in those which sometimes Ibrm in
the liver of Europeans residing in India, after in-
tense inflammation of the internal structure of the
organ, no cyst, membrane, or even pellicle can
be detected on the internal parietes of the ab-
scess ; the whole surrounding structure being in-
flamed, softened, and sometimes portions of it
hanging or floating in shreds in the midst of the
purulent colltction. In these cases the purulent
collection, although existing as a circumscribed
abscess, more nearly approaches the diflfused ab-
scess next to be noticed.

12. The functions of the membrane lining ab-
scesses are not confined to the containing and
isolating the purulent matter, so as to prevent the
contamination of the adjoining structures. Owing
to the absorption and exhalation proceeding in its
suiface, the contained fluid is continually renewed,
its qualities are modified, and its decomposition
prevented. It is not altogether removed from the
influence of life, but participates in the vitality of
the surrounding textures, as all fluids accumu-
lated in organised parts do, though in a feeble and
obscure degree. IM. Dcpuytren remarks, that it
is through the medium of this living envelope that
the matter contained in abscesses is augmented and
diminished in quantity ; is thickened, or rendered
more fluid ; or is occasionally ciianged by sub-
stances absorbed or injected into the circulation.
It is because the cysts of abscesses are connected
by an intimate sympathy with the chief centres
of vitality, that the excitation of the more impor-
tant viscera affects them in so marked a manner;
and that remedies, judiciously applied to these
viscera, often tend to promote the absorption of
the matter they cantain.

13. 2d, Of abscesses proceeding from acute in-
flammation in a cachectic habit oj body, deficient

vital resistance, and icith a tendenct) to sjiread ; or
Dift'w-e Abscess. — In debilitated and vitiated habits
of body ; in persons of exhausted vital energy,
whose assimilating and secreting organs are tor-
pid ; and owing to the operation of certain noxious
and inten>e causes, particularly those which con-
taminate the structure to which they are applied,
as various aYiimal poisons, animal and vegetable
matter in a state of decomposition, or whatever
produces, from its local or constitutional action,
a septic effect upon the living textures — from these
circumstances, especially, inflammatory action is

14

ABSCESS — DiiFus

not limited lo a particular part, or within rlistinct
bounds; and the fluid wliich is poured out from
the inflamed vessels is not circumscribed, or con-
fined to the centre of the inflamed part. The
inflammation which produces this unhealthy and
imperfect form of abscess is always characterised
by that state of asthenic or ataxic action, local
and general, which is incapable of producing co-
agulable lymph from the blood, that may limit
both the morbid action and the effused fluid.
(See art. Inflammation.)

14. This kind of abscess not infrequently
forms in erysipelas ; or after wounds, injuries,
and punctures ; and from the inoculation of
an animal poi-on. The characters of the suc-
cession of morbid actions it presents are want of
vital power and resistance, and a speedy solution
of tlie vital cohesion of the affected tissues. It
would seem that the influence of the ganglial
nerves supplying the capillaries of the part is ra-
pidly, or almost instantly, destroyed by the cause
of the disease ; and that the vessels, thus deprived
of a great proportion of the whole of their vitality,
allow the escape of the more fluid parts of the
blood, and the infiltration of the tissues. The
vessels pass rapidly, and without the previous
grades of healthy inflammation, into that state
which admits of the effusion of a watery or puri-
form sanies. The state of vital energy, and tiie
deficient crasis, or unhealthy condition, of the
blood itself, probably contribute to this result;
and, with the efl^ect of this effusion on the diseased
part, promote the rapid exhaustion of the remain-
ing action of the capillaiies.

15. Diffusive abscesses generally commence in,
and spread rapidly in thedireciion of, the cellular
tissue. They aflPect also, in a very marked man-
ner, the other structures placed in their way.
They seldom commence in the internal viscera,
as the liver, lungs, &c. ; but when they do thus
originate, as is occasionally observed in the latter
stages of malignant or ataxic fevers, in exhausted
states of the frame, &c., they nearly approach
the characters they assume in the cellular struc-
ture. In almost every case of this disease, the
constitutional disturbance is very remarkable ;
and the powers of the nervous system, particu-
larly that presiding overthe organic and assimilat-
ing functions, are uncommonly depressed. Locally,
the effusion of a watery, or sero-albuminous, or a
sero-sanguineous fluid, is nearly coeval with the
aflfection of the cellular tissue and congestion of
its capillaries. The vital cohesion of the inflamed
texture is rapidly dissolved ; and the fluid, abun-
dantly poured out in its areola; or cellules, distends
the part, diminishes its vital functions to the
lowest grade, and, at points, lacerates its tissue,
thereby partially cutting oflT its connection with
the adjoining structures. 'J'hus the fluid is eflTused
from the congested capillaries of the affected part
in numerous places : in soine, forming consider-
able collections; in others, mere infiltrations.
Parts of the cellular tissue itself, and, in rare in-
stances, as the mischief .proceeds, portions of ad-
joining or intermediate textures, are deprived of
nil vitality, sphacelate, fund mix with the fluid
e Abused.

If). In many cases the integuments participate
but injperfectly, and often not at all, in the mor-
bid actions, whilst the process, as now described,
is going forward ; and the great eflfusion into, and

tVE, ITS Pathology.

partial destruction of, the cellular tissue, have
enormously distended the limb or part in a dif-
fused manner, and to a great extent, and given it
a boggy or imperfectly fluctuating character. At
a later period, parts of the more attenuated or dis-
coloured integuments vesicate, ultimately burst,
and give issue at first to a discoloured puriform
secietion, which afterwards becomes offensive and
otherwise modified. When the skin is affected, it
generally presents a dark or livid hue: its tem-
perature is seldom above (excepting, sometimes,
at the very commencement of the antecedent in-
flammation), and frequently sinks below, the na-
tural standard.

17. With respect to the appearance of the se-
cretion in this form of abscess, I may state, that
it not only varies remarkably in different cases
but also at different stages of the same case. At
first, the fluid effused and infiltrating the cellular
structure consists chiefly of a limpid, reddened
serum, which readily flows from the divided struc-
tures ; in a more advanced stasre, the effused mat-
ter is less fluid, often high-coloured, but without
the whiteness and opacity of purulent matter.
Afterwards, the cellular membrane is engorged
with a white semifluid matter, which separates the
particles of fat and cellular tissue at an unusual
distance from each other. In subsequent stages
it continues opaque ; but often becomes reddish,
greenish, and more fluid. Ata still moreadvanced
period, the infiltrated cellular and adipose tissue
are entirely broken down, and the sphacelated
portions hanging into, or mixed with, the puriform
matter ; which sometimes now presents the appear-
ance of a brownish, purulent sanies, sometimes a
greenish pus, and at other times a sero-purulent
matter of various shades of colour and degrees of
consistence. At no period of the disease is the
matter contained in any circumscribed cavity, but
is gradually and irregularly lost in the surround-
ing cellular tissue ; without any demarcation, or
appearance of coagulable lymph about the cir-
cumference of the diseased part. In general, the
purulent secretion speedily assumes an offensive
odour, and its sensible qualities are otherwise
altered, and often variously, upon the admission
of air to the diseased surface.

18. The muscular structure, and other parts in
contact with the puriform matter, and in the way
of the spreading disease is generally niuch disco-
loured, softened, easily torn, and sometimes par-
tially destroyed. In some cases the muscles are
paler, in others darker, and more livid, than na-
tural. In rarer instances, the adjoining bones
and more resistant structures are also affected.
(See Inflammation, Diffusive.)

19. 3d, Abscesses coiiseiiueiU upon infiummation
of Imver grades of iiilensitij. — 'l"he more slow and
obscure the progress of inflnmtuation, the less
marked are the signs of irritation ])receding and
accompanying abscesses. It is not uncommon to
observe, in lymphatic and phlegmatic tempera-
ments, fluctuating tumours of various size^-, both
superficial and dccp-scated ; without any consider-
able pain or increase of animal heat, either ante-
cedent or subs((]ucnt to their formation. Puiulent
collections, of a chronic and indolent character,
generally proceed froin a low but continued state
of irritation, or from reiterated excitation of so low
a grade as scarcely to influence the sensibility of
the part ; and occur in constitutions of weak vital

ABSCESS — Chron

resistance and defective restorative energy. On
the other hand, the abscesses described in the pre-
ceding sections result from inflammaiion of a more
or less acute character, occasioned by active sti-
mulation or deleterious agents, and generally affect
the system in a more or less active manner.

20. Owing to the low grade of irritation in the
affected part, the vessels are but little, and often
scarcely perceptibly, injected. The abscess, in
place of commencing with a number of distinct
centres or foci, appears at first as a single isolated
collection in one or more of the cellular areolae,
and presenting, from the commencement, a mani-
fest fluctuation. In some cases, this appearance
of the affected part is less that of true phlogosis
than of a deviation from its nutritive actions. The
tissues, instead of attracting, in virtue of their
vital endowment, the nutritive particles ; and the
vessels, instead of imparting them in an appro-
priate condition, and exhaling a fluid suitable to
the. healthy state of parts, — are so far changed
as to fail in the performance of these actions ; the
vessels furnishing a fluid of a certain kind, appa-
rently composed of the particles or globules
which, under the influence of healthy vital en-
dowment, would have been separated from the
circulating fluid for the nourishment or growth of
the tissues, and of the watery exhalation destined
to lubricate them, and render them fitted for theii
functions.

21. In the chronic varieties of abscess, the pus,
being secreted under the influence of a lower grade
of excitation, differs from that previously described
(>S 7, 8.). It is frequently yellowish, serous,
transparent ; containing tiocculiof an albuminous
or fibrinous nature, and whitish, opaque appear-
ance : sometimes it is mixed with minute shreds
of cellular-like substances. In other cases it is
nearly analogous to mucus, from its thickness and
viscosity. In some subjects, when very slow in
its formation, it assumes a greater consistence and
opacity, resembling half-congealed lai-d or liquid
honey; and the tumours which it forms seem
to constitute a connecting chain between pure
abscesses and meliceious or steatomatous cysts.
These latter differ in no respects from abscesses
devoid of active inflammation, but in the greater
consistence of the matter they contain : and in
some cases, as M. Dupuytren remarks, it is diffi-
cult, if not impossible, to distinguish between them.

22. Owing to the extreme slowness of their
formation, and the absence of acute iriflammatory
action, the farietes of the present kind of abscess
have a more distinct organisation than those of
the first species. Vascular injection and red-
ness are here seldom observed exteriorly to the riist
enclosing the purulent collection. The skin cover-
ing the tumour, and through which the fluctuation
is readily felt, is generally free, moveable, and
unaltered. All the morbid action seems concen-
trated in the diseased membrane enclosing the
matter. This membrane or cyst is, internally, of
a reddish grey tint, and more or less intimately
connected with the surounding structure. It is
in some cases soft, thin, and cellular; in others,
thick, strong, and of a cellulo-fibrous, oi' even
fibrous, structure. The slower the tumour is in
enlarging, the more liable is the cyst to undergo
change, and to modify the state of the matter it
contains: and, hence, abscesses of a very slow or
chronic kind often approach slowly but nearly

ic, ITS Pathology. IS

to the characters of several other encysted tu-
mours.

23. The purulent collections which form around
foreign bodies, that occasion but little irritation,
generally belong to the present kind of abscesses.
They are always lined with a firm cellular cyst,
analogous to that enclosing the foreign body itself.
Tiie abscesses which proceed from bodies occasion-
ing great irritation are preceded by great pain
and iiiflanmiation, and belong to the preceding
kind of abscess.

24. 4th, Of symptomatic abscesses, or cnllectinvs
of matter at a distance J rom the places wliere the
piis is first formed. — In the foregoing sections I
have considered the formation of abscesses in, and
their limitation to, the primary seat of iiritation :
but if the parts affected are surrounded by a loose
areolar cellular tissue, readily permeable by the
matter as it is formed ; and especially if the state
of vascular action and vital energy of the frame
are insuflficient to the production of coagulable
lymph around the inflamed centre ; the matter
gradually finds its way in the course of the cel-
lular structure to adjoining parts, particularly to
those which are more dependent, infiltrates them,
and forms more or less distinct and fluctuating
tumours at a distance from the primary seat of
inflammation. Instances of this kind of abscess
are furnished us in diseases of the hip-joint, and
in ca>es of inflammation commencing in some or
one of tlie vertebiffi, or their fibro-cartilages. In
this latter case, if the disease commences in one
of the dorsal vertebras, the purulent fluid may
accumulate under the pleura, infiltrate the adjoin-
ing cellular tissue, and, following the direction of
the ribs, appear at some part of the side or back,
or even near the sternum, far from its origin.
When the inflammation attacks one of the dorsal
or lumbar vertebra;, or intervertebral structures,
it may travel in a similar manner behind the
pillars of the diaphragm, proceed in the course
of the psoffi and iliac muscles, following the cel-
lular tissue behind the peritoneum, and appear
exteriorly, most frequently under the crural arch,
but sometimes through the inguinal ring. In
other cases it proceeds to a shorter distance, and
points at the sacro-iliac symphysis, or in the angle
between it and the spine ; or it may extend down
the pelvis in various directions, following the
cellular substance surrounding the vessels and
nerves. Thus it may pass through the ischiatic
notch, forming an abscess at the internal part ol
the gluteal muscles ; or along with the great
sciatic nerve, and point on the superior and pos-
terior part of the thigh ; and, lastly, it may find
an issue in the perineum, at the margin of the
anus, or into the rectum, or even into the vagina.
In some rare instances a double tumour and open-
ing are formed. In the case of a female by whom
I was consulted, the matter had found its way to
the integuments of the sacro-spinal angle of the
loins, where it was punctured by a surgeon, and
yet had also burst its way into the vagina. In
the case of a groom whom I attended, a tumour
formed at the sacro-iliac symphysis, below the
crural arch, producing the most violent and pain-
ful tumefaction of the limb, owing to tiie pressure
of the matter on the nerves and veins ; and the
matter afiervvards burst into the lower part of the
sigmoid flexure of the colon.

25. 'Jhe matter proceeding from abscesses symp-

16 ' . ABSCESS— CoNSEcu

tomatic of inflammation and ulceration of bones
or cartilages is generally greyish, thin, mixed with
albuminous flocculi, minute clots of blood, and
portions of phosphate of lime. It exhales a nau-
seous odour: but this characteristic is present only
after tlie opening of the tumour, and when the air
has access to the cavity.

26. If we examine the cavities of symptomatic
abscesses, and trace tiiem from their origin to
their outlet, we shall find, in the former situation,
the cartilages and bones profoundly changed : the
bones are softened, friable, changed to a greyish
black, partially absorbed and carious, and their
periosteum destroyed. From this origin of the
disease is formed a channel or sinus, traversing
the cellular structure frequently in the course of
the large vessels or muscles, and terminating with
the external outlet of the tumour. The whole of
this canal or sinus is usually surrounded by a
softened, friable, or lardaceous state of the tex-
tures; and lined with a smooth, thick, firm, cel-
lular, or fibro-cellular membrane, which in some
eases is of a fibro-cartilaginous structure. At the
lower part, the canal generally dilates into a con-
siderable cavity, sometimes irregular or sinuous
in its form, and lined with the membrane usually
found in the more chronic kinds of abscesses.

27. 5th, Of consecutive abscesses ; or collections
of matter found in situations consecutirelii to its

formation in distant parts, between which there er-
ists no communication, — It has been not infre-
quently remaiked, that inflammation of a part has
taken place, and has gone on to suppuration ; that
the matter thus formed has been absorbed ; and
that it has subsequently formed in some other
viscus, generally in an internal organ. The nature
and procession of the morbid phenomena now
enounced have led to some inquiry, particularly
in recent times. The circumstances in which
consecutive abscesses occur in practice are the
following : —

Inflammation of the internal surface of the
uterus, or of its veins, or of both tlie substance
of the uterus and veins, occasionally takes place
after child-birth, and terminates the life of the
patient. On dissection, purulent infiltrations or
distinct collections of pus are found, in one case,
in the lungs; in another, in the liver; in a third,
in the substance of the brain ; in a fouith, in the
capsules of the joints ; and, in a fifth, in both the
lungs, liver, and perhaps, al-io, in the joint*. A
man, from injury of the head, has inflammation of
the sinuses of the brain, followed by all the symp-
toms of a vitiated state of the circulating fluid,
terminating in death; after which, abscesses, or
purulent infiltrations, are found in the liver or
lungs. A similar procession of ])honomena oc-
casionally results from phlebitis consefpient on
blood-letting, or other causes; also duiing the
suppurations following amputations, particularly
when the matter is confined on the face of the
stump, by the adhesion of the integuments which
liad been drawn over it. A child is seized with
severe or confluent sniall-pox ; and during, or sub-
sequently to, the secondary fever, fluctuating
tumours form in the joints ti'om matter accumu-
lated in their capsules. Upon dissection, the
cartilages are found eroded ; and, in other rare
cases of this kind, purulent collections are found
in the internal viscera. In other instances, ab-
scess disappears from external parts; the patient

TIVE, ITS I'aiIIOLOGV.

sinks with low fever; and, upon dissection, col-
lections of pus are found in internal organs. In
cases of this description, the following require
notice : — 1st, The state of the vital energies pre-
ceding or during the occurrence ; 2nd, Thesymp-
toins characterising the progressof the phenomena ;
and, 3rd, The nature of the results.

28. 1st, The energies and vital resistance of the
system are generally greatly impaired, either from
pre-existing or concurring causes, in cases where
consecutive abscesses form. (See article on Iii-
flammationof Veins.) 2nd, The depression of the

powers of life increases as the disease advances.
The nervous system is seriously aflfected ; the cir-
culating fluid betrays change in its appearances,
after its emission, or after death ; the soft solids
lose their vital elasticity and cohesion ; the surface
of the body and countenance become du=ky and
livid ; and low delirium, rapid and weak circula-
tion, &c. take place. 3rd, The purulent matter
is generally either infiltrated into the parenchy-
matous structure of some organ, or collected into
one or more distinct abscesses, or it is eflfused into
the cavity of one or more joints. When the mat-
ter is infiltrated into the texture of an organ, the
infiltrated structure is very frequently also soft-
ened. The purulent collections that are found in
other cases generally have no distinct cyst, and
the surrounding substance of the organ seldom
presents any marked redness or injection of its
vessels, or indeed any remarkable change, except-
ing in some instances a slight softening. The
matter is usually found in several distinct ab-
scesses or collections, varying from the size of a
small seed to that of an egg, or even larger.
Sometimes the immediately surrounding structure
seems impacted around the abscess, but not other-
wise changed. The purulent matter itself varies
but little from that which is observed in the ab-
scesses described in the first section. (^ 6, 7, 8.)
it is occasionally of a darker or greenish hue,
particularly when found in the liver.

29. As to the Origin of these purulent collec-
tions some doubts may be entertained. That they
are very intimately connected with the primary
inflammation and formation of matter in other
parts of the system, cannot be doubted, but in
what way cannot be so readily stated. It seems
to me extremely probable, from the attentive ob-
servation of the progress of a number of such
cases which have come before me in practice,
that, owing to depres-ed vital energy, and defi-
cient resistance of the frame, purulent matter
passes into and vitiates the blood; that the morbid
condition of the circulating fluid, thus induced,
depresses still lower the already weakened neivous
powers; and that the irritating matters cairied
into the circulating current change the state of the
capillaries of paienchymatous and some other
organs, so that they secrete purulent matter
without any evident sign of previous or accom-
panying inflanmiation. Several French patholo-
gists suj)pose that the purulent matter conveyed
into the blood circulates without coinbining with
it, and is merely deposited by the capillaries, or
separated by them, from this fluid in parts ; the
vessels and texture of which are most disposed to
permit its elimination, or the best constituted to
admit of its deposition. It is difficult to deter-
mine >n which of those ways the consecutive
abscess is foimcd. Indeed, both may ap[)roximate

ABSCESS — ITS Progress.

17

the truth, the consecutive formation of pus arising,
in one case, from the irritation occasioned by tlie
presence of morbid matters in the blood ; and, in
another, chiefly from the separation or secretion of
it in the parenchyma of an organ, without any
previous or attendant irritation.

30. II. Of the Progress and Terminations
OF Abscesses. — At any period of its existence, the
inflammatory action in an abscess may cease, and
the matter wiiich lias been formed be absorbed.
In these cases the purulent matter is carried into
the circulation ; and, whether the inflammation
is primarily and gradually extinguisiied in the abs-
cess, or whetlier intense pain and inflammation,
developed in some other organ, exercises on the
first centre of mischief a true revulsion, the ab-
sorption of the pus is only consequent upon the
subsidence of the local signs of inflammation and
congestion. The part loses its turgescence, red-
ness, increased heat, and tumefaction, and is re-
stored to its healthy state without any deformity
or cicatrix. In these cases the absorbed matter
is eliminated from the circulating ma<s, without
accumulating in it to a hurtful extent, by the
active or unimpaired functions of the various eli-
minating organs, particularly by the kidneys, and
mucous surface of the intestinal canal, — the mat-
ter, in some cases, being apparent in the urine, and
in the others exciting a temporary diarrhosn.

31. In other iu'^tances, the inflammation pro-
ductiie of suppuration being but slight, or being
less completely dissipated, and the solid tissues, and
particularly the firm and thickened cyst, opposing
the extension of the abscess, it occasionally rests
long stationary. In this case the pus remains in-
active and inoffensive in the pai t, like a smooth and
inert body lodged in a cyst. Abscesses will some-
times continue for a very long time unchanged,
and without occasioning much disturbance to the
economy, particularly when deeply seated. In
such cases the cyst becomes more and more firmly
constituted, thickened, and changed from the state
of the surrounding parts ; so that the pus is in
some measure isolated from the adjoining struc-
tures: in this state it may remain, as in the brain
and liver, for a considerable time, without any
very marked symptoms, until some accident or
exciting cause occurs to affect it and the adjoining
parts, when the usual course of the disease will
be resumed.

32. 'I"he foregoing changes are comparatively
rare. In the great majority of ca«es, pus dis-
tends, compresses, and obscurely excites, the
parts in which it is lodged. Instead of beinc/
diminished, the abscess is increased in size, an I
tends to find an external outlet, uniformly in the
direction of either the cutaneous or one of the
mucous surfaces. Purulent matter i*; thus sub-
mitted to the general law of the economy ; the
vital resistance, opposed to all substances calcu-
lated to excite or otherwise injure the textures,
detruding it by a regular proc-ession of phenomena,
as long as the energies of the system are not en-
tirely overwhelmed, to the nearest or most unresist-
ing part of the surface, and at last expellmg it
altogether from the body.

33. The succession of morbid phenomena oc-
casioning the deliverance of the system from col-
lections of matter is of great importance to the
practitioner, particularly as respects deep-seated
or internal abscesses. Generally the quantity of

Vol.. J.

matter is continually increasing, owing either to
the extension of suppuration in the inflamed part,
or to a continued secretion from the internal sur-
face of the abscess, or to the concurrent operation
of both causes. In consequence of this increase
of quantity, the parietes of the abscess are dis-
tended and applied more closely to the surround-
ing parts, which are pressed outwards by the
accumulated matter. This distending power is
equally exercised from the centre to the circum-
ference. But, as all the adjoining parts do not
exercise the same degree of resistance, the abscess
extends in the direction of the external or free
surfaces; its more deeply seated parietes being
sustained by all those parts which are placed
beneath tliem ; whilst the tissues which are exte-
rior to it, being deprived of aid, are readily ele-
vated and distended by the increased effusion.

34. As to the nature of this effusion, and the
changes it undergoes, certain questions have been
urged. It has been supposed that the matter
found in abscesses is not secreted in the state in
which it exists at the period of maturation : but
that the fluid effused is in a state which may be
called albuminous serum ; which, owing to the
continued exhalation and absorption taking place
in the internal surface of the abscess, is changed
into what is called well-digested pus. Others
suppose that the purulent fluid is secreted in the
state of pus, or nearly approaching to it, by the
membrane forming the cyst, and wliich, as it pre-
sents many of the characters of mucous membrane,
may, like this membrane, when highly inflamed,
secrete a purulent fluid. It is extremely proba-
ble that both views may be in a great measure
correct : for attention to the maturative process in
recent abscesses shows that the fluid first effused
is not pure pus ; and it is undeniably proved that
the matter contained in the different kinds of abs-
cesses is variously modified according to their
duration, their situation, and the circumstances
attendant on their progress. Whilst, on the other
hand, it must be conceded that the internal sur-
face of an abscess, particularly in a high state of
inflammation, or when irritated by the contact of
the air, will secrete a purulent fluid, or a matter
which very rapidly assumes the puriform charac-
ter; the vessels terminating in it giving issue not
only to the watery part of the blood, but also to
many of its smaller globules, so as readily to form
a pure pus, which quickly becomes thick, upon
the evaporation or absorption of a portion of its
more fluid constituents.

35. Another important matter, relative to the
progress and external pointing of abscesses, is the
fact, that inflammation generally seizes upon tlie
adjoining structures, as the internal membrane
is more closely applied to them. The parts
most distended and stietrhed .by the contained
fluid have the inflammatory action extended to
them from the parietes or membrane of the abs-
cess. To the inflammatory irritation thus induced
in the surrounding textures succeed their adhesion
to the parietes of the abscess ; absorption of their
solid elements, with attenuation ; and, lastly, ul-
ceration,— the integuments merely often resisting
for a considerable period the discharge of the
flui.l.

36. If we take as an example the not unfre-
quent occurrence of abscess in tiie substance of
the liver, and trace its progress in one of tliosg

C

18

ABSCESS — ITS Progress.

directions which it sometimes follows, namely,
through the diaphragm and lungs, until it emplies
itself into the bronchi, we shall find the follow-
ing to be ihe course of the morbid phenomena: —
As the inflammatory action and the serrstioa of
purulent matter proceed, the abs'^-ess which has
been formed, generally in cases of this kind in the
convex part iif the organ, advances towards the
surface ; the inflammatory action extends to this
part ; and lymph is thrown out, which, with the
pressure of the swelling and pointing of the abs-
cess, irritates the periloneal surface of the dia-
phragm, inflames it at the part opposite, and
occasions its agglutination at this situation to the
parietes of the hepatic abscess. As the tumour
points upwards, the inflammatory action advances
in the same direction ; extends to the muscular
structure of the diaphragm, which is softened and
attenuated, assuming at the same time a dark
or bluish tint; and invades the diaphragmatic
pleura, where it throws out coaguluble lymph.
This secretion occasions irritation and inflam.ma-
tion in the opposite part of the pulmonary pleura,
and the cohesion of the lung to the diaphragm at
the part where the collected matter is advancing
prominently upwards. As the parts thus succes-
sively involved undergo the softening process
consequent on inflammation, and yield before the
pressiire of the accumulated fluid, owing to their
diminished vital cohesion, absorption commences
and proceeds in the central or prominent part of
the tumour ; and the matter thus finds its way in
the direction which is most yielding, where the
inflammatory action most readily advances, and
where the resistance to it is thereby still further
diminished. I have had frequent occasion to
trace the above phases of the progress of large and
deep-seated abscesses ; and to satisfy myself (hat
they proceed in a similar manner, whether they
advance to the external surface of the body, or
open upon a mucous surface, or into a shut cavity ;
which last is a rare occurrence.

37. It is of importance to observe the procession
of phenomena now stated ; inasmuch as the suc-
cessive reddening, inflammation, adhesion, soften-
ing, and absorption of the various structures, as
the tumour advances exteriorly, are the guides to
a very important part of the treatment of these
formations. Thus, when we observe marks of
inflammatory irritation of the skin take place in
the situation of an internal abscess, we may infer
that the ulterior phenomena now enumerated, par-
ticularly adhesion, have taken place in the paits
beneath, and we may safely decide U|)on carrying
an incision fiom the centieofthe inflamed integu-
ments to the seat of ab'-cess.

3H. It must not be overlooked, that various
aberrations of purulent cnllections take place, in
their progress to the surface, and that they often
proceed in a direction opposite to that of gravita-
tion, owing to the resistance of l)oiies, fasci<c, and
aponeuroses ; which last oppose them in a most
reujarkable manner, and cause their extension in
various directions, giving ri^e to the most severe
local and constitutional sufterings.

39. Abscesses, besides, cause the inflammation
of parts placed between them and the centre of
the system, as respects Ihe direction of the circii-
l.iting vessels, as well as of those parts situated fx-
teriorly to them, although in a much less degree,
and followed by very different results; for, in-

stead of the thinning, erosion, and ulceration of the
exterior parts, tending to advance them to the
surface, the inflammation of the parts behind, or
more deeply seated than they, is frequently ac-
companied with thickening, and increased density
of structure; whereby the system is, in a great
measure, protected from their extension to more
internal and vital parts. Numerous instances
occur, where the periosteum or the peritoneum, the
pleura, the fibrous and synovial capsules, undergo
a marked thickening, opposing thereby an in-
creased obstacle to their extension in that direc-
tion, when abscesses form in the vicinity of those
membranes. When, however, the energy of the
system and its vital resistance are deficient, ex-
ceptions sometimes occur to this rule, and abs-
cesses find their way, when situated favourably,
to this mode of termination, into important cavities
and organs. Thus, an abscess seated deep in the
parietes of the chest or abdomen, may open into
these cavities, as in the case of the son of the
eminent M. Petit ; or an abscess in the liver
may find its way into the pericardium. But any
disposition to its opening internally, is opposed not
only by the thickening of the serous and other
membranes, &c., as here instanced, but also by
the support of the viscera underneath, which resist
the pressure and extension of the tumour in this
direction.

40. The progress and spontaneous opening of
abscesses, advancing in the manner now explained,
terminate with the erosion of the integuments,
which, having been reduced to a pellicle, have their
epidermis elevated in the form of a phiyctena,
which soon breaks, and gives issue to a portion of
the contents of the abscess; and the discharge is
renewed at intervals, by the gradual retraction of
the parietes of the cavity upon there-accumulated
secretion. The successive evacuations occa-
sioned by the reaction of the parietes of the
abscess, are particularly favourable in cases of
large abscess, by preventing any vacuity. In
cases of empyema, for instance, where the
artificial opening is often fatal, a favourable result
not unfrequently follows a spontaneous and suc-
cessive evacuation of the purulous collection : for
it is chiefly by imitating the natural process in
those cases, that we secure the greatest advantages
to the patient, where we find it requisite to open
symptomatic abscesses, as those usually called
lumbar ; and not by making large incisions, and
producing a large evacuation, whereby the air
has access to their cavities, but by successive
punctures, the margins of which are immediately
closed, upon the evacuation of that part of the
contents which are first expelled by the reaction
of their parietes.

41. The passage of air into the cavities of
abscesses is always followed by an increased state
of irritation of their lining membrane. The
hurtful eftecis of this communication have been
(lemou'-trated by IVI. Diii'uvi hen, and other
eminent men, although ilenied by others, but
without either the satisfactory proofs of experience
or of reasoning. In some cases the accession of
inflammatory action in the part, upon the access
of air, is very remarkable. In cases of small
chronic abscesses this efl'ect is often beneficial;
but in large and acute abscesses the irritation
thus induced may be too great for the powers of
the sysleni to withstand.

ABSCESS— Diagnostic Symptoms.

19

42. Under the most favourable circumstances,
the effects of the admission of air into the cavity
of an abscess are counteracted by the accom-
panying treatment; and the discharge soon
assumes a different appearance from that of the
matter first evacuated ; it becomes less white and
consistent ; and, subsequently, when the parietes
commence forming the adhesions which precede
cicatrisation, it is merelv a more or less copious
citron-coloured serosity.

After the opening of slow and indolent abs-
cesses, the serous, thin, and flocculent pus, with
which they are filled, is replaced by the discharge
of a more digested, homogeneous, and cream-like
fluid, indicating a more intense state of action in
their parietes.

43. Upon examining the interior of abscesses
which have been opened, it will be seen that their
parietes gradually discharge themselves ; that
they cast off the greyish and flocculent pellicle
which covers them ; and that they become
covered with cellular and vascular granulations,
of a lively red : nd solid appearance, formed from
coagulable lymph thrown on the inflamed surface,
into which new capillary vessels shoot, and re-
sembling the granulations on the surface of
wounds from which is exhaled the mati:er which
succeeds to that first discharged from them. The
parietes thus cleansed contract towards their cen-
tres, and in the direction of their most deeply
seated parts. They afterwards unite ; so that
the cavity, which has been thus circumscribed,
at last disappears. In the situation of the abscess
nothing is found but its cicatrix; at first con-
sisting of a cellular lamina, or plate, of various
thickness and density, penetrated by coagulable
lymph, and subsequently converted into a scarcely
apparent cellular line, which sometimes, at last,
entirely disappears.

44. But the progress of abscesses after they
have been opened is not always so favourable.
It may be premised, that the irritation proceeding
from the contact of air with the internal surface
of an abscess is, in general, in proportion to its
volume, and the unyielding state of its parietes.
When the abscess is small, the resulting irritation
is but faintly marked ; but if the parietes be of a
large extent, and if the abscess is deeply sealed,
particularly if it be in any of the viscera, the in-
flammatory excitement occasioned by the air not
only increases all the local phenomena, b t also
gives rise to serious constitutional disturbance,
often terminating the life of the patient. The
yielding state of the parietes, and their apposition,
are sometimes calculated to counterbalance the
bad effects occa'^ioned by their extent. AVhen
the diseased surfaces have been freed ' y the com-
plete discharge of matter, and admit of being
closely applied to each other, the admission of air
is in :i great measure prevented, and adhesions
frequently proceed rapidly. Where, however,
the parietes cannot be brought closely together,
and the cavity can be obliterated only by means
of granulations formed to an extent that may fill
it, the duration of the suppuration is prolonged,
and the effects produced on the constitution by
the extent of the discharge are often serious.

45. But this i< not all the mischief resulting
from the access of air to the cavity of an absee-s :
the pus which still remains, particularly i deep-
seated abscesses, is more or less changed by it,

and exhales an infected or putrid odour, pro-
ceeding from decomposition occasioned by the
temperature to which it is subjected, and its con-
tact with atmospheric air. It is also often ob-
served, that when large abscesses are opened, and
air gains access to them, the morbid excitement
thereby occasioned in their parietes re-acts upon
the principal vital centres ; the nervous systems,
the digestive organs, and the circulation suffering
from and participating in it, and the suppurative
process, is thereby greatly increased ; at the same
time the constitutional powers are much de-
pressed, the matter is rendered much more offen-
sive, and otherwise changed, according to the
seat of the abscess. As the powers of life sink
under the disease, the fluid secreted is more offen-
sive and disposed to decomposition, until it is
often doubtful whether the change proceeds more
from the access of air, than from the low state of
vital energy. Indeed, in many cases, tlie latter
cause seems much more influential towards pro-
ducing this state of the dischari^e than the pre-
sence of air; for we not infrequently observe,
that as long as the constitutional powers remain
but little depressed, the access of air has but
little effect, the discharge exhaling no offensive
odour; but as soon as, owing either to the increase
of inflammation in the cyst, or to other concurrent
causes, the febrile commotion is increased, and
the nervous system and digestive organs evince
serious disturbance and loss of energy, the dis-
charge becomes rapidly offensive and increased
in quantity ; the matter often changing from
more or less pure pus to a state approaching to
putrid sanies.

46. III. Of the Diagnostic Signs of Abscess.
When inflammation has attacked a cellular struc-
ture, or viscus, in which this tissue is a prominent
constituent part, and particularly if it be intense
in degree, rapid in its progress, and accompanied
with a pulsative pain, we may with confidence
decide upon suppuration being about to take
place This result is announced by a diminution
of the pain, which changes to a pulsatory sensa-
tion isochronous with the pulse ; by a feeling of
weight and tension in the part ; by a diminution of
the febrile action, succeeded by a large, broad,
open, sott, or undulating pulse ; and by irregular
chills or rigors, which extend, after various inter-
vals, along the back, loins, and sometimes the
lower extremities. If the matter is not soon
afterwards evacuated, the symptoms of chronic
irritation succeed ; especially small and frequent
puNe, heat or burning of the paluis of the hands
and soles of the feet ; irregular fits of perspira-
tion, and night swents ; loss of strength, and all
the characteristics of hectic fever, which makes
more or less rapid progress, and is sooner or later
followed by colliquative diarrhoea, according to
the seat and extent of the abscess, the con-titu-
tional powers of the patient, and the treatment
employed. The above symptoms indicate that
a permanent cause of irritation, and of constitu-
tional coiitamination, has succeeded to the state of
active inflammation.

47. The tumefied state which characterises
sthenic or phlegmonous inflammation is greatly
modihed after suppuration has advanced. It be-
comes less diffused, is much lessened in the cir-
cumference of the periphery of the tumour, and
seems more and more concentrated. Hence it

c 2

20

ABSCESS— Prognosis of.

becomes more elevated, prominent, and softened
at the centre of the surface. The redness and
tension undergo a similar change. The circum-
ference of tiie inflamed surface is restored in some
degree to the natural state ; but the more promi-
nent part acquires a dark red tint, afterwards a
bluish hue, and yields more and more to the pres-
sure of the subjacent pus. For some time pre-
vious to this siage the tumour evinces a more or
less distinct fluctuation when suitably examined,
and this sign becomes more manifest as the abscess
advances to the surface.

48. When an abscess forms in deep-seated parts
or viscera, particularly those protected by solid
envelopes, or by thick and unyielding structures,
the diagnosis rests entirely upon the nature of the
constitutional disturbance, and the disorder in the
functions of the aflfected organ or part, and here
the physician should seize and appreciate the
slightest difference taking place in the pulse, the
animal heat, and the state of all the natural and
organic functions. In these cases he requires the
most exquisite tact for examination in order to
arrive at an accurate opinion. The symptoms
which siiould guide him in cases of this descrip-
tion will be stated when I treat of the diagnosis
of the diflferent kinds of visceral abscess. I may,
however, remark at this place, that even in parts
much less deeply seated, when the cyst of an
abscess is greatly distended and very tense, fluc-
tuation generally is extremely obscure, or even
not to be felt, altliough its contents may be very
fluid. Also, when the purulent matter is con-
tained in no distinct cyst, but is disseminated
through the textures, or infiltrated between
fasciae or muscles, or is confined beneath apo-
neuroses, great incertitude may exist as to its form-
ation. The parts in such cases present more of
a diffused oedema than of a fluctuating tumour ;
and if fluctuation can be at all felt, it is only ob-
scurely.

49. It must be evident that the more feeble
and latent the phenomena of the precursory in-
flammatory irritation, the more difficult is it to de-
termine the period at which the elaboration of pus
commences. We frequently ob-^erve in practice,
particularly after phlebitis, injuries of the head,
fractures, and capital surgical operations, abscesses
form in the liver, mediastinum, lungs, kidneys,
or ovaries, preceded merely by obscure and occa-
sional pain, and furnishing no certain symptoms
of a local kind, by which we can decide as to their
formation, until the time that iliey appear exter-
nally, or are detected upon post murtein examin-
ation. In cases of this description, the constitu-
tional symptoms are our chief guides ; but even
these are often so uncertain and so imperfectly
developed as to leave us in doubt. 'I'he accession
in this ob'-cure manner of internal abscess is
particularly remarkable as respects those which
supervene on inflammatory disease existing in other
piirts, particularly to phlebitis, and which 1 have
denominated cDiisecnlive abscesses. (See Veins
— iiijlumrnation of.)

50. Sympioinatic abscesses generally escape
detection until they advance externally. Previous
to this, pain, uneasiness, tumefaction, &c., are only
felt chiefly in the pari originally aflfected. ]5ut
the symptoms already noticed (§4f) — 48.). espe-
cially llie uiiheallliy as|)cct of the surfac", the
state of the febrile action and of the pulse, the

niglit perspirations, the disorder of the respiratory
and alvine functions, will generally serve, in con-
junction with the changes in the part to which
symptomatic abscesses extend, to indicate the
nature of the mischief.

51. It is important, as M. Dupuvtren has
very justly remarked, to take into account, when
determining the existence of abscess, the greater
disposition inherent in some constitutions to form
purulent matter. In some persons, the least irri-
tation is followed by the suppurative process.
This is particularly the case in persons of a pale
visage, of a soft flaccid state of the diflferent
structures, and of the lymphatic temperament.
It it also remarkable in those whose vital ener-
gies have been lowered by previous disease ; by
chronic afl^ections of the digestive mucous sur-
faces ; and by those diseases which require the
performance of amputation, or other important
surgical operations. When the suppurative pro-
cess has continued for some time, and has after-
wards been suddenly stopped by an operation, or
any other ac.ive treatment, the disposition to form
abscesses is generally remarkable. A similar re-
mark may be extended to the sudden suppression
of any accustomed secretion or discharge. The
most familiar instance of this kind is noticed in
the breasts of nurses, which are extremely liable
to suppuration upon interruption to the secretion
of milk. These considerations should have their
due weight with us when estimating the signs of
the existence of internal abscess. Those symp-
toms which are peculiar to collections of matter
formed in each of the internal viscera are pointed
out in their respective articles.

52. IV. Of THE Prognosis OF Abscess. The
danger Irom abscesses is in proportion, 1st, to the
extent of their internal surface; 2d, to the depth
a' wiiich they are seated ; 3d, to the indolence of
their action, or the deficiency of vital action ac-
companying them ; 4th, to the severity and
danger of the disease by which they have bee.i
occasioned ; 5th, to the sinking or deficiency of
the constitutional powers under them ; and, 6tl),
to the severity of the symptoms accompanying
them, or produced by them. These positions are
so obvious, that no remarks need be offered in
support of them. [ may, however, observe, tliat
abscesses seated in internal viscera are always
attended with danger; but the degree of danger
will depend upon numerous circumstances con-
nected with their seat, the direction which they
take, the state of the vital energies of the frame
during their progress, the chances of their evacu-
ation, and the means of reparation and renovation
the constitution may still possess.

53. The prognosis of chronic, symptomatic,
and consecutive abscesses depends as much upon
the nature of the preceding disease, as upon the
state of the abscess itself. In chronic abscess,
the danger is in proportion to the extent of the
surface of its parietes, and to the gratle of consti-
tutional vice. In symptomatic abscess, the danger
depend- almost wholly upon the nature and extent
of the original disease, of which it is the conse-
([uence, and upon the largeness of surface extend-
ing thenc • to the ultimate limits nf suppuration.
In consecutive abscess, the danger is extreme ;
owing, in many cases, to the nature of the primary
<iisease, the depresseil slate of th • constitutional
powers, and to the vitiation of the circulating

ABSCESS— Tkeatment of.

21

fluid and soft solids of the body, with which it is
connected.

54. V. Of the Medical Treatment of Abs-
cess. — The indications of cure which we pro-
pose in abscess are, 1st, to remove the purulent
collection from the part containing it; and, 2d, to
procure the obliteraiion of the cavity in which it
was lodged. 'I'hejirst intention is accomplished
either by procuring the absorption of the purulent
matter, and its elimination from the body ; or by
opening the parieles of the abscess, and thus
giving a direct outlet to the contained matter.
When the means used to accomplish the absorp-
tion of the purulent matter fad, or when the cha-
racter of the abscess and state of the frame forbid
the employment of these means, opening the
abscess must be resorte<i to when the proper period
lor having recourse to the measure arrives.

55. 1st. Means which may be resorted to, in
order to procure the absorption of the purulent
matter, and its elimination from the frame. —
Numerous instances have occurred of ihe rapid
absorption of the matter contained in an abscess,
and of its discharge from the circulation, 1st, by
the urinary organs, the urine becoming abundant,
and containing either a puriform secretion, or
being otherwise altered ; 2nd, by the mucous sur-
face of tiie bowels, attended with diarriioea ; and,
3d, by the cutaneous surface, in the form of a
copious, thick, or viscid, and offensive perspiration.
These are the most common channels of elimina-
tion of the purulent secretion, when absorbed into
the circulation from the cavity of an abscess.
The purulent collection may, also, disappear in
consequence of other critical or accidental evacu-
ations; but this result is of rare occuirence, and
is a much more remote contingency than those
enumerated. Experience havingshown the possi-
bility, and the great advantages, of removing the
matter contained in an abscess by exciting absorp-
tion, the means most effectual in attaining this
end should be lir>t put in practice.

56. With this view, drastic purgatives may be
prescribed, when the state of the patient admits of
them, and next to them, such diuretics and diapho-
retics, as may be appropriate to the circumstances
of the case. Contemporaneously with the use of
those internal derivatives, external applications
should be employed, particularly those which pos-
sess discutient, resolvent, and styptic properties.
Frictions with stimulating substances, as ammo-
niacum, iodine, iodide of potassium, &c. ; cold,
warm, or tepid afTusionson the part, either of sim-
ple or mineral waters, or of sulphureous or saline,
natural or artificial, may likewise be tried con-
jointly with the internal means. But this energetic
plan of treatment , — this combination uf the re-
vulsive and discutient practice, -^— this methodus
1 erturhatrix, is not applicable to all cases. There
are many circumstances connected with the seat
and condition of an abscess, and with the state of
the different functions, that either altogether forbid
its employment, or require important modifications
and adaptations of it.

57. Thus, abscesses preceded by acute or active
inflammation, are rarely susceptible of being
ab-orbed ; the 0[)ening of them, therefore, is
almost inevitable. Chronic abscesses, which are
generally provided with thick cysts, also admit not
of removal by this practice; it being generally
reijuisite to excite a new action in their parietes,

which may modify their texture, and render them
susceptible of contracting the adhesions requisite
to their obliteration. The majority of purulent
collections which are removed by absorption, is
such as form rapidly, without much previous in-
flammation, and in debilitated habits, or in those
weakened by pre-existing disease. In persons oi
this description, the excitement or iriitation of the
kidneys, or of the inucous surfaces, will often over-
come the irritation existing in the seat of abscess,
and consequently promote the absorption of the
pus it contains ; at the same time that the fluid
abundantly secreted by the parts artificially ex-
cited will assume, in consequence of the state of
the patient, a puriform character. (Dupuytren.)
But, in the majority of instances of this kind, it is
necessary that the artificial irritation or excitement
shall be greater than that previously existing in the
seat of abscess, and that the organs or parts in which
it is induced be in a sound state ; otherwise the
revulsion cannot be either successlully or safely
practised. However we may explain the mode of
action of revulsantson abscesses of this kind, there
can be no doubt that it is alioost entirely in them,
and particularly when they are seated in lymph-
atic glands, that we can hope successfully to
employ this plan of cure.

58. When the evacuations procured from the
first passages, and from the kidneys and skin,
have no efl'ect upon the tumours, and particularly
if the stomach and bowels seem to support
their action with ^difficulty, they must be aban-
doned, and recourse be had chiefly to the more
direct means of cure. The local excitants, as
iodine, the sulphureous douches, frictions with
mercurial, camphorated, and terebinthinated lini-
ments, and the repeated application of blisters
for a short time, are only suited to the chronic
kinds of abscess, where little or no inflammatory
action exists. But these remedies should be
watched, lest they increase the heat and inflam-
matory action of the external or superficial part
of the tumour, and thus occasion their external
opening.

59. In the majority of abscesses, it is requisite
to keep three facts in recollection : 1st, that the
inflammatory action in their parietes does not
cease on the formation of the purulent collection ;
2d, that an abscess is generally a complication of
this inflammation, and of the retention of purulent
matter in the inflamed parts which formed it, the
inflammatory action being still present, although
in a somewhat modified state and grade, and still
continuing to form this matter ; and, 3d, that the
existence of pus does not necessarily or materially
change the nature of the action which produced
it. The therapeutical indications to which these
facts necessarily lead are important, particularly as
they show, w hat, indeed, has been proved by expe-
rience, that antiphlogistic remedies, especially those
of local application, should not be laid aside with
the supervention of suppuration. In the majority
of cases, and particularly when increased heat of
the part still continues, this class of local remedies
should be employed with an energy in proportion
to the activity of the local symptoms. As long as
pain, redness, heat, and tension remain around the
abscess, so long should leeches, or other modes of
capillary depletion, directed to its vicinity, be had
recourse to, particularly if the state of the patient
oflfers no urgent indications against the practice.

c 3

22

Emollient and astringent applications should also
be constantly employed. These will generally
reduce the inflammation of the surrounding tissue,
favour tlie resolution of tiie parts not yet suppu-
rated, limit the quantity of the morbid secretion,
and favour the maturation of the absce'^s, so that
it may be opened with the best hopes of success.
In some cases, the use of these antiphlogistic mea-
sures will give rise to the absorption of the puru-
lent matter, even after this had been attempted to
no purpose by means of revulsants.

60. It should be recollected that the surfaces
of abscesses are the constant seat of two kinds of
action ; one of exhalation or secretion, the other
of absorption ; and that wliatever excites or irri-
tates them increases the former, and whatever
soothes or diminishes this irritation lessens it, and
favours the latter action. This consideration
should lead us strenuously to adopt a continued
antiphlogistic and soothing treatment of the af-
fected part, until the thinning of the skin at the
most prominent part of the tum.our indicates the
necessity of opening it.

61. In symptomatic abscesses, the treatment
should chiefly be directed to the primary seat of
disease ; for as long a^ the mischief continues or
advances there, ihe purulent colleciion increases,
and diminishes as it subsides. Thus, the abscesses
that point near the anus or crural arch, in conse-
quence of disease of the vertebrse, will sometimes
disappear after the use of active means directed to
the original malady, and judiciously adapted to
the state of the patient.

62. Consecutive and spreading abscesses re-
quire a very different management from that now
pointed out. These generally occur in persons
of an unhealthy habit of body, or who have been
weakened by acute disease ; or they are the
result of an adynamic or ataxic and spreading
inflammation occasioned by a specific or poison-
ous agent ; and they are not unfrequently the
consequence of the inflammation of veins, or of
the presence of morijid secretions or purulent
matter absorbed into the circulation (§§ 25 — 28.),
or of the transfer of irritation from a distant part.
But from whatever cause they may proceed, — and
they may, and occasionally do, proceed from
either of those sources, — deficient constitutional
energy, and vital resistance to the influence of
the exciting cause, with a marked disposition of
the structures to be invaded by it, and to partici-
pate in the morbid action it excites, are their
constant concomitants ; requiring the energetic
use of those means which are the bcit calculated
to rouse the powers of tiie frame, to restore the
deficient tone of the capillary vessels, and to thus
enable them to form coagulable lymph, by which
the spread of the local mischief may be limited.
Instead, therefore, of having recourse to anti-
plilogistic remedies, the state of local action, and of
constitutional power, ref|ui res atonic, stimulaiing,
and restorative treatment ; conjoined witii ilie
means best calculated to promote the functions of
all the abdominal viscera, so that morbid matterb
may be eliminated from the circulating current,
and healthy nutritious elements conveyed into it ;
and with a pure air to perfect the changes which
it under;,'oe8 during respiration, and whicli are
requisite to the continuance of the functions of
life. 'l"he treatment necessary in such cases is
fully iletailed in the articles on Inflammation of

ABSCESS — Tbeatment of.

Veins, on Spreading Inflammation of the
Cellular Tissue, and on the treatment of Ani-
mal Poisons.

63. 2d, Of opening abscesses. — When we fail
in procuring the absorption of the puriform mat-
ter, its artificial discharge will, sooner or later, be
required, when this can be accomplished. Certain
abscesses require a more immediate performance
of this operation than others, and more particu-
larly the following: — 1st, Abscesses proceeding
from the escape, into the substance of any organ
or part, of irritating secretions or excrementorial
matters, as the urine, or fascal substances. 2d,
Abscesses preceded by very acute inflammatory
action, and occurring in cellular or adipose struc-
tures, 25 ;he margin of the anus, the sides of the
neck, or the groins. 3d, Purulent collections
deeply seated, or confined under fasciae or aponeu-
roses. 4tl), Abscesses formed in the parietes of
the splanchnic cavities, in order to prevent the
chance of their breaking internally. 5th, Abs-
cesses formed in parts througii which large nerves
and blood vessels pass, anil on which tlie purulent
matter occasions a painful and injurious pressure;
as abscesses in the neck, and underneath the
sterno-mastoid muscle, at the top and inside of the
thighs and arms, &c. 6th, Abscesses which em-
barrass the respiratory organs, and which press
upon the larynx, pharynx, or trachea, or which
endanger the integrity of those parts.

64. In all these tlie strict antiphlogistic treat-
ment will be requisite, unless they are of the
diffusive or consecutive kinds, with emollient
applications, in order to limit the extent of the
inflamed parts, to diminish their size, and to hasten
their maturation ; and in many cases this mode of
treatment must be continued for a considerable
time after the discharge of the matter, in order to
limit or prevent its re-accumulation, and to pro-
mote the collapse and diminution of the parietes
of the abscess. The cases where it will be fre-
quently necessary to retard the period of dis-
charging the purulent collection, are chiefly those
in which i( is formed in the internal viscera, as the
liver, spleen, kidneys, lungs, &',c. ; respecting
which 1 have treated fully under their appropriate
heads.

65. Chronic abscesses should be opened as
soon as it is shown that their absorption cannot
be accomplished ; or when they augment in bulk
under the dis<uitient and derivative treutment.
Symptomatic abscesses also require to be opened,
when we find that the means which we have
directed to the original seat of disease fail of limit-
ing their extension, or lessening their bulk. Con-
secutive abscesses require to have their contents
immediately discharged, when their situation
admits of this being done ; for I he morbid slate of
the matter they sometimes contain, and the weak
vital resistance opposed by the surrounding parts
and by the constitution, favours the contamination
of the adjoining structures, and, indeed, of the
whole frame. But this intention can seldom be
fulfilled, owing to the seat of the purulent collec-
tion ; an<l, wiien it is put in |iriiclice, it should be
f(dlowed by as complete an exclusion of the
atmospheiie air as possible.

66. J t does not come within the scope of this
work to notice, at this place, the different modes
of opening abscesses, and the treatment with
which the ojjeralion should be accompanied and

ABSORPTION — AS rnooucTivE of Diseasf.

23

followed. This necessarily differs in every case;
but that part of it which belongs to my province
is stated at the place wliere abscesses in the dif-
ferent viscera are discussed, and the means which
may be employed to procure the obliteration of
their cavities, the second intention of cure, are
noticed, with reference to abscess of each of the
important viscera and structures in which it is
liable to form.

BiBLiOGRAFiiY. — Stahl, De Abscessu et Furunculo,

IlalK, 1714 I.udtiig, De Aliscessu Latente, Lips. 17i8,

4to. — Meyer, De Absccs-u in Febribus, &c., Got. 17W.
— Schroeder,T)v Puris absque pra?gressa Inflammatione
Origine, Got. \7(j6.—Biii(fenave, t)e Abscessu Abdominis.
&c., Palis, 1774. — /•Viy, Ue Aposteinatihus, Lips. 1775.
— Daruin, Experiments on MuciUginous and Purnlent

Matter, Litchf. 1780 Salimith, De Diagnosi Puris, Got.

1783 J. Hunter, On the Blood and Inflammation, Lonrt.

— Hume, Dissert, on the Properties of Pus, Lond. 1788.
— Juslnmond, Versurh. lib. d. Entzundnng. &c., Leip.
1790. — Widekirid, AWgetn. Theorie d. Entiundungen.
Leip. ]TJ\. ~ Dupuy. Sui les Abces, on Tumeurs pu-
rulentes, Paris, 1804. — Lassus, Pathologie Chirnrgi-
c de, t. i., Piiris, 1809, Svo. — Pearson, Observat. on Pus,
Prilosoph. Trans. Lond. \S\\.—Jitisl. Uber Abscesse, in
dessen Magazin, b. i., Bt-rl. I81fi — Thumson, On Inflim-

mation, Eilin. 1823. ch. 9 Heurteloup, In Dictionnaire

des Sciences Medicales, t. i. et t. viii. p. 431 Richier,

■Art. Abscess, Encyclopad. Worterbuch der Medicinischen

Wisseiischafien, b. i., Berl. 1828 Roux, art. Abcis, in

Dictionnaire de Medeciiie, t. i. p. 4. — Tiupuytren, art.
Abces, in Dictionnaire de Medicine et de Chirurg. Pra-
tiques, t. i., Paris, 1829. (See also Bibliug. and Refer.
to the art. Inflammation.)

ABSORPTION. SvN. Absorptio, Lat. Absurp-
tinn, Fr. Die Einsaugung, Ger. Assorbimento,
Ital.

Classif. General Pathology and Thera-
peutics.
This is one of the niost important functions in
the system, and one of the mo^t frequent channels
through whieli disea-e is caused, perpetuated, or
removed. As to each of these relations it requires
a brief notice.

1. Of Absorption in relation to the Caus-
ation, Perpetuation, and the Removal of
Disease. — The importance of entertaining accu«
rate ideas as to the channels through which
noxious agents affect the system, must be mani-
fest. Without them, many of our pathological
doctrines must be erroneous, and the therapeu-
tical indications founded on them wor-~e than
useless: on the other hand, just views as to the
nature and extent of the causes which operate
through this medium, give rise to tiie most im-
portant inductions, — the chain of morbid causa-
tion is traced without interruption, the nature of
pathological conditions is moie accurately ob-
served, and ultimate effects are recognised in
due connection with remote causes. The prac-
tical advantages which accrue are great : pro
phylactic measures are based on sound princi-
ples ; remedial agents are directed with precision :
and the physician prescribes in a spirit of rational
induction, instead of blind empiricism.

2. The agents which afiect the system inju-
riously through the medium of absorption consist,

Jirst, of those which are external and foreign to
the body, and act upon it only occasionally, or
under certain circumstances ; and, secondly, of
those which are generated in the body itself, and,
when cariied by means of absorption into the
current of circulation, produce very important
effects. The former rank among the primary
causes of disease ; the latter are themselves the
result of disease, but become important secondary
causes, perpetuating and generally increasing its

severity. The first class invade the system on the
mucous and cutaneous surfaces, — the skin, the
lungs, the alimentary canal, &c. : the secoxrf class
form in the parenchyma or texture of organs and
parts, or are generated on secieting surfaces,
whence they are absorbed into the circulation.
On each of these I shall offer a few remaiks.

3. 1st, Of absorption on the skin in relution to
the production and removal of disease. — a. That
disease frequently proceeds in this way is evinced
by certain contagious and chronic affections of
the skin itself: that it is possible to produce
various derangements, by applying to it several
active agents, which affect this surface no further
than in being absorbed from it, may be proved
by direct experiment. But it is chiefly when the
skin is deprived of a portion of its cuticle, how-
ever minute, that we perceive affections produced
through the medium of cutaneous absorption.
Several eruptive and contagious diseases are
familiar examples of this; and the majority of
deleterious agents produce a most decided effect
when applied to the skin thus exposed.

4. b. The same channels through which disease
invades the system, are often the most suitable
through which to counteract or remove it. This
is shown by the treatment of sypliilis; by the use
of baths, lotions, fun.igations, and inunctions in
cutaneous and visceral affections: and by the
employ Jieiit of various remedies to the skin, which
are partially absorbed from it into the system.
When the skin is deprived of a portion of its
cuticle, it absorbs rapidly many of the most active
agents employed in medicine; and it is thus ren-
dered one of the most eligible situations to which
we can direct our plan of cure. Thus, when the
stomach will not retain the sulphate of quinine,
it may be efficaciously administered to the de-
nuded cuticle; or when we wish to produce an
anodyne effect upon the system, or to assuage
violent pain, the preparation? of morphia, as the
acetate, may be applied in this way. And in
various diseases, when the function of deglutition
is lost, or the mouth cannot be opened, certain
active remedies may be thus administered ; more
especially those which produce their effects after
having been absorbed into the circulation. Even
purgatives, as the croton oil, and elaierium, some
preparations of iodine, strychnia, prussic acid,
tartar emetic, &c., if judiciously employed in
this way, will be often productive of advantage,
and are not infrequently required to be thus pre-
scribed.

5. 2d, Of absorption from the litngs in relation
to the causation and removal of disease. — a. There
are very few, if indeed any, of the numerous
maladies which are usually denominated infec-
tious, that are not caused through the medium of
the lungs. And, though the greater proportion
of them are most pro bably induced from the
morbid impression which their exciting causes
make upon the nerves supplying this organ, yet
several of them are also, more or less, occasioned
by the absorption of the cause itself into the cir-
culation, and by its influence upon the blood, and
the nervous and vascular systems. Probably,
also, certain other causes of disease, of no mean
importance, particularly marsh miasmata, and
noxious animal exhalations, act directly upon the
organic nerves of the lungs, and on the blood
itself, through the medium of absorption. We

c4

24

ABSORPTION — ITS Pathological Relations.

have reason, moreover, not only to infer that the
more material causes of disease are absorbed from
the surface of tlie lungs, when inhaled into iheni
with the atmosphere, in the moisture of wliich they
are dissolved, or otherwise combined ; but, also,
that the foreign gases, which sometimes mix with
the air, act in some measure through the same
channel.

6. The organisation of the respiratory surfaces,
the nature of the circulating functions on these
surfaces, and the more immediate relation subsist-
ing between the air in contact with, and the blood
circulating in, tliem, will readily explain the rapi-
dity .with which foreign matters floating in the
atmosphere are frequently conveyed into the cir-
culation. Besides, we have strong reasons to infer
that several of the gases, and of the soluble sub-
stances which float in the air, are carried directly
into tiie blood from the surface of the lungs, with-
out passing along absorbent vessels. The experi-
ments of Professor Mayer, and of Drs. Lawrence
and CoATES, as well as those of MM. Segalas,
FoDERA, &c., fully confirm this inference ; whilst
those performed by MM, Magendie, Seilku,
FiciNus, TiEDEMANN, GMELiN.aod sevcral others,
show, that even in the alimentary canal, and espe-
cially when capillary vessels are divided in any of
our tissues, the function of absorption is not con-
fined to lacteal or lymphatic vessels, but is fre-
quently extended to the venous capillaries, which,
in respect of certain substances particularly, chiefly
perform this function. Hence I may conclude
that foreign substances dissolved in or combined
with, the moisture of the air, or mixed with this
fluid, may, when inspired, be carried from the sur-
face of the lungs into the blood, independently of
the absorbent vessels ; although, doubtless, these
vessels perform their appropriate functions in this
as in other parts of the body.

7. b. Therapidity of absorption in the lungs, and
the ready access to the blood \< hich foreign mat-
ters find through them, are sufficient to vindicate
their importance as channels through which to
convey our means of cure, not only in those ma-
ladies to which they are liable, but also in a num-
ber of diseases aflHecting the whole frame, or par-
ticular parts of it. General suggestions on this
subject are all that can be advanced in this place :
the particular recommendations for its use are
given in their appropriate places. Those gaseous
bodies which possess active medicinal powers ; all
those remedies which are more or less volatile, or
arc soluble in a(|ueous vapour; and many medical
sul)stances which may be rendered volatile or
soluble in water, when combined with other bodies
that do not destroy allogethertheir remedial powers,
may be prescribed advantageously through the
medium of the lungs. Chlorine, the nitrous oxide,
dilute oxygen gas ; the vapour of iodine, or the
KMlphuret of iodine; the vajiour of turi)eiitine,
camphor, of the common, the aromatic, or the py-
roligneous vinegars ; tar vapour ; the chlorides or
chlorurets of lime or of soda ; acjueous vapour hold
ing the active princi[)les of opium, henbane, hem-
lock, belladonna, digitalis, colchicum, &c., in so-
lution ; the volatile principles of various salts, the
aroma of a number of vegetable bodies, — all exert
|)0werful effiectsupon the system when administered
in this way.

8. c. Through this channel a number of fevers,
especially thoi-e which are characterised by great

depression of the powers of life, or which rapidly
pass into this state ; various chronic affections of
the lungs themselves, which are unattended by
acute inflammation, but consist chiefly of a mor-
bid state of the respiratory nerves, and are accom-
panied with spasm, and a morbidly increased
secretion ; the different kinds and forms of as-
phyxy ; the diseases which threaten life by inter-
rupting the respiratory functions ; and various
maladies in which the blood is vitiated, and where
it becomes important to act in a direct and de-
cided manner on this fluid, and on the circulat-
ing organs generally, may be successfully com-
bated.

9. d. The knowledge that we thus acquire re-
specting the channels, through which the causes
of many diseases invade the system, and the re-
medies for removing them may be eflicaciously
administered, furnishes us with important indica-
tions as to the employment of prophiiitclic mea-
sures, and rational plans of regimen and hygiene.
Miasmal or contagious fevers furnish us with nu-
merous opportunities of proving the justness of
these views. Observation shows us that the
causes of this class of disease act upon the system
chiefly from their presence in the air we breathe :
it further enables us to decide that these causes
invade the system chiefly through one of two, or
perhaps by both routes: viz. by the nerves sup-
plying the respiratory organs, or by the partial
absorption of the causes themselves, from the
pulmonary mucous surface, into the circulation.
From the same source, or from the collateral evi-
dence of experiment, we know that foreign sub-
stances do not so readily enter the circulation,
when its functions proceed with energy, and the
vital resistance is perfect, as when they act feebly
and imperfectly ; and that the depres-ing causes
of disease have less power over the nervous in-
fluence of the respiratory organs, and of the system
in general, when the vital actions which take
place in the lungs are performed with due acti-
vity. The same sources of observation make us
acquainted with the imjiortant facts that the dilu-
tion of the atmosphere, which contains the causes
of febrile diseases floating in it by free venti-
lation ; that the destruction, or neutralisation, or
counteraction, of these causes, by the evajioralion
of certain disinfectant and stimulating agents ;
and that a due energy of all the vital and secret-
ing functions, with an equable state of the mental
powers and manifestations, and with a steady con-
fidence, are the most successful means of prevent-
ing the attack and difl'usion of those nialadies.

10. By combinmg these facts as to the source,
mode of operation, and methods of counteraction,
of the chief causes of a most important class of
maladies, and by directing the measures they sug-
gest, as far as n)ay be, according to the peculiari-
ties of individual cases and diseases, we arc thereby
enabled to furnish persons, and even whole com-
munities, with instructions and means calculateil
either to counteract or to lessen the dangers to
which they are exposed.

11. 3il, Of (ihsoi-ption from the alimentary canal,
in connection uilh the causation of disease. — a. It
may be received as a pathological axiom, that the
rapidity and extent with which deleterious mat-
ters are absorbed from the digestive mucous sur-
faces, as well, indeed, as from the respiratory,
and other organs of the body, are nearly in pro-

ABSORPTION — ITS Relations to Disease.

25

portion to the depression of the nervous ener-
gies and vital resistance of the system. The
truth of this is evinced in respect not only of the
actions proceeding on tlie mucous surfaces, but
also of those taking place in the different organs
and structures. It is necessary to allude here to
the numerous agents which cause, counteract, or
remove disease, by their being absorbed from the
alimentary canal. Whilst many agents produce
their effects chiefly by modifying the states of the
nerves and .mucous tissue of this canal, others
act principally from being absorbed, either by the
lacteals, or by the venous radicles, and carried
into the circulation ; and a still more numerous
class seem to operate through both channels, im-
pressing immediately the nerves and tissues to
which tboy are applied, and subse(iuently being
absorbed into the blood, where they produce im-
portant effects not only upon this fluid, and on
the vascular system, but also upon the functions
of various secreting organs, especially those by
which they are eliminated from the body.

12. A very large proportion, therefore, of the
ingesta, whether alimentary, medicinal, or poi-
sonous, tiius acting upon the system chiefly
through the medium of absorption, the importance
of directing a considerable portion of attention to
this function in our pathological investigations, as
well as in the appropriation of medicinal means,
must be apparent. Besides these more obvious
relations of the subject, there are others which
have been either imperfectly investigated or entirely
overlooked. To these I can merely alluile : but
amongst the most interesting are the absorption of
unwholesome and imperfectly digested chyle from
the intestinal surface ; the absorption of a portion
of the vitiated secretions which occasionally accu-
mulate in the alimentary tube, particulary in the
coecum and cells of the colon ; the absorption of
some part of the faical matters, when they are long
retained in the above situation, as evinced by the
sensible qualities of the perspiration, foul state of
the skin, &lc., or of the obstructed and accumu-
lated urinary secretion, as proved by similar phe-
nomena ; the passage of bile into the circulation,
wlun it has been retained in the l^ver, the biliary
ducts, or gall-bladder, from torpor or obstruction
of these parts, or when it is secreted in large
quantity, and does not readily pass off with the
egesta. All these are very fruitful sources of
disease ; and, although generally connected with
some degree of pre-existing disorder, or of torpid
function, they are often the chief aggravating
causes of many of the maladies we are called
upon to treat, from the constitutional and visceral
disturbance they occasion and perpetuate.

13. There are few disorders which implicate
the digestive and chylopoietic organs, and very
few febrile diseases, which do not, at some period
of their course, evince signs of the absorption into
the circulation of a portion of the morbid secre-
tions or faecal fluids retained in the alimentary
canal, when due evacuations are not practised.
Therefore, besides the other effects produced by
medicines of this class, evacuation of these secre-
tions and fajcal matters from the prima via is one
of the best oflices they perform.

14. b. It is unnecessary to do more than to
allude to the advantages that accrue to the
scientific practitioner from some knowledge, — al-
though, in the present slate of medicine, necessa-

rily imperfect, — of the remedies which act by being
absorbed, either altogether, or in part, from the
alimentary canal. Most of those substances which
are found by experience the most eflicacious in
promoting the actions of the different secreting
viscera, and in producing a marked and permanent
change of the general state and functions of the
economy, operate after having been absorbed into
the circulating current, and conveyed through
this channel to vital and secreting organs ; and,
although, during the healthy performance of the
secreting functions, or whilst the vital energies
are not far reduced, these substances seldom accu-
mulate in the blood so as to be detected in it by
chemical analysis owing to the balance which is
preserved between the rapidity of absorption and
the activity of elimination, yet their passage
through it is proved by the fact, frequently-
observed in regard of all of them, of their being
found in the secretions of the eliminating or de-
puratory organs. This fact was established by
experiments performed by myself, — some of them
as far back as 1819, — and published in several
periodicals in 1821 and 1822.

15. 4th. Of absorption finm slructures during
diseaae. — a. Adipose and other tissues, undergo
waste and absorption ; the absorbed elements
forming combinations during circulation and ex-
cretion, thereby often perpetuating or aggravating
disease. — 6. \Vlien morbid secretions are gener-
ated, or accumulated in any organ or texture, or
when any part is changed in such a manner as to
secrete a matter different from the healtliy consti-
tuents and fluids of the body, liie matter formed
is, after a while, absorbed into the circulation,
and contaminates, in a more or less marked' man-
ner, according to its nature, the fluids and soft
solids, and thereby at last destroys life. Illus-
trations of this are furnished us in the pathological
history of internal and deep-seated abscesses ; in
some morbid states of the uterus ; and in malig-
nant diseases. The celerity vvith which the absorp-
tion of the morbid matter and the contaminaticn
of the frame proceed, is generally according to
the principle already recognised (^9.), — in pro-
portion to the diminution of the vital energy and
resistance of the constitutional powers.

16. c. The commencement of the contamination
can scarcely be determined by an appreciation of
symptoms; but the experienced observer will
readily recognise, in the colour of the surface of
the body ; in the state of the heart's action, and
of all the circulating functions, as well as in the
blood itself; in the failure of the energies of life ;
in the morbid condition of the nervous functions
and of the powers of the stomach, and indeed of
the whole digestive canal, sufficient proofs of the
early, as well as of the advanced progress of dis-
ease, arising from the absorption of morbid mat-
ters from the primary seat of morbid action, and
the consequent vitiation of the circulating fluids,
of the soft solids, and of the secretions and ex-
cretions of the body. (See Art. Bi.ood.)

17. d. In many of the more chronic diseases
which either commence with or terminate in the
malignant state, this contamination is frequently
first evinced by the tumefaction and pain of adjoin-
ing lymphatic glands, owing to the irritation pro-
duced by the mordid fluid conveyed into them : the
inflammation or obstruction thus produced in them
becoming an obstacle to the rapid transit of the

23

ABSTINENCE— MoifBiD Effects or.

morbid matters from the original seat of disease
into the circulation. But in many cases this is an
insufficient barrier ; and in others, these matters
seem to pass onwards, either without circulating
through lymphatic glands, or without occasioning
irritation, obstruction, or inflammation in them ; or
are almost directly conveyed into the venous circu-
lation. Whatever may be the channel of convey-
ance, there can be no doubt of the fact — the
practical importance of which is very great — that
the rapidity of the absorption of morbid matters,
and extent of their huitful effects on the constitu-
tion,- are in proportion to tiie depression of the vital
energies of the frame, — this depression being fre-
quently the cause of their absorption, particularly
in respect of purilorm fluids ; or at least the cir-
cumstance wiiich more especially favours its oc-
currence, and the rapidity of its progress.

Bibliography — Gaspard, Sur les Maladies Pntrides,
&c.in Tl/.A/ffyfffnrf^eVJourn.de Physiol., t. W.—J.Coplnnd,
in London Medical Kepository, vol. xvii. for May, 1822 ;
and ill his Notes and Appendix to M. Richeiand's Ele-
ments of Physiology, Loud. 182J and 182;», -Maf;endie,
art. Absorption, in Diet, de Med. et Chirurg. Prat t i.,
Paris, 1S29. — Fodera, Archives Gener. de Med., t. ii. p.
bT. — PioUet, Revue Med., 1826, t. i. p. 165.

ABSTINENCE. Its Morbid Effects. Syn. ^6-
stinentia, Lat. Astineuza, Ital. Die Enthal-
tiirig, Ger. Abitinence, Fr. Starvation from
Hunger.

Classif, I. Class, V. Order (Author, see
Clussijication in the Preface).

1. It does not come within the scope of this
work to enter upon the consideration of the thera-
peutical relations of abstinence ; but that the prac-
titioner should be acquainted with the states of
disease wliich it occasions, and with the best means
of treating it, is extremely important ; more espe-
cially as, when it is too rigidly enforced during
ihe treatment of several diseases, it not infre-
quently gives rise to effects of a serious nature,
which not infrequently have been mistaken for
the spontaneous course of the malady.

2. I. Of the Morbid Effects of Abstinence.
Abstinence has been long employed as a means of
cure, and generally as a part of the antiphlogistic
regimen, in a very great number of diseases, par-
ticularly in fevers and inflammatory aflTedions.
Very great difference, however, exists both among
writers and practitioners as to the extent to which
it should be carried, and the maladies in which
it ougiit to be prescribed. As to its applica-
bility to the class of diseases now noticed, there
is no doubt : but in disorders of debility, or of
irritation merely, particularly those which occa-
sionally bimuiate chronic inflammation, and in
various nervous affections, it is extremely injuri-
ous ; and 1 believe tiiat it has been carried to a
hurtful extent in many of ihe-e affections, particu-
larly by JinoussAis and his followers, as indeed
has been recently well siiown by ftlM. Piohry
and BjkRRAS. A case of tiiis description, which
liad been long under the care of M. JJhoussais,
very lately came before me, with many of the
morbid effects of this practice, which had been
carried to a hurtful extent, 'ihere can be no doubt,
however, that it is extremely beneficial, when
carefully watched and regulated, in many of the
diseases of the stomach and ils associated viscera ;
but the fact is e(|ually incontrovertible, that it will
oltei) produce effects very nearly resembling those
for which it has been prescribed. 'I'he importance,
iitrcfore, of keejiinx; these effects in recollection.

when treating several diseases, particularly those
of irritation and debility, must be apparent.

3. In appreciating the usual eflfects of abstinence
it is extremely requisite to be aware of two things:
1st, That the effects vary with the state of the
patient at the time that abstinence is endured ;
2d, that they differ materially according to the
suddenness with which it is entered upon, the ex-
tent to which it is carried, and the circumstances
with which it is associated. By very corpulent
and plethoric persons, abstinence is generally
borne well for a long period, and by those labour-
ing under febrile or inflammatory excitement ; and
it IS, in them, one of the most necessary means to
diminish the one and lower the other. In these,
paiticularly the latter, total abstinence may be
endured for many days ; whilst, if carried to the
same extent in healthy persons, its effects would
be fatal, or nearly so. Abstinence, also, is longer
endured by persons of the middle or matured
epochs of life, than by those of an early age.

4. That ihe absolute or sudden deprivation of
food should be productive of more rapidly serious
effects is very obvious ; but it is not so well known
that there are circumstances which modify the
effects of the less absolute states of abstinence, and
which, when thus combined, give rise to very im-
portant and dangerous diseases. In order to place
the subject more clearly before the reader, 1 will

first notice the effects of abstinence simply, and
unassociated with other causes of disease ; and
next, the morbid conditions, which its association
with certain influential agents usually occasion.

5. 1st. The morbid effects of simple abstinence.
— Keeping in recollection the modifications de-
pending upon the extent to which deprivation of
nourishment is carried, and the age and state of the
person at the time of its adoption, I may briefly
describe the morbid effects of abstinence as fol-
low.— Paleness and languor of the countenance ;
muscular debility and emaciation ; a weak and
small pulse; thirst; at first quickness of intel-
lect, constipation, and flaccidity of the muscles.
To these succeed increased frequency of pulse,
palpitations, alternating with leipothymia, or even
full syncope ; .headach or deliriunn ; flashes of
light before the eyes; tinnitus aurium ; slight
amaurosis ; parched state of the throat, and thirst ;
pains in the stomach ; great wakefulness, followed
by delirium, sometimes mild, but in other cases
furious, or at first mild or muttering, and afterwards
strong or furious ; sinking of the animal heat, or
alternate coldness and burning in parts of the
body ; antl lastly, morbid sensibility of the organs
of sense and surface of the body, and greally
depressed temperature, followed by insensibility,
stupor, or coma, terminating in death.

6. It is obvious that the severity and duration
of these .symptoms will vary in different cases,
according to circumstances peculiar to each.
But it is not so well known that tliey will be
actually produced by pursuing a too rigid absti-
nence in the treatment of vaiious diseases, and
particularly when the nature of the disease is mis-
taken : as when the irritative symiJtoms frequently
attendant upon diseases of debility, or on nervous
affections, are viewed as resulting irom inflamma-
tion. Many cases have occurred to me in the
course of praiitice, where the antiphlogistic regi-
men, wliich had been too rigidly pursued, was
itself the cause of the very symptoms which it was

employed to remove. Of these symptoms, the
affection of the head and dehiium are the most
remarkable, and the most readily mistaken for an
actual disease requiring abstinence for its removal.
A case of this description lately occurred to me.
A professional man was seized with fever, for
which a too rigid abstinence was enforced, not
only during its continuance, but also during con-
valescence. Delirium had been present at the
height of the fever, and recurred when convales-
cent. A physician of eminence in maniacal cases
was called to him, and recommended him to be
removed to a private asylum. Before this was
carried into effect, 1 was requested to see him.
A different treatment and regimen, with a gra-
dual increase of nourishment, were adopted, and
he was well in a few days, and within a fortnight
returned to his professional avocations.

7. The morbid appearances observed after fatal
cases of deprivation of food possess some interest.
'Jhe most remarkable are the emaciation and
absorption of every particle of fatty matter : the
paleness, flabbiness, softening, and emaciation
of tiie voluntary muscles, and of the substance
of the heart ; an exsanguined and pale state
of the viscera ; slight atrophy of the liver and
spleen ; diminished size of the stomach and
colon ; and particularly the increased vasculaiity
of the brain, and sometimes of the membranes
also, compared with the other viscera. It would
seem that a very large proportion of the blood
continues, as in many cases of great vascular de-
pletion, to be sent to the brain to the very last.
'I'his is obviously owing to the pressure of tlie
air on all parts of the body, froin which the
encephalon is guarded by its unyielding case.
In addition, also, to the vascularity of this part,
a limpid serous efi'usion between the membranes,
or in the ventricles, is sometimes met with.

8. 2d, Of the morbid eff'ecis of abstinence uhen
it is associated uith other hurtj'iil agents. ^These
effects are occasionally presented to medical men
under a variety of circumstances, and from a
varied combination of causes ; but in the gieat
majority of instances they result from deficiency
of tood merely, rather than from a rigid abstinence,
conjoined with the depressing influence of cold or
insufficient clothing, great or continued exertion,
01- with a moist and unwholesome atmosphere.
Thus we find the association of these causes, par-
ticularly insufficient or unwholesome food, labo-
rious exertion, mental depression, a moist, cold, or
unwholesome atmosphere or locality, not infre-
quently give ri5.e to purpura haemoirhagica,
scurvy, scorbutic dysentery or diarrhcEa, low or
typhoid fevers, affections of the brain and nervous
system, emaciation, with chronic ulcerations, tec.
— effects which have received a particular notice
in their respective articles.

9. 'iiie best illustration of the effects of this
association of other agents with a continued defi-
ciency of food is furnished by the diseases which
appeared a few years ago in the iNlilbank Peniten-
tiary. The prisoners confined in this prison were
suddenly put upon a diet from which animal food
was nearly altogether excluded, excepting in as
far as it entered into tiie composition of a weak
soup. They were at the same time subjected to
a low grade of temperature, to considerable ex-
ertion, and confined within the walls of a prison
situate in tiie midst of a marsh which is below

ACNE. 27

the level of the adjoining river. The conse-
quences were, first, the loss of colour, of flesh and
strength; subsequently, diarrhcea, dysentery, scor-
butic dysentery, scurvy; and, lasily, low ataxic
or adynamic fevers, or headach, vertigo, con-
vulsions, delirium or mania, apoplexy, &c. The
smallest loss of blood pioduced syncope or lei-
pothymia, and fatal results. Yet, in the great
niajority of the fatal cases, independently of the
le>ions observed in the mucous surface of the
digestive tube, or in other situations, increased
vascularity of the brain and its meninges, fre-
quently with effusion of fluid in the ventricles or
between the membranes, was found upon examin-
ation after death.

10. II. The Treatment of the morbid effects
of abstinence is very obvious, yet considerable
care is necessary to its successful issue in very
urgent cases. Nourishment should be adminis-
tered cautiously, in a very small quantity at a
time at first, but frequently. It ought to be
bland and farinaceous : animal food may be en-
tered upon subsequently, and the quantity gra-
dually increased. The animal warmth should be
promoted, at the same time, by the usual exter-
nal means — by frictions and warm applications;
and the bowels assisted by the occasional use of
bland enemata. Soups may be allowed early in
the treatment, but in a small quantity at a time,
ftlilk IS often prejudicial, unless diluted and made
into gruel with some of the farinaceous articles of
food. Internal stimulants are seldom required,
unless when symptoms of cerebral or nervous
irritation exist, when they may be given; parti-
cularly the preparations of ammonia, the aethers,
camphor, vegetable bitters and tonics, at first in
very moderate doses, in conjunction with sinall
quantities of an anodyne, as the extract of hop,
the extract of hyoscyamus or of opium, the
paregoric elixir ; and by warmth, frictions, and
stimulating applications to the cutaneous surface
and lower extremities. These means will gene-
rally succeed in removing the effects of simple
abstinence whilst they admit of removal. The
treatment of the effects resulting from the con-
junction of other causes with the one now discussed,
is considered under their respective heads.

Bibliography Curiie, Medical Reports, 4ioed., vol i.

p. 304 — Willan, Miscellan. Works, by A. Smith, p. 437.
— Barras, Traite sur les Gastralgies et les Enteralgies,
&c., 3d ed. 8io, Paris, lS2d.—Pwrrt/. Precede Operatoire
dans lExploration des Urganes, &c. &c., 8vo, Paris, 183!,
p. 36H.—P. M. Latham, On the Diseases in Ihe Milbank
Penitentiary, 8vo, Lond. 1824. — Andral, Precis d'Ana-

tom. Pathoiog., t. ii. p. 7l>9 Rostait, Diet, de Med. t.i.

p. l.')4 Ch.Londe, V>icl. de Med.et Chir. Prat., t. i. p. 103.

Cnllard de Martigny, in Magendie's Journ. de Physiol.,
&c., t. viii.p. 152. !■

ACNE. 'axvi. Derived, according to Cassius
{l<:at. et Med. Quest., &.C., Prob. 33.), from
aiifji.il. SvN. "lovBof, Gr. Varus, Lat. Phii-
dracia Acne, Sauv. Gutta Rosea, Darwin.
lonthus. Good. Bouton, Couperose, Fr. Die
Finnen, Ger. CarbiDicle, Stoue-pock, JVhelk.
Classif. 3. Class, Diseases of the San-
guineous Function ; 2. Order, Inflamma-
tion (Good); 7. Orc/er, Tubercles (Willaii
and Batemaii). IV. Class, 1\'. Order
(Author, seethe Classification).

1. Defin. Hard, inflamed, tubercular tumours,
suppurating very slowlii, occurring chiefly in the
face; sometimes, also, on the neck and slunilders.

2. I. Description. One or more, sometimes a
1 number, of these tubercles appear, generally in

2B

ACNE — Simplex — Indukata — Rosacea.

succes>ion, in tlie face, and sometimes on the neck,
shoulders, and breast, but never lower ; remain
permanent for a considerable time; and sujjpurate
slowly and imperfectly, leaving a dark or livid
mark, whicli gradually disappears. They occur
chiefly in persons of tiie sanguine temperament ;
commencing at the period of puberty, and gene-
rally disappearing after thirty or thirty-five. They
are common to both sexes, but are most frequent
and numerous in the male sex.

3. This is one of the most constant and unva-
rying in its characters of any of the afFections of
the skin ; but writers upou this class of diseases
differ widely in respect both of its particular cha-
racter and seat. Wiixan, Pi.enck, Bateman,
and Thomson consider it a tubercular affection ;
whilst ALrBERT, BiETT, and Rayer view it as
pustular. I believe, however, that both opinions
are in some respects correct; and that in cer-
tain forms or states of acne the tubercular change
is predoininant, little or no suppuration taking
place, but a state of slow inflammation giving
rise to a continued exfoliation of the cuticle, or
formation of thin scabs on their apices ; and thus
they slowly disappear; whilst in others the pustu-
lar character is very distinct, but always preceded
by the characteristic tubercular hardness. This
affection may be viewed, therefore, as forming an
intermediate link between the tubercular and pus-
tular eruptions.

4. In respect of the particular tissue in which
this disease is seated, some difference of opinion
also exists. The greater number of writers on the
pathology have considered this disease to be
seated in the proper structure of the cutis vera ;
many of them admitting, at the same time, an
affection of the sebaceous follicles very nearly
resembling it. Mr. Plumbe, however, attributes
it entirely to obstruction and chronic inflammation
of these follicles. 1 believe that this opinion is
too restricted ; and that, whilst one form of acne
evidently depends upon this cause, others are es-
sentially disease of the cutis vera.

5. Spec. i. Acne Simplex, Himple Acne. Syn.
GiUta Rdsea Hereditaria, Darwin. Dartre
Piistnleiue Miliare, Alibert. lonthm varus
s'unplex, Good.

Simple acne affects most frequently young sub-
jects at the period of puberty, and particularly
females. They generally appear on the forehead,
shoulders, and upper part of the thorax, and are
liable to recur at the menstrual periods, especially
in cases of dysmenorrhoea. Many of these vari
do not proceed to suppuration, but slowly subside.
They are very comtnordy developed in succes-
sion ; commencing with small, hard, and inflamed
tubeicles, of the size of a pin's head. 'J'hese
continue to enlarge for three or four days, and the
inflammation becomes more apparent. In seven
or eight days they have reached their greatest
size. 'I'hey are then dark red, sn)ooth, prominent,
shining, hard, and slightly painful to the touch.
After two or three days a small speck of matter
appi ars on the apices of some of them ; and
when these break, a thin humour exudes from the
tubercular induration, and dries on its surface,
forming a thin scab, which adheres firmly; but,
after a few days, is loosened at the edges, and falls
off; the tubercular hardness and livid redness gra-
dually subsiding, and disaooearing after three or
four vveeks.

6. In some persons this eruption recurs fre-
((uently at short intervals, the vari being more or
less numerous ; in others it is more extensive, and
never altogether disappears, although it is more
troublesome at one time than another. When
the vari are numerous, many of them undergo no
suppuration ; but the sebaceous glands are often
excited, giving the skin a greasy appearance. In
many of these cases, several of the vari assume
the characters of the next species.

7. Spec. li. Acne Indurata, Stune-pock.

The tubercles are larger, more indurated and
permanent than the foregoing ; and are apparently
the consequence of a slower and more deep-seated
inflammation. They often appear in considerable
number, of a conical or oblong-conoidal form ;
some of them assuming a roseate hue, and tend-
ing to suppuration at their apices; others remain-
ing in a hard, elevated state for a very long time,
without any appearance of the suppurative pro-
cess, or disposition towards it. In some cases, two
or even more of them coalesce, and occasionally
suppurate at their respective apices ; but one only
may undeigo this change. As they continue
they become more purple or livid, particularly
when they have no tendency to suppurate. When
they experience this process, the same process of
scabbing and exfoliation, already described {§ 5,),
is gone through ; but it sometimes happens that
when they experience any irritation they may
suppurate a second time. As they very slowly
subside, they leave a purple or livid discoloration,
and, occasionally, a slight depression, which is
long in wearing off, and which sometimes never
altogether disappears.

8. This species of acne generally is most fre-
quent and numerous along the rami of the lower
jaw, on the temples, the nose, and cheeks; also
on the back and neck. They are frequently ac-
companied by a greasy state of the skin, from
an excited state of the cutaneous follicles; are
commonly sore and tender to the touch ; and,
when numerous, are in every stage of progress,
giving tiie surface a spotted and variegated ap-
pearance,— owing to the prominence and redness
of some at their commencement, to the yellow
points in those that are suppurating, to the scaly
crusts covering those which have undergone this
process, to the lividity of those that have exfo-
liated or are subsiding, and to the discoloured
depressions which others have left after them.

9. The general health seldom sufl'ers mate-
rially from either the simple or the indurated
acne, excepting as far as regards some pre-existing
and concomitant disorder of the digestive func-
tions. If fever, or acute disease, attack persons
affected with these eruptions, the vari generally
disappear ; but they frequently also re-appear upon
its subsidence, becoming in some respects a criti-
cal eruption.

10. Spec. iii. Acne Rosacea, Rosy-drcij),
Syn. GiUta Rosea, Auct. var. Gutta Rosea
Hepatica, Darwin. lonthus Coi-ymhiJ'er,
Good. Dartre Pustulettse Couperose, Alibert.
Goutte Rose, Couperose Rougeurs, Fr. Kiip-

ferhandcl, Roth-nase, Ger. Carbuncled Face,

The Jirst and second species, described above,
might have been, with propriety, viewed as varie-
ties of the same species; but this is a very dis-
tinct species from the preceding. It consists of

ACNE — Punctata — Syphilitica.

29

small, slowly suppurating tubercles, accompanied
with a shining redness, and an irregular granu-
lated appearance of the skin of the part aflected.
This species commonly appears first at the end of
the nose, and afterwards spreads from both its
sides to the cheeks, which it never altogether
covers. At first it is not uniformly red ; but is
pale in the mornmg, and intensely red whenever
the patient is excited or heated, and particularly
after dinner, or drinking wine or spirits. After
some time the texture of the cuticle is gradually
thickened, and its surface granulated and varie-
gated by the ramifications of cutaneous veins, and
the suppuration of small, prominent vari, which
successively arise in different parts of the nose
and face.

11. This species of acne seldom appears before
the age of forty, excepting in those addicted to the
immoderate use of vinous or spirituous liquo'S, or
who possess great hereditary predisposition to it.
In advanced life, or in the worst of these case^,
it sometimes spreads to the greater part of the
face, even to the forehead and chin. The nose
usually becomes very tumid, and of a fiery red
colour, and sometimes is enlarged to an enormous
size. The nostrils, in these cases, are generally
distended, and their alse often fissured and divided
into lobes. In advanced age, this species of acne
becomes more livid ; and if any of the tubercles
suppurate, they often ulcerate, and are indisposed
to heal. In younger persons, who are attucked
chiefly from hereditary disposition, it is often ac-
companied with irregular red patches on the face,
which are often smooth, devoid of tubercles, and
accompanied with occasional slight exfoliations
of the cuticle. These patches are extended, or
aggravated by intemperance in food or drink.

12. Spec. iv. Acne Punctata, Maggnt Pimple.
Sy n. Crimones, Ai\ct. va.t.i Punctce Mucosce,
Darwin, lontlnis Varus piinctutus, Good.
Der Gries, Ger. Tannes, Fr. Grubs, Kng.

This is, in my opinion, the only species of acne
which is seated in the follicular glands ; and, al-
though often observed as the only form of erup-
tion, it also is frequently found intermingled with
the species already described, particularly the
first and second. It consists of a number of
black points, surrounded by a very slightly ele-
vated border of cuticle, proceeding from con-
creted sebaceous matter accumulated in the glands
and their ducts, whence it may be squeezed out iii
a vermicular form, the external extremity being
dark from its exposure. In consequ-ence of the
accumulation and distension, these glands some-
times become inflamed, and give rise to small
tubercles, with minute black points in the centre
of their external surface. J'hese tubercles sup-
purate partially, as the preceding, whilst others
remain stationary for a considerable time, and
several are distended witlinut even being in-
flamed, ^rhey are not infrequently mixed with
tubercles without the black punctae, which are
evidently owing to a similar obstruction, and to a
more complete closure of the outlet of the ducts.
In this species of acne the accumulated secretion
may be squeezed out.

13. Spec. v. Acne Syphuitica, Venereal Acne.
Syn. Gutta Rnsea iSyphiliiica, Plenck. Sy-
philide Pustuleuse MUiuire, Alibert.
Amongst the very numerous forms of cutane-
ous affection in wliich secondary syphilis may

manifest itself, this may be enumerated as one,
although not a common one. Plenck has given
a veiy correct description of it. This species
nearly resembles, in the size and form of the
pustules, the acne rosea. It chiefly afl^'ects the
forehead, face, neck, and upper part of the
trunk. The vari are round and conical, with an
inflamed, copper-coloured, tubercular base and
areola. They suppurate slowly at their apices,
where a yeliowi^h-brown scab is formed ; and
leave a dirty, dark, and slightly depressed mark.
They present a dark colour, and more perma-
nent tubercles, on the nose, the adjoining parts
of the cheeks, and forehead, than elsewhere ; and
are there observed in discoloured patches, in
every stage of their growth. They are frequently
found complicated with other eruptions, chiefly
of a scaly character, on diflfereni parts of the
body ; are always a secondary venereal affec-
tion ; and although sometimes unaccompanied
with other syphilitic symptoms, are most com-
monly attendeil with ulcerations in the throat,
with nodes, inflammation of the periosteum, and
nocturnal pains.

14. II. Diagnosis. — Acne can be confounded
only with ecthyma. The tubercular pustules of
the former, however, are small, slowly developed,
with an indolent and hardened base ; whilst the
pustules of ecthyma are large, superficial, unac-
companied with chronic induration, and forming
thick scabs, more or less prominent, much less
adherent, and such as never are formed in acne.
The characters of syphilitic acne, the antecedent
and accompanying symptoms (§ 13.), the colour
and predominance of the eruption about the nose
and commissures of the lips, the tendency of the
vari to ulcerate, and the associated affection of
the throat, and sometimes of the periosteum, suf-
ficiently mark the nature of this species of the
disease.

15. III. The PROGNOsispf acne regards merely
the persistence of the eruption, and the incon-
venience attendant on it. Acne simplex and punc-
tata are often of comparatively short duration.
The acne indnrata is mucii moie tedious ; and in
some constitutions will resist, even for many years,
every mode of treatment, particularly if the causes
in which it not infrequently originates be over-
looked. Acne rosacea is seldom or ever cured,
excepting by a strict attention to regimen.

16. IV. The Causes of acne are extremely va-
rious. The species simple < ,imlurala, and punc-
tata usually occur during youth, in the sanguine
and bilious temperaments, and disappear about
middle age. They are very generally connected
with chronic affections of the stomach, bowels,
and liver; with ha;morrhoids ; in some, with a
tendency to phthisis ; and in females with painful
and scanty menstruation. These S|)ecies, as well
as the acne rosacea, evidently arise in many cases
from hereditary predisposition ; and are most
common in cold and moist climates, — probably
owing to the use of ardent spirits. Excesses at
table, cold indigestible articles of food, sedentary
habits, fits of passion, anxieties of mind, and the
depressing pa'-sions, cold drinks — particularly if
taken when the body is oveiheatetl — the use of
irritating cosmetics, and disorder of the digestive
functions, are very common causes of these
eruptions. I believe, however, that the simple,
indurated, and punctated species of acne are

30

ACNE —

most frequently occasioned 1)\' uterine irritation,
and excitement, or an imperfect performance of
the uterine functions ; by constipation ; by torpid
conditions of the liver; and by the injurious ad-
diction to onanism.

17. V. Treatment. — In the treatment of these
affections, our chief attention ou^ht to be directed
to their pathological relations and cau'^es. These
latter must be removed as far as may be done ;
and the former should both guide our indications,
and direct our means of cure. Tiie apprehensions
entertained by the older writers, of proilucing
internal disease by the sudden repulsion of the
eruption, were founded on the results of observa-
tion, although explained by partially inaccurate
or unsound pathological views. Affections of
the stomach, bowels, chest, and head, have been
thus induced, and been relieved upon a re-appear-
ance of the eruption : but such consecutive dis-
eases are more common after the repulsion of
other eruptions. We should, however, as being
both the safest and the most permanent method
of cure, direct our remedies to the constitutional
or internal relations, as well as to the external
manifestations of disorder.

In the treatment of this, as well as many other
diseases, the causes, the state of the habit and
constitution of the patient, its morbid relations,
and its duration, are severally to be kept in recol-
lection.

18. 1st, Treatment of acne simpleT. — Indeli-
cate constitutions, the chief attention should be
directed to the state of the digestive function'^.
These should be promoted by gentle aperients,
combined with tonics, and the functions of the
skin promoted, by preserving a free transpiration
on its surface. With this view, sulphur may be
combined with magnesia, or with cream of tartar,
and confection of senna, and t;iken in a sufficient
dose, at bedtime, to procure a full evacuation in
the morning, or any one of the formulae (Ap.
Nos. 82. 89. 98.) may be had recourse to. These
may be occasionally changed for a powder with
rhubarb, sulphur, and magnesia, or for the ex-
tract or decoction of taraxacum, with carbonate
of soda or sulphate of potash. If the functions of
the liver are torpid, the following may be taken
for a few nights ; —

No. 6. B Pilul. Hydrarg. Cliloridi Coinp. 3). ; Fellis
Tauri Iiispiss. gr. xv. ; SapiinU Castil, gr. x. ; Extr. Ta-
raxaci .5 j. M. Fiant Pilulas xviii., quarum capiat binas
vel ires hora soinni.

After tiie bowels have beea evacuated, and tlie
secretions brought to a healthier state, the dilute
mineral acids, either alone or with hiiter infusions,
may be taken through the day.

19. When the eruption occurs in young ple-
thoric persons, and when it is in females attended
with scanty and difficult menstruation, small hloo'l-
letiings may be practised ; in the latter by the
application of leeches to the superior and internal
parts of the thighs. In more delicate females the
functions of the lower bowel* are to be promoted
by the piiula aloi's cum myrrha, combined either
witli |)ilula ferri composita, or with the extractum
gentiana;. When the eruption is obviously con-
nected with imperfect and painful menstruation,
the use of the warm salt water hip-hath, or of the
hip vapour bath, or warm salt water pediluvia,
after the application of a few leeches to the in-
sides of the thighs, will be extremely serviceaiile.
In such cases, the internal exhibition of the hi-

Treatment of.

bm-ate of soda, either in the form of pill or draught
combined with camphor, the extractum taraxaci,
or the extr. rutae, or, as directed in Form. Nos. 93.
184. 209. 254. will be found of great advantage.

20. In addition to these internal remedies,
which require to be varied according to different
pathological relations of the eruption, external
applications will be necessary ; and when con-
joined with the above treatment, or employed
subsequently to it, no dread may be entertained
of any injurious consequences from them. The
ancients, particularly Celsus, Pliny, Aetius,
Paiu.us, Actuarius, &c., recommended lotions
and liniments with vinegar and honey ; and these
sometimes combined with turpentine, emulsion
of bilfer almonds, myrrh, alum, soap, Cimolian
earth, the bruised roots of the lily, the cyclamen,
narcissus, and the fruit of the wild vine ; the
most of them calculated to be advantageous in
many states of the common forms of acne.

21. If the tubercles are much inflamed, and
inclined to be pustular, mildly stimulating appli-
cations are most serviceable, as dilute spirit, or
the pyroligneous acetic acid, or liquor ammonia
acetntis, with rose or elder-flower water. In the
more indolent cases, or when the skin can bear
an augmented stimulus, Willan and Bateman
recommend from half a grain to a grain, or more,
of the bichloride of mercury, in each ounce of the
vehicle ; or a drachm or more of the liquor potass(B,
or of the hydrochloric acid, in six ounces : and
Thomson advises that the emulsion of bitter
almonds, containing ten minims of hydrocyanic
acid to each fluid ounce of the emulsion, should
be the vehicle adopted. The solution of the
sulphuret of potassium, in the proportion of a
drachm to twelve or sixteen ounces of water, may
also be employed ; and, in the more obstinate
cases, the baths directed in Form. No. 14 — 17.
may be had recourse to. The solution of the hy-
drochlorate of ammonia, either alone or with the
bichloride of mercury, is often serviceable.

22. l"he lotion from which 1 have derived the
greatest advantage in practice, and which I hare
found the most generally applicable, is a solution
of the hihorate of soda in rose or elder-flower
water, or in water which had been poured in the
boiling state over sulphur, and allowed to infuse
for ten or twelve hours. The borax may also be
dissolved in equal (juantities of elder-flower water
and honey, and used as a lotion in the more
chronic cases.

23. 2d, Treatment of acne indnrata. — In young
and plethoric subjects, or in females, when the
eruption is accompanied with a scanty and pain-
ful menstruation, the treatment already pointed
out (§ 19.) should be put in practice. When
we suspect that sexual irritation or masturbation
is connected with the causation of the erii|)tion,
early rising, mental occupation, the use of genth;
cooling aperients, of soda combined with small
doses of camphor, soda water, sulphur with soda
or antimony, are the most serviceable internal
remedies. After these, the mineral acids, the
sul|)liiireous mineral waters, and gentle vegetable
tonics, will be useful. Where the eruption is de-
pendent upon torpid function of the stomach, or
liver, or bowels, mild alteratives, exhibited at bed-
time, as the pills already prescribed (§ 18 ), and
gon'le tonics through the day, will be refpiired.
In a most obstinate case, which some lime ago

ACNE — Treatment of.

31

came before me in a lady, whom all the prac-
titioners who had acquired a reputation in the
treatment of cutaneous afi'ections had attended,
strict attention to the state of the digestive and
uterine functions removed the eruption. The fol-
lowing electuary has sometimes been used by me
in this and other obstinate cases.

No. 7. B Potassse Bitart. in pulv. .1 j. ; Bi-boratis Sodae
3 ijss. ; Sulphuris Pra?cip. J ss. ; Contectioiiis Sennae et
S) lup. Ziiigiberis aa 3 jss. M. Fial Electuarium, cujus
capiat Coch. umim minimum omni nocte.

At the same time a solution of two grains of the
bi-chloride of mercury in four ounces of the com-
pound tincture of cinchona was prescribed, and a
teaspoonful of it directed to be taken twice daily,
in half a glass of infusion of chamomile flowers.
The lotion already recommended (§ 22.) was also
employed. In cases similar to this, and, indeed,
in all those accompanied with disorder of the
digestive functions, cold or drastic purgatives
ought to be avoided ; and the bowels should be
regulated with the pilula aloes cum myrrha, com-
bined with a little blue pill, or with the pill pre-
scribed above (§ 18.) ; or theext. aides purif con-
joined with the e.vtr. gentianse ; or the electuary
now directed. Advantage will also be obtained
from a draught of infusion of cascarilla, or of ca-
lumba. with carbonate of soda or potass, or the
liquor potassae, taken twice a day.

24. As to eiternal applications in this form of
acne, little need be added to what has been
already stated. The lotions with the bi-chlorile
of mercury, or with the borax, are most to be de-
pended upon, particularly when dissolved in an
emulsion of bitter almonds, or in camphor mix-
ture, with the addition of about twelve minims of
the hydrocyanic acid to each ounce of the vehicle.
In cases where the tubercles have at ail suppurated,
it will be advisable to open them with the point
of a lancet befoie the lotion is used.

25. At the commencement of the eruption, mild
emollient poultices and fomentations are useful ;
and afterwards, particularly i i the more obstinate
cases, M. Biett, and ailer him 1\II\I. Cazexave
and SciiEDEL, recommend the following ointments
to be used, in order to promote the resolution of
the tubercles : —

No. 8. R Protochloridi Hydrarg. et Ammonias* (Sub-
niur. Hydrarg.et Amnion.) 3 j — 3j.; Axungiae 3 j•Mi^ce.
Of this ointment I have had no experience ; but
the following I have employed with advantage in
several chronic eruptions, and in two cases of this
species of acne : —

No. 9. R Siilphureti lodinEE gr. xli — xxiv. : Axungije
3j. M.

Ambrose Pahe and Darwin considered that
blistering successively small portions of the face
was the most successful means of removing this
very obstinate eruption. This practice has been
employed at the hospital St. Louis, by IM. Biett,
with great benefit. When the disease has disap-
peared, he has derived great advantage from a
douche of cold sulphureous water in preventing a
return of it.

26. 3^, Tn treating the punctated species of
acne, it will be frequently necessary to press out
the accumulated and hardened matter from tiie
follicles. 'J'he vapour bath, the warm sulphur
bath, followed by fiictions either with a coarse

* Prepared by subliming equal qnantilifs of the bi-
chloride of mercury and hydrochlorate of ammonia.

towel or a flesh brush ; and lotions such as have
been already recominended, or a weiik solution of
pui-e potash, or of ox-gall, or of sulphuret of po-
tassium, also followed by frictions, are particularly
indicated in this species of acne.

27. liiternatlu, the solution of the bi-carbonate
of potash, or of chlorine, advised by Under-
wood and WiLLAN, may likewise be employed.
Sulphur, magnesia, soda, rhubarb, and the borate
of soda, are also of much benefit. Dr. Thomson
slates, that he has seen the skin completely cleared
by the use of the following alkaline tonic for six
weeks ; at the same time regulating the bowels: —

No. 10. R Zinci Sulphalis gr. xxiv. ; Liqiioris Potassse
3 xij. Solve. Suniantur guttae xxx. ex cyatho aquiE, bis
quotidie.

It ought always to be observed, as a general prin-
ciple, in this as well as in the other forms of acne,
that attention to the secretions of the abdominal
viscera, and to the general health, by promoting
the dige-tive functions, will of itself, independently
of external means, go far in promoting a cure ;
and that, without such intention, no cure will be
permanent.

28. 4th, The treatment of acne rosacea is gene-
rally unpromising. It should always have a strict
reference to the particular nature of the affection
of the liver, or digestive canal, or both, with which
this eruption is associated, and in many respects
symptomatic. A. rosacea often precedes serious
di-ease of the liver, more frequently co-exists with
it, and most commonly indicates a congested and
obstructed state of the viscus. To this organ,
therefore, ought our remedies to be particularly
directed. A modeiate blood-letting ; the applica-
tion of leeches on the region of the liver ; and, if
the eruption occurs in females, and is attended
with obstructed or scanty menstruation, leeches
also to tiie upper part of the insides of the thighs,
or bleeding from the feet, and stimulating pe-
diluvia, or the hip-bath ; the use of mild mer-
curials, or alterative and deobstruent medicines,
such as the pills previously described (§18.);
the blue pill, or the hydrargyrum cum creta with
soda and taraxacum ; Harrogate, Barege, and
other sulpiiureous mineral waters; the decoction
of dulcamara, lii|Uor potassaa, and chlorine or sul-
phureous fumigatmg baths, are severally of advan-
tage in some cases. But from none of these will
any permanent benefit be derived, unless the regi-
men presently to be noticed is rigidly observed,
and the pathological relations of the eruption ap-
pi'opriately treated.

29. Blood-letting in this, as well as the fore-
going species of the eruption, was stronjjly insisted
on by Ambrose Pare ; and certainly in the cases
pointed out as requiring this practice should never
be omitted ; more particularly when accustomed
discharges have disappeared, as the ha'morrhoidal
flux and the menstruiil evacuation. In this form
of the disease, much advantage will sometimes be
procured from tlie nitro-liydrociiloric acid foot-bath ;
and from a lotion with these acids ap])licd to the
affected parts twice or thrice a day (see F. 4, 5.).
This practice has received the sanction of JMftJ.
Biett, Cazenave, and Sciiedel. 1 he advantages
to be derived from the use of these acids as a lotion
will be more ceitainly secured by applying a few
leeches to the vicinity of the eruption, and after-
wards a fomentation, which may be followed
either by a spirit and alum or zinc lotion, or by

32

ADHESIONS.

the lotion with the bi-borate of soda (F.-334.)'
If lhe-!e fail, the nitro-hydrocloric acid lotion may
be employed. Stimulating and irritating applica-
tions ought to be avoided ;• and whilst the tone of
the <!igestive organs and the secretions of the liver
should receive the closest attention, drastic and
cold purgatives are to be avoided.

30. 5th. The treatment of the syphilitic or spe-
cific form of acne must be directed as in other
states of secondary venereal disease. At the same
time, however, that the mercurial preparations
are being exhibited, the external means which
have been recommended may be employed, ac-
cording to the particular form the acne may as-
sume, 'i'he mercurial preparations should be com-
bined with sarsaparilla or taraxacum, or both, and
with small do?es of antimony. The decoction of
Feltz, which chiefly consists of a combination of
these remedies (see F. 588.), is much employed
in these eruptions on the Continent, and may be
taken to the extent of a pint and a half daily.
When the tubercles remain long, the ointments
formed with the iodides of mercury or sulphur
(F. 774, 775.) may be employed twice daily, and
assisted by douches of vapour.

31. The diet and regimen of persons affected
with acne, particularly the A. rosacea, ought to
be carefully restricted. In the A. simplex, in-
durata, and punctata, the diet should be light,
nutritious, and easy of digestion. Cold, raw, and
indigestible vegetables, particularly cucumbers and
melons, and very cold fluids, should be avoided.
Moderate and regular exercise in the open air,
and early rising, as tending both to promote di-
gestion and invigorate the frame, are always of
service. In the acne rosacea, more will often de-
pend upon regimen, than upon the medical treat-
ment of the patient. The careful avoidance of
all its exciting and conrurrent causes, and of
excesses of every description, botii in eating and
drinking; tlie adoption of a mild farinaceous diet,
with a small portion only of light and nutritious
animal food, and of toast-water or barlev-water
for drink ; siiiinning mental excitement and de-
pression, a.i well as heating and fatiguing exertions ;
gentle and regular exercise, and attention to the
promotion of the secretions and functions of the
abdominal viscera ; are essentially requisite tolhe
removal of tiiis very obstinate and often uncon-
querable eruption.

Bibliography Ambrose Pari, De la Gouite Rose,

liv. xxvi. cli. xlv PIrnch, Doctrina de Morbis Ciitaueis,

&(■., 2J edit. Vien. 1783. — Dartain, Zoonomia, class ii.
I. 4. fi., pt cl. iv. 1, 2. i:!. and M. — Bateman, Synopsis of
Cutaneous Diseases, by Thoytipson, and Atlas, p. 'AX~ .
— Alibcrt. art. CoujieroiC ,\\\ Diction, des Sciences Med.,
t. vii. — /?/<;«, art. Co«;Avose, in Diction, de Medeciiic,

t. iv Itayer, Des Maladies de la Peau, &c., t. i. p. 44f>.

Paris, 18-20. —Plumbe,On the Diseases of the Skin, Kvo,
2J ed. Lond. lH'2i) Cazciiave, el Schedcl, Ahregc Pra-
tique des Maladies de la IVaii, 8vo, Pans, 1829, p. 208. _
Green, On Diseases of the Skin, Lonri. 8vo. 183.i. p. IGI.

ADHESIONS. SvN. Adhesions, Adhtrences,

Fr. l^ie AnhVmglichheit, Gcr. Congiunzumi ,

unioni, aderenzw, Ital.

Classif. — MoniiiDSrat'CTunE. — Thehaveu-

xics. — Chiefly a result of someone of the In-

Jlamnvitont Slates. — ^ee Infi.a.mmation.

1. Adhesions of opposite surfaces of tissues are

amongst tiie most common organic lesions presented

to our view in post mortem examinations. They

may be congenital, arising either from "an original

disposition of j)arts, or from intra-uterine disease.

As ihey aie commonly brou;^hl before us in prac-

tice, they are generally one of the consequences
of inflammatory action, affecting the adhering
surfaces, or which had afl^ected them previously ;
and occur in those parts which are in contact, or
so nearly in contact, that the efli'usion of a com-
mon product of the inflammatory act becomes the
medium of union.

2. It is requisite to all adhesions, that a fluid
be thrown out from the inflamed surface, previ-
ously to the adhesion being commenced. This
fluid varies somewhat in its characters with the
state of inflanimatoiy action ; but it soon passes
into a much more consistent condition, and thus
becomes the medium of adhesion. In some places
it is scarcely perceptible between those parts of
opposite surfaces which are naturally very nearly
or altogether in contact with each other, the ag-
glutinating medium being there so remarkably
thin ; whilst those parts that are further separated
in their natural state, have the interstices filled
up by a copious exudation. The fluid exuded in
thus variable quantities, has been denominated,
in its first stages, or inorganised states, coagulable
and coagulated lymph, albuminous exudation,
coagulated albumen, &c. When first poured
out from the inflamed surface, particularly of
serous membranes, it consists of a lymph-like
fluid, which soon becomes somewhat opaque,
more solid, and assumes the appearance of a
softly coagulated albumen, — its chemical pro-
ptTties very nearly approaching to those of pure
albumen, containing a small proportion of the
usual saline ingredients of the blood.

3. 'I'he longer this matter has been eflTused,
and the longer adhesions, which it has occa-
sioned, have endured, the more firm and more
closely resembling cellular or cellulo-fibrous tis-
sue do they become. This change in the state of
the adhesions, according to their duration, is fully
stated in the article on the morbid states of serous
membranes. It may, however, b' here premised,
that the medium of adhesion, which is first fluid,
and afterwaids albuminous and nearly solid,
soon becomes partially organised ; blood-vessels
shoot into it, and thus opposing surfaces become
more or less firmly united, according to the de-
gree of motion occurring between them, that
may either prevent their firm adhesion, or disturb
it after it has been already formed, and to the
state of the fluid which becomes the medium of
union. In some cases this fluid is secreted so
copiously, and is so deficient in the albuminous
constituent, the watery part being so predomi-
nant, that adhesions are formed only in difi'er-
ent, or in numerous and irregular ponts, be-
tween which serum in various states is efl^used,
separating the oppo-ite and partially united sur-
faces, stretchinir the adhesions, breaking down
some, and reducing others to cellular bunds run-
ning between these surfaces through the efl^used
fluid, which is in such cases usually very tur-
bid, and abounds in flakes of albuminous matter.
This appearance is not unusually observed in
cases of adhesion of the pleura, pericardium, and
occasionally of the peritoneum.

4. The conrrescible fluid, as will appear in the
secjuel, which is formed between the surfaces of
divided structures, originates in two distinct modes,
gtmerall.y assumes a firmer and more fibrous cha-
racter in its advanced stages, and undergoes a
more marked diminution of volume than is ob-

ADHESIONS

served in those adhesions which form on serous
surfaces. From this it will be apparent that ad-
hesions are formed by the medium, 1st, of a con-
crete inorganic albuminous matter ; and 2d, of
this matter, at a later period, in a more or less
organised state, and presenting various appear-
ances, according to the length of their duration,
and the nature of the inflammatory disease which
produced them. It will be also apparent, from
the foregoing, that the adhesion of opposite sur-
faces is not in itself a specific disease, but the
result of disease, — generally of inflammation in
some one of its grades.

5. Adhesions, in respect of their ultimate ten-
dencies, are either i-f/wirat/tie or morbid. — M. Cru-
VEiT.niER, who has divided them into two classes,
according to this view, comprises under the former
the adhesions between divided tissues and sur-
faces brought about by surgical aid ; to which I
may add those that lake place around puru-
lent formations, and prevent the extension or
effusion of the collected matter into adjoining
parts. Whilst the reparative class of adhesions
are staled to form generally between divided
structures and diseased sui faces, it should be
kept in recollection that all the tissues do not
admit of adhesion taking place immediately be-
tween theirdivided surfaces. Blood-vessels, nerves,
muscular fibres, and tendons do not unite, after
division. It is the minute vessels of the cellular
tissue which surrounds them, and their individual
fibres, that chiefly furnish the means of their
adhesion. From these vessels, if protected from
the atmospheric air, a coagulable lymph is thrown
out ; which gradually becomes vasculur, organ-
ised, and in a few days cell ulo- fibrous, and as
firm as the parts which formed it. This newly
produced substance is the medium by which the
muscular fibres, or other structures which had
been divided, are united ; and this gradually be-
comes thinner and less apparent, and admits of
the nearer approximation of the separated parts,
until they at last seem continuous, although the
existence of the medium of union may still be
detected. This constitutes primarij adhesion, the
union by the "Jirst intention" of surgeons.

6. When the flivision takes place between
bones, this exudation forms the callus, into which
ossific matter is deposited. Some pathologists
believe that the concrescible lymph, thus fur-
nished by the capillary vessels of the divided
surfaces, particularly those of the cellular tissue,
is the matrix, in which the peculiar structure, of
which nerves or muscular fibres consist, is after-
wards formed or deposited. But, if this were the
case, the firm, and even fibrous, matter into which
ihe medium of union is ultimately changed, would
at last disappear, and these structures be actually
continuous. This, however, never unequivocally
occurs ; for, although the uniting medium is re-
duced to a very thm, and scarcely perceptible,
substance, yet it may be made apparent by ma-
ceration and careful dissection.

7. When air is admitted between the divided
structures, or when primary adhesion fails of
taking place, a different process obtains ; minute
granula; or carunculae form upon their surfaces,
whence proceeds at first a fluid pus, subsequently a
more concrescible fluid, which forms a sort of false
membrane, and which, when the opposite s\irfaces
are ke|)t in a state of near approximation, be-

\'0T.. I.

: — Reparative. 33-

comes the medium of adhesion, unless the state
of the system is such as not to admit of the form-
ation of this concrescible fluid, and of the other
steps of this restorative process. When divided
parts come in contact with the air, the adhesion
is always formed in this manner, — by the sup-
purative process, — whatever may be the nature of
the structure which is thus circumstanced ; and
the false membrane, which is the medium of
union, becomes more thin, firm, and fibrous, and,
at the same time, less apparent with the lapse of
lime. This may be called consecutive adhesion.
When the divided surfaces are protected from
the air, and primary adhesion takes place, the
process is more rapid ; but its quickness will de-
pend upon the quantity of blood effused between
the divided surfaces. If this be considerable,
one of two things will result,— either the effused
blood will be absorbed, and a cyst, or cellulo-
fibrous medium of union, be slowly formed,
which will be gradually diminished in thickness ;
or the coagulum may act as a foreign substance,
keep up irritation of the vessels in the divided
surfaces, and cause suppuration, and consecutive
adhesion with the cicatrix formed by the medium
of union. (See art. Abscess.)

8. There is one important point connected with
adhesions in their various states and seats,—
whether reparative or morbid, whether primarily
reparative or consecutively reparative, and whether
taking place between cellular, serous, or other
structures, — which has not received the at-
tention from modern pathologists that its prac-
tical importance requires for it, and to which
John Hunter first directed notice. I allude to
the important truth, that adhesions of either of
the above descriptions, but particularly the pri-
mary reparative, whether taking place between
divided surfaces or around purulent formations,
either will not form, or, if in the process of form-
ation, will be dissolved, in c.ertain states of the
vital energies of the frame, and of the circulating
fluid. Great depression of the vital influence will
have this efl^ect, whether it be produced by the
exhaustion proceeding from profuse discharges,
by contagious and other noxious miasms, by the
close air of hospitals, and other places loaded
with animal effluvia, by the inoculation of cer-
tain animal poisons, by the absorption of puriform
or sanious secretions, or other morbid matters,
into the current of the circulation, by the mercu-
rial affection of the frame, or by the j^outy dia-
thesis. When the vital energies of the frame are
greatly depressed, and the tonic action of the
capillaries much relaxed, by causes acting either
exirinsically or intrinsically as respects the blood-
vessels, the ability of throwing out a concrescible
or coagulable lymph from the divided or inHamed
vessels is destroyed, and in its place is produced
an ichorous serum, or sanious fluid, winch may
either pass out, or, if no ready outlet is afforded,
will infiltrate itself through the tissues adjoining,
or be partially absorbed and vitiate the perhaps
already morbid blood. (See art. Blood.)

9. In order to prevent this very dangerous
state from supervening in all cases where the
repaiative process of adhesion is required, the ut-
most attention ought to be devoted to the state of
the vital energies, particularly as indicated by the
tone and frequency of the pulse, and the states of
the digestive organs. When the former becomes

D

34

ADHESIONS— Morbid.

very quick, and the powers of the latter fail, that
much dreaded state of the frame, which is insuf-
ficient for the formation of coaguhil)le lymph,
may be considered as approaching, if it be not
actually present. In all cases where blood-vessels
are liable to be inflamed, this state of the consti-
tutional powers, owing to the risk of the blood
being vitiated, is particularly to be guarded against.
Having advanced as much as belongs to my pro-
vince lespecting the reparative states of adhesion,
I proceed to stale briefly tne doctrine of Murbid
adhesions. The particular morbid adhesions are
noticed under the articles on the pathology of the
parts in which ihey form.

10. Adhesions in some one of the states de-
scribed above (§ 1 — 4.) are liable to occur, as a
consequence of certain grades of inflammation, in
the following situations: — 1st, In the cellular
tissue; 2fi, Between serous surfaces; 3d, Be-
tween mucous surfaces; 4th, Between synovial
surfaces ; 5th, In the internal surfaces of blood-
vessels ; ami, 6ih, Between the surfaces of morbid
or accidental formations.

11. A. Adhesions of Cellular Tissue. — The
fir-t step of the process is the exhalation of a
quantity of yellowish serum and of coagulable
lymph into the cellules of this tissue, which ulti-
mately agglutinates them together, upon the
absorption of the former, and the concrescence
of the latter. The consequence of this is, that
the piorluct of inflummation formed in the centre
of the inflamed cellular tissue, consisting chiefly
of the more fluid and least concrescible portion of
the exhalation, is prevented from permeating the
agglutinated cellules, and a barrier is set up
against it. If resolution takes place, and the pu-
rulent matter is absorbed, the surfaces of the
cavity become united, and the medium of union
is changed, as in cases of recent wounds, and in
the manner described above (§ 5.). If the parts
go on to the evacuation of the matter, adhesion
is also effected, as in the case of consecutive re-
storative adhesion {§ 7.) ; leaving, however, a
cicatrix, which is gradually dimitii-hed, formed
of the cellulo-fibrous medium of union. In all
cases of indammaiion of cellular tissues adhesion
of the cellules, from the exudation of a concres-
cible lymph, takes place ; and it is thisadheson
which forms the fibrous cysts ti abscesses, isohites
their contents from the surrounding structures,
and in some respects excludes them from the
econoToy. Adiiesions of the cellules of this struc-
ture also strengthen the cysts of aneurisms, and
form sera fibrous cysts around foreign bodies that
are accidentally lodged in it.

12. B. Adhesions between serous surfaces are
the next most common; being formed through
the medium, either of a more or less thick and
firm inorganic albumen, in the form of a false
membrane, or of this substance advanced to a
more or less organised state, and assuming either
the appearance of cellular tissue, with a surface
partaking of the serous character, or one of the
states about to be noticed. 'I"he organised nature
(if those adhesions has been denied by some ; but
the observations of Sioi.i., Hiinti;ii, JJupuy-
TuiN. Baii.i.ik, Meckel, Homk, LoiisriiiN, Ciiu-
vhiLiiirn, Gendiun', Baiion, and others, who
have traced blood-vessels in them, have put the
question at rest. Adhesions occur most frequently
bet^veen the pleura;, next in the peritoneum, and

next Jo these in the pericardium They are com-
paratively rare in the tunica vaginalis ; and in the
arachnoid they are still more rare.

13. It is not necessary to the formation of ad-
hesions between opposite serous surfaces, that the
pre-existing inflammation shall extend continu-
ously to both. VVhen the coagulable lymph is
thrown out upon one of the two inflamed surlaces,
— as, for instance, on the peritoneal surface of the
small intestines, — it seems to act as an irritant to
the opposite part of the omentum, with which
it is brought in contact, inducing inflammation
of that part only, and leaving the intervening
surface both above and below it unafteeted. The
part thus irritated by the contact of the coagu-
lable lymph, poured out by the part primarily
afl^ected opposite to it, becomes also inflamed,
and exudes this concrescible fluid ; and the
inflammation thus secondarily induced in a part
of the omentum, may advance to the external
surface of the omental duplicature, and, by means
of the exudation of this product of inflammation
in that situation, excite a similar state of action
in the directly opposite part of the peritoneum
reflected over the abdominal parietes. Thus the
inflammation and its consecutive adhesions may
proceed, without the disease having affected any
of the continuous surfaces intervening between
them. A .-imilar circumstance is sometimes ob-
served in respect of the convex surface of the
liver and peritoneal surface of the diaphragm.
Infldmmation, commencing in a part only of the
former, will excite it in the part of the latter
exactly opposite, and be followed by adhesion ;
and the inflammatory action, not infrequently ex-
tending upwards through the diaphragm to the dia-
phragmatic pleura, will be further followed by the
exudation of coaj^ulable lymph on its free surface,
which, irritating that portion only of the pulmonic
pleura opposite to, or in contact with it, will inflame
that part, and form adhesions with it, without
afTecting the continuous surface intervening be-
tween, and surrounding the adherent parts. The
unadhering cavity, however, not infrequently
contains a turbid or flaky serum, with patches of
false membrane, arising from a less acute state of
inflammatory action in those parts of the serous
surface immediately adjoining the adhesions. Thus
it is not unusual to find, in cases of acute inflam-
mation afl^ecting either the peritoneum, pleura, or
arachnoid, and limited to a particular part, a
similar state of disease, and the same product,
formed only, in the parts ojiposite, and most nearly
in C(mt!ict ; whilst the continuous surfaces sur-
rounding them are either altogether sound, or
much less afl'ected ; — most commonly only so
far as to give rise to a serous exudation, or slight
albuminous coating, in their immediate vicinity.

14. From tliis it will appear, that the near
approach, and more especially the immediate
contact, of opposite surlaces, and the want of
motion between the one surface and the other,
will favour the formation of atlhesions : thus they
are most fieciuent at the superior parts of the
pleura, between the convex suiface of the liver
and the dia])hragin, and the serous surfaces of
pans included in hernia;. The different species
of media, by which adiie-ions of serous surfaces
tire affected, are the following, according to M.
CiirvMi-nim : — An inorganised false membrnne ;
a fihtmentoiis adhesion, and a cellular adhesion.

ADHESIONS — Morbid.

35

in neither of which blood-vessels are evident ; a
permanent organised mtmhruDe ; and a lubercu-
lated membrane. All these originate in a concres-
cible lymph, as in adhesions of cellular tissues.
(See art. on Serous Membranes.)

15. C. Adhesions between mucous surfaces
are not frequent. Bichat denied the possibility
of their occurrence, unless destruction of the
mucous membrane had taken place. lie wns led
to this conclusion more by the functions of this
membrane in health and disease, than by observ-
ation of facts. There can be no doubt, however,
that the opposite surfaces of canals, covered as
they are by mucous membranes, occasionally
adhere, in consequence of very acute attacks of
inflammation ; but this occurs very rarely, owing
to the access of atmospheric air, to the pre-
sence of gases, to the various matters con^tantly
passing tlirough them, and to the nature of the
fluid which usually proceeds from inflammation
of these surfaces. The mo^t common exception
which takes place to the general inference adopted
by BiciiAT is met wiih in the vagina. I have
observed several ca-es, at the Infirmary for Chil-
dren, where adhesions of the oppo-ite surfaces
of this canal had taken place in consequence
of inflammation, — some of them at so early a
stage, that they were removed by merely forci-
bly separatini; the adherent surfaces, when the
mucous membrane was found perfectly entire,
but highly inflamed, and covered by an exuda-
tion similar to that which is thrown out upon in-
flamed serous membranes. Similar facis are
recorded by MM. Dupuytren, Villerme, Bres-
CHET, and Chuveilhier. Adhesion also of the
OS uteri, as a consequence of inflammation, is
sometimes observed. Occlusion of the Fallopian
tubes, and even the adhesion of the opposite inter-
nal surfaces of the uterus, have been occasionally
met with. Waltuer, Uenauldix, and Meckel
observed these changes so often in prostitutes, that
they attributed ihein to the frecpient irritation of
the p;trt3, and imputed the barrenness of these
females pait'y to this cause. But, in the cases of
occlusion of the Fallopian tubes, more is to be
imputed to the accumulation of an inspis<att'd or
albuminous mucus, the product of inflammation,
which, from its tenacity and consistence, cannot
flow along these tubes, than to actual organised
adhesion of their oppo-ite surfaces. The occa-
sional occurrence of obliteration of the canals of
the common bile-duct, and of the ureters from the
impaction of a calculus, seems to proceed from the
irritation and abiasion occasioned by calculi, and
the consetjuent exudation of a concrescihle flud,
which agglutinates their surfaces, and ultimately
tends to reduce them to a cellulo-fibrou^ chord.

16. Adhesions are either never met with in the
air-passages, or so rarely, as to render their actual
occurrence doubtful. I believe that, although
albuminous concretions are occasionally formed
in the bronchi, and frequently in the trachea
and larynx, Sec, they cannot be so produced as
to give rise to adhesions of the op|)Osite surfaces.
I'hcy never, or at least very rarely, become or-
ganised ; and although they may completely ob-
literate the canals of several of the bronchi, they
cannot have this effect on ihe trachea without
causing immediate death. The organisation and
form of the larger air-tubes completely prevent
their adhesion j although ihey are often nearly

filled up with concrete albuminous formations, as
a consequence of certain slates of inflammation.
Adhesions of the internal surface of the oesopha-
gus, or of any other part of the digestive tube, are
never met with ; although constriction, with thick-
ening, &:c. to the almost entire obliteration of
this canal, is not infrecjuent. As in the air pas-
sages, nature has made in the functions, during
health and disease, of the membranes which line
them, sufficient provision to prevent this lesion
from occurring. And we uniformly observe, when
inflammation attacks any poition of those tubes, the
preservation of the canal of which is essential to
life, that, although a copious albuminous exudation
will sometimes occur, its organisation will gene-
rally be prevented, and its detachment from the
suiface on which it is formed will be secured,
sooner or later, by the secretion of a more fluid, or
mucous, or muco-purulent matter underneath,
which loosens the concrete albuminous coating
or false membrane from i's attachment to the sur-
face on which it is formed. The circum.-tances
which chiefly seem to favour the formation of
adhesions between mucous surfaces, are — 1st,
The abrasion of the epidermis which covers them:
owing to which their secretions are changed, and
they partake more of the characters of cellular
tissue. 2d, Entire destruction of the niuious
membrane in a great part, or the whole, of the
circuml'eience of a canal, favouring its gradual
constriction, suppuration, and ultimate obliter-
ation. The bile-ducts, ureters, urethra, rectum,
and oesophagus occasionally furnish proofs of this
change in some one of its stages. (See art. on
Mucoi'S Membranes.)

17. D. Adiiesions of the synovial surfaces of
joints are rarely observed, excepting in cases of
anchylosis, of which they cannot be considered
even as the commencement, although they may
accompany the earlier stages of this change, par-
ticularly in anchyloses consequ nt upon rheu-
mati.-m. Rlany, however, of the alterations which
take place in the synovial appaiatus of tendons
are consequent upon their adhesion and obliter-
ation. Inflammation occurring in them primarily,
or exteniling to ihem from contiguous parts, is ge-
nerally followed by their adhesion, and reduction
to a state of dense cellular tis-ue. Hygroma
almost always terminates by adhesion.

18. E. The adhesion of the internal surface
of bliwd-veisels takes place through the medium
of the coagulated lymph secreted by the inflamed
va-a vasorum. The ves-el becomes impervious
in consequence of this exudation, which is poured
out in the form of a false membrane from its
internal surface. The lymph which is exuded,
particularly when its coagulable or concrescihle
property is well marked, fiequently produces
coagulation of the blood in contact with it ; so
that, generally, the oblitera'ion is occasioned both
by this lymph, and the coagulum of blood which
it occasions. In a short time the coagulum thus
formed within the inflamed blood-vessel becomes
more and more pale and den^e, sometimes par-
tially organised ; and, as its density is increased,
so is its bulk diminished : the coats of the vessel,
at tlie same lime, lose their specific characters ;
they seem constricted around tlie sub^^tance formed
within them, the middle coat becomes less di<-
lintlly fibrous, and at la-t they are reduced to
the state of a cellular, or fibro-cellular, chord.

D 2

36 ADIPOSE TISSUE

This may be viewed as thd primary form of their
adhesions, and its usual results. When, how-
ever, suppuration takes place in their internal sur-
face, the adhesion is formed consecutively in the
manner described above {§ 7.) ; or the primary
may pass into the consecutive form of adhesion,
particularly when the false membrane is insuffi-
cient to fill up (he entire canal of the vessel.

19. Adhesions take place more readily in veins
than arteries; are produced in both, and in lym-
phatics also, in the manner now staled, generally
in consequence of inflammatory action, attended
with sufficient power of the constitution to form
concrescible lymph (see the articles on Arteries
and on Veins) ; and sometimes, even after a very
slow and slight grade of this action, when the
opposite surfaces of the vessels are pressed toge-
ther by any tumour existing exteriorly to them.
When artificially excited in aiteries, as by the ap-
plication of ligatures, the inflammatory state which
produces the adhesion is not so prone to extend
along the axis of the vessel, or to occasion dan-
gerous effects, as when it is excited in the same
way in veins. When thus produced in these lat-
ter vessels, fault of constitution, an unhealthy
habit of body, unwholesome state of the atmo-
sphere, &c., or the other causes above assigned
{§ 8.), will generally interfere with the process,
and occasion that state of morbid action, and of
its products, which will vitiate the current of the
circulation, and even destroy life. (See Veins

— Iiijiammation of.)

20. F. Adhesions of the internal surfaces of
cysts, and other morbid formations, sometimes
take place from a consecutive state of inflamma-
tion extending to them. Large cysts, which in
consequence of their situation cannot be removed,
may be obliterated by their puncture, and the
production of inflammation of their internal sur-
faces, so as to procure their adhesion.

21. G. Adhesions may also form between
parts of the cutaneous surface, when deprived of
the cuticle, and kept in close contact. This is
not infrequent after scalds and burns, and is pro-
duced in a similar manner, as I have explained,
in respect of ailhesions taking place primarily,
and without suppuration, or subsequently to the
occurrence of this process in the cellular and
mucous tissues. Adhesions also occur in other
situations, as between the iris and capsule of the
crystalline lens, &c. ; but I have noticed tho-e
which more especially belong to my province.

Bibliography. — Bichat, An.itomie Generate, t. ii.

passim J. Copland, Lond. Med. Repos. t. xv, p. 372, —

Sciiuielten, Archives Gener. de Med. t. iii. p. 497., t. iv.
p. 3H6., t. V. p. .537. I.ond. Med. llenos. vol. xxii. p 3:i3.

— Renanldin, art. Adherences, in Diet, des Scien. Med.
t, i. — Hreschil, art Adherences, in Diet, de Mt'd. t. i.
p. 310. — Huron, On Tuberculated Accretions of Serous
Membranes, 8vo. 1819; and lllnstrations of Tuberculous
Diseases, 1822. — Cruvcilhier, Kssai snr I'Anat. I'iitliol.
t, i. p. U4. ; et art. AMdsimis, in Diet, de Med. et
Chirnrg. Pratiques, t. i. p. 317. — Meckel, Anatomle
Gener. et I'atliolof,'. t. Iii. passim. — Gendrin, Histoire
Anatom, des Inflainmalions, 2 t 8vo. Paris, I8'j7. —
Antlral, Archives Gen. de Med. t Iii. p. 24G. ; et Cli-
niqne Medieale, &e , t. iii. et iv. passim; et AnatOinie
J'.uholojjiinie, passim —-Craifiie, On General and Pathol.
Arnil. passiiii. (.See also /?iW;og. and Ilefcrences to art.

l.NFLAMMATION.)

ADIl'OSE TISSUE. ~ Tela adiposa, Lat. Tissu
l^raieaeuT, Vr, Das Felt, Germ. — Irs RIoiibio
Statics.

Ci.Assir...— IV. Class, IV. Ohdeu (Author,
see ihe Preface).

— Morbid States of.

1. The adipose substance is frequently either
diminished or increased far beyond the healthy
standard. — A. Excessive diminution of this sub-
stance, atrophif, occurs naturally in very aged
persons ; and there seems to be, even in early
life, a tendency to it hereditarily in certain con-
stitutions, particularly in those of a peevish,
anxious, and irritable temper. It is often met
with as a consequence of, or conjointly with,
pulmonary and other organic diseases, particu-
larly those which interiupt assimilation and the
supply of nutrition. But it is also a symptom of
all diseases, which impair the vital energies by
morbidly increasing the secretions and evacu-
ations; as in diabetes, dianhoea, and dysentery.
It also necessarily proceeds from long abstinence,
&c.

2 Atrophy of this substance may be temporary
or permanent. It is usually the former in early
or middle life, and continues merely as long as the
causes which occasioned it. It is usually perma-
nent in advanced life, and in those of an active,
peevish, restless disposition. In every case the re-
moval of the fatty matter is produced by absorption;
and, according to the experiments of JVIagendie,
Tiedemann, Gmelin, Mayer, &c., this process
may be ascribed, at least in part, to the minute
veins. The circumstance of fatty and oily mat-
ter being constantly found in the blood, but in
variable quantity, as shown by Trail, Babing-
TON, Le Canu, &c., seems to support this view ;
for, if taken up by the absorbents, it may have been
changed or assimilated in its passage through the
absorbent glands before it could have reached the
blood.

3. B. Excessive deposition or hypertrophp of this
substance (adiposis) is very common, aflTecting
the body generally, but sometimes locally only.
Persons have weighed as much as 500 or 600 lbs.
owing entirely to this state of hypertrophy. This
tissue is naturally abundant in females and
eunuc'is. Il;s hypertrophy is frequently occa-
sioned by excessive venereal indulgences, particu-
larly in early life, and when conjoined with high
living and indolence. It generally is attended
by a weak languid ciiculation, weak digestion,
with craving appetite, defective secretions and
excretions, and disinclination to active mental or
physical exertion. It also evinces a maiked here-
ditary character. Full living, particularly on food
which abounds with the elements of the fatty sub-
stance as sugar, spirituous and malt liquors, &c.,
tend greatly to promote it. The connection of
this morbid state with deficient assimilation ap-
pears fully proved. It would seem that in persons
who-e vital energies are diminished, whilst the
appetite remains unimpaired, or is excited by sti-
mulating licpiors, &c., the sanguifaction of chyle
does not take place so ra[)idly nor so perfectly as
in health ; that a large poition of this fluid assumes
an oily or fatty cluracter, and is deposited in the
adipose tissue, which thus becomes one of the
emunctories of the frame, in which a substance
that cannot leaddy be carrieil out of the circu-
lation by any other orj;an is set apart for the
purpose of future ab-iorption, assimilation, and
nutrition, as the wants of the system may reciuire,
and to.)>iev('nt its hu>'tful accumuhiiion in the
circulating fluid. 'J'hus, in persons otherwise ap-
parently healthy, the excessive accumulation of
fat is often one of the eailiesl and most remark-

A FTER-PAINS-r- Symptoms and Diagnosis.

37

of diminution of ihe vital energies of posed that it is first secreted in a solid form, and,

able

the frame. (See art. Ouesiiy.)

4. C. In many instances, when the powers of
the constitution are either greatly reduced or other-
wise perverted from the healthy state, the adipose
matter is also changed in roloitr, compositwn, and
consistence, becomii)g remarkably pale, or dark,
reddish, or gelatinous. It may likewise be, par-
ticularly in cachectic persons, uncommonly watery,
soft, smeary, or jelly-like ; and on the contrary,
but more rarely, hard, waxy, or even horny.

5. D. It may be a question whether or not this
tissue is liable to inftammatioti. Considering it
merely as a modification of the cellular structure,
chiefly in as far as it contains the falty substance
of the body deposited in its areolse, the containing
tissue only must be looked upon as that which is
liable to inflammation or any other disease; the
fat or contained matter being entirely passive, and
modified only by the morbid states of the tis-ue
which secretes and contains it. There seems little
doubt that the adipose tissue participates in the
variou-! states of diflTu^e inflammation ; whether
tiial attending upon ceitain forms of erysipelas, or
(ol'owing accidents, or the inoculation of morbid
matter. When thus inflamed, it rapidly parses
into a state of sloughy and fetid suppuration ;
large portions of it being not infrequently con
verted into an ash-coloured, semifluid pulp, mixed
with shreds of cellular tissue and albuminous
matter, cr becoming entirely sphacelated.

6. E. Ejff'usion of blood into the adipose tissue
occurs under similar circum'^iances to those con-
nected with haamorrhage into the cellular sub-
stance, but much less frequently. This change
has been occasionally noticed by Huxham, Ci.eg-
iiOBN, Craigie, and by myself and others, in
scorbutus, purpura hsmorihagica, and in the li-
quescent or malignant forms of remittent fever in
warm or unhealthy climates.

7. F. Of the tuvioins most frequently deve-
loped in this tissue, the most remarkable are — a.
Adipose sarcoma, which is surrounded by a thin
capsule of cellular tissue condensed around it, and
consists of an unusual accumulation of latty matter
in cells, the component fibies of which are so firm
as to give consistence to the tumour: it closely re-
sembles a local hypertrophy of the adipose tissue,
excepting that it is surrounded by a capsule ; and
it may have either a broad or narrow base ; — b.
Steatomatous tumours are chielly a peculiar modifi-
cation of the fatly secretion, which is accumulated
in masses, surrounded by a spheroidal cyst : they
are not formed of cells, in which the fatty matter
is deposited, but consist of a simple semifluid sub-
stance secreted by the inner surface of the cyst *
lliey occur more frequently in the cellular, than
in ihe adipose tissue; — c. Alheromatous and me-
licerous tumours are either modifications of the
steatomatous, or proceed from the change induced
in small riironic abscesses; but they are most
commonly the former when seated in this tissue.

8. G. Metalloid deposition is sometimes found
in both the internal and external adipose substance.
It may be either disseminated in the form of small
inky spots, or accumulated in spheroidal masses;
or found in a semifluid state and brownish black
colour, surrounded by a cyst formed by the con-
densation of the contiguous cellular tissue. As
to the state in which this peculiar matter is formed,
great diveisity of opinion exists. L.aenxec sup-

iike tubercular deposits, afterwards becomes soft.
I am, however, inclined to adopt the opposite
opinion ; viz. that it is secreted in a fluid or semi-
fluid state, and that it afteiwards becomes firm by
the absorption of its more fluid parts. The ob-
servations of Drs, CuLLEN and Carsweli., and
of BI.Chomel, seem to confirm this opinion.

BinLioGRAPHY. — Art. Graisse, Corpulence, and ObisH€,
in Diet, des Sciences Medicates. — Graefe, in Journ. fur
Cliirurp. iind Augenheilk. b. ix. p. iii. p. 367. — Grune,
I)e Sank ft MorbosA Pinguedinis in Corpora Secretione,
8vo. I5er. 18'J6. — 0«o, in Selt. Beobacht. b. ii. p. 166.—
Ckomcl, Nouv. Journ. de Med. t. iii. p. i\.— Craigie,
General and Pathological Anatomy, p. 62.

AFTER-PAINS. Syn. Parodynia Secundaria
Dolorosa, Good.

Classif.— 5. Class, 3. Order (Good). II.
Class, III. Order {Author).

1. Uefin. — Pains, more or less severe, either
continuing or supercening shortly after the eipul'
sion of the placenta in child-birth.

2. I. SYMPTOMS and Diagnosis. —Attacks of
pain in the abdomen are usually experienced in
the early part of the puerperal stale. They pro-
ceed, when very severe, from the contraction of
the uterus, irregularly excited by the presence of
coagula. They usually soon follow delivery, are
least severe alter a first labour, are increased upon
the application of the child to the breast, and last
for a day or two. They are generally aggravated
by flatulence and costiveness.

3. It is extremely requisite for the young prac-
titioner to be on his guard respecting the nature
and seat of pain after delivery, as the coramence-
rr.ent of the most fatal diseases to which the sex
are liable may be mistaken, if not carefully ob-
served, for after-pains. These latter are the re-
sult of the natural contractions of the womb, and
of its return to its former state ; and are distin-
guished from disease, particularly inflammations
of the uterus, ovaria, or pelvic peritoneum, by
their remissions, and by the absence of tenderness
or tension of the abdomen, especially on pressure.
The uterine discharge, also, is not obstructed ;
the milk is secreted; there is no shivering nor
vomiting ; and the pulse is seldom increased in
frequency.

4. When the patient's bowels have been neg-
lected previously to confinement, and when much
flatulence exists, the after-pains are often com-
plicated with colic, or they assume a colicky
character. In cases of this kind, the abdomen is
often somewhat more tense and distended than
usual ; the fits of pain are severe, with complete
remissions; the patient complains of flatulence;
the bowels are constipated : but the pulse is not
much afl^ected ; the skin, particularly of the
trunk, is not hot ; the tongue is moist ; and the
feet are often cold ; in a few cases there is retch-
ing. It is important to attend carefully to the
character of pain consequent upon delivery, and
to consider it in relation to the attendant symp-
toms, particularly the states of the pulse, and of
the abdomen. We ought, therefore, to inquire
into its exact seat, examine the pained part caie-
fully with the hand ; and, having ascertained in
what manner it is aft'ected by the examination,
we readily arrive at just conclusions as to its
nature. When it is felt in the regions of the
uterus and ovaria, and accompanied bv crtat fre-

D 3

38

AGE — Its Diffeeent Periods.

quency of pulse disorder of the lochia! discharge, , by reiroving flatu=, and promoline the restoration
tenderness, and fulness of the hypogastric region, ! of the uterus to its natural state! In the more
^c, the existence of the inflammaiory diseases of ' urgent cases, anodjnes may be conioired to the
the uterus and of us appendages, are to be in- j foregoing means ; for, when thus associated, they
lerrecl. It n be complamed of about the groin, will not act in preventing the contractions of the
"^7 .l^e 'he forerunner of phlegmasia dolens ; uterus. (For HvsTEnALoiA, and the various dis-
ana It It be telt about the hip, or in the muscles eases of the uterus in the puerperal and unimpie'r.

Ol the pelvis, abdomen, nr thidlio 'it rr,Q«T Uo I mt,jrl ctot^o o„„ it \ '^ °

of the pelvis, abdomen, or' thighs, it may be
rheumatic, ovi-ing to the application of cold in
some form or other. The pains of riieumatism
aie readily recognised from their seat, their ach-
ing or gnawing character, the manner of their
affecting the motions of the part, and the attend-
ant symptoms. '1 he diagnosis, however, of these
diseases is fully pointed out under their respective
head^.

5. II. Treatment. — The exhibition of an ano-
dyne, with attention to the state of the bov,eIs
subsequently, has generally been considered suf-
ficient for the relief of after-pains. In the more
severe cases, an anodyne liniment has been re-
commended to be applied to the abdomen, in
addition to the exhibition of a dose of laudanum
internally ; and, in protracted cases. Dr. Burns
advises a purgative — certainly the best pait of
the Irtatment usually resorted to. I am, how-
ever, of opinion, from remarking the results of
this practice, that the common or less urgent
cases would have been better left to nature; "and
that friction of the abdomen merely with any of
the liniments in the Appendix ( F. 297, 298.), or
friction followed by a purgative, or an enema, is
all that is necessary. We ought to recollect that
these pains are merely the result of the healthy
tonic contractions of the uterus upon the con-
gested veins, and the coagula remaining in it,
occasioning their expulsion, and the discharge of
the blood arcumulated in its sinuses ; and that
the more effectually these ends are accomplished,
particularly in unhealthy situations, and lying-iti
hospitals, the less risk there will be of the occur-
rence of dangerous forms of puerperal disease.

6. Whilst, however, anodynes allay the morbid
sensibility of the uterus, they tend to diminish its
tonic contraction, to induce a congested and re-
laxed state of its parieies and mouth, and to
favour the admission of air into its cavity. Air
when admitted, particularly under certain circum-
stances, is productive of the most dangerous re-
sults, from Its effects upon that portion of the
surface of the womb to which the pla( enta was
attached. Impressed with the justness of this
view, I have usually recommended frictions with
liniments over the region of the uterus, and a
purgative, or purgative injection, which will tend
essentially to favour the contraction of the uterus,
and the expulsion of the cause of irritation.

7. In cases complicated with flatulency and
colic ($ 4.), the above means are still more re-
quisite; but much will depend ujion the choice
of purgatives. Rly own experience, derived en-
tirely from consultation, is decidedly in favour
of a draught, consisting of half an ounce of the
oleum lerebinlhina;, combined with the same
quantity of oleum ricini ; or an enema, contain-
ing the same medicines. 'J he combination, also,
of a purgative with assnf(jetida, or any other
antispasmodic, and an injection, consisting of in-
fusion of valeiian, or containing assafotida, with
a due proportion of any aperient medicine (see F
130. Vib. 138.), will seldom fail of giving rel'cf.

nattd slates, see Uterus.)

BinLioGRAPHV — Dcnvian, Introduction to the Prac-
tice of Midwifery. &c. Lond. 1816, .Sth edit.- Caiclien
Iraite complet d'Accouchemens et des Maladies des
Ffinmes,&c. t. lii. Paris, 1 82f.. — ^Bwrnx, Prhiciiiles of
Midwifery, &c. L-.i.d. I'^24, p. 52G. -Good, Study of Me-
dicine, vol. v. — Bj/au, Manual of Midwifery, 3d edit.
Lond. 1831. ,

AGE.— Syn.— vi;fas, Lat. Das Alter, Ger. A<'e
Fr. Eta, Ital. "

Classif. — Pathology and Therapectic=.
1. In the succinct view I propose to take of the
pathological and therapeutical indications which
this subject will naturally suggest to the mind of
the practical physician, I propose, ^Vsf, to sketch
the successive epochs of life, and thus consider
the word in its generic acceptation. When I ar-
rive at those periods of existence to which the
word age is specifically applicable, the changes
which take place in the human frame, in respect
both of organisation and function, with the ad-
vanced progress of years, — with age in its specific
acceptation, will be fully stated, as furnishing im-
portant data for practical indications in the Treat-
ment of diseases of this epoch.

2. I. Of Aoe in its generic Accept.atiov,
—or different Epochs i<f Life. — Before I proceed
to consider the subject in its enlarged point of
view, I may briefly advert to the periods into
which the usual natural duration of human exist-
ence may be divided. Without occupying my
limits with the divisions adopted by ancient and
modern writers, I shall adopt that arrangement
of the diflferent epochs of life which has been
suggested to my own mind, from observing the
varying manifestations of life and function, and
the modifications of diseased action with advancing
age. The division which I have thus adopted
may require more to be said in support and illus-
tration of it, particularly in respect of its physio-
logical rel-itions, than I am willing to advance
on a subject which may be considered as nearly
verging on the speculative. Leaving, therefore,
out of sight many of the physiological and psy.'
chological views, which would arise out of an
extended investigation of the subject, I shall
merely briefly ad'vert to topics of practical im-
portance ; — those which concern the medical
jurist fall not within the scope of this work. (For
epoch o(fa-ial life, see Focius. )

3. Before proceeding to consider the diflferent
periods of age individually, it may be useful to
exhibit a view of the arrangement I intend to
follow ; —
i. Period, or that of Infancy.

1st Epoch, to the commencement of the first

dentition.
2d Epoch, from the commencement, to the
completion, of the first dentition,
ii. Period, or that of Childhood.

E\tending from the completion of the first to
the completion of the second dentition,
iii. Period, or Boyhood — Cirlhood.

From the seventh or eighth year to the com-
mencement of puberty.

AGE —

iv. Pekiod, or Adolescence.

Com mincing witli the first appearance of
puUerty, and extending to adult age.
V. Periou, Adult Age.

1st Epoch, or early adult age, or confirmed
virility.

2d Epoch, or mature age.
vi. Pebiod, Declining Age.

1st Epoch, declining age.

2d Epcf/i, advanced age.
vii. Period, Old Age.

1st Epoch, ripe old age.

2d Epoch, decrepitude — second infancy.

4. i. Period, or that of Infancy, {Infantia,
from the privation of speech,) commences with
birth, and extends to about the end of the second
year, when the first dentition is completed. It
may be divided into two epochs ; the first begin-
ning at biilh, and extendmg to the sixth or
seventh month, when dentition is fully com-
menced ; ihe second proceeding from this age to
the end of the period, the completion of the first
dentition, when the relations of the young being
with the external world are fully esiablished by
the developement of the sensorial and locomotive
organs. ,

5. A. During tlie^rjf epoch, or that preceding
the commencement ot dentition, all the structures
are merely in the course of developement ; par*
ticularly the osseous system, the cerebro-spinal
nervous system, and the organs of locomotion.
The functions are only atquiiing activity, and
seveial of them have not yet appeared. The
vital phenomena gain strength, whilst certain of
those functions, by which the young being is to
hold converse with the objects around him, either
begin to dawn, or have not yet merged into
existence. The manifestations of life are chiefly
vegetative, and the movements automatic or sym-
pathetic. The attitudes are generally without va-
riety, and the changes of the countenance express
meiely pleasure and pain to the spectator ; but,
to the medical observer, they convey important
infoimation, and often all that he can obtain
respecting the maladies incidental to this period
of lile. At this epoch, the position of the limbs,
the character of tlieir motions ; the cry, and its
numerous varieties; and especially the changes of
the countenance ; the state of the eyes and eye-
lids ; the openness, contraction, dec, of the eye-
brows ; the appearance of the lips and nostrils,
of the mouth, gums, and tongue; — all furnish
means of ascertaining the nature and progress
of disease.

6. a. At this stage the organs of digestion are
unsuited to any other food than that derived from
the breast of the mother; and so little capable
are they to as>imilaie any other, even of the
blandest and most digestible kind, or the milk of
other animals, that very few, not more than one
in six or seven, ever arrive at the more advanced
periods of life who are deprived of the kind of
nourishment nature intended for this epoch. At
this age the system is extremely susceptible of
external impressions acting upon the lungs, sur-
face of the body, and digestive organs ; and par-
ticularly to tlie iiiduence of cold. Recently re-
moved from a constant and unvaried waimth,
and having heretofore existed with all the mucous
surfaces shut from the action of foreign agents,
the young infant imperatively requires to be pre-

Infancv. 39

1 served, particularly during the first months of
this epoch, from the influence of a low range of
tem| erature, and trom its sudden chani;es. The
disposition to increased action in all the mucous
membranes, and the great susceptibility of the
respiratory nerves, require tlie surface of the
body, and particularly the organs of res[)iration,
to be guarded from atn.ospheiic vicissitudes; the
chief source of the diseases which are so pre-
valent and fatal at this age. A similar suscepti-
bility of the digestive mucous surface also exists,
and is but too frequently evinced by the slightest
change in the milk of the mother, or addition of
articles of food unsuited to the state of the diges-
tive organs. Much of the mischief, however,
which improper inge>ta are calculated to pioduce,
is guarded against by the copious secretion of
mucus, with winch the internal surface of the
stomach and bowels is covered, particulaily in
very early life.

7. The su-ceptibilily of the mucous tissues to
stimuli and irritants, and their proneness to in-
flammatory action at this age, extend al>o to the
cutaneous surface, as shown by the fiequency of
acute exanlhematous di^eases, and ot chronic
eruptions. The intimate sympathy existing be-
tween both these structures is very strikingly
evinced, by the frequent association of inflam-
matory excitement of the mucous surfaces, par-
ticularly of the digestive canal, with a similar
afl^ection of the skin. The co-existence and close
connection of inflammatory irritation of the di-
gesiive mucous surface, and an analogous state
of disease of the brain and its membranes, or the
supervention of the latter on the former, are also
often observed. During the first months of ex-
istence, vascular action in the brain is promi-
nently developed, and engaged in perfecting the
organi>ation of this organ : and partl\ owing to
this circumstance, as well as to the quantity of
blood sent to it, compared wiih the rest of the
body, and to the various causes tending at this age
to derange its circulation, is readily kindled into
an inflammatory state of its substance or mem-
branes, giving rise to active congestions, efl^usions
of fluid in the cavities and between the membranes,
and to various other organic changes paiticularised
in their appropriate articles.

8. b. With the susceptibility to be impressed by
the causes of disease, evinced chiefly in the ner-
yous centres and mucous surfaces, and p oducing
their efl^ects, not only on them but also on the
serous cavities, there is intimately connected a
marked disposition to be aflPected by medicines,
which exert their influence in an especial manner
upon the nervous system. Of these the most re-
markable are narcotics and irritating stimulants.
The susceptibility to the influence of the former,
particularly the preparations of opium, and their
efl^ects, primarily in increasing vascular actioa
in the biain, and secondarily in favouring con-
gestion in the same organ, according to the dose,
have appeared to me so important, that, duiing
an extensive public practice amongst this class
of subjects, I have scarcely ever ventured, during
this epoch, on the exhibition of these medicines,
excepting under peculiar circumstances, which
will receive a more particular notice in other
places. A similar caution is also necessary in
the use of stimulating and irritating substances.
'Ihe aperient medicines which are so often re-

D 4

40

AGE — Infancy.

quired at this age should be chiefly of a mild and
unirritating quality; and, whilst cold and moisture
must be avoided, too warm clothing, particu-
larly of the head, ought to be equally shunned.
Exposure to a mild, healihy air, frequent ablu-
tions of the surface with cold water during the
latter part of ihis epoch, — comnjencing first
with warm water, and passing on to the use of
tepid, and afterwards of cold water, as the infant
increases in strength, — followed by frictions,
and careful attention to the state of its evacu-
ations, are means which should not be omitted in
the management of this period of life. Although
Cold bathing is generally beneficial after the first
months of infancy have elapsed, care should be
taken not to subject the infant to the influence of
col.i beyond a minute or two, or longer than may
be requisite to the perfect ablution of the surface ;
for, at this epoch especially, the impression of
cold continued for any considerable time de-
presses the vital energies, and prevents the de-
velopement of that state of healthy secretion on
the surface, which usually follows the momentary
or brief action of cold, particularly wlien followed
by dry frictions.

9. B. 'I he second epoch of \\\\s peiiod, extend-
ing from the commencement of the first dentition
to its completion, embraces also the important
period of weaning. The natural changes pro-
ceeding in the different structures and functions
during [he Jirst epoch also continue through this.
As this period advances, the functions of external
relation, particularly speech and voluntary loco-
motion, commence, the phenoniena of perception
are more perfect, and the manifestations of mind
begin to appear. The instinctive desires and emo-
tions become more and more evident and active,
and furnish, with the other functions, important
indications of disease, and of the means of re-
moving it. 'J'he susceptibility of the nervous
system, and of the mucous surfaces, to be im-
pressed by the usual exciting causes of disease,

— particularly by cold, moisture, atmospherical
constitutions, and vicissitudes, contagious or in-
fectious miasms, and errors of diet and regimen,

— is unimpaired.

10. a. Teething, which terminates the preced-
ing epocli, and ushers in this, is commonly con-
nected with more or less disorder of the system.
In infants of a healthy constitution, and in whom
the powers of life are energetic, disorder is
scarcely perceptible unless from the operation of
very efficient causes ; but in those who are de-
bilitated, whose conformation has been originally
feeble, or imbued with any hereditary taint or
niorhid diathesis, or who have been weakened by
unwholesome food and impure air, this process
is often attended with great disturbance in the
frame, and, owing to the morbid sensif)ility and
irritability it excites, fre(|uei)tly kindles up most
tlangerous disease. During the process of /««(/(-
"'o> particularly at its early stages, the itching
and irritation of the gums are a constant source
of excitement, or focus, whence irritation extends
to the salivaiy apparatus, as proved by the in-
creased flow of viscid saliva. 'J'he continued
desire evinted by the little patient to allay the
itching ot the gums, by pres'sing between them
whatever it can lay hold of, and the evident dis-
tress expressed by it if this sensation, wnich is
known to be more insupportable than pain, can-

not be allayed, are indications which ought not
to be overlooked. If this distressing sensation be
not allayed by judicious means, the nervous sys-
tem becomes inordinately excited, febrile com-
motion is induced, the functions of digestion are
disordered ; and we are, consequently, not infre-
(juenily called upon to remove inflammation of
the membranes or substance of the brain, various
convulsive affections, and inflammatory disorder
of the digestive mucous surface, owing to the
extension of irritation along the alimentary canal,
as well as to the acidities formed in the stomach
and bowels, from the imperfect digestion of the
food. During dentition also, a marked disposition
seems to exist in the pancreas to become excited,
owing to its close sympathy with the salivary ap-
paiatus; and I am persuaded that several states
of diarrhoea observed at this epoch originate in,
or a'e perpetuated by, an increased secretion of
pancreatic fluid.

11. Owing, moreover, to the excitement and
irritation existing in the gums, aftections of the
respirytory and digestive mucous surfaces are
more frequently associated with one another, and
with increased vascular action in the nervous
centres and their envelopes. It would seem that
the irritation existing in the mouth disposes, from
its influence on the nervous system, the mucous
membranes not only to be invaded by the exciting
causes of disease, but also to undergo the morbid
action throughout. How frequently has the ex-
pei ienced practitioner observed inflammatory irri-
tation of the dige>tive and of the respiratory
mucous surfaces associated in the same case ;
and how oft^n has he had cause to suspect the
rapid supervention of irritation of the membranes
of the brain, or of the brain itself, either with or
without effusion, upon inflamniation of the di-
gestive mucous surface !

12. b. Weaning. — During this epoch wean-
ing must take place. This should not be earlier
than the eighth or ninth month, or later than the
fifteenth ; and the infant ought to have, at least,
four teeth quite through the gums before it be
commenced. The milk of the mother is the in-
fant's only food during the greati r part of the
preceding epoch, or, at least, until the fourth or
fifth month, unless the mother and child be in a
weakly slate. From this age upwards it requires
food in addition to the nourishment afforded by
the mother; but this must be given at first in
small quantities, and not oftener than twice daily.
As this peiiod of weaning ajiproaches, food in
larger proportion, and increased frequency, ii
necessary; and as soon as it shall have got teeth
to masticate animal food, this may be given it in
small quantity, and at first only twice in the
week. Animal diet is seldom refjuiied before the
completion of the first year, or previous to wean-
ing ; afterwards it may be given in gradually
increased fietjuency, as the termination of the
epoch approaches.

13. VVhil-t the infant is liable to most of the
maladies which affect it during the first months,
it is now also ex[)Osed to the invasion of many
more ; owing to the excitement occasioned by
teething, the state of the milk, particularly during
the last months of lactation, and the errors in
respect of both the (juaiitity and quality of the
food. At the same time, however, its vital ener-
gies are more developed, and its functions moie

AG E — BoviiooD.

41

perfect ; and thus increased resistance is opposed
to the extension of disease, and to its disorganis-
ing effects. All infectious and exanthematous
disorders are very prevalent at this age ; and, in
addition to the maladies of the mucous surfaces
already alluded to, the lymphatic glands, particu-
larly those of the abdomen and thorax, are fre-
quently the seat of disease ; and worms often
begin to form, particularly after the period of
lactation. At this age, also, owing to the changes
in the infant's food, as well as to the irritation
occasioned by dentition, the disorders which ori-
ginate in depraved or imperfect digestion and
assimilation are especially prevalent, particularly
aphthae, rickets, tubercules, marasmus, and tabes
mesenterica, remittent fever, scrofula, and nu-
merous cutaneous eruption-^.

14. c. The therapeutical indications at this
epoch chiefly relate to the care which is recjuired
to preserve the head cool, and ward off the vascu-
lar excitement to which it is liable. Anodynes are
less injurious at this period than in that preceding
it, and are often required, particularly in soothing
the irritability of the nervous system arising
either from difficult dentition, from the exhaustion
occasioned by previous treatment, or by disea>e,
and particularly in the advanced stages of whoop-
ing-cough and cioup. The state of the gums
requires particular attention ; and where there
is evidence of itching, this sensation requires to
be allayed, first, in the way that nature points
out, by pressing hard and smooth substances be-
tween ilie gums, as a coral, ivory ring, and what
is be^t, a gold ring, when this may be directed.
If the least appearance of local affection, as
tumefaction, redness, &c., or even merely con-
stitutional disturbance, manifest themselves, the
gums should be freely and deeply scarified. Ape-
rients of a mild and cooling nature, are often
required during this epoch ; and in it, as well as
in the preceding, blisters, even for a few hours
only, particularly when the respiratory mucous
surface is obstructed and its functions interrupted,
or when the energies are exhausted and the vital
resistance consequently reduced, must be employed
with extreme caution, and give place to the use of
those liniments which 1 shiill have occasion to re-
commend as substitutes for them under such cir-
cumstances.

15. ii. Period, or that of Childhood (Pite'
ritia), extends from about the second to the
seventh or eightli year, when the second dentiiion
is completed. During this period the develope-
ment of the different textures and organs pro-
ceeds rapidly, and their functions are more and
more perfect. The mental manifestations, par-
ticularly those which are intellectual, are de-
veloped, and the various moral emotions gain
strength. The distinctions which exist between
sexes throughout the whole physical and mental
constitution at more advanced ages have not yet
appeared. All the soft solids of the body evince
increasing firmness, vital cohesion, and elasticity,
and are protected by a firm covering of adipose
matter below the integuments, and in the interstices
between the muscles.

are generally acute; and, unless proceeding from
sources of infection, usually the result of local
inflammatory action, which evinces a marked di^-
position to terminate in the formative process, or
effusion of coagulable lymph, particularly when
the serous surfaces are implicated. The suscep-
tibility to infectious diseases, particularly tho<e
with exanthematous symptoms, is very great ;
as well as to inflammations of the difl'erent
textures and organs — to pneumonia, bronchitis,
cerebritis, meningitis, gastritis, enteritis, &c. ;
besides these, glandular obstructions, chorea,
verminous diseases, epilepsy, and the various
forms of angina, are very prevalent at this age,
particularly, in those whose digestive organs
have been neglected, and when morbid matters
have been allowed to accumulate in the prima
via.

17. 6, The therapeutical indications ap]dicable
to this age present lew peculiarities, besides tlie
necessity of resorting to active depletions, with a
cooling regimen and alvine evacuations in the
majority of its diseas-es ; and the keeping in recol-
lection the tendency of mucous sordes and se-
cretions to form and accumulate on the digestive
mucous surface. Such accumulations furnish a
nidus for the generation of worms, and sources of
irritation to this surface itself, and to the nerves
proceeding from it ; and originate many of the
affections which appear at this, and a subsequent
period of existence. The necessity of enjoying,
and the injurious consequences of the privation,
of wholesome nourishment and active exercise
in a pure atmosphere, and the advantages of
slee|)ing alone in a large well-ventilated apart-
ment, should not be overlooked, in their relation
boih to the production and to the removal of
disorder. The employment of the faculties of
the mind during this early stage of their de-
velopement should be left, until the last year or
two of this period, more as a matter of amusement
than of exertion; and, even then, greater attention
should be paid to the developement of the physi-
cal powers, — the organisation upon which sound
mental manifestations very intimately depend, —
than to the precocious and even hurtful excite-
ment of faculties which are merely budding into
existence. The emotions of mind, however, par-
ticularly those which are connected with temper
and disposition, ought first to receive attention ;
strict control cannot be prematurely applied in
this direction. In this and the preceding epochs
of life, it is indispensably requisite not to allow
the child to sleep with persons in bad health, or
who are far advanced in life.

18. iii. Period, or Boyhood — Girlhood. —
From the seventh or eighth year to the epoch of
commencing puberty, is chiefly characterised by
the continued growth of all the structures, and
the developement of the manilestations of mind.
Towards the middle and end ol this period, the
physical and mental distinctions of sex become
more and more apparent. — a. The frame, when
(rte from disease or hereditary taint, evinces a
sthenic diathesis, a predominance of the sanguine,
or sanguineo-nervous temperament, and a liabilny

16. a. If the constitution be not vitiated by I to nearly the same diseases, particularly those

hereditary or acquired taint, defective nourish'
ment, or previous ailment, or if the causes be not
of a depressing nature, disease at this period
assumes the sthenic character. Febrile diseases

proceeding Irom infection and inflammation, that
prevail during childhood. There is a greater
liiibility to be affected with idiopathic- continued
fever, with scrofulous enlargements and inflam-

42

AGE — Adolescknce.

millions, particularly of ihe lymphatic glands;
wiih various nervous affections, as epilepsy, con-
vulsion«, chorea, &c.; witii cut;meous eruptions;
with inflammations of the throat and air-passages ;
with tubercles, especially in the lungs and ali-
mentary canal ; with flexures of the spinal column,
and with verminous diseases. The nervous system
possesses great susceptibility of impre>sions, moral
and physical ; and inflammatory action has a
marked di'^po^ition to give rise to new formations,
unless when ajipearing in the advanced stages, or
as a sequela, of eruptive or infectious fevers, when
it generally occasions serous or seroalbuminous
effusions.

19. b. These diseases of this pei^d generally
requiie antiphlogistic remedies and evacuations,
especially purgatives, either alone or in suitable
combination, unless proceeding from depressing
causes, particularly those of a specific kind ; and
even there the necessity of resorting to alvine
evacuations, by means of laxatives, or purgatives
combined with tonics, is imperative. The vital
resistance is usually well marked, excepting in
those who have been deprived of wholesome
nourishment and pure air, or whose constitutions
are radically in fault ; and in these, whilst tonics
and other means of restoration are re<iuired, the
due evacuations of morbid secretions and accu-
mulations is equally necessary. Care also should
he taken during this, as well as in the preceding
period, not to allow the young to sleep in the
same bed with the old, nor even with those
advanced in age or debilitated, nor with too
many — not more than three — in the same sleep-
ing apartment, which ought to be large and well
aired. Want of attention to this, is one of the
chief causes of disease in early life in London
and other large towns. Acadeniies and boarding
schools for both sexes are continually furnishing
numerous proofs of this too generally overlooked
cause of disease, not only at this, but also at a
later stage of life. Attention is also necessary
to the exerci'-es of both the mind and the body.
Active amusements in the open air are now
particularly required. As this period advances,
the mental powers acquire such a degree of de-
velopement as to admit of their further improve-
ment and active exeition, — not only without risk
to the organisation with which they are related,
but with the ceitain prospect of advancing them
nearer to the perfection to which our natures may
attain.

20. During this and the earlier terms of life
frecjuent changes of locality and of air, particu-
larly from one healthy and open situation to
another, and especially to one wliich is more
salubrious, where this can be attained, are ex-
tremely beneficial, both in promoting the deve-
lopement of the frame and in removing diseases,
particularly those of a clironic kind, or which
affect the digestive and assimilating organs. In
many of these diseases more advantage lias been
derived from change of air than from the use of
medicine. Hut, during advanced convalescence
from these and febiile disea>es, the ben< fit ob-
tained from change of locality is most remaik-
able.

21. iv. PiciiioD, or ADOi,K«ti;N'CF,, commences
with the first appearance of puberty, and extends
to the twentieth year of females, and the twenty-
fourth of males. Puberty appears at various

ages, according to the climate, the circumstances
connected with education, and the constitution
of the individual. The usual period in this
country, is from the twelfth to the fourteenth
year for females ; and from the fourteenth to the
sixteenth for males. In the northern parts of
the island, it is often a year or two later in both
sexes. It is often observed earlier in boarding-
schools, both in respect of males and females.
In the latter (in London or its vicinity), I have
not infrequently met with instances of menstru-
ation at ten and eleven years; especially in san-
guine and plethoric constitutions; and where the
apartments, particularly those for sleeping, have
been crowded and close.

22. a. This is one of the most important epochs
of human existence : for during it the natural
developement of the sexual organs imparts a
healthy and tonic excitement throughout the
economy ; bringing to their state of full perfection
all the organs of the body and all the mani-
festations of mind, excepting those that are de-
rived from expeiience. The organs of respiration
and voice have acquired their full growth and
tone, the muscles their due proportion, and the
cerebio-spinal nervous sys-tem its beautiful or-
ganisation ; placing man, by the exercise of its
admirable function*, at the head of all animated
creation, — the dread of all other animals, the
wonder of himself. It is chiefly during this
period of life that the mind becomes stored with
ideas, derived both from the learning of the
ancients, the science of the moderns, and the arts
and accomplishments of highly civilised life; and
is more particulaily and more ardently engaged
in decomp.ising the information thus acquired,
and recombining it in new and useful and at-
tractive forms.

23. As the functions and destinies of this period
are important, so they require the supervision
of the experienced and the good. For, with this
developement and activity of both the physical
and mental powers, the instinctive feelings and
emotions of our nature have also reached the
utmost limits of their activiiy; and many of
them, particularly those which are related to the
perfect condition of the reproductive organs, ac-
quire an ascendancy, that both the dictates of
reason and moral restraint are required to con-
trol. Menre the propriety, both at this and the
prece<ling period of life, of improving the moral
affections of the mind ; of inculcating sound prin-
ciples of action and conduct, founded on moral
and religious obligations; and of placmg them in
such relations to the feeliiigs, the intellectual
manifestations, and, moreover, to the accomplish-
ments, the elegancies, and the endearments of
life, as to render them attractive to a state of
mind and constitution which is more easily allured
by example than taught by precept.

24. The evil practices which both sexes are
liable to acquire at thia peiiod of life, and to
which they more commonly become addicted,
when they associate in numbers at seminaries
and academies, demand the strictest prevention.
They have been too generally overlooked, both
morallv and medically, from the circumstance of
their consequences having been imperfectly ap-
preciated, 'i'here is no practitioner of observ-
ation and experience, — none even of limited
knowledge, — who is altogether unacquainted

AGE — Mature Age.

43

with the physical exhaustion, the mental torpor,
and all but annihilation of exis^tence, which is the
ultimate result of indulging them. From this
source frequently spring, impotency hereafter ;
the extinction of families and hereditary honours
— honours which such persons are incapable of
achieving; the infliction, during after-life, of
many of the diseases which proceed from de-
bility, and the exhaustion of the nouri.-hment and
vital energy of the various structures and organs ;
numerous nervous and convulsive maladies, as
hysteria, epilep>iy, neuralgia, chorea, melancholia,
mania, idiotcy, 6cc. ; the dangerous or fatal visit-
ation of fevers, diseases of the heart, disorders of
the digestive organs, preniature baldness and old
age, the formation of tubercles, and the pro-
duction of pulmonary consumption; and, lastly,
the transmissinn of weak and decre])it bodies and
minds to the offspring, of scrofula, rickets, verm-
inous complaints, marasmus, hydrocephalus, con-
vulsions, tubercles, chorea, &c. : the curse is
visited on the children to the third and fourth
generation, until the perpetuated punishment ex-
tinguishes the very name of the aggres-or.

25. b. The pnthotngical conditions of this
age are especially characterised by exalted
action. At the approach and commencement of
puberty, the -glandular system is extremely prone
to conge>tive inflammations, particularly the
lymphatic glands of the neck and arm-pits.
Tubercles are rapidly developed in the lungs;
and these organs are m.uch disposed to acute and
chronic inflammations of both their substance and
mucous surfaces. Pulmonary liaamorrhages usurp
the place of the epistaxis of earlier epochs ; and,
in females, dysmenorrhoea, protracted or retained
menstruation, chlorosis, hysteria, and occasion-
ally menorrliugia or leucorrhoea, occur. The
sanguineous diathesis and plethoric habit, in those
of a sound constitution, and the sanguine, irri-
table, and nervous temperaments, or the one
associated with the other, most commonly prevail
at this period of life.

26. The progress of disease is generally rapid,
and its character acute. Inflammations are more
prone to give rise to the formative processes ; and
febrile aft'ections, when they terminate by crises,
evince a preference to hsEmorrhages and sweats.
Idiopathic fevers, inflammations of the respira-
tory organs and of the brain or its membranes,
are the most common diseases of this age.

27. c The therapeutical indications require
but little remark ; for the system has now nearly,
or altogether, reached its full growth; and the
general inferences which guide the practitioner
in the employment of remedial means have now
reference, especially, to states of habit, consti-
tutional powers, temperament, and diathesis, ■—
physical manifestations, which are now, in a
great measure, developed, but which acquire
their most predominant characters in adult age.
As the maladies of this peiiod are frequently
inflammatory, and evince a strong tendency to
the formative process, and as the powers of life
ai-e now most energetic, vascular depletions, with
the antiphlogistic regimen, are often re(|uired,
and are well borne ; excepting in those whose
constitutions have been originally in fault, or
who have greatly injured it by the injurious
practice of masturbation, from which so many
suffer, both at this and subsequent epochs of life.

28. V. PF.niOD. — Adui-t Age may be divided
into the epochs, Isi, of early adult age ; and, 2d,
of mature age, or cinijiimed virilily. Of each of
these 1 shall take a brief notice.

A. Early adult age may be dated from twenty
to thiity in the female, and from twenty-four to
thirty-five in the male. During this epoch, if
the constitutional powers have not been injured
previously, the whole frame and its individual
organs continue to acquire strength ; and, al-
though the body has ceased to grow in height,
it increases in bulk, particularly the muscles of
voluntary motion, and tlie parities of the large
cavities. It is also more capable of enduring
continued exertion and privations; its vital en-
durance and resistance being greater than duiing
the period of adolescence. The fealuies and ex-
pression of the face ; the chai'acter, disposition,
temperament, and dialliesis, are more unfolded,
and towards the termination of this period fully
di>play their manifestations.

29. B. Mature age, or confirmed virility, may
be considered as being from thirty to foily, or
forty-five, in the female, and from thirty-four
to forty eight in the male. During this time of
life, the features of the countenance fully assume
those modifications of chaiacter arising from the
influence of the passions and emotions of the
mind ; and the appetites, habits, and occupa-
tions of life imprint upon the frame generally
certain appeal ances, arising from their continued
influence on the constitution. The mu-cular
organs, particularly the muscles of the extremities,
are proniinently marked ; the chest fully de-
veloped ; the body spaie and active ; liie adijjose
structure extremely scanty, and the abdomen
sm;ill, in those habitually devoted to laborious
employments, not of a sedentary nature, and to
active exercise, either on foot or horseback. The
sedentary, those addicted to the indulgence of
the appetites, and particularly those given to
the gratifications of the table, have laige abdo-
mens, small extremities, and large depositions of
adipose matter beneath the inl( giiments, between
the muscles, in the omentum, and suirounding the
viscera, with a weak and defective developement
of the muscular parts. The studious present
the chief marks of tiieir occupations on the fea-
tures of the countenance and character of the
head ; the appearance of the rest of the frame
varying with the habits and indulgei ces with
which study or the prosecution of science may
be conjoined. At tliis period of life also the
feelings, the anxieties, the disappointments, the
losses, and the vaiious moral emotions of life,
begin to manifest those eflfpcts upon the frame,
which become still more fully expressed during
the following epoch.

30. This and the preceding period of adult
age are, upon the whole, the most extmpt of ail
others from disease ; but about the age of forty,
and still more so as the age of fifty is approached,
the sangumeous circulation becomes more and
more languid, particularly in the veins ; hence
the frequency of venous coni;estions and visceral
obstructions, with the various diseases depend i >j
thereupon, particularly hemorrhoids ; bilious de-
rangements ; bilious and gastric fevers ; inflam-
mations ; aflections of the heart ; apopfexy and
paralysis ; derangements of the stomach and liver ;
haematemesis ; affections of the joints, as gout ami

44

AGE — In its spechic Acciptation.

ilieumatism ; diseases of the urinary organs ; hys-
teria and uterine disorders ; hypochondriasis, and
afftciions of the mind. At this period, therapeu-
tical means require to be striclly regulated ac-
cording lo the sex, constitution, temperament,
habits, and occupations of the affected.

31. II. Age, in its spfcific acceptation,
may be divided into two peuiods, and these into

Jour epochs: viz. 1st, Declitihig nge ; 2d,Adva7iced
age ; 3d, Old age; 4th, Decrepitude, or second
infancy. Before I proceed to consider these in-
dividually, 1 will take a view of the changes
which supervene with age in the structuies and
functions of the body.

Age, ill the specific acceptation of the word,
may be considered as commencing when the
vital energies of the different organs begin to de-
cline, — when the maturity of life glides into
decay. The period at which this change su-
pervenes varies very much in different persons,
according to their constitutions, employments,
and habits during the earlier epochs of existence.
In many it is so gradual as to be imperceptible ;
in others it is more obvious ; and in some it is
induced rapidly and remarkably, by mental an-
xieties and bodily disease. The usual period of
its advent, in both sexes, and the different epochs
into which age may be divided, will be stated in
the se(|uel.

32. As age steals on, all the functions are per-
formed more languidly than in earlier life. The
energies of the ganglial system decline, as
evinced by the digestive, circulating, and secret-
ing functions, which it actuates. The sensibility
of the cerebro-spinal system, and of its dependent
organs; the acuteness of our intellectual powers,
our moral emotions and affections, and the ac-
tivity and strength of the locomotive organs, — all
experience diminution, great in proportion to the
advances of age.

In noticing the pathological and therapeutical
relations of age, those changes of structure and of
function which supervene with it will Jint re-
ceive attention ; neit, the different terms into
which it may be diviiied, with those modifications
which diseased actions generally assume in each
term respectively, and those indications which
should guide our practice in the diseases to which
each is most obnoxious, will be briefly considered.

33. A. The wodijicatums of structure produced
by age are occasionally sligiit ; but most com-
nionly they are very remarkable, particularly in
certain organs. In some parts they are scarcely
perceptible, in others more obvious, consisting
chiefly of increase of density ; and in many they
amount to actual change of texture.

'I'he iiitegumenls, particularly those of the face,
and the hair, are amongst the earliest parts to
exhibit the advance of age ; and they most ob-
viously indicate the different stages of its pro-
gress. Tl'.e integuments of the face seem more
developed than in early or mature age. They
are denser and thicker, especially the cutis vera
and rete mucosuni ; which Kitter assumes also a
somewhat daiker tint. The skin appears more
loosely attached to the parts underneath it, chiefly
owing to the diminution of the subjacent fat, and
shrinking of the other soft solids Hence it ap-
pears, particularly in the face, neck, and hands,
fidcoid and wrinkled

34. The tuiirs of the head are perhaps the first

to evince the commencement of age ; and they
present the most common indications of the pro-
gress of decay, either by a more or less complete
change of colour, or a partial and general loss of
them. The change of colour at first consists of
a few while or grey hairs, scattered amongst
those of a natural hue ; but these gradually be-
come more numerous, particularly on the tem-
ples, until the whole hair is altogether grey, and
ultimately white and transparent. As this change
proceeds, the hair also falls out, especially on the
crown and forehead. There are, however, many
circumstances which accelerate these phenomena,
independently of age. Thus fevers, severe courses
of mercury, masturbation, &c., will occasion
the loss of the hair. But when it falls out from
disease, the bulbous roots not being obliterated,
its reproduction generally follows ; whereas,
when it is lost from old age or from masturbation,
it is never reproduced. There are also various
causes which occasion a cliaoffe of its colour,
particularly the depressing passions, intense ap-
plication to study, anxieties of mind, venereal
indulgences, &c., and which at the same time
accelerate the loss of it. The change of colour,
and subsequent loss of hair, seem to arise from
deficient nutrition, and consequent atrophy, or
destruction ol the bulb, together with some change
in the skin itself. In some cases it seems to arise
from chronic disease of the rete mucosum and
cuticle, as stated in the pathology of certain cuta-
neous affections.

35. The adipose and cellular tissues experience
considerable change. The fatty deposit dimi-
nishes with the progress of age, and it sometimes
becoiiies more fluid and watery, as well as of a
deeper tint. The cellular tissue is somewhat
denser, more fragile, and less elastic than in early
life. In some situations it assumes a fibrous
character, particularly that portion of it which
invests the muscular fibres. The serous mem-
branes are also more dense, more subject to ossific
deposits, and their fiee surface drier than in early
life. The 7nucous surfaces exhibit but little
change, excepting as respects their greater pale-
ness, and tendency to certain states of disease.
I'he fbrous siruccures become more rigid, and in
various parts the seat of ossific deposits. They
also assume a deeper colour, and firmer and
tougher consistence, whilst their physical cohe-
sion is much increased as age advances.

3G. The muscles of voluntary motion expe-
rience a very marked change, particularly at the
advanced epochs of age. They are much dimi-
nished in bulk. Their fibres are more rigid, less
readily influenced by stimuli, and less contractile
than in eaily life. They are also less under the
control of volition, much less energetic in their
actions, more flaccid, and endowed with less vital
tenacity. Their structure is also somewhat mo-
dified. They aie paler, sometimes of a light
yellow colour, and their fibres less distinct than
in youth. 'J"he tendons and aponeurotic expan-
sions of muscles, as well as the cellular tissue
intervening, are often partially ossified. I'orlions
of muscles, near their tendons, are sometimes
converted into a tendinous structure ; and the
si cretions poured into the sheaths of the tendons
are rcmaikably diminished. From all these ciianges
result the vacillating, embairassed, and weak
movements of the aged.

AGE — In its specific Acceptation.

37. The bones acquire a dense structure, and
even a somewhat increased size, particularly the
bones of the head, the sutures of which become
firmly united, first in the internal, and afterwards
in the external surface. Tlie cartilages are ossi-
fied, particularly (hose of the rib^. i he interver-
tebral cartdages become hard, inelastic, and
siirunk ; hence the impaired flexibility of the
spinal column, the bending forwards of tlie trunk,
and diminished stature of aged persons.

38. The blood-vessels undergo very rematkable
changes. The arteries are gradually diminished,
in proportion to the bulk of the body, as age
proceeds ; and the predominance of the venous
over the arterial system is more and more appa-
rent. Whilst the arteiial vessels become, on the
one hand, more dense and rigid in their coals,
their calibre diminished, their smaller ramifica-
tions altogether obliterated, and their vusa vasdrion
indistinct, the veins seem, on the other hand,
somewhat thinner in their coats, more dilatable,
and their calibre increased ; they are also more
tortuous, and hence their capacity is augmented :
so that, although the quantity of hlood contained
in the body is diminished, particularly at the most
advanced stages of life, about two thirds of it aie
contained in the veins. 15esides those changes of
capacity", the coats of the vessels present changes
of structure. The arteries are liable to ossific and
other deposits, rupture of their coats, &c. ; the
veins to varix, inflammation, &c.

39. The brain and nerves are also somewhat
modified by age. The inembranes of the former
are generally slightly thickened and^opaque. The
bulk of the brain is diininished, and its substance
firmer and tougher than natural, and less readily
acted upon by chemical re-agents. The nerves
i-eem to possess a diminished quantity of medul-
lary substance, and their blood-vessels are indis-
tinct. The ganglia become firmer, of a deeper
colour, and smaller than in early life.

40. The organs of sense undergo important al-
terations. The eyes are changed chiefly by the
diminished secretion of aqueous fluid into the
anterior chamber, occasioning less prominence of
the cornea, and a change of its refi active power.
The crystalline lens acquires a yellowish tint,
and is less transparent. The nerves of the eye,
p;irlicularly the optic nerves and ophthalmic
branch of the fifth pair, and the iris, are less sen-
sible than before ; and hence the dilatation of the
pupil, the distant sight, and the confused appear-
ance of near objects to aged persons. The ear
experiences a change similar to that which takes
place in the eye. 'i"he fluid occupying its inter-
nal cavities is diminished or altogether absorbed ;
and the auditory nerve rendered insensible to im-
pressions, from this and other changes in the con-
ditions necessary to its functions. The other
organs of sense, particularly taste and smell, have
also their sensibility similarly blunted.

41. But changes are not limited to the more
elementary structures of the body ; and organs of
sense, the viscera of digesiion, secretion, assimila-
tion, sangiiifaction, and generation undergo analo-
gous alteratiims. The teeth loosen or decay ; the
gums are partially absorbed ; and the jaws de-
prived of teeth and of their alveolae, approximate
more closely. Hence the projection of the chin,
its approach to the nose, and diminished capacity
of the mouth. To these causes are partly to be

45

imputed the change which takes place in the speec h
of the aged. 1 he stomachand bowels are gimerally
flaccid, owing to deficient contractility of theiV
muscular coats ; but the liver, pancreas, and spleen
present but little change, excepting they are, or
liave been the seat of disease, unless slight atrophy,
or enlargement and increased density. The uri-
nary organs are more frequently altered ; calculi
are not infrequently met with in the tubuli urini-
feri and pelvis of the kidneys; and the uiinary
bladder is generally thicker and firmer in its coat's
than in early life ; the prostate gland is commonly
somevvhat enlarged.

42. The lujigs are not necessarily changed by
age, further than that they become less elastic,
their air-cells enlarged, some of the bronchial
ramifications more dilated, and portions of them
emphysematous. They frequently, however, pre-
sent the remains of antecedent disease. The heart
partakes, although in a less remark;ible manner,
ot the changes experienced by muscular parts.
The tone and energy of its fibres are lowered ; its
structuie is softer, more flaccid, and occasionally
also paler. It is sometimes diminished in size ; or
some of its cavities are dilated, and their parieies
thinned ; and cartilaginous or ossific formations,
or both, occur in parts of its internal surface, par-
ticularly in the valves.

43. Ihe organs of generation experience a
marked alteration. The ovariu shrink, become
dense, and their vesicular structure changed.
'J'he uterus is diminished in bulk, unless it is
the seat of organic disease, to which it is very
liable, particularly at its mouth and neck. The
mamnut also waste, are soft, pendulous, and
lastly are entirely absorbed. The areolae become
dark, and the nipples shrink. At the commence-
ment of age they are subject to congestions,
indurations, and scirrhous disease. The testes
shrink, or become soft and small, or even nearly
disappear. The penis is shrunk, seldom expe-
riences the vital tuigescence', and lastly not at
all ; the faculty of generation having previously
disappeared.

44. In this rapid sketch of the chief changes
which the structures and organs of the body un-
dergo from age, there are several phenomena
which must strike the reader. 'J'he chief of these
are, the gradually increased density of thediflerenc
textures, and the consequent diminution of their
watery or fluid constituents, as well as of the
hlood Itself. In childhood and early life the tex-
tures are succulent, and the circulating fluid
abundant. But as age advances, they acquire
an increase of their physical cohesion, whilst their
vital attraction is diminished. 'J'his increase of
density and diminution of the fluid elements of
the structures, with the progress of age, are con-
stantly observed in the vegetable kingdom of
nature ; and, as we advance upwards, through the
various grades and clajses of animals, we find this
principle strictly adhered to. In addition to this,
another phenomenon is remarkable ; namely, the
redundance of osseous matter, as evinced not
only by the increased quantity of earthy matter
in the bones and cartilages, but also by tlie depo-
sition of this substance in the coats of the arteries
and in other textures. Somewhat analogous to
these formations, and sometimes even vicarious of
them, is the abundance of sabulous deposits from
the urine, frequently observed to occur either

46

AGE — In its specific Acceptation.

during tlie secretion and retention of this Haul, or
alter its rliscliarge.

45. Not only are tiie meelianical conditions of
the diffL-rent parts of the body modified by age,
as now stated, but tlieir chemical properties are
also similarly affected. The gelatin disappears, or
becomes changed to albumen ; the fibiin is in-
creased, and assumes a deeper hue, and is less
easjily affected by maceration or exjiosure to the
air. The phosphate of lime is augmented, and
often accumulates to a veiy hurtful extent, toge-
ther with the other earthy salts and urea.

46. B. Of the conditions of function charac-
terising the advance if age. — a. Although the
changes, which have been now described as
supervening in the different structures with a^je,
may hive originated in those imperceptible and
s-low modifications which the various organic
functions experience from peculiarities of consti-
tution, of food and employment, or from acquired
habits and indulgences; yet there can be no
doubt that, when once induced, they modify
still further these functions, and thus draw on
other lesions, and ultimately still greater alter-
ations of both function and structure, or even
speedily fatal disease. But we are not altogether
justified in considering these contingencies as the
primary causes of the changes now described.
We are rather to view them as more or less re-
mote effects of the failure of the vital endowment
of the frame, manifesting i'self first in a less per-
fect performance of the different functions, and
subsequently in modifications of structure, and
ultimately in very obvious lesions of both function
and structure.

47. b. It was supposed by Brown and others,
that the embryoat itseailiest formation is endowed
with a certain -uni or allotment of vitality, which,
in the earlier epochs of life, is engaged in the
formation of, and in bringing to perlection, the
different structures and organs of the frame ; that
it is gradually exhausting itself ever after, until it
at last expires ; and tlint the greater the excite-
ment of its different inanifestntions and functions
during the subst-quent stages of existence, the
more rapidly will its termination be reached ; that
the oil with which the lamp of human, and indeed
all animal, existence burns, is filled at its com-
mencement, and is never afterwards supplied ; and
that the more brilliant the flame, the shorter will
be its duration. This captivating hypothesis,
however, appears, on an intimate view, irrecon-
cilable with many of the phe.iomena of health and
disease. It cannot readily be conceded that the
allotment of viialiiy bestowed upon the germ or
germs Clin exceeil that posse-sed by the parents, —
for the hypothesis is, tliat the sum of vitality is
greater the younger the animal ; and that it dimi-
ni-hes with the advance of ihiys and years, from
the period of its endowing the embryo. But it is
obvious, that the greater vital endowment cannot
issue from the smaller; that the parents cannot
jiossibly impart to the embryo more than they
pO'^sess, they still retaining a portion afterwards:
more particularly when we consider that the
greater endowment is imparted not to one embryo
only, but to several, as is the case in the lower
animals, and olien in the human species al«o.

48. 1 he [jlienoinena, moreover, of disease fur-
nish us with proofs that this sum of vital endow-
ment is neither thus early and at once be-towed,

nor thus uniformly diminished, according to the
waste it experiences, without occasional reinforce-
me:it. We frequently perceive all the manifesta-
tions of life reduced, at different epochs of exist-
ence, nearly to total extinction, particularly in
several kinds of fever, when having received the
requisite aid from external stimuli, they have been
gradually restored to their former activity. In-
deed, the various circum-.tances in which the body
is placed, and the different states it presents at
different periods of life, and from numerous causes
which affect it, seem rather to favour the idea that
the su 11 of vitaliiy, and its manifestations in the
different organs, fluctuate more or less during the
allotted period of existence ; that a certain eman-
ation of vitality proceeds from the parents, great
in proportion to their constituiional powers ; but
that this endowment is con-tantly experiencing an
accession, first from the mother, and subsequently
from the common sources of air and aliment ;
th it this reinforcement is thus constantly supply-
ing the waste arising from the exercise of the
various functions, and adding to the bulk of the
structures, until manhood is reached ; and that at
this period the sum of vitality has reached its
greatest amount, from which it gradually declines,
owing rather to the waste, particularly that occa-
sioned by the exercise of the generative functions,
exceeding the supply, than from the continued
expenditure of what is at first bestowed and never
afterwards reinforced.

49. Having been induced by the foregoing, and
other considerations, to relinquish the former for
the latter hypothesis, I infer that the gradual di-
minution of the vital energies that accompanies
the progress of age is more or less manifested
throughout all the frame ; that the functions first
evince this decline, and that the organs them-
selves are at last modified in organisation, from
the slightest and almost inappreciable shades to
the most marked alterations. The changes of
structure, once induced, tend most es^en'ially to
heighten and to perpetuate the previously slight
disorders of function, until both the one and the
other undergo, by reciprocity of influence, most
important alterations, terminating at last in death,
and the dissolution of the frame. — I now pro-
ceed briefly to notice those changes of function
which, frequently related to the alterations of
structure described above, mark the existence of
Age.

50. c. 1 have, in another place, stated that, of
all the different tissues of the frame, the ganglial
system is tiie most intimately related, in every way,
to the vital influence which endows the body.
And it is precisely those organs which are most
immediately connected with this system that fiist
furnish proofs of incipient decline in the languor
or imperfei'tion of their functions. Amongst
those functions are compiised those of digestion,
secretion, circulation assimilation, the preservation
of the animal temperature, and generation. 'J'lie
functions of animal relation are not so soon af-
fected ; and at first the change in them is rather
secondary, and owing to tlie pre-existing change
of the functions of organic life, — of those func-
tions which are excited or actuated through the
medium of the ganglial system.

!')\ . As very intimately dependent upon the state
of the ganglial system, the secretions manifest,
with the advance of age, the most remaikable

AGE — In its specific Acceptation.

47

lesion. These are generally modified in quinHiti/,
in Jliddilij, and in quality. 1st, The quantity of
tile secretions, b )tli lecremenliiial and excreinen-
titial, is sensibly lessened. The salivary, ga-tric,
biliary, cutaneous, and spermatic secretions evince
this change. 2d, Their fluidity is diminished, as
shown by the salivary, the lachrymal, cutaneous,
and watery exhalations and secretions. And, 3d,
their properties are modified, as proved by their
marked tendency to assume, immediately as they
are secreted, irritating and acrimonious quaiilies, as
shown by their effects upon the tissues with which
they remain for any time in contact, and to pa~s ra-
pidly into decomposition. The urine, and occasion
ally the lachrymal, the mucous, the biliary, cuta-
neous, and sebaceous secretions evince this change.
It very generally happens that the secreted fluids
experience more than one of the above alterations ;
they being diminished both in quantity and in
fluidity, and at the same time deteriorated in
quality. This is remarkably the ca-e in respect
of the cutaneous, mucous, and urinary secretions;
the chief exception being furnished by the mu-
cous fluid, which is sometimes increased, although
it is of diminished fluidity and altered quality : but
this is rather an effect of disease, than merely of
advanced age.

52. Next to the function of secretion, and
owing to the same cause, — the diminution of vital
influence, — that of circulation is most sensibly
affected. The action of the heart is slower than
in early life, much less energetic, and occasionally
irregular. The capillary circulation is more lan-
guid, and a much smaller quantity of blood pene-
trates the extreme ramifications and nutritious
vessels, in consequence, most probably, of the
diminished calibre of those vessels, and the in-

from the inordinate accumulation of the secretions
poured into tht-m, and changes of the properties
of these secretions during their retention, either
occasioning their expulsion, or producing actual
disease.

54. As closely related, also, to the lowered
energy of the nerves of organic life, and conse-
quent languor of the ciiculation, tlie generation of
animal heat in the aged is evidently diminished,
although the causes which usually moderate it in
the young, — nainely,abundynt exhalation and eva-
poration trom the surfaces of the lungs and skin,
— exist in a much less degree in the former. The
functions of generation, are, however, those most
remarkably affected. In the fema'e the faculty
of concept, on is altogether abolished, and import-
ant changes occur in the state of her appropriate
organs; yet the sexual desire still lingers for a
while: and in the male, although the ability of
procreation may remain, under favourable cir-
cumstances, for some lime, it is at last entirely
abolished.

55. Thus we perceive, that as the different vis-
cera of organic life increase in density, and expe-
rience a diminution of vital expansibility and con-
tractility, so their functions become more languid
or imperfect, untd some of them cease to be per-
formed, and others are remarkably altered. Eut
the change is not limited to lhi~ class of structures.
Those organs which are devoted to the extension
ct our intercourse with surrounding nature, and
are subservient to the manifestations of mind, as
well as those manifestations themselves, in both
their intellectual and moral relations, undergo,
although at a more advanced period, in respect of
some of them, very marked modifications.

56. The changes that take place in the mus-

creased density of the tissues in which they ter- [ cular and their associated structures evidently

minate. The venous circulation is more congested,
and more prone to experience the consequences
of engorgements, particularly varicose dihitatii-ns,
giving rise to effusions of blood and other serious
diseases. The blood itself is not only diminished
in quantity, but is also of a darker colour, and is
probably also slightly changed in quality, parti-
cularly in respect of certain of its saline consti-
tuents. The absorbent system is less frequently
disturbed in its functions by age than almost any
other part of the frame, although it occasionally
evinces diminished power, but chiefly in connection

would render them incap.ible of performing those
actions, to which volition may impel them, with
energy, rapidity, and steadi-iess, even althoutrli
the nervous system of voluntary motion were
altogether unaffected. But this system, owing
probably to those slight, and nearly unappre-
ciable, alterations noticed above (§ 36 ), pos-
sesses much less energy and susceptibility of action
than in the prime of life, and therefore actuates
the muscles in a less vigorous manner.

57. The same condition of the brain and cere-
bro spinal nerves, which contributes to render the

with disease. To the predominance of the ab- actions of volition less piecise and energetic, seems

sorbent function over that of arterial circulation
has been partly ascribed, and with apparent jus

aKo to be connected with the less vigorous exer-
ci-e of the intellectual powers, and the imperfect

tice, the wasting and condensation of the stiuc- I conditions of the functions of sense. These func-
tures characterising the most advanced epochs of | tions generally indicate incipient decay before the
life. I powers of mind are affected ; and some of them

are nearly abolished, particularly hearincr and
seeing, before the latter evince any marked
change. But more commonly the decay of the
senses is soon followed, occasionnily as a neces-
sary result, by a slight fuihire of some of the
mental faculties. The memory, and the power of
a-sociation as intimately related to memory, are
the first to evince this declen-ion, generally by a
want of recollection of the names of persons, sub-
sequently of the names of things and of recent
events, or recently detailed information ; the
jiiilgment continuing eidier aliogeiher or but
slightly impaired. With this declining state of the
faculties, the emotions of the n.ind are often re-
; raaikaljly blunted ; the desires and affections are

53 As intimately connected with the weakened
energy ot the ganglionic and vascular systems,
the functions of digestion and assimilation are
languidly performed. The gastric, pancreatic,
and biliary juices are less abundantly secreted in
the aged than in those of early or mature years;
and the tonic contractility of the coats of the sto-
mach and bowels is diminished. Hence result
various dyspeptic ailments, flatulence, and a slug-
gish state of the bowels. The receptacles which
nature has provided lor the temporary retenti n
of the secretions and excretions, particularly the
biliary and urinary bladders, react imperfectly on
their contents, owing to the lowered power of the
nerves which actuate them : hence arise distention

48

AGE^Oi.D Age.

impairetl, excepting in as far as respect early-
formed associations and affections, which are
often recalled with acute and even overwhelming
emotion.

58. As age advances sleep is much lessened ;
and not only is the duration of repo?e abridged,
but also its soundness; the rest of the aged being
imperfect, and disturbed by dreams. It is dithcult
to explain this — indeed no satisfactory explan-
ation of it, has yet been offered ; but it is gene-
rally observed, particularly in very advanced
age.

•59. Such are the changes induced by age in
the various structures and functions of the body,
as evidently caused by the gradual decline of the
vital energy, from the period of full manhood to
its ultimate extinction. 1 have described them
as much divested as possible of the effects of dis-
ease. As now noticed, those changes gradually
lapse into death, — the lump of life having burnt
out, its oil having been exhausted, after a gradual
diminution of the supply, without any single
oigan evincing that state of di-^ease to which the
cessation of life can be ascribed. This is, how-
ever, not a common occurrence ; for, during the
gradual decay that marks the progress of agr,
some organ or other, owing to the deleterious influ-
ence of surroundins^ agents, or of mental emotions,
and the weak resistance of the vital influence,
experiences a more or less marked derangement,
which increases to actual disease, and either
abridges the remaining shoit period of existence,
or renders it less supportable.

I now proceed to notice the different epochs of
advanced age, with reference chiefly to the dis-
eases incidental to each, and to the therapeutical
considerations which should influence the treat-
ir.ent of them. (See Climacteric Disease.)

60. vi. Period, or Declining Age. — 1st
Epoch, or declining age, extends from 42 or
45 to 55 in the female, and from 48 to 60
in the male. — a. During this period the ap-
petites, occupations, and habits express them-
selves still more strongly upon the outward ap-
pearance of the frame than in that immediately
preceding it ; and the feelings, emotions, dis-
appointments, and anxieties of life manifest more
fully their effects upon the internal organs, as
well as upon the external aspect. Venous con-
gestions, visceral obstructions and engorgements,
with all the specific forms of disease already
enumerated (§30.), are more frequent than during
earlierepochs, particularly apoplexy and paralysis,
haemorrhoids, hepatic disorder, dropsies, siruitural
change in the kidneys and bladder, hypochon-
driasis, ha;matemesis, gout, and chronic affections
of the respiratory organs.

61. h. In this period, the second great change
to which the constitution of the female is liable
generally occurs, terminating that epoch in which
her sexual constitution is especially marked ; and
with this change frefjuently commence, or are
matured, several diseases of the female organs.
Alorbid changes of the uterus and its appendages,
as well as of the breast, are now very fretjuent ;
and sometimes ihey assume a malignant chaiacter.
Various maladies, to wiiich the female was less
exposed than the male, are now oltener met with ;
and her con-'titution, with its disposition to disease,
approaches more nearly to that of the male than
during the time of maiked uterine activity.

62. 2d Epoch, or advanced age, may be reck-
oned to commence about 55, and to extend to
63 or 68 for the female ; and to begin about 60,
and extend to 65 or 70, in the male. During
this epoch the nervous, circulating, and muscular
energies begin to languish, with the vital actions
of the different internal organs. The functions
of the sexual organs gradually disappear. The
female no longer conceives ; and sexual plethora
has ceased to supervene and to relieve itself by a
periodical disciiarge. The ovaria begin now to
be gradually diminished in bulk, and to assume
a firmer structure ; the appetite for procreation
slowly disappearitig(§§43.54.). — The male organs
also either become less disposed to their proper
functions, or nearly altogether lose the faculty
of performing them, particularly when the ener
gies of the constitution have been exhausted by
previous indulgences carried to an excessive
length, or by mental exertions. The teeth decay,
and the digestive functions suffer from the imper-
fect mastication of the food (§ 41.).

63. vii. Period, or Old Age. — 1st Epoch, or
ripe old age, dates from the preceding, and extends
to 75 or 80 in both sexes. During this term the
sensiferous and sanguiferous systems languish
more and more, and all the vital organs experience
a rapid decline of activity. The teeth fall out,
the gums are partially absorbed, and the digestive
functions are greatly impaired. The sexual organs
are nearly or altogether deprived of their func-
tions ; the digestive and assimilating viscera ex-
perience a maiked diminution of power ; and
senile marasmus, or the leanness of old age, ad-
vances (§ 53.).

64. a. The diseases of this and the preceding
epochs are chiefly weak or imperfect digestion
and assimilation ; chronic inflammations ; general
asthenia and cachexia ; apoplexies; paralysis; loss
of the senses of sijht and hearing; senile gan-
grene; comatose affections; dyspnoea; diseases of
the heart and liver; dropsies; organic changes
in the urinary and sexual organs of both sexes;
passive haemorrhages, from the stomach, bowels,
and urinary organs ; mental disorder; and gradual
extinction of the vital functions and energies.
Fel)rile and inflammatory diseases have a much
more marked disposition to terminate in organic
change, owing to the diminution of vital resistance,
than during the preceding epochs of life.

65. h. Thu therupi'utical indications of this period
are in some respects important, but chiefly with
refei'ence to the necessity of supporting the powers
of life (luring the diseases to which it is liable.
When inflammatory or febrile disorder is present,
and depletions or evacuations are necessary, we
should, particularly if we employ them actively,
watch tiieir effects, and resort to the use of means
calculated to support the frame as soon as indi-
cation-^ of exhaustion are manifested. Purgatives
at this period should, if frequently repeated, al-
ways be combined with warm, tonic, or support-
ing medicines, or with a restorative regimen ; and
a strict reference ought to be made to the habits,
constitutional powers, and feelings of the patient,
in all the remedies we prescribe. Old habits
must not be suddenly relinquisiied or opposed,
and tiie powers of life should be carefully
watched ; for, if unheedingly reduced, they will,
parti(!ulaily in large cities, often sink most ra-
pidly, wilho'it the ])ower,of rallying. When we

AG E — Decuepitude.

49

consider tliat, in persons advanced to this age, a
considerable portion of the arterial system is often
in a state of slow organic disease ; that the venous
system is prone to congestion, is sometimes re-
laxed and almost varicose, always deficient in
vital contractility, and scarcely able to perform
its functions; and that both the one and the other
cannot thereby so readily accommodate themselves
to sudden or copious losses of blood as in early
life and when they are perfectly free from disease,
we cannot be surprised at the sudden depression
occasioned by vascular depletion, or other means
which produce a rapid discharge by the emunc-
tories of the watery parts of the blood, or a sudden
depression of the nervous energy, even although
symptoms seemed unequivocally to demand their
employment.

66. The last epoch, or that of Decrepitude, or
second infancy, commences at from 75 to 85, and
terminates the life of those whose span of existence
is thus far prolonged. A greater number of fe-
males than of males reach this extreme age, espe-
cially the utmost extreme. During this period,
all the physical and mental powers rapidly de-
cline. The body emaciates, the muscles waste,
and the adipose structure is absorbed ; the inte-
guments becoming lax, wrinkled, dry, and dis-
posed to retain accumulations of sordes. The
knees totter and bend under the weight of the
body ; the trunk stoops, and is incapable of any
considerable motion, excepting forwards ; and
the features are wan, devoid of colour, wrinkled,
and emaciated, and apparently consisting chiefly
of integumental covering (§33.).

67. a. Congestions, enlargements, obstructions,
and even atrophy of the internal viscera; effu-
sions of fluid into the shut cavities; irregularity
of the heart's action from loss of its vital activity,
or structural change of its valves, its arteries, or
muscular texture, or from disproportion between
the capacities of its compartments ; lesions of the
vascular sy-.tem generally, in which either those
of the arteries or of the veins predominate. Pas-
sive haemorrhages from the mucous surfaces,
particularly those of the alimentary canal and
urinary apparatus ; general asthenia, or cachexia ;
and slow extinction of the vital and natural func-
tions of the frame, — the ganglial, tire cerebro-
spinal, and the circulating systems ; and the di-
gestive, the respiratory, the secreting, and excreting
organs, evincing individually, or either of them
conjointly with others, more or less disease, — are
tiie principal causes of death : andthusman, whose
mental and physical constitution and organisation
were objects of profound study and admiration to
himself, passes away ; the vital essence, that actu-
ated the wisely devised frame with which it was
so surprisingly associated, returning to the Divine
source whence it emanated ; and the gross male-
rials, which it combined and preserved in won-
derful states of association, assuming novel modes
of existence, and serving to form nevv beings
much lower in the scale of organised creation.

68. b. The rapidity with which acute disease
generally runs its course at this period, anrl the
celerity with which organic change will frequently
supervene and extmguish the dindy burning taper
of life, require great decision and circumspection
on the part of the physician. The resistance
which the energies of life usually oppose both to
the extension of disease to ether viscera from that

Vol. I.

first attacked, and to its disorganising efTects in
its primary seat, is now so excessively weakened,
that remedies, directed with a due regard to the
previous habits of the patietit, in support of those
energies, are particularly necessary. On the choice
of cordial remedies, and on their appropriate ap-
plication to the circumstances of individual cases,
will deficnd their success, and the reputation of
the physician. At this period,- depletions and
all evacuations, excepting such as are requisite to
carry off accumulations of morbid matters from
the primte vite, and which impart, along with
their evacuating operation, a restorative and cor-
dial influence, must be abstained from ; and care
should be taken that fainting, or even nervous de-
pression, may not supervene from their action.
Warmth, at this and the preceding terms of
advanced age, is indispensably required, both in
the clothing and apartments ; but it should be
equable, and not too high. The lungs of very
aged persons should be guarded from the ingress
of very cold air, as the impression of cold in this
organ paralyses its functions, arrests those changes
which the blood undergoes during respiration,
and induces apoplectic or comatose seizures, and
idiopatliic syncope or inaction of the heart. For
these reasons, also, atmospherical vicissitudes
should be assiduously avoided, as far as the means
of doing so are placed within our reach. There
is scarcely any measure more influential in sup-
porting the sinking vital energies of age than the
communication of animal warmth, particularly
from the young of our own species. This was
well known to the ancients, and is one of the
oldest restorative means of treatment practised,
having been adopted by David. The aged ought
also to avoid the use of very cold fluids, as being
apt to depress the energy of the stomach below
tiie power of healthy re-action. INIedicines, also,
particularly purgatives of a cold nature, as the
neutral salts, if exhibited at all, require to be
combined with warm aromaticS or stimulants, in
order to counteract their depressing influence
upon the alimentary canal, and on the nerves of
organic life.

Bibliography. — G. E. Stahl, De Morborum ^tatum
Funilamentis Pathologico Tlierapeuticis. Halae, 16fi8,4to.
— F. Hffinann, De ^f^taiis Mutatione Morborum Causa
et Keraeiiio. Hall. 1720, 4to. — Lmiuetts, Disser. Meta-

mniphosis Hiiraana in Amoen. Acad, vol.vii. p. 143

U'elsted, De Xxnte Vergonte, 8vo. Lond. \Tli.— Plaz, De

Brpvioris et Iiifirmioris Vita; Causis. Lips. 17S2 C. A.

P/ii/itcs, D(- Decremento Homiii., iEtatis Periodo, et Ma-
rasmo Senili in Specie. Halae, IK08.— J. //. F. Autenrielh,
De Ortu qiiorund. Morbor. Piovectior. jEt.Ttis,&c. Tub.

\iiOb J. Schneider, Handb. Uber die Krankh.des Mann-

baren Alters. 2 abth., 180S-12. — Pinel, in Archives Gen.
Mtdecine, t. xi. \>.l. — Foucart, in Ibid., t. v. p. 3'J8. ;
t. vi. p. 87. — P. J. B. Esptirron, Essai sur les Ages de
rHomme. Paris, Ann. vi. 8vo. — F. E. Jolly, Aper(;u
Physiol, et Medical snr les Premiers Ages de la Vie Hu-

maine, 4to. Paris, 1816 J. A. Gessner, De Mutationibus

quas subit Infans statim postpartum. Erlaiig. 1795

H. X. .Boer, Versuch einer Darstellung des Kindlichen Or-
ganismiisin Physiogolisch patholog.undTherapeut. Hin-
sicht. Wien. 1813. — /?. G. Sc*)-, Progr. de Morbis Se-
num. Viteb. 1807. — A. Carlide, Essay on the Disordersof
Old Age. Lond. 1817. — i. H. Frirdlaciider, Fiinda-

menta Doctrinie Pathologicse, &c. Lips. 1828. 8vo

Rullier, art. Age, Dictionnaire de Medecine, en 18 vol.,
t.prem. Paris, 1821. — I,. J. Begin, art. /ig<?, Dictionnaire
de Medecine et de Chirurgie Pratiques, t. i. Paris, 1820.

B. C. Faust, Die Perioden des Lebens. Berlin, 1791.

8vo. — C. IV. Hufeland, und R. A. Ritdolphi, Encyclopii-
disches Worteibuch der Medicinischen Wissenschaften.
Zwieter Band. Berlin, 1828. — J Johnson, The Economy
of Health, or the Stream of Human Life Irom the Cradle
to the Grave. Lond. 8vo. 1G87. — P. il. Roaet, Cyc.
Pract. Med. vol. i. p. 34.

E

50 AMAUROSIS — Pathology of.

AGRYPNIA. See Sleeplessness.
AGUE. See Fever — Intermittent Fevers.
AIR. See Disease, its Causation, liemoval, (S;c.
ALOPECIA. See Haiti, the Loss of.
AJMAUROSIS, from a/j.avp6s, obscure. Syn.
Guita Serena, Suff'usio A'/ar«,Celsus, Lucretius,
Pliny. Obscuritas, Hehetudo, Paulus /Egin.
Paropsis Amartrosis, Good. Caiaractu Nigra,
Auct. Germ, quibusd. L'Amaitrose, Fr. Die
Scliwurze Staur, Germ. Gotta Serena, Ital.
Stehelindlteit, Hoi. Sujf'itsion, Drop Serene,
Rlilton. Dimness of Si>ilit, Blindness.

Classif. 4. Class, Local Diseases ; 1. Order,
Impaired Sensations (^Cullen). 4. Clans,
Diseases of the jNervous Function ; 2.
Order, AfJecting the Sensations (Good).
Functional Amaurosis, I. Class, IV. Or-
der. Orj^unic Amaurosis, IV. Class, III.
Order {Author, see ihe Preface).
\, Defin. Partial or total blindness, from affec.
tion of the retina, or of the nerves, or of that
part of the bruin related to the organ of sight,
whether arising primarily from funciional disorder,
congestion, infammation, or any other change of
these parts ; or occurring from sympathy with otlier
organs. Or, in other words. Partial or total loss
of sight, from other causes than those ivliich obstruct
the passage of the rays of light to the bottom of the
eye.

2. Amaurosis is met with at all ages; but most
frequently in the moie advanced terms of life. It
is somelinses congenital ; and in these cases it is
often difficult to ascertain the nature and seat of
the affection. When it occurs at advanced periods
of life, an attentive inquiry into the history of the
disease, of the previous habits and ailments of the
patient, and of the various resulting and related
moibid phenomena, will generally ihrbw light
upon its pathology.

3. I. Seat of .\maurosis. — 1st, In the retina:.
— Viewing the delicate structure of the retina ; its
relation to the optic nerve, of which it is an ex-
pansion of great tenuity ; its connection with the
choroid and hyaloid membrane, and its nervous
and vascular communications ; and considering
the various morbid slates it is liable to undergo,
in consequence of its relations with these and
other parts; a partial, and even total, abolition of
its functions is to be looked for on some occasions.
It is, like all other parts of the frame, liable to
congestion and inflammation, with their usual re-
sults; and, like other nervous parts, its functions
are subject to a partial or complete extinction
without itself evincing any change of structure,
its sensibdity alone being impaired or abolished ;
owing either to some unuppreciable change, or to
some one or more of those alterations in its ad-
joining or related parts about to be noticed.

4. 2d, In the optic nerves. — 'J'liese nerves may be
more or less changed in some part of their course,
from the anterior pair of the corpora quadrigeminu,
along the thalami, the tubera ciiieiea, and their
partial decussation, until they terminate in the
formation of iheretinaa. In :)])preciating, however,
lesions in the course of the optic nei ves, the results
of experiments on them should be taken into con-
sideration : — if an oplic nerve be divided previous
to this decussation, sight is altogether lost on the
ojjposiie side ; but if the division be made be-
tween the decussation and the eye, vision is lest
on ihe same side.

5. 3d, In the ganglial nerves. — There is every rea-
son to suppose that the retina is in intimate commu-
nication with other nerves, and that it mutually
influences and is influenced by them. Branches
of the great sympathetic may be traced upwards,
from the first cervical ganglion, to the ganglion
lodged in the cavernous sinus; whence branches
proceed and communicate with the third, the fiist
division of the fifth, and sixth pairs of nerves.
Branches also passes from the cavernous ganglion
directly to the lenticular ganglion. As the internal
carotid artery passes into the cranium, it is sur-
rounded by the sympathetic nerves, which accom-
pany all its ramifications. The ophthalmic artery
is invested with these nerves ; its branches to the
choroid, iris, and retina being similarly provided.
Branches of nerves, moreover, proceed from the
lenticular ganglion, as IVL Ribes (JU^m de la Soc.
Mtd. d'Eniulution, t. vii. p. 99.), and others have
demonstrated, to the iris, giving more minute
blanches in their course to the retina. This con-
nection being established, morbid states of these
nerves and ganglia, or changes of structure in
their vicinity aflftcting their functions, must neces-
sarily impair the sense of sight.

6. 4th, Other nerves, as ihe fifth and third pair
are, in some cases, also the seat of amaurosis. It
has been shown by Magendie and Desmoulins
that the integrity of the fifth pair is necessary to
the perfect function of the retina ; and Mr. Mayo
has furnished evidence that the third pair is re-
quisite to the motions of the pupil. If the great
sypalhetic be divided in the upper part of the
neck, the pupil becomes contracted and immove-
able, and the eye wastes.

7. 5th, Parts of the encephalon connected with
the optic nerves in their course are occasionally
the seat of amaurosis, as pathological research and
experiment have shown. MM. Magendie and
Serues have proved that, when these parts are
wounded, the sight of the opposite eye becomes
either weak or extinct.

8. 6th, The pineal and pituitary glands are
frequently the only parts in which any alteration
can be detected in the examination of amaurotic
subjects. The connection of these glands with
the ganglial system is stated at another place.
Besides these, other parts of the brain, when the
seat of organic disease, are not infrequently the
principal source of amaurosis, as shown here-
after.

9. 11. Causes. — 1st, The predisposing causes
of amaurosis are very diversified. Amongst these,
the influence of heredilaiy disposition is well esta-
blished. Beer traced it in several families ; in one
of them through three successive generations, and
parliculaily in the females of that family who luul
not boine childien, it having appeared in them at
the cessation of the menses. Heir also states, that
dark eyes are much more liable to it than ihe light ;
the proportion being upwards of twenty to one.

10. VVliatever tends to favour sanguineous con-
gestion of, or seious iflusion in, the encephalon,
particularly insolation ; foiced exertions of the
mind or body ; excesses of passion ; the pregnant
and puerperal states; occujiations requiring fre-
quent stooping ; errors of diet, and neglected ail-
ments affecting the stomach and liver ; the abuse
of wine or spirituous litjuois; suppressed dis-
charges, particularly those from the nose and
ears; interruption or entire cessation, of the

AMAUROSIS — Pathology of.

51

menses ; the gouty, rheumatic, and strumous
diathesis ; the retrocession or suppression of
eruptive diseases; and habitual constipation; —
whatever exhausts tiie vital energy of the brain,
and nerves supplying the organ, as ciironic diar-
rhoea, typhoid fevers, the excessive use of snuff,
long-continued grief, prolonged suckling, neg-
lected (luor albus, excessive venery, and manus-
trupation ; — and lastly, whatever exhausts slowly
the sensibility of the organs of sight themselves ;
as the incautious use of the eyes in a glaring
light or on minute objects, and the existence of
strumous ophthalmia in childhood, generally pre-
disjhise to amaurosis.

11. 2d, The exciting causes are very numerous;
indeed, any of the causes enumerated as merely
predisposing to the alFection may excite it, when
acting long or intensely, although the successive
or combined action of various causes are gene-
rally required. Amongst the most common ex-
citing causes, are over-exertion of the sight ;
exposure to very bright light ; its occupation on
minute object*!, or employment in candle or lamp
light, and during the hours usually devoted to
sleep. The sensibility of the retina may be de-
stroyed, even by a single exposure to these causes.
Lightning is another cau^e, which seems to act
by extinguishing the sensibility of this very deli-
cate part. In general, however, it is the long-
continued over-excitement of the organs of sight
that occasions the gradual abolition of their func-
tions. Injuries on the eye, and in its vicinity, are
also frequent causes of the disease.

12. Poisonous substances occasionally pro-
duce an attack of amaurosis ; sometimes sud-
denly, at other times slowly. Belladonna, stra-
monium, solanum dulcamara, &c., fish-poison,
various fungi, and animal poisons, occasionally
have the former effect ; but it is most frequently
only of temporary duration ; whilst other nar-
cotics taken habitually, as opium and tobacco,
produce the latter effect, and in a more perma-
nent manner. 1 he poison of lead, blows on the
head, child-labour, and puerperal convuNion,
frequent attacks of epileptic or other convulsions,
cerebral apoplexies and paralysis, injuries of
the branches of the fifth pair of nerves (three
cases of which have come before me), an<l even
irritation of these nerves, will produce this affec-
tion ; it has also been observed to supervene to
gastric and intestinal irritation, particularly when
occasioned by worms; to hypochondriasis, and
accumulations of bile in the liver, &c. ; to frights,
and to the irritation proceeding from cations teeth.
The sudden suppression of epistaxis, of hemor-
rhoids, of the lochia, of the milk in nurses, of the
menses, or of the perspiration ; the repulsion of
eruptions on the head and behind the ears, and
the drying up of old ulcers, have, severally, occa-
sioned the disease. But most frequently it is the
result of two or more of these causes, acting
under circumstances of predisposition. Females
with dark eyes are extremely liable to the disease,
upon the cessation of the menses ; and, like deaf-
ness, it is apt to appear after severe attacks of
typhoid and scarlet fevers. Amongst the more
rare exciting causes of this affection, are the
gouty and rheumatic diathesis, or misplaced and
retrocedent gout and rheumatism ; the constitu-
tional effects of syphilis, and hurtful influence of
mercurial courses ; — all which have been assigned

as causes of the disease by some authors, and de-
nied by otheis; but, undoubtedly, producing it
on some occasions, although not so frequently as
the former believe.

13. 3d, The proximate or efficient causes o( ihis
affection are various. It has been disputed whe-
ther or not it can aiise from altered function only,
and without change of structure. JMr. Traveks
believes that it does, but JNIr. Mackenzie denies
it can depend upon morbid function merely ; and
other writers take opposite sides of the question.
Ihere can, however, be no doubt, if we atten-
tively consider the disease in relation to the ex-
citing causes and the effects which are observed
to result from them, that, although most com-
monly the consequence of some appreciable
change in some one or more of those parts in-
stanced as its seat (§ 3 — 6.), it is occasionally
unattended with such change, — at least to such
an extent as our observation of the effects pro-
ceeding from similar alterations would lead us to
expect. It should not be overlooked that the
operation of many of the causes which have been
adduced above is entirely vital — upon the func-
tions of life, as manifested in the organ, or in
remote parts of the frame ; — that their effects are
sometimes almost instant, and before organic
change could have be^n produced ; and that the
disappearance of their effects has been sometimes
as sudden, and often before the restoration of
morbid structure, providing that it existed, could
have been brought about. I believe, after a care-
ful perusal of the works which have been fur-
nished by surgeons on this disease, that a too
marked disposition has been evinced to consider it
as a result of organic change in the organ and the
nerves, and vessels connected with it, and without
relation to constitutional and vital causes.

14. When describing the seat of amaurosis,
the influence of organic changes has been briefly
noticed ; and a fuller reference to them will be
made in the sequel. Amongst the numerous
lesions of structure that occur in the brain and
its membranes, there are many that affect the
nerves of sight, more particularly the optic nerves,
or which implicate them organically in some part
of their cour-e in a very remarkable manner.
Alterations in the bones of the cranium, as well
in the membranes, obstructing the functions either
of these nerves or of the other nerves subset vient
to the perfect exercise of this important sense, are
also not uncommon.

15. The EFFICIENT CAUSES of this affection,
therefore, are, 1st, vital or functional, dependm"^
upon imperfect or abolished sensibility of the
retina, or of the optic and other nerves subservient
to vision, owing either to causes which, from their
direct and local action, depress or exhaust this
property, or to those which, from their primary
influence upon the frame, have an indirect de-
pressing effect, which is not limited to this organ,
although manifested in it in a more marked degree ,
owing to various concurrent circumstances. This
constitutes the functional form of amaurosis ad-
mitted by Beer, Wardrop, Travers, Sanson,
and others, and which Beer divides into two
subordinate kinds : first, that which proceeds
from direct depression of the vital sensibility of
the eye; and, second, that which is owing to in-
ordinate excitement, and consequent exhaustion of
this property,

E 2

52 AMAUROSIS

16. 2d, A congestive or infiammatory state of
the vessels of the retina, or parts immediatelq
adjoining, or the usual effects of these states. —
Portal, Ploucquet, Prochaska, Rousseau,
Sanson, Magendie, and other pathologists, have
observed varicose states of these vessels ; unusual
injection of the minute arteries of the adjoining
coats, and of the retina itself; a complete reti-
nitis; exudations of lymph under the choroid,
near the ciliary circle ; inflammaiion of the ex-
ternal surface of the sclerotic; vascular injection,
and firm adhesion of the retina to the choroid ;
partial detachment of the retina from this coat ;
and thickening, morbid density, and change of
colour of the retina. Ossification ; fibrous de-
generation, with partial thickening ; wasting, and
malignant disease of the retina, and even the
development of transparent vesicles in it, have
all been noticed by Hali.er, Morgagni, Heis-
TER, Sanson, and other authors.

17. 3d, Lesions affecting the optic nerves. —
These consist chiefly of tumours of various kinds
— osseous, fibrous, encysted, steatomatous, puii
form, aneurismal, &c. — formed in their vicinity,
either in the brain, the membranes, or in the bones
of the cranium, and involving, or compressing
them, in any part of their course. They are like-
wise, occasionally, the seat of some one, or even
more, of those organic changes of their proper
structure and sheaths, to which nervous parts are
liable. Their vessels may be varicose ; their
fibres may be infiltrated with serum ; they may be
injured by external violence, and they may be
wasted ; which last is very frequently observed.
Adventitious deposits, as osseous and earthy mat-
ter, malignant formations, cysts and hydatids,
may even form in their sheaths, although more
rarely than the foregoing lesions. The writings
of pathologists abound with instances of these
changes. When only one eye has been amau-
rotic, the optic nerve of that side has been found
wasted anterior to its partial decussation ; and on
the opposite side, posterior to this union. 13ut
this is by no means an uniform circumstance, and,
when observed, the atropiiy is not distinctly con-
tinuous. Indeed, the wasting has been detected
on the same side, after the union of these nerves,
as well as before. But if the opinion of Trevi-
RANus and VVollaston be correct, — that decus-
sation of these nerves at their union is only partial,
and that it takes place chiefly between the parts
which are nearest each oiher, — wasting of one of
them may be in one case more remarkable on the
same side, and in another case more observable
on the opposite side. When the amaurosis is
accompanied with wasting of the optic nerve,
from causes not primarily consisting of inflam-
mation or its conse(|Uences in the retina or ad-
joining coats, this nervous expansion is also
generally wasted, transparent, or changed in
colour. When the cause exists in the pineal or
piiuitaiy glands, the wasting is often chiefly ob-
servable at the union of the optic nerves. In
these cases, both eyes are afl^ecled. Facts illus-
trative of tiiis have been recor(le<l by Vieussens,
]Je IIaen, Rullieh, Rayer, Ward, and San-
son.

18. 4th, Lesions seated in the encephalon. — The
scope of this article will not admit of further
reference to the numerous changes which occa-
sionally produce amaurosis, from their afl=ecting

— Symptoms.

the optic nerves in their different connections with
various parts of the encephalon. All the alter-
ations which are described in the articles on mor-
bid structures of the brain and its membranes,
will produce the disease, when they impede the
functions of the optic nerves, although the struc-
ture of these nerves may be uninjured. The most
frequent and remarkable of these are, organic
lesions of the pineal and pituitary glands (§ 8.),
sanguineous and serous efl'usions, various kinds of
tumours, abscesses, softening of the brain, &c.

19. 5th, Lesio)is of 7ierves subsidiary to the
integrity of the organ and of its functions. — In-
juries, compression, and even irritation of the fifth
pair of nerves, particularly its ophthalmic branch,
of the third and sixth pairs, and of the ganglia or
their ramifications, by organic change in the brain,
its membranes, bones of the cranium, or parts in
the course of their branches, have been shown, in
numerous instances, to have been the chief effi-
cient causes of amaurosis.

20. III. Symptobis. — The symptoms of amau-
rosis are, 1st, those which the patient himself
experiences ; and 2d, those which the physician
detects in the eyes, or in the various organic and
animal functions. Each of these classes of symp-
toms are to be inquired into separately, com-
mencing with either of them. Each eye should
be carefully and separately examined ; and it
will be better that tiie other is excluded from the
light, whilst the examination is being made.

21. 1st, The patient complains of impaired
vision, which may be of gradual accession, or re-
markably sudden, and amounting to almost total
deprivation of sight. Hence the disease has been
distinguished by the epithets slow and sudden, in-
complete and complete, or imperfect and perfect,

22. At the coinmencement, the failure of vision
is sometimes only occasional, for a short time, and
after longer or shorter intervals (amaurosis vuga).
In some cases it assumes the form of day-blind-
ness, in othtrs of night-blindness : and it not in-
frequently recurs for a time after great exertion of
the eyes, either with minute or bright objects.
Transient and sudden attacks of the disease are
often the consequence of disorder of the digestive
organs, or rather tiie result of a state of the vital
manifestations which occasions equally loss of
sight as well as loss of the digestive functions.
The failuie of sight is often at first only partial —
extending only to a pait of the field of vision. In
some cases, intervening portions of the field are
obscured (visas interrupius). In other cases,
one half of it is hid from view (heminpia). Oc-
casionally objects are only seen in a particular di-
rection (visas ohliquus) ; and some patients discern
objects in a distorted form — crooked, mutilated,
shortened, lengthened, or inverted (visas defigura-
tas). Beer states that the flame of a candle will
often appear elongated, and as if separated into
several portions, to such patients, — a symptom in-
dicating disease within the head.

23. In some instances the failure of sight as-
sumes a myopic or a jiresbyopic form : but this is
not so fref[uent as the occurrence of false impres-
sions, in the form either of flashes of light, shining
stars, globes of light, and various other lucid spec-
tra (pitolopsia), or of musca; volitanles. False
impressions of c(dour (chrupsia^ are also frequent
attendants on the early stages of amaurosis. Lumi-
nous spectra aie commonly met with in plethoric

AMAUROSIS

persons, and wlien tlie amaurosis depends upon
increased vascularity, or inflammation of the re-
tina; motes, black specks, muscae volitantes, and
thick mists or clouds, when the affection is de-
pendent upon exhaustion of the sensibility and
vital energy of the organ, and when it occurs in
dyspeptic subjects from exhausting causes. Double
vision is also a common symptom, particularly
when the cause exists within the head.

24. As the disease advances, the field of vision
appears as if obscured by a cloud, or net-work ;
the hitter appearing grey or black in a good light,
but occasionally becoming white, silvery, yellow-
ish red, and luminous in the dark. In addition to
these, the patient sometimes complains, particu-
larly early in the disease, of some intolerance of
light, or of pain in the eyes on being exposed to
it. But, in other cases, from the very beginning,
diminished sensibility of the retina, and a constant
desire for a stronger light — a thirst of light— are
present.

25. Pain in the eyes, and commonly also in the
head, is one of the most important symptoms of
amaurosis. It should, therefore, be carefully in-
vestigated. We ought to ascertain its precise seat
and extent; its character — whether it be acute,
gravative, throbbing, occasional, or permanent.
The circumstances which relieve or exasperate it
should also be noted ; as the horizontal posture,
temperature, exercise, diet, the use of stimuli, &c.
We should also notice whether it be accompanied
with vertigo, tinnitus aurium, watchfulness, or
stupor, coma, forgetfulness, inability of exertion,
or failure of other mental manifestations; as, from
the nature and grouping of these symptoms, we
infer the nature of the efficient cause of the
disease, particularly as they suggest its existence
within the cranium,

26. Unusual dryness of the eyes and nostrils
sometimes is observed in amaurosis ; and in these
cases benefit is often derived from a restoration of
the secretions of the lachrynud gland, conjunctiva,
and Schneiderian membrane. (Mackenzie.)

27. The general health, and previous ailments
of the patient require a particular investigation.
The constitution and diathesis — whether he be
strumous or gouty ; whether he has had syphilis,
or undergone long courses of mercury ; whether
he has had typhoid fevers, or inflammations of the
brain, or apoplexy, paralysis, epilepsy, or injuries
on the head ; whether he has been subject to
complaints of the digestive organs, or has been,
or is, affected with worms : if a female, whether
she has been frequently attacked with paroxysms
of hysteria, or any of its anomalous forms, or with
convulsions in tlie puerperal state, and particu-
larly whether or no there exist any sign of disorder
in the uterine organs — are all particulars most
requisite to be known.

28. 2d, The form, colour, vascularity, and mo-
bility of the different parts of the eye, and habit
and appearance of the patient, next require inves-
tigation. The amaurotic patient walks with a gait
of uncertainty, and a staring and unmeaning look.
In some cases this want of convergency of the eyes
towards an object may amount to slight squint-
ing, occasionally with oscillation, and sometimes
with unusual fixity of the eyes. In some instances,
the motions of the eyelids, and of the eyes them-
selves, are more or less impeded, or even palsied,
— the levator palpebroe superioris, and the orbicu-

— Symptoms. 53

laris palpebrarum being often affected. These
phenomena are chiefly remarked in cases where
the motor oculi, or the facial nerve, is injured.

29. One or both eyes are often unusually pro-
minent. The colour of the sclerotica is frequently
somewhat changed — being either yellowish, bluish,
or ash-coloured. This coat is often covered with
small varicose veins. The con'-istence, also, of
amaurotic eyes is occasionally altered ; in some
cases the eyeball is firmer to the touch, in others
softer, than natural. In rarer instances, it is
flattened on one or more of its sides.

30. The pupil is generally sluggish and limited
in its motions, or altogether deprived of motion,
and dilated. More rarely it is contracted. In
many cases it is neither dilated nor contracted.
A widely dilated pupil, although generally at-
tendant on pressure on the brain, also occasionally
depends on other causes. Early or incomplete
amaurosis is rarely attended with dilated pupil ;
but after all vision is extinct, the pupil is generally
more or less expanded and motionless. It should
not be overlooked, that where only one eye is
amaurotic, the motions of the pupil of the affected
organ will often follow those of the sound one,
when protected from, or exposed to, light ; and
even, as observed by Janin, both eyes may be
completely amaurotic, and yet botii pupils will
vary in diameter with the intensity of light to which
they are exposed. This phenomenon can only be
explained by referring to the nerves supplying the
different parts of the organ. The iris, being chiefly
supplied with ganglial nerves, will often retain its
faculty of motion, when the efficient cause of the
disease aflects the optic nerves at any place between
their origin and their communication with the
third pair ; or when the affection of the optic
nerves within the cranium does not leave the re-
tina altogether deprived of sensibility, although the
impres-ion cannot be conveyed to the brain, the
subsidiary nerves, particularly the third and fifth
pairs, and the branches from the cavernous and
lenticular ganglions, still bestowing sufficient sen-
sibility and mobility on the iris to admit of motion'
on being stimulated.

31. Besides the size of the pupil, it is necessary
to attend to the characters of the motions of the
iris. This part may contract on one side, or in
one part, drawing the pupil to one side, or giving
it an irregular appearance. It may also seem as
protruded towards the cornea, or it may appear
sunk inwards, and have a funnel-like shape,
(INIackenzie.)

32. The appearance of the humours of the eye
is also important. In hydrocephalus, or when
occurring in young subjects, the pupil has the
natural black hue. But in eldeily subjects some
degree of glaucoma accompanies amaurosis. This
appearance is in general unfavourable.

33. The presence of the marks of injuries about
the face and head is important, as marking pro-
bable injury of parts within the cranium, or of
some nerves subservient to the perfect condition
of the organ. The character of the countenance,
the shape of the head, the state of the vessels of
the head and eyes, and the general habit of body,
require to be noticed. The inference which ought
to be drawn as to the exact nature of the disease
will be very different when it is met with in the
plethoric, the highly fed, and the indolent, from
that which will be deduced from its occurrence in

E 3

54

the emaciated or exhausted subject. The pro-
bable predisposing and exciting causes should also
be investigated, as they have an obvious relation
to their effects. Attention should.be directed to
the previous habits, indulgences, ailments, occu-
pations, and modes of life of the patient &c., with
the view of throwing light upon the causes and
pathological relations of the malady.

34. The duration of the disease is extremely
various. It may, in slighter cases, be only of a
few hours' or days' continuance; may altogether
disappear, either spontaneously or from treatment,
and never afterwards recur ; or it may return after
an indefinite period, from errors in diet, disorders
of the digestive organ?;, or from the operation of
the causes usually producing the disease. It very
frequently continues all the life of the patient.

35. IV. Stages, Ghades, and Fohms. — The
stages of amaurosis are incipient and confirmed. In
the former the sight is generally not altogether lost,
although more ur less impaired. Treatment will
often retard or check the progress of the disease,
isnd sometimes even bring about a pei feet cure. But
the blindness may be complete from the first : in
this case, medicines are generally without effect. In
iheconfirmed stage, the disease is usually stationary ;
but the sight is not always altogether lost: the
patient often retaining a perception of light and
shadow, or even of objects, when illuminated or
strongly contrasted. When this power of distin-
guishing any object or colour is still retained, even
in the slightest degree, the amaurosis is said to be
incomplete. When the patient is insensible even
to the presence of liglit, the disease is complete.
It may be limited to otie eye, in tiie incipient or
incomplete states; or it may affect both equally,
cither in an incomplete or complete form. It may
also be incipient in one eye, and confirmed in the
other ; and it may be more or less complete in
either. It may likewise, in one or other of these
states or forms, assume a recurrent or remittent
type ; but such cases are comparatively rare.

36. But, besides these stages and grades of the
disease, other forms occasionally present them-
selves, which will be more fully noticed in the
sequel. It may be Idiopathic, depending upon
changes, either_/'«7ic(J(iK(// or organic, taking place
primuriltj in the nervous apparatus of the eye, and
existing simply, and without any other associated
lesion : or it may be complicated wilii lesions of
adjoining parts, or with other diseases of the eye,
particularly of its humours, more especially with
glaucoma and cataract. It may also be consecu-
tive of other diseases; most frequently of organic
changes within the head, or in the vicinity of tiie
orbit, as in apoplexy, paralysis, &c. And, lastly,
it may be aymptoniulic of, or supervening to, pre-
existent disease of distant part<, particularly of the
abdominal vi-cera ; or it may be occasioned by
pregnancy, and more rarely by diseases of the
puerperal state. It is not infreijuenlly thus symp-
toniatic of colic from lead, accumulations of t<ccal
matters in the large bowels, hy|)ochon'lriasis, &c.

37. According to these states of the disease, its
different species will next be considered, and the
treatmetit wliich is appropriate to each of liiem
will subsequently be pointed out: for it is obvious,
that the success of remedies will, in this very diffi-
cult and variously com|)licated disease;, mainly
depend upon the strict appropriation of remedies
to its different varieties and states.

AMAUROSIS — Species of.

38. Spec, 1st, Functional Amaurosis.

■This

form of the disease generally arises, — 1st, from
suspension or exhaustion of nervous and sensorial
power ; from various local and constitutional causes
(§ 13.) ; from inordinate excitement or exertion of
the visual organs; from mental exertion, watchful-
ness, anil sedentary habits ; from the deleterious
action of mineral, vegetable, and animal poisons, as
lead, mercury, narcotics, &c.: 2d, from venereal
indulgences ; excessive secretions and evacuations ;
depression of the vital energies from diseases of
debility and exhaustion : and, 3d, from temporary
diminution of the local circulation ; from simple
congestion, or occasional determination of blood
in the veins or arteries ; and from the irritation or
disturbance of the digestive organs, or of some
other of the abdominal viscera.

39. 'J he symptoms of this species are, chiefly,
more or less obscuration of vision, occurring slowly
or suddenly, the vi^us nebulo.->us, and muscee vo-
litantes; a somewhat contracted pupil, and clear
stale ol the humours; equal imperfection of sight
in both eyes; pale, languid countenance, and de-
pression of the eyes in tlie orbits; a languid, small,
or weak pulse ; increased dimness, or sudden abo-
lition of sight upon quickly assuming the erect,
from the horizontal postuie. An improved state
of the sight after a light meal, or grateful stimulus;
nervous headachs; weak digestion, sluggish state
of the bowels, flatulency, foul or loaded tongue,
and indisposition for, as well as incapability of,
physical or mental exertion or occupation : weak-
nessiii the joints; occasionally nocturnal emissions,
&c. in the male, and leucorrhoea in the lemale.

40. This species of amaurosis may be, 1st,
Prinuiry and uncomplicated. — In this case it
usually proceeds from causes which depress or
exhaust the sensibility of the retina and its re-
lated nerves. 2d, It may likewise be consecutive ;
particularly of excessive secretions and discharges
from the uterus, mamma;, kidneys, testes, and
prostate ; or from exhausting and debilitating
diseases, as adynamic diseases, haemorrhages, &c.
3d, Sytnplomatic of, or complicated with, hysteria,
hypochondriasis, colica pictorium, diminished vital
energy of the digestive organs, and all the various
forms of indigestion ; the presence of worms in
the bowels: pregnancy; obstruction and accu-
mulation of bile in the bile-ducts or bladder, &c. :
and, 4th, Metastatic, or supervening upon impeded
or checked secretions and discharges; in which
cases it is generally accompanied with congestion,
or determination of blood to the head, in which
the eyes may partake, but not to an extent con-
stituting infiammatoiy action or organic change;
and it assumes a slate nearly approaching to that
characterising tlie next species.

41. Upcc. 2d, AnuDtrosisJiom active congesti<m.
— 'J'he existence of this species of the disease
is more a matter of inference, than almost any
other of thos^ in which 1 have divided the disease.
^ et it seems undoubtedly to exist; especially
when amaurosis is consequent upon obstructed
secretions and discharges, or the drying up of
eruj>tions; u])on frequent stooping, or wearing a
tight neckcloth ; upon fits of passion, when it
occurs in plethoric persons ; and after narcotic
poisons.

42. 'I'he symptoms indicating it, are throbbing
in the eyes, tinnitus aurium, turgescence of the
vessels of the sclerotica and conjunctiva, a some-

AMAUROSIS — Species op.

65

what contracted pupil, and clear state of the
humours ; turgescence of the features, or lividily
or bloatedness of tlie face ; fulness of the jugular
veins, prominence of the eyes, and impeded circu-
lation through the lungs or cavities of tlie heart.

43. This form of the disease is seldom primary
and uncomplicated. It is commonly consecutice,
or symptomatic, generally of obstructed discharges,
&:c. (§ 12.). of disease within the head, particu-
larly of sanguineous congestions, or effusions, and
diseases of the lungs and heart. It not infre-
quently occurs transitorily from pregnancy, epi-
lepsy, and hysteria; and more rarely from gout
and rheumatism.

44. Spec. 3d, Amaurosis from h^ammation of
iheretitia, and internal parts of theeife. — In stating
amaurosis to be often a symptom merely of reti-
nitis, I am supported by the opinions of many of
the best British and Continental writers on the
disease. But I believe it very seldom occurs,
that the inflammation is limited to tliis membrane,
but that the choroid and iri-i generally participate
with it in the morbid action ; and that, when
tliey, on the other hand, are thus affected, the
retina is also inflamed. Amaurosis is tiierefore a
consequence of inflammation of the internal struc-
tures of the eye: but does inflammation of these
parts uniformly produce amaurosis? It is not
always consecutive of iritis ; and I believe that
the retina may be inflamed, and yet but very
slij^ht amaurotic symptoms may be occasioned
thereby, particularly during tlie early stages of
the retinitis. It is chiefly when the inflammatory
action has produced some degree of organic
lesion of the affected parts, that amaurosis is
manifested.

45. This form of amaurosis generally proceeds
from nearly the same causes as the foregoing
(§ 10 — 12. ). It may be produced by syphilis, mer-
cury, eruptive and continued fevers, cold in any
form acting upon the eyes or face ; suppressed
discharges, or eruptions on the iiead or behind the
ears; injuries of the eye and adjoining parts;
concussions, and the usual causes of inflamma-
tion in other parts.

46. The symptoms vary with the extent and
intensity of the inflammation. In its slighter
slates, the progress of the disease, and of the
symptoms, is insidious and slow. In these cases,
little or no pain is complained of, either in the eye
or in the head. 'i"he pupil is more commonly
contracted than dilated, and the spectra are
usually luminous, but sometimes not very sensi-
bly so. With this slight and often chronic state
of inflammatory action, the amaurosis may be
increasing fast, and the observation of vision very
great, and yet the symptoms may not be dis-
tinctive ; if we except the appearances furnished
by the sclerotic, which, in retiniti-;, as well as in
iritis, abounds in red vessels, converging in distinct
lines, and forming, by their delicate reticulations, a
red zone round the cornea, and which thus furnishes
the only symptom, that can be depended upon, of
slight or incipient retinitis.

47. In the more intense states of inflammation
of the internal parts of the eye. the amaurosis is
attended with painful vision ; intolerance of light ;
sparks of fire, or drops of a red colour falling from
the eyes ; flashes of light ; pain darting through
the head, either from, or to the bottom of the eye-
balls; the pupils are dilated, and the humours

thick or muddy ; and there are more or less
acceleration of pulse and constitutional dis-
turbance.

40. I'his species of amaurosis is often primary,
or idiopathic ; it may also be simple or compli-
cated. When it occurs in a complicated form, it
is, most frequently, associated with iritis, with
meningitis, with eruptive or continued fevers,
and with rheumatism, gout, or syphilis. It may
also occur consecutively, and from metastatis,
particularly after the disappearance of exanthe-
matous eruptions, as in the measles, small-pox,
erysipelas ; of chronic eruptions ; and after the
suppression of habitual or periodical discharges,
secretions, and evacuations (§ 12.).

49. Spec. 4th, Amaurosis from advanced dis-
organisation of the retina and adjoining parts. —
Disorganisation of these parts is usually a result
of inflammation. But it is diflicult to determine
at what stage of the inflammation organic change
commences. I am to consider it here as far
advanced ; yet, the inflammation that occasioned
it may be still present. The causes of this species
are the same as those of the foregoing ; but the
symptoms are somewhat different. The vision is
more obscured. A film seems interposed between
the eye and field of vision. The pupil is sluggish,
and it is often scarcely dilated ; it is frequently
irregular. The margin of the iris sometimes
partly adheres to the capsule of the lens. The
sclerotic is often very vascular, and even livid,
from the enlarged and loaded state of its veins,
which are very numerous and tortuous. The
shape of the eye is sometimes changed, particu-
larly in the most advanced cases ; it is prominent
in some parts, and depressed in others. The
eyeball is occasionally, also, softer or firmer than
natural.

50. This form of amaurosis is always consecu-
tive of the second and third species, moie particu-
larly of the latter; and hence, participates in
many of their characters (§ 41-^48.), and occurs
under many of the same circumstances as they.
It is occasionally complicated with cataract, with
opacities of the cornea, or with disorganisation of
parts within the head.

51. 5/»er. 5th, Amaurosis from external inj uries
of the eyes. — A blow on the eyeball will not
infrequently occasion blindness, without produc-
ing any apparent injury of its visible parts. It is
difficult, or altogether impossible, to ascertain the
nature of the mischief that has been inflicted.
The concussion of the organ, and the lesion of
the sensibility of the retina and optic nerve, may,
in some of the cases, particularly when the con-
sequent amaurosis is merely temporary, constitute
the prmclpil or only change. In more perma-
nent and severe instances, it is very probable that
the delicate connections of the retina with the
adjoining parts are injured. Ecchymosis may
also be occasioned, or inflammation may super-
vene. In these cases the pupil is either dilated,
or of an irregular form ; and according to the ex-
tent of injury will the phenomena partake of the
characters which have been assigned to the third
and fourth species of the disease.

52. Spec. 6th, Amaurosis from disease icithin
the head affecting the functions of the optic nerve,
or other nerves subservient to the sense oj sight. — It
is obvious that disease within the cranium, either
of the substance of the biain, or of its membranes,

E 4

55

AMAUROSIS— Species of.

producing pressure of, or interrupted circulation
in, the parts with which the optic nerve is con-
nected at its origin, or during its course, or acting
in a similar manner on the nerve itself, will pro-
duce amaurosis. In these cases it is a consecvtive
affection — a symptom merely of disease, often
existing for a long time previously. I have al-
ready alluded to the nature of these lesions, and
to their extreme diversity (§ 17, 18.). Perhaps the
most common and the most interesting of them
are organic changes of the pituitary and pineal
glands, hasmorrhage, sanguineous congestion,
aneurismal and other tumours, &c. In these
cases it is very common to find cerebral symptoms
complained of long before the sight is affected ;
and to observe the gradual accession of the dis-
ease either in one or both eyes ; or first in one and
afterwards in another, with complete loss of vision,
followed at last by changes of the structure of the
eye.

53. When organic lesion of the pituitary
and pineal glands has occasioned the disease,
judging from the cases recorded by De Ha en,

Wenzel, Vieussens, Levfque, Ward, Rullier,
and Raver, both eyes are generally gradually
and equally affected, after the existence of ce-
rebral symptoms, chiefly consisting of pain and
weight referred to the more ;interior parts of the
head ; of a repugnance to exertion, apathy, loss
of memory, and weakness of the mental energies.
In casesof sanguineous congestion, or haemorrhages
in the situations referred to, the attack, is sudden,
and the blindness is often not the most remarkable
symptom.

54. In some cases resulting from organic dis-
ease within the head, cerebral symptoms, particu-
lai'ly tiiose of an acute kind, are not complained
of until the amaurosis is far advanced. In its
progress, objects frequently seem to the patient
disfigured or perverted. In many cases of amau-
rosis from organic change of the skull, mem-
branes, or brain, the affection commences with
intolerance of light, strabismus, giddiness, lumin-
ous spectra, convulsive motions of the eyes and
eyelids, contracted pupil, and turgescence of the
blood-vessels of the eyes, loss of hearing, smell or
taste, or both, violent headach, rapidly followed
by complete amaurc^is, protrusion of the eyeball,
and abolition of the external senses and of the
powers of mind.

55. This species of amaurosis is often comjHi-
cated with, or preceded by, epilepsy, paralysis,
apoplexy, otorrhoea, or disease of the ears, hys-
teria, and various nervous affections. It is chiefly
by attending to these antecedent disorders, or oilier
slighter cerebral symptoms, that we can form any
idea of the nature of the amaurosis. The appear-
ance of the eye, and particularly of the pupil, is
not to be dependeil upon ; for, although the pupil
is usually dilated and immoveable, the exceptions
are too numerous to admit of considering it us an
uniform occurrence.

56. .S/;ec. 7th, Amaurosis from disease of the
optic nerves, or of tlieir ^Iieaths. — This species of
amauro-is always advances slowly, generally com-
mencing in one eye, with a black cloud, which
grows more and more dense, great (liHfi;;urement
and perversion of objects, without pain of the head
or eye. There is, however, a sensation of pres-
sure ut the bottom of the eye, as if forcing the
eyeball from its socket. The pupil is generally.

from the commencement, much dilated, and an-
gular, from irregular action of the iris. By de-
grees, according to Beee, glaucomatous change
of the vitreous humour supervenes, and afterwards
of the lens itself, but without any varicose affection
of the vessels of the eye. At last the eyeball be-
comes somewhat smaller than natural, but com-
plete atrophy does not ensue.

57. Spec. 8lh, Amaurosis from lesiorts of
branches of the fifth nerve, ^c. — The experiments
of Bell and Magendie first threw light upon this
cause or form of amaurosis. I believe that it is
by no means infrequent. Four cases of it have
come before me in private practice ; in three of
which the principal trunk or branches of the
ophthalmic nerve were implicated. In one of
these the amaurosis was very slight; in the other
two it was very considerable, although not com-
plete, and was a consecutive phenomenon of
very extensive disease. I saw two of them, ia
consultation with respectable practitioners in my
vicinity. The fourth case very recently occurred
in a member of my own family. In it the frontal
branch on the right side was pressed upon by a
common boil , the sight of the eye was nearly
altogether lost, but was soon restored when the
boil broke.

58. Numerous cases are on record, in which
partial amaurosis is said to have occurred after
injuries and wounds of the eyebrows, cheeks, and
forehead ; or from the irritation and extraction of
diseased teeth. The appearance of the disease
from these causes was noticed by Morgagni,
PiNE[,, Beer, VVardrop, Travers, Penada,
RiuEs, &c., before the functions of this nerve
were so well known as they are now. Its occur-
rence from wounds of the eyebrows is mentioned
even in the writings of Hippocrates.

59. Amaurosis from these causes is, in some
rare instances, complicated with facial neuralgia,
toothach, rheumatism of the face, and tumours
or abscesses developed in the vicinity of the eye,
and within the cranium in the course of the fifth
nerve. 1 met with it in a case of otorrhoea, ter-
minating in caries of the bones, and extensive
disease of the internal parts in the vicinity. It is
also, in some cases, accompanied with paralysis
of the upper lid, and in others with paralysis of
different muscles of the eye. In these cases, the
third or sixth nerves have, most probably, been
chiefly affected. When the ophtlialmic nerve is
affected within the cranium, it is difficult, if not
impossible, to determine the particular seat of
lesion from the amaurotic symptoms. Facts have
not been observed in sufficient number, and with
requisite precision, to admit of any statement being
made respecting the pupil and motions of the iris
in this species of the disease. I believe, however,
that serious organic, as well as functional, lesions
of the organ may supervene to it.

60. There are other varieties of amaurosis par-
ticularised by BEr.ii, Wei.i.er, Sanson, and other
German and French wiiters, some of them of
rare or doubtful existence, or at least referable
to the species into which I have here divided the
disease. From amongst these I may enume-
rate the following: — Gouty amaurosis; rheu-
matic amaurosis ; amaurosis from the sudden re-
pidsion, or cure of cutaneous eruptions, or old
ulcers ; amaurosis from suppressed secretions and
evacuations ; puerperal amaurosis, &c. It is

AMAUROSIS — Diagnosis — PnooNosis.

57

evident that these are only occasional, and by no
means fiequent causes of the disease, which
ought to be kept in recollection by the practi-
tioner, but which can act only by inducing some
one or other of the forms into which it has been
divided ; more particularly the second, tliird,
fourth, and sixth. In as far as tliey may require
a modified plan of treatment, they will receive
attention in the sequel.

61. In addition to these, I may notice, the cat's-
ei/e amaurosis of Beeu, which is only met with in
tiie old, debilitated, thin, and emaciated: parti-
cularly those who are grey or white-headed. At
the commencement of this amaurosis, the iris re-
tains its mobility ; but it afterwards is slow and
the pupil dilated. Deep in the bottom of the eye,
a concave pale grey, or yellowish green, or reddish,
variegated opacity is observed. The further the
disease advances, the paler the bottom of the eye
becomes, the paleness extending to the iris, until
at last a slender vascular plexus — the ordinary
ramification of the central artery and vein — may
be discerned. With this state of the eye, decline
or total abolition of vision is the consequence.
This rare form of amaurosis seems to consist of a
deficiency of the pigmentum nigrum, and of the
tapetum of the uvea. It appears closely allied to
far advanced glaucoma, 'i'his form of the disease
is seldom or ever benefited by medical treatment.
62. V. Diagnosis. — Amaurosis is liable to
be mistaken for incipient cataract, and for glau-
cnma. When cataract is fully developed, the two
diseases can scarcely be confounded. That a
clear diagnosis should be made between incipient
cataract and amaurosis is of the greatest import-
ance in practice. — A. As to the impaired vision
in both diseases at their commencement, it may be
remarked that in cataract, the difficulty of sight
increases very slowly, and is compared to a dif-
fused mist, thin cloud, or gauze intervening
between the eye and the object; whereas in
amaurosis, the dimness or loss of sight is either
sudden or partial, resembling a fly, spots, or motes
covering parts of an object. However, a mist, or
thin cloud, often is complained of in incipient

health — excepting in the cat 's-eye amaurosis of
Beer, which is of rare occurrence, and presented
to us under circumstances not to be mistaken, -r-or
a paleness or greenness, visible only when the eye
is examined in particular directions, constituting
amaurosis with glaucoma. This appearance evi-
dently arises from deficiency of the pigmentum
nigrum, and incipient dissolution of the hyaloid
membrane ; and when it amounts to a high de-
gree, constitutes the cat's-eye amaurosis of Beeu.

65. Rlr. Mackenzie remarks on this subject,
that attention to the following circumstances will
generally enable the observer to distinguish glau-
comatous amaurosis and cataract : — 1st, The
opacity in glaucoma is always greenish, whereas
in incipient cataract it is always greyish. 2d, The
opacity in glaucoma appears seated at a consider-
able distance behind the pupil, or deep in the
vitreous humour ; whereas in lenticular cataract,
the opacity is close behind the pupil. In posterior
capsular cataract, the opacity is deep in the eye,
but is always streaked ; whereas the glaucomatous
reflection is always uniform, never spotted, nor
radiated. 3d, Upon close examination of the
surface of lenticular opacity by means of a doubly
convex lens, it is seen slightly rough, somewhat
dull, never smooth or polished — forming in these
respects, a striking contrast to the appearances
presented by glaucomatous opacity. 4th, The
eyeball, in glaucomatous amaurosis, always feels
firmer than natural ; while in cataract it presents
the usual degree of firmness. 5th, Glaucoma
proceeds very slowly in its course, scarcely in-
creasing for years; whereas the vision, in cataract,
much more rapidly declines, and keeps pace with
the growing opacity.

66. D. The mobility of the iris is a principal
source of diagnosis. For, in incipient cataract,
the contractions of the pupil are as extensive and
as vivid as in health ; but in incipient amaurosis
the pupil is either dilated and fixed, or its motions
limited and slow. Also, in -the latter disease, the
movements of the eyeballs and eyelids are often
imperfect, or difficuU ; whereas no impediment of
this description exists in cataract. In many cases

amaurosis, and, increasing in density, at last de- I of amaurosis, we observe a want of direction in

prives the patient of sight ; but a complete depri-
vation of sight never occurs in cataract. As inci-
pient cataract depends upon commencing opacity,
generally at the centre of the lens, the appearance
of a mi^t, &c., is generally most perceived when
the patient looks straight forward ; vision being
more distinct when he looks sideways. This com-
monly does not obtain in amaurosis, although it
sometimes does.

63. B. The degree of light which the pa-
tient desires is also important. When amaurosis
depends upon insensibility of the retina, there is
a great desire of strong light, and he sees the best
at noonday, or when objects are brilliantly illu-
minated. The opposite of this obtains in cataract ;
for a strong light, causing the pupil to contract,
the rays of light reflected from the object must
pass chiefly through the central and more opaque
part of the letis. In addition to this we should
attend to the antecedent and attendant symptoms
of amaurosis; especially vertigo, headacii, dis-
order of the digestive organs, tvithout which cata-
ract usually commences.

64. C. Upon examining the pupil, incipient
amaurosis presents either the jet-black colour of

the eyes, or a slight degree of strabismus, not in-
frequently with a want of power over the motions
of the upper lid, — symptoms that never occur in
cataract.

67. VI. Prognosis. — This is unfavourable.
When the cause of the disease is evident, and it
is merely functional, or simply congestive or in-
flammatory, and the patient young, or in the prime
of life, but under middle age, a complete cure is
not infrequent. This may be obtained although
much more rarely, even when the loss of sight is
total. But in every case the predisposing and
exciting causes, and the effects of remedies, must
be taken into account in forming our prognosis,
I\Iuch more commonly only partial amendment is
produced. Amaurosis is generally less unfavour-
able when suddenly, than when slowly induced.
\\hen the pupil is only slightly dilated, still
moveable, of its natural form, the eyeball neither
firmer nor softer than in health, and no glaucoma
present, the progno-is is obviously more favourable
than when the pupil is fixed in the states either of
expansion or contraction, or when the eyeball is
either boggy or preternaturally hard, or when the
botttom of the eye presents a greenish opacity.

58

AMAUROSIS — Theatment.

68. If the attack has been sudden, and nearly
complete, or if objects are seen in a perverted or
distorted form, or double ; if the amaurosis be
attended with want of power in the muscles of the
eyeball or eyelids, we should suspect that the
cause consists of general or partial pressure, or
other organic disease, within the cranium, which,
although indicating both danger and the perma-
nent loss of sight, will sometimes be removed by
energetic treatment. If one amaurotic and para-
lytic symptom slowly supervene on another, we
should dread the gradual development of tu-
mours, cysts, exostosis, &c. within the head, the
situation and nature of which can be suspected
only, and chiefly from the nature of the attendant
or preceding symptoms. But in all these the
prognosis is necessarily very unfavourable.
( 69. VII. Treatment. — In order to employ
remedies in this afl'ection with any degree of
benefit, it will be necessary to direct them with a
very particular reference to the pathological con-
ditions of the eyes, the brain, and system generally,
a^ now pointed out. Having separated the dis-
ease into the foregoing species or varieties, in
order that the treatment may be pointed out
with greater precision, I proceed to detail the
measures which I consider appropriate to each,
conformably to the most experienced authors and
to my own observation.

70. A. Of the first species. — The treatment
of this, the most strictly functional form of the
disease, should have strict reference to the causes
which induced it, — whether those acting directly
on the organ, or those which act indirectly, and
in consequence of inducing disorder of other parts.
When amaurosis proceeds from direct causes,
cither of a depressing or an exhausting nature,
the appearance of the eye, as well as the ciiarac-
terof the symptoms, require an attentive examin-
ation, ciiiefly with a view to ascertain the existence
of inflammatory action, or even active congestion
of the internal parts. A complete removal of
the causes must be insisted on ; and. if no symp<-
toms indicative of inflammation (§ 46.) exist, but,
on the contrary, debility, a languid circulation,
musc(E volitantes, or dark spectra, &c. (§ 39.),
tonics and stimulants, both internally and exter-
nally, are required. A light, nutritious, and
invigorating diet, with change of air, lepose of
tiie organs, moderate exercise, vegetable, and af-
terwards mineral tonic-:, and the usual means of
improving the digestive organs, and promoting
the functions of the bowels and secreting viscera,
are in the^e cases chiefly to he depended on.
Small doses of stri/chnine, or of the extract of iivx
vomica, may also be given (Fohm. 541. 565.).
\Vhen, however, we find evidence of congestion
or increased vascular action of the internal parts
of the eye to have been in<luced, the means to be
employed in the next species must be resorted to.

71. When this species of amaurosis proceeds
from interru])tion or disorder of the digestive func-
tions, as indiciited by the symptoms of such dis-
order, by a foul tongue, acidity and flatulence of
stomach, and lorpid bowels (§ 39.), emetics, as
recommended by KiciiTEri, Otto, ScuMucKEn,
Fi.EMMiNO, ScAiiPA, and Mackenzie, tr>ay be ex-
liiliited ; but, unless the symptoms of interrupted
digestion, or of indigestible and injurious sub-
stances remaining upon the stomach, or of biliary
obstruction, be uneciuivocally present, little ad-

vantage will be derived from them ; in plethoric
persons, or where these causes of disorder do not
exist, they may be even injurious. Amaurosis
from disorder of the digestive organ is generally
imperfect, and sometimes slight ; and its progress
slow. In this form, Scarpa recommends fult
vomiting to be produced by the patient taking
a spoonful, every half hour, of a solution of
three grains of tartar emetic in four ounces of
water; and, on the following day, opening pow-
ders to be commenced with, consisting of an
ounce of bitartrate of potash and one grain of
potassio-tartrate of antimony, divided into six equal
parts. The patient is to take one of these parts
in the morning, another four hours afterwards,
and a third in the evening, for eight or ten suc-
cessive days. The efl'ects of these are, nausea,
and increased evacuations from the bowels; and,
in the course of a few days, vomiting. If, during
their use the patient should complain of a bitter
taste in the mouth, vain efforts at vomiting, and
no improvement of sight, the emetic, as at first
directed, is to be again taken ; and this is to be
repeated a third or fourth time, if the bitter taste,
acid eructations, nausea, &c., continue. The re-
petition will often at last succeed in procuring the
discharge of a yellowish or greenish matter from
the stomach, to the relief of the head and eyes.

72. The stomach, and through it the liver,
having been thus acted upon, the following re-
solvent pills of Sciimucker are to be taken, to
the extent of fifteen grains, night and morning.

No. 11.1^ Gum. Sagapen., Gum. Galliani, Sapon.Venet.,
aa3j-; RheiSjss.; Antimonii Pot.-'l'artralis gr. xv.;
Ext. Glycyrrh. 3j. Divide in Pilul. gr. iij.

These pills are to be continued for four or six
weeks. Instead of these, the pills recommended
by RiciiTER may be prescribed.

No. 12. R Gum. Ammr.niaci, Gum. Assafoetid., S;ip.
Venet., Had. Valerian., Summit, Arnicae, aa 3ij. ; Anti-
monii Potassio-Tartratis gr. xviij.; Syrup, q. s. M. at
divide in Pilulas gr. iij.

From twenty to thirty grains are to be taken
three times a day for some weeks.

73. If these succeed in improving the state of
the stomach and sight, Scarpa directs means cal-
culated to strengthen the digestive organs, and
nervous system ; such as the daily exhibition of
bark and valerian, more particularly in periodic
amaurosis; a light, digestible animal diet, with a
moderate quantity of wine, and wholesome air
and exercise. He further prescribes, as advised
by 'I'mi.ENius and Moiuggia, the vapour of liquor
amrnoniw. directed to the eye, with the view of ex-
citing the nerves of the organ ; and employed,
three or four times a day, so as to occasion each
time a copious secretion of tears. In conjunction
with the use of this vapour, other external stimu-
lants, as blisters to the nape of the neck, behind
the ears, or to the temples ; irritation of the nerves
of the nostrils by sternutative powders ; and, lastly,
sparks of electricity may be resorted to. \'arious
volatile substances, spirituous, saline, and olea-
ginous, have been recommended to be applied to
the eyes, either in a stute of vtipour, or of solution,
and dropped into them, by Warner, Sa(;ah,

ftlANARDlIS, IJUNCKLER, ClIOMEL, St. YvES, Bud

Sciimucker ; but these require to be cautiously
resorted to. Substances of a like description
have also been prescribed in the form of collyria,
in this species of amaurosis. J'i.enck recommends
for this purpose a diachm of the crocus metal-

lorum dissolved in rose-water ; or a portion of the
following : —

No. 13. B Spirit. Lillior. Conval., Spir. Lavand., Spir.
Rorismar., Hydrochlor. Aniraon.,aa3j.; Spir. Bals. Vitae
Hoffman. 3 ss. M.

to be poured in the palm of the hand, and held
before the e^-es. The application of cold and
slightly stimulating washes and baths to the eye,
and bathing the whole head, or eyes, in cold
water, have been approved by Riciiter and Beer.
Mr. Travers, however, slates, that he has never
obtained any decided advantage, in amaurosis, from '
applications made directly to the eyes. Both elec-
tricity and galvanism have received the recom-
mendation of Ware, Lentin (Beutriige, iv. b.
p. 102.), and Os-^iander (Abhaiidl. Med. Soc. zii
ErUiiig. i.b. No. 8.). Moias applied in the course
of the facial nerves have been used by Larrey ;
and the actual cauleiy behind the ears by Kulo-
uoviTCH. (Archives Gener. de Mtd. t. xvi. p. 452.)

74. In this species of amaurosis, both in
cases of the above description as well in those
which proceed from the over exeitionof the siglit,
the external applicatuvi of striichnine promises to
be of considerable advantage. Mr. Liston, Dr.
Short {Lond. Med. Gaz. vol. v. p. 541.), and
Dr. Heathcote (Medico-Chirurgical Rev., July
1830), have thus employed it with decided bene-
fit. After blistering the temples, and removing
the cuticle, from one eighth to one fourth of a
grain of pure strychnine was applied to the de-
nuded surface on each side daily, and the appli-
cation renewed each day, and gradually increased
to a grain. In one case the quantity was in-
creased to three grains, but it is seldom requisite,
and it may sometimes not be safe, to exceed half
this quantity. In some cases it will be necessary
to re-blister, oftener than once, the surface, after
repeated applications of the .strychnine. Cata-
plasms of capsicum have also been employed with
advantage to the temples. Gahn mentions them
with approbation ; and I have seen them used in
amaurosis, with decided benefit, by the native
doctors in warm climates. Hoffmann and Trew
employed the cajeput oil in this manner, and
Warner the animal oil of Dippel.

75. Mr. Travers and JMr. Lawrence are not
advocates for the use of e7netics. The former pre-
fers to remove the gastric disorder by a course of
blue pill, with gentle saline aperients and vege-
table tonics. lie recommends the combination
of blue pill with colocynth, rhubarb, and aloes ;
and of soda with calumba, gentian, or rhubarb;
with the view of promoting or regulating the ab-
dominal functions. After these he advises the
use of general tonics, as the mineral acids, bark,
steel, and arsenic. Mr. Lawrence chiefly ap-
proves of attention to the general health, by resi-
dence in a pure air ; out-of-door exercise : mild,
plain, but nutritious food; gentle aperients, and
occasionally an active purgative ; repose of the
alected organ; counter-in itation by a succes-
sion of blisters, an open blister, or setons. Beer
is also against the use of emetics. He prefers the
employment of brisk cathartics; followed by the
use of anthelmintics, when we suspect the pre-
sence of worms in the bowels. Ilubefacients,
stimulants, and blisters to the temples and eye-
brows, are lavourably mentioned by him.

76. There can be no doubt of the propriety of
the measures recommended by the above writers;

AMAUROSIS — Treatment. 59

but are we to remain content with them alone, in
cases where amendment from them is either slow
or not apparent? I think not; and therefore are
we required to devise additional means. Those
already recommended by the eminent continental
authorities, as stated above (§ 71, 72.), and the
external medication already described {§ 73,74.),
have both authority and reason in their favour, if
duly followed. But it may be useful to suggest
others. For, in cases of this disease, the practi-
tioner will have reason oftener to regret the want,
than to be perplexed by a diversity, of rational
resources.

77. After having had recourse to evacuations,
to emetics with great ciiution, and, under the
circumstances slated above (§ 71.), always to
aperients, alteratives, and occasionally to bri-k
purgatives, promoted by enemata, suited to the
peculiarities of the case, and repeated as long as
the secretions are impeded, and the evacutions
offensive, or of an unhealthy colour, other internal
means must be sought for, if necessary. Amongst
these, in this species of the disease, camphor com-
bined with arnica, and in considerable doses, has
been recommended by Flemming (Hiifeland's
Journ. &;c. Jan. 1810, and May 1812) ; the rhus
toxicddendron, or the rhns radicans, in the form
of tincture, by Basse and Hufeland (Joiirn, der
Pract. Heilk. <^c. Jan. 1811); and phosphorus by
LoEBEL {Horn's Archiv, Nov. 1812, p. 397.)
IMusk, castor, assafoetida, valerian, and zinc, have
also been favourably noticed by Beer.

78. It is chiefly in this form of the disease that
advantage, if any, will be derived from the use of
aconilum, which, however, has received the appro-
bation of BoEHMER, Collin, Stoeller, Rein-
iioLD, Gesner, and other respectable authorities,
particularly when the affection is connected with
chronic rheumatism, or atonic gout, or occurs in
the gouty and rheumatic diathesis. Guaiucum
has been recommended by WiNTRiNOHAiu ; and,
under the circumstances of -disease now alluded
to, particularly when combined with camphor
and ammonia, and given after due alvine evacua-
tions have been procured, is calculated to prove
beneficial. The arnica montana, which has been
prescribed by Baldinger, Collin, Franck, 'J'ni-
LENius, and Angeli, is applicable to this form of
amaurosis only. It is most probably from having
employed it in very difierent states of the disease,
— in the inflammatory, or those depending upon
organic change within the head, — that it has been
disapproved of by Riciiter and Schmucker.

79. The chief ccmp/jfa(/i))(s of functional amau-
rosis require no very difieient trealmeni to that
which has been described. The not infrequent
association of the disease with ivorvis demands the
use of anthelmintics, followed by purgatives, and
the administration of vermifuge enemata, 6cc.
(see Art. Worms), and afteiwards by vegetable
or mineral tonics. But, in the majority of cases
of even functional amaurosis, the use of the pre-
parations of iron requires caution. AV'hen the
disease is occasioned by lead, or accompanied with
the lead colic, or attended by paralysis of any
other parts of the body, the e.xhibition of calomel,
with camphor and small doses of opium, followed
by purgatives and antispasmodic and aperient
enemata, is extremely serviceable. After the
secretions and functions of the abdominal viscera

; are restored by these means, stnichnine, or the

60

AMAUROSIS — Treatment.

extract of nux vomica, may be prescribed both
internally and topically. (Form. 542. 565.)
The connection of the disease witli hysteria, hypo-
chondriasis, obstructions of any of the abdominal
secretions, chiefly requires the combination of
antispasmodics with aperients ; chlorine, iodine,
or sulphureous baths ; the occasional exhibition
of a brisk purgative; and, afterwards, the warm
salt-water bath, tonics with stimulants, and strict
attention to the secretions and functions of the
digestive organs, and to diet, air, and exercise.
After all obstruction is removed, cold bathing, or
chalybeate or salt-water baths, followed by fric-
tions of the cutaneous surface, may be used.

80. B. Of the second species. — When amau-
rosis is attended with tliose symptoms which 1
have described as marking active congestion of
tiie internal parts of the eye, or of the head or
thoracic viscera (§ 41.), a very different treat-
ment to that enjoined above is requi.-ite. In the
first species of amaurosis, blood-letting is generally
prejudicial — it has even caused the disease; but,
in the congestive species, blood-letting, either ge-
neral or local, or both, according to the circum-
stances of the case, is indispensable. In every
form of the disease the means of cure must be
regulated by the apparent vascularity of the eye,
the plethoric state of the countenance and body,
and by the state of the arterial pulse, examined,
not only at the wrists, but also in the carotids and
temples.

After depletion, to an extent which the well-
informed practitioner will be led to adopt accord-
ing to the particular characters of the case, the
promotion of the alvine discharges, and of the
cutaneous and alvine secretions, will next require
his attention, as salutary modes of derivation and
evacuation ; and afterwards the application of
blisters, setons, issues, and other counter-irritants,
behind the ears, or to the nape of the neck, will
generally be necessary to complete, or to render
permanent, the cure. The ointment of tiie potas-
sio-tartrate of antimony, moxas, the mezereon
issue, tiie actual cautery to the nape of the neck,
or to the occiput, and errhines, have severally
been recommended by eminent continental writers
in this state of the disease.

81. 'Ihe slioxcei-ballt, sponging the head with
cold water night and morning, the cold douche, or
the effusion of a stream of cold water on the head,
are means which ought not to be neglected in
those cases in which the congestion is of an
active character, or approaches to tiie inflamma-
tory state. When this form of the disease is con-
secutive of interrupted or suppressed discharges
or evacuations, the restoration of these must be
attem])ied. If the menses be so ])pressed, leeches
to the pudenda, or the insides of the t()[)s of the
thighs ; or bleeding from the feet ; the prepar-
ations of iodine, aloetic purgatives, and otiier
emmenagogues ; stimulating pediluvia, and the
hip-hulh, with the other means usually resorted to
in cases of amenorrlia'.a, are to be employed. Jf
it proceeil from suppressed haiinorrlioids, leeches
may be applied to the vicinity of the anus, and
purgatives, with calomel, colocynth, and aloes,
prescriljed. If it siijiervene on the disappearance
of gout or rlieuniatism, sinapisms and iriitating
cataplasms may be directed to the extremities,
and free alvine evacuations procured ; after which
colchicum, combined with alkalies or magnesia,

and, in some cases, with ammonia or camphor,
may be exhibited, or aconitum combined with an-
timonials, and purified sulphur ; and rubefacients
applied behind the ears, or to the temples. When
it appears after the suppression of eruptions, and
healing of old ulcers, the use of the tartar emetic
ointment, setons, and perpetual blisters behind
the ears, are particularly indicated. If it follows
a suppressed cold, Weller recommends weak
sternutatories, with calomel or hellebore.

82. Mr. Travers has very justly remarked,
that a loss of balance of the circulation, pro-
ducing undue determination of blood to the head,
often exists independently of general plethora,
and is aggravated by sanguineous depletion. It
is sometimes even met with in corpulent persons ;
and is not infrequent after over-excitement and
chronic inflammation. Instead of requiring loss
of blood for its removal, this state of the disease
demands an equalisation of the circulation, by
promoting the various secretions, and the deriv-
ation of the excessive supply to other parts by
the means now stated, assisted by an abstemious
and regular diet, gentle exercise in the open air,
the promotion of the functions of the liver and
bowels, and the means usually employed to be-
nefit the general health. Even in some of these
cases, the local means noticed above, as the va-
pours of ammonia, &c. (§ 73.), may be service-
able in restoring the tone of the vessels of the eyes.

83. C. Of the third species. — Inflammation
of the internal parts of the eye, particularly of
the retina, requires decision, in the more intense
cases, and a vigorous but judicious application
of the usual antiphlogistic remedies. In the
slighter cases, the exact nature of the disease may
be mistaken for either of the foregoing species.
Slight or slow inflammatory action may exist
without any material afl^ection of the pulse, or
pain of the organ ; but the appearance of the
blood-vessels of the sclerotic, and the state of the
iris, will olten indicate its presence when other
signs are wanting. When the attack is acute,
both general and local depletions are required.
In these cases Plenck has advised the perform-
ance of arteriotomy ; Si'iGELius and Hoffmann
of blood-letting from the frontal vein ; and Sau-
VACEs from the jugulars. But vascuhir depletion
is not to be relied upon alone. Active evacu-
ations from the bowels, determination to the skin
by small and repeated doses of antimonials, and
the use of the tartar emetic blister or plaster be-
hind the eais, or to the nape of the neck, are to be
also ado|)ted.

84. If these means fail of producing a very
decided improvement in a very short time, we
must endeavour to aflfect the mouth slightly with
mercury, without pioducing salivation. In order
that this may be done with lajjidity, and with as
little mercury as possible, the preparations of this
mineral to be employed will be advantageously
combined with .James's jiowder, or com[)oiind pow-
der of antimony, and small doses of camphor. The
treatment is, in such cases, similar to that usually
resorted to in iritis. Much of the advantages to
be procured from the use of mercury in this form
of amaurosis, as well as in iritis, depends upon
the pronqititude with which it is employed, [n
this TuAVF.KS, I-AWRENCK, Macken/.ik, and others
agree. Indeed, the use of calomel, and other
preparations of mercury, either alone, or com-

AMAUROSIS

bined with other substances, has been adopted in
the inHammatory states of amaurosis, from the
time of Heistek and Boerhaave, Bang, Hud-

EMANN, SCHMUCKER, ZUICKEU, and BrEITING,

agree in recommending tiiem. Boettcher ad-
Vises the combination of calomel wilh belladonna ;
and Hey, calomel with camphor; both being
judicious modes of combining this medicine.
iMead, Stahl, Hoffmann, and Isenflamm, ad-
vise the production of salivation ; but I agree
with Travers in considering the affection of the
mouth as sufficient. The use of mercury is much
praised by Beer in such cases, as well as in tho-e
of a syphilitic origin, or which are complicated
with engorgement of any of the abdominal vis-
cera. Care should be had not to employ mercury
in debilitated or scorbutic persons, and when tiie
eye is soft or boggy. iNIany of the continental
writers, and Mr. Ware, prefer the bichloride to
other preparations. It is best exhibited, as recom-
mended by Van Swieten, dissolved in brandy,
and taken in a basin of sago or gruel. It may be
continued for six weeks, or even longer.

85. The success whicii has resulted from the
exhibition of the oleum terehiiithinie in iritis in-
duced me to prescribe it, after depLtions, in two
cases of this form of amaurosis , and with satis-
factory results in both. In persons far advanced
in life, in scrofulous subjects, and in debilitated
persons, this oil is certainly a less hazardous me-
dicine than the mercury exhibited so as to affect
the system.

86. In the slighter or more chronic inflamma-
tory forms of amaurosis, particularly when met
with in the description of subjects just now al-
luded to, much circumspection is necessary in the
use of depletions : general blood-letting is here
inadmissible, particularly when this class of pa-
tients are ill-fed, and live in close and ill ven-
tilated streets and apartments in large towns, and
local depletions only are indicated. In cases of
this description, and under these circumstances,
the oleum terebinthina; will prove a valuable me-
dicine ; and even, although we may deplete thus
locally, the internal exhibition of tonics, with a
nutritious diet, attention to the alvine secretions
and evacuations, and a wholesome air, will prove
the most beneficial remedies,

87. This form of amaurosis, as well as the
preceding, will occasionally supervene fi'om sup-
pressed evacuations and eruptions, and, more
rarely, from misplaced gout and rheumatism.
(§ 48.) In such cases, the treatment already re-
commended, as appropriate to each of these ($ 81.)
will be equally applicable here.

88. Besides the above means, it has been re-
commended by BnoMFiELD, to insert an issue in
the scalp ; by Hoffmann, to apply leeches to the
insi<les of the nostrils; by numerous authors, to
employ errhines and sternutatives, with the view
of provoking a copious secretion from the Schnei-
derian membrane ; and by as many others, to use
the actual or potential cautery, setons, moxas,
&;c. to the nape of the neck, or to the occiput.
Leeches and counter-irritants are safe, and some-
times useful, remedies in this and the preceding
species ; but errhines and sternutatives may be
hurtful, unless the affection has arisen from sup-
pressed discharges from the nostrils. They are
most serviceable in the functional state of the
disease. The safest that can be employed in this

— Treatment.

61

species of amaurosis is the one recommended by
the late Mr. Wake. It consists of ten grains of
the hydrargyrus sulphuratus, well mixed with a
drachm of common sugar: a small pinch of it
generally produces a copious discharge of mucus
from the nose.

89. D. Of the fourth, and remaining species. —
When we have reason to suspect that the amau-
rosis depends upon advanced organic lesion of
the internal parts of the organ, consequent upon
inflammation, we should still bear in mind that,
with the supervention of such lesion, whatever it
may be, the inflammatory action seldom alto-
gether subsides, but continues, more or less, in a
chronic, atonic, or disorganising form. Ihere-
fore the propriety of still having recourse to local
depletions, particularly if these have been ne-
glected early in the disease, to purgatives, deriva-
tives, or revulsants; the cold douche to the head ;
and, afterwards, to the use of stimulating vapours,
when we have reason to suspect that the change
continues rather in consequence of lost tone of
the vessels, and inaction of the absorbents, than
from increased action. Under such circum-
stances, the vapour of camphor and acetic acid,
or of the liquor ammonia;, may be tried.

90. a. If the amaurosis have arisen from exter-
nal injury of the ball of the eye, or concussion of
the organ (§ 51.), the chief indication is to pre-
vent, or to repress, increased vascular action, by
the means already recommended ; to attend to
diet and regimen, and to keep the organ in a
quiet inactive state for some time ; after which, if
the affection still continue, the treatment must
be directed according to the particular lesion,
functional cr organic, that may have been pri-
marily or consecutively produced.

91. h. When the history of the case leads us
to suspect the dependence of this affection upon
difease within the head (§ 52.), or tumours
pressing upon the optic nerve, &c. ($ 56.),
the treatment must necessarily be directed, ac-
cording as the symptoms referable chiefly to the
head may lead us to infer the nature of the pri-
mary lesion. If such symptoms, particularly the
temperature of the head, and the action of the
carotids, indicate the existence of congestion,
interrupted circulation, or increased action, the
treatment must be accordingly. But, under al-
most every circumstance, counter-irritation, and
external as well as internal revuUants, will
prove safe, and sometimes serviceable, means of
cure.

92. If we have reason to suspect the formation
of tumours ; thickening, or other change, of the
membranes or of the bones, particuhirly as a
consequence of syphilis ; and extravasations of
blood, or of serum, within the cranium, or in the
course of the optic nerves, &;c. (§ 52.), the
internal use of the preparations of iodine, and
particularly of the iodide of mercury or of po-
tassium (see Form, 323, 324.), should not be over-
looked. I have employed these preparations
with much benefit in three cases of amaurosis
connected with paralysis ; two of them conse-
quent upon apoplectic seizures. In the intervals
between the courses of iodine, deobstruents, and
alterative doses of blue pill, with the extracts of
sarsaparilla and taraxacum, or with the decoction
or other preparations of sarsaparilla, should be
prescribed.

62

ANGINA PECTORIS — Symptoms.

93. c. When the affection seems connecter! with
lesion of the nther verves sitbservientto vision (§ 57.),
the treatment must necessarily depend upon the
seat and nature of this lesion, and, in some rarer
cases, upon the state of the associated derange-
ment. If it be connected with neuralgia of the
nerves of the face, disorder or irritation of these
nerves may exi^t at their origin, or in their
course through the membranes and bones of the
cranium. The cause may also be external — in a
diseased tooth or stump, or a partially separated
external branch of the ophtlialniic trunk of the
fifth nerve. In all such cases, as well as in the
other forms, states, and associations, of the fifth,
sixth, seventii, and eighth species, which have
been enumerated, the treatment must vary in
each, and be dirtcted according to the very nu-
merous pathological conditions, which tlie well-
informed pathologi>t will detect, either as their
efficient causes, or as their related effects.

94. Throughout the treatment of this disease,
the practitioner should keep the following facts iu
recollection: — 1st, an appropriate, and hence
successful, method of cure should have an inti-
mate relation to both the remote and proximate
causes of the disease, and the natural or morbid
diathesis of the patient : 2d, It must be directed
after a minute inspection of the eyes, and exa-
mination into symptoms connected with the head
and the digestive viscera : 3d, It must be modified
according to the nature of its related, associated,
and symptomatic disorders: and, 4th, That much
of the success will often depend upon the strict
regulation of the patient's digestive and organic
functions ; upon diet and regimen ; and upon a
regulated exercise both of the organ of sight and
of the body, with a "pure and temperate air.
Keeping these indications in recollection, the
practitioner will modify and adapt the treatment
to the presumed nature, seat, complication, and
relations of the disease.

Bibliography.— Cradok, Generalia circa Suffusionem,
Guttam Serenam, et liiflam. &c. Leid. \C\)i. — Heistcr,
Apologia et Ulier. Illiistratio Sjstematis sui de Catar.,
Glaucom., et Amaurosi. Alt. 1717, Vlmo. — CEheme, De
Amaurosi. Leip. 174S, 4to. — Warner, Descript. of the
Human Eye and its Diseases. Lond. Mhi. — Sproeael.'m
Miscel. Ber(il.t.vi.p.64.— SaKWrtgM, Nosol.Metli.t.i.p.7l6.
_rn«A-a, HistoriaAiinauroseos,Viiidob.l781.— PtoMci/Mc/,
De Amaurosi. Tubing. 1789.— Schmiicker, Chirurgisclie
Wahrnehmungen. Ber. 1774. _ et Vermische Cliirurg.
ScVirif. 1786. — Richtcr, Aiifansgriinde der Wunderziieik.
Goet. 1790. — Scarpa, Osservasioni sulle Malattie degll
Occhi. Venet. 1802; 2d ed. \%W.— Flnjani, Collezione
d'Osservazioni. Rom. 1803. — \Ven-x,el, Manuel de I'Ocu-
liste, &e. Paris, 180G. — Kiesscr, Ueber die Natur, Ursa-
chen, Kennzeichen, und HeiUmg des Schwarze Staars.

Goet. 1811 Beer, Lehrevonden Augenknmkheiten, &c.

Wien. 1817.— H'ardrop, On the Morbid Anatomy of the
Human Eye, 2 vols. Hvo. Lond. IH\S.— Trnvers, Synopsis
of the Diseases of the Eye, &c. Lond. 1820, 8vo. — Ste-
venson, On the Nature, &c. of the different Species of
Amaurosis, Lond. 1821.— Dcmours, I'recis Theorique et
Pratique sur les Maladies des Yeux. Paris, 1821 — Wriler,
Manual of the Diseases of the Human Eye ; by Mon-
teath. Glasg. 1821, 2 vols. V,\n.—Haiier, Archives Gener.
de Meiiecine, t. vi. Paris, 1823. — Marjulin, art. Amau-
rose. Diet, de Med., t. ii. Paris, 1822. — i'nnsora, art.
Amaurasc, in Diet, de Med. et Chirurg. Pratiques, t. ii.

Paris, 1829 Lawrence, Lectures on Diseases of the

Eye; Lancet, vol. x., \m'i. — Benedict, art. Amauro-
sis, In Encyclopadisches Wiirterb. der Mediciiiischen
Wissenschaften. b. ii. IJerl. 1828. _ Mackenzie, Practical
Treatise on the Diseases of the Eye. Lond. 1830, 8vo.
— It. Middleniore, On Diseases of the Eye. Lond. 183.'),
Hvo. vol. ii. p. 2.')2. — (See also Bibliog. and liefer, to art.
Evi'.)

AMENORRIKEA. See MENsmuATioN.
AiVlNlOS. See DnopsY OF THE Amnion.
AM/l^MlA. See Blood, Dejiciency of.

ANASARCA. See Dnopsv of the Cellular
JMemhrane.

ANEURISM. See Aorta, Aneurism of; and
Arteries, Morbid Structures of.

ANGINA. See Croup. Laryvx, hiflammaiions
of. Pharynx, Iiiflammations of. Throat,'
Injiammations of.

ANGINA PECTORIS. Syn. Cardiogmus
Cordis Sinistri, Sauvages. Augiiui Pectoris,
Ileberden. Asthma Arthriticum, Schmidt. Dia-
phragmatic Gout, Burton. Asthma Dolorifcum,
Darwin. Syncope Aiiginosa, Parry. Angor
Pectoris, J. Frank. Asthma Convulsiviim,
Eisner, Pnigophobia, Swediaur. Sternodyiria
Syncopalis, Sluis. Asthenia Pectoralis, Young.
Stenocardia, Brera. Asthma Spastica- Arlhri-
ticum, Steelier. Sternalgia, Baumes and Good.
L'Aiigine de Pottrine, Fr. BrustbrUune, Herz-
Memme, Brustklemme, Ger. Angina di Petto,
Ital. Suffocative Breastpang, Eng.

Classif. 2. C/ass, Diseases of the Respira-
tory Function ; 2. Order, Affecting the
Lungs, their Membranes, or Motive Power
{Good). II. Class, I. Order (^Author,
see Preface).

1. Defin. Acute constrictory pain at the lower
part of the sternum, inclining to the left side, and
entending to the arm, accompanied with great
anxietii, difficulty of breathing, tendency to syncope,
and feeling of approaching dissolution.

2. This affection was not recognised as a distinct
disease by medical authors, until Dr. Heeerden
described it as such in the Medical Transactions
of the London College of Physicians (vols. ii. and
iii.) ; but the works of Morgagni and Hoffmann
show that they were not unacquainted with it in
practice. It was also noticed by Poter {Opera,
No. 22. p. 302.), under the head " Respirandi
difficultas quffi per intervalla deambulantibus in-
cidit;" and he remarks respecting it, that the
attacks were sometimes so severe that persons had
been suddenly carried off by them. Obscure no-
tices of affections, which probably were of this
nature in some instances, may also be detected in
authors from Hippocrates downward.s. From
amongst these, the reader may refer to Aret^.us
(Opera, p. 7. Oxon. 1723), Cojlius Aurei.ianus
(lib. ii. c. i. p. 348.), Barteletti, {Methodus in
Dijspnaam, Bon. 1632), and others, adduced by
Zechinei.li {Sulla Angina di Petto, Pad. 1813),
who supposes that the case of Seneca {Opera, t.
ii. p. 136.), which he has himself described by the
term suspirium, was actually this malady. Dr.
Cullen has passed Angina Pectoris over in his
work ; but it has been well described by Drs.
Fotiiergill,\Vali,, Duncan, Butter, Pehcival,
Darwin, Macbride, Hamilton, 1\1ac«ueen,
Johnstone, Haygartii, Parry, Niciioll, and
Good, in this country ; and by Jurine, Brera,
Lentin, Despohtes, Kreysig, Riiter, Zeciii-
NELLi, and Stoelleu, on the Continent, and by
Dr. Chapman, in America.

3. Pathology. — I. Symptoms. — An attack of
this disease is often preceded by considerable de-
rangement of the digestive organs, especially by
flatulence, acid or acrid eructations, or other
symptoms of indigestion, with torpid bowels, pains
in the limbs, and occasional spasms about the
chest ; but it fre(]uently also attacks a patient, par-
ticularly when walking or ascending an eminence,
without any, or with but slight premonition.

ANGINA PECTORIS — Causes.

63

4. A. In its acute form the patient is seized with
a sense of painful constriction of tlie chest, par-
ticularly at tlie cardiac region, about the lower
part of the sternum, inclining to tlie left and ex-
tending to the left, occasionally also to the right,
arm — at first no further than the insertion of the
deltoid muscle ; but the pain often successively
reaches to the elbows, wrists, and sometimes even
to the fingers. Tiiis is the mildest form of the
disease, and soon subsides with the disappearance
of its exciting cause.

5. In the more violent form of the attack, the
pain and sense of constriction in the chest, and
pain in the left arm, which also frequently extends
to the right, amount to excruciating agony ; being
likened, by Laennec, to the piercing of nails or
the laceration by the claws of animals. This
feeling is accompanied by a sense of syncope or
suftociition, sometimes vvith suffocative orthopnoea,
consulsive dsspncea, and palpitations; always
with extreme anxiety, and a sense of approaching
dissolution. The suffocative sensation is charac-
terised by concomitant tightness and fulness of
the chest, and flatulent distension of the stomach,
and irritative feeling in this organ, which is re-
lieved by eructations. During this period the
pulse is variously affected, sometimes little ciianged,
at other times extremely weak, iiTeguiar, indis-
tinct, or intermittent ; and occasionally it is full,
active, and bounding. If the attack has been
induced by walking or exercise, the patient sud-
denly stands still, from a feeling that perseverance
in either would pioduce a total suspension of
living power. In the slighter attacks, or early in
the disease, rest merely will often immediately
remove it ; but this is seldom the case in the pro-
tracted and severe forms in which it frequently
occurs.

6. The paroxysm continues from a few minutes
to one or more hours, according to the severity
and the duration of the disease. When the mal-
ady has assumed a chronic form, and its attacks
occur during the night, or when the patient is at
rest, the paroxysm is less violent, but generally of
much longer duration; whereas, when it is in-
duced by exertion, &c., it is of extreme violence,
but of short continuance; the average duration of
the fit may be about half an hour. Upon its
cessation the patient merely retains a slight feeling
of the various symptoms, with numbness of the
arms, particularly the left. When the disease
is of short standing, the paroxysms occur at long
intervals, which are gradually shortened, until
there is but little exemption from them, and the
afTection assumes a less acute character.

7. B. The chronic form of the disease is charac-
terised by the circumstance of its being frequently
a consequence of the acute ; by the occurrence
of the fit from the slightest causes, and alter short
or imperfect intervals of exemption ; by its recur-
rence when the patient is at rest or asleep ; and
by its much longer duration, but less extreme
violence. Even if this form be induced by exer-
cise, rest has little influence in shortening its
duration, as in the precetling ; and the paroxysm
has been protracted, not only for some hours, but
even for several days. Palpitation of the heart,
irregular and intermitting pulse, are more fre-
quently concomitants of this state of the disease
than o( the other. In the case of a very eminent
and learned member of the profession, whom I

long attended in this form of the disease, the
attack has often continued as now described, with
little remission, for several weeks. Sometimes the
irregularity of the pulse is observed only during
the paroxysm; but in some cases it is continued,
as Dr. FoTiiEHGiLL has correctly remarked, during
the intervals, particularly when they are marked
by imperfect relief.

8. 'i his form of the disease may also occur
primarily. It has twice presented itself to main
this manner. During the severity of the attack,
leipotliymia, a feeling of dissolution from the in-
tense agony, and these followed by palpitations,
and an irregular stale of the pulse, generally occur.
In some cases the agonizing pain extends, not
only to the arm or arms, but ascends also up the
throat and lower jaw, accompanied with a severe
sensation of spastic constriction. In the majority
of cases the above sensations are only piesent
when excited by motion, by assuming suddenly
the erect posture, or even by attempting to read ;
a neuralgic kind of pain generally, however, being
felt under the sternum, and extending to the arms:
but in some cases, and in two which occurred to
me, the exacerbations were often referable to no
very evident cause, they sometimes occurring
during the night, although the above causes
generally induced them.

9. Notwithstanding the remarkable distress
characteiising the paroxysm, this disease, par-
ticularly in its acute state, sometimes does not
early affect the constitution, or entail any per-
manent lesion ; the patient often enjoying toler-
able health in the intermissions, and performing
all his functions naturally, and without embar-
rassment, until shortly before an attack. After
its protracted continuance, however, the vital
energies of the frame, particularly as they are
manifested^in the digestive and circulating organs,
give way. Marked disorder of the chylopoietic
viscera, attended with various dyspeptic symptoms,
occasionally with great in ital>ility of the stomach
and bowels, impeded respiration, anxious and
pale countenance, flabby state of the integuments
and muscles, marked derangement of the circu-
lation, oedema, dropsy, &c., at last supervene.
But it more generally happens that the patient
is carried suddenly off by a paroxysm before this
state of the system is occasioned ; or he sinks
under the complicated derangement proceeding
from an attack, and from some one of the orwaniij
changes which the continuance and repeated fits
of the disease had iiiduceil.

10. II. Causes. — I. Predisposing. — This disease
usually attacks the middle aged, and those beyond
it ; and men much more frequently than women.
Of nearly one hundred cases, about seventy were
upwards of fifty years of age ; and seventy-nine
out of the number were males ; nearly one half
terminated fatally, and almost the whole of them
suddenly. It has been said also to occur more
commonly in robust and corpulent persons with
short necks. But Jurine and Chapman dispute
this. JNIy own experience agrees with theirs in
respect of its being equally common in persons
of a spare as of a full habit. It is most prevalent
in those of gouty and rheumatic diathesis, and
w!io lead an indolent, or studious and sedentaiy
life, or who have been subjected to much and
continued anxiety and distress of mind, or in-
dulged in much^ food, and spirituous or ether

64

ANGINA PECTORIS — Diagnosis — Prognosis.

liquors, Jurine and Parh state that they have
scarcely met with it under fifty years of age. The
most violeut and distinctly marked case of it
which ever came before me occurred in a gentle-
man at the age of thirty-four. During 1821, I
attended an unmarried lady, aged twenty-six, who
laboured under it in a slighter form ; and re-
cently, in 1830, another single female, at the age
of twenty-five, came under my care, with tlie dis-
ease in its most violent grade. In both these
females it seemed perfectly unconnected with
uterine disturbance, menstruation being regular,
and no tendency to hysteria having at any time
evinced itself, or could be detected, my attention
having been directed to this point. They both
ultimately recovered, after a long treatment, and
the employment of very decided measures. Nearly
all the cases which have come under my observ-
ation were more or less referable to mental
causes, particularly to disappointment, anxiety,
and other depressing passions. Dr. Hamilton
conceives that there is an hereditary disposition to
the affection. If we consider it to be of gouty
origin, as contended for by Butter, Macqueen,
RiTTER, Stoeller, Thilenu's, Elsnir, and
Chapman, an hereditary disposition may be also
conceded. But, although very satisfactory proofs
have been adduced by these authors, and par-
ticularly by Dr. Chapman, in an able paper he
has recentlv published on this disease (American
Journ. of Med. Sciences, No. xiii. p. 67. ). yet it
does not seem always to depend upon gout. Of
the four cases which occurred to Dr. Black, of
Newry, one only was subject to gout (Med. Chir.
Trans, vol. vii.).

11. 2d, The disease is usually excited by walk-
ing, especially walking against the wind, or up
hill ; by ascending a fiiglit of stairs, or any ac-
clivity, particularly when the stomach is full or
distended by flatus. It is also readily induced by
either the exciting or the depressing passions, and
by whatever perturbates the mind or occasions
emotion. It may also be induced by the most
trifling causes, in some susceptible and irritable
habits, as by gentle walking, coughing, speaking,
or reading aloud ; by suddenly assuming the erect
posture ; by strainingat stool ; or even by a meal,
however moderate, &c. It may also occur in a
state of absolute repose, particularly when the
disease has become chronic ; and the patient may
be roused from sleep by an attack.

12. 1 have seen it occasioned by rapid changes
of temperature, particularly by a rapid change to
great cold ; but different persons seem differently
affected by extreme states of atmospheric teinpe-

.rature. In some sljolit cases the fit has been
shortened, by the patient struggling to overcome
it, by frequently attempting to make a full in-
spiration ; but this has also failed. The patient
is incapable of making this attempt in the more
severe paroxysms.

13. 111. Diagnosis. — Angina pectoris is more
liable to be confounded with asthma tlian witii
any other disease. But a close attention to the
phenomena attending upon both iifl'ections, will
readily disclose a very great difference between
tlum. 'I'lie paroxysms of asthma always come
on during the night, or at the close of llie day :
they are characterised by a heavy dyspna'u,
wheezing, and cough, are relieved by expecto-
rrition and exposuieto fresh air, and subside gra- j

dually towards morning. They are not excited
in the same way, nor by similar causes, nor
marked by the acute and peculiar pain in the
sternum and left arm, which is distinctive of
angina pectoris. The stethoscope and percussion
furnish us with no signs peculiar to the disease
under consideration, unless it be complicated, as
is sometimes the case, with organic lesion of the
heart and lungs, or with effusion of fluid within
the cavity of the pleura or pericardium, wiien they
materially assist us in ascertaining the nature of
the complication ; and they also serve, by enabling
us to ascertain other affections of the heart, to dis-
tinguish between it and them.

14. IV. Prognosis. — In recent cases, of no
very violent character, recovery will frequently
take place under judicious management. But wlien
the disease has become inveterate from neglect, or
from being associated with, or from having given
rise to, organic lesion, and when it has appeared
in a decayed constitution, or has been preceded
by other diseases of the heart or lungs, an un-
favourable result should be apprehended sooner
or later to take place ; but the period of its oc-
currence is uncertain ; and the event is generally
sudden — sometimes like an electric shock ; the
movements of the heart being instantly arrested.
This issue is often occasioned by a full meal, or
by exercise or mental emotions ; but it also occurs
in old or chronic cases, when the patient is at
rest, and apparently uninfluenced by any circum-
stance or occurrence. When it is followed by
symptoms of effusion of fluid within the thorax, or
oedema of the extremities, a fatal termination is
seldom far distant.

15. V. Proximate Cause, &c. — Notwithstand-
ing the number of examinations which have been
made after death from this disease, but little light
has been thrown upon it. This is not so much
owing to the absence of morbid appearances as
to the extreme diversity of those which have been
observed. Like epilepsy or dyspnoea, it has
presented almost every lesion to which the organs
which it affects are liable. Many of these may
be viewed as accidental concomitants, or as con-
current causes ; and not infrequently as results
of the repeated functional disturbance occurring
durinw repeated attacks. In several instances, not
the slightest morbid appearance could he detected :
but more frequently the heart and the large vessels
in its vicinity have presented marks of disease, ge-
nerally varied in its natuie, and opposite as to its
characters. The most common of these are ossi-
fication of the coronary arteries ; ossification of
the valves of the heart or of tiie arterial trunks;
enlargement of some of the caviiies of the heart,
either with diminished or increased tiiickness of
their parietes, but most fiecpiently with fatty de-
generation, or soltening, paleness, ami tenuity of
the muscular structure of the organ ; varicose dila-
tation of the coronary veins (Brera) ; depositions
of adipose matter, to the extent of impeding its
functions; effusions of serum, blood, tivc. into the
pericardium or cavity of the pleura, &c. (Fother-
(jii.L, Black, &c.) It has justly been remarked, by
Dr. UwiNS, " that there is scarcely any malform-
ation of the heart or its blood-vessels, that has
not been occasionally found after death, from
what would be considered angina pectoris : while,
on the other hand, individuals have fallen victims
to the affection, fully niaiked, and the most accu-

ANGINA PECTORIS —

nite post morlem examination has not been able
to detect the slightest indication of structural de-
rangement."—(Cn/H/ie/irf. of Theoret. and Pracl.
]\Ied.) — In some cases the only morbid appear-
ances observed have been in other, and distant
organs, from that which seems to be, if not the
chief seat of the disease, at least the organ chiefly
affected in its functions by it — the heart and
large vessels having been altogether exempt from
lesion. These appearances were adhesions of the
serous surface of the lungs to adjoining parts ;
serous effusions into the pleura ; thickening of the
respiratory mucous surface ; dilatation of the
bronchi ; cedema of tiie intervesicular cellular
tissue of the lungs; abscess and tumours in
the mediastinum ; ossification of the cartilages
of the ribs (Wichmann, Jahn) ; tubercles, en-
largement, scirrhosity, iSic. of the liver (Percival,
Latham, Brera, and Walker) ; scirrhus of the
pylorus, &c.

16. These lesions serve less to throw light on
the precise nature of the disease than an attentive
examination of the morbid phenomena during the
lifeof tlie patient, and a calm appreciation of their
relations, particularly with respect to the agents
tending to diminish, remove, or to exasperate
them. This aflfection has been considered by
many autliors as spasmodic, "although the part
immediately concerned seems not to have been
designated or understood." Dr. Chapman re-
marks, that this hypothesis is rendered probable,
by the general complexion of the disease — its
causes, symptoms, and cure — and by its analogy
to other disorders confessedly of this character.

17. Dr. FoTiiERCiLL supposed it to be occa-
sioned by obesity, and particularly by a collection
of fat about the heart ; lie also considered that it
was sometimes sjmpt'omatic of water in the peri-
cardium or cavity of tlie thorax. Parry, Jenner,
Burns, Krevsig, Bostock, and some others, have
viewed this aflfection as a species of syncope oc-
casioned by the accumulation of blood in the
heart, from an ossification of the coronary arteries.
Drs. HosACK and Forbes conceive that it most
frequently arises from a plethoric state of the
blood vessels, more especially from a dispropor-
tionate accumulation of blood in the heart and
large vessels. To the first and second of these
opinions it may be objected, that there is no ob-
vious connection between the effect and the
cause ; for, as the cause is permanent, the eflPect
should be continued, or at least present but
little abateirent, whereas the intermissions be-
tween the paroxysms are often characterised by a
)-eturn of the healthy functions. It may be further
stated, in opposition to this hypothesis, that many
fatal cases have occurred in which this par-
ticular lesion was not found on dissection. La-
ENNEc stales that he has examined several sub-
jects who had laboured under this diseasCj and in
none of them did he find the coronary arteries
ossified. Besides, cases are recorded by ]\Ior-
oAGNi, Senac, Watson, Corvisart, Andual,
and others, in w+iich ossification of these vessels
were not productive, during life, of the sufferings
characterising this disease. Indeed the coronary
arteries were often found ossified in old persons,
who had not complained during life of any
aflfection of the heart, and who certainly never
were attacked by this malady. As to the last of
the above opinions, viz. that adopted by Dr.

Vol. I.

Patholog7Cal Relations. Q5

IIosACK, Dr. Chapman has very justly observed,
"that even allowing the fulness and irregularity
of the circulation contended for, which 1 am by
no means disposed to do, as uniform-concomitants,
these I should take to be rather the eflfects of pre-
vious irritation or excitement, than the cause of
the disease. Do we not abo know, that such a
condition of the vessels can exist without inducing
angina pectoris? Were fulness and irregularity
in the circulation only required for the production
of the disease, instead of a rare, would we not
have it as a daily occurrence 1 Tiie fact, more-
over, is, that angina pectoris, though oftener, per-
haps, attacking the plethoric, is to be met with, as
I have before said, in the feeble and attenuated."
I may add to this, that the severest case of the
disease which has ever occurred to me was that of
a gentleman who had suffered severely from re-
peated and profuse haemoptysis, and other sym-
ptoms of disease of the lungs. All these disap-
peared, but were followed, after some time, by
angina pectoris. He was feeble and attenuated ;
but it was considered advisable to try the eft'ect of
blood-letiing to a moderate extent: this gave no
relief; it was repeated, but the symptoms were
evidently aggravated by the measure.

18. Dr. J urine considers the disease as a ner-
vous affection ; and he supports this opinion by
refeiring to the sudden and unexpected manner
of its attack — to its sudden termination in death,
or restoration to health- — the nature of the ex-
citing causes of the paroxysm — the equality and
regularity of the pulse, in the majority of cases,
during the paroxysm — to the state of the respi-
ration— to the painful sensation extending to the
upper extremities — and lastly, to the circumstance
of antispasmodics being beneficial in its treatment.
The proximate cause, he adds, consists of an
affection of the pulmonary nerves, disturbing the
functions of the lungs, impairing the decarboni-
sation of the blood, and producing the pain in the
sternum. This afl'ection of the pulmonary nerves
is communicated to' the cardiac plexus, and de-
ranges, secondarily, the heart and large vessels.
The imperfect decaibonisation of the blood di-
minishes its stimulating influence on the heart and
lungs, giving rise to repeated attacks, until it
occasions the death of those organs, and then of
the brain.

19. IMM. Desportes and Laennec have
adopted a nearly similar view of the disease, with
this difference, that they consider its particular
seat may vary according to circumstances. Thus,
JM. Laennec states, that when there exists, simul-
taneously, pain in the heart and lungs, we may
presume that the affection is seated chiefly in the
pneumo-gastric nerves ; but where there is simply
stricture of the heart, without pulmonary pain or
difficulty of breathing, its site is in the nerves
which the heart receives from the great sympa-
thetic. But he supposes that other nerves may
also be implicated at the same time, either by
direct anastomosis or by sympathy ; and that the
branches of the bronchial plexus, particularly the
cubital, are nearly always so affected. " The
anterior thoracic originating in the superficial
cervical plexus are, moreover, frequently impli-
cated ; and this is sometimes further the case with
the branches derived from the lumbar and sacral
plexuses, when the thigh and leg participate in
the attack, which occasionally happens."

F

66

ANGINA PECTORIS — Treatment.

20. BuEUA, Zechinelli, Aveuardt, and some
others consider the disease to be occasioned by
pressure of enlarged abdominal viscera on the
heart, particularly of enlarged liver. Joseph
Frank conceives it to proceed from congestion
of the cavities of the heart, occasioned by defec-
tive nourishment of its muscular structure ; this
defective nutrition itself resulting from previous
inflammation, or from metastasis of gout or rheu-
matism, or from disease of the coronary arteries.
{Friix. Med. Univ. Fr<Ecep., t. ii. p. 260.) Re-
specting these, it may only be added, that the
symptoms of angina pectoris are very seldom as-
sociated with enlargement of the abdominal vis-
cera ; and that, althougii they are much more
frequently connected with the lesions alluded to by
Frank, this connection is by no means uniform,
and is obviously not one of cause and effect ;
these lesions being ratiier coincident and partial
results of the morbid state of the nerves, the altered
sensibility of which constitutes one of the chief
characteristics of the disease. It may be further
stated, that Dr. Darwin views it as a particular
species of asthma, producing ciamp of a pecuiinr
kind in the diaphragm, or the other muscles of
respiration ; and Dr. Butter, whde he conceives
it to be of gouty origin, also refers it to the respi-
ratory organs, particularly to the diaphragm. On
these opinions it is unnecessary to comment.

21. Dr. Chapman, to whose valuable paper I
have already referred, states, " That the disease is
a species of neuralgia, I am entirely persuaded,
commencing for the most part in the pneumo-gas-
trie nerve, and spreading in different directions,
as other nerves may become involved. Tiie de-
rangement of the heart and other structures, with
wiiich it is sometimes associated, I hold to be
coincidences or effects, and not the cause ; since,
among many reasons which might be adduced in
corrolDoration of it, tiie disease has undoubtedly
prevailed independently of such organic lesions,
and, conversely, these have existed without occa-
sioning it. But what is the immediate cause of
the irritation of the nerves, inducing this neuralgic
condition, giving rise to the subsequent pheno-
mena of the disease? This is a question, which
hitherto has not been clearly answered. J\Iy con-
viction is, that it is derived from irregular gout,
which misplaced, thus operates as an irritant of
the nerves, and probably first of those of the
stomach."

22. It will be remarked from the foregoing,
that JuRiNE, De'^portes, Laennfc, and Chap-
man agree so far as to impute the disease to a
species of neuralgia of the pulmonary and cardiac
nerves, affecting the functions of the ht'art and
respiratory organs, and extending by nervous con-
nection to other parts ; the organic lesions found
in fatal cases being either coincidences, or effects
of the disease; and after an attentive examination
of the phenomena attendant on several cases of
the affection which have come before me, I see
no reason tor differing materially from this opinion.
With regard to tiie origin of tiiis affection of the
nerves in misplaced gout, I cannot so implicitly
agree with Dr. ('hapman. 'i'he connection had
been previously remarked by several physicians, as
I have already stated, particularly by those whose
names have been adduced, as well as by Schmidt
and liurtTON, — a circumstance favourable to the
idea that it is founded in truth ; and evidence of

it may even be found in Dr. Musorave's very
excellent, but now scarcely ever noticed work, on
Anomalous Gout. VVichmann, however, has dis-
puted this connection, and apparently with much
reason. The notice which had been taken of this
morbid relation is very candidly referred to by
Dr. Chapman, who has adduced the particulars
of six cMses in which this affection was evidently
connected with gout, and in which recovery
took place, alter means had been successfully
employed to invite this disease to the extremities.
In the majority of those cases, the patients had
never previously suffered a gouty attack, and yet
the means employed were successful in causing
it to appear in the lower extremities.

23. But whether this disease is merely a form
of misplaced gout, or an affection sui generis,
which, when occurring in persons of a gouiy dia-
thesis, the induction of the regular gouty parox-
ysm ill the extremities generally removes, my
experience does not enable me to decide. In two
persons whom I was lately called to treat, and
with whom I have been long acquainted, I have
no reason to suspect a gouty tendency ; but the
connection so satisfactorily established by Dr.
Chapman is evidently by no means infrequent,
and is one which ought never to be overlooked
during treatment, for I have remarked it in several
instances. I believe that, in addition to the ner-
vous character of the malady, the substance of the
heart is often weak, thin, pale, and attenuated,
or even softened, or fatty, as if its substance were
imperfectly and unhealthily nourished ; and that
its cavities, consequently, had become occasionally
dilated and congested. This view is accordant
with the treatment generally found most success-
ful in removing the disease. In a great propor-
tion of the cases before referred to (§ 10.), of
which I had made notes, chiefly collected from
authors, dissection had been made in about fifty
of those which were fatal ; and out of this num-
ber nearly forty presented some degree of disease
of the heart or large vessels; — most frequently
ossification of the valves, coronary arteries, and
aorta ; and fatty sofiening and emaciation of the
heart. But whether these lesions are the conse-
quence or the cause of the disease may be disputed.
I believe they are the latter.

24. VI. The Treatment of this disease neces-
sarily respects, 1st, the measures which may be
adopted during the paroxysm ; and, 2nd, those
which should be resorted to in the intervals, with
the view of effecting a perfect cure.

25. 1st, In respect of the means which may be
emphn/ed during the Jit, ivith the view of diminish-
ing its dnration and violence, no very precise or
dogmatic direction ought to be given. J\Iuch will
depend upon the peculiar characters of the case.
The patient should always be placed in a stale of
tranquillity; and, particularly, if the countenance
be pale, and the carotids pulsating feebly, in the
supine or reclining position. The propriety of
bleeding in the fit has been discussed by several
physicians, and depends entirely upon the parti-
cular features of the attack. Where the sym-
ptoms are urgent, the patient plethoric or vigorous,
or the pulse full and possessed of lone, there can
be no doubt as to the propriety of the measure.
Dr. Read (Uuh. i\Ied. Trans., vol. i. p. 105.) has
re(;orded a case wliicli well illustrates the good
effects of this treatment during the paroxysm. In

ANGINA PECTORIS— Treatment.

6T

more questionable cases, where the pulse is weak,
and the countenance is collapseil, bleeding from
the arm ought not to be had recourse to. It is
doubtful whether or not cupping even should be
employed ; but where this latter state is not ex-
tieme, and especially in cases of intermeiliate
grades of severity, cupping between the shoulders,
to a small or moderate extent, as the case may
seem to require, will generally afford relief, par-
ticularly if used simultaneously with derivatives to
the extremities.

26. But in nearly all cases, and still more par-
ticularly in those characterised by syncope, and
an imperfect action of the heart, frictions with
stimulating and irritating substances ought to be
previously employed over the anterior parts of the
thorax, and stimuLmts and antispasmodics exhi-
bited internally. As to the extent and repetition
of the blood-letting, whether general or local, the
practitioner ought to be able to decide, being
guided in this, as in other remedial means, by the
apparent energies of the constitution, and the state
of the vascular system ; if these admit, and espe-
cially if signs of plethora, or of congestion of the
cavities of the heart and large vessels of the chest,
exl>;t, the depletion may be carried to a consider-
able extent, or repeated, accoiding to the relief
obtained. The object here is to reduce the body
to be moved to a nearer relation to the state of the
moving power, at the same time that we endeavour
to increase the energy of the latter.

27. I should add, that the propriety of bleeding,
in the paroxysm particularly, has been much
disputed, and especially by continental authors.
Where the pulse is feeble and soft, and the action
of the heart weak, it is generally inadmissible;
but, wherever we entertain doubts respecting it,
the external and internal use of stimulants and
antispasmodics, with frictions, should be cautiously
premised, and only local depletions adopted ; or
depletion of every kind should be entirely omitted
until after the paroxysm, when either general
or local blood-letting, according to the particular
circumstances of the case, may be practised with
necessary precautions. I have employed mode-
rate blood-letting in three cases, in which the pro-
priety of the measure seemed questionable, the
patients being of spare habits of body, and weak-
ened states of system ; but every precaution was
taken to prevent immediate ill effects from the
operation. In one of the three relief was afforded ;
in another, the advantage was very doubtful ;
and, in the third, the disease was evidently exas-
perated by it, although slight benefit seemed to
result from it at the time. In one of those cases
the serum of the blood had a milky appearance,
from the presence of an oily matter, resulting from
imperfect assimilation. From this evidence, there-
fore, I infer that, where there are no signs of
vascular plethora or cardiac congestion, or where
the vital energies of the patient are depressed, and
we presume the substance of the heart is attenu-
ated and imperfectly nourished, we should be ex-
tremely circumspect in having recourse to vascular
depletions of any description, and should particu-
larly avoid bleeding from a vein ; but, at the same
time, we should be equally careful not to ad-
minister too active stimulants.

28. Next to the employment of depletion, un-
der the above restrictions, in suitable cases, and
with the concomitant means recommended, the

bowels may be opened by a purgative 'medicine,
combined with some warm antispasmodic and car-
minative, as ether, spiritus ammonia; aromaticus,
camphor, musk, castor, spiritus anisi, capsicum,
&c. ; and these may be given at intervals subse-
quently. I have seen much relief afforded by full
doses of camphor with opium, or with hydiocyanic
acid. In the slighter attacks, and where the stale
of the vascular system and constitutional energies
render it prudent to withhold depletion, friction
with stimulating liniments over the thorax and
epigastrium, as the following-
No. 14. R Liiiimenti CamphorEe Comp., Linim. Am-
monise, aa 3j.; Tinct. Capsici 3iij. M., —

the internal administration of antispasmodics, and
the exhibition of a purgative medicine, will be
sufficient to give some immediate relief. The
following will generally fulfil the intention: —

No. \h. ^. Infiisi Valerianse 3xj. ; Spirit. AmmonifE
Foetid. 3 ss.; Tinct. Castorei 3 ss.j Acidi Hydrocyauici,
lllii. M. Fiat Haustus his tcrve ill die capieiiilus.

No. 16. R Iiil'usi Senna; Comp. Jjss.; Tinct. .Sennse
Comp. 3ij.; Spirit. Ammon. Arom. 3jss.; Tinct. Carda-
mom. Comp. 3j. M. Fiat Haustus statim sumendus, et
repet. si sit oecasio.

No. 17. R Mist. Camphors Sj.; Liq. Ammon. Acet.
3 ij.; Spirit. iEtlier. Siilpli. Comp. 5j. ; Tinct. Camphorje
Comp. 3j.; Syrup. Papaveris 3j. iVI.

29. Emetics have been spoken favourably of by
Ur. Good {Study of Med., t. i. p. 667.). In a
case of great severity, in which vomiting occa-
sionally occurred when the paroxysm was excited
by taking food into the stomach, I was induced
by this symptom to try the effect of an emetic during
an attack ; but no benefit was derived from it.

30. The employment of derivatives to the ex-
tremities, particularly the lower, is generally
beneficial, and ought not to be omiited in the
paroxysm, whether we adopt the opinion as to the
gouty origin of the disease or not. Stimulating
pediluvia, and sinapis7ns or blisters, with all the
other measures employed under similar circum-
stances in irregular or misplaeed gout, had the
effect, in the six cases of the disease published by
Dr. Chapiuan, of inducing the regular gouty
paroxysm, and of affording speedy relief. The
affusion of cold ivater has been recommended by
some authors, but it is a dangerous remedy in this
disease. Cold epithems to the head have been
nicntioned by J.Frank (Prax. Med. Univers.,
part ii. p. 273.), as having been used with advan-
tage ; they seem less objectionable. A similar re-
mark may be applied to the tepid affusion on the head.

31. 2d, The means which may be employed dur-
ing the intervals or remissions between the parox-
ysms are either general or topical. With respect
to the Jirst of these, a most studious attention to
avoid the exciting causes of the disease must be
inculcated. Next to this, all existing disorder of
the digestive organs should be attended to and
removed ; and the diet and regimen of the patient
strictly laid down and enforced. As the powers
of the digestive organs are generally diminished,
and the bowels either costive or irregular, vege-
table bitters, with an occasional alterative aperient,
either given alone, or in combination with an anti-
spasmodic or anodyne, will often prove beneficial.
With the view of thus strengthening the digestive
organs, and removing spasm, Sch.effer {Volks-
krankheiten, Jun. 1807) recommended vegetable
bitters with opium, musk, camphor, or assafcetida,
and Er.sNER prescribedthe/n/</roc/i/ora/eo/ awmoni'a
with Hoffmann's anodyne. Sulphate of zinc, re-

F 2

68

ANGINA PECTORIS — Treatment,

commended by Perkins (Mem. of Med. Soc. of \
Loud., V. iii.), in doses of a grain, with a quarter 1
of a grain of opium, given twice a day, has a |
similar action; but it generally is necessary to I
give it more frequently, and to increase the doses.
With the same view 1 have given the hiidrocyanic
acid, either simply, or combined with the oxide of
zinc, forming a cyanide of sine, and in one case
particularly, with greater advantage than from
any other means. I have reason to believe that
the cyanide of iron will prove equally beneficial ;
but my experience of its effects is too imperfect as
yet to allow me to speak decidedly as to its merit-;
in this disease.

32. In a case which occurred to me many years
since, I employed the preparations of iroH, parti-
cularly the sesquioxide and sulphate, bemg led
to adopt them by the neuralgic characters of the
case, and certainly with apparent advantage ; but
local means were also in operation at the same
time. Wherever we have reason to suppose that
the heart is debilitated, imperfectly nourished, or
altenuiited, the employment of tonics, particularly
bark, and the preparations of iron, either alone or
with antispasmodics, is particularly indicated, with
strict attention to diet and regimen. Auscultation
will be of great service, by intimating to us the
particular state of the heart, which must in a great
measure regulate our practice.

33. In a case of the disease which came under
my care in 1824, I prescribed the nitrate of silver
ti itu rated with a vegetable extract, as recommended
by Sementini. This substance was continued in
increa>ied doses, until it occasioned an eruption,
resembling nettle-ra^h, on the skin, — an effect
noticed by this physician. The relief affordeil by
it, after this eruption began to appear, was decided.
The patient is at the present time in the enjoy-
ment of tolerable health. At the period of my
prescribing this substance, I conceived that its ex-
liibition in this disease had originated with myself ;
but I subsequently found that it had been given
in two cases of angina pectoris, with advantage,
so long ago as thirty year-s, by Dr. Cappe (Dun-
can s Annals of Med., vol. iii.).

34. Arsenic, in the form of Fowler's solution,
had been recommemled in this disease by Or.
Alexander (Med. Comment., vol. xv. p. 373.),
at a period antecedent to the introduction of the
nitrate of silver into prac^ce as an internal me-
dicine ; and subsequently by Sir G. Hi.ane, who
gave it with advantage, combined with digitalis
and mercury (Med. Chtr. Trans., vol. iv. p. 136.).

35. Besides these, preparations of hark and
other vegetable tonics have been recommended,
either alone, or in combination with antispasmodics
and anodynes. The hydrosnlphuret of ammonia,
in gnidually increased doses (from eight drops to
thirty) twice or thrice daily, 'i'lie different prepa-
rations of valerian, the ammonio-sulphate of copper
and snlphaie of quinine, have likewise been em-
))loyed, and occasionally with decided advantage :
from the last of these, combined with an anodyne,
jiarticularly with opium and camphor, I have
oltserved much benefit to be derived. The follow-
ing formulae may be employed.

No. 18. R Inl'usi Kosae Co. .3 xj. ; Qiiininae Siilph.
jir. J— ij. ; Acidi Sulpli. Arom. Itlx.; Spirit. jEtlier.
.Sulph. Comi). 3j.; Tinct. Opii 111, xij. M. Fiat Hau,tus
l)is in die capipndus. Or,

No. 19. R Kxtracti Aiittiemid. 3ij.; Quinina; Sulph.
cr. xij.; Massac I'iltil. G;ilt)an. Comp. 3j. ; Camphora;
Sutjacta', gr. xv., I'ulf. Cajisici, 3j.; Syrup. I'apaveriB,

q. s. Misce bend et divide in Pilulas xxiv., quarum capiat
uiiam ad biuas vel ires bis terve quotidie.

Having derived much advantage from the inter-
nal use of the bi-borale of soda in dyspeptic irri-
tability of the alimentary canal, 1 was induced to
einploy it in a case of this disease which occurred
to me a few years since, in doses of ten to twenty
grains, given in the decoctum althaeae. It pro-
duced some relief; but the case was of the
greatest severity, and little benefit, at least of a
permanent description, was derived from any
means which were adopted, excepting from prus-
sic acid.

36. Mercurials have received the sanction of
Brera. I have employed them in three cases, at
first as an alterative ; five grains of blue pill hav-
ing been directed occasionally at bed-time, and
subsequently so as to affect the mouth. In one
of these the alterative do'-^e had a beneficial effect
upon the state of the stomach and bowels ; but
this was of short duration. When, however,
pushed further, so as to affect the gums, great
irritability of the system, fever, restlessness, and
increased pain, anxiety, and sinking, were occa-
sioned by it. In the other case, evidently con-
nected with hepatic disorder, the blue pill was
also at first given as an alterative on alternate
nights. It affected the gums after a few doses,
and afforded relief. It was now pushed with the
intention of inducing salivation; and a somewhat
violent efftct was produced on the mouth, which
was relieved upon exciting the salivary glands.
Decided advantage was now procured ; the bowels
were kept open by means of a stomachic aperient,
an issue inserted in one of the thighs, and change of
air recommended. This patient perfectly recovered.

37. Where plethora exists, blood-letting in the
intervals will be serviceable, with a light abste-
mious diet. When the paroxysms are apt to oc-
cur during the night, I have found an opiate
given at bed-time, as recommended by Dr. He-
BERDEN, of great service. In one ca^e of this
de.scription I gave the acetate of morphine, in the
dose of an eighth of a grain, but it occasioned
such distressing feelings of sinking, and general
depression of the powers of life, that stimulants
were required ; yet the same patient had expe-
rienced relief from opium combined with camphor.
On one occasion I tried the effects of iodine in
the form of the tincture ; but although its use was
adopted with great caution, seven drops only hav-
ing been given three times a day, it occasioned an
increase of all the symptoms, apparently owing to
its irritating effects on the digestive mucous sur-
face, and the idiosyncray of the patient. I may
here notice the practices recommended by Sciile-
sisGv.ii. (II ujeland\ Journ., vol. i. p. 57.), con-
sisting in the exhibition, every two hours, of the
extract of the lactuca virosa, in doses of two
grains, with half a grain of digitalis. What effect
may we expect from the use ofcolchicum ? Where
the disease seems to originate in gout, the colchi-
cuin might be tried; but its use would require
great circumspection. In my opinion, it should
only be given in combination with stimulants, or
antispasmodics and tonics, the tinctura colchici
composita being the most promising preparation of
it in such a case.

38. Although the patient labouring under this
disease is generally incapable of any, excepting
the most gentle, exercise ; yet this should be

ANGINA PECTORIS — Theatmfnt.

69

taken under favourabfe circumstances ; and change
of air, particularly to healthy, dry, and elevated
situations, should not be overlooked. It will
generally be observed, that persons labouring un-
der the worst form of the disease, incapable even
of walking or sitting upright for any time, will
bear well, and even be benefited bv, rapiil travel-
ling in a carriage. This was first evinced to me
by the case of a gentleman of great scientific and
literary attainments, residing for a time at Paris,
where I was called to him in the summer of 1829.
He was anxious to return to Englan<l, from a
dread of dying abroad. He undertook the jour-
ney with me, and was better during it than either
previously or subsequently. He has since taken
long journeys, willi similar advantage.

39. Secnudli), Much benefit will be often re-
ceived from topical means. Under this head
rubefacients, ismes, and setons deserve particular
notice. The latter have been employed on the
insides of the thighs by Macbridk and Darwin.
Kreigelstein and VVolff also have observed
advantage to be derived from them, when inserted
either in this or in other situations. I have re-
sorted to a peculiar form of issue in several case-
of this disease, and, upon the whole, with much
benefit. In one case, however, it failed of having
the least good efFect.

40. The form of issue to which I allude, and
for the knowledge of which I am indebted to my
learned friend Dr. Hutchinson', is the bark of
mezereon root, deprived of its external cuticle,
and, alter having been soaked for some time in a
little water, placed upon the surface of the part
from which we wish to procure a discharge. This
bark should be confined to its place by means of
adhesive plaster, spread on paper of larger dimen-
sions than the part covered by the meztreon bark.
The bark may be renewed every night, until it
procures a copious discharge. In some cases the
effect is produced in a single night, or in twenty-
four hours. When the discharge becomes copious
the bark may be renewed less frequently. The
adhesive plaster serves both to keep the mezereon
in its situation, and to retain the discharge, so as
10 preserve it from soiling the clothes. When it
is abundant the plaster may be renewed, and the
secretion renioved, as its occasional acrimony often
tends to heighten and to extend the irritation.
In a severe and chronic case of this disease, vvhicii
occurred to me in 1830, I employed this form of
issue, and kept a surface of about four inches
square over the left small ribs discharging as long
as the patient would endure this treatment, 'I'he
disease disappeared, and up to this time it has not
returned, 'i'he advantages of this issue are, that
the patient can manage it from the beginning with
great ease ; and it may be readily increased to any
extent, an«l the discharge augmented, according to
the exigencies of the case.

41. Artifcial eruptions, from the ointment or
plaster of the putassio-tartrate of antimony, have
now usurped the place of setons and issues; but,
from a very extensive experience of the former,
both previous and subsequent to the publication of
an article on them in the London Medical Repo-
sitory for April 1822, I consider them of mfeiior
efficacy in some diseases, and particularly in this,
to the pea-issue, or the issue now described. It
is singular that the advantages to be derived from
the production of artificial pustulation, in the

treatment of varioiisdiscrders, were so little known
or appreciated until the appearance of Dr. Jen-
ner's pamphlet on the subject, since the practice
had been recommended long previously in the
Lectures of the second and third Monros on
Morbid Anatomy, as being frequently preferable
to the use of blisters; and had been found ser-
viceable by Goodwin, Actenrieth, and Kreig-
elstein, in this afTeclion, in which it had been
employed by them at the end of the last century.
Liniments with croton oil, are equally serviceable
and more immediate in their efTecls.

42. Blisters, either frequently repeated, or kept
discharging for a longer or shorter period, have
received the sanction of Peucivai, and many
others. But little benefit will be deiived from
them, unless they be used in the way now named.
liiiLENius recommends (Med. nnd Cliir. Bemer-
kungen, i. p. 183.) lepeated blisters applied be-
tween the shoulders. I agree with him in the
selection of tiiis place in preference to others for
their application, as well as in the propriety of
repeating them frequently. M. Laennec stales
that he has derived great advantage from magnet-
ism, used in the following manner, both in alle-
viating the paroxysm, and in preventing its acces-
sion.—He applies " two strongly magnetised steel
plaies, of a line in thickness, of an oval shape,
and bent so as to fit the part, — one to the left
pra?cordial region, and the other exactly opposite,
on the back, in such a manner ihatthe magnetic
current shall traverse the affected part." (Diseases
of the Chest, p. 705.)

43. When the affection is complicated wilh
other diseases, particularly with organic lesions of
the heart, or enlargement of the liver, the treat-
ment should be modified accordingly. In order
to ascertain the nature of such complications, aus-
cultation may be resorted to ; for, although it
gives us no information respecting the simple dis-
ease, it often enables us to detect the lesions wiih
which it is sometimes associated, and to direct our
means of cure more appropriately, and with hap-
pier results, than we could otherwise do. When
the substance of the heart is weakened or attenu-
ated (§ 23.), tonics, particularly sulphate of qui-
nine, sulphate of zinc, and the various preparations
of iron, given in decided doses, are particularly
indicated. In other cases, as well as when the
liver is affected, issues are generally serviceable.
When the disease is connected with enlargement,
&c. of the liver, mercury is almost indispensable.
In all cases, whether simple or complicated, atten-
tion to diet and regimen, a pure air, amusement
without excitement, and an equable and contented
state of mind, are not only requisite to recovery,
but are also necessary to render it permanent.

Bibliography. Sa?<2jagc«,NosoIogiaMethodica, tom.ir.

p. 120. edit. 8vo Heberdfn, Medical Transactions of the

College of Pliysicians, vol. ii. p. .59. 176^!. — Eisner, Al>-
handlungiilierdieBrusthrauiie. Kcemgab.niS. —Scho'jffer,
Dissertat. de Angina Pectoris. Getting, 17b7. — Butter,
Treatise on the Disease commonly called.\ngina Pectoris,

Loud. 1791 SfAm/rf^, Dissert. di> Angina Pectoris. Got'.

1793. — Varry, An Inquiry into the .Symptoms and Causes

of the Syncope Anginosa. Lond. 1799 Hisse, De Angina

Pectoris. Halle, 1800. — Darwin, Zoonomia, vol. iv. p. 42.
\ HOO. — Stoeller, Journ. der Pract. Heilkiinde von HiiJJe-

land, 17 b. 1x03 Ja/in. Ueber die Syncope Anginosa,

Huleland's N. Journ. 1806 Bcaawfs, Traite Eleraen-

taire de Nosologic. 1806 Despories, Traite de I'Angine

de Poitrine. \%\\.—BlaLkal, Observations on the Nature
and Cure of Dropsies, &c. Lond. 1813. — Kreysig, Die
Krankheiten des Herzens, Svo, Berl. — Zechineili, Sulla
Angit>a di Petto. Pad. 1813.— JaWn?, Memoire sur I'.'^n-.
gitie de Poitrine, couronnepar la Societede Medecineda
F 3

70

AORTA — Nfrvous Pulsation of.

Paris. 1815.— Zaennfc, Traite de rAuscuItatioii Mediate.

Paris. 1826 Chapnian, American Journal of Medical

Sciences, vol. vii. Phil. 1831 Jo//^, in Uictionnaire de

Medfccine et Cliirurg. Pratiques, &c., torn. ii. Paris, 18'29.
— J. Hupe. On Diseases ot the Heart. Lond. 8vo. 1832.
p. 47-1. — Bouilland, Traite Clinique des Maladies du
t'oeiir. Paris, 8vo. 1835. torn. ii. v. 491.

ANIIMATION, SUSPENDED. See Asphyxy.

ANTIPATHY. Syn. 'Ar'TiiraeTjs, Gr. Antipa(hia,

Lat. Der Wideruille, die Aiitipalhie, Ger.

Anti]mthie, Fr. Antipatia, Avversioiie, Ital.

Aritipathia Sensilis, et A. InseusUis, Good.

Ci.A.'siF. — 4. Class; 4. Order (Good).

I. Class; IV. Order (Author).

1. Defin. Internal horror and distress on the
perception of particular olyects, aith great restless-
ness, <)»• with fainting.

2. This singular affection has merely been men-
tioned by CuLLEN : it has, liowever, received
more attention from Sauvages, Linn«us, Vogel,
Ploi'cquet, Passament, and Good. The last
named writer has needlessly divided it into two
species — sensite and insensile antipathy ; the
former arising from objects or subjects which
strike some one of the senses ; the latter fiom the
presence of an object, as soon as it comes within
the sphere of some unknown influence, although
unperceived by any of the senses.

3. There are numerous instances of singular
antipathy on record ; and most persons of observ-
ation have met with others in tiie course of their
experience. The vulgar explain them generally
by considering that the mother hud experienced a
fright from the objects of antipathy during the
early months of pregnancy — and there are, no
no doubt, some facts which countenance the sup-
position. Thus, .Tames the Fjrst could not endure
the sight of a drawn sword — Rizio was killed at
the feet of Queen JMary when pregnant with him ;
and many other instances are mentioned by writers :
but more frequently the persons themselves, who
are thus affected, have experienced friglits during
the early months of infancy, or have had their
minds early and indelibly impressed by certain sub-
jects. Peter tlie Gi'eat h^d a fall from a bridge
into the water, when an infant ; and he could not
afterwards endure to hear the rattling of a car-
riage passing over a bridge. Persons often retain
tiie antipathy to the sight of crabs, lobsters, &c.
which had been occasioned by fright from them
in infancy or childhood. A man-sprvant in the
aulhoi's family, ailvanced in life, had so great an
antipathy to the sight of a mouse, that he would
fly as fast as he was able from the place where one
was seen; and become quite frantic at the sight.
lie stated that his mother, who likewise had an
antipathy to mice, had been distressed by one
thrown upon her when pregnant with him. Some
jjer.'-ons cannot endure certain odours, from the
faintness, or sickness, or sense of anxiety and dis-
tress they occasion. This appears to proceed from
yieculiar i(lios\ncrasy. 1 have likewise seen per-
sons who could not touch certain smooth objects
without feeling a peculiar sliu<liler or horror, fol-
lowed by faintness in some. Tiiis appears to arise
Irom associations excited in susceptible or sensitive
minds.

4. The most singular instances of antipathy
are those which occur at the presence of objects
unperceivtd by any of the senses, forming the
insensile antipathy of Dr. Good. 'J'Iius, a cat
concealed in a room has been known to produce
ii most indescribable distress or horror in a person

wlio has not perceived it by any one sense, and
has been, in no other way, informed of its pre-
sence. Some singular idiosyncrasy, doubtless,
exists in such cases. Sauvages conceives that an
effluvium proceeds from the animal, which, com-
bining with that emanating from the person thus
affected, occasions the unpleasant sensations upon
his peculiar organisation or idiosyncra.sy. This
is, perhaps, the only opinion that can be formed
on the subject.

5. The Trfatment to be adopted for the re-
moval of antipathies consists chiefly of resolute
endeavours to overcome the morbid impression,
by gradually accustoming the mind to its influ-
ence. Indeed, this is the only remedy that can
be resorted to. Its adoption, successfully oi
otherwise, will entirely depend upon the mental
energy of the patient. But there cannot be a
doubt, that all impressions, however unpleasant
or distressing, may be ultimately overcome by
repetition, and a firm resolution either to endure,
or not to be affected by them. The following
works will furnish some curious information on
this subject, with much trifling, silly hypothesis,
and irrelevant matter: —

Bibliography. 7.?>)5J«i, Diss. Antipathiae Sineulares,
&c. Jen. 1G78.— S. Ruttray, Adilus Novus ad Occultse
Sympathiset Antipathiae Causas. Glasg. 1658.— A'. Z)i/!iy,

Theair. Sjmpathet.. p. 138 Rudolph, De Antipathia

Humana. IJasil. 1700 Schurig, t'hylologia, pp. 9G. et

163. et seq Menfz, Disser. Antipathiae Phys. Phaenom.

ad suas Causas Revocata. Lips. 1708. — Du l'oism,Y>e
Antipathia Humana. BaMl. 1701. — Zwingcr, De Anti-
pathia Humana, Fascic. Dissert. Select., n. 1. — Sc/iwmi-

mer, De Antipathia. Jenae, 1669 Hermstadt, Wun-

derbare Kriil'te der Natur durch die Symp. und Anti-
pathic. Rotenb. 1776, 8vo. — Passament, Essai sur les

Antipathies. Paris. 1811 M. Good, Study of Med. by

Coopfr, vol. iii. p. 366.

ANUS. See Rectum.

AORTA. Syn. Arteria Magna. Aorte, Fr.

Aorta, die grosse Schlugader, Hauptstamm aller

Korperpulsadern, Ger. Its Disfases.

1. This most important vessel is liable toall the
lesions which have been noticed under the article
Arteries. Some of them, however, when seated
in this artery, are so important, particularly as
respects their effects upon adjoining viscera, and
their extremely dangerous consequences generally,
that I propose to give a succinct account of then)
in this place. In doing this, 1 shall so far depart
from the alpisabetical arrangement, in respect of
the subordinate heads of the subject, as may be
requisite to the consideration of it in strict patho-
logical order. Functional disorder, therefore, of
this vessel will he Jirst considered ; next, inflam-
mation ; and, lastly, those lesions which usually
result from inflammation, &c., as aneurism, con-
striction, obliteration of the vessel, &c.

2. I. Nervous Pulsation of the Abdominal
Aorta. — Classif. 11. Class; 1. Order. —
This is not an infrequent affection in weak, ema-
ciated, and tlelicatc persons, and frarliculaily
hysterical females. It is often associated with
collections of air in the colon or stomach ; and
with accumulations of hecal matters or morbid
secretions in the coecum. It is also not infre-
quenllv conse(|uent upon neglected dyspepsia.

3. i." The Symptoms are generally very character-
istic of the nalureof the com[)laint, and sufficiently
serve to distmguish it from organic lesion of the
vessel, 'i'hc niovbid pulsation is generally asso-
ciated with nervous or hysterical symptoms, and
is of a variable character. It is increased and
diminished, sometimes without any evident cause.

AORTA — Inflammation of

but more frequentlj' by mental or moral affection
and emotions, or by constitutional causes. Dis-
orders of tlie stomach, and irregularity of the
uterine functions, also sometimes occasion or re-
produce it ; and 1 have observed it to follow upon
the paroxysms of sinking or Ifcipothymia, to which
very delicate females are occasionally liable.

4. Upon pressing the stethoscope firmly over
the aorta, the pulsation will be generally fell
limited in extent, in its transverse or lateral direc-
tion, but it will be very perceptible in tiie course
of the vessel from the bifurcation to the epigastiium.
Instead of the gradual, steady, and stioug motion
or impulse attending aneurism, there is fell a vi-
gorous and smart jeik; and the sound is either
merely a slight whizzing, or is scarcely to be heard.

5. ii. The Treatment of nervous pulsation of the
aorta will entirely depend upon the peculiar cir-
cumstances of the case in which it occurs. If the
paroxysm is severe, the preparations of aether, as-
safoelida, valerian, and ammonia, should be exhi-
bited. I have seen much benefit afforded by strong
coffee and green tea in these cases. The dependence
of the affection on mental emotions indicates the
propriety of advising a tranquil state of mind and a
mild diet, with attention to the regular functions of
the bowels. In cases evincing much irritability,
mental or corporeal, hyoscyamus, conium, or the
acetate or sulphate of morphine, in very small
doses, particularly hyoscyamus combined with
camphor, will be found useful. The preparations
of morphine, however, should be cautiously admi-
nistered in this affection. In a case which occurred
to me sometime ago, the sixteenth part of a grain
only of the acetate of morphine was followed by
unpleasant depression. Upon the whole, more
advantage will accrue from the antispasmodics
than from the sedatives just named ; but in ca-^es
characterised by attendant irritability, the com-
bination of sub>tances belonging to both these
classes of remedies will be of great service.

6. In all ca>es of this affection occurring in fe-
males,— and the gieat majority of them do occur
in this sex, — the state of the menstrual discharge
should receive the utmost attention. When the
more distressing state of the affection subsides, a
more tonic regimen and plan of cure may be
adopted. The bitter infusions and decoctions, par-
ticularly those of caluiiiba, cinchona, cascarilla,
and chamomile, with the alkaline preparations,
&c., and subsequently the preparations of iron,
the shower bath, cold salt water bailiing, clialy-
beates, regular exercise in tiie open air, and ligiit
nutritious diet, are the means chiefly to be de-
pended on. W hen assncialed with other ailments,
it is generally symptomatic of them, and tlieiefoie
in such cases the treatment must be directed to the
primary complaint.

7. II. Infi-ammation of the Aorta. — Svn.
Aortitis. Aortite,Vr. Die Aortenen(z'uiidung, Cer.
Classif. II. Class; II. Order. — Inflammation
of the aorta occasionally takes place, but more
fiequenlly in a chronic than an acute form, and
commonly consecutively of inflammation of the in-
ternal surface of the heart, and during the course
of certain states of fever. The internal membrane
of the vessel is sometimes alone inflamed, parti-
cularly when the disease takes place during fevers,
or extends to it from the internal surface of the
heart's cavities ; but, in several ca^es, the sub-
jacent cellular tissue, or both it and the internal

71

membrane, are chiefly affected. Aortitis seldom
originates in the exterior coals of the vessel.

0. i. The Causes of aortitis are, — 1 st, External
injuries, as blows, contusions, falls, &c.; 2d, Vio-
lent, or too long-continued exertion ; 3d, The use
of hot, stimulating, and aciid ingesta, spirituous
liquors, and the introduction, by absorption or
oilierwise, of irritating poisons and morbid secre-
tions, &c. into the circulation ; 4ih, The extension
of inflammation from the heart, lungs, pleura, and
pericardium, and the suppression of the eruption
in eruptive fevers; — M. Portal slates (A7iat.
Med., t. iii. p. 157.) that he has met with it in
cases of this description ; — and, 5th, The causes
which are productive of diseases of the heart.

9. ii. The Symptoms can scarcely be stated with
any hopes of enabling the practitioner to distin-
guish this disease, which is generally met with in
conjunction with oiher maladies; particularly
fevers, and inflammations of the heart, lungs, peri-
cardium, and pleura, and disclosed to us only by
post 7norlem examination. — a. \\ hen inflammation
more or less acute extends along the descending
aorta, the patient generally complains of a smarting
and painful sensation in the direction of the spine,
with a violent feeling of pulsation of the aorta ;
extending to the iliacs, without any appearance of
enlargement or tumour; and unaccompanied by
smallness of puUe in the remoter arteries, particu-
larly those ol tlie superior parts and extremities of
the body. In tlie more acute cases, a sensation of
heat is (ell in the region of the vessel, sometimes
with oppressive anxiety, ieipolhymia, or tendency
to faintiui.', and always increased force and vivacity
of the pulsations of the vessel.

10. I). The chnmic states of this disease admit not
of recognition until they have produced some one
of those organic lesions, which occasion marked
obstruction of the circulation, or aneurismal dila-
tations. Dyspnoea upon slight exertion, emaciation,
a pale yellowish tint of countenance, palpitations,
hypertrophy and dilatation of the heart's cavities,
oedema of the extremities, &c., are then the usual
symptoms ; and, although they furnish no certain
evidence of the existence of this disease, yet when
they are present, without the signs of narrowing
of, or obstruction in, the oiifices of the heart's ca-
vities, and of the origin of the aorta, chronic dis-
ease of the aona may be presumed to exist.

] 1. c. Aortitis, particuliirly in its chronic states,
is occasioniilly co7)iplicated with hypertrophy of the
left ventricle ; the hypertrophy either causing the
inflammation of the aorta, or the latter occasioning
the former, paiticularly when the canal of the ves-
sel is narrowed or obstructed by the effects of the
inflammation. Tiie other complications have been
already noticed (§ 7 — 9.). It is chiefly owing to
the more frequent occurrence of the disease m a
complicated than in a simple form, that it is so
commonly overlooked, and so difficult to be as-
certained even when its existence is suspected.

12. iii. The Prognosis of this di-^ease, when its
existence is presumed, is always unfavourable ; on
account both of our ignorance of much that is im-
portant respecting its symptoms, complications, and
consequences,andofthe fatal nature, sooiierorlater,
of a great part of the effects to which it gives ri<e.

13. iv. 'i'he Lesions produced by inflammation
of the aoria are nearly the same as those I have
enumerated in the article on tiie lesions of arteries,
But as these changes, when iifiecting this important

F 4

AORTA — ANEunisM of.

vessel, are often the first step to the formation of
aneurism in it, 1 shall here briefly allude to then)
as they actually appear upon examination. Aor-
titis, whether occurring simply, or with disease of
the heart or other related viscera, presents the
esuhs of various grades of activity. In the more
acute cases, the internal surface of the vessel is
of a deep or dark red, sometimes approaching to
purple: and both the internal membrane and the
middle coat are easily torn. The connecting cel-
lular structure and the fibrous coat are much more
injected with blood than natural ; and coagula,
more or less firm, and of a fibrous character, some-
times adhere to the internal surface of the inflamed
part : but this is not often observed in the aorta,
as the current of the circulation thiough it seems
to wash away the fluid as soon as it is effused, and
before it coagulates on the surface which pro-
duced it, Obtiteratiiui of the aorta (see § 53.)
may, however, arise either from external pressure,
or from false meinbranes formed in its internal
surface, so as to obstruct the current of the cir-
culation in it ; or from depositions of lymph be-
tween its coats, sufficient to produce the same
effect, the obliteration being thus a remote conse-
cjuence of the obi-truction.

14. The results of chronic aortitis, are more fre-
quently met with than those of the acute. These
are yellow spots, or yellow curdy matter deposited
under the inner membrane, which may burst from
the distention and the friability occasioned liy the
inflammatory state ; the curdy matter projecting
like a tubercle into the canal of the vessel ; bony
deposits, which are also just formed under the
internal membrane, and in like manner become
exposed and washed by the current of the blood
in the vessel ; thickening and induration of the
coats of the aorta; friability and softening of one
or more of them ; ulceration commencing in the
lining membiane, and extending more or less
through the exterior tunics, till at last dilatation of
the external coats in the form of a pouch, or tatal
hasmorrhage, ensues ; and cracking, and laceration
or dilatation, which, with the former lesions, ge-
nerally originate the different forms of aneiuism
to which ihis vessel is liable (see § 18.). In a
case which occurred to Dr. J. Wilson in the Mid-
dlesex Hospital, the internal surface of the ascend-
ing aorta and the arch was extensively ulcerated,
without dilatation,

15. Dilatation of the coats of the aorta may
first occur, and then the inner or middle coats
give way when it has reached a certain pitch : or
the laceration of the inner coats, with or without
previous ulceration, may lake place previous to the
dilatation. But either state of disease — dilatation
or laceration — (Specially the laltr, seems to pro-
ceed liom a nearly similar pre-existing change of
the inturnal tunics, one evidently connected with
slow inHammalory action. Kven dilatation, which
has been attributed to debility of structure, is more
fie((uently a result of infiammalion, which in fict
occasions here, as it does everywhere else, debility
of structure ; defective vital cohesion of the texture
being a general result of inflammation.

It), v. TiiKAi MtNT. Aortitis recpiires the same
treatment as other acute inflammations. Gineral
and local blood-letting, perfect repose, both moral
and physicil, and the rest of the antiphlogistic re-
gimen are indispensable, 'i'lie preparations of (/i-
liilalis in order to quiet the heail's action, cooling

aperients to remove faecal accumulations, and
counter irritants to elicit a determination of the
fluids to external parts, are amongst the most eflfl-
cacious means. In resorting to counter-irritation,
care should be had not to employ substances cal-
culated to excite general irritation by their use in
this way. The ointments or liniments of the
potassio- tartrate of antimony (see F. 305, 749.)
are the only means of this description ; excepting
issues, which should be used in this disease.

17. When those symptoms appear which have
been stated to result from chronic aortitis, or its
effects, local depletions, — particularly when signs
of congestion of either the heart, lungs, or head,
appear, — a restricted diet and regimen, perfect re-
pose of body and mind, attention to the abdominal
functions, and the use of the tartarised antimonial
ointment, or seions or issues, are the chief means
that can be called to our aid. Other remedies
may, however, be employed, with the view of al-
leviating or removing the contingent symptoms
and ailments that may supervene.

18. III. Aneurism of the Aorta, — Aorteiir
rysma. — Die Aorlenweitung, Ger. — Classif.
IV. Class ; II. Order. — i. Aneurism of the aorta
is a not infrequent consequence of inflammation,
particularly of its more chronic forms. The changes
in the parities of the vessel, constituting aneurism
of it, are the following : — 1st, Simple dilatation of
the whole circumference of the vessel ; 2d, Dila-
tation of one side only, in a sacculated form, with-
out rupture of its coats, or true aneurism; 3d,
Dilatatio.i of the external or cellular coat of the
vessel, occasioiieil by rupture or ulceration of thj
internal and middle coats, or conseciitii'e oi false
aneurism ; and, 4lh, Ulceration orrupture of the in-
ternal coats taking place after their dilatation, and
occasioning the still further dilatation of the cellu-
lar coat, constituting mixed or comjwund aneurism,

19. A. Simple dilatation of the whole circum-
ference of the aorta may occur to a greater or less
extent along the vessel ; it may be limited to a
small portion only; or it may occur in several parts,
giving the vessel an irregular shape, and forming
several oval expansions of it. The second of these
is the most common. The dilatation is various in
extent ; it is frequently as great as twice or thricj
the natural calibre of the vessel, or even greater.
It is usually more evident in one side than in an-
other, and is attended with some one or more of
the organic changes described as consequent upon
chronic inflammation of the aorta (see § 13 — 15.,
and AiiTEuiES, Valhologq of), particularly thin-
ning and thickening of the coats, thereby resem-
bling passive and active aneurisms of the cavities
of the heart. The situations in which this change
of diameter of the vessel oc(^urs most frequently,
are the ascending poition and arch , but it is not
infrequent in the descending aorta. Dilatation of
the pulmonary artery is very rare. This simplest
firm of aneurism, a It hough frequently accompanied
with vaiious moibid depositions in the coals of the
vessel, never contains laminated coagula, unless
the lateral dilatations very nearly approach the
state of sacs or pouches, constituting the next
variety. In some cases of this form of aortic
aneurism, similar changes are also met with in
some of the large arterial trunks, as the subclavian,
coeliac, and iliac arteries.

20. li. True aneurism, or extensive dilatation
of a portion of the ciicumference of the aorta, fre-

AORTA — Aneurism of.

73

qu'ently has a neck of less diameter than the body
of the sac. It seems to arise from a hiss of elasti-
city and vital resistance of tlie portion of the
vessel thus affected, in consequence of chronic
inflammation and its effects. Owing to this cause
the dilated portion of the vessel often presents
many of the lesions described as consecutive of
the mflanimatory state, particularly reddened
spots, minute fissures, atheromatous, caitilagi-
Dous, or ossific deposits, &c. Tiiis variety most
commonly affects the ascending portion and arch
of the aorta, and siioots out from its anterior or
lateral parts. It often attains a considerable size,
being sometimes as large or larger than the foetal
heart, and generally inclmes toward the right side
of the chest. The dilated coats of the vessel
are generally thicker, and but very ran ly thinner
than natural, unless in parts of the aneurismal
pouch. When it arises from the root of the aorta,
and the inner and middle coats burst, fatal extra-
vasation takes place within the peiicaidium ; no
false aneurism taking place in this situation, owing
to this part of the vessel being destitute of the
cellular coat. Coagula do not trequently form in
true aneurism as long as the current of blood in
the sac continues to be not much obstructed ; but
when, owing to the narrowness of its mouth, or
to retardation of the cuirent of circulation in it,
a partial stagnation takes place, coagula then
form, frequently in an irregular or conlused state,
but sometimes in regular layers.

21. C. Aneurism with ulceration of the in-
ternal coats, or false aneurism. This variety
arises, 1st, from rupture or fissures of the internal
coats, owing to a loss of their vital cohesion, and
to friability consequent upon chronic inflamma-
tion, associated with fungous, calcareous, and
steatomatous deposits ; and is often occasioned
by accidents, or violent or sudden extension of
the ves-el ; 2d, from ulceration following scro-
fulous and chronic inflammations, and the de-
tachment of various depositions formed in the
internal membrane. Cases have been recorded
by Laennec and Guthkie, wherein fissures of
the internal coats of the vessel, in>tead of pro-
ducing aneurismal dilatation of the external coat,
had dissected it from the fibrous tunic along the
greater part of the length of the vessel ; but such
occurrences are very rare. This vaiiety of aneu-
rism cannot be fonne<l at the commencement of
the aorta : it is most frequently met with in the
descending aorta, and the part oj)posite to the
tumour or sac is generally not in the least dilated.
Numerous instances of this variety of aneurism
are recorded by modern authors.

22. D. Mixed or compound aneurism. After
all the coats of the vessel have been dilated to
a certain extent, forming either simple expansion
or true aneurism, but, owing to the less extensi-
ble properties of the internal coats, conjoined with
the effects of previous or existing inflammatory
action, rupture or ulceration of them takes place,
the impulse of the current of the circulation di-
lates still further the yielding cellular coat of the
vessel, and a sac or cyst is thus not infrequently
formed of this coat surmounting the primary
aneurism. In this case the peifoiated internal
coats form the neck of the cyst, which is always
narrower than the cyst itself. When the ruptured
part of the internal coats is considerable, so that
the impulse from the current of blood prevents its

coagulation in this cyst ; or, when in this, as in
the other varieties of aneurism, coagulable lymph
is not formed, so as to give rise to layers of fibrin-
ous coagula within the sac calculated to support
if, rupture of the sac will sometimes occur, and a
diffused form of aneurism be the result.

23. E. Of certain changes connected with
aneurism of the aorta. In some rare instances
an aneurism of this vessel has been observed by
Haller, Dubois, DupuvrnEN, and Laennec,
consisting of hernia of the inner coat through the
ruptured fibrous coat. But it is obvious that
aneurism, or tumours of this description, can sel-
dom reach any considerable size without being
either ruptured, owing to the more friable nature
of the internal membrane, or confined by granu-
lations and adhesions on its external surface, as
shown by the experiments of Hunter, Scarpa,
and Home. Solid small tumours, of the size of
nuts, and closely attached to the aorta, have been
desciibed by CoRvisARxand Hougson ; the latter
of whom supposes, with Laennec and Beutin,
tliat they are the remains of spontaneously cured
aneurisms, their sacs having been filled with co-
agula, and their size afterwards diminished by
absorption. The deficiency of the coats of the
ve-sel, at their points of union with it, seems to
confirm this opinion,

24. a. One of the most important changes
connected with tliis disease is tlie deposition of
fibiine and the formation of coagula on the inter-
nal surface of the sac. This process generally
appears to proceed by progressive steps ; and the
deposition thus presents successive layers. The
mo-t central of these generally consists of blood
only, more or less firmly coagulated ; and each
layer becomes firmer, drier, and paler, and more
and more fibrinous, until the parietes of the sac is
reached. In many cases, the most external layers
chiefly consist of a whitish or greyish yellow
fibrine, more or less opaque and friable. Some-
times they nearly resemble dried paste. The
more recently formed coagula are soft, loose, and
often only partially adherent to the layer next it.
In some cases, blood seems infiltrated between
the layers. Those next the ves-el are generally
united to it by a fine cellular-like tissue, furnish-
ing appearances of a partial organisation. These
depositions evidently proceed from the effusion of
coagulable lymph from the internal surface of the
aneurismal sac, and the partial stagnation or
retardation of the blood, favoured by the narrow-
ness of the neck of the sac, and the inflamed, un-
even, or rugged state of its internal surface. When
neither of these states exists, as is often the case
in lespect of the first two varieties of the disease, and
particularly when the neck of the pouch is wide,
neither coagula nor layers of fibrinous deposits
are formed. When, however, inflammation of
the internal surface of the dilated vessel or of the
sac exists, and when a morbid secretion takes
place from it, this will originate coagulation of
a portion of the blood which come; in contact
with it, and form, at the same time, a bond of
union between the coagulum and the internal sur-
face of the dilated coats of the vessel. The
thickness and compactness of the coagula in
aortic aneurisms are often remarkably great, and
are chiefly to be imputed to this mode of origin.
(See art. Blood.)

25. b. As the aneurismal tumour enlarges, it

74

AORTA — Aneurism of.

generally occasions impoitant changes both in
itself and in adjoining parts. Those which re-
spect the sac itself are chiefly thickening of tiie
dilated coats, or thinning of tliem ; and, in some
instances, of both these changes in tlie same case.
When the extension of the sac is considerable, or
when moderate, if opposed by a firm substance, as
cartilage or bone, ulceration or absorption of the
parietes of the sac, inflammation of its more ex-
terior parts and adhesion to adjoining structures;
and, ultimately, as the tumour increases, perfo-
ration or rupture of the more prominent part, fol-
lowed by fatal haemorrhage, take place. 'J'he
mode in which the aneurism bursts is different,
according to its situation and the structure which
it compresses and destroys ; thus it not unfre-
quently breaks by ulceration and perforation of a
limited part of the sac. In some cases, particu-
larly when it opens into a serous cavity, distinct
laceration of the more exterior covering occurs ;
when it reaches a mucous surface or the skin, a
slough is formed on its most prominent part, which
is soon detached, and fatal hsemorrhage is the
result. In the majority of such cases, the proper
coats of the vessel may have been long previously
destroyed at one part or other of the sac. But,
if tlie aneurism form at the root of the aorta, rup-
ture or ulceration of the proper coats of the vessel
is followed by instant effusion of blood into the
pericardium. Rupture of the aneurisnial tumour,
as respects the coats of the vessel, whether burst-
ing into a hollow cavity or upon a surface, or
forming a diffused aneurism, is generally trans-
verse ; but it is, in some cases, longitudinal, when
it implicates all the coats of the vessel ; or the rup-
ture of the internal coats is transverse, and that of the
external coat longitudinal ; the former being almost
universally transverse. The effects of aneurism
upon adjoining parts require particular notice.

26. F. Of the effects of aortal atieitriims on
adjoining iniits, and tlie sititations in which iliey
break. The effects of aneurisms on adjoining
parts necessarily depend upon their volume, firm-
ness, and position. The heart, lungs, trachea,
large bronchi, oesophagus, pulmonary artery, large
veins, thoracic duct, and various organs con-
tained in the abdominal cavity, may be displaced,
atrophied, or partially destroyed, by the compres-
sion occasioned by them.

27. a. The vena cava is not infrequently more or
less obstructed by the pressure of aortal aneurisms.
]\I. RtYNAUD (Journ. Hehdom. t. ii. p. 109.) met
with a case in which this vessel was very nearly
obliterated by an aortal aneurism, and ]M. Bouil-
I AUD mentions a ca-se in which the superior vena
cava was so much compressed by an aneurism at
the arch of the aorta, that apoplexy was caused by
it (Diet, de Med., et Chir. Pra<., t.iii. p.403.) ; and
CouvisAUT (Journ. de Mtd. pur MM, Corrisart,
&c., t. iii. p. B5.) and RiatiiN, relate similar in-
stances. The tlioracic duct has also been de-
stroyed by it, as was observed by INI. I^aknnk(;,
Mr. lloDCjsoN and Sir A. Coorr.u met with cases
in which the common carotid and subclavian
arteries were completely obliterated by the pres-
sure of aorlal aneurism.

28. /). When the jiressure of an aortal aneur-
ism destroys an adjoining viseus or structure, the
ulcerative inflammation is often extended from the
parietes of the sac to them, followed by the ad-
hesion and nbsorjition or ulceration of the parts

most compressed, until the tumour bursts, in one
of the modes now staled (§ 25.), into one or other
of the following situations: — Aneurism of the
ascending or pericardial aorta generally opens
into the pericardium : in three cases it bursts into
the pulmonary artery, recorded by Dr. Wells
(Trans, of Society foi- Impr, of Med. and Chirurg.
Knowledge, vol. iii. p. 85.), RI. Si'e (Journ. de
M^d. Contiu., t. xxiv. p. 124.), and JMM.Payen
and Zeink (Bui. de Fac. de Mtd., No. 3. 1819).
Aneurism of the arch of the aorta may break into
the trachea, oesophagus, pleural cavity, or into
the pericardium. That of the descending aorta
generally bursts into the pleura, oesophagus, pos-
terior mediastinum, or into the lungs. Aneurisms
of the pectoral aorta most frequently burst into
the left pleura ; they have, however, been known,
but in two instances only, — recorded by M. La-
ennec and Mr. Chandler, — to open into the
spinal canal, having destroyed the bodies of the
vertebra?, which are generally more or less in-
jured in cases of aortal aneurism of considerable
size. When seated in the ascending aorta, they
often destroy the sternum ; in both cases causing
interstitial absorption of. the bone, and often of
the parietes of the sac and fibrinous layers of
coagula in contact with it, so that the blood
washes the bone itself. The cartilages usually
resist the pressure of aneurisms, either altogether,
or much longer than the bones; and when the
periosteum is inflamed by the pressure of the
aneurism, an ossific deposit is not infrequently
formed around the tumour.

29. c. Aneurism of the aorta may, however,
destroy life, even without breaking in any of the
above directions ; either by impeding the action
of the heart and displacing it, or by compressing
the organs of respiration, or by occasioning con-
gestion, infiltration, and hepatization of the lungs ;
or by compressing the oesophagus, or injuring
some of the thoracic ganglia; or it may destroy
or compress the thoracic duct and large veins, as
stated above (§ 27.), to a fatal extent.

30. d. The bursting of an aneurism of the
aorta is not necessarily followed by instant death,
as has been shown by MM. Laennec and
IMahjolin, and very recently by Mr. S. Cooper.
In a case read by this very able surgeon, at
the Medico-Chirurgical Society, where the aorlal
aneurism had pointed under the left shoulder-
blade, but subsequently broke into the oesophagus,
several pounds of blood were discharged by vo-
miting and stool, yet the patient lived for many
months aftervvaids, and pursued a laborious occu-
pation ; a second ha;morrhage at last proving
fatal. When the sac of an aorlal aneurism bursts,
and the blood flows into a cavity or viseus, from
which it is readily discharged, death usually is
soon produced. Rut when the opening in the
sac is so situated thai the blood is effused into
the cellular structure, and what was before a
true or encysted abscess becomes a diffused one,
life may be prolonged for some days or weeks,
or even longer. This, however, will depend upon
the situation in which the rupture lakes place,
and the natuie of the parts into or upon which
the blood is effused. When the sac of an aneu-
rism is ruptured, the laceration is generally in the
same axis, or nearly so, with the opening into the
sac, owing to the impulse being greatest in this
direction, unless a divergence is occasioned by

AORTA — Aneuhism of.

75

the unyielding nature of the parts in tliis situation,
and by the slight resistance opposed by parts
immediately adjoining.

31. G. Of the causes of aneurism of the aorta .
Diseases of arteries, and consequently aneurism,
are much more frequent in men than in women.
Mr. Hodgson states that of sixty-three cases of
aneurism, external as well as internal, seen by
him, only seven were in females. But the pro-
portion of cases of aortal aneurism met with in
females is certainly much larger tluin this, 1 have
seen tliree cases of aortal aneurism in females ;
but I have certainly not seen nearly twenty-four
cases in males, which is the proportion here
indicated. Syphilis and the use of mercury have
been considered predisposing causes of aorta!
aneurism, but upon no just grounds. I am in-
clined to believe, with JNlr. Guthuie, that the
habitual use of ardent spirits has a more marked
predisposing effect than any other cause with
which we are acquainted. A more immediate
state of disposition is created in the vessel itself
by inflammatory irritation of its parietes, and the
consequent diminution of its elasticity and vital
cohesion, or power of resistance opposed to the
casually augmented impulses of the heart, espe-
cially during mental excitement and corporeal
exertion. Hypertrophy of the left ventricle, par-
ticularly if consequent upon chronic inflanima-
licu of the vessel, and influenced by moral and
physical causes, will tend to produce dilatation
or rupture of the coats of the aorta. Tlie most
frequent exciting causes undoubtedly are exces-
sive mental emotions, and violent exertion, par-
ticularly of the trunk of the body, and when
suddenly made ; but it seems evident that a morbid
state of the vessel has existed previously, at least
in the majority of such cases.

32. ii. Of the symptoms aiid diagnosis of aortal
aneurism, Tliese naiuiall}' divide themselves
into, — 1st, the rational or general signs; and,
2d, tiiose which are detected by auscultation.

a. The rational si/mptotns of aneurism of the
aorta, whilst the tumour still remains concealed
in the large cavities, are very equivocal. The
eflPects produced by it also proceed from vari-
ous other diseases. Those symptoms, even when
considered collectively, are extremely fallacious ;
but when viewed in connection with those whicii
are detected by auscultation, they are very im-
portant aids to diagnosis. 1st, Aneurism of the
pectoral aorta occasions a sense of oppression
or infarction in the chest ; but this is felt in
various diseases of the thoracic viscera. Dissi-
milarity of the pulse in both wrists is sometimes
present ; but tliis is also met with from diseases
of tlie subclavian anery, from tumours pressing
upon it, or from an irregularity in the distribution
of the brachial or radial arteries. A purring
tremor, as pointed out by Corvisart, is some-
times perceptible when the hand is placed upon
the middle and upper part of the sternum : wlien
distinctly felt, it indicates aneurism of the ascend-
ing aorta : it is also felt above the clavicles in
aneuiism of the arch, and is one of the surest
symptoms of the first and second varieties of the
disease ; but it is often indistinct when the aneu-
rism is sacculated and contains layers of coagula.
'J'his tremor, however, sometimes proceeds from
other causes than aneurism, more pariicularly
from the mucous rattle sealed in the large bron-

chi ; but, in this case, the purring tremor is not so
constant or continued as in aneurism.

33. Pressure from this disease on the trachea
and large bronchi occasions a wheezing or sibil-
lous respiration, which is generally permanent,
referable to the lowest part of the throat, and
sometimes with a whispering or croaking voice ;
the breathing is also anxious and laborious. Pres-
sure of the tumour on the oesophagus renders tle-
glutition of solids diflncult and acutely painful or
lancinating, and sometimes even impracticable.
But these effects upon the function of respiration
will be produced by various diseases of the larynx,
and by frequent accumulations of viscid mucus ia
the upper part of the trachea. The attentive ob-
server will, however, readily ascertain the exist-
ence of these affections. Other tumours may also
exist and occasion similar symptoms both of respi-
ration and of deglutition ; but, in such cases, the
diagnosis is often impossible.

.34. When the aneurism has eroded any of the
bodies of the vertebra, a gnawing or boring pain
is fell in the spine; and, when the tumour aft'ects
the brachial plexus of nerves, an aching of the
left shoulder, extending to the neck and scapula,
with impaired power, formication, and numbness
of the arm is complained of. Rheumatism of
the shoulder-joint, or parts adjoining, and severe
spinal disease, are often attended with similar
sensations ; and the symptoms referred to the
shoulder and arm are frequently present in peri-
carditis, organic diseases of the heart, and angina
pectoris, from the ramification of branches of
nerves from the cardiac ganglia to the brachial
plexus.

35. Pulsation felt beneath the sternum, or
ribs, at the upper part of the thorax, is amongst
the most certain signs of this disease : but we
should recollect that it will also be occasioned by
any tumour interposed between the thoracic parie-
tes and the aorta, and in contact with the latter;
by adhesions of the pericardium to the heart and
effusions of fluid into the former, and by consi-
derable enlargement or dilatation of the heart
itself. Pulsation above the clavicles, although a
frequent symptom of aneurism of the ascending
aorta or of its arch, may likewise proceed from
other causes, as enlarged glands, or various kinds
of tumours, receiving the impulse of the sub-
clavian arteries ; from subclavian aneurism, and
aneurisms of the innominata and common ca^
rotid, between which and aortal aneurism the
diagnosis is most difiicult, as Bi'rns, Cooper,
JMoNRO, and Hodgson have pointed out. \'iolent
pulsations of the carotids have been adduced as
a sign of aortal aneurism ; but they may arise
from nervous affection of the heart, hypertrophy
of the left ventricle, or from obstruction of the
flow of blood in the descending aorta, or in the
subclavian arteries.

36. When aneurism of the ascending aorta
attains a certain size, a tumour is usually formed
about the filth and sixth ribs of the right side:
when seated in the anterior part of the arch, it
appears at the third and fourth ribs of the same
side, at their sternal extremities, when in the upper
part of the arch, the tumour rises above the ster-
num and sternal ends of tlie clavicles. \V hen aneu-
rism is seated in the descending thoracic aorta,
and in the lower part contained in the thorax, it
often points, after destroying the ribs and bodies

76

AORTA — Aneurism of.

of the vertebrae, unrler the left shoulder-blai'e,
and pushes out this part. The strong pulsations
always present in the tumour indicate its nature.
Notwithstanding, it may subside, or altogether
disappear for a time under an appropriate treat-
ment. Previous to the appearance of the tumour
the symptoms are, as already shown, extremely
fallacious.

37. In the advanced stages of aneurism of the
thoracic aorta there are generally coughs with
mucous or bloody expectoration, dyspnoea, and
even orthopnoea, dysphagia, attacks of spasmodic
suffocation, pain in thi' left shoulder, axilla, inner
side of the arm, and ascending up the left side of
the neck, with pricking pains in the tumour, and
sometimes with a sense of whizzing or rushing at
the top of, or under the sternum, and occasionally
sensible to the hand. A dragging downwards of
the larynx is sometimes complained of. All fe-
brile symptoms are generally absent. Although
these are the rational symptoms which are most
to be depended upon, they must be viewed with
those reservations which I have particularised in
the preceding paragraphs.

38. 2d, \Vhen the aneurism is seated in th ■
ahdovniKil aorta, acute pain is complained of in
the lumbar region, occasionally shooting into
either hypochondria, and downwnrds into the
thighs and scrotum. It is generally constant,
but is also sometimes intermittent. It is often
exacerbated into violent paroxysms, being dull
and fixed in the intervals. It is aggravated by
constipation, change of position, or pressure on
the loins, and is unattended by any sense of heat
in the part. In some cases there is also numb-
ness of the lower limbs, as in that recorded by
Mr. Mayo {Med. Gaz., April, 1829), where
the aneurism was situated between the crura
of the diaphragm, and the dorsal pains were ex-
cruciating. The patient often complains of severe
fits of colic, accompanied with spasm of the
abdominal muscles, and occasionally there are
nausea and irritation of the stomach, but with
little loss of appetite. Constipation is always
present. Decubitus on the left side or back offeu
produces great distress, and occasions palpitation,
which generally subsides upon turning on the
face or right side. Coldness, formication, prick-
ing, and numbness of the lower extremities, are
not infrequent ; and in some cases paraplegia has
occurred, with involuntary evacuations of the
urine and fa;ces.

39. The tumour may not becomo perceptible
externally ; but as it increases it will press in-
juriously upon, and sometimes displace, one or
other of the abdominal viscera, particularly tliv
stomach, liver, and even the heart. When the
tumour can be delected extertially, it has ge-
nerally been on the lift side, nearly on a level
with the last dorsal vertebra. When large, it
often in)pedes the action of the diaphragm, and
thus deranges the respiration. In some cases it
has pressed upon the pericardium, and thus had
the double pulsation of the heart communicated
to it. (See Cases by Drs. Graves and Stokes,
Dull. Ilosp. Repin-ts, vol. v. p. 24.).

40. I). Si^tis fitrniJied bi) amcullalion. Dul-
ness of sound upon jeicussinii of the upper sterniil
portion of the chest and cartilages of the right
ribs, although present in aneurism of the pectoral
aorta, also occurs in other lesions of the thoracic

viscera. Dr. Elliotpon states, that a thrilling
sensation given to the hand only, or chiefly,
when applied above, or to the right of the cardiac
region, and a bellows-sound heard in the same
situation, may justly give a strong suspicion of
the disease, but that neither the bellows-sound
nor the thrill, always occurs. In four cases out
of seven he found both wanting. Laennec never
observed the thrill before the tumour became
visible externally. He considers that the chief
diagnostic of aortal aneurism is a strong and
single pulsation, discernible by the ear in the
situation of the aneurism, synchronous with the
pulse at the wrist, stronger and louder than the
action of the ventricles, and unaccompanied by
the sound of the auricles. When, however, the
aneurism comes in contact with the pericardium,
a double instead of a single pulsation of the
heart is communicated to the tumour. This was
remarked in the cases recorded by M. Ckuveil-
niFR, and Drs. Graves and Stokes.

41. Dr. Hope observes, that it is unimportant
whether the pulsations be single or double ; for,
though the latter, may be distinguished from
the beating of the heart by unequivocal cri-
teria, viz.: — " 1st. The Jirst aneurismal sound
coinciding with the pulse, is invariably louder
than the healthy ventricular sound, and ge-
nerally than the most considerable bellows-
murmurs of the ventricles. — 2d, On explor-
ing the aneurismal sound from its source to-
wards the region of the heart, it is found to
decrease progressively, until it either becomes
totally inaudible, or is lost in the predominance
of the ventricular sound. Now, if the sound
emanated from the heart alone, instead of de-
creasing it would increase on approximating
towards the precordial region. — 3d, I'he second
sound actually does sustain this progressive aug-
n;entafion on advancing towards the heart; and
as its nature and rhythm are found to be precisely
similar to those of the ventricular diastole heard in
the prajcordial region, it is distinctly identified as
the diastolic sound.* The second sound, there-
fore, corroborates rather than invalidates the evi-
dence of aneurism afl^irded by the first ; for, if
both sounds proceeded fiomthe heart, hoth would,
on approximating towards or receding from it,
sustain the same proijressive changes of inten-
sity." {Diseases of the Heart and Great Vessels,
p. 425.) Besides these views, with which I con-
cur, the sound of the aneurismal pulsation is deep,
hoarse, and of short duration, commencing and
terminating abruptly, louder than (he loudest
bellows-murmurs of the heart, and of a rasping or
grating character.

42. 'J'he sound of aortal aneurisms is generally
audible in the back; and, when the descending
aorta is the seat, it is louder in this situation than
on the breast. If it presents the abrupt, rasping
character, when heard on the back, the evidence
of aneuiism is complete' ; for, as \)r. Hope ob-
serves, the loudest sounds of tlv heart, when
heard in this situation, are so softened and sub-
dued by the distance as totally to lose their harsh-
ness. This is in accordance with the opinion of
M. Ukrtin, who very correctly ob.serves, that
when the stethoscope is applied upon the sternum
in aneurism of the substernal aorta, and on the

* Sep Arts. Auscultation and Heart, aa to the sounds
of this organ.

AORTA — ANEuniSM of. — Treatment.

77

back, near the pectoral spine in aneurism of the
descending aorta, the disease may be recognised,
before any external tumour is seen, by a strong
single sound, of greater intensity than that of the
heart. The pulsations of aneurismal tumours of
large arteries are indeed so intense, hoarse, sharp,
and peculiar, as to be readily recognised by a
person who has once examined them with the
stethoscope, although the sounds they furnish
cannot be readily described.

43. Tiie furring tremor, already noticed as
felt by the hand, may also be ascertained by the
aid of the stethoscope. It is chiefly found above
the clavicles, in cases of simple dilatation of the
ascending aorta and arch and sacculated aneurism
in the same situations. In old and large aneu-
risms, containing layers of coagula, it is generally
absent, and is more intense the more unequal
and rugged the interior of the diseased portion of
the vessel, particularly when it is studded wit!)
osseous or cretaceous deposits. Dr. EIlliotson
slates, that when the aneurism is large, a single,
and more frequently a double, bellows-sound is
often heard in the seat of aneurism, distinct
from the beating of the heart : when the sound
is double, the first is heard along with the puNe,
the latter, often the louder of the two, afterwards.
The bellows-sound in these cases may be ascribed
to the passage of the blood from the dilated aneu-
lism into the narrower cumraencement of the
healthy vessel ; and, when the sound is double,
the second may proceed from the reaction of the
dilated part of the vessel impelling a portion of
the blood into the narrow and healthy vessel
after the action of the left ventricle.

44. 2d, Aneurism of the ahdominal aorta is
more easily detected by auscultation than aneu-
rism seated within the chest. A constant and
powerful pulsation is felt by the hand, and still
more remarkably by the ear resting on the
stethoscope, accompanied with a brief, loud, and
abrupt bellows-sound ; but not so hoarse as that
of aneurisms in the chest. The pulsation is
single, unless the tumour comes in contact with
the diaphragm and pericardium ; and it is either
inaudible or very indistinctly heard in the back.
By pressing the instrument in various directions,
so as to bring it as close as possible to the
tumour, its seat and dimensions will be ascertained.

45. iii. Trlaiment. — The method of cure first
recommended by Valsalva has been since very
generally adopted, not only in aneurisms of the
aorta, but also in similar diseases of arterial
trunks. I believe, however, that it has been
often carried to a very hurtful length. I have
seen cases in which aneurismal tumours had
existed for a long time without any increase, as
long as the patient avoided any marked vascular
excitement, and continued his wonted diet ; but
when repealeii depletions and vegetable or low
diet were adopted, great augmentation of the
tumour and fatal results soon followed. In three
cases which occurred in my own practice, and in
which the method I am about to recommend was
employed, a marked amendment was the conse-
quence.

46. In order to devise a rational method of
treating this formidable lesion we should con-
sider, in the first place, the process adopted by
nature to remedy it ; and having correctly inter-
preted this process, we should endeavour to assist

nature in accomplishing it. We have seen that
aneurismal dilatation, &c. of arteries, particularly
of the aorta {§§ 14, 15.), commences in slow in-
flammatory action, and that as the coats dilate or
rupture, lymph is thrown out, which coagulates
the blood, entangling its fibrine and red globules,
and thus a fibrinous coagulum, attached to the
inner surface of the vessel, is formed, and by its
aid the inflamed and otherwise diseased coats of
the vessel are strengthened, particularly as the
fibrinous layer of coagulum becomes more and
more consolidated or organised. Now, what are
the circumstances proper to the circulation and
state of the constitution calculated to promote this
change on the one hand, or to counteract it on
the other ; for whatever advances it, or assists
nature in its completion, will tend to remetiy the
disease; whilst whatever counteracts it, will lead
to fatal results ? I shall first consider the mea-
sures calculated to counteract the process which
nature adopts to remedy the disease.

47. a. 1 believe that there is no position in
pathology more firmly established, since it was
insisted upon by John Hunter, than that what-
ever greatly lowers the vital energies will impede
the formation of coagulable lymph and fibrinous
coagula, especially in diseased vessels; and that
increased rapidity of the circulation, throbbing of
the arteries, abstraction of the fibiine and red
globules of the blood, by repeated or large de-
pletions, and the absorption of serous, watery,
or unassiinilated materials into the current of
the circulation, in order to supply the place of
the portion of blood abstracted, will, with other
effects, inevitably tend to prevent those changes
from taking place which we wish to bring about.
That large depletions produce increased quick-
ness of the pulse, reaction of the heart, thiobbing
of the arteries, and all the efl^ecis now instanced,
must be evident to every thinking and experi-
enced observer ; and that these effects are actually
those which counteract the changes which nature
produces, in order to remedy disease of the cir-
culating system, must be equally manifest. That
these results will be still further promoted by
undue, or too great abstinence, is no less obvious ;
and yet, how frequently do we find both inor-
dinate depletion and unreasonable abstinence re-
commended, in the very teeth of their fatal con-
sequences on numerous occasions, for the cure of
aneurisms.

48. b. But what are the means which are cal-
culated to advance the process which nature
uniformly adopts in order to restore as nearly as
possible the vessel to a healthy state ? These
may be stated, in a few words, to be whatever
restrains or retards the action of the heart, with-
out reducing the vital energies of the frame, and
the preservative influence they exert, both on the
coats of the vessel, and on the surrounding
structures. Conformably with this view, strict
ijuietude of hodij and mind, a light digestible diet,
the careful avoidance of spirituuus and malt liquors,
and the adoption of moderate general or local
depletions, only if the state of the circulation
unequivocally requires them, are chiefly to be
relied upon ; and, as far as my own observation,
and the careful study of the cases recorded h^
various writers have enabled me to judge, they
are the only means which deserve any share of
confidence. Whilst change of air is generdly

15

AORTA — CoNsmiCTiON and Obliteration of.

beneficial, exercise on foot, or on horseback,
especially the latter, must be avoitled, and the
utmost attention should be always directed to the
digestive, secreting, and excreting functions.

49. When, in consequence of the energetic
action of the heart, or the plethoric state of the
circulation, or excessive action of the tumour, we
determine on depletion, it ought to be performed
in the recumbent posture ; and the quantity as
well as the manner of abstracting it should be
such as to prevent any risk from too great depres-
sion, and its consequent reaction, whether of the
heart or of the arteries. When the disease is
attended with paroxysms of palpitation, depletion
will be seldom of any use, and should therefore
be cautiously employed in such cases. Local de-
pletions may be resorted to when local pains are
complained of; but, if the tumour has nearly
reached any of the surfaces, they are seldom
productive of benefit.

50. Digitalis has been generally recommended ;
it may be of some service when exhibited cau-
tiously, and in moderate doses, but its full efl^ects
must be guarded against. The same remarks
apply to colchicum. The superacetate of lead,
combined with the acetic acid, and small doses
of opium, is pieferable to digitalis ; and any
hurtful effect that would arise from it will be
prevented by an occasional dose of castor oil. In
cases attended with palpitation of the heart, or
inordinate pulsation of the tumour, 1 have pre-
scribed the sulphate (if zinc, and the sulphate of
alumina, generally combined with small doses of
camphor and hyoscyamiis, with considerable be-
nefit as palliatives. '1 he acetate of lead may also
be exiiibited in a similar state of combination.

51. The application of ice to the tumour has
been advised by continental physicians; but it
is often productive of much distress. A lotion,
or repeated sponging, and occasionally the con-
tinued application of epithems may be employed ;
and either of those recommended in F. 157. 332.
336. may be adopted. Perfect repose, however,
morally and physically, with careful prevention
of plethora and sur-action of the heart, is indis-
pensable ; other means will be useful, chiefly in
as far as they conduce to these states. By en-
deavouring in this manner to biing about the
spontaneous cure of aortal aneurism, it may be
supposed that we risk inducing the obliteration of
the vessel : but I believe that this is not so likely
to occur in the aorta as in smaller arteries; and
even were it to occur, the result does not appear
so hazardous as the continued increase of the
aneurismal tumours ; as suflncient evidence is on
record of the possibility of a collateral circulation
being established.

52. 1\'. llunuUE OF ALL THE COATS OF THE

Aorta, without aneurismal dilatation of the ves-
sel, is a very rare occurrence, and has been met
with only after violent external injuries, such as
falls, or leaping from a great height, and from
mental excitement, when the vessel has been
previously diseased. In the Ephemcrides Phy-
sico-Medic.'c Naturaj Curiosorum (Dec. iii.
Ami. ii. Ohs. 70.), a case is recorded, in which it
was ruptured by u blow on the hypochondrium.
INIr. Jami:s liiis recorded an instance of rupture
and instant death in an active seaman, previ-
ously in good health, from jumping out of his ham-
mock (Loud. Med. and I'hija. .lonrn., vol. xviii.)j

and Mr. Arnott has given a similar case, pro-
duced by a violent concussion of the body, from
falling from a scaffold {Ibid., vol. Iviii. p. 19.).
The most instructive case, however, of rupture of
the aorta without aneurism has been minutely
detailed by Mr. Rosf. {Lond. Med. and Phys.
Journ., vol. Iviii. 4io. p. 15.). In this case, as in
the others, the coats of the aorta were all rup-
tured. They were more readily lacerated than
usual, and the inner coat had a thickened
stertomatous appearance. A case is given
by Dr. Hume {Glasgow Med. Journ., vol. iv.
p. 148.), in which rupture of the aorta took place
in a strong man upon getting into bed, followed
by death in a few hours. An aperture, the s^ze
of a quill, was found in the vessel about two
inches above its bifurcation. No account is given
of the state of its coats.

53. V. Constriction and Obliteration of
THE Aorta have been observed by several pa-
thologists. Stoerck {Annales M6d. ii. p. 262.),
Meckel {Mtmuires de Berlin, 1756), Sandifort
{Observat. Anatom, Path. iv. No. 10.), and Dr.
Graham {Trans. Med. Chir. Soc, vol. v. p. 287.),
with other recent authors, have recorded cases rf
extreme constriction of the aorta; whilst M.
Desault (Journ. de Chirurg. 1792), M. Bras-
dor (Renieil Periodique de la Soc. de M£d. a
Paris, t. iii. No. 18.), Dr. A. Monro (On
Aneurisms of the Ahd. Aorta, p. 5.), Dr. Good-
isoN (Dub. Hnsp. Rep., vol. ii. p. 193.), J\I.
Velpeau (Revue Med., t. iii. 1825., p. 326.),
and M. Reynaud (Journ. Hebdom. de Mtd., t. i.
p. 161.), have adduced cases wherein this vessel
was entirely obliterated, the circulation having
been preserved by the anastomosis and enlarge-
ment of the arteries sent off above and below the
seat of obliteration.

54. With respect to the origin of this lesion, it
may be referred primarily to inflammation of the
vessel. But various intermediate changes will
necessarily have taken place, from the more im-
mediate efl^ects of inflammation to the complete
obliteration of the vessel. It is probable that, in
some rare instances, as in large arterial trunks,
the transverse rupture of the internal membrane
of the vessel, with the consequent effusion of
lymph, and formation of fibrinous coagula, may
so obstruct its canal as to give rise to its partial
or total obliteration, without any aneurismal
tumour having formed ; and it is not improbable
that obliteration or constriction of the canal may
have proceeded in other cases, from the advance<l
stages of the spontaneous cure of aneurism ; the
(leposition of fibrinous coagula, and the subse-
quent changes which had taken place in them,
and the diseased coats of the vessel, having ended
in obliteration, and the establishment of a col-
lateral circulation.

BiDLiOfinAPHY. — Morgagni, Do Sed. et Caus. Morb.
epist. xvii. et xviii. — \ic/io/s, Pliilos. Trans, vol. xxxv.
p. 4'1,'J. ct vol. Iii. p. 2G!t. — Haller, De Aortse Venacque
Cava" Gravior. quiljustlain Morbis. Got. 1749 — Burns,
On Uisfascs of the Heart, &c. p. 20G — Cruveil/irer, Siir
I'Anatom. I'atholog. Paris, 181G, t. ii. p. 00 — Hodgson,
Oil Diseases of Arteries, &c. p. 127 — Corvisart, Sur Ics
Maladies du Ccciir, &c. p. 313 — Scarpa, Kiflessioni ed
Osservazioni sull' Aneiirisina. Pavia, 1H04. — Kreysin,
Die Kraiikheitcn des Herzens. Uerl. IS[4-lf>. — Testa,
Delle Malattie del Cuore, >S:c. Nap. WH>. — Proud/oiil,
I'.diii. Med. and Surg. Journ. vol. xxii. — I.aennec, De
I'Auscultation Mediate, &c. 2d ed. Paris, X^iri.—Noverre,

Sur les Ancurysmes de I'Aorte. Paris, 1820 Aniirat,

Cliiii(pie IMedicale, &e. t. iii. Paris, I82.i BouiUaud, .Siir

le Diagnostifiue des Aneurysmes de I'Aorle. Paris, 1823.

APOPLEXY-^ Approach or premonitory Signs of.

79

A/b«ifon,iiiTrans.oftheMe(lico-Chirurg. Soc. of Eilin.

vol. iii Guthrie, On the Diseases and Injuries of Ar-
teries. Lond. 1S30 liertin, et Bouillaud, Traite des

Malad. du Coeur et des Gros Vaisseaux. Paris, 1824. —
Graves, Slakes, .ind Beatty, in Dub. Hospit. Uep. vol. v.

Elliolson, On the Diagnosis of Diseases of the Heart

&c., fol. Lond. 1H31. — Hupe, On Diseases of the Heart
and Great Vessels, &c. 8vo. Loud. 18:51 ; and Medical
Gazette volumes, vol. iv. passim — Stokes, in Dublin

Med. Journ. vol. v. p. 400 Green, in ibid. vol. vii.

p. 231 Geddinns, in Amer. Cyc. of Pract. Med. part vii.

p. 152. — See also a number of detached instances of
disease of the .-iorta adduced by Ploucquet, in his Medi-
cina Digesta, from various authors, to whom I have not
thought it necessary to refer.

APHONIA. See Voice, Marhid States of.
APHTHA. See Thrush.
APOPLEXY. Deriv. and Synon. Apople.iia,
from anoTT'Kha-a-tu, percutio. Aphonia, Hip.
Nervorum Resoliitio, Cels. Morbus Attonitus,
Lommius. Sideratio, Percussio, Molinar.
Schlagfiuss, Ger. Apoplexie, Ft. Accidente,
Colpo, Gocciola, Ital. Apoplexya, Pol.

Classif. — 2. Class, Nervous Diseases; 1. Or-
der,ComsXoi^e AS&cUons(^CuUen) . 4. Class,
Nervous JNIaladies ; 4. Order, Affecting
the Sensorial Powers {Good). IV. Class,
III. Order {Author, ^ee Preface).

1. NosoLOG. Defin. a loss of conscitiusness.
feeling, and voluntary motion ; or in other ivords,

a suspension of the functions of the brain, respira-
tion and circulation being more or less disturbed.

Path. Defin. Consists of defective vital energy
with hemorrhage, or derangement of the vascular
system of the brain, and their consequences.

2. Distinctions. There are lew disease.s which
present a greater variety of modes of attack, or
which depend upon a greater number of lesions
of the organ affected, than that now under con-
sideration. Its sources, modes of manifestation,
and morbid relations are numerous, and many of
them difficult of investigation. I'hese circum-
stances have given rise to various attempts at
arranging the phenomena of the disease in such
a way as to indicate the relations which subsist
between the changes witiiin the head, on which it
depenils, and the mode and progress of attack.
Apoplexy has long been described as consisting
of certain forms, which have been distinguished
by some authors as the sanguine and serous, with
reference to the nature of the effusion ; by others,
as the nervous and btlious, according to their idea
of the more immediate causes. By several writers
it has been, with more justice, divided into active
or sthenic, and passive or asthenic ; or entonic and
atonic, according to the state of the constitutional
or vital powers and respiration, and the degree
of vascular action accompanying it. Al! tiiese
arrangements are, however, only partially founded
in truth : in many respects they are entirely er-
roneous. Wherein they are either the one or the
other will appear in the sequel. M. Cruveilhier,
one of the most recent and best writers on the
disease, confines the term apoplexy to the occur-
rence of spontaneous ha;morrhage in the brain,
and divides it into two species: — 1st, That con-
sisting of a collection of blood in a torn part of
the brain, or on its surface from a ruptured ves-
sel ; and, 2d, That with sanguineous infiltration
into the softened structure — or capillary exu-
dation into, and combined with, its substance.
The defects of this arrangement, as well as of
this pathology, particularly in regard to practical
purposes must be apparent; for it will often be

impossible to asceitain, during life, whether ex-
travasation of blood has actually taken place, or
inerely great congestion of the vessels, with or
without serous effusion ; and many cases of true
apoplexy occur occasioning death, as well as
where complete recovery takes place, without
either of the lesions to which lie imputes the
disease having existed.

3. In the account which I will endeavour to
give of the disease, its common form of approach
and attack will be described ; next, the different
modes in which the attack is made, di.stinguishing
the principal forms it assumes ; and afterwards
will be noticed several important states of the
malady, arising from peculiar causes and ante-
cedent affections. When detailing the different
varieties and states of the disease, it will be made
manifest that the distinctions heretofore offered,
although occasionally obtaining, have no uniform
or even general relation to the lesions existing
within the head ; that apoplexy, with the sym-
ptoms described as characteristic of se7-ous effusion,
has been frequently found to proceed from
sanguineous extravasation ; and that the san-
gtiineous has sometimes only presented slight
serous effusion : a similar objection being also
applicable to all the other distinctions above enu-
merated.

4. I. Description. — i. Of the Approach,

OR PREMONITORY' SiGNS, OF ApOPLEXY. The

importance of recognising the approach cf this
disease, must be evident to the practical reader;
for judicious measures, employed at this period,
will often succeed in preventing an attack, or will
render it less severe, even when they fail of avert-
ing it altogether. The most common precursory
symptoms are, a tendency to sleep at unaccustomed
periods ; a heavier sleep than usual, particularly
if accompanied with profound, laborious, or ster-
torous breathing, stridor of the teeth ; nightmare ;
succussions of the frame, or cramps; a lethargic
feeling and drowsiness even during the waking
hours; more rarely, unusual wakefulness; pains
in different parts of the head, or general head-
ache or megrim ; a sense of weight or fulness in
the head, or of pulsation of the arteries; inco-
herent talking, resembling intoxication ; a turgid
appearance of the veins cf the head, particularly
of the forehead ; lividity or redness of the counte-
nance ; slight or imperfect attacks of epistaxis ;
loss of recollection ; irritability of temper, or
unusual serenity or apathy of mind ; a disposition
to shed tears; suffusion of the conjunctiva; col-
lapsed appeaiance of the aiae nasi; moats floating
before the eyes, or dimness of vision (amaurosis) ;
scintillations, or bright or shining coruscations
before the eyes during darkness ; inability to
follow the line in reading ; double vision, or a
sharper sight than usual ; difficulty in shutting or
opening the eyes; noises in the ears; dulne.ss of
hearing ; a sensation of an unusual fcetor ; dry-
ness of the nostrils , continued sneezing ; frequent
yawning; singultus; stammering, or indistinct
articulation ; the substitution of one word ftr
another, or forgetfulness of words and names ;
difficulty of swallowing, or fits of coughing upou
deglutition ; leipothymia, vertigo, or a .sensation
approaching to fiiintness ; difficulty of writing, oi
inability to spell the wonis, or to follow a straight
line ; torpor, or numbness, or pricking of the ex-
tremities; itching, or formication of the suiface;

80

APOPLEXY — Simple and Primary.

pains of the joints or limbs ; a feeling of fatigue
upon slight exercise ; partial or slight paralytic
afTeftions, chiefly of the muscles of the fice, or
confined to a limb or part of a limb, occasioning-
drooping of the eyelids, imperfect utterance, slight
distortion of the mouth ; an unsteady or tremulous
gait; tripping upon ascending or descending a
stair, or in walking ; difficulty in voiding the
urine, &c.

5. ii. The characteristic Symptoms, or those
CONSTITUTING THE Attack. After one or more
of the foregoing signs, or after the succession of
two or more of them, and their continuance for a
short or long period, the phenomena which con-
stitute the disease supervene. Sometimes the
premonitory signs are so slight, and of so short
duration, as to escape notice, the attack being
severe and sudden : at other times they are very
remarkable, and several of them are grouped to-
gether, the attack advancing either gradually and
severely, or suddenly, and disappearing rapidly ;
yet recurring after an indefinite time. The mode
of approach and attack sometimes has a close
relation to the state of internal lesion ; but, occa-
sionally no such relation can be traced, as will
be shown and explained hereafter. The premo-
nitory signs, as well as the early part of the
attack, generally present more or less either of
augmented or diminished vascular action, parti-
cularly about the head, according to the state of
the vital powers. The character of the sym-
ptoms, therefore, in respect of degree of vascular
action and constitutional power, should receive
the utmost attention, as being our best guide to a
successful treatment.

6. A. In the most severe and sudden forms of
attack, — the Apoplexia fulminans of the older
authors, and some of the continental writers of
the present day ; ihe. fortissinia of Dr. Cooke and
others; xhtiapoplexiefoudroyanteoixXx^ French, —
the patient is struck down instantly, sometmies
froths at the mouth, has a livid countenance,
complete relaxation and immobility of the volun-
tary muscles and limbs, and unconscious evacu-
ation of the urine and faeces ; ami dies very shortly
afterwards, either with or without stertor, or rattle
of the respiration, with cold, livid extremities,
cold perspiration, and sometimes a cadaverous
cast of countenance.

7. 7i. In the more active or sthenic forms of
attack, — the Apoplexia fortis ; the entouic apoplexy
of Dr. Good; A. exijuisila of various authors, —
the patient is more or less suddenly seized with
profound stupor, the eyes being either open or
closed ; the breathing deep, slow, sonorous, or
stertorous; and the pulse slow, full, hard, or
strong: sometimes irregular or unequal. In this
state of the disease, the above are often the chief
symptoms, no signs of paralysis being ohscived.
Hut frequently the mouth is drawn to one side,
the eyes are distorted, and one eyelid immove-
able, with relaxation, loss of sensation and of
motion of a limb, or of one side of the body ; the
arm of the non-paralysed side being often closely
a|)|)lied either to the chest or to the genital organs.
In this latter slate of the disease, there is some-
times also some degree of paralysis of the urinary
bladder, or of its sphincter, giving rise to ischu-
ria, or enuresis, or a combination of both, 'i'he
jjatient generally lies on the paralysed side, which
is relaxed, inciipahle of motion, and insensible to

the application of irritants ; whilst the limbs of
the opposite side are sometimes subject to spastic
contractions.

8. C. In the more gradual seizures, or those
of a less complete character, — the atonic apo-
plexy of Dr. Good ; the Apoplexia imperfecta, the
parapoplexia of various writers, — the patient, after
experiencing some of the premonitory symptoms,
is seized with alarming vertigo, leipothymia, or
feeling of faintness ; sickness at stomach and
vomiting ; disturbance of the senses, particularly
of the sense of sight ; loss of memory ; partial
loss of sense, consciousness, speech, and voluntary
motion ; weak, irregular, and sometimes quick
pulse, with more or less of sopor,

9. Besides the foregoing forms of apoplexy, —
which differ merely in respect of the state of the
constitutional powers, the severity of attack, and
the grouping of the symptoms, and not as to the
organic lesions which occasion them, — other dis-
tinctions ofl^er themselves, which are still more
deserving of attention, as generally having a more
intimate relation to the changes which are going
on within the head, than the degrees of severity
of seizure merely. Viewing, therefore, the pre-
monitorj' symptoms as common to all its varieties,
I shall divide the disease according to the form,
manner, and complication of the attack, and con-
sider, briefly, — 1st, The sudden form of apoplectic
seizure, in its simple state, and unassociated with
paralysis; 2nd, The gradually increasing, or in-
gravescent attack ; 3rd, These states of seizure
complicated with paralysis; and 4th, that form
which commences with paralysis, and after an in-
definite period passes into complete apoplexy.

10. iii. Simple and Primary Apoplexy. A.
Description. In this variety of the disease the
patient falls down deprived of sense, conscious-
ness, and voluntary motion, is like a person in a
very deep sleep, with his face much flushed,
tumid, and occasionally livid ; his breathing slow,
deep, and stertorous ; his pulse full, natural in
frequency, or slower than usual. Sometimes
slight convulsions of the limbs, or contractions of
the muscles occur, or contractions of the muscles
of one side, and relaxation of those of the other.
The attack, in rarer instances, is either ushered in
or accompanied with general convulsions, passing
into complete apoplexy, or profound coma. The
patient may continue in this state of profound
stupor for several days; or he may recover after
some hours, or even minutes, when judicious
assistance has been instantly procured.

] 1. B. This form of the disease terminates, 1st,
in pel feet recovery, — often in the course of a
few hours, — but rarely when the attack has con-
tinued longer than one or two days. I iiave,
however, seen cases of perfect recovery in com-
paratively young or robust subjects, after the
apoplectic state had been of several days' dura-
tion. 2n(i, In death, which may take place in the
course of a very few hours, or alter some days, but
most commonly from the first to the fourth day.

12. C. The appearances which this class of cases
present on dissection may be arranijed into — 1st,
Those which are insuflficient to account for the
symptoms, or their termination in death ; 2nd,
Those which proceed from intense injection and con-
gestion of the membranes of the brain, and of the
cerebral structures; 3rd, Those which are accom-
panied with an eft'usion of serum, or engorgement

APOPLEXY — Simple and Primary fon»r.

81

of the vessels of the head, or both ; and, 4ih,
Those whicli are Httendtd by extensive extravasa-
tion of blood.

13. 1st. Cases of apoplexy in whiih no mor-
Ind tipjiearaiice could be detected after death,
have been recorded by Wilms, Stark, Powell,
and AuEncnoMCiE ; and similar casts have oc-
curred to IMOHGAGNI, TiSSOT, QuARIN, OzA-
NANAM, FOOEKE, and IIlLDENBrtAND. It is tO

this variety of apoplexy th;it the term nervous has
been applied by several eminent authors, particu-
larly by KoBTUM, ZuLiAM, and Hildenbrano.
NiccLAi referred it to spasm of the meninges;
Lecat and Weikaku to spasm of the nerves and
vessels of tiie brain. Borsieri termed it conml-
sive apoplexy ; and Tissot and some oth r authors
hii>teric apoplexy. HilijEnbrand conceives that
it is the cause of death in contagious typhus ;
patients dying jifter profound coma in this disease,
without any effusion or appearance of congestion
or compression, but apparently from a sudden
collapse of the nervous energy of the brain. Apo-
plectic seizures, rapidly terminating in death, have
been occasionally observed to occur in epileptics
and maniacs, as recorded by Fodere, Nacquart,
Belloc, and Gendrin, without any manifest
lesion of the encepiialon. This particular slate
of the brain seems also, in some instances, to ob-
tain in the course of a few other diseases, and to
be occasioned by certain external causes, parti-
culaily injuries pioducing concussion of the
brain, lightning, extreme cold, and poisonous
substances.

14. A case occurred to me of this description
in a man aged about forty, who had complained
of vertigo, leipothyniia, and loss of recollection,
suddenly followed by profound sopor. He had
been blooded largely when I saw him. His
breathing was not stertorous ; his pulse was weak,
small, and quick, and his countenance sunk.
'I'he brain, on a careful examination, presented no
change in colour or consistence, and was even
less vascular than usual. Tlie pineal gland was,
in my opinion, smaller and softer than natural,
and contained scarcely any of the small gritty
bodies which are generally found in it. The
pituitary gland was not examined, the case having
occurred lo me a number of years ago, and be-
foiemy attention had been directed to the nature
and functions of this part.

15. 2d. In a large proportion, however, of this
class of apoplectic cases, excessive iujeclicn of (lie
vessels of the pia mater, and engorgement oj the whole
vasciihir system of the encephalon, are tlie chief
lesions. I'he pressure to which the brain has been
Subjected from this cause, as well as the interrupted
stale of the circulation, whence the attack most
probably proceeded, being sufficient to destroy life
in a few minutes, or a very few hours at the furthest.
This forms the t-implest sate of sanguineous apo-
plexy, and is of comparatively rare occurrence.
It constitutes the coup de simg of the French, and
is observed in those cases of coup de soleit, or sun-
stroke, which proves rapidly fatal. I have met
with it in two cases of this description.

16. 3d. Serous effusion is one of the most fre-
quent appearances found in this form of apo-
plexy ; but it seldom occurs alone, being generally
accompanied with engorgenient of the veins and
sinuses of the brain. It is often alsoobserxed in
the symptomatic and complicated stales of apo-

VOL. i.

plexy which v\ill come under consideration in th®
se([uel. 1 he very judicious observations which
have been made by Dr. AnEnoROMBiE and M.
Crcveilhier, particularly the former, as to the
relation which tiiis lesion presents to the apoplec-
tic state, is well deserving of the attention of the
pathologist. I perfectly agree with them in con-
sidering the distinction proposed between san-
guineous and i-erous apO|ilexy as not supported
by observation ; for many of the cases which ter-
minate by serous effusion, exhibit in their early
stages all the symptoms usually assigned to san-
guineous apoplexy, such as flushed countenance,
strong pulse, vigour of constitution, &c. ; whilst,
on the other hand, many of those accompanied
by paleness of the countenance and feebleness of
the pulse will be found to be purely sanguineous ;
even the pre-exi-tence of dropsical effusion, or the
leuco-phiegmatic diathesis, or great age, &c., fur-
nish no certain data, although a strong piesump-
tion, of the attack being that depending upon the
effusion of serum.

17. The serous effusion in those cases in which
it constitutes even the chief lesion, cannot be
viewed in any other light than in that of a result
of pre-existing disturbance of the circulation, de-
pending, as will be more fully alluded to in the
sequel, either upon imperfect vital tonicity or
action of the vessels, or upon obstructed circula-
tion, especially in the veins and sinuses of the
organ, or even upon both. Another circum-
stance, well deserving of notice, and evincing
that the serous effusion is of itself to be viewed
as merely a part, and indeed no very important
part, of the existing lesions, although the most
demonstrable, is the fact also insisted on by Dr.
Abercromeie, that the quantity of fluid effused
bears no propoition to the degree of the apoplec-
tic symptoms: for we find it in large quantity
when the symptoms have been slight; in small
quantity when they have been both strongly
marked and long continued ; and, finally, we
find most extensive effusion in the head, where
there have been no apoplectic symptoms at all.
The inference, therefore, clearly deducible from
the most faithfully observed facts, is, that the
effusion is not the cause of the apoplectic seizure,
but the consequence of that state of circulation
on which the disease more immediately depends.
Indeed, I am even of opinion that a considerable
portion of the effusion lakes place either imme-
diately before death, or soon alter life is extinct ;
and that several cases referred to serous effusion
have not arisen from this cause, the quantity of
serum having evidently not been gieater than we
have reason to believe naturally exists in the
head, as Lecessary lo the regularity of its func-
tions, under the varying states of circulation, and
of atmospheric pressure on the surface of the
body, fiom which the unyielding bones of the
cranium protect it.

18. 4th, Eitetisive extravasation of Hood is a
rare occurrence in this form of apoplexy, being
most commonly observed in other varieties of the
disease. When, however, exiiavasation is met
with, it is either found diffused about the base of
the brain, and }ressing upon the medulla oblon-
gata inthe fouith xentricle, or in both the lateral
ventricles, fum rujilure of some disea^e(l vessel,
or from extra\asaiion of blood near to, v\itlj lacer-
ation of the cerebral striictoe at, the surface of

G

APOPLEXY — Ingravescent Fon.M.

82

the brain. When extravasation of blood is found,
tlie attack has generally been characterised by
symptoms closely approaching those of the next
variety, viz. an invading and slight attack, ra-
pidly followed by a short interval of sensibility,
which is as quickly followed by profound coma
and death.

19. ill. The gradually increasing or in-
gravescent Apoplexy. — A. Description. — In
lliis form of the disease the patient is not at first
seized with loss of sense and voluntary motion ; or
if he be so seized, the attack is momentary, and
passes oft" without the use of any remedy. It
more usually commences with a violent and sud-
den attack of headach, very frequently accom-
panied with paleness, sickness, and vomiting.
Sometimes the patient sjftks down from its sever-
ity, pale, faint, and exhausted ; and experiences
a slight convulsion, but recovers from this state
in a short time. Tliis invading and slighter attack
generally soon abates, or some of the symptoms
subside, and others continue in various degrees or
differently modified. The pain is generally re-
ferred to one side of the head, and the vomiting
sometimes returns. Coldness, paleness, and
faintness are complained of, with all the other
symptoms indicating a serious shock received by
a vital organ. The pulse is weak and frequent,
the countenance cadaverous and sunk, and the
patient feels depressed, but sensible. After this
stale has endured from an hour, to two, three, or
even more, the surface acquires some heat, and the
pulse improves in strength. The face now be-
comes flushed, and the features expanded. The
oppression increases rapidly ; he answers ques-
tions slowly and heavily, and at last sinks into a
state of profound stupor or coma. The period
which elapses from the invading attack, to the
continued and perfect coma, varies from less than
an hour to thiee days. But Dr. Abercro.mbie,
who has illustrated this form of apoplexy in an
able manner, has observed an interval of not
more than twenty minutes, and has seen it pro-
longed to a fortnisfht.

20. B. I'his is the most fatal form of apoplexy,
very few lecovering from it. On iiispectiun after
death, extensive extravasation of blood is always
met with. From the whole hi-^tory of this class
of cases, Dr. Abkrcrombie thinks that they de-
pend upon the rupture of a considerable vessel
without any previous derangement of the circu-
lation, the rupture probably arising from disease
of the artery at the part which gives way. He
conceives that, at the moment when the rupture
occurs, a temporary derangement of the func-
tions of the brain takes place, but that this is
soon recovered from ; and the circulation then goes
on without interruplion, until a (juantily of blood
has been extravasated sufficient to produce coma.
This may possibly be the case, particularly in
those instances where the coma soon follows the
first attack. I am more inclined to think that a
depressed or deranged state of the vitiil energy
and circulation of the brain, similar to that which
occurs in the foregoing variety of the disease,
takes place at the commencement of the seizure,
and that the extrava'-ation freciuenlly accompanies
the reacli<m, su[)erveningon tlie oppr<ssion which

f)recede3 the perfect attack ; or, if extravasation
lave taken place in I he fir^l instance, that it is only
to a small amount, the state of energy of the cir-

culation of the organ at the time preventing it from
proceeding to any considerable extent, and that
it is afterwards renewed in the same situation, or
even in a difterent part, upon the reaction which
takes plare soon after the shock which the first
seizure occasions. Dr. Abercromeie is of opi-
nion, that in some cases the extravasation com-
mences with the early part of the attack, and that
it goes on until such a quantity has been accu-
mulated as IS sufficient to produce fatal coma;
and that in others, after the rupture h:is taken
place, the ha;morrhage is stopped by the form-
ation of a coagulum, and, after a considerable in-
terval, bursts out afresh and is fatal. It is by no
means improbable that some cases present the
phenomena which this accomplished physician
contends for, whilst others may proceed in the
manner which I have suggested. A chief reason
for my believing that this form of apoplexy fre-
quently originates in the way I have stated, is, that
I have met with cases in which the disease was
gradual, or consisted of several attacks of either
incomplete or complete loss of recollection and
voluntary motion, from which the patients had
recovered, but had at last been carried off by a
more severe seizure ; and yet, upon dissection, ap-
pearances of recent extravasation merely, or of
congestion and engorgement, with or without
serous effusion, but without the least extravasa-
tion of blood, were the only lesions which ex-
isted.

21. The rapidity with which the disease ad-
vances, will, of course, depend upon the nature
of the lesion, and upon the size of the vessel or
vessels from which the hjemorrhage proceeds, and
the extent of the extravasa'ion. The situation,
also, will have some influence ; inasmuch as a
small extravasation, if it press upon the medulla
oblongata or the annular protuberance, will be
more certainly and rapidly fatal than a much
larger effusion into the ventricles, or into the sub-
stance of the hemispheres.

22. C. 'Ihe Appearances on Dissection, chiefly
consist of extensive extravasation of blood, most
commonly in some paitof the brain in the vicinity
of the ventricles, as the corpora striata and thai-
ami optici, or some other situation adjoining those
cavities, and which frequently lacerates the cere-
bral structure, and passes into and fills the ven-
tricles. In some instances the lia;inorrhage takes
place in a part of the brain nearer to its periphery
than its internal surfaces : in such cases the
blood ruptures the cerebral substance, and is
effused on its suiface. In the more suddenly
fatal cases, this is observed to have occurred
generally towards the base of the brain.

23. Jn cases of profound coma supervening
after a considerab'e time from the first seizure,
the parietes of the cavity formed in the substance
of the brain by the effused blood, are softened,
discoloured, and broken down, eviilenlly indi-
cating that in these cases softening and disorgani-
sation had cither preceded the seizure, or speedily
followed the first extravasation, and that a re-
currence of the lia:morrliage had produced a
lacerated opening, communicating either with the
ventricles or the exterior sui face of the organ. In
a considerable pr()|)ortion of cases of this form of
apoplexy, the arteries are either oss'fied or other-
wise diseased. The veins and sinuses al«o some-
times present morbid ai>pearances (§29.).

ArOPLEXY — In

24. In rarer instances the extravasation of
blood takes place in tlie cerehellum. Wlien the
effusion is eitlier in this situation or below it, the
symptoms are more severe and rapid in their pro-
gress than when it is in the substance of the
brain. '1 his remark is also applicable when the
blood flows from or into the svibstance of the
annular protuberance, or accumulates around the
medulla oblongata and foramen magnum. In
some of those latter cases, which are much rarer
than the foregointj, the fatal result is rapidly pro-
duced. In nearly all the cases of extiavasation
taking place, eitlier within or near the surface of
any part of the cerebral structures, it is extremely
dilbcult, if not entirely impossible, to trace its
exact source, or the vessel or vessels vihence it
has proceeded. It is very probable that the la-
ceration produced by haemorrhage separates seve-
ral vessels, and thus a greater number are laid
open than are concerned primarily in producing
the extravasation. Besides, the softening of the
surrounding cerebral structure may destroy adili-
tional vessels, and give rise to secondary extra-
vasations of blood, either into the original cavity,
thus forming a more recent portion or layer of
coagulum, or into the surrounding structure in the
state of capillary infiltration.

25. Besides the foregoing sources and seats of
extravasation, others have been observed. INI.
Seures describes a ciise in which the haemor-
rhage had occurred in the substance of the pons
varolii, whence the blood had burst into the occi-
pital fossa. It may also take place from the
superficial vessels, forming the meningeal apo-
pte.iii of this writer. In cases of this description,
the blood generally seems accumulated between
the dura mater and arachnoid ; but cases have
been recorded, in which the blood appeared to
have been discharged from the retiform ylexus of
vessels at the base of the brain, and confined
beneath the pia mater. The hsemorrhage may
also proceed from ■ulceration and rupture of a con-
siderable arterial re^sel. Dr. RJills met with a
case in whicli it was traced to ulceration and rup-
ture of the basilar artery; and JMohcagni and
Stu RES have found it proceed from a similar
lesion of the internal caioiid. RIoncAGNi, De
Haen, and Hufelaxd. have traced the extrava-
sation to the vessels of the choroid plexus. This
is probably the source of the haemorrhnge when
it is confined to the ventricles, without lacer-
ation of the surrounding substance of the brain.
Rupture of one of the lateral sinuses has also been
observed : a case of this description occurred to
Dr. Douglas. (^Ediu. Med. Essays and Observ.
vol. vi.)

26. Small aneurisms in various paits of the
cerebral vessels may have formed, and by their
rupture occasion apoplexy. Serres relates cases
in which aneurism occurred in the basilar artery,
and in a small artery in the circle of Willis.
{Archives Gen. de Med. t. x. p. 419.) Similar
cases are also recorded by Blane and Hodg-
son. Numerous other instances of extravasation
from disease of the cerebral vessels have been
noticed l)y Morgagni, Lieutaud, De Haen,
Baillie, Portal, Lallemand ; and especially by
BouiLLAUD (Mem. de la Soc. Med. d'Emul.l.ix.),
and Dr. Bright {Medical Reports, vd. ii. p. 266,
ct seq.), who have adduced seveial proofs of this
kind of lesion. In a case of apoplexy recorded

CnAVESCEKT FORM.

83

by Bang, the extravasation had taken place be-
tween the occipital bone and dura mater. Dr.
Watts, of New Yoik, met with a case in whicii
the ha'morrhage had proceeded from the erosion
of a vessel in connection with caries of the inner
surface of the parietal bone.

27. hijiltration of the blood info, with soften-
ing of, the cerebral structure, also seems to form
one of the lesions which are sometimes met wiili
in this form of apoplexy, although not nearly so
frequently as in the seizures which supervene on,
and are accompanied with, paralysis, where this
state of softening forms the principal lesion ; where-
as, when it occurs in this variety, it is one of seve-
ral other changes, or at least a subordinate one.

28. Perhaps the most common causes of hae-
morrhage in this form of apoplexy, particularly
when occurring in the substance of tlie brain, are
ossification, earthy deposits in various places, and
a peculiar fiiability, of the vessels of the organ.
This state of the vessels, as disposing to aneurism
and haamorrhage. has been well illustrated by
Scarpa, and is justly insisted upon as being con-
nected with apoplexy by Abercroiibie and Cru-
VEiiHiER, and frequently met with in the brains of
elderly persons. " There is much reason to be-
lieve," Dr. AEERCROMiiiE remarks, " that th's
diseased condition of the arteries of the brain may
sive rise to a variety of complaints in the head ;
and that, after going on for a considerable time
in this manner, it may at length be fatal by rup-
ture." The remarkable frequency of osseous or
cretaceous deposits, &c. in the arteries of the brain
in cases of apoplexy, had been noticed by Cor-
TFSius and Morgagnt. There can be no doubt
that changes of this description, in connection
with alterations of calibre and of vital cohe-
sion taking place in vessels, the coats of whicli
are remarkably thin and fragile even in the
healthy slate, will readily dispose them to rup-_
ture ; particularly when influenced by the varying
actions of the heart, and the diflTerent emotions of
the rtiind, or when congested by derangement of
the vital energy bestowed on them by the ganglial
system, or by disonler of the veins or sinuses, and
interruption to the return of blood through those
channels. Indeed, there is every reason to believe
that the ha?monhage may even pioceed from the
smaller veins, in many of the casts where con-
gestion has been concerned in originatmg it, and
especially when the return of blood from the
head has been interrupted so as to produce the
disease. It may therefore be inferred, that the
laceration of the cerebral structure is occasioned
by rupture of either an arteiial or venous capil-
lary vessel or vessels, and extiavasation of blood ;
and that, in cases of this description at least, the
morbid change commences in the vessels, and not
in the cerebral tissue itself, the cerebral structure
being only consecutively diseased.

, 29. Cases have also occurred, in which this
species of apoplexy has arisen from disease of the
sinuses, chiefly thickening, induration, and ob-
struction or obliteration of their canals. AV'lien
this is the case, the veins running into the sinuses
are generally enlarged, tortuous, engorged, and
as if varicose. I have met with cases in whicli
all the symptoms of this disease proceeded from
the development of tumours in the central parts
of the brain, and similar instances have been re-
corded by several writers.
G 2

84

30. Besides disease of the vessels of the brain,
lesions of the membranes, as o'sific depcsiti=, ossifi-
cation of the falx (Morcagm), but particularly
derangements of the circulation in them, espe-
cially in the pia mater, — as evinced by copious
extravasation on the sui face of the hemispheres, or
at the base of tiie encephalon, — and inordinate
injection and congestion, deserve to be enumerated
among the sources of this variety of apopiexy ;
although they are, perhaps, more frequently pro-
ductive of congestion and serous effusion, and
consequently of the most common foims of tlie
preceding species. But there can be no doubt that
this form, as well as the foregoing, will also some-
times proceed, although much more rarely, from
injection and engorgement of the vessels of the
membranes and of the brain itself, without extrava-
sation ; and that in other instances the degree of
congestion, and the accompanying serous effu-
sion, when occurring without extravasation, are
not of themselves sufficient to account for the
fatal i~sue, without imputing something to the
vital condition of tiie encephalon itself.

31. iv. Apoplexy complicateh with, or

TERMINATING IN, PaRAI.VSIS. A. DeSCliptio)! .

— This form of the disease may take place either
suddenly or in the manner of the immediately
preceding variety ; but more frequently the lat-
ter, with the additional phenomenon of paralysis,
which may be either coeval with the attack, or
supervene as the apoplectic stale passes off. In
the majority of cases, the patient complains of
symptoms referrible to the head, particularly of
acute pain in one part of it ; and is suddenly or
gradually seized with stupor or profound coma,
loss of speecii and voluntary motion — with per-
fect apoplexy. The mouth is often distorted, and
the patient moves the limbs of one side ; whilst
one or both limbs of the opposite side are found
to be deprived of all motion upon their being
pinched or tickled. The patient geneially lies
on the paralysed side, and one or both the oppo-
site limbs are sometimes contracted or slightly
convulsed.

32. In other cases, the seizure is less perfectly
apoplectic in its character, varying in the degree
of coma and disturbance of the respiration ; and,
as the seizure declines, the paralytic symptoms
become the prominent disease. In some instances
of this description, the comatose state is slight or
of short duration ; but the eyelid, or orbicularis
of the eye, of one side is paralysed ; or the eyes
are distorted, the mouth twisted, and the tongue
drawn aside upon itsbeing held out. In the major-
ity of these cases, the speech is either altogether
lost or greatly impaired ; but the patient appears
sensible of his situation, and even attempts to
express himself by words or .signs : but he is fre-
quently incoherent, unintelligible, and without
recollection, even when the power of speech is
partially retained. In many of this class of cases,
com[)lete hemiplegia exists, or gradually mani-
fests itself as the seizure de.-lines. Sometimes
one limb only is affected, which is commonly the
arm ; although the leg is sometimes the only pa-
ralysed |)art. In rare casts the power of swallow-
ing is lost, owing to paralysis of the muscles of the
pharynx and tlie upper pait of the oesophagus.

33. This form of apoplexy presents various
modifications in its further progress, which may
be ariangcfl under liie following heads : —

APOPLEXY COMl'LICATED WITH Pahalvsis.

a. Tiie apoplectic attack may, under judicious
treatment, pass off entirely and (|uickly, and
leave no trace of its existence after a short lime ;
the paralytic symptoms, particularly wlien slight,
either disappearing with it, or soon afterwards.

b. The recovery from the apoplectic seizure
may be more gradual, taking place only in the
course of some days ; whilst the paralytic symp-
toms require several or many months for their
removal.

c. The apoplectic seizure may be either quickly
or slowly removed ; but the paralysis may be per-
manent,— may continue for years, either until
the patient is carried off by a subsequent seizure,
or by some other disease.

d. In other cases, tlie patient experiences a
very partial recovery merely, or is subject to
several exacerbations ; is confined to bed or his
room, speechless or paralytic, or the latter only,
with his mental faculties either more or less im-
paired, or but little affected ; and at last sinks
gradually exhausted, after many weeks, or even
months; sometimes having become comatose for
a short time before death.

e. The apoplectic se zure may pass off in a
shorter or longer time, leaving either hemiplegia,
or paralysis of a single limb, or impaired speech
and mental faculties ; and may recur after a
period of indefinite duration, and either carry off
the patent, or leave his symptoms greatly aggra-
vated. In this latter case, either another seizure
again takes place after a time, or he sinks into
the state characterising the immediately preceding
modification.

34. B. The morbid appearances which this
variety of apoplexy, in its different states, pre-
sents, are very diversified : — 1st, In some cases,
HO lesion is detected sufficient to account either
for the symptoms or the termination ; 2d, In
other cases, serous effusion merely to a slight
extent, or little beyond what we have reason to
suppose usually exists within the cranium, is
found, sometimes conjoined with more or less
congestion of the vessels; 3d, In some instances,
congestion is the most remarkable and only mor-
bid appearance; and, occasionally, this state is
connected with disease of the arteries, geneially
of the kind already described (^ 28.).

35. 4th. Eatraiasation of blood into a defined
cavity is amongst the most frequent lesions met
with in this form of apoplexy. We have already
seen, that, when llie ha?n)orrhage is very con-
siderable, or bursts its way into the ventricles, or
to the surface of the br.iin, the apoplectic seizure
is complete; and, owing to the quantity of blood
effused, and the pressure thereby occa.-ioned on
the whole encephalic mass, the patient is either
suddenly carried off before any paralytic symp-
toms become evident, or rendered comatose, and
incapable of sensation and voluntary motion in
every limb. In the majority of cases in which
extravasation takes place in this form of apoplexy,
there is every reason to Lelii ve, from its small
extent, that it is merely a consequence of the
simjile apoplectic state occasioned by congestion
or interrui)tion to the circulation, — these states of
the circulation being followed by the extravasation,
on which the paralytic symptoms chiefly depend.

36'. 5th. The extravasated blood presents vaiious
appearances, according to the period which has
elapsed from its cfl'usion ; and the surrounding

portion of t!ij brain, and parietes of the ca-
vity formeJ by the coagulum, likewise undergo
changes — in some ca<es extremely slight, in
others very extensive — which generally have an
intimate relation to tlie various states the patient
has presented in the progress of the disease.
When the cerebral substance surrounding the
extravasated blood continues but little changed,
coagula of considerable size are gradually and
often completely absorbed. About fifteen or
twenty days after the attack, the more fluid part
of the effused blood disappears, and the coagulum
is firm and of a dark brownish colour. At a re-
moter period it assumes more of a firm and fibrous
texture, and the dark red or brown tint is lost.
At last the coagulum is nearly or altogether ab-
sorbed ; and a small quantity of fibrinous matter,
of a slightly reddish colour, which after a time
passes into a loose cellular-looking substance,
only remains. These changes generally take place
at the end of four or five months; but exceptions
not infrequently occur. RroBE found blood in
the apoplectic cavity after twenty months ; JMou-
i.iN met wiih a small coagulum at the end of a
year; and Serres has observed firm coagula at
the termination of two and three years.

37. The parietes of the cavity aha experience
an important change. They frequently consist of
a firm yellowish membrane ; and, when the co-
agulum is altogether absorbed, this membrane
forms a more or less complete cyst and well-
defined cavity, which is either empty or contains
a little very loose cellular substance connecting
its opposite sides in all directions ; sometimes with
yellowish bands of a denser consistence running
through it. Dr. ABERCROMBrE has never found
the cavity entirely obliterated ; while Dr. BRroHx,
JM. CRuvErLHiER, and some ether French patho-
logists, have seen it in some instances, after a
remote period, reduced to a dense nucleus ; and,
in others, to a linear induration resembling a ci-
catrix (§53.). In some cases the cyst has been
found distinctly organised, and with blood-vessels
ramified in it.

38. The firm membrane constituting the apo-
plectic cyst, or covering the sides of the cavtty,
seems to form soon after the extravasation has
taken place, and apparently arises from the lymph
thrown out upon the torn surfuce of brain. It
may generally be detected as early as a fortnight
or three weeks after the attack, or even earlier.
At a remoter period, when the coagulum is re-
moved, it is either empty, or it contains a serous
fluid, usually tinged with blood or the remains of
the coagulum. IlroBE and other French writers
suppose that the serous fluid is exhaled from the
membrane covering the cavity, and absorbed
after dissolving a portion of the coagulum. When
blood is extrava-sated into the ventricles in cases
of this description, although extravasation in this
situation much more rarely occurs in this than in
the preceding form of the disease, there seems no
doubt of the possibility of its absorption. In this
Ciise, the membrane Hiring the ventricle, contain-
ing the effused blood becomes thickened, and of a
yellowish colour. JM. Riobe records a case of
apoplexy, with palsy of the left side, which was
completely removed. The patient died of diseased
lun^s after eighteen months; and the right lateral
ventricle contained a small (luantity of coagulated
blood, and its membrane was changed as now de-

APOPLEXY — coMrLiCATED wtrtt Paralvsis, 85

scribed. Absorption of the coagulum, with the
formation of a cyst similar to those formed in the
cerebral structure, also takes place wiien thj
blood is effused on the surface of the brain, or in
the cellular structure of the arachnoid and pia
mater.

39. As the coagulum disappears, the paralytic
symptoms in some cases subside; but more fre-
quently the improvement is only partial, and the
patient continues paralytic, although the coagu-
lum is either altogether or in a great measure
absorbed, and all unusual pressure or interruption
to the circulation is removed from the adjoining
parts of the brain. It would sxm that the fibres
of cerebral structure being once ruptured, and
not being susceptible of a direct reunion, remain
ever aft.rwards incapable of conveying volition
to the paralysed limbs, which are always on the
side opposite to the seat of lesion in the ence-
phalon.

40. In some cases of apoplexy complicated
with paralysis, the apoplectic symptoms pass
away speedily ; and the paralysis also disappears,
either with the apoplectic attack or very soon
afterwards. In these, sufficient time for the
absorption of extravasated blood has not elapsed :
are we therefore to infer that it has been effused,
and recovery taken place notwithstanding ? I am
more inclined to think that no effusion has oc-
curred in these cases ; but that either congestion
of vessels in a part of the brain, sufficient to in-
terrupt the functions depending on it, or retard-
ation of the circulation through it, owing to
ileficient vital energy of the part, occasioning a
temporary abolition of its function-, particularly
the power of voluntary motion, or both these
states, have merely existed. In many cases, one
or more coagula, in distinct parts of the brain, or
cavities or cysts in older attacks, are found, and
generally their number has a relation to the num-
ber of seizures. But it occasionally happens that
extravasation takes place in two parts of the en-
cephalon, either at the same time or during the
same attack ; and thus the number of legions will
be greater than of the seizures- and in other
cases, particularly in the next form of the disease,
the second or even third extravasation takes
place in tiie same situation as the first ; forming
either an external layer with appearances distinct
from the centre coagulum, or a separate portion
with the characters of more recently efl^used
blood.

41. 6th. The substance nf the brain surrounding
the extravasated blood otten presents important
le-^ions ; chiefly consisting of change of consist-
ence and colour. This portion of brain is some-
times very much softened, and is either colour-
less, or of a yellowish or greenish yellow tint ;
or presents the u^ual appearances proceeding
from capillary injection or sanguineous infil-
tration. This change of structure seems to
commence from five to ten days after the san-
guineous extravasation, and to arise from inflam-
matory action having taken place in the part
surrounding the eflfused blood. We have already
seem that the formation of a membrane around
the coagulum, upon the lacerated surface of
brain, is necessary to the reparation of the apo-
plect'c effusion ; and that the membrane seems
formed from lymph thrown out upon this surface,
if the local action necessary to the production of

G 3

86 APOPLEXY — rnECEDKD

tins membrane and to the process of reparation
pass the healthy standard, inflammation is the
result; occasioning either a considerable effusion
of serum or a second haemorrhage, as already
stated, or softening of the surrounding cerebral
structure. This consecutive inflammatory action
may also give rise to exhalation of serum into the
ventricles or into the sub-arachnoid cellular tissue,
according to the situation of the primary extra-
vasation ; or even, though much more rarely, to
a secretion of puriform matter. It sometimes
happens, when the consecutive inflammatory
action has been slight and of long duration, in-
duralion of the surrounding cerebral texture takes
place, the intellectual faculties having been ge-
nerally much iinpaired in these cases; which,
liowever, are much less frequently met with than
those of consecutive softening.

42. There is no part of the brain exempt from
the lesions described under this form of apoplexy,
although they are most frequently observed in the
corpora striata, the thalami, and the substance
of the hemisphere-;. They likewise occur, though
less frequently, in the cerebellum, annular pro-
tuberance, &c. In all these situations the pa-
ralytic symptoms affect the side opposite to
that in which the lesions of the encephalon are
seated. Some exceptions, however, to this have
been recorded ; but either the various circum-
stances connected with the cases, in which they
liave been said to have occurred, have been in-
suflficiently investigated, or they admit of explan-
ation without invalidating the accuracy of the
general inference. 0( forti^-one cases in which
extravasation of blood was found in the brain on
dissection, by M. Rochoi'x, eighteen were in the
left side, seventeen in the right, and six in both
sides. Of these forty-one, there were twenty-four
in the corpora striata ; two in the thalami ; one
in both these situations; and one under the cor-
])us striatum : making altogether twenty-eight
cases in the corpora striata and vicinity. Of the
remaining cases, five were in the middle of the
hemispheres ; two in the posterior part of the
ventricles; two in the anterior and inteiior part
of the hemisphere; three in the posterior and in-
terior part ; and one in the middle lobe. (See art.
Bhain — Alterations in Substance — llcemorrhage.)

43. V. Apoplexy, commencing with Para-
lysis, WHICH, AFTER AN INDEFINITE PEHIOD, TEU-
WINAIES IN A COMPLETE ApOPLECTlC AtTACK.

A. Description. — The commencement of this form
of disease is various. The patient often complains
of pain, vertigo, and other symptoms referrible
to the head ; with want of recollection, loss of
memory of words, cramps, pains, or with numb-
ness, pricking, tingling, or weakness of a limb or
limbs on one side, generally beginning in the hand.
'I'lic sjieech is sometimes at first affected, or the
inoulli and eyes distorted ; the limbs being sub-
sequently jjaralysed. Jn many instances the
local syuijjtonis continue in a state short of para-
lysis for a considerable time previously to this state
being fully developed. In this case, inflamma-
tory action sealed in a part of the brain has often
existed, although the synq)ton)s have been so
obscure as not to have Lecn detected. Alter a
j)eriod of indefinite duration, the [)aialytic symp-
toms are followed by a comjjlete apoplectic seiz-
ure, occasionally preceded or accomj)anied with
spasms or convul.-ioiis of the unparalysed limbs;

BY Paiialysis.

or the attack supervenes on repeated aggravations,
or after a gradual increase and extension of these
symptoms. In some cases the patient sinks gra-
dually into a comatose stJite ; from which he
may at first be partially roused, and give rational
answers, the state of complete loss of sensation
and voluntary motion having gradually advanced.
From this state the patient seldom or never re-
covers. In certain cases the apoplectic seizure is
more sudden, but is not so profound, or it passes
away more quickly than in others. The apoplec-
tic attack having occurred, the patient is either
carried off by it, or he recovers after a time the
state in which he was previous to it, or he is left
by it in a still worse condition : either gradually
sinking, and at last dying in a state of exhaustion
or coma; or experiencing a recurrence of the
apoplexy, which terminates his existence. This
forms a variety of M. Cruveilhif.u's second spe-
cies of apoplexy. It is often a result of previous
acute disease, proceeding from a feeble capillary
exudation.

44. As soon as the patient suffers the first com-
plete apoplectic seizure, the progress and termin-
ation of the disease very closely agree with the
description given of the immediately preceding
form ; but tlie appearances observed on dissection
are frequently somewhat dirt'erent, and are alto-
gether much more diversified.

45. B. Appearances on Dissection. — ]Many of
the changes observed after this form of the dis-
ease are entirely similar to those described under
the foregoing head (§ 41.); whilst others fall
under a different article, where they are fully de-
scribed (see article Paralysis). There are
some lesions, however, which seem more strictly
related to the present variety of complicated
apoplexy, than either to the other varieties of the
disease on the one hand, or to simple paralysis on
the other. The most frequent morbid appear-
ance which I have met with in this form of
apoplexy, or seen described in the woiks of
Bayle, Recamier, Cayol, Rostan, Riobe,
Serres, Cruveilhier, Lai.lemand, BouiL-
LAUD, ADERCROMniE, and Genorin', who have
paid great attention to its pathology, consists of
softening, with a reddish tint, of a portion of the
brain. In cases which I have examined, the
softening was accompanied with infiltrution of
blood into the cerebral structure. In some cases
the softening and infiltration increased from the
circumference to the centre, whilst in others the
change from the healthy state to this took place
abruptly ; the diseased part presenting the ap-
pearance of a cavity containing a softened and
reddish pultaceous mass, which could be removed
without evincing any connection with the sur-
rounding brain. In some instances the softened
part is of a ycllowi-;h green tint, and the sur-
rounding portion of brain more vascular than
natural. The parts most commonly affected
with this lesion are nearly those which are most
frequently the seat of hajmorrhage ; the chief
difference being, that the grey substance of the
hemispheres is oftener the seat of the former than
of the latter.

4G. As to the origin of this particular form of
softening of the cerebral structure, I must refer
the reader to what I have adduced respecting it
in the article on the Alterations in the Substance
of the BiiAiN. As however, the origin of this

APOPLEXY —

species of softening has a very intimate relation
to the treatment of this chtss of cases, it becomes
Q matter of importance to trace its origin. 'J'iie
Freiicli patiiologists, with very few exceptions,
ascribe it to inflammation of the cerebral struc-
ture. 'J'liere can be no doubt that it sometimes
proceeds from this source. But as soon as tlie
inflammatory action lias given rise to this change,
the vessels no longer enjoy their requisite tone
— their vitality has evidently become exhausted,
and they allow the red particles of blood to
escape from them, and to be infiltrated into the
cerebral structure ; as we observe sanguineous
infiltrations into the parenchymatous structure^,
to occur in scurvy or in purpura liffiinorrhagica.
When the softening arises from this cause, the
paralytic and apoplectic seizure more frequently
is met with in patienis not far beyond the middle
age, and whose consliiutions are not much injured ;
and the attack is more commonly preceded by
acute or febrile symptoms, than when it proceeds
fiom the cause about to be adduced.

47. Dr. Abercrombie considers that it also
depends upon disease of tiie arteries, chiefly
ossification, thickening, contraction, or separation
of their inner coat, occasioning a failure of the
circulation, and ganurene of the part of the brain
which is supplied by the diseased vessels, as is
observed to take place in the toes of aged per-
sons. This may possibly occur ; but still we
have no satisfactory proof that it does so. This far
I may concede, — that the disease proceeds from
a change of a state of the capillaries of the part,
and of the cerebral structure in which they
ramify, otherwise we should not observe infiltra-
tion of blood, and great softening of structure ;
but which of the two is the primary lesion is very
ilifiicult to determine. Most probably, both are
dependent upon the state of that part of the gan-
glial system which supplies the encephalon, par-
ticularly its blood-vessels.

48. The other appearances with which this
lesion is associated in this form of the disease,
consist of the morbid states of the arteries of the
brain already noticed ; of aneurisms (Blane re-
cords a case which arose from rupture of aneu-
rism of the internal carotid^ ; congestion of the
vessels, veins, and sinuses ; more rarely extrava-
sations of blood in some one of the situations and
states already noticed, or the remains or marks
of antecedent haemorrhage ; empty cysts from
which coagula have been absorbed ; portions of
the brain in various degrees of induration ; puru-
lent collections in different forms; encysted and
other tumours of various descriptions; a large
proportion of the lesions described in the articles on
the Alterations in tlie substance o( ihe Brain ; thick-
ening, injection, or ossifications of tiie membranes;
and, occasionally, accumulations of serum in the
sub-arachnoid cellular tissue, and in the ven-
tricles. The furtiier exposition of this form of
the disease, especially in relation to the paralytic
symptoms, falls more appropriately under the head
of Paralysis, where they are fully discussed.*

* I msysulijoin the following classification of apoplexies,
accoriiii.g to a different principle to that adopted above.
It is baseil upon the chief pathological states from wliich
the attack proceeds, and approaclies nearer the arrange-
ments adopted by tlie German pathologists, particularly
Harless (/)(•)■ Specieltcn Xosulogie, Sfc. p. 131. Cobl.
1K24.), than that usu;illy followed by our own writers.
In some respects it may be preferable to that which has

Its Symptoms, Stc. 87

49. vi. Of the Piir.NOMENA of the Disease
WHICH have no I'ARTICULAR detendence upox
ITS SEPARATE PoRMS. — A. 'Phcrc aic certain
si/mjitoms cccasionally met with in all the slates
of apoplexy, to which I shall briefly refer. The
pulse is frequently full, strong and slow, or of
natural frequency, particularly in \.\\e first, thirds
and occasionally in the fourth varieties into
which I have divided the disease. In other
cases, especially in those which are extreme, and
particularly in the second »x\d fourth varieties, it
is often small, feeble, and unecjual or irregular.
The respiration, both as to strength and fi-e-
quency, geneia'ly presents similar characters
with the pulse : when the latter is slow and
strong, the former is deep, slow, and stertorous;
and when the pulse is weak and frequent, respir-
ation is quick, less laboured, and much less
sonorous. Deep sighs are occasionally observed
in all the forms of the disease. 'I he state of the
pupils is very various : sometimes they contract
and dilate independently of the influence of
light ; but in thefrst and tltird varieties they are
geneially dilated ; and they are often contracted,
or one is contracted and the other dilated, in the
second, third, and fourth varieties. Contraction
of the pupils has been remarked as a not infre-
quent attendant on the worst forms of apoplexy,
and particularly on those characterised by a ten-
dency to spastic action, by Aret.'eus, and re-
cently by Chevne, Cooke, and various other
pathologists. The features are usually large,
bloated, relaxed, and flushed ; but they are some-
times pale, and even collapsed, particularly in
the ingravescent and consecutive forms of the
malady. The facal and urinary evacuations
sometimes take place involuntarily, in all the
varieties of the disease.

.50. The muscles most frequently paralysed,
either antecedently, consecutively, or at liie
same time, with apoplexy, are those of the su-
perior and inferior extremities, particularly those
of the superior ; next thos ; of the tongue and face ;
and lastly, the muscles of respiration. In gene-
ral, the power of feeling is more or less deficient,
as well as of voluntary motion of the afliiicted

been now fully described, particularly as I have here
placed those forms of the disease which depend upon the
nervous or vital energy of the enceph.ilon in a more pro-
minent point of view, than they can hold in a cl.issifica-
tion framed according to the syrnptoms and mode of
seizure, in connection with the iiiteinal lesions.

I. SanguiiSeohs Apoplexy, — with extravasation of
blood in some part within the cranium.

II. Congestive and Seroi^s Apoplexy,— from ob-
structed return of blood from the head, and frequently
from the metastasis of gout, rheumatism, or eruptive
diseases.

III. Asthenic Apoplexy, — Nervous Apoplexy of
Authors, — from depression, exhaustion, or abolition, of
the vital influence bestowed on the encephalic organs,
and occasionally giving rise to extravasation of blood, or
of serum, and to congestion of the cerebral vessels.

A. From intoxication. B. From narcotic poisons, and
mephilic gases. C. Yrom a stroke of lightning. /J. From
the influeiice of great or continued cii/d. E. From ex-
haustion of the mental and bodily powers, and from con-
vulsive affections. F. From violent mental emotions.

IV. Apoplexy from 1're-existing Chronic Lesions
within the Cranium, — from tumours, inflammations,
abscesses, &'C. See.

V. TRACMAric Apoplexy', — from external injuries.
Concussion, or shock of the vital powers of the organ ; —
pressure from depression of bone or extravasation of
blood.

VI. CoMPLicATEn Apoplexy, — supervening at the
invasion, or advanced stages of febrile diseases of an ady-
namic or asthenic type.

G 4

APOPLEXY — RELATIONS of Symptoms, &c.

88

limb or side ; Lut sometimes voluntary motion is
lost, whilst sensation remains. There are also
very rare cases i^ccided, where the feeling only
was lost, and sensation has been observed pa-
ralysed on one side, and motion on the other.
These phenomena will be more particularly con-
sidered and explained in the article on Paralysis.
As the patient convalesces, sensation returns in
the paralysed limb before the power of voluntary
motion ; and generally the lower extremity re-
covers its functions before the upper, unless dis-
ease of the spinal chord, producing more or less
of paraplegia, coexist with, or is consequent upon,
the apoplectic disease, — an occurrence which is
sometimes met with.

51. B. The duration (if the apoplectic state is
extremely various. The attack may terminate
fatally in a few minutes, paiticularly \\\& first
variety J or it may pass away in as short a lime,
and the patient recover, especially in this and the
third form of the disease. Dr. Cooke thinks
that death seldom or never occurs in less time
than one or two hours, in genuine apoplexy ; and
I believe, as respects those apoplexies which
consist of cerebral haemorrhage, this is generally
the case ; but when large haemorrhage takes
place into the ventricles, and about the base of
the brain, death is very quickly produced. An
attack often, however, continues for a much
longer time, generally from several hours to as
many days. If no remission of the symptoms,
be observed after twenty-four hours, the disease
generally terminates unfavourably. 'i'he pro-
gressive or ingravescent variety sometimes con-
tinues for several days; the apoplectic stale be-
coming more and more profound ; and at last
usually ending fatally.

52. C. The termination of apoplexy has already
been noticed, when describing the different forms
of the disease. I may, however, remark gene-
rally that the attack may end as now slated, or it
may go off completely, leaving no further ill
effects than a tendency to recur upon the action
of the remote causes. This favourable termin-
ation, however, is entirely owing to the nature of
the causes ; a larger proportion of cases either
terminates in, or is accompanied with, paralysis.
When the speech and mental faculties are af-
fected in a marked manner from a first attack,
they return but slowly ; the memory, the strength
of mind, and force of character, are more or less
impaired ; the patient becomes we;ik, puerile,
ea-ily excited, and timid ; and a disposition to a
subseciueiit attack is produced, which either car-
ries him off, or weakens siill further his mental
and motive powers, until perlect imliecility of
mind and body is occasioned. Sometimes, after
repeated attacks, with marked injury of the men-
tal fiiculties, a considerable diminution of the
volume of the cerebral convolutions is observed
upon dissection, — they no longer fill the cranial
vault; but the space is occupied by a greater or
less quantity of serum infiltrated in the sub-
arachnoid cellular tis-sue, and not only on the
exterior surfjce of the convolutions, hut also
between their anfractuc^ities. Jn some: cases
tliis change is more remarkably developed in
certain convolutions llinn in others, or in those of
one lobe or hemi-iphere than in the rest.

53. 1). The changes which the seat of haemor-
rhage undergoes have already been described at

length {§§ 37 — 40.). The most remote change?
which have been observed in the ruptured part
of the brain, from which the coagulum has been
absorbed, are, in some cases, a complete cyst,
either empty or enclosing a little reddish serum,
or a loose cellular substance ; in a few instances,
a firm nucleus, seemingly consisting of the
fibrinous remains of the coagulum, and in others,
according to Cruveilhier, merely a linear in-
duration from the cicatrisation of the lacerated
cerebral structure. In whatever form ihe remains
of the coagulum and laceration may present
themselves, at periods remote from the seizure
which these lesions occasioned, no direct union
of the divided fibres of the brain is observed to
have taken place. ICven when an apparent union
of the divided cerebral structure is noticed, it
will be found to have been brought about in-
directly, and through the mediuni of the cellular
or fibrinous substance left after the absorption of
the coagulum ; the cavity having giadually closed,
owing to the atrophy of the ruptured fibres, and
the hypertrophy of those surrounding them from
having had to perform additional offices.

54. JE. Of the supposed relations subsisting
between the seat of hcEinorrhage, or lesion of the
brain, and the symptoms accompanying and fol-
lowing the attack. — M. Cruveilhier states that
those parts of the brain most subject to haemor-
rhage, or laceration from the external injuries
occasioning counter-stroke of the cranium, most
commonly present extravasation of blood in apo-
plexy. This seems to some extent correct, as
far as relates to corresponding frequency ; but
there are parts of the encephalon, occasionally
the seat of apoplectic lijemorrhage, which aie
seldom or never so affecled from this species of
external injury.

55. a. It has been supposed by RIM. Serres,
FoviLLE, and Pinel-Grandciiamp, that lesions
of ihe coi'pora striata are followed by paralysis of
the lower extremities, and those of the thalami
by palsy of the upper. 'J'his inference is, how-
ever, neither supported by anatomy, nor borne
out by facts : a mere coincidence of inttrnal
lesion with external signs cannot always warrant
the inference that liie disordered function has its
origin in ih • part diseased, especially when we
are ignorant of the ollices of such part. 'J'lie
upper and lower extremities are most frequently
paralysed from apoplexy ; and the corpora striata
and thalami are the parts in which the apoplectic
ha;n)orrhage most frequently occurs. Hence the
coincidence of these lesions of structure and
functions must be frequent. Put these parts of
the brain are sometimes diseased without the cor-
respondent affection of the limbs contended for;
whilst, on the other hand, the extremities are often
paralysed without any lesion of those parts.

56. b. 'i'he disciples of Gall consider the
anterior lobes of the brain as presiding over the
organ of speech, and as the seal of the memory of
«ords, &c., and that therefore lesions of this pi'rt
affect this organ, as well as this particular slate of
recollection. iM. JSouiliaud has suj)poited this
opinion by the liistory of several cases; and M.
C'uiivm.iiii I! has controverted it, by adducing
the details of others ( A'.iia'. Vuhlioth. Med. 1826).
Several other Picncli pathologists have also
espoused opposite sides, and adduced cases sup-
[01 ting their views. The inference deducible

APOPLEXY — Diagnosis.

89

from the facts already accumul;itid is, tliat a co-
incidence of lesion of these functions, and of the>e
parts of the brain, is someiiines ol)served ; but the
rehition between them is neither so uniform nor
so precise as to warrant the opinion that there
exi^t-; any necessary dependence of these par-
ticular functions upon the parts of the brain to
which they have been ascribed. Without re-
fe ence, however, to the part of the brain on
which the memory of words depends, it has been
remarked by M. Itard, that aged persons struck
by apoplexy frequently lose the recollection of
tiiem in the following order : — First, want of re-
collection of proper names, next of substantives,
afterwards of verbs and adjectives; which last are
often the only words which can be recollected.

57. c. It was contended by ]\IM. Delaye,
F0V11.LE, and Pinel-Gkandchamp (Noiiv.
Journ. de Med. 1821^, that disturbance of in-
telligence depends upon lesion of the gvei/ sub-
stance of the biain, whilst disorder of loco-
motion proceeds from change of the white or
meduliirij structure. But this doctrine seems no
better founded than the preceding, being open
to the same objections which have been urged
against them. Lesion of the cineritious substance
is, perhaps, more frequently accompanied with
spasms and convulsions at (he commencement of
the attack, than when it is seated in the medullary
stiucture.

58. d. The cerebellum. — MoncAGxi has re-
corded that Valsalva once stated to him, that a
case of apoplexy to which he was called was
seated in the cerebellum. Dissection verified the
diagnosis ; but he does not mention the symptoms
on which Valsalva founded his judgment. M.
Sekres, adopting the doctrine of Gall, says, that
erections or seminal emissions, in men, and dis-
charges, sometimes of a sanguineous appearance,
from the female organs, are the distinguishing
signs of apoplexy of the cerebellum. M. Cru-
VEii.HiER states that he has seen apoplexy of this
part, but that these symptoms were not present.
Some cases have certainly occurred to counte-
nance the opinion of Serues, and others to over-
tlirow it. It seems more probable that the effusion
in the cerebellum affects the medulla oblongata,
and occasions a partial asphyxia and stasis of the
blood, from the influence of this part upon the
respiratory class of nerves, and thus induces a
slate favourable to erection. Cuuveilhier states
that he failed to produce this symptom by iiri-
taling the cerebellum of dogs. 1 may, moreover,
add, that the symptoms contended for by Serres,
and the followers of Gall, as distinctive of cere-
bellic apoplexy, have occurred in cases wherein
the cerebellum has been found sound on dis-
section.

59. Apoplexy of the cerebellum occasions,
cateris paribus, a more serious lesion of the func-
tions of circulation and respiration, and is more
dangerous than apoplexy of the cerebrum. The
symptoms are evinced on the side opposite to
the seat of lesion, in this as in other apoplexies.
The opinions that the cerebellum is the regulator
of all the voluntary movements, and the source of
all sensibility, according to certain Continental
physiologists, particularly J\IiM. Flouuens, Fo-
DERA, FoviLLE, and Pinel-Grandchamp, have
not been confirmed by the history of apoplexy
seated in it. The hypothesis of Rolando, pro-

fessor at Turin, that the cerebellum performs a
function analogous to the Voltaic pile, in gener-
ating a fluid or principle requisite to the func-
tions of voluntary muscular action ; and that it
transmits this fluid, under the influence of the
brain, and through the channel of the spinal chord
and nerves to the must-Ies ; seems much more
accordant with comparative physiology, and the
pathology of the nervous systein.

60. e. The annular protuberance — the point of
junction of the spinal chord, brain, and cere-
bellum— the centre of the cerebro-spinal system,
is sometimes the seat of apoplexy, notwithstanding
its density. When the extravasation of blood in
this pari is to any considerable extent, immediate
and complete paralysis of the trunk, and of both
the superior and inferior extremities, is produced,
with the most profound lesion of respiration, quickly
followed by death. When the effusion is to a
small extent, and in one side of the protuberance,
the paralysis which results seems on the opposite
side of the body, as may, indeed, be inferred from
anatomy. The extravasation must be to a small
extent, to admit of recovery. Sometimes the
effused blood is observed to have been disposed
in layers between the lamina of white matter
entering into the structure of the protuberance.
The reparation of the apoplectic lesion of this part
takes place in a similar manner to that which T
have already described (§ 37 — 40.). It would
seem that the smallest division of the fibres of this
part is followed by permanent affection of feeling
and motion.

61. Connected with this subject, IM. Flourens
concludes, from his experiments and observations,
that the cerebral lobes, the cerebellum, and the
tubercula quadrigemina, may lose a considerable
but limited portion of their substance, without
losing the exercise of their functions ; and they
may re-acquire them after being totally deprived
of them: that the spinal marrow and the medulla
oblongata are the only parts which directly afl'ect
the same side of the body w ith that in which they
themselves are affected ; whiUt the tubercula
quadrigemina, the cerebral lobes, and the cere-
bellum, alone produce these effects upon the op-
posite sides to that in which they are disea-ed, —
the former acting in a direct course, the latter in a
cross direction. These inferences, however, want
confirmation in several particulars.

62. II. Diagnosis. — Apoplexy is, in general,
readily recognised : but it may occur in such a
way and under circumstances which will render
Its diagnosis a matter of difficulty. Thus we may
be called to a patient, of whom nothing is known,
with the following symptoms: — Coma, laborious
or stertorous bieathmg, relaxation or rigidity of
the limbs, complete loss of consciousness; he
may or may not have had convulsions, or a blow
upon the head ; there may be hemiplegia or
not. In this case, is the patient in a state of
dead drunkenness, asphyxied, poisoned by nar-
cotics, or affected with the profound coma con-
sequent upon epileptic or hysteric convulsions?
Is it concussion of the brain ; the advanced
effects of organic di--ease within the head — iis
of cysts, abscess, or of inflammation terminating
in effusion ; or fever, either at its commencement
or close, with apoplectic symptoms ? It is true
that these states differ but little fr.im apoplexy ;
the difierenca consisting chiefly in grade, unkss

90 APOPLEXY

haemorrhage has taken place when paralysis
generally manifests itself. But it should be
at the same time recollected, that there is some-
times hsmorrhaue without local palsy, and even
palsy without sanguineous extravasation. Tlie
iliignosis of such cases is very important; but
without information of the circumstances con-
nected with tlie history of the case, its diffi-
culty is extremely great. 1 once treated a case
of adynamic fever, originating in infection, and
commencing with sudden loss of sense and volun-
tary motion, as a case of apoplexy, and gave an
opinion accordingly. The history of the case,
and its subsequent course, sliowed the error.
When paralysis is present, the nature of tlie case
is then manifest, although the particular cause of
the palsy may be a matter o( doubt. We should,
therefore, incjuire after this symptom by observing
the attitude and motions of the patient, by pinch-
ing the extremities, tickling the soles of the feet,
&c. The existence, also, of stertorous, labo-
rious, or snoring respiration, will confirm the dia-
gnosis.

63. a. It should be kept in mind that, whilst the
comatose state consequent on epilepsij or hyderia
way closely resemble apoplexy, ihe convulsive
stages of these diseases may give rise to the true
apoplectic state. But, in the usual consecutive
coma of epilepsy there is no stertorous breathing,
and the limbs are not so relaxed as in apoplexy.
'J'iie coma, which supervenes to inflammation of
the membranes of the brain, is chiefly to be dis-
tinguished from apoplexy by the antecedent symp-
toms, and by j_the loss of sense and cerebral
function being greater than the loss of motion ;
independently of the association of paralysis, so
frequently characterising the apoplectic seizure.

64. b. The symptoms consequent upon injuries
of the head, whether simple concussion, or com-
pression from depressed bone, or extravasation of
blood, are in all respects identical with certain of
the varieties of apoplexy described above, and are
not to be distinguished from them, but in respect
of the exciting cause. A similar remark is ap-
plicable to cy^ts, tubercles, and other tumours
slowly developed in the encephalon, which some-
times produce no very marked external sign of
disease, until apoplexy, and still more frequently
hemiplegia, su<ldenly take place. In such cases
there is no actual difference in the proximate
cause of the abolition of function, hut only in the
compressing body whereby abolition of function
is occasioned.

65. f. In cases of loss of sense and voluntary
motion from the action of narcotic pnisons, or
brealiiing detelerioiis gases, there is also little
actual diflx'ience from several of the apoplectic
states descril)ed above (§ 10.), excepting that tlie
functions of the lungs have, in the <'ase of breath-
ing deleterious gases, been primarily afTicled ;
for the chief lesion is to be referred to the state
of 7ieri}oiis eiierf^ii and riisciilar action in the brain,
ill circulation being retarded, and its vessels con-
ge-ted with dark blood. Indeed, in many such
cases, the (rue apoplectic condition, either with
or without hemiplegia, is produced ; although, in
the majority, the state of profound but simple
coma is the result.

66. (/. In os/f/ii/.tm the lesion of function com-
mences in the lun^js, the j)ulse being citiier dimi-
nished in strength or entirely abolished ; whilst

— Prognosis,

in apoplexy the lesion is in the head, and the
pulse is generally fuller and stronger than natu-
ral ; but the exceptions to this state of pulse are
numerous. In syncope, the marked diminution,
or almost entire absence, of the pulse, paleness of
the countenance, and the very gentle or scarcely
apparent respiration, are sutficient to distinguish
it from apoplexy, even in its weakest forms ; ex-
cepting at the commencement of, or early in, the
apoplectic attack, when the states of vital energy
of tlie brain, in both afTeclions, are not materially
different.

67. e. Complete intoxication may readily be
mistaken for apoplexy ; and, in some case-, may
terminate in this disease. Tiiis state of intoxi-
cation is evidently attended with congestion of
the vessels of the encephalon. The smell of the
breath, and the appearance and smell of the mat-
ters thrown up by the retching that frequently
accompanies intoxication, will readily distinguish
this state. Tiie greater frequency, also, of the
pulse, and absence generally of stertorous breath-
ing, in drunkenness, will also assist the diagnosis.
But these symptoms are occasionally observed in
apoplexy ; and, on the other hand, the pulse may
be slow or natural, and the breathing stertorous
in the former: but this is very rare, particularly
slowness of the pulse.

68. f. In concussion o( the brain, the state of its
circulation, and the influence of that portion of
the ganglial system which supplies it, are as re-
markably depressed as in the weakest form of
apoplexy, — in concussion from the shock re-
ceived, in apoplexy from internal causes ; in many
cases no difference existing. In some instances,
however, even of this form of apoplexy, the respira-
tion is much more laborious, the countenance
somewhat more tumid or distorted, and the pulse
fuller and more developed than in concussion. In
tlie stronger states of apoplexy there can be no
risk of mistake, the characteristic symptoms of each
being very different.

69. III. Prognosis. — An attack of apoplexy
is always dangerous: — 1st, It may be fatal im-
mediately ; 2d, It may also be fatal within two
or three days, and previous to reaction having
commenced ; and, 3d, It may occasion death
during reaction: — a, by a recurrence of the
attack ; h. by inflammatory softening and inlil-
tration of the cerebral tissue surrounding the
extravasated blood ; c. by the exhalation of se-
rum ; d. by inflammatory action of the membranes
of the brain and subjacent cellular tisssue, and of
the membrane lining the ventricles. Even in nmre
favourable circumstances, it leaves behind it debi-
lity of feeling, motion, and of the mental faculties;
and a first attack is generally followed by a second
or even a third.

70. A. The iinfarourahle symptoms are fre-
quency or intermittence of the pulse ; continu-
ance of the symptoms for twenty-four hours, or
for little more than iialf of this time in the strong
apoplexy, after a judicious treatment; very pro-
found coma, and obtuscness of the senses ; invo-
luntary discharges of the urine and fajces ; con-
traction of the pupils, or contraction of one or
both pupils accompanied with spastic actions of
muscles ; very laliorious stertorous breathing, par-
ticulaily if attended with foam about the mouth,
and a weak pulse; cold and profuse sweats; the
occurrence of convulsions the association of

APOPLEXY — Causes.

91

heniipleyic symptoms wil\i the apoplectic, and
complete loss of vision. Frequent yawning or
continued somnolency indicate effusion, or in-
creasing effusion. Quarin observes very justly,
that wlien tiie patient frequently applies the hand
to a determinate part of the head, or when deli-
rium supervenes, or if partial perspirations occur
early in tiie attack without benefit, the result is
generally fatal. Complete hemiplegia, without
coma, but with integrity of the mental faculties,
and perfect motion and sensation of the non-
affected side, IS less dangerous than a more par-
tial paralysis, with stupor or coma. When one
pupil is contracted and the other dilated, the
existence of unequal pressure may be inferred.
It has generally been slated that complete loss of
feeling and motion, accompanied with coma or
stupor, is extremely dangerous. Cruvkilhier
remarks that he has seen recovery in such a case.
I have seen it in three cases, one of which was
seen by Dr. Hooper.

71. Delirium is an unfavourable complication ;
and indicates either the escape of blood from th.e
seat of extravasation upon the membranes which
it irritates, or the occurrence of inflammation of
tiie ceiebral structure or meninges. Acceleration
of the respiration, and vomiting supervening spon-
taneously, unless from matters occasioning the
attack, are very dangerous symptoms. A similar
remark is applicable to loquacity, or complete loss of
speech, particularly when attended with a frequent
pulse.

72. When the disease occurs in the course of
insanity, or in epileptics, or after previous attacks,
or alter palsy, an unfavourable result may be ge-
nerally anticipated ; a nearly similar conclusion
inay be drawn if it seize aged persons, and broken
constitutions, upon the disappearance of gcut from
the extremities. In the majority of cases of apo-
plexy proceeding from efficient causes originating
in the brain, a perfect recovery is not to be ex-
pected. On this, INI. Portal has insisted strongly ;
and although it is just as a general rule, many
exceptions will present themselves. If the pulse
sink, or intermit, or become remarkably quick ;
and coldness of the extremities, or cold clammy
sweats come on ; or the power of respiration be
greatly drminished ; inevitable or fast approaching
dissolution may be predicted.

73. B. The favourable signs of the disease are,
a moderate attack ; a decline of the symptoms
after treatment, and particularly if a warm, ge-
neral, and gentle perspiration take place; the
occurrence ol discharges of blood from the nose,
liaimorrhoidal vessels, or uterus ; and a free stale
of the bowels, with consciousness of all the eva-
cuations. The accession of the menses, of the
piles, or of ptyalism, have been justly viewed
as the most favourable signs by Hippocrates,
SciiADT, DoL-Eus, and many subsequent writers.
GoAVARTS considers haemorrhage from any part,
j)arlicularly epistaxis, ptyalism, a copious and
general perspiration, with fi'ee alvine and urinary
discharges, the most favourable signs. The acces-
sion of fever has been considered favourable by
Hippocrates and Portal ; but many experienced
authors do not agree with them. 1 believe that,
although some may recover from this state, it
indicates the accession of inflammatory action of
the portion of brain or membranes adjoining the
seat of haimorrhage ; which will be dangerous in

respect of the extent to which it may proceed,
and the effects it may produce on the part, j)arti.
cularly in causing a renewal of the haemorrhage.
In all cases, the practitioner, even under favour-
able appearances, should give a cautious pro-
gnosis until the tenth day ; the eighth being that on
which an unfavourable change is apt to occur, and
the extravasation to be renewed.

74. IV. Causes. — The causes of apoplexy,
both predisposing and exciting, have generally a
direct or indirect influence upon the state of the
vital energy and circulation of the brain. The
manner, however, in which causes may individ-
ually iijfluence either the vital condition or circu-
lation varies extremely ; and the action of several
of them is even peculiar. Those causes, which
in some cases are merely predisposing, may in
others be exciting ; and changes previously in-
duced in the organisation of the brain, or in the
state of its vessels, even from causes which lead to
other maladies, may, either directly or indirectly,
occasion apoplexy.

75. i. The predisposing causes nf apoplpxy. —
This disease occurs most frequently in persons of
the male sex, owing to their habits, and greater
exposure to the exciting causes ; and in the far
advanced stages of life. The majority of authors
state the period intervening between forty and
seventy as that in which it is most common ; but
it is not infrequent at both earlier and later
epochs, particularly the latter. IM. Rochoux
found, ill 63 cases attended with extravasation of
blood, that 2 were between 20 and 30 years of
age, 8 from 30 to 40, 7 from 40 to 50, 10 from
50 to 60, 23 from 60 to 70, 12 from 70 to 80, and
I from 80 to 90 years. I have met with the
true haimorrhagic apoplexy at the early age of
eighteen. The hereditary tendency of the disease,
as shown in several instances by Forestus, Wep-
FEii, Portal, Blane, Frank, and others, cannot
be doubted.

76. The form and habit of.body may also pre-
dispose to the attack ; but, 1 believe, much less
frequently than is usually supposed. A large head,
short neck, full chest, sanguine and plethoric
constitution, and corpulency, are generally con-
sidered signs of disposition to it ; but the state of
the heart's action, and of the circulation throrigli
its cavities, with a plethoric slate of the vascular
system, has a more marked influence, as will ap-
pear in the sequel. In the 63 cases which have
been minutely analysed by JVl. Rociioux, only 10
were fat and plethoric persons, 23 were thin, and
30 were of the ordinary habit of body. He there-
fore maintains that there is no external appearance
of habit and temperament whereby the disposition
to apoplexy is indicated.

77. Long and intense thought; disappoint,
ments; depressed and anxious states of mind;
the habitual indulgence of the temper, passions,
and appetites ; the irritable and sanguine tem-
peraments; sedentary and luxurious living; too
great sexual indulgence, particularly when ac-
companied with full living; habits of intoxication,
or the too free or constant use of wine and malt
liquors; laborious employments, especially when
they require the stooping posture ; the suppression
of accustomed ha:morrhages, discharges, or ha-
bitual diseases, particularly those which are
accompanied with evacuations; and the neglect
of vascular depletion after their suppression ; th

92 APOPLEXY

influence of otiier disea'^e*, particularly those of
the heart, liver, lungs, kidneys, and di2;estive or-
gans; a ofoiitj' diathesis ; extremesof temperature,
particularly when conjoined wiih moisture; sudden
vicissitudes of temperature; frequent indulgence
in sleep after a full meal ; the use of neckcloths
worn too closely around tlie neck ; sleeping with
too low a pillow, particularly after a meal ; and
lying too long in bed ; are among the most com-
mon predi'iposing causes.

78. Albeuti and Seiz have insisted on the
greater frequency of this disease amongst the
sludintts than in other classes. Frank says that
the greater proportion of his apoplectic patients
had been previously subject to hjemorrhoids. The
use of tobacco, particularly in the form of snufF,
has also been considered to favour the occurrence
of apoplexy. As to the influence of weather and
seasons, it may be stated, that Morgagni and
Lancisi observed this disease most frequently in
hot weather suddenly following cold and rainy
seasons. Kaiser says that he met with the greatest
number of cases in the months of October and
November; and Hippocrates, Galen, Forestus,
Kellie, and others, have noticed the influence of
coW in producing it. I believe that very cold
weather, or cold conjoined with moisture, favours
its occurrence in very old subjects ; and that very
hot and moist seasons occasion it in robust and
plethoric persons. The influence of hot weather
in its production has been insisted on by IMor-
GAGNi and Cheyne. The Franks found apo-
plexy most prevalent at Petersburgh ami \Viina
during the height of summer (J. Frank, Prax.
Med. Univ. Friecep. t. ii. p. 308.)-

79. Apoplexy seems to be as frequent in the
poi-ireU as in the richest classes ; but in the former
it is more commonly attended with paralysis, and
oftener assumes an asthenic or weak character,
the attack chiefly proceeding from frequent ex-
posures to the vicissitudes of season and temper-
ature, from severe and long-protracted exertion,
and a less nutritious diet. In the latter it more
generally assumes the strong oractive form, arising
mo<t frequently from ease, luxury, and various
indulgences.

80. It will be observed that nearly all these
causes act by habitually favouring determin ition
of blood to the head, or by impeding its return,
and by dimini>hing the vital energy of the brain
at the same time that they favour a plethoric state
of its capillary vessels. These derangements of
vital manifestation and of circulation, when fre-
quently pro'luced, will occasion furtlier ciianges,
and sometimes will, upon the occurrence even of
the slightest exciting ciiuses, terminate in those
lesions which constitute the disease itself.

81. ii. The exciting causes frequently art in a
similar manner to the foregoing; but generally in
a more sudden manner and intense degree. 'I'hese
are, immoderate perturbations of mind, as con-
sternation, terror, fear, despondency, anger, dis-
appointments, anxiety, distress of mind from losses,
sorrow, violent chagrin, gnat joy, imnio lerate fits
of laughter, iind all painful, (lepressing, or excit-
ing mental emotions and exertions. Numerous
illustrations of the inmiediate influence of the
above passions in producing the disease are to be
found in ilie writings of AnETiT.us, Forestus,
Zui.iAM, Poutat,, J5oiiciii;r, Ciieyne, Cooke,
Aur.nciio.MLiE, ^c.

, — Causes.

82. Intemperance in eating and drinking is
amongst the most common exciting causes of the
disease ; and numerous instances of its immediate
ill effects are adduced by the above writers, and
by BoNET, IMoRGAGM, ^Iead, Fotiiergu.l, and
others. Oppletion and distension of the stomach
prevent the descent of the diaphragm, impede
the dilatation of the cavities of the heart, obstruct
the circulation through the lungs and the return
of blood from the head, whilst the vital energy is
abstracted from the brain, and determined to the
digestive organs, in order to dispose of the load
by which they are oppressed. Owing to this
procession of phenomena the vessels of the ence-
phalon are engorged at a time when their vital
energies are diminished ; while the rapid influx of
fluid matters into the circulation as the process
of digestion advances, tends to heii;hten the vascu-
lar fulness and disposition to eflTusion. Besides,
habitual intemperance of this description gener-
ates a plethoric state of the system, with con-
gestions of internal viscera. Spirituous liquors
are seldom productive of apoplexy until after a
continued addiction to them, unless they are
taken in excessive quantities ; and perhaps the
habit of drinking much malt liquors or wine is
still more frequently a cause of the disease, than
indulging in spirits, which, when they occasion
apoplexy, act more upon the vital endowments
of the brain, than in causing extravasation of
blood ; the chief changes produced by them,
being serous efl"usion with injection of the vessels.
Sir A. Carlisle has adduced a case of apoplexy,
arising from drinking an immense quantity of gin.
Upon dissection, the odour of the spirits was detected
in the serum effused in the ventricles of the brain.

83. Connected with the use of spirituous or
fermented liquors, I may here allude to the in-
fluence of the class of narcotics, particularly
opium, stramonium, hyoscyamus, tobacco, &c.,
the excessive use of which sometimes occasions
all the symptoms of congestive apoplexy, and
even extravasation. Of all the narcotics, the
difl^erent species of monkshood most readily occa-
sion apoplexy, when taken by mistake. I was
consulted in the case of a young man who had
incautiously chewed some seeds of this plant; he
was shortly afterwards seized with a sense of
numbness of the face, soon followed by complete
apoplexy, as described under tiie third variety of
the disease, from which he recovered with great
diflnculty, and with palsy of one side, with which
he continued to be affected.

84. Nearly allied to the operation of narcotics
is that of the fumes of charcoal, and various
mephitic gases, which, whilst they diminish, or
altogether arrest the changes affected by respir-
ation on the blood, thus occasioning asphyxia,
and earns without stertorous breathing, some-
limes produce all the symptoms of complete apo-
plexy, owing to their effects upon the vital en-
dowment of, and circulation in, the brain. In
respect of the modns operandi of narcotics and
deleterious gases on the system, somewhat diflVr-
cnt opinions imve been entertained by Cullfn,
Goodwin, Curiiii',, Oiuu.a, Hrodie, and others
who have investigated the subject. There can,
however, be no doubt that they act chiefly upon
the ganglial system, particularly on that part
which actuates the brain, when they produce
apoplexy, destroying the influtuce of this system

APOPLEXY — Causes.

93

^

on tlie vessels of the enceplialon, and thereby
relardin;; the circulation in, and favouring con-
gestion of, its capillaries, and interrupting the
functions of the organ.

85. Violent straining in lifting heavy weights,
or muscular exertions; straining at slool ; the
venereal act, particularly under unfavourable
circumstances, or too frequently repeated ; the
metastasis of other diseases, especially of gout
and rheumatism ; whatever impedes the return
of blood from the head, as a de|)endent posture
of the head, or holding it long in an averted
position, or looking backwards without turning
the body, particularly when the neck is short;
sleeping upon too full a meal, especially with a
neckcloth or other ligatures around the neck ;
violent fits of coughing or sneezing ; pregnancy
and child-birth ; exertion of body, with an anxious
mind; stumbling; the use of the warm bath;
and the sudden exposure to heat or cold ; are
among the most frequent exciting causes of
apoplexy.

86. The effect of the sun's raifs in producing
what is commonly called coup de soleil, is well
known. iNIany of the seizures thus occasioned
amount to complete apoplexy, in some one of its
forms, particularly the first and third. But other
conditions of heat will also sometimes occasion
an attack, as heat combined with moisture, and
the exhalations from a number of persons crowded
together in ill-ventilated apartments. The in-
fluence of crouded rooms and assemblies in
causing apoplexy is well known, and in occasion-
ing headach, and sense of fulness in the vessels of
the encephalon, even in persons not predisposed
to an apoplectic attack.

87. Cold also, particularly when applied sud-
denly to the surface of the body and lungs, ex-
cites the disease in aged persons, whose vital
energies are already greatly impaired. The ves-
sels of the brain in this class ef subjects are
weak, fragile, and liable to rupture, or to permit
a portion of their serous contents to escape. Be-
sides, cold depresses still lower the vital powers
of the frame, and tends to retard the circulation,
whilst ii drives the blood from the surfaces into
the large viscera, and particularly into the ence-
phalon, which, from its unyieldirig case and ex-
emption from atmospheric pressure externally, is
more obnoxious to congestion, retarded or inter-
rupted circulation, and compression from vascular
fulness, than any other organ; occasioning
lethargy in the rubust or young, and apoplexy
in the old or predisposed. Cases illustrative of
apoplexy produced by long exposuie to great
cold, particularly when the disposition to sleep
which it induces is yielded to ; by the incautious
use of the cold bath, and of ice applied to
the head ; and by the practice in Russia and
Poland, of using a snow bath after the warm
bath; have been recoided by VVepfer, Waltheb,
Penada, Macard, Brandis, Keilik, Portal,
and Frank. Of about filly perfect cases of the
disease, the causes were analysed by Dr. Cheyne,
and ranked as follows: — 1st, Drunkenness and
habitual indulgence in exciting liquors; 2d, 'I'he
form of the body; 3d, Temperament, sanguine,
sanguineo-choleric, choleric ; 4lh, (Jlutioiiy ; 5tli,
liidolence; 6th, Mental anxiety; 7ih, Hts of
passion; Blh, External heat; 9th, The use of
tobacco. (Un Apoplexy and Lethargy, p. 149.)

88. iii. Modus operandi of the above causes. —
If we endeavour to trace the relation subsisting
between these causes, and what we know of their
uniform efiTects, either upon the brain or on other
parts of the body, we shall find that they tend
first to excite, and afterwaids to exhaust, the
vital energy, and to di>tend the capillaiies of the
part. JVow, as the brain is enclosed in an un-
yielding case, it must follow that, when the
capillaries are excessively distended, the veins,
which are the most yielding, will be propor-
tionately compressed, whilst the force of the cir-
culation in the arteries will tend to perpetuate
this distension, and consequently the compression
of the veins. 1 hus the circulation will be re-
larded ; the portion of the gangliul system sup-
plying the brain be likewise, to a certain extent,
benumbed by the increased pressure to which it
is subjected, and the functions of the organ
abolished, even without extravasation having
occurred. Upon dissection after death, the
blood, which had distended excessively the ca-
pillaries, will be found to have passed into the
veins, giving the appearances of venous con-
gestion meiely, as is uniformly observed in other
parts of the frame, which have been the seat of
congestion, without inflammation, — venous con-
gestion, at least to any considerable extent,
being incompatible willi the physical condition of
the encephalon during the life of the patient, un-
less it be occasioned by impeded return of bloud
through the sinuses and large veins, although
conge>tion of its capillaries undoubtedly fre-
quently exis:s.

89. When hemorrhage takes place, the efl^used
fluid will occasion more or less pressure, accoid-
ing to its extent ; but from the condition of the
encephalon, the pressure will almost equally
affect all parts of it ; the blood being thereby
prevented, to a certain extent, from returning by
the veins, whilst the capillaries and arteries will
be unnaturally distendid. This sjate, however,
will pass off after death ; and venous congestion
only, with extravasation, present iiself. When,
however, the extravasation is large, the pressure
will prevent both the veins and the capillaries
from receiving their due proportion of blood ;
whilst the ganglial system of the encephalon will
be analogously, or injuriously, affected. But this
topic will be pursued heieafter.

90. iv. Conseculiie and complicated Apoplexy.
— An attack of apoplexy may be caused by other
diseases, in vaiious stages and states of their pro-
gress. It may occur after the pre-existing disease
has disappeared, and in consequence of its di--
appearance, as in the case of suppressed lidjnior-
rhages, particularly epistaxis and haemorrhoids ;
or suppiessed evacuations and eruptions, as tho-e
from the uterus, bowels, &c. ; or it may supervene
in such a way as will lead us to infer that its
occurrence has been the cause of the disappear-
ance of the pre-existing malady, as in cases of
misplaced or metastatic guut, rheumatism, <J<c. ;
or it may likewise appear in the course of other
diseases which it cannot thus displace, and as-
sume the character of a most serious or fatal
complication. '1 he importance of these moibid
relations of apoplexy re(|uires lor them a more par-
ticular notice than they have generally obtained.

91. A. Consecutive. — The sujcrvenlion of apo-
plexy after suppressed lia;morrhagcs, evacualionsi.

94

APOPLEXY — CoMPucATioNS.

and eruptions, has Leen satisfactorily noticed by
many writers ; and seems to proceed from unusual
fulness of the vascular system, owing to the sup-
pression, and the accidental co-operation of causes
which determine the blood to the head, and favour
its extravasation. Besides the suppressed evacu-
ations, noticed above (§ 90.) as being influential
in causing an attack, 1 may mention the sudden
healing up of chronic ulcers ; the arrest of ha-
bitual perspiration from the feet; unusual con-
tinence ; and suppression of the lochia or of
leucorrhcea. It is not infrequently observed
after suppressed otorrhcea ; and from inflammation
of the ear having extended to the membranes and
substance of the brain, and produced abscess.
I have met with several cases of this description
in which the apoplectic state was complete, and
attended with hemiplegia. Numerous instances are
also recorded by Lallemand, Gendrin, Itard,
and other writers. (See Brain — Abscess in.')

92. -B. Metastatic. — The occurrence of the
disease, from misplaced or njetastatic gout, has
been noticed by IMorgagni, Weickabd, JNIus-

GHAVE, JuNCKEN, ToDE, HaGENDORN, CoNRADI,

and Cheyne. The last-named author thinks that
the symptoms differ, when occurring from this
cause, fiom those which constitute true apoplexy.
I believe, however, that they differ in no respect,
in general, from those which characterise con-
gestive apoplexy ; and that, as hamoirhage within
the head does not commonly constitute the attack
of apoplexy from this cause, hemiplegia or paraly-
tic symptoms seldom accompany it.*

93. Nearly similar seizures to the foregoing
will occur from attacks, or metastasis, of rheu-
matism to the memi)ranes of the brain. The apo-
plectic symptoms are, however, seldom so fully
developed as in other cases, a comatose slate
being the more usual result. On dissections of
taial ca«es of this description, RIorcagni, Hoff-
mann, Pi.enciz, Ranoe, Weickakd, and Stoll,
found the membranes injected, thickened, and
with setum 'interposed. Very nearly similar
symptoms and appearances within the head result
from en/sipelas extending to the membranes of the
encephalon. Here, as well as in the rheumatic dis-
ease of the same structures, the apoplectic state is
not so stronoly marked as in its more idiopathic
forms ; and paralysis rarely occurs, exceptmg in
the advanced progress of the cerebral disease.

94. C. CompUcutitms. — Apoplexy occasionally
supeivenes in the course of many diseases, even
at the commencement of some of them, and be-
comes (issoci(/tefZ with them. — a. It is sometimes
an attendant upon the cold stage, or the period of

• Some years since I wrs called to a medical friend in
Westminster, who, after compl.iinlng of symptoms of
iniligrstion, was suddi'iily sii/.cii with t'omplcte apoplexy,
w ith stertorous lireatliiiij;, l)iit witli no signs of paralysis,
for which the usual means were promptly and decidedly
employed. On the following day a complete attack of
gout in both feet took place, with disappearance of the
cerebral disease. Warnith to the leet, and aperients,
were prescribed ; but from his easerness to rid himself
of the pain, and to visit his patients, he took, contrary to
tlie advice given him, a large <lose of colchicum. A few
minutes afterwards the gout lelt his feet, and seized his
Btoniach ; whence it was with difficulty recalled to the
extreniitiei'. This was the first time he had ever been
feized with gout, and the first part it attacked was the
brain, in as ctiinplete a form of apoplexy as cm be con-
<e vecl. Metastasis of uout to tlie head may also ocea-
tiuii in (la mm at ion of llic brain, with coma, or lethargy.

invasion, in fevers, particularly those which pro-
ceed from concentrated marsli effluvia, and from
the infection of animal miasms. The epidemic
prevalence of apoplexy, noticed by Baglivi,
Lancisi, Morgagni, Formey, and Stoli,, may
be explained by a reference to this connection ;
although the observations of the Franks and
Cheyne, which are conclusive of the great fre-
quency of the disease in hot and moi>l sea.sons,
seem to countenance the opinion of these authors.
When apoplectic seizures usher in fevers, whether
paludal or infectious, the attack is seldom accom-
panied or followed by paralysis. In a case,
however, of perfectly formed apoplexy ushering
in a case of endemic fever of a warm climate,
which occurred in my practice, paralysis super-
vened upon the seizure. An attack of true
apoplexy may also occur in the stages of depres-
sion and collapse of adynamic and typhoid fevers,
particularly in the former stage: in the latter,
coma is generally present, but it very rarely
amounts to the true apoplectic state ; and when
it does, hemiplegia generally attends it.

95. b. The occurrence of apoplexy after fp;7p/)i(c
convulsions, the convulsions and eclampsia of
the puerperal state, and, more rarely, during the
hysteric fit, is well known. It may even take
place during the pains of labour, without pre-
vious convulsion, and in the latter months of
pregnancy. In these cases the attack ofll'ers
nothing to distinguish it from the first, second, or
third varieties described above. It is a not in-
frequent termination of inflammation of the brain,
or of its membranes. Indeed, there seems every
reason to suppose that acute inflammation of that
part of the cerebral structure in which ha;nior-
rhage takes place, not infrequently precedes the
extravasation. It also occasionally supervenes
upon mania, and the various states of iiisanitif,
paiticularly in its fourth or last-noticed form
(§ 43.). It also occasionally arises from inter-
rupted circulation through the lungs, — a fact
well demonstrated by Bonet, Bang, IIuxiiam,
J.Frank, and Chlyne. Its occui-rence during
the advanced stages of both acute and chronic
diseases of the air-passages and lungs, particularly
those characterised by violent attacks of cough,
has al^o been observed by myself, most frequently
in hooping-cough, bronchitis, asthma, and emphy-
sema of the lungs.

96. c. The connection which sometimes subsists
between apoplexy and orga^iic disease of the heart,
especially hypertrophy of the left ventricle, has
been remarked by Valsalva, Morgagni, Lii r-
TAUD, Testa, Portal, Cheynf, Rutierand,
Ber'iin, and Hope; and has been viewed by
them in the light of cause and effect, the apo-
plectic seizure arising from the cardiac disease.
ConviSART and Rocnoux, physicians of large
experience, have thrown doubts upon the nature
of this connection ; have likewise denied the fre-
(jueiicy of its occurrence ; and have viewed these
diseases as sometimes consecutive in their origin,
although co-existent in their advanced s^tate, but
without the relation of cause and effect: thus con-
sideiing the occurrence of apoplexy or paralysis
in the advanced stages of disease of the heait as
entirely an accidental coincidence. But, as I have
contc nded many years ago, in the London Medical
Ihpository, when such a complication of morbid
slates is fierjuent, prominent, and obsr rves the same

APOPLEXY — Complications,

95

succession, a more intimate connection than mere
sequence or coincidence ought not to be entirely
rejecteJ, particularly when admitting of a rational
explanation. The frecjuency of apopUxyor pa-
ralysis, and the general presence of the latter when
tiie former occurs in tlie advanced progress of car-
diac disease, especially lesions of the orifices, and
hypertrophy of the left side of the heart, have led
nie to believe that more than mere coincidence
actually exists. It is, however, by no means im-
probable that the disposition to organic change
throughout the whole vascular system, sometimes
associated with disease of the heart, may so far
exist in the delicate vessels of the brain, as to fa-
vour the occurrence of haemorrhage from them
when the action or impulse of the heart is increa'^ed
by disease or tiie influence of passion or emotion ;
or when the return of blood from the head is im-
peded by congestion, or interrupted circulation
through the lungs or right side of the heart,

97. d. The association of apoplexy and hepatic
dhurder has been noticed by Stoll, Ualdinger,
JMoLL, Chevne, and others. The circumstance
of icteric patients frequently being cut off by
apoplexy marks the connection, I have met with
several cases in which both apoplexy and para-
lysis have supervened to, and become complicated
will), heptatitis, both acute and chronic, particu-
larly the latter. The liver is seldom diseased
without disordering the functions of the brain ;
and I believe that accumulations of vitiated bile
in the gall-bladder and hepatic ducts, independ-
ently of any actual disease of the liver, will pre-
dispose to the apoplectic seizure. I am the more
confirmed in these opinions by having observed
disease of the biliary apparatus in a very large
proportion of those who had died of apoplexy
or paralysis ; and, in many of those who have
recovered, the active use of purgatives had pro-
duced morbid evacuations, containing a large
quantity of blackish green, greenish, or yellowish
brown bile, before much amendment had taken
place. It may, however, be conceded that serious
disturbance of the brain equally induces disorder
of the liver; and that the latter may have been
occa^iioned by the former. But this merely proves
the frequency and intimacy of the association.
It should also be kept in recollection that the
apoplectic seizure generally masks the hepatic
affection ; the practitioner should, therefore, ex-
amine the region of the liver, where, as well as
at the epigastrium, fulness, and, in some cases,
the existence of tenderness may be detected : and,
as the consciousness of the patient returns, the
hepatic disorder will occasionally become more
manifest. This complication is so important and
frequent, that it ought always to be looked for
in practice ; for many of the causes which oc-
casion hepatic disorder also give rise to cerebral
disease : and the production of either the one or
the other singly, often favours the appearance
of the other subsequently. I have no doubt,
however, that an inflamed or actively congested
state of the substance of the liver has a very
marked effect in exciting that state of the capil-
lary circulation of the brain on wliich the apo-
plectic seizure has been shown to depend (^88.).

98, e. The influence of gustiic disorder in pro-
ducing apoplexy, not merely as evinced by in-
toxication, a surfeit, &c., but also by some one
or moie of the several ailments which charac-

terise impeded or otherwise disordered function
of the stomach and intestines, has been noticed

by SCIIENCK, SciIROEDER, VVEICKARn, MlZLER,
FoTlIEIiGlI.L, SciIjErFEn, Tmi.ENlUS, IIuFELAND,

l.ouvEU- ViLEERMAY, and Chomel ; and more
strongly insisted on by Broussais and his fol-
lowers. Although the gineral dependence of the
latter on the former has been too absolutely con-
tended for by Brol'ssais, the occasional connection
cannot be doubted. Indeed, in several of those
cases wherein the association with hepatic dis-
order is obst'rved, gastric and intestinal disturb-
ance is also evinced. But however complicated,
whether with either gastric or hepatic disorders
only, or with both conjoined, apoplexy is, perhaps,
as often the concurrent result of the same causes
that produced these disorders, as a disease springing
from and dependent upon them. The fact ought
not to be overlooked, that the vital manifestations
of the stomach, liver, and brain, although different,
are yet actuated by the same system of nerves —
the ganglia! ; and that, notwithstanding the in-
dividual parts of this system seem to perform
modified offices, yet the healthy condition of
the one is necessary to the perfect functions of
the rest : and, consequently, a morbid state of
one considerable portion of the series will neces-
sarily, sooner or later, be followed by derangement
throughout, — causes which operate upon one part
of the circle, thus having their effects extended to
other parts remote from the seat of primary im-
pression. It should not, however, be overlooked
that a large number of instances of gastric af-
fection, retching, &:c., accompanying the apo-
plectic seizure, proceeds from the sympathetic
efl^ect produced upon the stomach by the severe
injury or shock sustained by the brain.

99. /". The occurrence of apoplexy, either after,
or during attacks of colica pichmiim, has been no-
ticed by Hagendorn and Cheyne. Although
palsy is the common consequence and state of com-
plication, yet apoplexy, with or without paralysis,
particularly the former, is sometimes met with.
An instance occurred to me some time s-ince of a
patient having died of apoplexy duiing an attack
of this disease. The constipated slate of the
bowels to which persons affected with cerebral
disease are liable, when neglected, or not readily
yielding to medicine, will sometimes favour the
occurrence of the apoplectic attack.

100. g. The association of apoplexy with disease
of the kidneys has been noticed by several writers,
particularly Bonet, Litirf, RIorgagni, and
Bright. The occurrence of apoplexy, particu-
larly serous apoplexy, after suppression of urine,
is not uncommon. By some writers, however,
the suppression has been imputed to pre-existing
disease of the brain. But this is a supposition
merely : for, in the great majority of cases, the
kidneys and ureters offer evidence of having been
the parts primarily aflTected. The experience of
BoNET and IMonGAGNi, and of numerous later
writers, fully support ihis conclusion. Besides,
the cerebral nervous system can only indirectly
influence the urinary secretion. That apoplexy,
coma, or lethargy, should occur when the urinary
secretion is suppressed, and the vascular system
overloaded, may be readily imagined. The occur-
rence of the disease, as a conse<]uence of organic
change in the secreting structure of the kidneys,
whereby their functions are more or less ob»

APOPLEXY — Pathological States.

tructed, has been illustrated by the cases recorded
by Dr. Buight.

101. h. The sudden or more gradual superven-
tion of apoplexy after the slow development of
many of the o)-gunic changes which are desci ibed
in the article on the Puthotogy of the Brain, — in
some cases even when little cerebral disorder had
previously been complained of; in others when
more violent and even paralvlic symptoms had
occurred, has already been noticed {§§ 45 — 48.),
and has also received due attention in the article
on Palsy.

102. V. The Pathological States consti-
tuting Apoplexy have been in part compi-iseil in
tiie observations offered on the principal kinds of
apoplectic seizure, and on the modus operandi of
the remote causes {§ 88.). There can be no doubt
that much misapprehension has existed on this sub-

• ject, and consequently that the treatment adopted
h.is been frequently either nugatory or injurious.
'I'he opinion tiiat the d sease depends upon com-
pression solely, has been too generally adopted,
■without considering the relation in which such
compression, granting its existence, stands in to
the causes which occasioned it, and the symptoms
it produces. The idea that compression is indis-
pensable to the existence of the disease has thus
been empirically assumed, and acted upon in
practice. A careful consideration, however, of
the morbid appearances on dissection, in relation
to the symptoms, and to analogous changes and
their phenomena, have led me to infer that com-
pression of the brain never can take place; that
pressure exists in the great majority of cases, but
even that it is not indispensable to the apoplectic
state ; and that, although retarded circulation,
whether caused by pressure or by any other slate,
seems very fre([uently to obtain, it does not con-
stitute the only morbid condition of the brain in
apoplexy, — or, in other words, that apoplexy is
not merely a disease of the vessels of the brain,
although these vessels are either consecutively or
coetaneously afl'ected. It should not, however,
be overlooked, that even those who argue for
compression being the cause, do not thereby im-
ply, as their opponents would nr.ake it appear,
that the tissue of the brain is actually compress-
ible, but contend for the effects which pressure
undoubtedly produces upon living and sensible
parts. Therefore, although the brain is not com-
pressible, it does not follow that it may not be
affected by pressure, even independently of the
obvious effects which pressure must produce on
its vessels and the circulation through them.

103. Before entering further on this subject, it
will be necessary to premise, that the circulation
of the brain, like that of other important organs,
is chiefly under the dominion of that portion of
the ganglial sys'em of nerves which is ramified
on its blood-vessels, and is distributed otherwise
to the organ itself; and that an exhaiisted or
morbidly depressed state of the influence those
nerves exert on the circulation and maiiihst-
, ations of the brain, with the cc.nsequent efl'ect this
stale has upon' the capillaries particularly in
dilating or congesting them, and disposing to
their rupture, is the principal cause of, and often
consiiiut(,s, the apoplectic seizure, — whether this
influence emanate liom their chief centres, or from
the local sources provided for the peculiar ofhces
ol the organ, as the pineal and jiiii.itnry glands.

104. From this it may be inferred, that the
proximate cause of a large proportion of the cases
of apoplexy, not omitting even those which are
attended with retarded circulation and ha;mor-
rhage, is here imputed primarily to the condition
of that part of the ganglial system which supplies
the blood-vessels of the brain and the brain itself.
That this actually is the case, is shown by the
nature and mode of operation of the remote causes
of the disease ; by the frequent affection of the
functions of the brain previous to an attack; by
the nature of the principal part of the pheno-
mena accompanying the attack ; by the disorders
observed subsequently, when partial recovery
takes place ; by the tendency to relapse ; and
by the morbid appearances which present them-
selves on the dissection of fatal cases.

105. It is obvious, that the appearances in these
cases are merely ultimate le>ions, as in all fatal
cases of organic disease, and some of them even
post mortem changes ; and yet, although the most
advanced in the procession of morbid phenomena,
they are often of themselves obviously insufhcient
to occasion death. Leaving out of question
those cases which are unattended with extrava-
sation, the venous congestions, even admitting
their existence, or the serous effusion, found in
the other cases, are seldom such as to account of
themselves for the event: inasmuch as they are
frequently observed to an equal, or even greater,
extent in cases where neither apoplectic nor co-
matose symptoms had preceded death ; and are,
as I have alieady shown (§ 88.), the result of the
accumulation in the veins, after death, of the
blood which had distended the arterial capillaries
during life, and thus had been instrumental in
abolishing the cerebral function^.

106. The circumstance of the morbid changes
being insufficient to account for the result, had
induced various writers, particularly Kortum,

ZULIANI, ScHELLtR, SciI«FFER, and IIlJFELAND,

to consider apoplexy frequently to proceed from
the state of the nervous power, which they con-
sidered defective; and led VVeickaiid to contend
that it seldom depends upon compression. Dr.
AiiEitciioMBiF, evidently influenced by the above
considerations, refers the disease to interrupted cir-
culation in the vessels of the brain, owing to pres-
sure from the eft'u>ed blood, or to other causes.
It is extremely probable that a retarded, if not an
interrupted, state of the circulation vety generally
obtains ; and that, partly in consequence, the
sensific and motific powers are not generated.
This, however, is only a matter of inference ;
for we have no evidence that complete interrup-
tion of the circulation of an organ or part can
exist for any time, and its functions be i-o rapidly
restored, as is sometimes observed in apoplectic
seizures, or without gangrenous disorganisation
being sometimes the result; and even if we admit
this state of the circulation, we must still refer it
to some antectdent and more general morbid con-
dition.

107. That a congested state of the vessels and
letarded circulation of the brain should, however,
exist, owing to the diminished, or exhausted, or sup-
picssed slate of that influence which undoubtedly
actuates the vessels, may readily be conceded ;
but that, even in the brain, ihctffu-ion of a small
portion of blood should occasion pressure sufficient
to inteirupl the circulation through it, recjuiies

APOPLEXY— Pathology of.

97

fuilher proof. It seems more probable, and con-
sonant witli facts observed in other parts of the
body, tliat, in cases where the extent of effusion
or external injury warrant the admission of pres-
sure, this state gives rise to the apoplectic seizure,
as much from the effects it produces upon the
ganglial apparatus of the encephalon as from in-
terrupted circulation through its vessels.

108. The pathological condition of the
BRAIN, iherefore,inapoplexies, may be stated to be
as follows : — a. That the tissue of the brain is not
sensibly compressible ; but, being lodged in an
imyielding case, it may be injuriously affected by
pressure, chiefly by displacing the contents of its
blood-vessels, altering the healthy relative propor-
tion of their contents in each of the series of
vessels, and impeding the circulation through a
part or the whole of the organ : and that pressure
exerted in one part, whether from distended ves-
sels, extravasated blood, or the development of
tumours, when reaching a certain pitch, will almost
equally affect the whole of the organ, particularly
when the pressure is great : the yielding nature
of the cerebral structure, as well as the unyielding
ca=e in which it is placed, must necessarily give
rise to this result.

109. h. The various states of vascular impulse
and action, impeded circulation in the veins and
sinuses of the brain, and distension of its capil-
laries, whether arising from the influence of the
organic nerves on the blood-vessels, or from mor-
bidly increased action, or from obstruction in the
large veins, the lungs, or the right side of the
heart, will, either individually or in partial con-
junction, occasion the above effects, owing chiefly
to the unyielding walls of the encephalon.

HO. c. Owing also to this physical condition of
the brain, the pressure of the atmosphere which
influences the venous circulation of all other
parts of the body, cannot modify in a direct or
sensible manner that of the brain : and hence the
cranial cavity must always contain nearly the
same quantity of blood during life, the differences
which occur being chiefly those of rapidity of cir-
culation, and of relative proportion in each part of
the series of vessels ; an increased quantity in
the capillaries thus causing a proportionate dimi-
nution in the veins. Owing likewise to this con-
dition, the forcible injection and distension of one
set of vessels will necessarily diminish the capa-
city of, and obstruct the circulation through, the
other ; and that part of the series which is nearest
to the propelling power — the first to receive the
impulse of the heart, and the nearest capable of
being much distended by it — will, from relative
situation, overcome the distension, and diminish
the capacity of that beyond it. Thus the arterial
capillaries of the brain will be the first distended
from increased action of the heart and large ar-
teries, and, by their distension, will soon overcome
that of the veins, if it had previously existed ;
and hence by compressing them, impede the cir-
culation through them.

111. The frequent inflammatory character of apo-
plexy, or the common occurrence of reaction, will
be readily accounted for from what has now been
stated ; for whether the attack commences with di-
latation or increased action of the arterial capillaries,
or with exhaustion or deficiency of their vitul power,
or with retardation of the circulation through the
veins and venous capillaries, the result will gene-

VOL. i.

rally be augmented action of the arteries going
to the brain, extending itself in some measure to
the heart, and this state will continue until the
abolition of the cerebral functions shall have
impaired or altogether destroyed, tiie heart's
action.

112. d. Upon tracing the relation subsisting
between the various causes of the disease, the
symptoms and the appearances on dissection —
upon remarking, as far as my own observation
has gone, the frequency of change in the pineal
and pituitary glands of apoplectic patients, I
am induced to infer that functional lesion, or
organic change, often commences in that portion
of the ganglial system which supplies the ence-
phalon and its blood-vessels ; and that, owing to
exhaustion of its influence, the capillaries lose
their vital tone, have their circulating functions
impaired, become more or less dilated, and are
disposed to rupture.

113. e. When apoplexy proceeds from causes
of an obviously exciting nature, or from sur-actioii
of the heart and arteries, it seldom occurs until a
certain degree of exhaustion of the vital tone of
the capillaries has taken place, whereby they
become dilated and congested, so as either to
press the encephalon against its unyielding case,
and, owing to the pressure, impede the return of
blood by the veins ($§ 109, 110,), or to give rise to
extravasation, which, when considerable, has a
similar effect ; injection of the arteries of the
brain and its membranes resulting equally from
both, owing to the obstructed circulation through
the veins.

114. y. Where pressure unequivocally exists,
it may also benumb or suppress the vital in-
fluence of that part of the ganglial system which
supplies the encephalon, thereby heightening the
effect produced both on the organ itself and on its
circulation.

115. g. There are cases of apoplexy that pre-
sent the phenomena, which have given rise to the
appellation of weak apoplexy, and which occur from
depressing causes, operating upon exhausted states
of the encephalon and frame generally. These
causes directly suppress or abolish the vital in-
fluence of the organic or ganglial nerves of the
brain, and consequently the cerebral functions,
without producing further change of its vascular
system, than retarded circulation in so slight a
degree, as not to amount to great distension and
compression, and without occasioning extravasa-
tion of blood, although extravasation often does
supervene to this state, giving rise to pressure and
its consequences, so as to heighten or prolong the
primary lesion, and to occasion paralysis.

116. h. In cases proceeding from depressing
causes, acting on a plethoric habit of body, the
effect is also more or less directly produced on
the organic nerves of the brain, whereby the
capillaries lose their tone, are congested and
dilated, or ultimately ruptured, and the return of
blood by the veins retarded, whilst the smaller
arteries and capillaries are more and more en-
gorged by the impetus of the blood in the large
arteries, the pressure thereby occasioned suppress-
ing the cerebral functions as in the other cases.

117. i. W'hen the disease proceeds primarily
from impeded return of the blood from the head,
the congestion only commences in the veins;
but, as the action of the heart and arteries con-

H

98

APOPLEXY — Treatment of.

tinues, the capillaries are soon afterwards injected
and dilated ; and, in proportion as they enlarge
from the distending power to which they are more'
immediately subject, the veins are compressed,
owing to the physical condition of the brain, more
or less emptied, and admit of the greater dilatation
of the capillaries, some one or more of which may
be even ruptured from the increased action and
distension.

118. k. In cases accompanied with h(Enwrrhnge,
and consequent laceration of the cerebral struc-
ture, the deprivation of function may be as much
an effect of suppression of the vital influence of
the organ, owing to the shock produced by the
injury, as of pressure upon the veins, and con-
sequent injection of the arterial capillaries. In
cases of this description, the state described above
($ 112. (i.) may exist, and be followed by hse-
morrhage and laceration of the part in which it
occurs, producing the abolition of the cerebral
function, great vital depression, sickness, and
other signs of dangerous injury sustained by a
vital organ. The pressure occasioned by the
haemorrhage will be followed by obstructed cir-
culation, and, under favourable circumstances,
by increased action of the arteries and heart to
overcome it.

119. I. In apoplexy presenting on dissection
congestion and serous effusion, these states may be
often considered rather in the light o(post mortem
changes than the pathological states which had
existed previously to death ; it may even be pre-
sumed that the distension and congestion of the
capillaries, chiefly the arterial capillaries of the
organ, had overpowered its functions ; and that,
as in other parts, when the injection of the blood
into them no longer is continued, and the distend-
ing cause has ceased to exist, they have gradually
discharged their contents into the veins, which
now had space given them for dilatation, owing
to the emptying of the capillaries ; and thus the
blood has passed into the veins soon after death.

120. m. Ilaemorriiage in the brain may result
from the following states : — a. Exhausted vital
energy of the ganglial organic nerves supplying
the vessels and organ favouring their distension
and rupture : |3. Diseased state of the coats of the
vessels themselves : y. Organic change of the cere-
bral structure, extendingto, or influencing the state
of, the vessels ramified m it : 5". Increased impetus
of blood from augmented action of the heart and
larger arteries, combined with either of the other
states : e. Impeded return of the blood from the
head, similarly associated.

121. n. The vital energy of the organ, resulting
chiefly from the mutual influence of the ganglial
and vascular systems, may be so far aflPected as
to occasion the attack with all the organic changes
observed in fatal cases ; and sometimes in such a
manner as to constitute the disease, even without
these changes having taken place ; although they
are most frequently produced, thereby heightening
the primary lesion.

122. o. As corollaries from the foregoing, I infer
that apoplexy often originates in exhausted or
supj)rcssed influence of the ganglial apparatus of
the cncephalon, with a congested state of its
arterial capillaries, or impaired condition of their
circulating functions, and still more frequently in
extravasation of blond, either or all of which
changes must necessarily exist to the extent of

suppressing the functions of the organ ; and that,
as apoplexy does not uniformly depend upon the
same pathological state of the nervous influence
and circulation of the brain, particularly in respect
of the kind or degree of vital depression and vas-
cular reaction, a due regard ought therefore to be
had to the nature of the change in each case, as
far as it may be ascertained, and a treatment
strictly appropriated to it adopted.

123. VI. Treatment. — The treatment of apo-
plexy has long furnished subjects for discussion, not
only as respects the more subordinate means of
cure, but also as regards the most energetic mea-
sures and the intentions with which they should
be employed. This is evidently owing to the
difference which has been long acknowledged to
exist in the pathological states constituting the
disease, but which has recently been questioned.
Without recurring to the changes so fully de-
scribed above, I may remark, that a person is
seized witii apoplexy, and, instead of being
blooded, is treated with stimulants and restora-
tives, and yet he recovers without paralysis having
supervened. Another person is blooded largely,
and he recovers. A third is treated in a similar
manner, and he becomes hemiplegic in the course
of the attack ; and a fourth is also blooded, and
he dies. Now these are very common occur-
rences, and point to very important considerations,
which I will pursue a little further. A thin,
spare, and debilitated man staggers as he walks,
and falls down in the street, with pale countenance,
feeble pulse, and laborious or slightly stertorous
breathing. He is blooded by the nearest medical
man almost immediately, and recovers. A large
man, of a full habit and lax fibre, suddenly be-
comes apoplectic, and is instantly treated with
stimulants, and volatile substances held to the
nostrils, and his consciousness and voluntary mo-
tion are restored in a few minutes. One practi-
tioner of large experience states, that he never
draws blood from a patient in apoplexy, excepting
under peculiar circumstances, and avers that he
is more successful in his treatment than those
who do. Another considers that when one full
blood-letting fails of giving relief, no benefit will
be derived from pushing it further, but much risk of
giving rise to paralysis. A third physician equally
eminent and experienced, confides in blooddetting
almost solely, and carries it often to a great
amount ; and a fourth, whilst he discards depletion,
trusts to stimulants chiefly.

124. I3ut if we examine into their success, we
shall find, perhaps, that some difference as to
degree may exist ; and that, whilst many patients
seem benefited, others experience no relief, if they
be not even actually injured, by the kind of prac-
tice thus exclusively adopted. There is, however,
one part of the treatment which is more or less
adopted by all; this is the use of purgatives;
which, when judiciously administered, are the
most generally applicable and beneficial of all
the means usually advised. Were it possible to
ascertain during life the exact pathological con-
dition obtaining in the various case s of apoplexy,
and to convey a correct description of the signs
by which each may be known, then the basis for
a rational method of cure could be firmly laid ;
but the skilful practitioner is guided in the treat-
ment he adojjts by considerations, circumstances,
and appearances, which scarcely admit of de-

scription; and all attempts to impart his know-
ledge comes far short of his wislies.

125. The metliod of cure in apoplexy neces-
sarily divides itself into : — 1st, Tliat which is
required when an attack is threatened, in order
to prevent it, — or the propliylactic treatment;
2d, The means which are to be adopted wlien tlie
disease is developed ; and, 3d, The plan which
should be subsequently pursued, with a view of
perfecting recovery, and preventing a return of
the disease, — or the consecutive treatment.

126. i. The Treatjient which may be em-
ployed TO PREVENT AN AtTACK WHEN IT IS

THREATENED. — It is difficult to State the means
which may be resorted to with this view, as they
ought to be directed with strict reference to the
circumstances of the case ; which are almost
always difTerent, and, not infrequently, even op-
posite. A strict regard must neces^a^ily be had
to the habits, age, and constitution of the patient;
the predisposing and exciting causes ; and tlie
evidences of previous adment or existing disorder
in remote but related organs. The character of
the countenance ; the pulse, particularly in the
carotids ; the temperature of the head ; the state
of the abdominal functions, secretions, and dis-
charge*, must be our chief guides. It should not
be overlooked in this stage, any more than when
the disease is fully formed ; that it may result
from nearly opposite states of the vascular action
of the brain, and of the circulating system gene-
rally ; that, although the majority of cases are
attended with that appearance of countenance,
and action of the arteries, which warrant the in-
ference of existing congestion, retarded circulation,
or even increased vascular action in the brain, —
there are others, in which the external characters
of the head, the face, and action of the carotids,
would lead us to infer, either that the vital energy
of the organ is so far depressed as to give rise of
itself to abolition of the cerebral functions, or that
the extr.ivasation of blood and laceration of the
structure of the organ lias occasioned such a
shock to its vitality as to be followed by the same
effect on its functions ; vascular reaction some-
times supervening in either case, and thus im-
parting to the attack similar characters to those
possessed by seizures which originate in, or are,
from their commencement, attended with, vascular
turgescence or increased action.

127. In the premonitory state of the disease, it
scarcely can be admitted tliat extravasation or its
consequences has occurred, unless in those cases
preceded by paralysis ; but the signs of incipient
congestion, or increased action, are frequently
present ; whilst also, in many otiier cases, the
symptoms of exliausted or depressed vital power
are manifest ; this latter state being more fre-
quently antecedent to congestion of the capil-
laries than is generally supposed, although the
fully formed disease may evince inordinate action,
with all its usual consequences. Even in the
early stage of an attack, this state of the vital
power of the organ will often constitute so import-
ant a part of the disease, and will yet be attended
only by simple congestion and retardation of the
circulation, that the use of stimulants may then
be beneficially resorted to ; whilst soon afterwards,
when reaction has supervened, they would no
longer be admissible, large depletions, &c. being
then required.

APOPLEXY— -Treatment of. 99

128. We should, therefore, endeavour to in-
terpret correctly the origin of the premonitory
symptoms, and prescribe accordingly. It' the
countenance is full or flushed, the eyes promi-
nent or suffused, the pulse of tlie carotids full or
strong; or even if, with this state of the counte-
nance, they are natural; blood-letliiis;, genevAl or
local, but preferably cupping on the napi' of the
neck, should be prescribed. If these symptoms
have come on after the disappearance of hajmor-
rhages and discharges, this treatment is still more'
imperatively required, aid should be directed to
tlie restoration of the pre-existing disorder, assisted
by other means, such as irritating purgatives, re-
vulsants, and external derivatives.

129. When, on the other hand, the action of the
carotids is weaker than natural, the countenanc
sunk, and the head cool, &c., oppo.site measures
are called for: restm-atives, antispasmodics, and
stimulants are here of service, but their use re-
quires caution ; for if the pulse in the carotids is
full, or strong, or at all above the nitural standard,
although the countenance be sunk or pale, and
if the attack threatens to commence " ith para-
lysis, stimulants given internally, or eve:i the
outward use of them, as volatile substances held
to the nostrils, would be hurtful. In such cases,
blood-letting must be resorted to; and a purgathe
of quick operation, assisted by enemata, exhi-
bited.

130. There are few cases, presenting even the
premonitory signs of an attack, that will not be
benefited by a judicious use of purgatives, parti-
cularly such as are suited to existing disorder of
the digestive and biliary organs. In those cases
which evince a disposition to vascular excitement
of the brain, — where the premonitory signs are
accompanied with plethora, heat of the head,
injection of the conjunctiva, and flushed coun-
tenance,— after depletions and purgatives have
been resorted to, the potassio-tartrate of antimony,
or James's pou-der, given in moderate doses, and
combined with saline medicines, so as to act
gently upon the skin or the bowels, and continued
for some time, has always appeared to me pro-
ductive of advantage : but it is only in such
cases that antimony is useful as a prophylactic ;
where, also, digitalis may be given with the view
of lowering the action; but its use in these cases
requires great caution.

131. When the incipient symptoms present
much of the character of vital exhaustion of the
brain, the combination of purgatives with gentle
stimuli and vegetable tonics and stomachics has
proved the most successful in my practice. If
the symptoms appear after the suppression of
haemorrhoids, aloclic cathartics, or the extract of
colnc^nlJi, combined with calomel, are amongst
the best that can be employed ; as they tend to
induce, by their action on the rectum, a return of
the hemorrhoidal affection.

132. In threatened apoplexy froui congestion
and impeded circulation through the lungs, heart,
or liver, local blood-lettings and purgatives are
necessary. In cases characterised by a combi-
nation of either of these states with exhaustion or
debility, the abstraction of a small quantity of
blood by Clipping, and afterwards dry-cupping,
issues, or blisters, are sometimes very service-
able.

133. The inser ion of setons or issues in the
H 2

100 APOPLEXY —

nape of the neck, or the use of ths tartar emetic
ointment ; and, in very urgent cases, large issues
in the scalp of the occiput, particularly when the
precursory sympt 5ms evince a paralytic charac-
ter ; cold-sponging the head night and morning,
or the shower-bath, with a free state of the alvine
secretions and excretions, especially where there
is a disposition to congestion, or increased action
in the brain, and after blood-letting has been
employed ; stimulating or irritating pediluvia, or
a blister applied to the nape of the neck, and kept
open for some time, in similar cases and preceded
by the same measures, constitute important items
of the preservative treatment.

134. The patient ought carefully to avoid all
the predisposing and exciting causes of the disease
(^^ 77 — 87.), particularly crowded apartments,
the application of cold to the feet, and violent
mental emotions. He ought to sleep with his
head and shoulders somewhat elevated ; and rise
early in the morning. The diet should receive
particular attention : it ought to be spare in all
cases accompanied with plethora ; but not too
low, when this state of tlie vascular system does
not exist, and when the vital energies of the brain
are already depressed or exhausted. It should,
in these latter, be of moderate quantity, and di-
gestible. In all cases, tranquillity of mind and
body ought to be carefully preserved ; and sti-
mulating beverages avoided, with very few ex-
ceptions, which are to be made in favour of those
only who present great cerebral and constitutional
exhaustion. The beverages for these should be
gently strengthening, but not heating, and used
in moderation.

135. ii. The Treatment of the Apopiectic
Attack. — Tiie patient should be carried into
a well-ventilated and spacious apartment, and
placed with his head and shoulders very consider-
ably raised, or in a sitting or semi-recumbent
posture, with every thing removed from his neck.
Directions should also be given to have hot water
in readiness, llis countenance, state of the eyes
and pupils, the degree of fulness, flushing, or
pallor of his face, the temperature of his head,
state of the pulse in the carotids, and condition
of his limbs in respect of sensibility, capability
of motion upon their being pinched, &c. ouj^ht
to be carefully examined ; and, according to the
evidence thus obtained as to the state of internal
lesion, the propriety of depletion, and the extent
to wiiicli it is to be carried, should be promptly
decided on.

136. A, Treatment of apoplexy unattended by
depression of vascular action, or by marked ex-
haustion of vital power. — a. If the pulse be strong,
or full, and especially if the countenance be
flushed, livid, and tumid, general blood -lettitig to
a large extent, or according to its effect, is to be
instantly employed. Much discussion has taken
place as to the propriety of opening a vein of the
paralysed or non-paralysed side, when paralysis
accompanies the attack. AuiavEus, Valsalva,
MoiiGAOM.and Cullen advise it to be performed
in the sound side, whilst lUoi.ivi prefers the
other : this is, however, a matter ot little im-
portance.

137. The n' xt points are the extent to which
1 Jo d-letting may be c;irried, and how fnr certain
states of the frame and pulse warrant the ])r,ic-
tice. In robust, plethoric, and full-living pert;oiis,

Tueatment of.

particularly when the attack has proceeded from
exciting causes, and paralysis is not present, thirty
or forty ounces may be abstracted at once ; and
the operation may be performed a second or even
third time to a somewhat less extent. When,
however, the habit of body is spare, the peison
far advanced in life, the pulse not full or strong,
or little fuller than natural, the heat of the iiead
not increased, and the countenance neither full
nor flushed, we must be cautious not to carry it
too far. In cases of this kind, local depletions,
particularly cupping between the shoulders, or on
the occiput, and leeches to the neck and behind
the ears, seem preferable. Age is no reason
against venesection, if the symptoms indicate its
propriety ; but very old age, even when the oper-
ation is otherwise indicated, is a strong reason for
great caution in its performance. In aged persons,
local depletions are more serviceable ; but even
these, employed either indiscriminately or too
largely, may occasion a very dangerous, or even
fatal, collapse.

138. An intermitting or irregular pulse has very
justly led practitioners to hesitate as to the em-
ployment of blood-letting. But a single symptom
is not to guide us in the use of this, or any other,
remedy. If, conjoined to either of tliese states
there be slowness or fulness of pulse, stertorous or
strong breathing, constitutional vigour and ful-
ness of habit, tumid, flushed, or livid counte-
nance, blood-letting, even to a very considerable
extent — either general or local, or both — may be
practised ; but when, with irregularity and inter-
mission, the pulse is also small, we.ik, or quick,
the countenance pale, the temperature of the
head either not increased, or somewhat depressed,
and the res])iration weak rather than strong,
blood-letting would be highly injurious : a very
opposite treatment is then called for.

139. In cases where it is a matter of doubt
whether or not general blood-letting should be
carried further, or be adopted at all, local blood-
letting, to an extent which circumstances will
point out, may generally be still employed, and
often with great advantage. Vascular depletion
being indicated in one form or other, the situation
in which it should be performed next remains to
be considered. The temporal artery has lieea
recommended to be opened by some : others
advise the jugular vein. When the disease arises
from congestion, and when the face is livid, the
attack strong and the operator expert, the jugular
vein may be opened, as sanctioned by Vaisalva,

MOHGAGNI, lllESTER, FrIEND, LaNCISI, StOLL,

BuRSERi, ;md Portal. But undue pressure of
the vein, either before or after the operation, must
be avoided. Ideeding from the feet, they being
plunged in warm water, has been very generally
])rescribed by Continental pliysicians ; and, ii
those cases which have occurred after the dis-
appearance or retention of ha;morrhages and
periodical discharges, or from metastasis, the
practice is very judicious.

1 40. h. Local depletions in this d"se;i: e are usually
directed on the temples, na; e of the neck, or be-
tween the shoulders. I ])refer the lattersituation,
as well as c»/);)(Hi,'-, to the use of leeches, — the
firmer being much riuicker and more decided in
its operation. Hii'i'Ockati-s, Aretaus, and
]\Ion(;A(;M advised cupping to be performed on
the occiput: and 1 unequivocally agree in the

practice. If leeches are applied, the neck, occi-
put, and behind the ears, are the best situations.
Lancisi and CnuvEiLniEK advise them to the
inside of the nostrils, after general blood-letting,
particularly in apoplexy preceded by epistaxis ;
and Waltiier (De Apop., p. 88.), to the veins
near the canthus of the eye. In cases of sup-
pressed haemorrhoids or menses, the application of
leeches to the anus, the anterior part of the insides
of the thighs, particularly after blood-letting from
the feet, certainly is frequently productive of ad-
vantage, even although it very often fails of re-
storing the suppressed evacuation.

141. Some physicians rely almost entirely on
blood-letting, whilst others too frequently discard
it. Others more rationally view it as a most im-
portant, and a frequently, but not an universally,
required remedy. It is by not attending to the
pathological states, which I have endeavoured to
point out {§ § 108 — 122.), and to the changes of
vascular action which take place during the attack,
that sucli difference of opinion exists, and the in-
discriminating practitioner is led to the injurious
adoption of one mode of practice only. Among
those who prescribe blood-letting almost unre-
servedly, and to a great extent, I may adduce
the respected authorities of Cullen, Cheyne,
PiTCAiRN, Cooke, and Abehcrombie ; whilst
the injurious effects of the practice in many
cases, and its applicability to certain states of the
disease only, have been ably argued for by

KlRKLAND, FoTIIERGILL, HeBERDEN, BaHBETTE,

and Darwin. There can, however, be no doubt
of the propriety of having recourse to vascular
depletion in the states of apoplexy now under
consideration, — the general character of the
symptoms, circumstances of the case, and the
effects produced by the first bleedings, being our
chief guides as to the extent to which it should
be practised. But in the forms of apoplexy clia-
racterised by marked deficiency of vital power
and action, or sometimes at the commencement of
the seizure, when the symptoms, owing to the
severe shock sustained by the brain, very closely
resemble those of concussion, and before the
powers of life recover themselves, and react
(§ 111.), blood-letting would generally be attended
either with fatal sinking, or with effusion, giving
rise to hemiplegia where effusion had, as yet, not
taken place, and with a fatal increase of it, in
some where it had already existed.

142. c. Next to blood-letting, acfii'e p?/r^a<f('fs
are most deserving of notice, as being very gene-
rally applicable and beneficial. In many of the
most severe and sudden attacks it is often difficult,
and sometimes impossible, to administer purgatives
in the usual form by the mouth. But we may
always succeed by mixing from 10 to 15 grains of
calomel in sweet butter, and placing it upon the
root of the tongue. In some cases two or three
grains of powdered camboge may be added to it.

143. (/. Whilst we are waiting the operation of
the purgative, it will frequently be advisable,
particularly when there is much heat of head,
and action of tlie carotids, to plunge the feet and
legs in warm water and apply cold to the head,
either in the form of affusion of cold water, or of
epithem. Great care is necessary not to con-
tinue affusion too long, nor to depress the temper-
ature too low, as the risk of inducing hemiplegia
will be increased by the practice, particularly

APOPLEXY — Treatment of. 101

when vascular action is not considerable. After
the affusion has depressed the temperature to

about the natural standard, cold lotions or epi'
thems,.or even frequent cold-sponging, will be
sufficient ; but increased heat generally returns,
and then tlie affusion should be again resorted
to. In general, as soon as the temperature of
the head becomes natural, and continues so for
some time, and the fulness of the features entirely
subsides, cold applications may be omitted. As
thus used, they have received the sanction of
Thilenius, Crell, Weickard, Carrette, We-
ber, and Abehcrombie ; but Quarin very judi-
ciously cautions against the indiscriminate and
loo long continued use of them. Cruveiliiier,
and other French physicians, advise the applica-
tion of ice for an hour or two, twice or thrice a
day, to the head; but, excepting in the more in-
flammatory states of the disease, it is not required,
and may even be attended with risk.

144. If the purgative already exhibited does
not operate in about four hours, one or two drops
of croton oil should be placed upon the tongue,
mixed with a few drops of castor oil, or in a little
sweet butter, as advised above ; and, about an
hour afterwards, the action on the bowels ouglit
to be promoted by the following enema : —

No. 20. R Olei Ricini, Ol. Tereliinth., aa 5j.— Jjss. ;
Decoct. Avenae, 3 xij. M. Fiat Enema.

This will generally succeed ; but if it come
away without feculent or copious evacuations, it
should be repeated in from one to six hours, ac-
cording to the extent of its effect. In obstinate
cases, one part of croton oil added to about
eight or ten of castor oil may be assiduously
rubbed over the abdomen. This, however, will
seldom be requisite, as a repetition of the enema
will rarely fail, and will act more beneficially
on the disease than the introduction of so irritat-
ing a substance as croton oil into the circulation.
In some cases it may be advisable to render the
enemata more irritating by the addition of com-
pound extract of colocynth. Irritating injections
are enjoined by Aretteus, Forestus, and many
modern authors, particularly Thilenius. la
cases following haemorrhoids, they are more
especially indicated, after leeches have been
applied to the vicinity of the anus.

145. After the bowels have been fully evacu-
ated, we must still endeavour to excite the alvine
secretions, particularly those of the liver. The
region of the liver and epigastrium should be ex-
amined : and, if there be fulness there, cupping
may be performed in this situation. The calomel
may be repeated in smaller doses, oftener than
once, and combined with some preparation of
antimony, or James's powder. In all cases where
the apoplectic seizure is attended with increased
vascular action, antimony may be given ; but
sickness or retching should be guarded against.
It will be frequently observed that a repetition of
the calomel, particulaily after full depletions,
will be soon followed by a flabby state of the
tongue, indicating its incipient action on the
mouth, and the propriety of admitting it, and of
continuing the purgatives. It is frequently not
till now, particularly where the apoplectic seizure
has been preceded by much torpor of the liver
and accumulations of viscid bile in the trail,
bladder and hepatic ducts, that the purgatives
succeed in bringing away dark, greenish black,

II 3

102

APOPLEXY— Treatment of.

offensive motionpjthe discharge of which is generally
followed, in robust subjects, by rapid amendment,
146. e. When the disease is attended with hemi-
plegia, or when the paralysis appears in the
course of the attack, we may generally presume
that extravasation has taken place. In these
cases very large or repeated depletions will not
much accelerate the removal of the effusion ; this
is a work of time. The object rather is to arrest
the haemorrhage by the operation ; but even this
will not be so readily accomplished, owing to the
physical condition of the organ. Indeed, if the
depletion be carried beyond a certain extent, in
relation to the peculiarities of the case, the risk
of renewing the haemorrhage will even be in-
creased ; for, as we cannot, as already stated,
materially diminish the quantity of blood in the
brain, we only accelerate its circulation by large
depletions, and thereby risk an increase of the
mischief. On this account, therefore, the inten-
tions vvitli which blood-letting is to be employed,
are, 1st, to arrest the heemorrliage, and 2d, to
diminish or keep down the action of the heart and
arteries: but, although essentially requisite in
the majority of cases, full blood-letting will be of
itself insufficient to accomplish these purposes ;
and we have therefore to bring to its aid the
application of cold to the head, active purgatives,
derivatives, and a judicious combination of anti-
monials and cooling saline medicines, which
ought always to be exhibited at short intervals,
and continued for some time during convalescence :
two or three grains of blue pill being also taken
at bed-time, and an aperient draught the follow-
ing morning. Any of the following saline me-
dicines may be employed when we wish to lower
the action of the heart or arteries of the brain : —
No. 21. R Vini Antimonii Potassio-Tart.ltl xvj. — 3ss.;
Liq. Ammon. Acet. 3ijss. ; Potassae Nitratis gr. v.— x. ;
Aquae Puric 3 x. ; Syrupi Croci 3 ss. M. Fiat Haustus,
tertia vel quaria quaque hoia sumendus.

No. 22. R Potassse Carbon. 3 j. ; Succi Limon. recent.
Sjss. vel q. s. ; Aq. Fceniculi 3 iii.; Vini Antimonii Pot.-

Tart. 3 ij jiij. ; Synipi Tolutan. 3 ij. M. Fiat Mist.

cujus sutnantur cochlearia duo larga, secunda vel tertia
quaque hora.

No. 23. R Potassae Nitratis gr. x.; Aq. Cinnamomi
.^ j.; Liq. Ammon. Acet. 3 ijss. ; Spirit. Aether. Nit. 3 ss.;
Syrupi Limonis 3 ss. M. Fiat Haustus, tertiis horis capi-
endus.

147. When the measures stated above leave
considerable exhaustion, and paiticularly if ac-
companied with sopor, weak action of the carotids,
a cool state of the head, and unperspirable surface,
it will generally be necessary to venture upon
the use of very gently restorative and diaphoretic
medicines. I'hese ought, however, to be cau-
tiously commenced willi ; and, when we have
reason to infer that the attack has proceeded from
extravasation, which is most frequently the case,
we should carefully watch their effect, or delay
thein until alter the twelfth or fourteentii day
from the seizure. Inflammatory action in the
surrounding portion of brain, consetpient upon
the extravasation, usually supervenes from the
fifth to the fourteenth day. iJuring this time,
therefore, perfect quietude of body, stillness, and
silence, and disengagement of the senses and
mental faculties, should be enjoined, and febrifuge
medicines prescribed, in order to suppress local
action, and the consequent fever which often
manifests itself at this period. The patietit should
be cither kej)! in bed, or on a couch, with his
head and shoulders well elevated ; aud visitorb

ought not to be admitted to him. The eighth
day is generally the most dangerous, as respects
either a renewal of the haemorrhage, in the im-
mediate vicinity or surface of the parietes of the
hemorrhagic cavity, or in a different part of the
brain, or the occurrence of serous effusion be-
tween the membranes or in the ventricles. During
the first days, therefore, of the attack, we should
only venture on the more gentle febrifuge dia-
phoretics ; and after the second or third week,
somewhat more restorative means may be em-
ployed, if the state of the vital energies requires
them. The following may be resorted to in the
order in which they are placed : —

No. 24. R Potassa? Nitratis gr. v vij. ; Mist. Cam-

phorse, Aq. Fceniculi, aa 3 ivss. ; Liq. Ammon. Acet.
3 ij. — 3iij.; Spirit, blither. Nit. 3 ss.; Syrupi Limonis 5ss.
M. Fiat Haustus, quarta quaque hora sumendus.

No. 25. R Vini Antimonii Pot. -Tart. lU xii xx.;

Mist. Camphora; 3 Mj.; Aq. Cinnamomi 3 ss. Liq. Am-
mon. Acet. 3 iij.; Syrupi Aurantii 3 j. M. Fiat Haustus,
quarta vel quinta quaque hora capiendus.

No. 26. R Mist. Campliorje 5 j- ; Liq. Ammon. Acet.
3 ijss. ; Spirit. Ammon. Arom. Ttl, xx. — 3 ss. ; Syrupi
Tolutan. 3j. M. Fiat Haustus.

No. 27. R Infusi Calumba; (vel Infusi Valerianae),
Mist. Camph()rse,aa 3 v. ; Sodae Carbon, gr. x. ; Spirit.
."Etiier. Sul|ihur. Comp. 3 j. M. Fiat Haustus, bis terve
in die siynendus.

Before I proceed further, in noticing the other
remedies which may be resorted to, or have been
recommended, I will state the means which are
most appropriate to the weaker states of the dis-
ease, and when the system is greatly depressed
by the shock of the local lesion, or before increased
action has taken place.

148. B. Treatment of the depressed states cf
apiipiectic seizures. — It will be apparent from the
particular details I have given of the symptoms,
causes, and pathological states of the disease —
1st, That much depression or exhaustion of the
vital powers of the brain exists in some cases
throughout the attack, even rapidly terminating
in death without any effort at vascular reaction,
particularly when this state is mistaken, and
treated by depressing remedies ; and, 2d, That
this depression is often analogous to concussion
of the brain, owing to the extent of the local
lesion ; and, like this result of external injury, is
frequently followed by reaction of the heart and
arteries ($4111 — 118.), when the lesion constitut-
ing the seizure is not so great as to overwhelm
the powers of life.

149. It is owing, in my opinion, either to the
employment of too large blood-lettings in some
cases, to the having recourse to them at all in
others, or to practising them without sufficient
regard to this period of the seizure, and before
the occurrence of reaction, — the time when they
are imperatively called for, — has supervened,
that the practice has disappointed many who
have adopted it, and led others to employ an
opposite mode of treatment in an equally exclu-
sive, and hence dangerous, manner. The judi-
cious use of gentle stiwidi during this state ot de-
pression will have the effect in some cases of bring-
ing about a moderate reaction, when death would
be the result of other means; and, by diminish-
ing and shortening the stage of depression in
others, and thereby lessening the congestion of
the capillaries of the brain, that inordinate degree
of arterial action consequent upon theobstruction,
and indirectly produced l)y it, will be prevented.
In some more doubtful cases, as when the j)allor
of the countenance is connected with a natural, or

APOPLEXY— Treatment of.

103

Hot very depressed state of the pulse, and temper-
ature of the head, and vvlien there are vomiting-
and other symptoms, indicating that haemorrhage
and laceration of a portion of the cerebral struc-
ture have occurred, blood-letting may be advan-
tageously conjoined with cordial remedies, calcu-
lated to restore the tonic contractility of the vessels
of the brain.

150. Jt will appear from what has been stated,
that those who deny the efficacy of blood-letting
are in some respects justified by the frequent
alterations of the vessels and deficient vital energy
of the brain, and by the injurious effects of the
remedy in some cases, whilst they err in a too
gener.d recommendation of opposite means. Both
parties, however, place great dependence upon
active purgatives, and 1 believe that much of the
success obtained by the abettors of both modes of
practice is to be ascribed to them.

151. In apoplectic cases, therefore, with signs
of deficient vital energy of the brain and consti-
tution,— and, when we refer to our experience, or
consider the nature of many of the exciting causes
as well as the very far advanced ages of the great
majority of apoplectic patients, the number of
such cases will appear by no means small, — and
at the commencement of some seizures, before
reaction has supervened, when the countenance
is pallid or sunk, the pulse of the carotids weak
or small, the temperature of the head not in-
creased, and profound sopor, rather than very
stertorous or strong breathing, is present, gentle
restoratives, administered either internally or ex-
ternally, are the most serviceable.* Ihe pro-
priety, then, of attending to the fact, that apoplexy
often is originaili/ dependent upon the state of
tlie sensorium — upon the depressed vital energy
of the encephalon, as well as upon extravasation,
or primary or consecutive vascular turgescence,
and increased action — is manifest. And hence
will appear the reason that restorative measures
are required in some cases and not in others, or
at one stage of an attack and not at another ;
physicians being led, by the success obtained from
one method of cure on some occasions, to employ

* Travelling in the summer of 1825, in one of the short
stages, 1 sat opposite an aged and corpulent man, who,
very soon after our leaving town, suddenly lost his
consciousness and power of motion. His countenance
became first pale, then bloated and inexpressive, his
breathing slow and sliglitly stertorous, all his muscles
completely relaxed, and he fell, in a few seconds, upon
those sitting around him. We were only a few doors
from a chemist's shop; the coach was stopped, and he
was carried thither. He was now profoundly apoplectic ;
a copious perspiration flowed from his face and forehead,
the veins of which were distended, and all his senses
were completely abolished. There was no sign of hemi-
plegia,— but tliere was general and complete loss of
motion and sensation. His neckcloth having been re-
moved, the pulsation of the carotids was found to be
slow, and of natural strength and fulness. Whilst he
was held in a sitting posture in a chair, cold water was
poured gently over his head from a sponge, and his head
frequent;ly sponged with it ; volatile salts also were held
for a short lime, and at intervals, to his nostrils. The
power of deglutition was at this time abolished, so that it
wMs impossible to administer adraught, chiefly consisting
of a small quantity of spiritus ammonia; aromaticus and
camphor mixture, which was prescribed. In a very few
minutes his consciousness returned, he took the draught,
and in a short time afterwards, he walked to a coach, in
which I accompanied him home. He now complained
only of very slight confusion of ideas, with scarcely any
headach, but his carotids beat more tirmly. One tuU
blood-letting, and an active purgative, were now directed.
The next day he was perfectly well, and has continued
so. What would have been the result if he had been
largely blooded prcvioubly to the leactiou ?

it too generally, and hence in many instances io
whicii it is inappropriate.

152. The restorative means that may be re-
sorted to, scarcely admit of particular notice. The
practitioner must be guided in his choice of them
by the circumstances of tiie case. Where there
is sopor, or coma, or lethargy, witiiout much
stertor of breathing, and when hemiplegia or pa-
ralysis is not present, camphor in moderate doses,
either alone, or combined with ammonia or the
spir. icth. stdph. coynp., the tiitct. lavand, comp., and
various others, may be adopted. It is only in
such cases, and when the action of the carotids
is weak, the head cool, and tlie countenance
sunk, that the i)i/iis/()HS of arnica or of serpe)itaria,
which have been recommended by Quarin,
Aaskow, Werner, and Tiiomann, are admissible.
In more doubtful cases, the preparations of am-
monia, the ipiritus (CtJieris nilrici, the infusion of
valerian, may be cautiously exhibited. In some,
particularly at the commencement of the seizure,
volatile suhstances, such as the preparations of
ammonia, and aromatic vinegar, held to the nos-
trils occasionally, will be of much service. Where
the attack is either preceded or accompanied by
hemiplegia or paralysis (§j 31 — 43.), stimulants,
whether exiiibited internally, or held to the nos-
trils, may be more huriful than beneficial. In
these, even t!ie use of cold applications to the
head, excepting there be marked increase of tem-
perature, is seldom productive of much advantage.
Purgatives are, however, required, but the choice
and repetitionof them should entirely depend upon
the state of the secretions, the torpor of the bowels,
and the character of the stools.

153. C. Remedies which have been recommended,
and are admissible in certain states of either the
sthenic or asthenic forms of attack. — a. Emetics are
amongst the remedies, the admissibility of which
has been most questioned. The young practitioner
will, if he have recourse to written authority, be
quite bewildered by the diversity of opinions re-
specting them in this disease. 'He will find Syden-
ham, PlTCAIRN, KiRKLAND, SeLLE, FoT IIERGILI,,

CoLOMBiER, CoNRADi, and Faber, in favour of
them ; and Hagendorn, Borseui, Quarin,
Waltiier, Cullen, Tuessink, Richter, Por-
tal, and Cheyne, opposed to them. But,
when the attack has been brought on by an over
loaded state of stomach, by intoxication, narcotic
poisons, or other hurtful ingesta, and more espe-
cially when hemiplegia is not present, or if the
attack be of the active kind, and full depletion
has been performed, emetics may be both safely
and advantageously administered. This opinion
seems agreeable to the recommendations ol Hip-
pocrates, MoRGAGNi, Stole, Blane, and the
late Professor Gregory.

154. h. The propriety of having recourse to
blisters has likewise been questioned. The great
majority, however, of authorities are favourable
to the practice in some state or other of the dis-
ease, the situation, the period, and form of attack,
being the chief points of dispute. Bartholi-
Nus, Candler, Cullen, and many others, re-
commend them to be applied to the head. Whilst
ToDE, Baglivi, Stoi.l, Portal, and Picque
consider them injurious in this situation. In the
active states of the disease, in those forms which
are complicated with hemiplegia, or are preceded
by it, blisters on the head seem hazaidous reme-

11 4

104

APOPLEXY— Treatment of.

dies, and are, moreover, in the way of more ap-
propriate means ; but in the weakest forms of the
disease, when, from the depressed state of vital
energy of the brain and lowered action of the
carotids, the sensorium requires to be excited,
they may be of service. Where, however, there
is any doubt respecting the propriety of applying
them in this situation, it will be better to omit
them, or to direct them to another part. When
stupor or coma exists, and the symptoms are not
of the strong character, they may be applied to
the nape of the neck, between the shoulders, or
insides of the thighs or legs, after general or local
blood-letting has been practised.

155. c. Sinapisms, or stimulating frictions and
liniments, applied to the lower extremities, are
very generally applicable, particularly after re-
sorting to pediluvia, care being afterwards taken
to preserve a continuance of the increased flux of
blood to these parts, when thus procured, either
by warm applications, or by a frequent renewal
of the above means. Sternutatoi-ies have been
considered injurious by Baillou, Morgagni,
BucHNER, and others, and I conceive with great
jiistice. A nearly similar opinion may be given
respecting electricity and galvanism, which have
been recommended to be tried by some authors.

156. d. The exhibition of mercury, chiefly in the
form of calomel or blue pill, in large doses, so
as to act upon the biliary secretion and bowels,
and subsequently to excite salivation, has been
recommended by Dol;eus, Schubig, Ghisi, and
Horn. My experience of the practice has led
me to think favourably of it in most of the apo-
plectic states, when the powers of the constitu-
tion are not far reduced, and the patient is not
very old. Anlimonial preparations have already
been prescribed, and are of much service in the
more active or strong forms of the disease, whe-
ther accompanied with hemiplegia, or without it.
They are not so admissible, however, in the very
depressed states of vascular action, and in the
forms of attack which commence slowly, or are
preceded by, or attended with, paralysis, indicat-
ing softening and infiltration of the cerebral sub-
stance. James's poivder, and the pntassio-tartrate
ttf antimony, are the best preparations; the former
of whicii may be advantageously combined with
calomel ; the latter with saline medicines. (See
R 21, 22. and F. 854.)

157. e. Setons, issues, and maxas have also been
advised, particularly when stupor continues after
the more urgent symptoms have been mitigated.
I concur with Lancisi and La Motte in consi-
dering them very deserving of adoption in such
cases. Moxas applied on the occiput produce
a more rapid effect, and are tlierefore preferable
during the period of attack ; setons are more
suitable in the prophylactic and consecutive
treatment. The actual cautery and moias have
been strongly recommended by AtnucASis, wiio
directed them in the course of the coronal suture ;
by Marcki.i.us Ddnatus, who prescribed them
to the occiput ; by Sciieliiammir, to the vertex ;
by SciiREiiiER, to both the vertex and soles of the
feet; by Misticiiei.i.i, to the feet; and by 'J'ni-
EENius and Sevehinus. Tliese means are very
trenerally applicable, and may be resorted to in
the worst cases of apojilcxy, particularly those
complicated with hemiplegia, and when brought
in aid ol iippropriate means.

158. In cases characterised by a full, tumid,
flushed, and livid countenance, full or strong
pulse in the carotids, heat of head, with or with-
out hemiplegia, I prefer, after copious general
depletion, scarifications of the scalp, more or less
deep and extensive, to be made over the occiput,
so as to allow of a free sanguineous disciiarge.
The practice has been recommended by Hippo-
crates and Morgagni. Cupping glasses may
be also applied over the scarifications, when we
desire to procure a more copious discharge. In
the low or weak states of the disease, dry-cupping
on the nape of the neck may be tried, as advised
by Aret^us.

159. /. After the attack has been so far miti-
gated that the patient has recovered the faculty of
deglutition, I have often seen decided advantage
derived from a draught consisting of equal quan-
tities of the oleum terebinlhintz and oleum ricini,
particularly when the bowels required to be fully
acted upon. If the attack possess the sthenic
character, and signs of fulness of blood about
the head still continue, about half an ounce of
each may be exhibited on the surface of mint
water ; and, if necessary, repeated a second or
third time, from twelve to twenty-four hours in-
tervening between each dose. This will promote
a more complete revulsion from the head than any
other means that can be employed, particularly
when preceded by calomel, or other cathar-
tics, or followed by the enema prescribed above.
(§ 144.) In the weaker states of attack, when
we wish the medicine to act partially, by being
absorbed into the circulation ; and in casts
where, from the mode of seizure and progression
of the disease, we suspect haemorrhage or infiltra-
tion of blood in the brain, the following draught
may be exliibited ; I have found it serviceable
in such cases, even in some attended with the
most unfavourable symptoms ; as very frequent,
small, and intermitting pulse, and unconscious
discharges, &c. :

No. 28. R Olei Ricini, Ol. Terebinth., aa 3 ss — 5 ij. ;

Tinct. CapsiciAnnui HI x xvj. Olei.Cajuputi HI iv.— vi.;

Aq. Mentli. Vlrid. 3jss. Fiat Haustus, omne bihorio
sumendus ad secundum, tertium, vel quartum vicem.

In some instances, where the lethargy has been
profound, and the constitutional powers far de-
pressed, I have derived much advantage from
camphor, ammonia, and ether, given in suitable
doses in the intervals, and continued after the
above medicine had been carried as far as was
considered either necessary or prudent.

160. It is generally requisite to have the hair
of the patient cut very close, or shaved off, as
soon after the .seizure as possible ; and to attend
to the injunction of MoncAONi, never to omit in-
(juiring after the state of the urinary discharge,
and examining the hypogastrium, lest accumu-
lations of urine take place, whicli should be im-
mediately removed by the catheter, to prevent
their injurious, efl'ects on the disease, and on the
bladder.

161. D. Of the treatment of the consecutive avd
complicated states of apoplectic seizures. — a. A
great majority of such cases requires but very
slight modifications of the measures already stated.
The importance of directing our means so as to
restore suppressed discharges, &c. when the attack
arises from this cause, has already been pointed
out. When it proceeds from the extension of

APOPLEXY — Tbeatment of.

105

inflammatory action to the brain, and its termina-
tion in abscess, effusion, &c., the principles stated
above are still applicable. If the disease possess
either a gouty or a rheumatic character (§§ 92,93.),
bleeding from the feet, local depletions, sina
pisms, or other rubefacient applications. Sec. to
the lower extremities, or to the joints or parts
antecedently affected by gout or rheumatism,
active purgatives, and the preparations of
colchicum combined with soda, and moderate
doses of camphor, are the most advisable re-
medies. In most cases of this description great
accumulations of morbid sordes have formed on
the digestive mucous surfaces, and thick or viscid
daik bile in the gall-bladder and hepatic ducts ;
therefore, after cupping on the nape of the neck,
active calomel purges, promoted by enemata, are
to be given, previously to having recourse to col-
chmim, which ought to be combmed with alkalies,
— with ammonia or other restorative medicines,
if the attack presents the asthenic character, and
with aperients : active revulsants being simulta-
neously employed.

162. b. When the apoplectic state arises from
erysipelas of the head and face, incisions made into
the scalp of the occiput, so as to allow a free
discharge ; cupping on the nape of the neck ; ac-
tive purgatives, consisting first of calomel com-
bined with the potassio- tartrate of antimony or
with James's powder, and compound extract of
colocynth, followed by the draugiit of turpentine
and castor oil advised above (§ 159.) ; and saline
medicines, with the vinum anlimonii ; are the
means most to be depended upon. In cases of
this description the most active purgatives are
required, and must be frequently repeated. The
croton oil may be here exhibited, as already ad-
vised (§ 144.), and enemata should be adminis-
tered from time to time. These already pre-
scribed (§ 144.), or F. 141. 151, are most to
be depended upon in this state of disease. Re-
vulsants, and rubefacient pediluvia, are also ser-
viceable aids.

163. c. When the apoplectic attack occurs on
the invasion, or in tiie advanced stages of /eters
(§ 94.). the general principles of treatment al-
ready laid down cannot be departed from. When
it comes on at the commencement of fever, gene-
ral or local depletions are required, with cold
affusion to the head, purgatives, saline medicines,
and counter-irritation. But even here, the pro-
bable state of the circulation within the head
should be inquired into previously to the adoption
of the means of cure ; for, if the head be cool,
the action of the carotids natural or below the
healthy standard, and the attack be unattended
by paralysis, restorative measures are called for,
although the subsequent occurrence of reaction
will afterwards require active antiphlogistic mea-
sures. When the attack occurs in the last stages
of continued or eruptive fevers, it most frequently
presents the asthenic character, and is often an
aggravated state, or a modification merely, of
coma, unless hemiplegia accompany it. In
these cases, local depletions from the occiput,
ihe neck, and behind the ears ; active purgatives;
revulsanls, and counter-irritants, as blisters or
sinapisms to the lower extremities, nape of the
neck, or epigastrium ; camphor, coinbined wit;h
ammonia, a:tlier, and liquor ammoniaj acetalis,
particularly when the head is cool, and the puls-

ation or the carotids is neither full nor strong ;
and, in the most asthenic cases, camphor in larger
doses, the infusions of arnica, or of serpentaria
(F. 222. 262.), are chieHy to be depended upon.
After local depletions and jevulsants have been
prescribed, and one or more doses of calomel and
rhubarb premised, the draughts directed above
(R 23. 26, 27, 28.), or F.270. 863., followed by
enemata (F. 138. 149.), may be exhibited.

164. d. The association of apoplectic seiziins
with disorders of the digeitive organs, particularly
those of the liver (§§97,98.), requires local deple-
tions from the right hypochondrium and epigas-
trium, followed by blisters in this situation, and a
strenuous use of purgatives and mercurial prepa-
rations, until the secretions assume a healthy ap-
pearance. When the attack proceeds from im-
peded circulation through the lungs and right side
of the heart (§§ 95, 96.), local depletions, counter-
irritation, and diaphoretics, are chiefly to be de-
pended upon. But in these cases care must le
taken not to deplete too much, as the circulation
may be still more impeded by the loss of power
thereby produced. In some instances of this kind,
it will even be necessary to support the vital ener-
gies by suitable means, and to deplete the vascular
system at the same time. When the attack is
occasioned by hypertrophy of the left ventricle,
general and local depletions are better borne
tlian in the foregoing cases, and may be carried
to a considerable extent. In both descriptions of
cases, revulsants and counter-irritants, paiticu-
iarly by issues, and the tartar emetic ointment, are
beneficial.

105. e. When the attack is occasioned by nar-
cotics or spirits taken in immoderate quantities,
the stomach should be emptied by the stomach-
pump, or by an emetic, a moderate blood-letting
having been premised ; and afterwards, the cold
affusion to the head ; internal stimuli, as cam-
phor, ammonia, and ajther ; warm, strong coffee ;
and purgative enemata, should.be prescribed. The
occurrence of the seizure, also, during c/f/M/aftojn-,
or after epileptic or hysteric convulsions, requires
large blood-lettings, preferably from the feet, the
cold affusion to the head, cathartic injections, &c.*

166. Attacks consequent upon colira-pictouum
{§ 99.), two instances of which have occurred to
me, generally require local depletion, full doses
of calomel, followed by active purgatives and
enemata (§ 142.). The draught of castor oil and
turpentine (§ 144.), or the croton oil followed
by injections, are here chiefly to be confided in.
If purgatives given by the mouth are thrown off
the stomach, — a circumstance which not infre-
quently occurs in these cases, — a large dose of

• I was called in 1826, in consultation, to a case of puer-
peral convulsions which had terminated in the apoplec-
tic state. When I saw the patient, the labour had not
proceedid so far as to admit of delivery by means of in-
struments. The pulse was slow and full ; thebreatliing
slow, laborious, and stertorous; the lips puffing and
frothy, the countenance tumid and livid ; all the limbs
flaccid, insensible, and incapable of motion. She had
been blooded largely before 1 was called. The feet and
legs were directed to be placed in a pan of hot water,
aTid the saphenip veins to be opened. Whilst the blood
flowed, the cold effusion on the head was empl.iycd.
These means were evidently beneficial, though insuf-
ficient. A cathartic enema (F. 149.) was tlirown up
immediately, and with gre^t difficulty : consciousness
slowly returned ; when the decoction of the secale cor-
nutum, with as much biboras soda; as it could dissolve,
was administered. Uterine action afterwards came on,
and the patient recovered.

106

APOPLEXY — Treatment of.

calomel will generally be retained ; and will allay
the irritability of the stomach : other medicines
may be afterwards exhibited, or a mixture of
crotoa and castor oils rubbed over the abdomen,
and cathartic injections thrown up. Tlie other
states and complications of the disease must be
treated according to the views and principles
already explained, and with due reference to the
nature of the pre-existing disorder, when it appears
to be a consecutive affection, or a principal part of
a complicated state of disease.

167. iii. Treatment subsequently to the at-
tack, OR THE Consecutive Treatment.— The
symptoms consecutive of apoplexy have a strict
relation to the changes which take place in the
seat of lesion. The absorption of the blood, and
the process of cicatrisation, require several months
for their completion. Duiing this lime great
care should be observed to prevent inflammatory
action from taking place around the extravasated
blood, and a return of the hsmorrhage. This
object is best attained by adopting very nearly
the same measures as have been recommended
to prevent the accession of the attack (§ 126. et
seq.). A too sedentary or studious mode of life,
watchfulness, much indulgence of sleep, frequent
stooping, and all the remote causes of ihe disease,
must be carefully shunned. The strictest tem-
perance and moderation, in respect both of eating
and drinking ; moderate exercise in the open air ;
tranquillity of mind, sedulously avoiding the
least approach to bodily or mental fatigue, and
excitement of the feelings or passions ; the pre-
servation of a fjce state of the alvine secretions
and excretions, by means of mild and deobstruent
purgatives and cathartic enemata ; general or
topical blood-letting, particularly every spring
and autumn, with low living or a vegetaljle diet,
when there is a tendency to vascular plethora ;
caustic issues, or setons in the nape of the neck,
or in the course of the cervical spine ; the use of
the tartar emetic ointment, so as to keep out for a
considerable time a pustular eruption on the part
to which it is applied ; sleeping on a hair mattress,
with the head and shoulders slightly elevated, and
early rising ; are amongst the most efficacious
means that can be adopted.

168. For persons who are prone to plethora, in
addition to periodical depletions and low diet,
the following pills and electuary may be taken on
alternate nights: —

No. 29. B rilul. Hydrarg. Chloridi Comp. gr. iij, ;
Pulv. Jiu-obi Veri gr. ij.; Saponis Castil. gr. iv. M.
Fiiint Pilulsc ij. h. s. s.

No. 30. H PotasscE I?i-t>irt.3 j. ; Soda; Ui-boratis gr.
X. (vel Magnesia; ;)j.) ; Conl'ectionis Senna;, Syrup. Zin.
giberis, aa .jj. M. Kiat Electuaiiuin, pro dose, hora
somni, alternis noclit)US suinenduni.

109. When the disease is connected with the
gouty diathesis, vegetable diet, the carbonnles of
the fixed alkalies, with the extract of taiaxacum
or the preparations of aloes, the occasional use of
an active cathartic, and the other prophylactic
measures recommended in the article on Gout, are
requisite. In all cases, as much benefit will now
accrue from a strict atten'.ion to regimen and diet,
as from medicine. The food should be light and
digestible, of very moderate rjuanlity, chiefly
farinaceous, and taken at regular hours. Suppers
eliuuld be avoided, or be extremely light, and
taken a considerable time before the usual hour
of repose. Fish, and ripe fruits, may be partaken

of in moderation ; and the waters of Cheltenham
occasionally tried, or the following used as a
substitute : —

No. 31. R Magnes. Sulph. ? ss. ; Potassa; Sulph. 3 ij. ;
Infus. Kos« Co. et Mist. Campliori3E aa 3 iijss. M. Ca-
piat Cocli. iij. ampla primo mane quotidid.

170. After attacks of the more asthenic states
of apoplexy, a more tonic regimen than that
directed above may be adopted ; but it should be
conjoined with the same attention to the digestive,
secreting, and excreting functions. Attacks of
this description most commonly proceed from de-
pressing or exhausting causes, which ought either
to be avoided or counteracted ; and when they
are not characterised by plethora, or disposition
to increased action, gentle tonics combined with
aperients, a light strengthening diet, the occa-
sional use of the preparations of strychnine, or
iodine, as recommended in the article on Palsy,
and the mmeral waters of Bath, Leamington, or
Buxton. The following may also be occasionally
taken : —

No. 32. B Potassa; Sul|)iiatis 3 ij. — 3 iij. ; Infus. Rosse
Co. 5 vijss. ; Acidi Sulphur. Arom. 3 j. ; Tinct. Aurantii
Co. .5 ss. M. Capiat Coch. iij. ampla primo mane.

171. In all cases of the consecutive treatment,
the progress of the paralytic or hemiplegic afTec-
tion towards removal should receive attention.
In the more favourable cases, as the period of
attack recedes, first sensation, and afterwards
motion, return in the paralysed limbs ; and ge-
nerally the lower extremity experiences the
amendment before the upper. As recovery pro-
ceeds, the patient should always wear his hair
cut short, and sponge his head with spring water
night and morning. In summer he may use the
shower bath daily, if he be not far advanced m
life or much debilitated. As nmch of the treat-
ment described in the article Palsy, as may suit
the circumstances of the case, may also be adopted
for the removal of this common sequela of the
attack. (See also Asphyxy, and Poisons.)

BiBLlOGiiAFHY. — Hippocrates, srtp/ vova-uv, lib. iii. p. 488.

et Aplior., sect. vi. 67 ArctiEus, De Sign, et Caus.

Diut. Morb , 1. i. c. 7.; Curat. Acut., 1. i. c. 4 Galen, De

Locis Atl'ect. 1. iii. c. 10. \i,—/Elius, Tetral). ii. Serm. ii.
c. 27. — CceUus Aurelianus, Acut. Morb. 1. iii. c. 5. — Ori-
basius, Synop. 1. viii. c. G. — Furesius, Opera, 1. x. obs.Cy.

et seq Avicenna, Canon. I. iii. tr. 5 Schenck, De Apo-

plexia. Jen. 158'2 — Wepjcr, Anat. de Apoplcxia, p. 437.
—lionet, Sepulcliretum Anat., 1. i. sect. ii. obs. 37. ST. —

Sj/dcnhtDii, Opera, p. fi/V. — liaglivi, Prax. Med. i. c. D

/'idl/inck, l)c Apoplcxia. Jen. ItiSO Lancisi, De Siibit.

Mort., p. I'iO. — Seiz, Apop. Fern, et Mort. Uruuit. Morb.
All. 1714 — Murgagni, De Sed. et Caus. Morb., epist. ii.
iii. V. xi. xxvi. Ix. Ixii, Ixiii, et Ixvii. — Hoffmann, l3e
Apoplexia. HaliE,1728; et Opera, sup. ii. p. 2.— JmhcAcb,
De Apoplcxia ex Podagra txetrograda, &c. Giess. 1733.

— Miisgruve, De Artiiritide Anomala, c. 1.5. — Borseri,

Do Apoplcxia, p. 82 Saitvages, Nosologia Method., t. i.

p. 818 HilislicheUi, Tratlato dell' Apoplessia. Kom-dB,

]7M.—Ilang, ill Act. Iteg. Soc. Med. Havn., vol. i. p. 118.
y.'il — Weielcurd, Vermischte Schriften, v. i. et ii. p. 21.
c/sc!. — Folliergill, in Mcd.Observ. and Inquiries, vol. vi.,
and Woiks, vol. iii. p. •>U. — Selle, Med. Clin. p. 40.—
Seluirig, Sperniatologia, p. 2IJ1. et seq. — IVaii/ier, De
Scarilicatione Oecipitis, plur. Cap. Morbor. Auxilio.

Lips. 1741 — Piteahn, Klein. Med , 1. ii. c. 2 CuUen,

Outlines, &c., vol. iii. p. 182 J. Hunter, On the lllood,

&e. 4to. ed. p. 213 Buerhaave, De Morb. Nervorum,

p. G40 — Dicmerhroeic, De Morb. Capiiis, N. i2 De

Jlacn, De Apoplcxia. Leid..l745 ; et Ilat. Med., p. iv. c. 5.

— Sloit, Ratio Medendi, p. iii. 133.; et Pradcct., p. 3G7.

— Mangold, Apoplexite plures, praiter Sanguineam et
.Serosiiin,&c. ICrf. 170.5. —Marqiiet, Tiaitede I'Apoplexie.
Paris, 1771) — Nieiiiajtn, De Apoplcxia; Path, et Therap.
llaKx', \n2.—lj,-utaud, llistor. Anat. Med., 1. iii. Ob. 177.
203, \c — 'J'/iili/ti/ix. iVlcd. und Chir. Reinerkuiigen,

p. 7G (luiinti, Aniiiiadvcrsiones, cap. l.— 1'enadn, Os-

hcrv.i/.ioni v. Wcigd's Hal. Hibl. iv. b. i. p. IliJ llasler.

Von den Artcn und llrsai-hcn dcr Schlagdiissc. I.aiidsh.
1787 — y»«fe'f«/(yMM, Do Apop. cjiisquc Spec. Var. Leid.

APPETITE, MORBID.

107

1793. — Kirkland, On Apoplectic and Paralytic Affections.

Lond. 1792 Andrews, On the Apoplexy. Phil. 1793.—

Heil. De Locis in Apop. AfTectis. Hal. 1795 ; at Memorab.
Clin., fas. iv. n.4. — I'loucqucI, De Vi Vital! in Apoplexia.
Tub. \1'M.— Portal, Anatomie Medicale, t. iv.p. 99. ; et

Sur I'Apoplexie. 8vo. Paris, IHIl Heeler, Brownii

Sent™, de Apop. Examcn. Erf. 1800 Craivfoot. Ob.serv.

on the Opinion that lixtrav. is the Cause of Apop. &c.
Lond. 1801. — Boucher, Journ. de Medecine, t. xlviii. p. 7fi.

Darivin, Zoonomia, vol. ii. p. 402 Fodere, DeApoplexia.

Aven. 1808 Montain, Traiie de I'Apoplexie. Paris,

1811. — Chcync, On Apoplexy and Lethargy. Lond. 1812.
— Riobe, Sur I'Apoplexie, et Epancliement de Sang dans
le Cerveau, &c. Paris, 1814. — Cheyne, in Dublin Hosp.
Kep., vol. i. p.Slii.— PoK'f/, On the Pathology ofthelJrain,
Wed. Trans, of Lond. Col.olPhys., vol. v. p. 198. 181-'i.—
Novlin, Traite de I'Apoplexie, &c. Paris, 1819— Coo/ic,

On Nervous Diseases, vol. i. Lond. 1820 Dunctm, in

Ellin. Med. and Surg. Journ., vol. xvii. 1821. — Craigic, in
Ibid., vol. xviii. 1822. — J. Co]iland,m Lond. Med. Repos.,
t. xviii. p. 20. — Scrrcs, Nouvclle Division des Apoplexies,
Annuaire Med. Cliirurg. des Hop. Paris, 1819; et Anat.
Conip. du Cerveau, t. ii. Paris, 182G. — Brichelcau, Sur
I'Apop. in Journ. Complement, du Diet. des Sciences Med.

t. i. p. 129. 289., et. t. iv. p. 17. Paris, 1819 J- Frnnk,

Interp. Clin., vol. i. p. 139. ; et Praxos Med. Universa;

Prsecep., pars ii. vol. i. sect. i. p. 330. et seq Krilof,

Journ. des Progres, &c., t. xii. p. 248. — Johnson's Miv
dico-Chirurg. Review, voi. i. p. 1.; Edin. Med. Chirurg.
Journ., vol. xxvii. p. 83. — Good, Study of Med., edit, by

Cooper, vol. iv. p. 025 Prichard, On Diseases of the

Nervous System. Lond. 1822. — Lallcmand, Recherches
A at. Path, sur I'Enccph. et ses Depend. Paris, 1820 —
1829. — Rochoux, art. Apoplexie, Diet, de Med., t. ii. —
Keltic, in Med. Chirurg. Trans, of Edin., vol. i. — Mills,
On Morb. Appear, in Disord, of the Brain. Dub'. 182().—
Bouillaud,Uem. dela Soc. Med. del'Emulat.,'t. ix. p. 147.
Paris, 1826. — Hooper, On the Morbid Anatomy of the
Brain. Lond. I82G. — Abercronibie, Researches on Dis.
eases of the Brain, &c. Edin. 1828. p. 201. — Cruveilhier,
art. Apoplexie, Diet, de Med. et Chirurg. Pratiq., t. iii.

Paris, 1829 Bright, Medical Reports, vol. ii. p. 266. et

seq. Lond. 1831 Kreyssig, Encyclopadisches Worterb.

der Med. Wissen., b. iii. p. 94 Series, Edin. Med. and

Surg. Journ., vol. xxvi. p. 83 Mitchell, in Ibid. vol.

xxix. p. 96 H. Clutterbuck, in Cyclop, of Pract. Med.,

vol. i. p. 120.

APOPLEXY OF New-born Infants— 1. Ge-
nerally proceeds from a protracted or difficult
partuiition, particularly when the infant is large
and plethoric, or when the chord has passed around
the neck, occasioning both interrupted circulation
in the chord, and obstructed return of blood from
the brain. The apoplectic state in new-born in-
fants is accompanied vvith tumefaction of the face,
head, and neck, which, with the whole surface of
the body, is generally of a bluish or violet colour.
1'he muscles are flaccid, the limbs flexible, and
the body warm. The pulsations of the heart and
of the chord are generally obscure, or not to be
felt ; respiration is suppressed ; and death soon
takes place, in extreme cases, if judicious means
of restoi ation be not resorted to.

2. Upon examination of fatal cases, the vessels
of the encephalun are engorged with blood ; and
occasionally blood is extravasated in the sub-
stance of the brain, or between the membranes.
The lungs are also generally congested. It is
evident tlmt the pressure of the turgescent vessels
and extravasated Ijluod upon the brain, and
origin of the respiratory nerves, prevents the re-
spiratory actions from taking place, and that all
attempts to excite respiration will be inefleciual
until the pressure is removed. The umbilical
chord should therefore be immediately divided
and allowed to bleed to the extent of two or
three spoonfuls, according to the size and strength
of the infant. When the apoplectic state is oc-
casioned by congestion of the vessels merely,
respiration will take place as soon as the vessels
are unloaded, if no mechanical obstacles to the
entrance of air into the lungs exist, ftlucosities
should be caiefully removed from the throat.

mouth, and nostrils ; and, if the respiration does
not spontaneously take place, insufflation of the
lungs, as recommended in the article on Asphyxy
of New-horn Infants should be performed.

3. ^Vhen the circulation is so torpid that the
blood will not flow from the portion of umbilical
chord attached to the infant, the little patient
should be placed in a warm bath, rendered more
stimulating by some salt, or by a little mustard ;
the portion of chord attached to the abdomen, or
the abdomen itself, may be pressed momentarily,
at several times, and in the direction of the divi-
sion. If these means fail of procuring blood, one
leech may be placed behind each ear. In some
cases the apoplectic symptoms return after respi-
ration has been established. This is generally ow-
ing to some interruption to the circulation through
the lungs. In these cases of secondary attack,
the application of one, or generally two leeches,
placing the body or the lower part of it in a warm
biith, and, if requisite, inflation of the lungs, and
the other measures advised in the article on
Asphyxy, must be resorted to ; and they will be
successful if the case admit of recovery.

Bibliography — Gardicn, Traite d'Accouchemens et
Maladies des Femnies et des Enfans, t. iii. p. 130. —
Desonneaiix, Diet, de Medecine, t. xv. p. 163.

APPETITE, MORBID.

Classif. 5. Class, Local Diseases ; 2. Order,
Depraved Appetites (Cullen). I. Class,
Diseases of the Digestive Functions ; L
Order, Affecting the Alimentary Canal
(Gnod). II. Class, I. Order, (Author).

1. Defin. — Excessive craving for food, or
desire for improper substances.

2. In this genus may be included two species,
viz. 1st, Excessive or insatiable craving for food ;
and, 2nd, A desire for improper substances, or what
is not food. These states of function occur in
practice variously associated ; and although ap-
parently different in themselves, yet they are
often individually connected .with similar states
of the constitutional energies, and dependent
upon nearly the same state of lesion, whether
functional or organic. It would seem that mani-
festations of function often differ mostessentially, in
different persons, or under different circumstances,
owing to causes which are so slightly dissimilar
as not to admit of distinction or even, in some
cases, to appear very nearly the same. In all, or
the great majority of cases, belonging to these
forms of morbid function, the general pathologi-
cal states of the sysiem are nearly ihe same ; the
difference, even when it is most marked, being
chiefly referrible to variations in grade, and to
states of the stomach, in respect of its sensibility,
its .secretions, tonic contractions, and states of its
villous m'embrane, which can only be matters of
inference, but seldom of demonstration. As re-
gards their nature, these affections are much more
Irequently sfimptomatic of lesion of function of
structure in some other organ, than idiopathic, or
constituting primary disease of the stomach itself.

3. Spec. I, Insatiable Appetite. — Syn.
Bulimia (from 0ov, the augmentative par-
ticle, and Xi/uoj, hunger), Fames Canina,
Limoiis avens. Good. Bulimus Poli/phatria,
Lycorexia, Cynorexia, Auct. Lat. Faim Ca-
nine, Fr. Der Heisshan^er, Ger. Dyspepsia
Bulimia, Young. Gluttony, Canine Appetite.

4. Defi.v. a cruiing Jor food beyond the

108

APPETITE, MORBID — Causes op.

natural wants of the system, sometimes most ex-
cessive in degree.

5. i. Varieties. An inordinate appetite ii some-
times observed in the course of fevers and other
acute diseases, particularly in convalescence from
them ; and in the progress of a number of chronic
diseases. It is not infiequent in cases of extreme
exhaustion, from whatever cause ; and it may
depend upon an acquired habit. But in order to
consider it with some degree of precision, I will
oflfer some remarks, 1st, upon habitual indulgence
in an excessive quantity of food, or gluttony ; 2d,
an insatiable appetite from exhaustion; 3rd, on the
excessive appetite, which, from the extreme vo-
racity of the patient, has been called canine ;
and, 4th, on the voracity which is followed by
vomiting. These constitute varieties of nearly
the same disease.

6. A. Habittially excessive appetite, the Bulimia
Helticonum of Cullen. — In some cases, the ex-
cessive indulgence of food has been of so long
duration, and seemingly attended with so good
a state of the general health, as not to appear in
the light of a disease; but the results ultimately
are the production of so great vascular plethora,
and disorder of the secreting' functions, that, as
soon as the vital energies begin to languish, apo-
plectic, paralytic, or other maladies supervene.
This variety of morbid function may be hereditary,
but it is oftener acquired. It is not infrequently
observed in persons, originally of a strong con-
stitution, who have indulged in large and frequent
meals from having little else to engage their minds ;
and thus the vital energy has become concentrated
towards the stomach and the rest of the digestive
organs, exalting all their functions. Persons of
this description usually become large, bulky, or
corpulent ; and if they take much exercise, the
great indulgence of their appetite may not materi-
ally shorten their lives ; but when sedentary habits
and indolence are conjoined with it, apoplexy and
organic disease of the liver, stomach, bowels,
&c. are the common results.

7. JB. Inordinate appetite from exhaustion. —
This is often a symptom of other diseases, and is
chiefly dependent upon altered sensibility of the
nerves of the stomach, proceeding from weakened
vital power. In many cases, however, it appears
as the chief ailment, as after great fatigue of body
and mind ; after excessive venereal indulgences ;
in cases of great emaciation, sometimes without
any evident cause ; and during convalescence
from fevers and other acute diseases. It is very
often observed as an attendant upon organic dis-
eases of the stomach, pylorus, mesenteric glands,
liver, uterus, &c. It has also been remarked in
cases where due nourishment could not be con-
veyed into the system, owing to disease of the
absorbent system ; and it is frequent in the last
stages of chronic maladies, when about to termi-
nate fatally. In many of such cases the craving
for food is attended with a distressing feeling of
inanition, sinking, aud faintness. Some of the
cases of excessive appetite that occur in preg-
nancy, or from the presence of worms, may also
be referred to the debility and altered sensibility
of the nerves of the stomacii. And tiiose which
accompany inanition fiom a defective siipjjly of
cliyle to the blood, may be attributed partly to the
fame cause, and partly to the instinctive wants cf
the system.

8. C. Voracious or canine appetite, the Buli-
mia Syncopalis of Cullen. — Uhis extreme form
of the disease is generally dependent upon some
organic change of the stomach ; but this is more
a matter of inference than of observation. The
chief seat of disease may even be some other
organ. The quantities of food, particularly ani-
mal food, cooked or raw, taken by some persons
afflicted by this disease, are truly surprising.*
One of the most remarkable cases in record is
that published by M. Percy (Diet, des Sciences
Mtd., art. Cas. Rares). Both Cullen and Good
are incorrect in stating that this form of Bulimia
is attended with faintness. This is only an oc-
casional symptom, which was absent in both the
cases that occurred to me, as well as in that
recorded by Dr. Crane. (Loud. Med. Repos.,
vol. xvii. p. 293.)

9. D. Voracious appetite followed by vomiting,
the Bulimia Emetica cf Cullen. — This variety of
bulimia frequently proceeds) from inflammatory
irritation about the pylorus, but more commonly
of the mucous surface of the stomach itself. The
quantity of food devoured in this description of
cases is often as large as in the last variety ; but
shortly after having been taken, it is either alto-
gether, or in part, thrown up, very little altered,
and thus the patient continues alternately to
crave for and to reject his food. This form of
the disease has generally been imputed to a scir-
rhous state of the pylorus ; but the case of Dr.
Crane, already alluded to, was evidently inde-
pendent of such a cause.

10. ii. Causes. — a. The remote causes of buli-
mia are chiefly hereditary predisposition ; the habit
of eating largely, voraciously, and without due
mastication ; chronic debility, arising from ob-
struction of the mesenteric glands, liver, &c. ; the
suppression or disappearance of chronic eruptions,
the healing of old ulcers, or the suddenly arresting
habitual discharges, and the pathological condi-
tions noticed in the foregoing remarks.

11. h. The' immediate cause, or state of the organ
on which it depends, seems to be somewhat dif-
ferent in the diflTerent varieties, even whilst the
state of the constitutional or vital power may be
considered to be, in the great majority of cases,
very nearly the same. I believe that in many
instances the voracious appetite is owing to an

* I have met witli two very remarkable instances of this
affection in children, — the one of seven years of age, the
other of nine. In both these, but in the younger espe-
cially, the quantity of food devoured was astonishing.
Every thing that could be laid hold of, even in it» raw
state, was seized upon most greedily. Besides other
articles, an uncooked rabbit, haKa pound of candles, and
some butter, were taken at one time. The mother slated,
that this little girl, who was apparently in good health
otherwise, took more food, if she could possibly obtain it,
than the rest of her family, consisting of six besides her-
self. In both this and the other case, tlie digestion seemed
to be good. Three or four larg(^ feculent motions were
passed daily, and a nauseous smell emanated from their
i)odii'S. These children, who were both very intelligent,
complained of no other uneasiness than a constant gnaw-
ing or craving at the pit of the stomach, which was never
altogether allayed, but which, shortly after a meal, impel,
led them irresistibly to devour every thing that came in
their way, in the shape of food, however disgusting.
Nearly twenty years ago 1 saw, for a short time, aease of
this description, which occurred in a child of about the
same age, and occasioned alarm, owing to the circum-
stance of a large quantity of raw lish having been de-
voured by it. The result in this case did not come to my
knowledge ; but the former cases, which occurred at the
Inlirmary for Children, recovered by means of the treat-
ment which will presently be noticed..

APPETITE, MORBID — Treatment or.

irregular distribution of the vital energy, and its
concentiatiou in the stomach, tlie neivesoflhis
viscus being morbidly sensible, the muscular
coats more irritable, particularly in the fourth
variety of the disease ; and the mucous coat in a
state of erythism, or vascular excitement, and
yielding a much larger quantity of its proper
fluids than in health. The excited state of the
nerves of the organ will necessarily be followed
by increase of its secretions, greater vascularity of
its inner coat, and a disposition of the muscular
tunics to react upon the enormous quantity of
food wiiich distends them; and thus there will
result the craving of extreme hunger, a rapid so-
lution of the food, and a quick transfer of it
into the duodenum; or, if the reaction takes place
suddenly, either vomiting or simple regurgitation
of it, as in cases of rumination, which is some-
times complicated] with bulimia. The more re-
mote effects of this state of the organ are, torpor,
debility, and a sense of faintness arising from the
concentration of the vital energy, and determin-
ation of the circulation and secreting function
towards the stomach and associated viscera, and
tlie proportionate abstraction of vital influence
from the brain and heart ; imperfect as>imilation ;
irritation of the digestive mucous surface, from
unwholesome and unchanged food ; an impure
state of the blood, disorder of the secreting organs
and morbid secretions, — all tending to disorganis-
ation, and to the destruction of life.

12. c. The morbid appearances found on dissec-
tion consist chiefly of inordinate distenison of the
stomach and duodenum ; a vascular and corru-
gated state of their mucous surface, constituting
complete hypertrophy of these viscera ; a flabby,
softened, and sometimes thickened appearance of
all these tunics (Hagstroem); displacement of
tlie right extremity of the greater part of the
stomach low in the abdomen (French) ; indur-
ation and thickening of its coats (Goudret) ;
the insertion of the common bile-duct into its
pyloric extremity ( V^esalius and Bonet) : dilat-
ation of the oesophagus (Schurig) ; taenia in the
bowels ; lumbrici in the stomach and duodenum ;
enlargement and other organic lesions of the
liver : scirrhus, thickening, and even dilatation
(KuYscii), of the pylorus; thickening of all the
cnats of the duodenum, forming hypertrophy of
this part ; and various organic changes in the
mesentery, its glands, the pancreas, spleen, and
very generally in the mucous surface of the small
and large intestines. ]\I. Beclaud observed, in a
case of bulimia, the valvulae conniventes as large
as in carnivorous animals. And M. Landre-
Beauvais found, in a case complicated with pul-
monary consumption, an unusually large size of
the small intestines, and the gall-bladder wanting.

13. d. Symptotnutic bulimia. — Inordinate appe-
tite has sometimes been observed in cases of
chronic disease of the brain, particularly in slow
inflammation of its substance, threatening, or ter-
minating in, insanity. A very marked case of
this description, and two or three slighter in-
stances, have come before me in the course of
practice. I have also met with it at the com-
mencement of hydrocephalus, and in epilepsy.
When thus dependent upon disease of the brain,
the inordinate indulgence of the appetite is often
followed by vomiting. In the case of epilepsy,
however, in which I met with it, vomiting never

109

took place, although the quantity of food some-
times taken was most excessive. The first, or
slighter variety of the malady, is not uncommon
in epilepsy, particularly iu the hereditary epi-
lepsy of adults ; the second variety sometimes
occurs in hysteria, chlorosis, and pulmonary con-
sumption ; and the fourth, occasionally, in chronic
encephalitis.

14. Bulimia is more frequently met with, par-
ticularly in its slighter forms, in pregnancy and in
verminous affections, and is then very generally
attended with an urgent feeling of inanition and
faintness. When it occurs in pregnancy, there is
usually a fanciful longing for particular articles
of food, of which an enormous quantity is de-
voured. A remarkable excitement of the nerves
of the stomach may be inferred to exist in these
cases, greatly augmenting the secretion of gastric
juice. When the affection proceeds from worms,
it may be imputed to the irritation of the nerves
and mucous surface of the stomach and duode-
num, whereby the circulation of, and secretions
poured into, these viscera, are much increased,
whilst the vital actions of the rest of the frame
languish more or less.

15. iii. Treatment. — The means of cure
should have strict reference to the immediate cause
to which we attribute the disorder. A. In the Jirst
variety of the disorder, it is generally in vain to
state any means of cure. They entirely rest
with the patient, by whom medical advice will
seldom be followed. I have great doubt of a
single glutton having been deterred from the
habit he has acquired, by the injunctions of his
medical adviser, until an attack of illness occa-
sioned him alarm. The cure is sufficiently simple,
and may be cojnprised in the single recommenda-
tion of employing his mind and body more, that
he may abuse his stomach less.

16. B, In the second variety, great attention is re-
quired to adapt the treatment to the circumstances
in which it presents itself. The nature of the
malady of which it is most commonly a symptom,
must necessarily be our guide ; and as the means
should be strictly appropriated to the peculiarities
of the case, no general rules can be stated with
propriety, further than that the effects of whatever
is employed should be carefully watched, and that
more mischief will result from indulging the
craving complained of, than from opposing it, and
allowing no more nourishment than the nature of
the case, or the system, may seem to require, la
the bulimia that occurs in convalescence from
acute diseases, the wants of the economy are gene-
rally greater than in other cases, and here more
may be allowed ; if fever or disorder follow the
indulgence, a purgative will generally remove it.

17. C. The preceding observations apply likewise
to the third and fourth varieties of this disease.
The cases which occurred in my practice were
cured by an active course of nauseating purga-
tives, consisting chiefly of the oil of turpentine
with castor oil. In one of the cases, where the
voracity was almost incredible, the first dose of
the turpentine was followed by the sudden ap-
pearance, over the whole trunk of the body, of a
most copious and thick eruption, more nearly re-
sembling porrigo favosa than any other, and by
the equally sudden relief of the symptoms. This
treatment was left off; when, after a few days,
the eruption disappeared, and the voracious ap-

no

petite returned. It was ultimately removed per-
manently by the hydrarcr. ciim creta, combined
with soda, taken at bed-time, and a turpentine
draught in the morning of each tliird or fourth
day. Leeches were applied over the epigastric
region ; and either the tartar emetic ointment, or
liniment, was rubbed upon the same situation till
a copious eruption of pimples was produced. The
strictest regulation of the diet was enjoined.

18. D. In the varietii attended with partial or
general regurgitation, or vomiting of the food
taken in excessive quantity, the best effects will
result from obliging the patient to abstain almost
altogether from food, or to take a small portion of
nourishment in the least possible bulk. Great
distress from hunger will be felt for a few days,
but this will gradually subside. In the instructive
case published by Dr. Crane, this plan was per-
sisted in ; and portable soup, made into pills, was
given, as the only nourishment, for several weeks :
the patient recovered perfectly. A nearly similar
treatment had been previously employed by Mr.
Wastell with success. (Mem. of Med. Soc. of
Land., vol. iii. No. 2.) Where, however, the
stomach is not so irritable as to throw oflf any
portion of the ingesta, and has become distended
and enlarged from habitual ingurgitation, a gra-
dual diminution of the food will be better borne,
and perhaps be more efficacious, than its sudden
reduction. The propriety of employing deob-
struents, small doses of the blue pill, combined
with ipecacuanha, active cathartics, either by the
mouth or in the form of enema, and external irri-
tants and revulsants, in cases of this description,
cannot be questioned. Exercise, where it can be
taken ; and employment for both body and mind,
as far as circumstances will permit; are also most
useful adjuncts.

Bibliography N. Jossius, V)e Voluptate, Dolore,

Fame, &c. Rom. 1580. — ■ Van der Meer, Diss, de Fame
Canina. Lugd. Bat. 1660. — Vesalius. Anatom., I. v.c. 3.
8. — ^onf<, Sppulchretum Anat, 1. iii. sec. ii. obs. Let
3. — Sc/iurig, Chylologia, p. 2 — 17. — De Reus. De Bulimo
et Appetita Canino. Leid. 1673. — Mortimer, in Philos.

Trans., No. 176 Kivinus, De Fame Canino, et Bulimo.

Lips. 1716. — Sativagcs, Nosol. Metli. t. ii. p. 21.'> — Fretic/i,

Memoirs of Med. Society of Loud., vol. i Hngstrocm,

Kiilin Reportorium, h. iv.p. 630 — Cullen, Synopsis, ci. —
A. F. Wallher, De Obesis et Voracibus, &c. in Delect.
Opuscul. Med. Col. a ./. P. Frank, p. 236. Lips. 1791.— J.
M. Good, Study of. Medicine, vol. i. p. 142. — Landre-
JSeauvais, art. Boulimie, Diet, des Sciences Med., tom. iii.

APPETITE, VITIATED — Causes of.

Vitiated or Depraved Appetite.
Pica, Citta, Malacia, Pseudwexia,
Pica. Good. Dtjspepsia Pica,
Der Sonderbare Appelil, Ger.
An appetite for substances which are

Spec. II.

— Syn,
lAmoxis
Young.

1. Defi.m.
not food.

2. i. Causes. — This state of the appetite some-
times occurs in children, from an early accpiired
liabit ; and it is frequently observed in idiots,
from want of ability to discriminate what is or is
not food, or from perversion of taste. Various
substances also, which are abhorred in one cli-
mate, constitute the chief articles of diet in
another. Thus, the ('alifornians live on snakes,
rats, lizards, &c., and numerous tribes of Africans
on monkeys, dogs, snakes, &c. It is very fre-
quently observed in pregnant, hysterical, and
chlorotic females, and it is sometimes connected
with certain kinds of mental emotion. 1 have
met with several instances of it in females at the
age of commencing puberty, when neither hy-

steria, in any of its forms, nor chlorosis, existed.
In these, and perhaps in the great majority of
cases, it is altogether a symptomatic afTection,
arising from altered sensibility of the nerves, anil
modified state of the secretions of the stomach,
occasioned by imperfect function, or changed
condition, of a related organ, particularly of the
uterus, ovaries, large bowels, and brain,

3. When it is observed as the primary disorder,
it has generally been owing to a habit, commenced
at first with the view of improving the shape and
complexion. Females early in life sometimes
have recourse to acids, particularly vinegar, and
chalk, for this purpose. The form of the disease,
which has been described by Dr. John Hunter
as dirt-eating, by the negroes in the West Indies,
and which has even assumed an epidemic cha-
racter, is, perhaps, more than other forms of it, de-
serving of being considered as idiopathic. The
earth they devour chiefly consists of a loam or
clay, and may possibly be taken by them from
the circumstance of their having found it assuage
the painful sensations produced in the stomach by
acidity. This affection is much more frequently
met with in the female than in the male sex ; but
instances of its occurrence in the latter are not
rare. I have seen several instances of it in males ;
and in females it is often practised in so concealed
a way, as not to come to the knowledge of the
medical attendant.

4. The substances which occasionally become
the objects of desire are sufficiently numerous.
Medical records abound with them. Cinders,
spiders, lice, flies, insects, toads, serpents, wood,
hair, paper, earth, clay, chalk, vinegar, and other
acids, and even ordure, have all been devoured
in cases of this disease. Various other substances
have been swallowed, more as singular exploits
than from actual longing for them. Thus we have
accounts of persons taking into their stomachs
clasp-knives, musket bullets, billiard balls, gold
watches, and Louis-d'ors; and, what is still more
singular, generally discharging them by stool a
few days afterwards. Knife-eating seems to have
been no uncommon feat, as we have instances
recorded of London, Prussian, Bohemian, North
American, and 13razilian knife-eaters. Our friends
of the United Slates seem to have surpassed all
others in the rapacity which their knife-eater
exhibited; for in June, 1822 (New York Med.
liepos. Oct. 1822), after having been duly
initiated in the art, by swallowing a gold watch,
chain and seals, billiard balls, and various other
articles, at diirerent limes, which had passed
through his callous digestive tube, he swallowed
fourteen knives in the course of the day. This
was his great, but his last exploit, for he died two
months afterwards ; having passed two of the
knives by stool, the remaining dozen being found
in the I)ody, — eleven in the stomach, and one in
the oesophagus.

5. The articles most commonly fancied by young
females are paper, cotton, thread, chalk, vinegar,
and other acids. I once saw a sickly-complexioned
lad, who was in the habit of eating sand ; and a
robust .seaman, who occasionally would devour n
whole wine or ale glass, having previously crushed
it in small pieces with his teeth, and yet no bad
effects resulted, at least for many months after-
wards ( LoHrf. Med. Uopos.jVo]. xviii.). The only
other instance on record, where this most danger-

ARTERIES— THEIR Diseases.

Ill

ous feat has been performed, is given by Came-
RARius (Memorah. cent. v.).

6. Wiien pica is complicated with biiUmia, as
is sometimes observed, most singular and even
astonishing feats in the way of devouring sub-
stances of the most unsuitable kind are on record,
— many of them also so large, that the possibility
of their being conveyed into the stomach, if they
liad not actually been found there, might have
been doubted. Some really astonishing and au-
thentic instances of this kind have been related
by M. FouRNiEn (art. Cas. Rares, Diet, des
Sciences Mtd. t. iv. p. 135.).

7. ii. Treatment. — The means of cure must,
of course, have strict reference to the morbid con-
dition of the system, of which it is so frequently a
symptom. If it accompany pregnancy, 1 believe
that the axiom which M. Francier adopts as
the title of a treatise on the subject should be
adopted, viz. A pregnant woman affected with
pica should be well purged. If it be attendant
upon chlorosis, aloetic purgatives, with emmena-
gogues, and these followed by or given alternately
with tonics, are the most suitable means, and are
equally beneficial in the pica which occurs about
the period of puberty. In hj'steria, similar mea-
sures, combined with valerian, assafoetida, cam-
phor, and other antispasmodics, are indicated.
In these three symptomatic forms of the disease,
any of the Formulas for those medicines in the Ap-
pendix may be adopted.

8. When the affection presents an idiopathic
character, which is comparatively rare, it is most
commonly owing to a weakened state of the digestive
organs, with, perhaps, an altered sensibility of the
nerves, and acid state of the secretions of the
stomach. In these cases, the combination of vegeta-
ble tonics with alkalies, and attention to the alvine
secretions andexcretions, are chiefly required. The
treatment of cases of the affection induced early
in life from habit, will be unsatisfactory, or without
avail, until the cause is removed ; but it differs in
no essential particular from that now stated. In
many cases the pernicious habit has commenced
with early puberty, and, as well as in the cases
associated with chlorosis, hysteria, pregnancy, and
irregularity of the menstrual discharge, is evidently
dependent upon the state of the uterine functions.
(See Chlorosis, Menstruation.)

Bibliography. — Francier, Ergo Gravidfe Pica Labo-
rantes Purgandae. Paris, 1615 — Bech, Dissert, de Pica

Pr£egnantum. 4to. Lugd. Bat. 1653 Schuster, De Pica

seu Malacia, !Arg. 1658. 4to. — A. Castro, De IVIorbis

Mulierum, 1. iii. p. 389 Forestus, Opera, 1. xviii. obs. 7.

et 1. xxviii. obs. 65. — Sc/ici'der, De Appetitu Gravidar.

Wit. 1670. 8vo Horslitis, Opera, vol. ii. p. 160. — Sau-

va^es. Op., t. ii. p. 212. — Meyer, Diss, de Pica et Malacia.
Erf. nOi. — Schurig, Chylologia, pp. 38. 45. 49, &c. _
Scheideinantel, Beytriige zur Arzneykunde, No. 5. et
No. 34. — Gruner, Dissert, de Pica et Malacia. Jen^,
1791. — Hunter, On Diseases of the Arn.y in Jamaica.
8vo. — Cullen, Synopsis, c. iii. — Good, Study of, Medi-
cine, vol. i Gardieri, Traite Complet d'Acconchcmens,

et des Mala(iies des Filles, des Femmes, et des Enfans.
Paris, 1826.

ARTERIES, THEIR Diseases. — • Syn 'Apnipia,

Gr. Arteria, Lat. Artere, Fr. Eine Schlagader,

Pulsader, Ger. Arteria, Ital. Artery, Eng.

1. The morbid conditions of arterial vessels

cannot be appreciated, either in respect of their

causes, symptoms, or consequences, unless their

organisation and connections with other systems

of the frame be clearly understood. It does not

fall within my limits to notice all the connections

which these vessels present with other parts of

the body ; but there are a few to which I will
brifcHy allude, as most material in the causation
of their diseases, and of certain sympathetic affec-
tions with which these diseases are related.

2. I. Organisation. — The arterial tubes are
essentially constituted, 1st, Of an external and
adventitious txinic, consistmg of a very delicate
and condensed cellulo-filamentous tissue. This
tissue is never infiltrated by serum, nor loaded by
fat ; and possesses the greatest degree of resistance
of all the other coats of the vessel. 2d, Of a
proper coat, consisting of fine circular fibres
placed closely together, and forming a strong
tissue of a dun yellowish colour. The nature of
this tissue has been a matter of much dispute
with pathologists. It certainly does not possess
the physical and chemical properties of the fibres
of voluntary muscles, from which it chiefly dif-
fers in being much more close in its structure,
and more elastic and fragile than they. 3d, Of
a very delicate cellular tissue, like a fine pellicle,
the second cellular tunic of Haller, interposed
between the fibrous or proper coat and that next
to be described. It is in this fine membrane that
the minute vessels supplying the arteries, and
which proceed from the adjoining parts, terminate;
and here also the ultimate distributions of the
arterial nerves may be supposed to ramify, al-
though they cannot be clearly traced further
through the coats of the vessel than the proper
fibrous tunic where I have distinctly followed
them. This is the most vascular of the tunics
strictly constituting arterial vessels ; and one in
which many of those changes which will fall
under consideration commence. 4th, Of an in-
ternal membrane, presenting no linear or fibrous
structure, semi-transparent, more readily detached
from the one next to it in the longitudinal than
in the transverse direction, and fragile. This de-
licate membrane is not possessed of vessels carry-
ing red blood in the healthy state, but it is pene-
trated by minute red vessels when inflamed. It
lines, with scarcely any perceptible modification,
the canals of all the vessels conveying red blood,
and the cavities of the heart.

3. The arterial vessels thus formed are sur-
rounded by a sheath of loose cellular tissue, more
or less abundant in some parts than in others,
permitting the vessels to accommodate themselves
to their varying state of dilatation, constriction,
&c., and transmitting the vessels which are em-
ployed in their nutrition. The elastic properties
of the proper coat of the vessels, serve also to ac-
commodate their capacity to the state of the cir-
culating fluid ; and as it is generally supposed
that they are in a certain degree of distension
during life, owing to the quantity of blood con-
stantly being impelled through them by the
heart's contractions, so it is believed that the con-
tractions which they display on the removal of
this fluid is at least partly owing to the abstraction
of the distending cause.

4. No trace of longitudinal fibres can be de-
tected in arteries. The elastic properties which
they present in the direction of their axis, when
extended beyond their natural limits, and their
retraction upon their division, are chiefly owing
to the dense cellular coat immediately surround-
ing the proper fibrous structure of the vessel.
The different degrees of tenacity presented by the
various structures composing the parietes of these

112 ARTERIES —

vessels, acting conjointly with the elasticity of the
proper coat, have been considered by many as
sufficient to account for the absence of ha;mor-
rhage after laceration of these vessels. Doubtless
these circumstances contribute, but I conceive
that they are insufficient of themselves to account
for this and other phenomena, which will be no-
ticed in the sequel.

5. The arteries are surrounded by the ganglial
nerves, which form a reticulum around them ;
and from this reticulum very minute fibrillee are
given off, and dip into their fibrous tunic. This
disposition of the ganglial nerves on the arteries
ought to be kept in recollection when we inquire
into the functions and diseases of the latter. How
far it is necessary, not only to the discharge of
the most manifest actions which the arterial sys-
tem performs, but also to those changes which the
blood undergoes in disease, and to the assimila-
tion of the chyle, and other absorbed fluids, I
have ventured to state in the article on the Pa-
thology of the Bi.ooD. It is evidently to the very
intimate connection of this class of nerves with
the arteries, and the effects resulting therefrom,
that we must impute those changes, whether
functional or organic, which take place in the
latter, and which influence the state of the blood,
and the circulation through them. (See the
Author's Appendix to Richehand's Physiology,
p. 556.613.)

6. II. Nervous Affections of AnTERiES.—
Classip. : — II. Class, I. Order (Author).

7. There is sometimes disorder referrible to a
particular artery, or arteries, evidently depending
on an affection of the nerves supplying them. Of
this description are, 1st, Neuralgia of the arteries ;
2d, The violent pulsations sometimes felt in a
large arterial trunk. 1st. Laennec admitted the
existence of neuralgia of arteries, and considered
it to be characterised by acute pain in their course,
with increase of their pulsations and the bellows
sound ; and to be independent of inflammation,
as shown by the sudden accession and remission
of the symptoms, and their periodic recurrence.
That this affection is sometimes connected with
irritation, or with an inflammatory state of its
nutritious vessels, may or may not be the case ;
but it is certainly not always so connected.

8. 2d. Violent pulsation of arteries is more
commonly observed unaccompanied with exces-
sive pain. In these cases a loud bellows sound
is often heard in all the principal arteries, parti-
cularly those in which the increased pulsation is
felt. This affection generally supervenes and
disappears suddenly in nervous and debilitated
persons, particularly after large losses of blood.
IMorbid anatomy has not as yet thrown any light
on its nature ; and therefore we can only refer it
to some peculiar influence exerted by the nerves
supplying the vessels thus affected, and probably
depending originally upon the state of the vital
energies of the frame. It is sometimes associated
with hypertrophy of the heart. In this case, it is
in a great measure to he imputed to that disease.

9. Treatment if these affections. — When neu-
ralgic pain is felt in the course of arteries, and is
quite unaccompanied by inflammation, the same
treatment which is recommended in the article
on the painful affections of Nkrvks may be
adopted. After morbid secretions and inte-linal
colluvies have been carried off by purgatives.

Inflammation of.

tonics combined with antispasmodics may be
employed. The preparations of iron, the sulphate
of quinine, ammonia, camphor, alone or com-
bined with opium, colchicum, belladonna, or hy-
drocyanic acid ; the external application of the ace-
tate or muriate of morphine, or the cyanuret of
potassium, &c. may be tried. In the cases of in-
ordinate pulsations, unassociated with pain of the
arteries, attention to the alvine secretions anrl
excretions, and the use of tonics and antispasmo-
dics, will generally be productive of advantage.
As these functional disorders are generally con-
sequent upon disturbance of some internal organ
or part, sometimes a distant or remote effect of
pre-existing disorder, the seat and nature of such
disturbance should be investigated, and the treat-
ment directed accordingly. In all such cases,
residence in a dry and salubrious air, occasional
change of air, gentle and regular exercise, and a
light and nutritious diet, will be of much service.
CSee art. Aorta, % 2 — 6.)

10. III. Inflammation of Arteries. — Syn.
Arteritis, or Arteriitis ; Artereitis, Hilden-
brand. UArtdrite, Fr. Pulsader — , Ar-
teri — , Schlagaderentz'undung, Ger.
Classif. 111. Class, I. Order (Authoi-,

see Preface).

11. Defin. — Great and tumultuous vascular
excitement, palpitations, anxiety, sense of heat and
throbbing in the course of the principal arteries,
followed by collapse of the vital energies, and occa-
sionally by gangrene of a limb.

12. This disease was not entirely unknown to
the ancients, as Aret«us makes mention of in-
flammation of the aorta. But notwithstanding
the incidental notice which was taken of inflam-
mation of arteries by Morgagni, and Boerhaave,
and afterwards by Grant, the attention of the
medical practitioner was never directed to the
subject, until J. P. FRA^■K noticed it in a parti-
cular manner. It is, therefore, to the last-named
author that we are chiefly indebted for the nume-
rous researches of pathologists respecting it in
modern times. Since the appearance of Frank's
work, arteritis has received due notice from
Testa, Kreysig, Reil, Baillie, Burns, Cor-
visart, Schmuck, Portal, Scarpa, Hodgson,
Travers, Ribes, Laennec, Breschet, Dalbant,
Vaidy, Bertin, Bouii.laud, Guthrie, Titoi^s-
SEAu, and several others, and it is now generally
recognised as a specific and most important dis-
ease, sometimes occurring piimarily, occasionally
consecutively and conjoined with other diseases,
by no means of rare occurrence, and, in whatever
form it presents itself, always threatening the
most serious consequences.

13. i. Pathology of Arteritis. — Arteries,
being composed of distinct tissues, may be sup-
posed to be liable to all those kinds of inflamma-
tory action, to which each of their constituent
parts are most disposed. However frequently
inflammatory action may originate in one rather
than in more of the coats of an artery, it seems
seldom to continue thus limited, but soon affects
the rest to a greater or less extent. It may even
seize simultaneously upon all the coats ; but this
is, 1 think, of comparatively rare occurrence. The
individual tis'^ues of an artery most frequentlv
inflamed, in a primary manner, are the internal
membrane of the vessel, and its connecting cel-
lular tissue.

ARTERIES — Inflammation of, its Pathology. 113

now described. It seems extremely probable that

14. Arteritis may be jmrtial or general, as re-
spects its extension through this cla»s of vessels ;
and it may present every grade of activity, from
the most acute to the most chri)nic form. It ge-
nerally attacks one or more of the arterial trunks
iind larger branches. When it affects the arterial
capillaries, it constitutes, in the opinion of some
pathologists, inflammation itself; but whether it
can be demonstrated as existing in this latter class
of vessels, or in what respects it may either differ
or agree with inflammation when it does thus
exist, are points which have not been yet settled
by the few pathologists who have agitated the
question.

15. Inflammation may possibly, however, seize
upon a number of arterial ramifications in an
organ, especially in an unhealthy habit of body,
or in a part injured by external violence or exces-
sive cold ; but when it is thus seated, all circu-
lation through the part is quickly interrupted,
owing to the effusion which takes place and
destroys the permeability of the ves.-els. The
consequences in such cases are, 1st, sphacelus
and gangrene of an extremity or part, as we ob-
serve in cases of fro«t-bite ; and 2d, when the
inflammation is limited to the capillaries of a
circumscribed portion of an organ, particularly
when this portion is surrounded by healthy struc-
ture, a breaking down of the texture, and its
conversion into a foetid purulent-like matter, as in
gangrene of the lungs, and some kinds of abscess
<brmed in the parenchyma of several organs.

16. In constitutions possessing the power to
limit the inflammation, which has thus seized
upon a congeries of arterial vessels, by throwing
out coagulable lymph, the extension of the in-
flammatory process to the larger branches and
trunks is prevented ; and, if the pan already af-
fected be an extremity, a di-;tinct line of separation
is thus drawn, or if it be situated in the centre of
an organ, a cyst is thus formed by the lymph
effused, tending both to the limitation of the in-
flammation, and to exclude, as it were, the parts
which the loss of circulation has deprived of vita-
lity, from the. surrounding living textures, and
fiom the contamination which the defect of this
natural partition would allow to take [dace.

17. Wiien the constitutional powers and vital
energy of the vessels of the part are insufficient
for the formation of the means of limitation here
pointed out, the inflammatory action of the sm iller
arterial vessels extends itself to the larger trunks;
and the affection of these, in addition lo the pre-
existing inflammation of the small branches, in-
creases the mischief ; the gangrene extending
it>elf without any line of separation being formed.
In this case the constitutional powers fail rapidly,
owing to the contamination of the surrounding
structures and circulating fluid, from the absorp-
tion of the products of inflammation through the
venous capillaries of the part, which seldom escape
participaimg in the disease.

18. Such seem to be the results of inflammation
affecting a congeries of arterial vessels, or the
arterial branches and their ramifications tlirough-
out an extremity ; and I conceive that tho-e in-
flammations which are rapidly followed by spha-
celation and gangrene, as well as some lesions
considered under different heads, and which have
been generally referred to the common seat and
consequences of inflammation, are of the nature

Vol. I.

several lesions of a disorganised and disorganising
description, following rapidly upon the first deve-
lopment of deranged circulation, arise from the
source now contended for ; or, in other words,
that some of the consequences usually referred lo
common inflammation, in conjunction with pecu-
liarity of habit and of the part affected, actually
spring from inflammation and obstruction of the
arterial vessels, and cannot be otherwise satis-
factorily explained.

19. Inflammation of arteries, like inflamma-
tions of all other parts, may, however, give rise to
effects which will vary according to the degree of
intensity of the morbid action, the coat or coats
of the vessel in which it originates, or to which it
extends, and the habit, diathesis, and constitu-
tional energy of the patient. The duration of this
disease, as well as its constitutional effects, will
also depend upon the above circumstances; and
in inflammation of this part of the system, more
perhaps than in the inflammation of any other
part of the body, excepting merely the rest of the
circulating organs, the primary effects and pro-
ducts of the inflammatory act will be rapidly pro-
ductive of ulterior effects, serious in their nature
and results, even after the morbid action which
originated them had altogether disappeared, and
could be recognised only in those remoter but pal-
pable consequences, some of which have been
alluded to in the preceding paragraphs, and which
will be more fully referred to in the sequel, par-
ticularly in the section on the morbid structure of
arteries (§ 38.).

20. ii. Causes. — 1st, The predisposing causes
of aiteritis are generally those of inflammation in
general ; but those which seem especially to favour
the production of this disease, are the gouty and
rheumatic diathesis; the middle and advanced
epochs of life ; certain constitutions of the atmo-
sphere, or epidemic influence ; peculiarity of cli-
mate, and whatever occasions-a diuiinution of the
crasis of the blood, or imparls to it an exciting
influence on the vessels ; indulgence in the use of
much animal food, and vinouj and spirituous
liquors ; a plethoric habit of body, particularly
when conjoined to the sanguine and irritable tem-
peraments; prolonged high temperature ; intem-
perate and luxurious habits ; the constitutional
effects of syphilis or mercury ; the suppression of
accustomed discharges, particularly the sangui-
neous ; reiterated or prolonged attacks of nervous,
convulsive, or spasmodic diseases ; and deficient
secreting powers of the various emunctories, as
the kidneys, liver, &c.

21. 2d, The exciting causes of this disease, be-
sides those which are more commonly productive of
inflammation, are congelation of parts from great
cold, and the sudden exposure to a higher tem-
perature; insolation ; punctured, incised, lacerated
or contused wounds ; surgical operations ; ligatures
of arteries after the operation of aneurism (Cline,
AfiEnNETHY, &c.), or amputation, and from tying
the umbilical chord (Okhme) ; excessive suffering
from long-continued operations ; continued and
fatiguing exertions ; sudden and violent muscular
action ; the sudden extension of a part occasion-
ing the elongation of the vessel and rupture of its
internal coat ; pressure in the course of arterial
vessels ; violent fits of passion ; great mental
emotions ; e\haustion of the vital powers ; puru-

114

ARTERIES — Inflammation of, its Pathology.

lent and morbid secretions ; animal matters and
poisons absorbed into tlie circulation ; chemical
agents of any description introduced into the
vascular system ; and the sudden repulsion or
suppression of exanthemutous levers and eruptive
diseases. Pout,il records an instance of tiie
disease which was occasioned by the repulsion of
the eruption of measles. I met with an instance
of inflammation of tlie internal membrane of the
heart and arteries, in a fatal ca-^e of malignant
scarlatina, with an imperfect and evanescent
eruption on the skin. M. Breschet details se-
veral cases in which the disease was consequent
upon erysipelas and chronic abscesses. I have
found the internal surface both of the arteries and
of the veins dark red, and softened, iu two fatal
cases of puerperal fever, cliaracterised by evident
signs of absorption of sanious matter from the
uterus. A case also lately came before me of
erysipelas followed by gangrenous escars on the
sacrum, where the internal surface of the sangui-
ferous system, and particularly of the aorta and
large arteries, as far as they were examined, pre-
sented a similar appearance. In all these cases
the inspection had been made within eighteen
hours after death.

22. The causes of arteritis consist, therefore,
1st, of those which act externally as respects the
vessels ; and, 2d, of those which irritate in a di-
rect manner the internal surface of the arteries
themselves, by being conveyed into the circula-
ting fluid, the properties of which they may have
previously changed. But, in whichever of those
wavs they may act, tlieir fiist eflTect seems to be
to change or influence the vital energies of the
organic nerves ramified to the coats of this system
of vessels.

23. 3d, Anatomical characters. — As to the par-
ticular tissue of the arteries, in which the inflam-
mation originates, I am of opinion that a careful
examination of the phenomena of the disease in
connection with its causes and complicaiions will
warrant the inference, that, when it arises from
those causes which act exteriorly to the vessels
(§ 21.), and which are chitfly local in their oper-
ation, the inflammation is generally limited as to
its extent, being confined to a part only of tiie
arterial system, or to two or more considerable
branches; that it often affects more than one of
the coats of the vessel in this case ; and that it
generally assumes the sthenic characteis, giving
rise to those changes which usually result from
this form of inflammatory action, such as the
effusion of coagulable lymph, forming fibiinous
concretions and false mendjranes in the interior of
the vessel, obstructing or obliterating its cavity ;
red vascular injection, thickening and softening of
its tunics ; and suppuration, with or witiiout ulcer-
ation of its internal niendjrane.

24. On the other hand, when the disease ori-
ginates from causes existmg within the vessels,
and acting through the medium of the blood
itself, and more especially when it is complicated
with malignant and eruptive fevers, with erysipe-
las, &c., or is caused by the absorption of morbid
secretions, &.c. into the current of the circulation,
tiie vascular excitement is rapidly followed by
symptoms of an ataxic or astiienic character ; the
inflammation is chiefly confined to the internal
surface of the vessels, but it extends more or less
throughout the whole arterial system, and, in

many cases, also to the inner lining of the cavities
of the heart, and even of the veins. In cases of
this description, the lesions of the arteries which
it occasions consist chiefly of a dark red or violet-
coloured injection of the inner membrane and
connecting cellular tissue ; great softening and
friability of those tissues, with slight sanious
infiltration of the walls of the vessel in diflferent
parts.

25. It should not, however, be overlooked, that
the inflammation of an ailery may frequently
commence irom local causes, and originate in, and
be for a time confined to, a particular trunk or its
branches, presenting all the signs of the sthenic
form of inflammatory action, and yet, owing to
causes lowering the vital energies of the frame, or
to the absorption of the matters secreted fiom the
inflamed vessel into the current of the circulation,
or to both, may pass into the generally difl^used
and ataxic state ol the disease.

2(5. iii. Symptoms of Acute Arteritis. — These
will necessaiily vary according to the stage of the
disease, the severity and activiiy of tlie attack, and
the organic changes which the inflammatory action
has occasioned in the affected vessels. I shall
therefore adduce, /;«/, those symptoms which cha-
racterise the disease previous to the supervention
of those changes which afl'ect this system so as
materially to impede its functions, or to change
the condition of the circulating fluid ; and next,
those signs which indicate important changes in
the state of the vessel, and of the blood itself.

27. Thejiisl sUige is one frequently of much
obscurity ; and win n the inflammation is limited to
the vessels of a single limb or organ, it is very
difficult to distinguish it from the common inflam-
mation of the pait. While the internal tunics of
the vessels are yet the chief parts affected, and
the eflfusion of lymph into their interior has either
not supervened, or not obstructed their canals,
the patient generally feels, either after a rigor, or
at first alternating with rigors, an increase of the
pulsations of the vessels of the part, with a sensa-
tion of heat, uneasiness, or pain. When arteritis
is more general, and particulaily if it be con-
nected with inflammation of the heart's internal
surface, as occasionally occurs, the symptoms
are those of fever of an extremely inflammatory
type, as has been remarked by J. P. Frank {Dts
Cur. Horn. Morb. t. ii. p. 175.) and M. Bouil-
LAUD {Traite Clin, el Exp. de Fiivres. p. 175.^ ;
commencing in I'igors, at first alternaiing with,
and followed by, great anxiety, irritability, rest-
lessness, uneasiness, a sensation of burning heat
and remarkable pulsation, with increased sensi-
bility in the course of the large arteries. The
patient complains of general and unremitting
throbbing throughout the system, sometimes felt
more intensely in one part than in another. The
surface of the body is hot, tumid, and injected ;
the tongue red, the papillae erect, and its base
furred and loaded ; the bowels are costive ; thirst
is urgent and unquenchable ; the urine scanty,
voided with a sense of scalding, and high-coloured ;
the patient is distressed with palpitations. The
pulse at this stage of the disease is strong, tumul-
tuous, throbbing, full, and frequent ; and the
contractions of the heart hurried and tumultuous.
To these are sometimes added cough, occurring
ill paroxysms, with fits of dyspnoea. When tho
iiiOainii.utioa extends to the aoita and internal

ARTERIES

•Inflammation op, its Pathology.

11-

lining of the heart's cavities, the characteristic
symptoms of inflammation of those parts (see
Aortitis, &c.) are superadded to the above.

28. The second stage is chiefly ciiaracterised
by the greater severity of the symptoms, indi-
cating tiiat serious changes are advancing in the
internal coats of the vessels, and influencing not
only the state of the vital energies of the sangui-
ferous system, but also the stale of the blood. At
this period of the disease, the pulse generally be-
comes extremely frequent, and often wiry, weak,
and irregular; whilst the palpitations, anxiety,
and paroxysms of dyspnoea increase. The tongue
is either dry, the papilla; erect, and its centre
furred with a dark mucus or sordes ; or it is
smooth, glossy, and of a dark tint. The patient
is liable to startlngs and spasms in different parts
of the body. The desire foi' drink increases ; tiie
strength sinks ; the countenance at first shrinks,
is pallid or haggard, but, towards an unfavourable
close of this stage, it often becomes somewhat
bloated, cedematous, or cadaverous, occasionally
injected, and the lips purplish. The extremities
are frequently cedematous ; and they, as well as
other parts of the body, are sometimes affected
with wheals, ecchymosis, pblyctenae, or laige
vesications. In some cases, eflusions of sero-
albuminous fluids take place in some of the shut
cavities ; the surface of the body is covered by a
cold perspiration ; the extremities become cold,
and sometimes of a purplish red colour; and a
low muttering delirium appears during the night,
from which, at last, the patient is never entirely
exempt. To these often supervene a tendency to
syncope upon raising the head ; irregular palpi-
tations ; weak, irregular, hurried, and quick
pulse ; and a quick, short, and difficult respir-
ation; sometimes orthopnoea and distressing cough.
Hiccup and convulsions at last appear, and the
patient expires.

29. If the intlaramation be seated in large
trunks, the serum effused from the internal sur-
face of the inflamed vessel necessarily comes in
contact with the circulating fluid ; hut I believe
it does not readily mix with it in persons of a
sound constitution, or whose vital energies have
not been mateiially affected, but forms a coagu-
lum, which either sheaths the internal surface of
the vessel, partially obstructing it, or altogether
filling up its channel. In this case, the symptoms
indicate interruption of the circulation through
a considerable branch of an artery : the limb
becomes cedematous, cold, leucnphlegmatic, or
purplish coloured, with irregular phlyctens and
large vesications on its surface, which sometimes
go on to gangrene ; especially when the disease
has extended to the collateral arteries, which,
if they had remained unaflTected, would have per-
formed the functions of the inflamed and ob-
structed trunk.

30. When ateritis occurs in a weak or cachectic
habit of body, the fluid secreted from the inflamed
internal surface of the vessels, owing to the state
of the constitutional powers, will not coagulate,
but, being of a dissolved and sanious quality,
readily mixes with the blood, and no interruption
to the circulation through the inflamed vessels
occurs : but the energies of life become depressed
from the morbid slate of the vital current thus
occasioned, and many of the symptoms of ataxic
or malignant fever manifest themselves; — such

as great prostration of the powers of the frame ;
low delirium ; an impeded and morbid state of
the secretions and excretions; weak, quick, and
irregular pulse; a cadaverous and lurid counte-
nance ; accumulations of dark mucous sordes about
the tongue and mouth ; flaccidity of the soft solids,
with the rest of the phenomena described as con-
sequent upon Injiammatinn of Veins.

31. iv. Chronic Arteritis. — The more acute
and active states of arteritis, although frequently
admitling only of a doubtful recognition during the
life of the patient, are more readily ascertained than
the chronic forms of the disease. These latter, how-
ever, seem more frequently limited to particular
arteries than the acute, and hence oftener produce
local effects; but these are generally so slight,
and of so equivocal a character, that they com-
monly escape detection, and are unattended to by
the patient until the lesion on which they depend
arrives at that degree of advancement which
seriously disturbs the functions, and even the
vitality, of the part. A very large proportion of
the lesions which will be described hereafter
(j 38.) seem to originate in chronic states of in-
flammation ; and, if not actually commencing in
these states, they are frequently complicated with
them. It will be unnecessary further to notice
those symptoms which seem to indicate the pre-
sence of chronic arteritis, than to state that thev
consist of many of the signs already adduced as
attendant on the acute forms of the disease, but
in a much slighter degree ; and frequently no
functional lesion can be remarked. When, how-
ever, the circulation through the vessel becomes
impeded or obstructed, we may infer chronic dis-
ease of the arteries from the inequality or entiie
absence of the pulsation in these arteries supplying
the part whose functions are most affected ; from
oedema, coldness, disioloiiration, vesications, or
from signs of the grangraena senilis in a limb ; or
Irom a feeling of weakness, and a state approaching
to paralysis of an extremity or part.

32. V. Complications. — The states of morbid
association of which arteritis forms an especial
part have been more frequently disclosed to us
after death than recognised during life ; nor is it
to be expected that, in some of the associations in
which it has presented itself, it can be ascertained
by the most diligent investigation of the case pre-
vious to dissolution. We are still so much in
want of faithfully observed cases of the disease,
even in its simple and unmasked forms, and of
correct informatiou on various topics respecting
its history and pathology, as to render our dia-
gnosis imperfect and doubtful , and how much
more difficult must be our attempts to recognise
it in its complicated forms, when it is masked by
other diseases, the phenomena of which obscure
it from the observation of the practitioner, and even
abstract the attention of the patient himself from
the feelings it may awaken. In noticing, there-
fore, the complications of which this disease often
forms a part, it is with the sole view of turning
atteniion to their importance, and in order that
the circumstance may receive due consideration,
when we give our prognosis respecting those ma-
ladies with which it has been found associated,
and when we devise means for either their relief
or their removal.

33. Inflammation of the arteries has been ob-
served in fatal cases of inflammatory and malignant

12

116 ARTEIUKS— Morbid Structure of,

fevers, and in lliose which have been charactei-
ised by great vascular excitement at their coni-
Tnencement, witii symptoms of ataxy during their
progress. In the great majority of such cases, it
is a consecutive affection occasioned either by a
greater concentration of the morbid action in a
particular system, as explained when treating of
fevers ; or by an alteration of the properties of
the blood, owing to huitful materials having ac-
cumulated in it froni deficient action of the eli-
minating organs, or to a morbid state of the ner-
vous influence imparted to the blood from the
vessels in which it circuhiles. (See Blood.)

34. Owing to similar causes, arteritis is some-
times consecutive of eruptive fevers, particularly
when the eruption, and the morbid evacuation of
■which it consists, are imperfectly developed or
prematurely suppressed ; or it may supervene to
small-pox, occasioning the most dangerous part of
the symptoms forming the secondary fever of this
disease. In cases of this description, the arteritis
is almost always general, chiefly limited to the
serous membrane of tlie arteries, but extending
also to the same membrane of the veins ; and
evidently induced by the altered state of the
blood, and the presence in it of hurtful materials.
To this cause chiefly is to be imputed its occa-
sional occurrence during erysipelas, phlebitis, and
as one of the chief lesmns observed in fata! cases
of those diseases to which the term puerjieral

fevers has been applied. The complication of
arteritis wiih phlebitis i< one of the most frequent
which occurs. That this should be the case, we
might infer from the circumstance of the same
causes generally acting upon both divisions of
the vascular system, particularly those which act
through the medium of the circulating fluid.
j\I. BRESCHtT found inflammation of the internal
surface of the veins in a very large proportion of
the cases (8 in 13) of arteritis which he has de-
tailed at length in his interesting memoir.

35. Arteriti-i has likewi-e been found associated
with injtammation of the heart, with that of the
lungs, and with telanus, particularly traumatic
tetanus. A ca^e of this last complication is alluded
to by the wiiter of an able article in the second
volume of the Medico-Chirargical Review. It
has also been observed, although rarely, conjoined
with seroiLS effusion into the shut cavities, parti-
cularly the pericardium, pleura, and peritoneum.

36. vi. Diagnosis. — It has been very justly
remarked by the writer to whom I have already
referred, that, until numerous and diversified
observations in clinical practice, illustrated by the
examination of fatal cases, shall have fuither
enlarged our knowledge of this malady, any
attempt to delineate the symptoms which are
diagnostic of its presence must necessarily be
somewhat imperfect. Hut it may generally be
inferred, — when the principal symptoms which
have been enumerated appear — when the heat
and pain attendant on this, as on other inflam-
mations, are not concentrated in one part or organ,
but are more or less generally diffused, particu-
larly in the course of the arterial vessels — when
these sensations are arcompanieil with an audible
or perceptible impetuosity of action, propagated
from the large trunks to the smaller and more
BU])erf)c:al ramifications — and when, moreover,
anasarcous injection of the surface or of the limbs

patches, supervene, — that the disease is inflam-
mation of the arterial system, either in its partial
or general form,

37. vii. The Prognosis of arteritis may be said
to be, upon the whole, unfavourable, even as
res]iecls its more immediate effects, in the acute
states of the di-ease ; but chiefly as regards its
remote consequences in its chronic forms. The
prognosis is more unfavourable when it i< com-
plicated with, or supervenes on, other diseasfS
($§ 33 — 35.): The morbid changes which it
usually occasions are fully described in the next
section of this article.

Before proceeding to offer any observations on
the treufmejif of arteritis, I will desci'ibe the various
changes of structures which arteries present, as
the greatest proportion of these changes are pro-
duced by inflammatory action in some one of its
various grades or states.

38. IV. JMoRBiD Structure OF Arteries. —
1st, Lesions of the individual coats of arteries. —
A. Redness of the inner membrane of arteries
is often observed in post mortem examinations. —
a. It seems to proceed from three causes : \>t, from
the imbibition of the colouring particles of the
blood remaining in the vessels, being entirely
the consequence of death, and the result of in-
cipient decomposition ; 2d, from a change in the
slate of the blood occurring in the course of the
disease which occasioned death, and existing some
time before this event ; and, 3r(l, from a morbid
or injected state of the capillaries ramified in the
coats of the vessel, or terminating in this mem-
brane. In an epidemic amongst horses, which
occurred at Paris in 1825, characterised by
symptoms of disease of the thoracic viscera, no
morbid appearances were found in the lung':,
but the internal membrane of the large vessels
was uniformly red, and the muscular structure of
the heart remarkably softened. From the ex-
periments of Gendrin {Hist. Anat. des Injiam.
t. ii. p. 9.), it is evident ihat the same varieties
of colour, which we occasionally observe in
arteries after death, may be produced by artificial
irritation. There is, however, this imj)ortant
difference, — th it when their redness is produced
artificially, it is accompanied by other alterations
of ti'isue, such as softening, serous or purulent
infilti'ation, &c. ; whereas, in almost all the cases
where the arteries have been found of a red colour
throughout, the change was unattended by any
other morbid appearance in them. 1 believe that
this colouration of the internal membrane of the
arteries, as well as of the cavities of the heart, is
more frequently owing to a morbid condition of
the blooil itself, than to any inflammatory change
in them. This opinion is confirmed by the cir-
cumstances and states of disease in which it com-
monly occurs; these chiefly consi-ting of de-
pressed vital energies, deficient secreting power,
and a consequent morbid condition of the blood
itself.

39. b. The internal membrane of arteries some-
times loses its tenuity and natural transparency,
either in a few isolated points merely, or through
a gr'cat extent of its surface. I his state may
amount to considerable thickening and opacity;
but in many cases these appearances do not de-
pend upon any remarkable change in tiiis mem-
brane, but upon an albuminous exudation in its

followed by wheals, vesications, or ecchymosed | connecting cellular tissue

ARTERi; S — MoimiD STnucTinfi or.

117

40. c. Softening also takes place in tliis mem-
brane, wliicli is sometimes so friable as to be re-
duced to a pulpy mass by the slightest scrapinp:
with the scalpel. Possibly, owing to this state of
the inner membrane, its laceration may take place
upon stretching the vessel by the more violent
motions of the body, or of a limb.

41. d. i?»/)<(()eor laceration of the internal coat
of an artery is sometimes met with : it necessarily
occasions an effusion of lymph from ilie lacerated
part, and the projection of the flaps of the divided
coat into the canal of the vc'^sel, either partially
or entirely obstructing it. To this occurrence is
chiefly to be imputed the cases of spontaneous ob-
struction of arteries, whicii are sometimes met with.
This subject has been well illustrated by Mr. Tur-
NKR, in the third volume of the Transactions of the
Medico-Chirurgical Society of Edinburgh.

42. e. Ulceration of the internal membrane of
arteries is not infrequent. The ulcers are gene-
rally round ; occasionally one only is to be
found. Sometimes the large arterial trunks, and
particularly the aorta, are studded with them.
But this is raiely observed, unless other alter-
ations exist in the subjacent tissues, such as
ossification, softening, &c. M. Boiullaud is of
opinion that the ulceration of the inner coat occa-
sionally admits of cicatrisation.

43. B. The middle coat is more frequently
diseased than the internal. It is often saj't and
friable, and deprived of its natuial elasticity;
giving ri<e to serious modifications of the func-
tions of the circulating system. RI. Andral has
found this coat remarkably hijpertrophied ; the
yellow fibrous tis-^ne of which it is composed
being as evident in the human subject as it is in
the horse. This change may be confined to par-
ticular parts, occasioning irrfgularities in the
diameters of the arterial canals, or it may extend
throughout a whole artery. The fibrous coat may
also become otr()/)/H>a'. In this state it approaches
to the appearance of cellular tissue, and is much
thinner, resembling the tunic of veins ; and the
artery loses its elasticity and collapses when di-
vided. This coat may also require much rigidity,
and be transformed into cartilaginous or even
osseous lings, embracing the whole circumference
oT the vessel. This change is rarely met with in
the aoita, but it not infrequently occurs in large
arterial trunks, as the femoral artery, &c. Ulcer-
ation may extend to and penetrate this coat, most
frequently advancing from the internal membrane,
and be followed by dilatation or rupture of the
external tunic (§ 47. et seq.)

44. C. The external oh celhilar coat of
arteries is liable to fewer alterations than the
other coats; it often remains sound when they are
extensively diseased, when it has alone to sustain
the column of blood injected through it. But it
also frequently participates in the changes of the
other coals, becoming ruptured from the pressure
of the stream of blood thrown into it, and more
rarely ulcerated. — The foregoing changes of the
individual coals of an artery combine to affect its
functions and condition, and give rise to important
alterations of its structure and of its calibre,
which may be increased, diminished, or entirely
obliteraterj. Each of these requires a separate bat
brief consideration.

45. 2d, Changes of the structure and calibre
of arteries, — A. Aneurism. — a. True atieurism,

or diUitalion oj' arteries occurs — 1st, in a part only
of its circumference, and, 2d, in its entire cir-
cumference : the latter is the more frequent oc-
currence of the two : it may embrace but a small
extent of the ves^el, or it may extend to a con-
siderable portion ; as, for instance, to nearly the
whole of the aorta. Dilatation of a part only of
the circumference of an artery is rare, but cer-
tainly not so rare as to warrant some authors in
disputing its existence. M. Andral states, that
on more occasions than one he has traced dis-
tinctly the three arterial coats passing over the
walls of a sac which seemed as if appended to
the artery, with the cavity of which it commu-
nicated. Dilatation either of a part, or the
whole, of the circumference of an artery, consti-
tutes the true aneurism of authors ; and according
to its extent it may constitute simple dilatation, or
true aneurism in its first stage, and sacculated
aneurism, or the advanced state of this disease.

46. The coals of a dilated portion of artery,
although not ruptured, may be otherwise altered.
They are frequently thinner than natural, and the
middle coat is generally deprived of its elasticity.
In this state the vessel yields like a vein to the dis-
tending impetus of the blood. In other cases, the
coats of the dilated portion of artery are hyper-
trophied. JNI. Andral likens this state to the dila-
tations of the stomach and heart, which are often
accompanied with an increased thickness of their
parietes.

47. b. False aneurism. — Mixed aneurism. —
Dilatation with rupture of one or more of the
coats, constituting the false aneitrism of authors,
is another frequent alteration. The internal and
middle coats are those most frequently ruptured,
the blood coming in contact with the external or
cellular coat or sheath, dilating it in the form of a
pouch, and thus forming the anenrismal sac. 'i he
parietes of this sac are generally much thicker
than the cellular sheath of the vessel was originally,
owing to the gradual condensation of the sur-
rounding cellular tissue from the pressure of the
tumour, and the additional envelope it thus ac-
quires. The interior of the sac is filled more or
less with fibrinous coagula, arranged in concentric
layers, the more exterior of which frequently
become so dense as to be distinguished with diffi-
culty from the paiietes of the sac. Around the
exterior of the sac a degree of irritation is induced,
giving rise to adhesions, which unite it more or less
firmly lo the surrounding parts. But these parts
sufl^er other changes, paiticularly as the anenrismal
tumour increases: they are mechanieally com-
pressed or displaced ; or thev are worn away by
absorption promoted by its pulsations, or by in-
flammatory irritation terminating in ulceration and
destruction of parts. This eflFect upon the adjoin-
ing structures has been shown under the article
Aneiirism of the Aorta, and it islherefore unne-
cessary to illustrate it further. According to some
authors, yu/>e a»/eur!sm consists of the ulceration
or perforation of the internal coats, and of the
dilatation of the external tunic only ; the changes
above de-cribed constituting mixed aneurism.

48. c. Diffused aneurism, &;c. — In general the
irritation created around the sac attacks, after a
lime, the sac itself, occasioning its ulceration and
perforation. Haemorrhage is then the result,
which may be so great as at once to occasion
death. It is frequently arrested by the anato-

I 3

IIB ARTERIES — MoK

mic il relation'^ of tlie pnrt : as when blood flows
into the pericardium ; or wiien the blood passes
into the parenchyma, or loose cellular tissue con-
necting different organs or structures ; in which
case it passes into the sta\e of diffused aneurism.
In some cases the hemorrhage is arrested by
adhesions formed around the sac, constituting a
second envelope to it, which confines the blood,
and prevents it for a time from being further
eflused Perforation of the sac, however, may
take place without hasmorrhage, or even the pro-
(iucli n of diffused aneurism. This happens when
a part in contact with the sac supjilies the place of
that portion of its parietes which has been de-
stroyed, and affords sufficient resistance to the
escape of the blood. Thus we have seen that the
blood, in aneurism of the Aorta, may actually
wash the partially de-troyed vertebraj.no effusion
taking place till still further destruction is occa-
sioned ; and the tumour, in other cases, coming
in contact with the periosteum, produces thicken-
ing of this structure, or the secretion of an osseous
matter from it which partially surrounds the sac,
forming an envelope to it, and preventing the
escape of its contents, until this also is destroyed.

49. In false and mixed aneurisms, the inner
and middle coats are Hist perforated or ruptured,
anfj the third coat either remains entire, or gives
way at some remote period, and thus a secondary
diffused aneurism is formed (§48.). But there is
another form of diffused aneurism, in which all
the coats of the vessel are ruptured or perforated
at once, and the blood, passing entirely out of the
vessel, forms no sac, but is diffused in the adjoin-
ing parts; or it impacts the cellular and parenchy-
matous structure in its vicinity into a species of
sac or envelope ; or it is poured out into a shut
cavity, or into some organ, whence it may be
discharged externally, thus constituting primary
diffused aneurism. In the majority of cases, how-
ever, the aperture in the artery is the result of
ulceration of one or more of the coats of the vessel,
the remaining tunic giving way before the impetus
of the circulation ; the blood being either confined
by the surrounding parts, or escaping into a
cavity, according to the situation of the artery, and
of the apeiture in it. This perforation and ruptuie
of all the coats occur chiefly in the arteries of in-
ternal viscera, as in the splenic, hepatic, emulgent,
iliac, &c. In a case recorded by Mr. Gunn {Edin.
Med. and Snrg. Jmirn. vol. xxxi. p. 90.), these
changes took place in the pulmonary artery.

60. Aneurisms may terminate fui-onrably, a
spontaneous cure being sometimes effected" by
some one of the following processes : — 1st, by a
gradual contraction of the sac, and absorption of
the coagula ; 2d, by the compression exerted by
the sac upon the part of the artery immediately
above it ; 3d, by gangrene of the sac and obliter-
ation of the artery ; 4th, by iiiflammaticm or ab-
Sfiesses in the vicinity, and the coagulable lymph
thrown out, obliterating the aitery, as in the pre-
ceding case; and 5th, by inflammation of the
sac extending to the artery, and giving rise to ad-
hesive inflammation of its interior, and ultimately
to its obliteration.

•01. li. JVakhowino of arteries is either con-
genital or the effect of disease : when the latter,
it i* very frequently associated with, or occasioned
by, ossific deposits,— a change which will be consi-
dered in the sequel. It is chiefly in the aorta aud

EXT) SxnUCTURE OF.

large vessels departing from it that we meet with
either congenital or morbid narrowing. Congeni-
tal contraction of the aorta is generally connected
with extreme thinners of its parietes ; and in some
cases this defective development has been so re-
markable that the abdominal aorta has not equal led
the usual size of the external iliac artery,

52. The contraction of the aorta, or of an arterial
branch, may exist throughout its extent, or may
be confined to a particular part. The abdominal
portion of the aorta is more frequently contracted
(see Aorta) than the thoracic; and when the
former is narrowed, the latter is often dilated.
Sometimes, however, the artery retains its natural
calibre both above and below the constricted
part : instances of this have been recorded by
M. Paris, in the second volume of Desault'*
Journal, and by M. Reynaud (Journ. Hehd. de
Med. t. i. p. 161.). In many cases of constriction
such as I have now noticed, it is difiScult to deter-
mine whether this change has been congenital or
the result of disease, inasmuch as the coats of the
vessel have appeared unaltered from the healthy
slate. But there can be no diflfieulty in deter-
mining in favour of the latter alternative, when the
coats of the contracted portion are thickened, or
contain ossific deposits, or are otherwise changed.
When the contraction is the result of disease,
it is sometimes very remarkable, the cana' of the
vessel being nearly obliterated. The narrowing
found in the principal trunks or branches of ar-
teries is almost always the result of inflammatory
disease ; most commonly of ossific deposits, or of
chronic inflammation.

53. C. Obliteration of arteries is frequently
observed. This lesion may occur in any part of
the system, even in the aorta itself, but it is most
commonly met with in the second or third order
of arteries. The smaller branches may also be ob-
literated ; but they less frequently become the
objects of examination than the larger trunks.
The canal of an artery may be obliterated, 1st, by
fibrinous coagula adhering firmly to the parietes
of the vessel, or incorporated with them ; 2d, by
the conversion of the vessel to a ligamentous
chord ; 3d, by osseous concretions, or other mor-
bid growths, filling entirely its cavity; and, 4tli,
by the advanced progress of aneurism to a spon-
taneous cure.

54. a. The Jirst species of obliteration has been
found in the aorta by Professor Mon'ho {Edin.
Journ. of Med. Scieyice, vol. ii. p. 351.); the part
affected being somewhat contracted and filled up
by a plug of fibrine, which adhered to the surface
of the vessel by coagulable lymph. 'I'his form
of ilisease is common in the arteries of the extre-
mities, particularly the lower, and is sometimes
owing to the rupture of the internal coat of the
vessel. It occurs also in cases of gangrajna seni-
lis, and, with the liiird species ($56.), is a fre-
quent cause of the gangrene. It seems most pro-
bable that it is a more immediate consequence oi
inflammation than the secoud species.

55. b. The second form of obliteration is not
uncommon in large branches of arteries, and has
been found, in two cases, in the aorta : it is evi-
dently a more remote cause of inflammation than
the foregoing. The circulation being entirely ob-
structed, by the coaj;ulable or fibrinous lymph
poured out by the inflamed or ruptured internal
membrane, and by the coagula thus formed, and

ARTERIES— ]\ronBiD Stiuictiihe of.

119

beings kept up by the enlargement of collateral
brandies, the obstructed part is deprived of its
lunciions, and subsequently undergoes those
changes which all vascular or other canals expe-
rience when they no longer are pervious to the
fluids which usually circulate through them, —
they have the fibrinous coagula, which have been
formed in their cavities, and the lymph effused
between their coats, absorbed, and their coats be-
come condensed into ligamentous chords.

66. c. 1 he thiid species has been met with in
the aorta by Dr. Goodison (^Dub. Hasp. Rep.
vol. ii. p. 193.), and M. Velpeau (Rev. Med.
1825, t. iii. p. 326.). In Dr. Goodison's case,
an osseous deposit surrounded the canal of the
vessel, which was completely filled at this part
with a dense fleshy and hbrinous mass, resembling
tlie structure of the heart. A similar obliteration
also existed in the iliac arteries. In M. Vel-
PEAu's case, the obliteration was owing to the
formation of a scirrhous or carcinomatous tumour
in the vessel, resembling similar tumours deve-
loped in difl'erent parts of the body. Obliteration
by polypous or other growths, by fibrinous
coagula and coagulable lymph, by ossific deposits,
&c. are also lound in large arterial branches,
especially in those supplying the lowerexlieniiiies.
The obliteration of the arteries by ossihcalion is
one of the principal causes of the gangrene ot
aged persons. When a considerable artery, or
even the aorta, becomes either much obstructed,
or entirely obliterated, in any of the above ways,
the circulation is generally carried on by enlarged
collateral vessels.

67. d. I'he fourth species has been observed
in several laige aiterial trunks. Dr. Monro's case
of obliteration of the aorta may be partly ascribed
to this cau?e ; the coats of the vessel, although
entire, being dilated below the constricted part.

58. D. AUJOMINOUS AND PURULENT AIaITER.

— M. (Jendiun {Hist. Anat. des liijium. t. ii.
p. 9.) has clearly proved, by his experiments,
that, when an artery is aitificially irritated, its
parietes soon become injected, swollen, softened,
and infiltrated by a serous Huid ; its internal sur-
face is coated by an ulbiiminous exudation, and
coUeciions of pus form, either in the interior of the
ves-el, or between its coats. He has, moreover,
demonstrated that, if the artery continues full of
blood during the experiment, this fluid is coagu-
lated, and altered in a variety ot ways by the mor-
bid secretion poured into it from the internal surface
of the inflamed vessel. Similar appearances have
been observed from disease, particularly in the
aorta and large arterial trunks, where they are
most obvious. Mr. Hodgson and M. Bouillaud
found the internal surface of the aorta lined with
a perfect _/u/se membrane ; and when this was re-
iwoved, the surlace of the vessel was of a briglit
red colour. M. Andkal has observed the inter-
nal membrane of the artery raised by small abs-
cesses, sometimes as laige as the size of a nut,
situated between the internal and middle coats.
It is probably to the bursting of those into the
vessel that ulceration of the internal tunics is
owing. Piis is also sometimes found in the in-
terior of arteries, either unmixed with the blood,
or mixed with it and altering its appearance.

59. E. AiniiROMATOus matter is frequently
found between the inner and middle coats of ar-
teries. It was first noticed in this situation by

MoNiio and IIalieh. It is generally of the
consistence of suet, of a fatty opacjue iippcai-
ance, is greasy to the touch, with niinute gritty
particles thinly scattered through it. In some
cases it resembles a semi-concrete pus, and seems
to result from the changes which pus may have
undergone subsequently to its secretion. In other
cases the atheromatous matter has a cheesy ap-
pearance, or It abounds in gritty particles, which
occasionally even exceed the suety or fatty part ;
and the deposition thus passes into the form of a
calcareous concretion. Jt is extremely probable
that these varieties of morbid formation are con-
nected with chronic inflammatory action of the
coats of the vessel.

60. A variety of the atheromatous matter has
been described by Mohcagni, Scarpa, Sienizel,
and Craigie, under the denomination of steuto-
matous deposition, 'i'he name, however, as Dr.
Craigie has remarked, is not well chosen, inas-
much as this formation is not adipose, but a firm
cheesy or waxy matter, of a yellowish or fawn
colour. It seems merely a more concrete variety
ot the foregoing, and differing from it chiefly in
the absence of gritty particles. It is moie fre-
quently found at the bifurcations of arteries, but
it is not limited to those situations; and is gene-
rally deposited between the inner and middle
coats. When the quantity of this matter is con-
siderable, it encroaches on the calibre of the ves-
sel. This substance is met with either alone, or
with patches of calcareous deposit. It probably
derives its origin fiorn a similar source to the
atheromatous matter ; and, according to Scarpa,
always terminates in ulceration ; but this is not
invariably the case, as it has been observed, par-
ticularly when unattended with calcareous torm-
ations, distending the coats of the vessel to a great
extent without any ulceration. This change,
however, takes place very generally, either when
the deposition of this matter is considerable, or
when associated with calcareous furmations.
W hen ulceration takes place, the coats ol the ves-
sel are soon destroyed to a greater or less extent,
and rupture follows ; taking place, as shown by
JMr. Hodgson, in a transverse direction to the axis
of the vessel, and giving rise to extensive or fatal
haemorrhage, or to circumscribed or diffused
aneurism, according to the situation of the apei-
ture in the vessel.

61. F. Calcareous or ossemis coiicretioiis are
the most frequent moibid appearances presented by
arteries. These concretions, however, differ from
healthy bone chiefly in wanting the fibrous struc-
ture, in not being necessarily deposited in a car-
tilaginous matrix, in consisting of a larger pro-
portion of phosphate of lime, and less animal
matter, and m presenting an irregular, homo-
geneous, and unorganised appearance. Bichat
and Baillie considered that the larger proportion
of persons above sixty years of age have some
part of the arterial system affected by these tonn-
ations. This change is very seldom observed in
early life. Young lound it, however, in an infant ;
Wilson in a young child; and Andral in the
aorta of acliildofeightyearsol age. M. Andral
has met with ossific laminaj in the aorta, in five
or six persons of from eighteen to twenty-lour
years of age : and an extensive ossification of the
superior mesenterie artery of a person not ([uite
thirty. This species of formation always is seatid

1 4

120

ARTERIES — Ossification or.

between the mu-cular coat and the internal mem-
brane, which it olten detaches from its connec-
tiiins ; and it originates either in the atheromatous
matter described (§ 59.), the place of which it
sometimes take^ ; or in those whitish patches al-
ready noticed, which apparently consist of an
alhuminoiis exudation formed between the inner
and middle coat<, and" which pass from the albu-
minou-i, first to the cartilaginous state, and sub-
sequently to that of bone.

62. a. But this is not the only change which
the vessel undergoes , for whilst the calcareous
deposits are going forward, the middle coat be-
comes either hypertrophied, thuscontributing to the
thickened appearance winch the vessel sometimes
presents, or atrophied, being apparently replaced
by the calcareous concretion, and leading to the
mistaken opinion that this coat itself has been
transformed into bone. The osseous concretions
exist in various forms : sometimes they consist of
minute grains ; at other times of irregular plates
of different sizes ; occasionally they incrust the
artery and convert it into an inflexible tube ; and,
more rarely, they give the sensation of a number
of small bodies moving on each other, and as if
jointed together.

63. The ossific concretions may be very con-
siderable, without in any way changing the calibre
or even the form of the vessel ; or they may pro-
ject into it so considerably as to obstruct, or
even to obliterate its canal. They thus occasion
gangra-na senilis. Is has even been supposed, —
and the opinion is very probable, — that they
may project through, or penetrate the internal
membrane, and fall into the cavity of the vessel ;
and, being conveyed onwards with the current of
blood until they arrive at arteries of smaller ca-
libre, may thus completely obstruct them. The
calcareous concrelioiis found in some rare instances
plugging up the canal of the vessel, evidently are
produced in this way.

64. h. As to the comparative frequency of this
lesion in various arteries, I may add a few re-
marks, derived from the interesting materials
supplied by M. Andhal {Anat. Path. t. ii.
p. 393.). The aorta is the most liable of any to
ossification in some part or another; but every
one of the branches proceeding from it may like-
wise be the seat of this change. The coronary
arteries are frequently ossified, both in their
trunks and in their subdivisions. The large ves-
sels which arise from the arch of the aorta often
present at their origin a bony ridge projecting into
their interior. The cerebral arteries of old per-
sons are frequently found studded with cariilagi-
nous and osseous lamina;; and M. Bouim.aud
has shown that this change disposes remarkably
to apo|)lexy with sanguineous extravasation. Os-
sification is very common in the splenic artery,
but exceedingly rare in the hepatic, and coronary
arlery of the stomach. A bony ridge is ol'len
found at the origin of the common iliacs. The
arteries of the lower extremities are not infre-
quently the seat of these concretions ; and they
sometimes occur in the radial arte y of aged [)er-
Bons. IM. Anduai, has never met with this
alteration in the hypogastric artery. llAr.r.Fn met
with it once in this vessel (Opusc. I'atli. Ohs.59.);
and this is the only case ol the kind on record.
— All the morbid depositions desciibed above
liave been found in the pulmonary artery, but

much more rarely than in the aorta and vessels
proceeding from it.

65. c. Origin of osseous formatiuns in the or-
teries. — The Ossification of arteries has been
ascribed by many authors to slight chronic in-
flammatory action. The experiments of M. Raykr
and M. Cruveilhier seem to confirm this infer-
ence,.as an occasional occurrence at least, parii-
cularly in the fibrous and cartilaginous structures :
increased vascular action of those structures, aiti-
ficially excited, being generally followed by
ossiform depositions ; but, in a number of cases,
particularly in those where the deposit takes
place in the cellular tissues, no inflammatory ac-
tion can be detected previously to this change :
besides, increased vascular action frequently
exists, without being attended with ossiform de-
positions. This lesion therefore cannot be al-
together ascribed to this cause, although frequently
resulting from it, in a certain order of tissues.
It would be more correct to consider it merely as
a consequence of disorder of the natural proci-ss
of nutrition and secretion, frequently induced, in
particular tissues, by a chronic state of inflam-
matory action. But to what cause is this disorder
of the nutritive function to be imputed, particu-
larly when it occurs in parts which have not
evinced any sign of inflammatory action, as in the
cellular tissue connecting the internal coats of
arteries ? The importance of this inquiry may
appear from the very great proportion of persons,
in advanced years, who are affected, in some
organ or tissue, with this lesion, and from the
remarkable part it performs in the production of a
number of dangerous diseases.

66. In answer to this, M. Andral very plau-
sibly observes, that physicians have frequently
noticed the existence or succession of three dif-
ferent forms of calcareous productions in persons
of a gouty diathesis : 1st, gravel and urinary
calculi; 2d, hard concretions in the small joints;
and, 3d, ossiform productions in the arterial sys-
tem and other parts. Is it not, therefore, probable
that morbid ossification proceeds from a similar
cause to those other calcareous formations? We
have seen that gout generally originates in an
excessive use of animal food, conjoined with de-
ficient assimilative and secreting powers of the
frame. The highly azotised blocd of a person
thus circumstanced becomes surcharged with
urea and phosphate of lime, as evinced by the
state of the urinary secretions, which always,
in such cases, abounds with uric acid and the
earthy salts. The experiments of M. Magundie
have proved that by changing the diet of a person
who has been living chiefly upon animal food,
and by substituting substances containing no azote,
the uric acid and phosphates disappear from
the urine. May we not, therefore, infer that
in consequence of the excessive use of animal
food conjoined with imperfect assimilative and
secreting powers, these substances will accumu-
late in the blood to a hurtful extent ; the urinary
organs being unable to eliminate them entirely
from the circulating fluid ? The necessary result
of this state of the blooil will be, that these sub-
stances will occasionally be deposited in other
parts, giving origin to the uric acid concretions
found in the small joints, nr.d to the phosphate of
lime deposits found in the arterial system and
some other parts. From this it will be apparent

ARTERIES — Theatmentof TiiEin Diseapes.

121

that the ossific formations met with in the arteries | tendency, also, to limit tiie iiifiiimrnation by llie
are derived tVom a similar origin to that wliieh ] foimation of coagulnble lympli, when the period
has been more fully explained under the articles | of resolution is past, may also be overcome by loo
Gout and Urinary Calculi. The increased j great depression of the vital energies, wliicli ought
vascularity, observed frequently to co-exist with ! therefore to bfe supported in extreme cases, and not
the morbid secretion of calcareous matter, may depressed too low in others.

proceed from the irritation produced in the capil
laries by the moibid matters circulating in them ;
or it may be a necessary attendant upon the se-
cretory process, especially when this process is of
a morbid description ; or ihe accidental occur-
rence of irritation and increased vascular action

70. li. The more chronic states of arteritis
require cooling purgatives, occasional depletions,
and a low refiigerant diet and regimen. A vege-
table, particularly a farinaceous diet, is extremely
serviceable in these states of the disease, chiefly
by preventing the consequences to which they

in the interior coats of the vessel may prove tlie I usually lead. The richer and more stimulatim;
determining cause of the ossiform deposit, to the , kinds of animal food, and particularly pork, should
formation of which a disposition harl previously j be con^taiitly avoided, and all tendency to pie-

existed, owing to the excessive abundance of the
phosphates in the bloud. If this explanation of
the origin of ossification in the arteries be correct,
a rational method of preventing and combating
this lesion is presented to us for adoption.

67. V. TnEATMENT. — A. Tile more acute states
nf arteritis re(iuire the same general principles
and details of treatment as inflammations of other
parts. General and local depletions, calomel
and oleaginous purgatives, cathartic enemata, dia-
phoretics consisting chiefly of camphor, antimony,
and opium, tkc. (F. 39. 184. 358. 460.); cool-
ing diluents, and the rest of the antiphlogistic
rejiimen, are indispensably requisite. After a
copious depletion, practised so as not to occasion
full syncope, the following wdl be found of service
in preventing the re-accession of increased vascu-
lar action.

No. 33. R. Camphorae rnsse gr. iij v.; Pulv. Jacobi

Verigr.v.(vel Antiiiionii Potassio-Tart. gr. ss.^; Calomel.

gr. xij. ; Opii Puri gr. ij iij. ; Coiiserv. Kosar. q. s. ut

tiat Bolus, statira post venaesectionem capiendus.

68. In the more acute states of arteritis, digi-

thora suppressed or subdued. In the chronic as
well as the acute diseases of arteries, physical and
moral tranquillity is particularly required. Tlie
abdominal secretions and excretions ought to be
duly examined and regulated, \indue sinking of the
vital energies prevented or counteracted, pure air
prescribed, and due attention paid to the digestive
functions.

71. C. The consequences of inflammation of ar-
teries, whether those more palpable changes which
constitute the different kinds <jf aneurism, or those
which are merely matters of more doubtful in-
ference, can be treated only upon the above
principles: above all, vascular pleihora must be
avoided, -and tranquillity observed. Tliere is,
however, one fact, which, I consider, should not
be lost sight of by the practitioner, nnd which is
the result of attentive observation ; namely, that,
even in aneurism, more mischief will be derived
from depressing the vital energies of the frame too
low, tiian from observing a more moderate, or
rather a less vigorous, mode of treatment. When
carried too far, relatively to the circumstances of

talis and emollient diluents, with nitrate of potash, the case, those guards which the Restorative powers
or the vegetable acids, may be exhibited. After i of the frame set up against the extension of the
depletions have been carried as far as may be ' disease are thrown down ; the destruction of ad-
con-.idered prudent, and when there exists no joining parts extends; the fibrous coagula which
constitutional vice contra-indicating the practice, fortify tlie weakened parietes of the vessel, and
the mercurial preparations may be given to the tend even to a spontaneous cure of the disea-e
extent of afl^ecting the gums. The repetition of (§ 50.), assume, as Mr. Guthiue has very justly
the bolus now prescribed will generally be suf- j remarked, a loose and spongy state, and allow the
ficient for this purpose, the bowels having been j blood to pass through it, or between it and the
well evacuated previously. In this form of ar. coat or coats of the vessel ; and the disease, con-
teritis, Hildenbrand recommends (Insiit. Med. sequentlv, makes rapid progress. There can be
t. iii. p. 26.) cold epithems over the seat of the no doubt, as hinted at by this eminent surgeon,
inflamed vessels, the internal use of lemon ices, that the extension, and ultimately the bursting, of
and the cautious exhibition of ihe superacelate aneurisms, are not altogether owing to the im|>etns
of /euri and opium (F. 206.), alter depletions have of the blood in the vessel ; and that, therelure.

been practised. Colchicum may also be given, or
substituted for digitalis; but these medicines re-
quire great caution in their exhibition, particu-
larly after large depletions, and when antimonials
precede or accompany them. The diet ought to
be very low, cooling, and chiefly farinaceous;
and, during recovery, the more heating kinds of
animal food should be abstained from. During
the disease, as well as during convalescence, per-
fect tranquillity of body and mind should be in-
sisted on.

69. In some states of acute arteritis, it may
not be advisable to lower the powers of life too
much ; as we may thereby ri^k the occurrence of
arterial throbbings, the extension of di--ease along
the internal membrane of the vessel, and the
vitiation of the circulating mass by the secretion
poured into it from the inflamed surface. The

the treatment which is solely directed to this
point must be deficient. The suggestions novv
cfltred {§§ 69, 70.), as well as those stated in the
article on Aneurism of the Aorta, will be suffi-
cient to guide the practitioner in this respect.

72. D. The complicutiims of inflammations of
arteries, and theii' conseciuences (^ 32. et seq.),
require attention to the fact, that, when arteritis
supervenes in the course of other diseases, it is
generally during those stages which are charac-
terised by depression- of the constitutional powers,
when the circulating fluid becomes materially
changed from its healthy condition, and most
probably loaded with an unusual quantity "of
unassimilated, morbid, or irritating materials. In-
deeil, these are the circumstances which favour
the occurrence of all inflammations affecting the
different circulating systems— the lymphatic as

122

ARTS AND EMPLOYMENTS— AS Causes of Disease.

well as the venous ; and they account at the same
time for the very fre(]uent aseociation of arteritis
with phlebitis, particularly in the last stages of
febrile anil eruptive disease*. 1 hese considerations
n iturally suggest the propriety of having recourse
to such measures as may be best suited to indi-
vidual cases for the prevention of inordinate de-
pression of the energies of life, during the advanced
stages of diseases, when we fear the supervention
or the existence of arteritis ; or as may support
those energies, whilst we excite the organs whose
functions are chiefly to eliminate irritating and
hurtful matters from the circulation. By thus
opposing too great depression, turtlier deterioration
of tlie blood is more likely to be prevented than
by any other indication of cure ; whilst the re-
moval of the cause, — the source of irritation of
the internal surface of the vessels, — presents a
probable chance of the disappearance of its effects.
(See Acuta — Diseases oj.)

Bibliography A. Inflartunation and its Consequences.

— Lnngsverl, l)e Ait.et Venar. Adfectibus, Prag. 1764 —
Murgagni, De Sed. et Caus. Morb., epist. xxvi. art. 35, 36.

— Oi/i'/ie,Ue Morbis Itecent. Natorum. Lips. 1773

J. P.Frank, De Curandis Hominum Mnrbis, t. ii. Manh.
J792 —Sckmtick, Observat. Med. de Vasor. Satiguif. In-

flammatione. Heidelb. 1794 Spattgenberg, in Hurti's

Archiv fiir Med. &c., b. v. 2 belt, n. I — Sanse, Dissert,
de Vasor. Sanguif. Inflanimatione. Hal. 1797 — Portal,
Anatomic Meduale, t. iii. p. 127. Pai is, 1803. — Schivilgui,
jn bibliotlieque Mtdicale, t ■x.\\.—Treviramis , Biologie,
b. V. p. 414. — J. Hodgson. Diseases of the Arteries and

Veins. Lond. 1815 Jiemrr, Dissert.de Plethora Sanguin.

Helmst. 1797 Kieysig, Herzkranklieiten, iii. theil.

Ber. 1817. s. 2G9 — Dalbant, Oliservat. pour servir a
I'Hist. de I'Arterite. Paris, \%\'i. — Bryani, in Loud.

Med.Repos.t. xviii.p.6 raidy,\n Journ. Complement.

Aout, \>il'J. — Back, in Revue Medicale, Mai, 1820.—
Kertnedy, in Ju/insou's Med. Chirurg. Review, vol. ii.

p. 60 Breschtt, De I'Arterite, Jonrn. de Progres de

.Scien. Med. t. xvii. p. 119. Par. 1829 — BuuiUaud, Art.
Arterite, in Diction, de Med. et Cliirurg. Pratique, t. iii.
Par. 1S29. _ Langenbeck, Nosol. und Therapie d. Chir.
Krankh. bd. i. p. 589. Gotting. 1822.— A'aM»n«nn, art.
Arteritis, Medicin. Chirurg. Encyclocadie, band iii.
Berlin, 1829. — V.N Hildenbrand, Institutiones Practico-
Medicae, t. iii p. 21. Wien, 1822.

B. Morbid Structures, ^c Cowprr, Philosoph. Trans.

No. 285. p. 1391 Aaish, ibid. No. 309. p. •2-26.—Murgng7ii,

De Sed. et Cans. Morb., epist. xxiii. art. iv. 6.. xlvi. art.
'JO — Fo.sf//M.<, Dissert, sistens Moibos Arteriarum, &c.
Jena, 1757. — Gemwa, in Halter's Biblioth. Med. Pract.
ii.p. VJ%.— iyalter, Obueiv. Aiiat. p. 44 — Stenstel, Haller's
Di>p. ad Morb. Hisioriam, &r. t. ii. p. biT. — Bicliaf,
Aiiatomip Generate, t. ii. p. 'i\i'i.—Baillie, Trans, of So-
ciety lor Imp. of Med. and Chir. Ivi.owledge, vol. ii. p.
y.Vi.— JVcniiel, in IJuJeland's Journ. der Pract. Arzeney-

kunde, b. viii. St. 4." p. 100 Scarpa, SuU' Aneurismo,

cap. v. § 22. — C/iaujisier, in Journ. Gener. de Med. Mars,
IKll, p. 3]8. — Maunoir, in iliid. Mars, 181i, p. SzS.—
Jldgstrom, in Hnjcland und Ilimly, Jonrn. der Pract.
Heilk Jul. 1811, p. y>\.— Trovers, in Med. and Chirurg.
Trans, vol. iv. ji. 438. _lc//o/y, ibid. vol. xii. p. 505. —
Muudiiii, Archives Ccii. de Med. t. v. p 137.— Turner,
Transac. of M( d. and Cliirurg. Soc. of Edin. vol. iii. p.

lOn. Craifiie. Klcmcnts of Gen. and Pathol. Anatomy,

J). 87. — A. Monro, ui i:din. Journ. of Med. Sciences, vol.
ii. p. 3^\. — Andral, On I'alhological Anatomy, by Town-
send, vol. ii. p. 3C7.- Oulhrie, The I)ise.ises and Injuries
of Arteries, &c. Lond. 1830. (A work that should be
in the hands of every piactitioner.)

AR'l IIIUTIS. See Gout.

AK'IS AM. KMl'LOYMEN'iS Classif,

— Paiiioi.ogv. — Lliolof^ii.

1. An inquiry iiiio the diseases caused by the
prosecution ot the various arts of civilised life
is of the utmost inriporlance to the scientific pro-
fessor of medicine in ail countries, but particularly
in this; for in no other country are ihe useful arts
to exiensively pro^ecuttd as in (Jieal liiituin.
'J'lie great impoitunce of the subject has been
acknowledged by the success of the able works ot

2. As it would be foreign to my plan to take
into consideration at this place the diseases occa-
sioned by the numerous arts which furnish em-
ployment and subsistence for a very large part of
the population of this and many other countries,
particularly as these diseases will be considered
in their more important relations in other places,
and many of them under distinct articles ; 1 will
here confine mvself to a succinct account of the
effects which the prosecution of the various useful
arts directly or indirectly produces in the frame ;
interspersed with a few remarks as to their influ-
ence in modifying the characters of various dis-
eases, and as to the means by which their injurious
effects may be partially prevented or counteracted.

3. In offering these observations, I will only, in
some respects, observe the arrangement adopted
by Ramazzini, and closely followed by Fourcroy
and Patissier. This arrangement is founded on
the nature of the causes producing the diseases to
which artisans are liable. The First Class of
causes consists — 1st, Of conjinemeiii, and insnf-

Jicient ventilation; 2d, Of undue exertion; and,
3d, Of sedentary habits. The Seconu Class com-
prehends — 1st, Undue exertion of particular
parts, and insufficient exercise of other parts ;
2d, Unnatural or constrained positions in different
emptoiftnents ; and 3d, Temperature and moisture.
The Third Class embraces those causes which
consist of material molecules, and which, coming
directly or mediately in contact with the body, in
the state either of vapour or of minute disinte-
gration, penetrate the organs, and disorder their
functions. These are — 1st, Mineral molecules;
2d, Vegetable molecules ; 3d, Animal molecules ;
and, 4th, Mineral and vegetable molecules acting
mechanically. On the operation and effects of
each of these, as being intimately connected with
the nature, complication, and removal of diseases,
I proceed to offer a few remarks.

4. I. Class first. — 1st, The hurtj'ul infltienceof
confinement and of insufficient ventilation is great
in proportion to tlie youth or early years of tlio.^e
who are thus circumstanced. In the majority of
factories, artisans are congregated in great num-
bers, necessarily confined during the greater part
of the day in the same apartment, which, being
usually warmed by artificial lieat, — by pipes con-
ducting heated air or steam, — have not the air
renewed with that rapidity which necessarily ob-
tains in apartments provided with the fire-places
in common use. The consequences are, that those
confined in them breathe an impurer air than
under ordinary circumstances ; and experience the
debilitating influence occasioned by an atmosphere
loaded with an increased quantity of carbonic acid
gas and animal effluvia.

5. Persons who have already attained to their
full growth, and tho.se particularly who have
nearly reached the meridian of life, seldom ex-
perience the deleterious effects of confinement
under such circumstances, to nearly the same ex-
lent as those in early life. When the subject was
brought before parliament by Sir Robert Peel,
Mr. Owen, of New Lanark, stated, respecting
the children employed in his manufactory, that,
iilthough they were extremely well fed, clothed,
and lodged, looked fresh, and, to a superficial
observer, were healthy in their countenances, yet

Ramaz/.i.m, jMirat, Patissier, aiitl TiiAtKUAii, their limbs were geneially deformed, their growth
on the diseases of ailisuns. I stunted, and they were incapable of making much

ARTS AND EMPLOYINIEN

progress in the first rudiments of education. This
statement, which appears to have been made as a
result of large experience, agrees with the observ-
ations of other able men. The evidence of Sir
AsTi.EV Cooper is even still more decided, and
is perfectly in accordance with the experience of
every competent judge. The result of conHne-
nient, this eminent surgeon state'^, is not only to
stunt the growth, but to produce deformity.
Every traveller in countiie'^, the population of
which consists chiefly of those whose avocations
bring them much in the open air, or in agricultural
di-:tricts, must have remarked not only the much
more lully developed frames, and larger lower
extremities, of the inhabitants of those parts, but
aUo the more phlogistic or inflammatory charac-
ters of their disorders, and their greater vital re-
sistance and powers of restoration when exposed to
the causes, or suffering from attacks of disease,
than are manifested by the inhabitants of crowded
iiianutacturing towns.

6. Not only is confinement in itself detrimental
to the frame, particularly during the epochs of
developenient of the various structures of the
body, when air and exercise are nearly as requi-
site as food to their perfection, but the construc-
tion of the apartments, the want of ventilation,
the accumulation of animal effluvia, and the
moral depravation consequent upon continued
assemblages of persons little under physical and
moral control, essentially increase its injurious
efl^fcts, and co-operate with it in impressing an
asthenic character on the frame ; in dispo-ing to
the formation of tubercles, and to the strumous
diathesis; in depressing the vital energies and
uiental manifestations ; and, con?equently, in dis-
posing the body the more to the usual exciting
causes of disease, and the mind to vicious habits
and indulgences.

7. 2d, Over eiertion is a very frequent cause
of disease among many artisans ; and, like con-
finement, it is the more injurious the earlier in
life it comes into operation. In the lower ani-
mals, particularly in the horse, the consequences
of over-exertion are fully manifested. '1 his ani-
mal seldom reaches one half of its natural life as
eniployed in this and many other countries. As
to the effects of over-exertion on man, much will
depend upon his habits and modes of living. When
well fed, and of regular habits, its injurious con-
sequences are neither so great, nor so snon ap-
pear, as when he is poorly fed or addicted to the
use of spirituous liquors.

8. Over-exertion shortens life, 1st, by injuring
the continuity, cohesion, or relative situation of
various parts; 2d, by inducing that degree of ex-
haustion which runs on to irremediable or falni
disease; and, 3d, by that gradual and insensible
expenditure of vital influence, beyond the power
of reinforcing it, whereby the mean duration of
human life is shortened. The trades which chiefly
illustrate the above positions are coal-heavers, na-
vigators or ballast-dredgers, smiths, miners, &c.

9. It should not be overlooked, that in many
trades the artisan is not only subjected to confine-
ment in close and imperfectly ventilated apart-
ments, but is at the same time obliged to over-
exert his physical powers. In such cases the ill
effects are necessarily greatly augmented ; more
especially in children or very young persons, who
are naturally impatient both of confinement and

TS — A3 Causes op Disease. 123

over-exertion ; and in ihem particularly are the
injurious effects, moral as well as physical, chiefly
manifested. JVlany of those who become the most
drunken, immoral, or feloniously depraved, have
been initiated in vice from the associations formed
in factories.

10. 3d, Sedentary habits, are also adverse to
health, but only in a negative manner, as respect's
persons living in well ventilated and wholesome
situations. The simple neglect of due exercise,
however, is after a time generally productive of
disease, owing both to its effects upon the nervous
and muscular energies — the manifestation of all
our functions being improved by a moderate ex-
ertion of them— and to its influence on the se-
cretions and excretions, which require a certain
degree of muscular exercise for their promotion.
Literary men suffer in a particular manner from
want of bodily exercise, chiefly owing to the
over-exertion of the mental powers, the bent
position of the trunk, and the stagnant air of close
apartments. Clerks, and various artisans, suffer
also from the same cause, particularly tailnrs,
shoemakers, watchmakers, weavers, jewellers, &c.
In some of these, the pressure made upon the
lower part of the sternum and stomach proves
very injurious.

11. Mr. DoBSON furnishes very instructive in-
formation as to the eflPects of confinement to ii
particular posture and in a close atmosphere upon
tailors. Of 334 men, employed by Stultz &, Co.,
in London, six are above sixty years of age ;
fourteen about fifty ; and the greater number of
the remainder about forty. Three of the six
above sixty have curvature of the spine. Their
most common affections are dyspepsia, diarrhea,
headach. giddiness, and anal fistula, to wtiich
latter they are so subject that they have a " fistulu
club." They attribute their complaints to tlie
bent posture of their bodies for thirteen hours a
day, and the heat of the work-hop. Tailors are
.the most intemperate set of workmen in London.
A large proportion of them die annually of
phthisis. (TiiACKn AH, &c. p. 17.) The diseases
most commonly observed amongst shoemakers are
chronic inflammations of the stomach, liver, and
bowels, occasioned by the pressure of the last
on the lower part of the sternum, where it occa-
sions, in those who are long-lived, a considerable
depression.

12. The sitting posture, when long or habitu-
ally continuerl, is very huriful in persons of
sedentary habits. M. Patissier remarks, that it
causes the lymphatic to predominate over the
nervous, sanguiferous, and muscular diathesis.
Artisans and others who adopt it early in life,
rarely acquire vigorous constitutions, or reach
old age, although old age soon overtakes them.
Persons with this habit soon become subject to
dyspeptic disorders, to aflPections of the kidneys
and urinary organs, to constipation, hccmorrhoiils,
various cachectic afl'ections, obesity, and, in fe-
males, to fluor albus, and difficult or irregular
menstruation. When, in addition to along-con-
tinued sitting posture, the trunk is bent, and
pressure frequently made over the epigastrium
and sternum, as with shoemakers, weavers, at-
torneys' or bankers' clerks, ice, gastrodynia,
nervous palpitations, chronic gastiitis, pulmonary
consumption, chronic pericarditis, and imperfect
digestion, excretion, and assimilation, amounting

124

ARTS AND EMPLOYMENTS — AS Causes of Disease.

even to complete astlienia, are the not infrequent
re?ults. The luiitful eiTects of the sitting posture
and bent state of the trunk are much increased by
<ieficiency of food on the one hand, or by too full
living on the other ; and by habitual excesses of
any kind, but particularly in the use of ardent
spirits.

13. Literary men who are of sedentary habits
are liable both to tiie disorders which result there-
from and to those which depend upon over-
exertion of the mental faculties. Amongst tlie
latter, melancholy, hypochondriasis, cephalalgia,
paralysis, apoplexy, palsy, inflammation of the
brain or of its membranes, mania, and softening
of the brain, hold a piominent place. All these
evils are, however, in a great measure prevented
by moderate diet and regimen, by avoiding ex-
cesses of every description, by regular and mode-
rate exercise in the open air, by early rising, by
sufficient but not too much sleep, with attention
to the digestive organs, and to the promotion of
the abdominal secretions and excretions.

14. II. Cr.Ass Second. — 1st, The undue exer-
tion of particniur organs, with or without insuffi-
cient exercise of other parts, is often productive of
most mjurious ett'ects ; but much of the evds im-
puted to this cause by MM. Gosse, Merat, and
Patissier, are either imaginary, or merely matter
of occasional coincidence. A. The consequences
of undue muscular exertion are chiefly hernia,
aneurisms of the large vessels, dilatation of the
cavities of the heart, haemorrliages from the lungs
or nose, injuries of tlie ligaments and intervertebral
spaces, sprains and lacerations of muscles ; and
are chiefly met with among those occupaiions that
are of a laborious kind, as porters, coal-heavers,
draymen, &c. Of all these injurious consequences,
herniae are very much the most frequent. Amongst
all those persons who bring the back and superior
extremities into frequent energetic exercise, it
will be ob'-erved that the muscles of these parts
are not infrequently developed either at the ex-
pense of those of the lower extremities, or to a
fiegree far beyond ihem. This partly arises from
the shuffling gait of those persons, and from not
throwing the gastrocnemii muscles into action.

15. B. Over-exertion of tlie vocal organs is
not infrequently productive of disease. I'he
nffections which proceed from this cause are
hnemoptysis, laryngeal phtliisis, aphonia, oedema
of the glottis ; functional, and sub'^equently or-
ganic, diseases of the heart and laige vessels;
nervous and cerel)ral affections. The persons
most liable to be affected by this cause are public
dingers and orators ; but I believe that the ill
effects resulting from it, in any of the above states
of disease, are not so great nor so frecjuent as
some writers have staieil. Much of the mischief
imputed to this cause is referrible rather to the
enthusiasm of singers and orators, to the passions
which are calleil up during the exercise of their
powers, and to the various disr-ipations and ex-
})osures into which their avocalions lead them,
'J'he occurrence of musico-mania from excessive
musical etithusiasm is known to all physicians.
It is obvious that the first signs of the accession
of the above diseases in the persons of singers and
orators, re()nire strict avoidance of the cause.

16. C. 'I'iie continued or intense action of tight
on the eyes, and apjitication of them to small ob-
jects, as utnong^t workers at irnn forges and fur-

naces, engravers, watchuiakers, embroiderers
painters, &c., are ofien followed by injury to, or
entire loss of, sight ; persons thus employed being
liable to amaurosis, cataract, inflammation of the
retina, iris, or capsule of the lens, and to short-
sightedness, owing to the more convex form the
eye acquires from continued compression by the
muscles attached to the eye-balls.

17. 2d, Unnatural or coiistrained positions are
extremely injurious in the prosecution of any art
or employment. Occupations that require long-
continued standing have been said to be produc-
tive of varices in the lower extremities ; but I am
not aware that such affections are more common
amongst printers, who usually stand at the frames,
than in other persons. There is no doubt of
i/?irf»e pressure made upon any particular part of
the body in the exercise of any art or trade, or
even slight pressure when long continued, being
most injurious. This is remarkably the case when
the pres-ure is made upon the abdomen, par-
ticularly over the epigastrium, and still more so if
it impede the actions of the respiratory muscles.
Various occupations, which are injurious from
this cause, might be pursued with great assiduity
by attending to those circumstances, many of them
trivial, which may remove or counteract it. Thus
clerk-, and others, who are often injured by stoop-
ing over a de>k, and by pressing the chest against
it, as well as by the silting posture too long con-
tinued, would be much benefited by frequently,
or even occasionally, standing at a raised de.-k.
Tailors and shoemakers are also very liable to
suffer from this cause. The stooping posture is
not infrequently productive of cerebral and nervous
afl'eclioiis ; hence the frequency of them in gar-
deners. Working in constrained positions shows
its effects most decidedly in miners and colliers,
who labour chiefly in the sitting or kneeling pos-
ture, frequently with the body bent in the greatest
degree, in an unnatural atmosphere, often con-
taining hydrogen, or carbureited hydrogen, and
carbonic acid gases, and with artificial light. They
are, moreover, exposed to changes of air, and oc-
casionally work with their feet in water. They
are generally spare men, with slightly curved
spine, and bowed legs. When the dirt with which
their skin is usually loaded is removed, the com-
plexion seenis sallow and unhealthy. 'J'heir com*
plaints are asthma, rheumatism, disorders of the
head, intolerance of light, &c., evidently resulting
from the circumstance just stated connected with
their employment, and their exclusion from the
beneficial influence of sunshine, light, and air.
'J'hey are not generally very intemperate, yet they
seldom live beyond fifty.

18. 3d, Temperature and moisture, and par-
ticularly rapid vicissitudes of ihem, are extremely
j)roductive of disease amongst artisans, but chiefly
from negligence, and the want of caution in ex-
posures to them. Forgers, glass-blowers, brass
and iron founders, l)akers, biewers and various
other classes of artisans, are liable to be affected
by the high temperature in which they work, and
by impiudent exposure to cold when perspiring,
and olten without any additional clothing. The
most fref|U(nt consequences are checked perspira-
tions, producing catarrhs, rheumatism, bronchitis,
asthma, and inflanmiation of the lungs, or of some
one of the abdominal viscera.

19. a. The bad effects of moisture only are pro-

ARTS AND EMPLOYMENTS — AS Causes of Disease.

12^

blematical, or at least not very remarkable. It
is only from the circums^tance of its being either
tlie cause of a greatly depressed temperature, or
the very common vehicle in which other agents
oi disease are dissolved, and thereby diffused in
the air, or applied in a more active slate to the
different organs, particulaily the respiratory, that
it becomes a very active agent of disease, as is
demonstrated by the etioIog\ of the intertropical
and malignant diseases. When exposure of the
external surface of the body to moisture is in-
jurious, tiie mischief is caused chiefly by the de-
pressing effects of the low temperature which it
occasions. The animal heat is less rapidly car-
ried off by entire submersion in water, than by
aspersion merely. In the former case there is no
evaporation, in the latter more or less evaporation
takes place, and much cold is theieby generated.
The histories of shipwrecks abound in proofs of
this position. Dr. Currie, in his well known
work, has adduced a striking example of it. It
is owing to the evaporation which takes place
from damp or moist clothes, and the consequent
rapid reduction of their temperaiuie, that disease
is occasioned by them,

20. Artisans who, from the laborious nature of
tluir occupations, perspire copiously, and thereby
render their clothes damp, seldom suffer from
this cause while they continue their labours ; but
when they relax, or desist altogether, their wear-
ing the moistened clothes, particularly in a state
of exhaustion, is frequently productive of disease.
Inattention to, or inability of, changing damp or
wet clothes, are the most common causes of the
disorders met with in milkmen, gardeners, fisher-
men, washerwomen, fullers, water carriers, and
persons whose occupations are chiefly out of doors.
In marshy or unhealthy localities, the effects ol this
cause are greatly increased. 1'he steepers and
cleaners of hemp and flax are extremely liable to
inlermittents, ouing to the conjunction of vege-
table effluvia with moisture. Even peisoiis con-
stantly employed in crowded factories, where the
stagnant air becomes loaded with the foul vapours
exhaled from the lungs of a number of persons,
may have their clothes so saturated with moisture
fis thereby to occasion the usual consequences of
cold, when exposed to a drier or opener air. It
should be kept in recollection, that cold, when
it continues to act for any time upon the frame,
is sedative — it depresses the vital influence ; and,
when acting partially, or directed to parts of the
body only, that it is one of the most productive
causes of alieied energy and sensibility of the
nervous system of such part, of irregular di.-tri-
butions of vital influence and of the blood, and
consequently fruitful of inflammations, and of
morbid discharges and actions.

21. I>. The prevention of diseases resulting from
the description of causes adduced under this head
is important. Wearing flannel next the skin is
amongst the most efHcacious. For those who are
exposed to moisture from out-of-door vocations,
the use of external garments of dressed skins,
or of tanned leather, or of oil-skin, during the
time of exposure, is extremely serviceable, and
is yenerally adopted by the fishermen of northern
countries.

22. III. Class Third. — \!it,The muiera I nwle-
cules, which, either in the form of vapour or of
minute disintegration, come in contact directly or

mediately with various parts of the body, are
extremely frequent causes of disease in artisans ;
and some of the maladies they produce are pos-
sessed of specific characters,

23. A. Mercury is one of the most common
causes of the diseases of artificers, particularly
workmen in quicksilver mines, glass-platers,
gildeis of buttons, toys, &:c. Dr. Gusse has re-
niaiked the greatly increased sensibility of those
persons to cold, even to the slightest diminution
of temjierature, evidently owing to depression of
the vital energy and organic action-, and con-
sequently of the process of animal calorification.
Persons long or habitually exposed to fumes of
quicksilver are generally affected with ulcerations
of the mouMi and fauces ; painful or rlieumatic
affections of the periosteum, joints, limbs, and
ligaments, particularly after exposure to cold :
eruptions on the surface of the body, and all the
affections to which the term pseudo-'-yphilis has
been applied; as well as many of those which
are usually denominated cachectic. The effects
are altogether the same, although slower in their
accession and piogress, as those which result from
a too long continued, but not violent mercurial
course.

24. a. Amongst the most important of the affec-
tions produced by the fumes or oxides of mercury
in artisans is the mercitritil -pahif, the tremhtemeut
mercuriel of the French pathologi>ts. It is almost,
but certainly not altogether, peculiar to these
persons. Its approach is generally gradual, but
occasionally sudden ; it usually commences with
slight convulsive snatches, followed by agitations
and tremors of the affected muscles, particularly
those of the arms, which it first attacks, occurring
as it commonly does amongst the workers in nier-
cury. If the person continues his employment,
the affection extends to the lower extremities anil
whole body. He becomes incapable of muscular
exertion, and even of the avocations requiring tlas
least precision of muscular action. Restlessness,
falling out of the teeth, constipation or disorder
of the bowels, a dry and brownish state ol' thj
skin, slight atonic convulsions, cephalalgia, de-
lirium, great depression of the nervous power-,
and of the general health, take place, in which
state the patient may continue to live for many
years. (IMerat and Colson.) Although it i.5
chiefly long-continued exposures to mercurial
preparations which produce this affection, a single
exposure to the fumes, eveu for a lew lioun:,
when they float in the air, may occasion it ; the
effects being both rapid and violent when their
vapours are inhaled with the atmosphere, and act
upon the extensive surface of the bronchial tubes
and air-cells.

25. b. The habits of the workmen exposed to the
fumes or oxides of nieicury, render the treatment
of this affection extremely dithcult, owing chiefly
to the circumstance of their frequent recourse to
spirituous liquors, for the temporary advantage
they afford, and to their deferring having recourse
to medical aid until the disease becomes con-
firmed. In recent cases, leaving off the trade
that occasioned it will alone produce a cure. In
long-continued or confirmed cases, benefit is ob-
tained with much more difficulty ; and, when pro-
cured, the disorder is extremely apt to retuin alter
the sligh.test exposure to mercurial fumes. De
Haen prescribed eledricity in the cases wliicU

126

ARTS AND EMPLOYMENTS — as Cavses of Disease.

occurred to him. Lettsoji recommended sul-
phur ; and I believe that its good effects are very
considerable. In a case which lately came be-
fore me, of violent cephalalgia, with muscular
tremors, &c., after a severe mercurial course,
large doses of sul, hur merely, given every night
ill treacle, produced a cure in a few days. JMr.
Pearson chiefly relied upon exposure to a dry
and open air. Sementini slates, that he obtnined
uniform advantage from the internal use of the
nitrate of silver, beginning with an eighth of a
grain, and gradually increasing the dose to three
grains in the dny. I have lately em|iloyed the
tincture of iodine in two cases of this aflTection
wilii success ; and in one in-tance I prescribed
strychnine, but lost sight of the patient before its
effects were apparent. Mr. Eart.e (^Lond. Med.
Gaz. vol. xi. p. 31.) gave five grains of the extract
of conium, three tmies a day, with benefit.

26. c. It is obvious that it is of importance to be
in the possession of plans to prevent the injurious
effects of mercury on those employed in the arts
in which it is used. These are sufficiently sim-
ple, and consist ciiiefly of common attention
to cleanliness, and avoiiiing the fumes of the
mineral during the various p;irts of the processes
of gilding. Workmen should avoid touching the
amalgams that are used with the naked hand ;
and ought to make frequent ablutions, particu-
larly before taking a meal. During the process
of volatilising the mercury by heat, the utmost
caution should be exercised in performing the
operation with a stove in which the current of air
is very brisk, so that the fumes may be carried fully
up the flue. In most of the manufactories in tiiis
country, the stoves are now sufficiently well con-
structed for this purpose, the carelessness of the
artisan being the chief cause of danger from his
occupation. M. Jussieu states, that the free
workmen in the large cjuicksilver mines at Alma-
den, who took care to change their whole dress,
and attended to cleaidiness, were but little af-
fected by their occupation ; but that the slaves,
who could not afford a change of raiment, and took
iheir meals in the mines generally without ablu-
tions, were subject to swellings of the parotids,
aphthous sore throat, salivation, eruptions, and
tremors. (M^m de I'Acad. des Sciences, 1719,
p. 474.)

27, B, Lead. — a. Injurious effects from lead,
in the various states in which it is used, are very
frequent and often fatal. Its oxides may be car-
ried off in a state of vapour, dissolved in volatile
substances, as by turpentine in painting, and thus
be inhaled into the lungs, and act most injuriously
on the frame. It may also pass into the alimentary
canal in various ways, or it may be absorbed from
the skin, particularly of the hands, where it wdl
both ait locally, and be carried into the system,
and |)roduce its efliects as when introduced by the
two former channels. These effects are chiefly
lead colic and paralysis. The workmen employed
in lead mines, those who are engaged in procur-
ing it from its ores, who cast it or manufacture its
various preparations, and who use them in the
diflferent arts, as pluiribers, glaziers, painters in
oils or water-colours, colotr-griiiders, type-loun-
ders, printers, are the most li.ihle to l)e affected
by lead ; but all cImsscs, under certain circum-
stances, may also experience injurious effects from

t. I'he deleterious nature of this mineral is cer-

tainly very great ; but the fatal results are surely
not one in three annually, as stated by Sir John
Sinclair,

28. i'. M. Merat has furnished some very in-
teresting information respecting the frequency of
colica pictorum in the various classes of artisans
who came in contact with any of the different
pieparations of lead. It is derived from the list,
kept at the hospital La Charile, in Paris, in the
years 1776 and 1811, The total number in both
years were 279. Of these 241 were artisans,
whose trades exposed them to the poison of lead,
viz. 148 painters, 28 plumbers, 16 potters, 15
porcelain makers, 12 lapidaries, 9 colour-grinders,
3 glass-blowers, 2 glaziers, 2 toymen, 2 shoe-
m.ikers, 1 printer, 1 lead miner, 1 shot manufac-
turer. Of the remainder, 17 belonged to trades
exposed to copper. Of the 279 cases, 24 were
under twenty years of age, these being chiefly
painter boys, not above fifteen ; 113 were between
nineteen and thirty ; 66 between twenty-nine
and forty ; 38 between thirty-nine and fifty ; 28
between forty-nine and sixty j and 10 older than
sixty. Among the 279 cases, 15 died, or 5'4 per
cent. (See the article Colic, from Lead.)

29. c. The inensures of prevention from the action
of the preparations of lead differ in no respect from
those which have been stated in relation to mer-
cury (§ 26.). They chiefly consist of strict atten-
tion to personal cleanliness. The instructions
given by M. Merat are very complete, but are
too particular to be followed by workmen. He
recommends that the working clothes should be
made of sirong compact linen, be changed and
washed once or twice a week, and be worn as
little as possible out of the workshop ; a light
impervious cap ought always to be worn on the
head. The artisan should never take his meals
in the workshop, or without strict ablution of the
hands, mouth, and face ; and he ought to break-
fast before leaving his home,

30. Derangements of the digestive organs ought
to be watched with care. If colicky symptoms
occur, he should leave off" work, and take an
aperient. He ought always to guard against
constipation. The diet of those exposed to be
aflfected by the preparations of lead is of conse-
quence. It should be light and digestible ; and
poor acid drinks ought to be avoided, particularly
cider, as themselves often containing lead. Va-
rious articles of diet have been recommended as
calculated to impede the hurtful action of lead
on the frame. Hoffmann mentions brandy — a
somewhat dangerous recommendation. Fat food
has been accounted preservative. De Haen
states, that the workers in a lead mine in Siyria
were much affected by a colic and palsy, but, by
being told by a quack doctor to eat a good deal
of fat, particularly at breakfast, they were exempt
from these diseases for three years (liat. Med.
p. i. ch. ix.) Similar facts respecting the good
tflPects of fat meat, as a preventative of the effects
of lead, are recorded by Sir George Bakf.r
(Trails, of Loud. Coll. of Phys. vol, ii. p. 457.)
and Mr. Wilson ( Ei//«. Phys. and hit. Essays,
I. p. 521.) Those who work at furnaces in which
lend IS smelted, fused, or oxidised, should be
])rolected by a strong draught through them. iMr.
Ijhaii), of the extensive mines at Leadliills, in-
formed Professor Ciiiustison (see his most vula-
ahle work on Poisons, difc. p, 506.), that wherever

ARTS AND EMPLOYMENTS

furnaces of such a construction have been built,
the colic has disappeared.

31. C. Copper, although extensively used in
the arts, is seldom productive of much disease.
l^AfissiER states, that the workmen in copper
becoiiie prematurely oU, liaving a meagre and
sickly appearance. This is, however, as much
owing to their confinement in ill-ventilated places,
and iniemperance, as to the metal. Mlrat has ad-
duced evidence of their being frequently subject
to colica pictorum. They are likewise liable to
diseases of the respiratory organ-;, — particularly
those engaged in filing the metal ; but this is en-
tirely owing to the meciianical irritation occa-
sioned by the finer particles when inhaled into the
lungs. Asthma is frequent amongst brass-founlers,
owing probably to this cause, and paitly to the
vaporisation of a poriion of the zinc with which
copper is amalgamated.

32. D. Zinc, arsenic, and autimonii are seldom
productive of hurtful effects amongst arti^^ans ;
owing probably to the first being chiefly employed
in the metallic state, in whicli it has no effect,
although it is deleterious when oxidised ; and to
the circumstance of arsenic and antimony being
generally used in small quantities.

33. E. The acrid vapours, which proceed from
the mineral acids, often pioduce violent effects
when respired ; chiefly asphyxij, and severe in-
flammation of the air-passages, but they are
easily guarded against, and chiefly by operating
in nearly open places. Persons who prepare
articles for gdding, by cleaning them in aqua-
fortis, are equally liable to respire the vapours of
these acids, but may avoid them with even a mo-
derate share of caution. The inflammations of
the respiratory organs occasioned by them, differ
merely in respect of their intensity, from the same
diseases proceeding in an acute form from other
causes. Chlorine gas, when respired in consider-
able quantity, produces inflammation of the air
passages. Thc'chief effects of habitual exposure
to it are acidities and other complaints of the
stomach. I'he trades in which workmen are ex-
posed to chlorine do not seem to be unwholesome.
Corpulent men are soon reduced by it to their
natural size. During the epidemic fever that
raged all over Ireland from 1816 to 1819, the
people at the chemical manufactory at Belfast
were entirely exempt from it,

34. 2d, Molecules of animal matter in a state of
decay are frequently productive of disease, both
ia persons whose avocations expose them fre-
quently to this cause, and in those who approach
il only incidentally. Nightmen are chiefly ex-
posed to this source of disease, particularly in
Paris. I'he gases evolved when emptying the
fusses d'aisances of that capital are frequently
productive of serious and even fatal consequences.
The exact nature of these varies with the vapours
evolved, Ammoniacal vapours usually occasion
what the French term la mitte : sulpiiuretied hy-
drogen, hydro-sulphuretted ammoniacal gases,
and azote, produce le plomb,

35. A. The symptoms of la mitle are smarting of
the eyes, with the sensation of sharp or pungent
odour and uncomfortable feeling about the nuse.
To these succeed pain, extending to the forehead,
and discharge from the eyes, occasionally with
blindness enduring for two or three days. These
effects, if not very intense, generally puss off by

•AS Causes of Disease.

127

shading the eyes, and exposure to the open air ;
if they are more severe, the application of cold
epithems to the eyes, and protecting them from
the light, are usually elficacious.

36. B. Le plomb is of two kinds ; 1st, that oc-
casioned by azjte, and which is simply AsniYxv
(which see) from the privation of respirable air,
attended with coma or stupor; 2d, that caused by
suljihuretted hydrogen and hydro-sulphurettud
ammoniacal ga^es, which is the most dangerous
and common, and is generally attended with con-
vulsions. (See Poisons.) The former is com-
monly prevented by a free circulation of air; the
latter is avoided by employing the chlorurets of
lime or of soda, a solution of which is poured in
the privies, and reservoirs or drains, shortly before
they are emptied. (See Treatment if Asphyxy
and of Poisoning foy deleterious Gases.)

37. C. The animal effluvia proceeding from
slaughter-houses, dissecting-rooms, chandlery or
adipocire manufactories, and other places wheie
animal substances are manufactured or employed
in the arts, are seldom so concentrated as to be
proJuclive ot disease ; but there can be no rational
doubt of their unwholesome influence when con-
centrated, or accumulated in a stagnant atmo-
sphere. The liability of butchers and cooks to
be corpulent has been absurdly enough ascribed
by some superficial writers to the absorption of
nutritive particles from the air, without attending
to the fact of a much larger quantity of animal
food being taken by them than by any other class
of persons.

38. Dr. WiTHERiNO had noticed (Letter to
Dr. Bkddofs, 1793) the comparative exemption
of butchers and catgut makers from phthisis M.
Patissier has made the same remark; and Dr.
Beddoes has added to these employments soap-
boilers, and the fishermen and fi>h-wives in the
vicinity of Edinburgh. Glue and size boilers are
exjiosed to putrid and ammoniacal exhalations from
the decomposition of animal refuse. But these
workmen are generally fresh-looking anil robust.
A similar observation is applicaiile to buckram
manufacturers. Tanners are subject to animal
vapours; but so combined with the odours of lime
and tan as entirely to counteract any injurious
effect which the former might produce. They are
much exposed to wet and cold ; yet they are ge-
nerally healthy, robust, and tolerably exempt Iro n
pectoral diseases, particularly consumption. Mr,
TuACKrfAH states, that he has carefully inquired
at several tan-yards, and could not hear of a single
example of this disease.

39. 3cl, Vegetable molecules. — Corn-millers suffer
remarkably from breathing an air loaded with the
particles of flour. They are chiefly affected by
indigestion, asthma, and morning coughs with ex-
pectoration, terminating either in consumption or
in asthma; and are generally pale, sickly, and
short-lived. This is the case only with those who
work in the mills. Those amongst them who
labour in the open air with the carts are not thus
affected ; but, as other persons raising heavy
weights, are subject to hernia;. Maltsters aio
liable to the same diseases, arising from the same
agents, and from the heated and sulphureous air of
the kilns. Bakers are exposed to similar causes,
but to a much less extent, and suffer accordingly
— chiefly from cough, asthma, affections of the
stomach, rheumatism, and a peculiar chronic

12f5

ASPHYXY.

eruption on the skin. Snuff-makers are exposed
to tlie dust of the tobacco ; but tliey are not so
much affected by it us may be expected. They
chiefly complain of disorders of the head, stomach,
and air-tubes: of the former, from the narcotic
effect of this vegetable, and of the last from its
irritation. The narcotic odour to which hibacco
maintfactiirers are liable is not productive of any
very appreciable mischief, owing to their having
become insen-ible to its influence.

40. 4th, 1 shall here briefly notice tliose trades,
the workmen in which experience the very inju-
rious effects of inhaling an atmosphere in which
various vegetahU, animal, or mineral molecules are

Jliiating, — causes wliich, although very dissimilar
in themselves, generally act in nearly a similar
manner — namely, by irritating the bronchial
surface, and superinducing various modifications
of disease, according to peculiarities of constitu-
tion, temperament, and habits of life. — a. The arti-
sans who suffer the most from these causes are
dry-grinders an<l needle-pointers; edge-tool, gun-
barrel, and other grinders ; flax-dressers, and pearl
and born button makers ; iron, brass, and other
metal filers ; stonecutleis, miners, and quarriers,
particularly in sandstone ; wool-carders and
(bather-dressers, sawyers, turners, weavers, and
starch-makers. All these suffer more or less,
generally in the order here followed (needle-
pointers and dry-grinders the most, and starch-
makers the least), from chronic bronchitis, in one
or other of its modifications : in some, from the
spasm of the bronchi thereby occasioned, with
the symptoms of asthma predominating; in others,
with those of chronic inflammation extending to
the lungs; in a few, with pulmonary emphysema ;
and in many, with tubercular and cretaceous
formations. The most inflammatory effects seem
to result from needle-pointing, dry-grinding, and
stone-cutting ; whilst the more asthmatic affections
proceed fiom the horn and pearl button manufac-
turing. These workmen seldom live above forty
years, and the greater number not beyond thirty
or thirty-five. They often experience but little in-
convenience till some time before the fatal disease
takes place; but they are as often affected in early
Id'e, particularly pearl and horn button makers,
tlie disease subsequently assuming an asthmatic
character.

41. b, Vaiious means have been invented in
order to prevent the molecules or dust arising in
these trades fiom accumulating and being inhaled
into the lungs of the wuikmen ; but nearly every
measure liitherio advised has been neglected by
them. Among-t other contrivani'es, the muzzle
of damp crape recommended by Dr. Johvstone,
the sponge by JJr. Gossk, and M. D'Ancti's
" fourneau d'ap])el," which is, however, not known
in this country, may be named. The best means
yet devised seems to be that invented by iVIr.
Auhahams of Sheflield, in whicii magneiic attrac-
tion is employed to ariest the floating metidlic
particles, 'ibis, as well as the use of the "damp
bag " suspended over the stone, in grinding and
pearl button turning, are most useful inventions.
Jn mining, ([uarryiiig, or cutting stones, dry grind-
ing, 6».c., much ^ood would prottably result from
havini; moistened or wet woiillen curtains sus-
pended over the heads of the workmen, and in
such a way as to be agitated through the aii of
the place. The simpler the means, and the less

trouble required in their use, the more likely are
tht-y to be adopted.

42. c. In respect of the treatment of the pul-
monary diseases which result from these causes,
very little difference from that employed under
ordinary circumstances is required. The frequent
use of emetics is adopted by the workmen tliem-
selves; and there can be no doubt of their utility
in the most of the diseases ol the air pas-ages.
The other means of cure are fully noticed in their
respective places.

BiBHOGRAPHY ija?n»nnj!»/. Opera Omnia Medica.

Gen. 1717 — Merat, in Diction, des Sciences Medicates,
t. vi. p. 32.- Pat/ssier, Traite des Maladies des Artisans,
et des celles qui resultent des diversns Professions, &c.,
8vo. Paris, 1822 — Meiat, Trahedcln Colique Metallique,
Hvo. Paris, lHi2.—Berlianit, p:ssai Medical sur les Pro-
fessions et les Metiers. Paris, 181.^.— Spcer, in Dulilin
Hosp. Reports, vol. iii. p. 161.— f. T. Th.ickra/i, The
EHects of the principal Arts, Trades, and Professions,

i:c. on Health and Longevity, &c. London, 8vo. IsSI

Colson, Sur le Tremblement Metallique, Sec, in Archives
Geiier. de Med. t. xiv. p. 102., et t. xv. p. 3.^8. — P. S.
Kiiif-hr, On Grinders' Asthma, in North of Engl. Med.
and Surg. Jouru. vol. i.

See Worms.

See Dropsy of the Peritoneal

ASCARIS
ASCITES.
Cavity,
ASPHYXY. (From the privitive a, and acpv^co,
I beat, I leap. — Svn. ^Aatpt'^la, Hip. Aspliyiia,
Auct. Lat. Apopleiia Siiffocata, Cullen. Asthe-
nica Siiffocatio, Young. Asphyxia, Le Pauls
7nanqiiuHt, Fr. Der ScheiiUod, Pulsstil Island,
Eine toftttiche Ohnmacht, Ger. Mancamento di
Pi'lso, Ital.

Classif. — 2. Class, Nervous diseases ; 1.
Order, Comatose Affections (Ciillen) 4.
C/(iss, Diseases of the Nervous Function ;
4. Order, Affecting the Sensorial Powers
(Goad). I. Class, III. Order {Author,
see Preface).

1. Deiin. Suspended animdiion proceeding from
a primary arrest of the respiratory actions, the
other functions being thereby abolished.

2. Asphyxy, accoiding to its etymology, should
be ilefined the cessation of the action of the heart.
In this case it would be synonymous with certain
forms of syncope, from which, however, it most
essentially differs. Yet even in syncope the most
complete, the action of the heart never altogether
cease^ ; it is only unusually weakened, and pre-
viously to respiration being affected. Attention to
the phenomena to which the term asphyxia has
been so long applied, will infoim us that the ac-
tions of respiration are primarily arrested ; that
the functions of circulation are subsequently
abolished ; and that death is the result of this suc-
cession of events. It may, however, be stated, in
justification of the change of signification which
this term has undergone, that there is no state of
the system from which recovery is possible, that is
characterised by a more complete abolition of the
action of the heart than this, allhough it takes
place secondarily only, from the airesl of the re-
spiratory functions.

3. Asphyxy has been very generally viewed ns
proceeding from c;iuses which act in various ways ;
and the opinions respecting their nature and mode
of operation have been extremely deficient in
precision and accuracy. Accoiding to the mean-
ing which I have atiached to the term, as slated
above, asphyxy can only occur in a direct or
piiiiiary form, from causes which either exclude

ASPHYXY— Causes of.

129

the air from tlie lungs, prevent its renewal, or
abstract that constituent of it wiiich is requisite
to the respiratory functions. Authors iiave, how-
ever, included, under the head of asphyxies,
those states of suspended animation whicii pro-
ceed from tlie respiration of deleterious gases;
and Dr. Good has comprised under it death or
suspended animation from lightning and from
intense cold. In every case of the action of
deleterious gases, of lightning, and of intense
cold upon liie system, the respiratory orgnns, al-
liioiigh one of the channels for the action of the
latter, are not the first to have their functions
ai rested. The action of all thtse agents is pri-
marily exerted upon the ganglial and nervous
syslems ; and, owing to tiieir eflects upon these
systems, the function of the brain, of respiration,
circulation, &e. are subsequently abolished. As the
action of the greater number of deleterious gases,
«hen respired, is similar to that of other irritating
and narcotic poisons, I shall consider them under
the head of o-aseoKS po/so/is (see Poisons). When,
l/owever, they are of such a kind, or are present
to such an extent, as to irritate violently the
larynx, and, by exciting spasm of it, to exclude
the air, or so as to disphice, and to occupy the
room of, the respirable atmosphere, their action
is similar to other agents primarily occasioning
simple asphyxy ; and they therefore require no
further notice than by adducing them as causes
of this state. In respect of the influence of cold
and lightning upon the frame, it may be ob-
served that, although exciting and concurrent
causes of asphyxy, and producing this, with
other changes, in tlie vital functions, but in very
diffVrent ways, they act directly upon the nervous
system, and give rise to asphyxy only secondarily ;
and, like the more poisonous gases, chiefly through
the medium of this system, particularly that part
of it which presides over the functions of the brain
and heart. Their action will therefore fall under
different heads.

4. I. Causes. — Asphyxy takes place in a
primary and simple form, from whatever excludes,
or prevents the renewal of, air in the lungs of a
healthy person, or consecutively upon other af-
fections or diseases, especially those affecting the
nervous system, and particularly the respiratory
class of nerves. In the former state of the frame
it is an idiopathic ov esseiitiat affection; in which
light it will be chiefly viewed in this place : in
the latter it is symptomatic, or rather one of the
modes in which disease terminates liie. Those
states of asphyxy may pToceed, first, from a pri-
mary cessation of the mechanical phenomena of
respiration, and, secondly, from a primary defiiult
of the chemical changes which take place during
the respiratory actions.

5. To the FIRST of these is to be referred the
asphyxy which depends upon inaction of the
respiratory muscles {A.) ; and ( B.) upon deficient
expansion of the lungs, the inspiratory muscles
performing their functions. A. Deficient or im-
possible action of the inspiratory muscles pro-
ceeds, 1st, from mechanical obstacles applied to
them, as in the instances of death occasioned by
earth falling upon the trunk of the body, and
pressing it so strongly as to prevent them from
expanding the thorax : 2d, from deficient or in-
teriupted influence of the nerves supplying these
muscles, as from injuries or division of the pufu-

Vol. I. ^ "

mogastric nerve ; injury or pressure upon the
medulla oblongata or spinal chord, either from
fracture or dislocation of the spine, particularly
of Its cervical portiun ; and from the paralysis of
the nervous system occasioned by a stroke of
lightning, or any other cause abolishing its energy :
and, 3d, from want of activity, or deficient irrita-
bility of the inspiratory muscles themselves, as
from the benumbing influence of cold, and the
suspended animation of new-born infants.

6. B. The asphyxy which proceeds from a
deficient expansion of the lungs, is generally
owing, 1st, to mechanical impediments, as the
passage of some of the abdominal viscera through
the diaphragm, the accumulation of fluids in the
pleura, or similar causes : and, 2d, to paralysis
of the nervous energy of the lunjjs, as in cases
of death from cold, from lightning, from various
poisonous gases, &c. ; whereby tlie vital expan^i-
bility of the organ is abolished, along with the
other respiratory actions.

7. The SECOND class of causes, or those which
act by impeding or abolishing the chemical
changes effected by respiration, may be referred
to two heads: — 1st, Those which present a me-
chanical obstacle to the entrance of air into the
lungs, as strangulation ; submersion ; the intro-
duction of foreign bodies into the larynx, trachea,
or even the large bronchi : and, 2d, Those which
consist of a deficiency of respirable air, as a too
rarified atmosphere, or the presence of azote,
hydrogen, carbu retted hydrogen, sulphuretted
hydrogen, or indeed of any of the deleterious
gases. It is evident, however, that asphyxy is
often occasioned by the combined operation of more
than one of its proximate causes. Thus it may
proceed from paralysis of the respiratory muscle-,
and of the nervous energy of the lungs them-
selves; and hence be characterised by abolition
of the respiratory efforts, by deficiency of the
expansive power of the organ, and by arrest of
the chemical ch^ges which take place during
respiration : and, on the other hand, several of
the remote causes act by individually producing
more than one of the pathological conditions now
specified.

8. II. Characteristic PHENOMENA of asphyxy.
— i. When asphyxy takes place slowly, especially
from causes which interrupt the nervous influence
actuating the respiratory muscles, it commences
with greater or less diflBculiy of elevating the
thorax ; anxiety, with urgent desire to inspire,
and constant attempts to fill the lungs, giving
rise to continued gaspings, or quick, short, and
imperfect respiratory efforts ; pandiculation ; ver-
tigo ; failing of consciousness and sensation ;
sometimes to convulsive movements both of the
limbs and trunk, followed by immobility of the
parietes of the thorax and abdominal muscles,
weak and languid pulsation of the heart, aud
absence of pulse at the wrist ; the face is coloured,
livid, tumid, injected, and its veins distended ;
the hands and teet, as well as the face, present
a reddish violet hue ; and the cutaneous surface
patches of a similar tint. At last the circulation
is entirely arrested, and asphyxy is complete. The
animal temperature, however, and the absence of
rigidity of the muscles, continue for a long time
afterwards, — almost always for a much longer
period than from death under other circumstances,
and from other proximate causes.

K

130

ASPHYXY — Pathology of.

9. These phenomena vary, particularly as re-
spects the rapidity of their progress, according to
tlie causes whence they proceed, and to the ex-
tent to which air is excluded from the lungs.
Wiiere no obstacle to the action of the inspiratory
muscles is present, — the obstruction to respiration
existing in tlie air passages, — the efforts to renew
the air in the lungs are much more convulsive
and laborious. Tlie anxiety is extreme, but of
short duration, and rapidly followed by abolition
of consciousness, voluntary motion, and of the
fua Hions of circulation. In this case the descrip-
tion of SiiAKSPEARE is physiologically accurate : —
" But see ! his face is black and full of blood ;

His eyeballs further out than whf-n he lived,

Staring full ahastly, like a strangled man ;

His hair upreare i ; his nostrils stretch'd with struggling ;

His hands abroad dis))lay'd. as one that grasp'd

And tugg'd for life, and was by strength subdued."

10. In cases where asphyxy arises from a sud-
den abolition of the nervous influence of the re-
spiratory muscles, as from injuries inflicted on
the medulla oblongata, &e., or when the trunk
of the body is so compressed as to prevent all
action of these muscles, but particularly when it
proceeds from the former cause, the phenomena
supervene and succeed each other with great
rapidity ; but generally in the order in which I
have enumerated them, excepting that all respira-
tory eflTorts are instantly suppressed. In drowning,
however, the progress of the symptoms aie less
rapid and somewhat different, as will be shown in
the sequel.

11. ii. The duration of life in cases of as-
phyxy is very different, according: a^ the causes
■which occasion it act with greater or less prompt-
ness, or more or less peifectly, in preventing the
renewal of air in the lungs. In general, the more
slowly that abolition of the respiratory function
takes place, as in cases of drowning, the longer
does the action of the heart continue, although
feebly and slowly, even after respiration has
ceased; and to this circumslagce, as well as to
the fluidity of the blood, which is long preserved,
is owing the power we possess of recalling the
aspliyxied to life; the more slowly the state of
asphyxy supervene?, the longer the person retains
the ability of being reanimated, and vice versa.

12. The leniJth of lime, however, after which
resuscitation cannot be accomplislied, is neces-
sarily varied by different circumstances ; and not
only by the causes of asphyxy, and their modes
of operation, but also the strength of constitution,
age, and previous health of the person, and tiie
manner in which abstraction of air has taken
j)Iace. I\luch will also depend \ipon the changes
\vhich the asphyxy lia^ produced in the brain, —
the degree of congcslion, or the occurrence of ex-
travasation there, — circumstances which, when
present to any very consideral)le extent, more par-
ticularly the latter, will generally preclude the
jjossibilily of reaninuition.

13. lii. Appearances observed on dissection of
asplnjxie.il persons. — A reddish or violet red hue
of tiie countenance and viirious parts of the sur-
face of the body, which continues to retain its
warmth an unusual length of lime after death :
this tint does not arise from the position of the
body ufier death ; and is chiefly seated in the
mucous or vascular tis'^ue of the skin, which,
upon incision, allows the blood to escape in a
state of fluidity. 'I'lie eyes arc bright and pro-

minent ; the mouth sometimes natural, at other
times expressive of suffering ; the limbs are rigid,
and continue in this slate unusually long, alter
having been late in assuming it. The veins and
sinuses of the brain generally are filled with a
daik fluid or semi-fluid blood ; the substance and
cavities of the brain are not otherwise materially
altered. The base of the tongue is generally
lull or injected, and even tumitied, and its papilla;
developed ; the mucous membrane of the larynx,
trachea, and bronchi, is injected and red — the
colour becoming darker as we descend from the
larynx to the bronchial ramifications, where it
assumes a violet or reddish brown tint. Tlieir
smaller branches often contain a little sanguineous
frothy mucus. Tlie lungs aie distended, rise
around the pericardium, and present a blown or
blackish brown hue ; their parenchyma, when
divided, are of a redder tint, but give out, upon
pressure, large drops of a thick, fluid, and very
black blood. The liver, spleen, and kidneys are
gorged with blood, presenting a similar appear-
ance, file veins of the heart are congested ; and
its right cavities, the vena cava, and other large
veins, are engorged with black and senii-coagu-
lattd or fluid blood.

14. III. Thkory of Asphyxy. — It is chiefly
to Goodwin and Bichat that we are indebted for
the near approaches which have recently been
made to a satisfactory and consistent theory of
asphyxy, upon which a rational mode of treat-
ment may be based. The venous blood sent by
the right ventricle to the lungs, which contain a
diminished quantity of air calculated to convert
it into arterial blood, is returned to the left side
of the heart, but slightly changed from its venous
state, from whence it is propelled through the
arteries to the different organs. The consequence
of the imperfect changes effected in the blood,
owing to the interruption or cessation of the re-
spiratory actions, is imperfect excitation of the
most important organs of the body ; and in pro-
portion as the blood sent from the left side of the
heart is possessed of more of the venous charac-
ters, the absence of excitation is more manifest,
until, as respects the brain, and lungs paiticularly,
which are the first of all the organs to experience,
the eflecis resulting from the circulation of venous
blood, a sedative or stupifying effect, but negative
in respect of its nature, is produced upon ihein ;
as is fre(|uently evinced on the brain in cases
where asphyxy takes place slowly, and when the
blood sent from the left side of the heart is com-
pletely venous in its characters.

15. In tracing the phenomena it will be ob-
served, that the ca|)illary system of the lungs is
the first to experience a loss of their vital tone
and undergo congestion. This arises from the
following causes : — Isl, The absence of the usual
stimulus of pure air in the air-cells: 2d, The
circumstance of their being the first to receive the
blood after being returned from other parts of
the body fully charged with venous properties:
3(1, The cessation of the mechanical actions of
respiration ; and, with them, of the expansive
motions of the lungs themselves : 4th, The arrest
of those changes vvliich the blood undergoes from
oxygenated air, and the influence of a daiker
lilood than usual upon the ])ulmonary vessels:
5lh, The loss of nervous influence, arising from
the sedative effect of venous blood upon the

ASPHYXY — Pathology of.

131

nervous centres, when circulating in arterial
vessels: and, 6th, The circumstance of the sys-
temic capillary vessels retaining their tonicity and
power of reacting, For a longer time, upon their
contents, when circulating venous blood, than
the pulmonary capillaries; consequently the
blood is returned by them into the veins, and
thence to the right side of the heart to be sent to
the lungs, which are the first, from this and the
foregoing causes, to experience congestion, and to
lose the power of restoring it to the left auricle.
Thus it will be seen, that the interruption to the
circulation commences in the capillary system of
the lungs, in consequence of the stop put to the
mechanical and vital actions of this organ ; and
that the heart, which does not cease to contract
until the functions of the lungs and brain have
been abolished, no longer is supplied with blood
from the lungs ; the left side of the heart being
thus the ultimum moriens.

16. The early and manifest effects of asphyxy
on the brain have been fully proved by the ex-
periments of BicHAT. This organ is deprived of
its functions, and the comatose state is rapidly
and profoundly expressed ; the venous blood con-
veyed to it, chiefly from its negative effects, giving
rise to all the phenomena usually occasioned by a
narcotic poison. Even the heart itself, although
tlie last of the three organs to experience the
etftct produced by the circulation of venous blood,
is soon enfeebled in its action. This evidently
arises partly from the abolition of the functions of
the brain, and partlj', or even in a greater degree,
fiom the circulation of dark blood to the ganglia
and nerves, whence the heart derives its action,
and to its proper structure. But the experiments
of Dr. Edwards, Dr. Williams, and Dr. Kay
show that the circulation of dark blood does not
destroy the irritability of muscles, but that it is a
less powerful supporter of this property ; and con-
sequently that the irritability of the heart is not
abolished, as Biciiat supposed, but only insuffi-
ciently excited. Indeed, if this property were
destroyed, resuscitation would be impossible.

17. The long continuance of the animal heat
after the total cessation of the heart's action can
only be explained by the integrity of the vital
energies of the frame at the time of the event, by
the continued fluidity of the blood, and the cir-
culatory or oscillatory motion of this fluid in the
systemic capillary system for a considerable time
after tlie heart has ceased to contract, — pheno-
mena, which have been satisfactorily observed in
cases of asphyxy. The patches of lividity, and
the dark colour of the surface, depend upon the
injection of the capillaries of the surface with dark
blood, and the engorgement of the veins. The
slow accession of rigidity of the limbs after death
is referrible to the longer duration of the animal
temperature, and the fluidity of the blood than in
other cases ; and to these causes also are to be
imputed the possibility of resuscitation after a
longer period from the cessation of respiration than
in any other morbid condition of the frame. The
marked rigidity of the limbs, after the body is
quite cold, must be chiefly imputed to the perfect
state of the vital energies when asphyxia took
place.

18. It has long been observed that the body of
an asphyxied person appears to contain much
more blood than that of an individual who has

died in a diflferent way. Biciiat explains this by
supposing that the organs receiving venous blood,
which is devoid of the materials necessary to
nutrition, yield all the fluids which they usually
furnish without appropriating those which they
usually do under other circumstances ; so that the
quantity of blood is actually increased, particularly
in cases where the asphyxy takes place slowly.
In proof of the accuracy of this view, it has been
stated that, when asphyxy occurs suddenly, and
the functions cease rapidly, less engorgement of
the venous system and of the lungs is observed,
than when death is caused more slowly, as in the
case of asphyxy from burning charcoal. Perhaps
the quantity of blood in the system seems greater
from the circumstance of its fluidity, or rather the
absence of congulation ; for when this takes place,
the serum of the blood partly escapes into the shut
cavities after death, and exudes through the ves-
sels and tissues.

19. From the foregoing, therefore, it may be
concluded that the cessation of the actions of
respiration, — first the mechanical or muscular
actions, next the vital or expansive motions of
the lungs, — is soon followed hy an arrest of
the pulmonary circulation, afterwards by abo-
lition of the nervous functions and influence,
and lastly by cessation of the heait's action,
in conse((ueiice of the blood not being restored
to the left auricle and ventricle; the latter
of which, however, continu: s to contract as long
as blood is senV to it. Hence, as respects the
circulation, first, stagnation of the blood in the
pulmonary capillaries upon the cessation of re-
spiration takes place ; next, a deficient supply of
blood to the leftside of the heart ; and, lastly, an
accumulation of it in the pulmonary arteries, and
right auricle and ventricle, which are no longer
able to overcome the resistance opposed to its
passage in the congested pulmonary vessels. Thus
it will be seen that the left ventiiple is actually the
uttimnm 7noriens, and not the right, as supposed
by many. Upon this view of the procession of
plienomena in death from aspiiyxia, our endea-
vours to restore animation are fountled.

20. IV. The varieties of Asphyxia, in a
practical as well as physiologicul point of view,
deserve particular notice. The respiration of se-
veral gases is often followed by fatal consequences ;
but as asphyxy is only one of the deleterious
effects they occasion, I have considered them in
another place (see Poisons — Gasenas). Of all
gaseous bodies from which asphyxy may arise,
azote and hydrogen alone act simply by produc-
ing asphyxy ; and they have this effect only when
they are present in considerable quantity in the
air, or when they are respired for some time. The
effects which they produce difler in no respect,
in the present state of our knowledge, from those
described above.

21. A. Asphyxiifrom suhmerswn. — a. There are
various circumstances, both proper to the indivi-
dual, and connected with the submersion, which
will modify the resulting asphyxy, and should be
taken into account in our endeavours to restore
animation. When a person is immersed in water,
he is seized with an urgent feeling of anxiei;y at
his breast ; his pulse becomes weak and frequent.
He struggles to relieve his distress, and thereby
rises to the surface of the water, and throws out
some air from his lungs. His anxiety continues

K 2

132

ASPHYXY — Tp.eatment of.

to increase, and Iiis pulse becomes weaker ; his
struggles are renewed with more violence ; he
r'ses to the surface again, throws out more air
from the lungs, and makes hurried attempts to
inspire, and in some of these attempts a quantity
of water goes down the throat with the air, and
excites cough and spasm of the glottis. These
efforts tend to determine blood (o the head, which,
owing to the impeded state of respiration, partakes
of the venous properties; and rapidly induces,
from this circumstance as well as from the pres-
sure it occasions, insensibility, loss of voluntary
motion, slight lividity of the suiface of the body,
particularly of the face, loss of pulse, relaxation
of the sphincters, and as the body sinks to the
bottom, the expulsion of a portion of the air con-
tained in the chest.

22. b. On dissection, nearly the same appear-
ances as those already described are found. In
addition to these, a frothy fluid is met with in the
trachea, and ramifications of the bronchi, with
soine water, the quantity of whicli varies in differ-
ent cases. From Dr. Goodwvn's very satis-
factory experiments, confirmed by JMr. Colebian
and Professor RIeyeii, it appears that this smalf
(juantity of water enters during the struggles to
inspire, and, mixing with the mucus of the bron-
chi, forms a frothy fluid, insufficient, however, to
occasion the fatal changes in drowning. A con-
siderable quantity of fluid is found in the stomach.
According to Dr. Cirky, the vessels of the
brain are not particularly distended ; but there
are exceptions to this. Dr. BEnctR, of Ge-
neva, found that the air remaining in the lungs
had lost nearly all its oxygen. JMr. Coi.eman
states that the left ventricle of the heart is
never entirely empty, it generally containing
about half the quantity of that found in the right
ventricle ; and that a little blood is also found in
the aorta.

23. r. In cases where a person, in falling into the
water, has been struck on the head and stunned,
or is intoxicated, or benumbed with tiie cold and
fright, the efforts at preservation will scarcely be
niade, and the case will be more completely that
of simple asphyxia. In cases of this desciipiion
the countenance is generally pale. The period
after which reanimation may be procured is ex-
tremely various — generally from five minutes to
three quarters of an hour. Of twenty-three per-
sons recovering from drowning, one had been
three tjuartets of an hour under water ; four, half
an hour; three, a quarter of an hour; and the
rest for shorter periods. Dr. Edwards has very
satisfactorily demonstrated that life is more lapidly
extinguished by submersion in water of a very
low temperature than in that of higher grades,
evidently owing to the sedative cflTects of cold
upon the nervous system. When submersion
takes place duiing intoxication, there is greater
risk of congestion or extravasation in the brain
being superinduceil ; and if syncope, by the fright
attending submersion, occuis, fatal congestion and
jtaralysis of the heart and lungs will chiefly su-
jiervenc, but in a slower manner than under
other circumstances; and, as M. Leroy (Ar-
chiv. Gen. de Med. t.xvii. p. 469.) sujiposes, thus
admitting of resuscitation at a longer period after
submersion.

24. /{. Asjilniiif J'rnni sirangvlalion. — When
aspli}xy is produced by iianging, and if the ex-

clusion of air from the lungs is complete, the fol-
lowing appearances are generally observed : — After
loss of sensibility, epileptic convulsions, some-
times slight, at other times marked ; and gene-
rally attended with erections and emissions ; tur-
gidity, suffusion, and lividity of the face, extending
to the shoulders, chest, arms, and hands: the
eyes are open, projecting, and their vessels in-
jected ; the features are distorted, and the tongue
thrust out of the mouth ; the external muscles of
respiration are firmly contracted ; the hands are
clenched, and the sphincters relaxed. When the
air is not perfectly excluded in hanging, the suf-
ferings are prolonged, the engorgement of the
head and fuce is greater, the lungs are less loaded
with blood, and the vessels of the brain more
congested, than when the air is completely ex-
cluded. In the majority of cases of asphyxy
from hanging, the lungs contain more air than
after death from natural causes, or from suffoca-
tion by a pillow when the air is only imperfectly
excluded from the lungs.

25. There can be no doubt, that although
death is caused by asphyxy in cases of strangula-
tion, as proved by De IIaen, JVIonro, and others,
the interruption which the cord occasions to the
return of blood from the head, and the consequent
congestion of the encephalon, accelerate death.
In some instances, also, there is reason to believe
that fracture, dislocation, or subluxation of the
vertebias of the neck is produced in the e.secution
of criminals ; but it very rarely, or perhaps never,
occurs in cases of suicide by strangulation. To
these additional effects upcn the ( ncephulon and
medulla oblongata is to be partly imputed the
want of success in our attempts to restore anima-
tion after strangulation.

26. V. General Treatment of Asphyxia.
— The indications which naturally suggest them-
selves from the consideration of the causes of as-
phyxia, their mode of operation, and the ultimate
results which they produce, are, 1st, to remove
the patient as soon as possible from the causes
which occasioned the asphyxied state; and, 2d,
to restore the function of respiration, and, through
it, the circulation. The necessity of fulfilling the
former of these is sufficiently obvious, and the
means of doing so will necessarily vary with the
nature of the cause, which should be instantly
ascertained ; but without delaying the employ-
ment of means to restore respiration.

27. The restoration of the function of respir-
ation is to be attempted by various means, calcu-
lated, in \\\e Jirst place, to dislodge the impure
air contained \n the lungs ; serondlii, to replace it
with pure air; thiidlii, to excite the remaining
vitality of the nerves and muscles; anti, J'cvrlhly,
to restore the circulation by measures calculated
to return the blood from the lungs to the left
side of the heart. The siinultaneous attainment, as
far as may be, of these objects, is to be attempted
by a judicious combination of means. — a. The
patient should be jdaced on his back, in an ojien
air of a mild or somewhat high temperature, of
from 65 to 70 deg. of Tahr., with the chest,
shoulders, and head slightly elevated. lie should
be stripj)cd of his clothing, and enveloped in a
warm blanket. None but the assistants ought to
be admittt'd into the room. The body should be
placed at a convenient height for the em|doyment
of the measures of reanimation. I'lesmre should

ASPHYXY — Treatment of.

133

llien be maile upon tlie breast and abdomen, al-
tenidtiiig with reLhialion, in such a manner as to
simulate the actions of the chest in respiration.
By this means the foul air will be thrown out; of
the lungs ; and the restoration of the capacity of
the thorax, upon the removal of the momentary
pressure, by the elasticity of the costal cartilages,
will draw fresh air into the lungs. It will some-
times be of service to apply a hand upon each side
of the thorax below the arm-pits, and by gentle
shocks endeavour to expel the vitiated air. Whilst
this is being performed, bottles of warm water
should be placed to the feet, under the knee-
joints, between the thighs, and under the arm-
pits. Dry warmth is particularly beneficial when
applied to the epigastric region. Warm stimu-
lating frictions over the surface should also be
employed.

28. b. After having used pressure so as to si-
mulate respiration for a few moments, insujflation
of the lungs is next to be resorted to. This may
be performed by the mouth, or by a bellows.
^V'llen the latter is not at hand, the former must
be adopted. The operator having closed the nos-
trils, and applied his mouth to that of the patient,
is to blow forcibly into it, pressing the chest after-
wards, in order to expel the air, and again blow-
ing forcibly into the chest. If the lungs cannot
be inflated in this way, the operator should blow
into one nostril, having closed the other and the
mouth ; and if a small wooden tube can be pro-
cured, this may be used for the purpose, by in-
serting one end of it into the nostril, and blowing
into the other ; or the pipe of a bellows may be
inserted into it.

29. c. Iiisujfiation of the lungs by the breath of
the operator has been recommended by some in
preference to the use of the bellows, on account
of the higher temperature of the air thrown into
the lungs by the former mode ; whilst others pre-
fer the latter method, on account of the purer air
furnished by it. I believe that the advantage of
the highei- temperature of the former nearly coun-
terbalances the disadvantage of less purity. If,
therefore, insufflation by the bellows of a warm air
could be had recourse to, considerable benefit
might be obtained. If the bellows are used, the
pipe is to be introduced into one nostril ; and,
wiiilst the mouth and other nostril are closed,
and the pnmum adami pressed gently backwards
and downwards by an assistant, the bellows are
to be opened and immediately closed, so as to
throw air into the lungs by a single stroke ; after
which, allowing the mouth and nostril to open,
the chest is to be pressed so as to expel the air :
thus air is to be forced in, and again expelled,
about fifteen or sixteen times in a minute, so as
to simulate respiration.

30. d. The external and internal use of stimulants
has been recommended by J. P. Frank and De-
VERGiii. Of this class of me;ins, galvanism huKls
the first place ; but it is seldom that an apparatus
can be procured. When it can be obtained, slight
shocks may be directed through the diaphragm or
heart ; or if an electric apparatus is at hand, as
strong shocks of electricity as the machine can
furnish may be tried. Wlulst we are proceeding
with insufflation of the lung", frictions of the sur-
face of the body, particularly over the chest, on
the insidus of the thighs, &c., in order to promote
the circulation and the animal heat, should be

continued ; and the nostrils may be irritated, or
touched occasionally with a feather dipped in
spirits of hart-horn or of aromatic vinegar. Sub-
stances which are likely to increase the coldness
of the surface by their evaporation should not be
employed by friction. The introduction of warm
stiinuLiting Jluids into the stomach, by means of
a flexible tube and syringe, has been recom-
mended, and may be tried after insufflation of the
lungs has been performed for a short time. Mure
advantage, however, will probably accrue from
the administration of a clyster of warm spirits and
water than from the injection of stimulants into
the stomach, unless this can be done with an
apparatus admitting of easy application. To-
bacco-smoke has also been directed to be thrown
up the rectum ; but it is a more uncertain remedy
than the clyster now mentioned.

31. e. i3/(;ed(;70- is one of the measures respecting
which the gieatest difference of opinion has ex-
isted. In certain circumstances it is often of
great service, and in others detrimental. It is
generally proper when the countenance is swollen,
injected, or purplish ; the veins full or distinct ;
and the skin reddish, or approaching the violet
tint. It is not always, however, possible to obtain
blood ; but even when we fail in procuring it, the
opening which had been made should be carefully
closed and bandaged, in order to prevent subse-
quent hsemorrhage, which may occur when least
expected. Bleeding is also often required during
the progress of recovery, particularly when the
respiration is laborious, the brain loaded or op-
pressed, and when delirium, the not infrequent
attendant on restored animation, is present,

32. f. The means now recommended, particu-
larly frictions, inflations of the lungs, and the oc-
casional use of stimulants, should be persisted in
for several hours, unless stiffness of the limbs, and
other indications of death, present themselves.
Convulsive snatches of the respiratory muscles,
with gaspings, followed by sighing, a more na-
tural respiration, and slight palpitations, are the
first signs of returning animation. When the cir-
culation is restored, convulsions sometimes take
place, and suddenly destroy the patient. Sue h
seizures may occur even a considerable time after
recovery has apparently been effected. The
patient should therefore be watched for several
days ; and if an attack of this kind occur, blood-
letting, and artificial respiration during its con-
tinuance, may save the patient. Delirium, and
all the forms of morbid reaction which occasion-
ally appear during recovery from asphyxy, require
depletions, with the means usually employed to
restore the secretions and excretions, and to ex-
cite the emunctories to carry off the hurtful ma-
terials accumulated in the blood during the state
of asphyxy.

33. \'I. Treatment of particular kinds
OF Asi'iivxv. — A. Of asphi/ry from submersion.
But little, in addition to what has been stated
above, need be adduced under this head. The
body should be carried from the place of sub-
mersion to where means of restoration are to be
used, in the prone posture, the bead and shoulders
not being elevated ; but neither of them bent,
or hanging in an injuiious posture. The wet
clothes are to be immediately removed,. the moulii
and nostrils cleansed, and the body placed in
warm blankets; this should be done as soon as

K 3

134

ASPHYXY^ OF New-boun Infant?.

the body is fount!, if the weather be cold, and the
distance to the place where resuscitation is to be
attempted be considerable. The directions given
in preceding paragraphs (^§21 . et seq.'), are now
to be followed. Some advantage will be derived
from placing the body in a warm sun, or before a
fire, or surrounding it with dry warmth ; heated
substances may likewise be applied to the epigas-
trium, tlie extremities, and insides of the thighs.
Where a warm bath can be readily procured, the
body may be placed in it, and the temperature
regulated to about 98° or 100°. J/»ma//(eat, pro-
ceeding from some of the domestic lower animals
or from a healthy person placed by the side of the
body, is, especially in the cases of childien, a
very efficacious mode of resuscitation. But all
these means should not interrupt the performance
of artificial respiration. I'he other measures re-
commended in the foregoing section may also be
resorted to, with the exception of bleeding, which
is seldom beneficial until the circulation has been
restored ; when it will not infrequently be re-
quired, to subdue morbid reaction, in conjunction
with other remedies calculated to restore tlie se-
cretions, &c. (§ 32.) *

34. B, Asphyxy from strangulation requires
the same measures which have been described
under the head of general treatment (§ 26. &c. ),
and particularly bleeding, which may generally be
advantageously performed in the jugular vein.
The head and shoulders ougiit to be raised as
high as may be consistent with the means used
for resuscitation ; and, if a restoration of anima-
tion be effected, the usual means of guarding the
brain from the ill effects of reaction or congestion
to which this organ is more liable after strangula-
tion than after asphyxy from other causes, are to
be put in practice.

35. In cases of asphyxy from obstruction of the
glottis and larynx, or from substances having
passed into this situation, or into the trachea, the
operation of tracheotomy should be resorted to.
Several instances of this description have been
recorded, wherein it has been successfully per-
formed. In all cases of recovery from asphyxy,
the patient should be carefully watched for two
or three days, and every appearance of reaction
affecting any organ, more particularly the brain,
instantly subdued by means appropriate to the
circumstances of the case. Pure air, and the use
of deobstruent purgatives and diuretics, are gene-
rally necessary, in brder to purify the circulating
fluid, and change it from tiie unnatural state it
had assumed during the asphyxy.

Bibliography. — A. Louis, Surla Certitude des SIgnes

dc la Mort, 12mo. P;iris, ITS'i Pia, Detail des Succes

de rUtablissement quo la Ville de Paiis a fait en faveiir

des Noyes, 8vo. Lyon, 1768 Gardantte, Sur les Morts

apjiarentes dites Asjiliyxies, 8vo. Paris, ]777.— Ctu//rcai,
Mem sur I'Aspliyxie par Submersion, Rvo. IJord. ITD'J.
— I'lirtnl, Sur Ic 'j"rallcmeiit des Asjiliyxies, 12mo. Paris,

181 1 Cullcii, ill Kdiii. Med. Comment, vol. iii. p.24.'i. —

.7. Ibmlcr, Observations on the Animal Kconomy, p. KiU.;
and Pliilos. 'I'rans. for 177fi, p. 412. — Goodwyn, Of the
Connexion ot Life with Kespiration, p. 82, &c. Lond.
l-m. — Jiichal, Sur la Vie et la Mort. Paris, An. 8. —
CuUmnn, On .Suspended Respiration, p. 218. — licrgcr, Sur

la Cause de I'Asphyxie par Submersion. Gen. 1805

Vurri/, Ob.serv. on ."Vtiparent Death from Drowning, &c.
— Kile, in Duncan's Med. Comment, vol. xiv. p. 107. —
Oijilit, Secours a doiiner aux Person. Uinpois. ou As-
phyxies, 12ino. Paris, 1818; et Archives (Jener. deMed.
t. xiv. Y.hXi — Manni, Del i'rattaincnto degli Annegati,

8vo. I'esaro, 1H21) l.croij, Recherches sur 1 'Asphyxies,

Rvo. Paris, 182!). — Edxnards, De I'lnfluence des Agens
Physiques sur la Vie, pai t i. ch. 1 ., tt part iv. ch. 4. Paris,

1821. — Piorry, in Journ. Hebdom.de Med. t. iii. p. 550.
— Devergie, ait. Asj>hyxie, Diet, de Med. et Chir. Pratiq.
t. iii. p. .'?42. — U'tllinms, in Edin. Med. and Surg. Jimni.
xix. p. 524. — Kay, in Ibid. vol. xxix. p. 42. — M. Bour~
grois, in Archives Gener. de Med. t. xx. p. 120.— Meyer,

Lonil. Med. Repos. vol. iii. N. S. p. 436 Humane So-

cicly's Fifty-seventh Annual Report, 1831, p. 62 P. M.

Itoget, in Cyclop, of Pract. Med. vol. i. p. 167 C. H.

Marc, Nouv. Recherclies sur les Secours a donner aux
Noyds, &c., 8vo. Paris, \%'ih . — Lancet , No. 629. p. 806.
R. Dunglison, art. Asphyxia, in Amer. Cycl. of Pract.
Med. vol. ii. p. 465. {A most able treatise.)

1. ASPHYXY OF New-born Infants is fre-
quently met with, particularly in those who are
naturally feeble, or weakened by rupture of tlie
chord or laceration of the placenta in consequence
of sudden delivery, or of the operation of turning,
especially when required by uterine hasmorrhage.
It is also occasioned by compression of the chord,
and a protracted parturition.

2. Besides the absence of respiration and of
muscular motion upon delivery, the surface is
pale ; the flesh and limbs are soft and flaccid ;
the heat of the body is rapidly diminished, but
the circulation slill continues, at least for some
time. Several cases which are vievv'ed as asp/ii/xu,
more properly belong to syncope or loss of blood,
or participate in those states, as well as in privation
of the respiratory actions. This privation may
depend upon imperfect circulation in the pul-
monary aiteries, and through the lungs ; or upon
inactivity of the respiratory muscles, and torpor
of the nerves which supply them, owing to im-
perfect circulation in the biain ; or upon these
causes conjointly. Care should be taken to dis-
tinguish these cases from apoplexy ; as tiie states
of the vascular system, and of circulation in the
brain, and consequently the treatment which is
required in each, are very different.

3. The treatment of these cases consists of de-
ferring the ligature of the chord for some time ;
of taking care that no blood is lost from dividing
it ; of enveloping the infant in warm flannel ; of
holding it near a warm fire, or plunging it in a
warm bath, rendered exciting by means of salt
or mustard ; of removing all obstruction to the
passage of air into the lungs from about the throat
and mouth ; warm frictions of the surface of the
chest, with gentle succussalion with the palm of
the hand on the shoulders ; tickling or irritating
the nostrils and arm-pits with a feather; dropping
a little diluted aromatic, or ammoniated spirit
upon the lips ; and most particularly inflation of
the lungs by the breath of the medical attendant,
eitlier blown directly into the mouth, the nostrils
being closed, and the trachea gently pressed back-
wards ; or through a curved tube introduced into
the larynx, as recommended by Ciiaussier, and
employed by him at the " Maison d'' Accouchemens"
in Paris. This latter method is certainly pre-
ferable. Insufflation is to be managed in the
same manner, in other respects, as described in
the foregoing article. But 1 think that the breath
of the attendant is better suited to infants, than
cold air thrown into the lungs by a bellows.

4. M. Desoumeaux complains of his want of
success from inflation of the lungs, even when
carefully and assiduously employed, and places 1
more dependence upon means calculated to ex- \
cite the respiratory muscles to contract. For this
purpose he recommends a species of spirit douche,

and directs the practitioner to take a mouthful of
brandy, and dash it forcibly against the anterior
parieles of the chest. He states that this is sel-

ASTHMA -

dom requirerl oftener than twice or thrice. INIe-
chanical irritation of the nostrils, or exciting
powders applied to the pituitary membrane, may
be cautiously tried ; a stimulating clyster may
also be thrown up. Galvanism or electricity
may likewise be resorted to when within our reach.
We should not relinquish our endeavours at re-
suscitation under two or three hours, or even
longer ; and, if we ultimately succeed, the state
of the infant should be carefully watched for two
or three days.

Bibliography.— Burns, Principles of Midwifery, &c.
8th edit. p. 5y2._Ga»(//<«, Traite Coraplet. d'Accouche-
nieiis, &c.. t iii. p. I3ri._ Ucsormcaux, art. Nouvcaux -nes.
Diet, de Medecine, t. iii. p \h\',. — JVilson, in Glasgow
Med. Journ. vol. il. p. 237. — See Dublin Med. Joiirii. for
July, 183fi, passim.

ASTHMA. Deriv. and Synon. "^AaO/xa, an-
helatio : from &cti, I breathe ; aad/xdi^v, I
breathe with ditficulty. Suspirium, Celsus,
Seneca. Dyspiuva Spastica, Auct. X;\t.
Mitspathica Spastica, Ploucquet. Asthma
Chronicum, J. P. Frank. Asthma Coiivid-
sivum, Baglivi, Alberti, Hoffmann, Sauvages.
Asthma Spiisticum, Juncker. Pnensis Asthma,
Young. Asma, Bolsaggine, Ital. Fcnisse,
Asthme, Fr, Die Engbrlistigheit, das Keu-
chen, Ger.

Classif. 54. G. Asthma ; 3. Order, Spas-
mi ; 2. Class, Neuroses (CiiUen), 4. G.
Asthma ; 2. Order; 2. Class (Good). 37. G.
Asthme Convulsif; 4. Order; 4. Class
{Piiiel). II. Class, III. Okder (Author,
see Preface).

1. Defin. Great Difficulty of breathing, re-
curring in paroxisms, accompanied with a wheezing
sound, sense oj constriction in the thorax, anxiety,
and a difficult cough, terminating in, mucous ex-
pectoration.

2. There are few diseases, the nature of 'wliich
has been a subject of greater doubt and difference
of opinion than asthma. Until the writings of
Fi.oYER, Willis, Hoffmann, Alberti, and
JuNCKER, directed particular attention to its pa-
thology, it was geneially confounded with dy.sp-
noea, being usually denominated inteiniiltent or
remittent dyspnoea. By these writers, and more
recently by Sauvages, Cullen, Pinel, and
Georget, asthma was considered as essentially
nervous in its nature; and the lesions found upon
the dissection of fatal cases viewed as its conse-
quences, and not as its causes. More recently,
and even at the present day, among many, it has
been considered as a symptom of organic change
of either the heart, large blood vessels, or of the
lungs, air-tubes, &c. But tliis doctrine, although
generally accurate in respect of Dyspncea, is
quite erroneous as applied to asthma.

3. Physiology or Asthma. — The dependence
of dyspnoea, not only upon organic lesions of the
organs seated within the cliest, but upon the form
of the thorax, upon di.seases of adjoining viscera,
and upon the state of the air-passages, is sufK-
ciently obvious. The difficulty of breathing pro-
ceeding from these sources may be either con-
tinued or remittent; but it never is, whilst the
causes on which it depends aie in existence,
characterised by intervals of peifect ease. True
asthma, however, pre>ent!3 iniervals of healthy
respiration ; and although repeated returns of the
attack will generally induce some change in the
organisation of either the lungs or the principal

Pathology of. 135

organs of circulation, yet ihi.s is not uniformly the
case; and moreover, an attentive examination of
the thoracic viscera, in recent attacks, fails of
detecting in them any appreciable change, par-
ticularly during the intervals between the parox-
ysms. The disease has even proved rapidly fatal
during the attack, and yet no alteration adequate
to account lor the symptoms could be detected
on dissection. Instances of this description have
been adduced by Wichmann (Hujeland's .Journ.
b. i. p. 18.), Parry, Georget, Andral, Laen-
NEc, and Guersent, and justify the opinions cf
those who have referred the disease chiefly to the
nervous system. In some cases, alter repeated
returns of the attack, and when they have in-
duced organic change, the intervals are less dis-
tinctly marked, consist of remissions merely, and
the disease may, at last, pass into confirmed
dyspnoea.

4. A. The structure ofthe air-passages and bron-
chi evidently shows that these parts are suscep-
tible of preternatural or spasmodic constriction.
During 1821 and 1822, when engaged in some •
researches into the pathology of diseases affecting
the trachea and bronchi, 1 was enabled distinctly
to trace muscular fibres throughout those parts,
both in man and in the lower animals. 'The dis-
position of those fibres, in many of the lower
animals, and the mode of their connection with
the cartilaginous rings, are peculiar, and beau-
tifully adapted to guard against the contingencies
to which they are liable from varying positions
and habits of life. Upon those, however, I can-
not here enter. About the same time that my
attention was directed to this subject (Lond, Bled.
Repository, vol. xxii. p. 418.), the researches of
Reisseissen of Berlin, and of Laennec and Cru-
VEiLHiER of Paris, appeared ; and the results, in
respect of the structure of the bronchi and larger
ramifications of the trachea, upon the whole, agree
with what I had observed. It had been denied
that the membranous, or any. other part of the
air-passages contain muscular fibres. But this
was asserted chiefly by those who cannot believe
that a part is muscular, unless the fibres are the
same in appearance as those which enter into tlie
composition of the muscles of voluntary motion.
Other anatomists, who take a more comprehen-
sive view ofthe conformation and functions of the
muscular system, consider, with greater justice,
that the muscles which are acted upon by the
will, form an older by themselves; and that there
is another and a very imporlant order of muscular
parts, which are not directly influenced by vo-
lition, but which Contract from stimuli acting on
them, either immediately or mediately, and which
present certain peculiarities in respect of the ap-
pearances of their fibres, of the mode of their
distribution, and of the manner of their connec-
tion with internal tissues and organs. Now, the
fibres which are discovered in the trachea, and
traced to the smaller ramifications ofthe bronchi,
are in every respect similar to other involuntary
muscular fibres, in their organisation ; in their
connection with a mucous surface, forming, in
many respects, a tunic concentrically with the
mucous coat ; in being disposed in circular fibres,
surrounding hollow tubes; and in being supplied
entirely by ganglial or involuntary nerves. The
disposition of the fibres, therefore, which are de-
tected in the air-passages, being altogether similar
K 4

i36 ASTHMA — Pathology of,

to tliat which obtiiiiis in other cunals, the mus-
cular structure of which is not disputed, as in the
alimentary tube and urinary hladder ; the organ-
isation of the fibres being also similar; their con-
nection to a mucous surface, and the circum-
stance of their being supplied with the same order
of nerves, being at the same time considered ; are
we therefore to be surprised that agents affecting
either the mucous surfaces thus related to them,
or the nerves supplying them, should be followed
with analogous effects to those which we observe
after the action of agents directed to the mucous
surface or nerves of the alimentary canal ?

5. B. The lungs possess a vital power of expansion.
— The structure of the air-passages, then, would
lead us, independently of the results of observ-
ation, to infer that the circular fibres are liable
to experience, with all other involuntary muscular
fibres, a spasmodic constriction ; and it evinces,
particularly in the conformation of the cartila-
ginous rings with which the trachea and larger
ramifications of the bronchi are provided, a
marked provision against an inordinate continu-
ance or degree of this constriction ; the rings, by
their permanent elasticity, acting as antagonists
to the circular fibres, preveniing extreme con-
striction, and at last overcoming long-continued
spasm, particularly in those larger branches, the
inordinate constriction of which might have the
effect of excluding the air from a very large por-
tion of the lungs. In the larger ramifications of
the bronchi, the muscular fibres connecting the
extremities of the cartilaginous rings are thus
antagoni>ed by these rings ; but, in the smaller
ramifications, where the rings cease to be de-
tected even in the imperfect forms in which they
there exist, and where the fibres are perfectly
circular, the only provision which can prevent an
inordinate constriction of those fibres, is in the
structure of the lungs themselves, which must
necessarily undergo a change in bulk, and be-
come more condensed by this constriction, in
those parts, at least, to which the spasm extends;
unless we believe that the lungs, like various other
organs, are endowed with an expansive power, —
a power which physiologists and pathologists
have too much overlooked in their exposition of
the healthy and morbid actions of the animal
economy.*

6. 'J he mechanism of the expansive power is
so little understood, and generally so insufficient
for ilie explanation of this phenomenon, that we
must refer chiefly to the vital actions of the part,
which mu-t necessarily depend on the eneigies of
the body generally. The expansile action of the
penis, nipple, heart, uterus, &c. cannot be ex-
plained by their organisation only : it is mani-
fested to us only during life, and the perfection as
well as imperfection of this action are always ac-
cordant with the degree of vital energy with which
these organs are endowed.

7. 1 have long since had occasion to remark
that the motions and functions of the lungs (Pliy-

* Tliat the lungs, however, really posf ess this property,
may be inferrfd from the permanent elasticity of their
structure, which continues for some time after death ;
and which is still more marked during life, as shown by
•xposing the luiif;s of a living animal. This state may be
with propri.-ty called the vital expansibility of the linigs,
inasmuch as the degree of this slate is chiefly dependent
upon the vital c-nergy of the system, and p:trtly on the
peculiar organisation of the lungs themselves.

siological Notes, (5fc. to M. RicHEnAND's Physio-
logy, 2d ed. p. 628.) have been too generally and
exclusively referred to the mechanism of the re-
spiratory organs, and to chemical changes pro-
duced in the lungs, to the neglect of a much
higher influence, always controlling, modifying,
or altogether changing, the subordinate powers to
which their functions have been thus referred.
That the vital energies of the frame are most
powerfully exerted in the lungs, thiough the me-
dium, especially of the organic nerves with which
they are provided, must be evident to all who
will contemplate the nature and extent of the
changes constantly taking place in these organs
upon the blood circulating through them ; and
the relation which subsists between their functions
and the vital energies of the system generally.
Now, it does appear to me that there exists a
vital expansion of the lungs independent of that
which they experience from atmospheric pres-
sure, and from following the dilated parietes of
the thorax during inspiration. In experiments
upon living animals, where the walls of the chest
have been opened, the lungs are observed to
swell and contract alternately. This fact, which
was first insisted upon by M. Roux (Melanges
de Chiriirg. p. 87.), has since been duly appre-
ciated by Prus, Laennec, and a few others.
Even in cases where the portion of lung has pro-
truded itself after a wound of the chest, — a cir-
cumstance which could only occur from active
expansion of the lung itself, — this portion has
been, although thus unnaturally placed and sub-
jected to the pressure of the atmosphere, observed
to dilate during inspiration. The not infrequent
occurrence of ossification of the cartilages of the
ribs in old persons, and consequent perfect im-
mobility of the ribs, even without any evident
dyspnoea, furnishes another proof of the inherent
expansibility of the lungs: for without having
recourse to this vital property, we cannot explain
the performance of the actions of inspiration and
expiration by the diaphragm alone.

8. This vital property, thereiore, with which
the lungs, in common with some other organs,
seem to be endowed, together with the disposi-
tion and elasticity of the cartilaginous rings of the
bronchi, furnishes an antagonising force to the
unnatural constriction of the tubes from spasm of
their circular fibres ; and, while it serves to explain
the natural functions of the organ, with their mo-
difications from the various influences to which
this property is subjected, is one of the sources to
which we are to impute some of the diseases, and
more especially the one under consideration, to
which the lungs are liable.

9. Having thus shown, from the structure of
the air-pa,«sages, that they, in common with all
other hollow tubes of the body, admit of spasnjo-
dic constriction, and tliut they also present a pro-
vision against the undue extent or continuance
of this state, I should further reniurk, that a
close observation of the phenoniena of disordertd
respiration is sufficient to convince us that they
fretiuently experience this state owing to the
operation of certain causes acting either directly
on the mucous surface of the tubes, and im-
pressing the nerves terminating in it, or originat-
ing in and irritating the nerves themselves, either
at their origins or in their ramifications and con-
nections.

ASTHMA

10. I. Symptoms and Hisronv of Asthma. —
The premonitivij symptonis of this disease are
languor, sickness, flatulency, and other dyspeptic
disorders ; heaviness over the eyes, and headacli j
uneasiness and anxiety about tl)e prtecordia, with
a sense of fulness and straightness in this rejjion
and in the epiga-triuni. In some cases pain is
complained of in tiie neck, wilh uncommon drow-
siness and stupor. It is also olten preceded by
costiveness and inefficient calls to stool.

11. A. The invasion of the attack of spasmcdic
asthma is generally soon after midnight, or about
one or two in the morning, and during the first
sleep. The patient wakes suddenly from a sense
of suffocation. He feels a most distressing tight-
ness at his chest, with great anxiety, difficulty of
breathing, and impediment to the free admission
of air into the lungs. He assumes wilh eager-
ness the erect posture, and cannot bear the least
incumbrance about the ciiest. The breathing
is wheezing, interrupted, and laborious. The
shoulders are ra'serl, the elbows directed back-
wards, and every effort .made to enlarge the
thorax. Owing to the inteirupted circulation
through the lungs and heart, the countenance,
which was at first pale and anxious, becomes,
pariicularly in plethoric habits, red or bloated,
and covered with perspiration. The eyes are
prominent, and the conjunctiva injected. A con-
siderable quantity of pale urine is usually passed
at the commencement, or previous to the acces-
sion, of the paroxysm; and the lower extremities
are usually cold. The pulse is generally acceler-
ated, weak, irregular, and often intermittent. Dur-
ing the fit, the patient has commonly an instinc-
tive desire for cool fresh air, which always revives
him. A small or close room is offensive, and all
warm substances given internally increase the
flatulency of the stomach and bowels, and aggra-
vate the symptoms. When the fit has continued
from half an hour to one, two, three, or even four
hours, it leaves the patient ; and his respiration,
pulse, and feelings assume their natural state.

12. I'his is the common course of a first and
moderate attack of the disorder. Somelimes the
patient has but one such fit ; but more generally
a slight constriction of the chest is fell through
all the succeeding day, and the paroxysm rtlurns
at the usual period of the night; and this con-
tinues for three, four, or even seven days; when
the patient is at last altogether relieved from the
attack. The disease may be suspended for a
month, or several months ; but it i» liable to re-
cur from changes of air, errors of diet, and from
the operation of the other causes productive of it.

13. la some cases the attack is more severe
from the commencement, and continues, with
slight remissions, for several days, accompanied
with a harsh suffocative cough, great distension
of the abdomen from flatus, and more or less of
the symptoms which characterise the complaint in
the severer states resulting from repeated attacks.

14. When asthma once seizes on the system, it
seldom fails of recurring, though the intervals
between the paroxysms are of very uncertain dur-
ation. In many cases it recurs periodically every
ten days or a fortnight. Sometimes the attack
returns at the full and change of the moon, or at
one of those periods only. It has been observed
to recur in females just after the menstrual dis-
charge, or to precede this evacuation, Tersuns

Symptoms of. 137

who have become subject to the disease seldom
escape an attack in the spring and autumn.

15. After repeated seizures, the disease oft( n
assumes the mont violent and distressing features ;
the difficulty of breathing in the fit amounts to
the utmost degree, and is attended with the
greatest tightness over the whole chest, the patient
feeling as if he were bound with cords. His
anxiety at this period is inexpressible, and he la-
bours in respiration as if every moment would be
his last. Severe vomiting also frequently occurs.
The matter discharged is slimy and frothy, or of
a greenish yellow colour. He is subject to palpi-
tations and faintness ; and cool fresh air becomes
absolutely necessary. About this period a loo.-e
siool sometiines takes place. The eyes are pro-
minent, the face sometimes pale, sometimes high-
coloured, bloated, or livid : the nose and ears are
cold : the face, neck, and chest, covered with per-
spiration. The pulse is generally extremely weak,
irregular, and even intermittmg ; there is often
much difficulty of swallowing. The patient can
scarcely speak, cough, or expectorate, and ilio
stomacli and bowels are much distended with
flatus. As the paroxysm abates, the cough be-
comes freer, and is attended with the expector-
ation of a little viscid mucus ; and, in proporiion
as the cough and expectoration increase, the dis-
tressing symptoms abate ; this evacuation, which
had been retained by the spasm of the air-vessels,
indicating a solution of the spasm and a freer
access of air to the cells of the lungs. An easy
and free expectoration, particularly if it be ac-
companied with softness and moisture of the skin,
and a sediment in the urine, is a certain indication
of the subsidence of the attack. Sometimes when
the paroxysm is unusually long, the patient
experiences only a single occurrence of it during
the attack.

16. B. The Humoral form of asthma is gene-
rally gradual in its accession, and attended by
extreme oppression, a suffocative cough, and u
copious secretion and expectoration of mucus
from the commencement of the seizure (§ II.).
It is sometimes the consequence of repeated at-
tacks of the preceding variety ; and is generally
more severe and of longer duration than it, owing
to the accumulation of viscid mucus in theaii-
vessels conspiring wilh the spasm it occasions to
aggravate the symptoms. There are also less
perfect intervals of ease in this form of the malady,
ihan in the spasmodic. Alter the subsidence of
the patient's sufferings during the first night of the
attack, and while the expectoration is easy and
copious, the lungs slill continue irritable through
the day, and the respiratory function embarrassed
from the slightest causes. At the approach of
night, the fit recommences with the usual symp-
toms, and the night is • passed neaily as the
former. On the thiid day the remission is n)ore
complete, there is some additional expectoration,
and bodily motion is performed with less distress,
but still with great inconvenience. After the
paroxysm has been renewed in this manner for
three or four nights, or for a longer period, some-
times for several days or even weeks, — for the
duration of an attack varies much, — the expec-
toration and cough are more easy and fiee, the
daily remissions become more perfect, and the
strength of pulse and vigour of action increase.

17. When the chest is examined by the ear or

133

ASTHMA — Symptoms of.

stethoscope, the sound of respiration is weaker
during the fits than in tlie intervals, but it is sel-
<iom altogether suspended in certain points of the
chest ; it is attended by a sonorous rattle, flat or
sibilous, imitating the chirping of birds, the note
of a violoncello, or the cooing of a wood-pigeon.
With this there is frequently intermixed a mucous
rattle ; but this conveys the impression of being
produced by a thinner fluid than the mucus of
common catarrh. In the intervals of the attack,
these various species of rattle exist, but in a much
less degree. The respiratory sound is louder
than during the paroxysms ; sometimes it is al-
most puerile. If the complaint have occasioned
dilatation of the bronchi, the respiration assumes
more or less the character of the variety called
bronchial ; in all cases it varies in intensity at
different points of the chest, and these points
change their situations from day to day (Laennec).
The chest generally sounds well, throughout the
attack, upon peicussion.

13. I have stated (§ 16.), that the humoral
form of asthma is often consequent upon re-
peated attacks of the spasmodic ; but this latter
may also occur, although rarely, after the former ;
or the attacks in some persons present an evident
complication of both forms of the disease. The
stomach and bowels are extremely liable to dis-
order in asthmatic persons, particularly in those
subject to the spasmodic form of the disease.
Colic pains, flatulence, loss of appetite, an irre-
gular state of the bowels, and a disturbed, im-
paired, and unrefieshing sleep, generally harass
the asthmaiic patient, even in the intervals be-
tween the seizures. In females, the menses are
generally impaired or irregular, and an attack
often precedes the period of the menstrual dis-
charge, the supervention of which generally acts
as a crisis of the attack.

19. Symptoms of fever are not essential to the
disease, though tliey often occur, especially when
the humoral asthma, or an attack of catarrh, is
complicated with the convulsive. Hectic fever,
colliquative diarrhtea, faintings, palpitations, vo-
mitings, coldness of the extremities, swelled legs,
and other dropsical symptoms, are common in the
last stage of the disease, and indicate organic
changes in the substance of the lungs or heart,
with obstruction to the circulation in these or-
gans, and efl^usion of fluid in the chest, — results,
however, which can only be ascertained with pre-
cision by means of auscultation and percussion.

20. C. Teniiiiuitions. — An attack of asthma
generally terminates in one of three ways: 1st,
By a return to the healthy function: 2d, By in-
ducing furtlur lesion ; in which it either disap-
pears, or becomes complicated : and, 3d, In death.
On each of these 1 shall offer a few remarks.

21. rt. Although the paioxysms of asthma fre-
quently terniinatu in a return to the htalthy
functions, a perfect immunity from future attacks
can rarely be procured. Yet these attacks may
be frequent, severe, and of long duiation, recur-
ring for a long series of years ; the patient, not-
withstanding, arriving at a very advanced age,
before a fatal issue takes place. 15ut they often
produce the following organic L sions.

22. l>. The most common conse(|uences of the
disease to which I may now advert, are chronic
inflammation and dilatation of the bionchi ; the
different forms of emphysema and oedema of

the lungs; haemoptysis; tubercular formations,
with which asthma may also be associated from
its commencement; enlargement, and dilatation,
&c. of the cavities of the heart ; effusions of
fluid in the pleura or pericardium ; and wasting
of the heart, or polypous, concretions, within iis
cavities. As the reader will find all those lesions
treated of under their distinctive heads, I shall
here only remark respecting them, that, when they
supervene to asthma, many of the distinctive
characters of this disorder entirely disappear in
those of the superinduced disease, and the lesions
of the respiratory functions assume the distinctive
features of chronic, continued, or remittent dysp-
noea. Severe attacks of asthma may also ter-
minate in congestions or effusions within the head,
giving rise either to epilepsy, coma, or apo-
plexy.

23. It was already remarked, that auscultation
and percussion furnished merely negative inform-
ation in the different forms of asthma. But this
information is still important, inasmuch as it inti-
mates the non-existence of any of the foregoing
organic changes; and when they do exist, those
means of diagnosis enable us not only to recog-
nise them, but also to ascertain witli precision
their nature, progress, and extent, and thus to
form an accurate diagnosis and prognosis in re-
spect both of the primary disease and of the con-
secutive organic changes.

24. c. When the disease ends in death, this
event is brought about generally by superin-
ducing some one of those changes already re-
ferred to as terminations of the disease, or of
those lesions, with which it is frequently asso-
ciated {§ 22.). Death may, however, occur, but
much more rarely, from the severity of the at-
tack ; the requisite changes not being effected on
the blood by respiration, owing to the obstructed
state of the air-vessels, either from spasm or the
accumulation of viscid mucus, or from both,
whereby the nervous centres are' supplied with
blood unsuitable to their functions, and the lieait
ceases to contract with suflicient energy to pre-
serve the circulation in a requisite state of acti-
vity through the lungs and brain.

25. D. Tlie uppeuraitces (ijter death may he m-
ferred from what has already been stated. These
appearances are rather the consequences of the
tlisease, than the disease itself; lor it is seldom
that we have an opportunity of examining the
body in recent and uncomplicated cases of
asthma. ^^ here, however, this has been done,
the lesions, even when any have been detected,
have been insufficient to account for the disease.
WiLi-is records a case of piotracted asthma, in
which no morbid appearani e could be detected ,
and similar cases have occurred to Laennec, An-
uitAi,, Ciiuvi'ii.iiiFR, BooiLLAun, Jolly, and
others. Friinus, after extensive experience, states
that he has been unable to detect any lesions
which can be attributed to uncomplicated asthma.
'J he changes which have been noticed, therefoic,
by authors, are to be viewed chiefly as acciilental
(iccui tenets, or associated nialad.cs; and, per-
haps, moie fiequently as the remote results of
Hpealed or protracted attacks. The appearances
usually observed in fatal cases are the same -on
have been dcsciibed (§ 22.).

25. II. VAHitiiLS OF Asthma, and of tiieih
rAinoLOGY, — Sauvagis has euumeiuted no Itts

ASTHMA— Varieties of.

139

than eighteen forms of this disease, many of them
presenting no modification of the phenomena
constituting the disease, but merely pecuharities
as to cau>-e, particularly as respects the .occa-
sional causes. Sevei'al of his varieties, also,
strictly belong to the more generally symptomatic
complaint to which the term Dyspncea is usually
applied. The varieties of idiopathic asthma, ac-
cording -to CuLLEN, are the Spontaneous, Ex-
ANTHEMATic, and Plethoric. Dr. Breic, who
has given a comprehensive account of the disease,
has divided it into forms which have reference
chiefly to the doctrine which he has espoused re-
specting its pathology. He assigns to it four
species: — 1st, Asthma produced by the irrita-
tion of effused serum in the lungs; being its most
common form : 2d, That occasioned by the irrita-
tion of aerial acrimony in the lungs ; 3d, That
dependent on irritation in the stomach, or some
of the abdominal viscera: and, 4lli, That depend-
ent upon habit. Dr. Young has adopted a similar
arrangement.

26. JM. Laennec has given a simpler view of
the disease, and assigns it two forms, viz. asthma
attended with puerile respiration, in which the
vital expansibility of the lungs is increased, from
a temporary augmentation of the want of the
system for respiration, occasioned by some un-
known modification of the nervous influence ; and
spasmodic asthma, from a spasmodic con-triction
of the air-tubes. Dr. Good has divided the dis-
ease into the dnj and humid; but he has en-
cumbered these two species with nearly as many
varieties as have been assigned by Sauvages.
The dry or nervous asthma he subdivides into
the simple, metastatic, phlegmatic, vaporose, and
organic, — a refinement which is neither founded
in nature, nor can be available in practice ; for a
simple nervous asthma may be induced by in-
jurious vapours, or by repelled eruptions, and
hence we have the first variety produced by
either his second or fourth ; and the second, or
the phlegmatic nervous asthma, may proceed
from the same vaiieties. His fifth variety is cer-
tainly not admissible under asthma, unless as a
consequence of the disease, but falls more pro-
perly under dyspnoea, either in its contmued or
remittent forms. The Humid or ctim/HO/i asthma
he subdivides into the simple, plethoric, and
atonic, — a division much more accurate than the
foregoing, but still objectionable, inasmuch as it
is impossible to draw any line of demarcation
between them, and as the three varieties insensibly
pass into one another.

27. By the great majority of authors who have
written on the disease, it has been viewed simply
in respect of its Idiopathic and Symptomatic
forms ; both, however, presenting modifications
resulting from peculiarity of causes, and the cir-
cumstances of the patient, butmsufficiently marked
to constitute distinct varieties. In the following
observations I shall observe the same distinction,
and divide the Idiopathic form of the disease
into, 1st, The nervous asthma ; 2d!y, The primarily
spasmodic asthma j and, 3dly, The pituitous or
humid asthma.

28. 1st, Nervous Asthma. The asthma with
puerile respiration, Laennec, — Char. Anhe-
Uitionfrom a feeling of want of a more complete
respiration than the patient enjoys, the pulmonary
eipansion distinctly taking place with promptitude,

completeness, and uniformity, so as to furnish u
general puerile sound on auscultation; usually
accompanied with a slight cough, and ivith a free
mucous expectoration.

29. This form of the disease was first accurately
described by Laennec, who pointed out the dif-
ference between it and the forms depending on
spasm of the air-tubes. In this variety no spasm
seems to exist in the smaller air-vessels and cells ;
for the whole tissue of the lungs is dilated to its
full capacity, and with unusual promptitude and
completeness, so that the puerile respiration is
heard in every part of the chest ; whereas in the
other varieties the respiration is generally some-
what more indistinct than in health. M. Laen-
nec contends, and apparently with justice, that
the wants of the system, in respect of respiration,
may be exactly measured by the intensity of the
respiratory sound; and that the intensity varies
much, according to many circumstances, and par-
ticularly according to the age of the individual,
it being much greater in childhood than in adult
life. There is no morbid affection, he observes,
which can be more satisfactorily referred to
simple disorder of the nervous influence, than this
dyspnoea accompanied with puerile respiration.
In cases of this kind, the respiratory sound has
resumed all the intensity which it possessed in
early life. The pulmonary expansion evidently
takes place completely and rapidly in all the air-
cells, and yet the patient feels the want of a more
extensive respiration than he enjoys ; and the
lungs, although dilated to their utmost, have not,
nevertheless, capacity enough to satisfy the wants
of the system. This affection is common in per-
sons affected with chronic mucous catarrhs,
attended by a copious and easy expectoration ;
but even in them, during the severest attacks, the
completeness with which respiration is performed
is quite astonishing. Nevertheless the patient feels
oppressed, and requires a more extensive respiration
than his organisation allows; the wants of the sys-
tem in respect of this function being increased be-
yond the standard of health.

30. In this form of the disease it is not in the
small air-tubes that we are to lock for its proxi-
mate cause, but in the trachea and large bronchial
trunks, and particularly in the nervous influence
itself; and this will equally hold good even if we
adopt the chemical theory of respiration, and
refer the affection to an extraordinary want of
oxygen in the blood, arising from impeded func-
tion of the respiratory mucous surface, owing to
the mucous secretion covering it. M. Laennec
believes, as this species occurs only in persons
affected with chronic mucous catarrh, that it can
never amount to asthma, without the catarrhal
complication. Adults and old persons, he re-
marks, who have puerile respiration without
catarrh, are not, properly speaking, asthmatic;
but they aie short-breathed, and dyspnoea is in-
duced by the slightest exertion, though when
silting still they frequently experience no oppres-
sion whatever.

31. This variety may be considered as depend-
ing upon a temporary augmentation of the want
of the system for respiration, occasioned most
probably by some unknown modification of the
nervous influence ; and apparently consisting in
an expansile action of the lungs increased much
beyond the healthy standard. But here a ques-

140 ASTHMA

lion suggests itself, viz. can this augmented
action of tlie lungs be owing solely to the state
of this organ, or is it associated with, or partly
depending upon, increased activity of the respira-
tory muscles, particularly the diaphragm? M.
Laennec states that it cannot be produced at
will by a full inspiration ; and, therefore, infers
that this state of the lungs is a primary condition
of them, and not depending on increased inspira-
tory efforts.

32. From this consideration I am led to infer
that, although the vital expansile action of the
lungs may be increased in this variety of asthma,
it is accomplished with, and much assisted by,
augmented activity of the diaphragm, which per-
forms its office more promptly and completely in
this vaiiety of asthma than in any other; that
instead of the disease being characterised by
spasm of the smaller ramifications of the bronchi
and air-cells, as in the second variety of asthma,
the air penetrates more fully into them than
usual ; and that, if any spasm exists, it is limited
to the trachea and large bronchial tubes ; the
exalted state of expansion of the lungs, and of
function of the diaphragm, being an effort to
counteract this morbid condition of the large
tubes, and to supply the wants of the system by
a more forcible inspiration ; the increased rapidity
with which the air is thereby made to pass
through the strictured canals making more than
amends for the diminished calibre of the passage.
This form of the disease is frequently symptoinatic
of nervous affections, particularly of hysteria,
when the globus hystericus affects the state of
the trachea, and of various diseases, in which the
blood is imperfectly changed in its circulation
through the lungs. But when thus symptomatic,
it is often slight and evanescent.

33. 2d, Spasmodic Asthma. Syn. Periodic
Asthma. Convulsive Asthma, WiUis, Baglivi,
Boerhaave. Asthma Siccum, Musgrave. Occult
dry Asthma, Etmulter. Spasmodic Asthma, La-
ennec. Dry Asthma, Good. — Char. Parox-
ysms sudden, violent, and of short duration, at-
tended ivith hard si)asm('dic constriction in the
chest; slight, dry, and difficult cough, and with a
scanty expectoraiion, occurring only towards their
close.

34. I stated that the vital expansive action of
the lungs was increased in the foregoing variety.
In this the ramifications of the air-tubes, and
peihaps the air-cells themselves, seem to be unna-
turally constricted. 'I'lie respiration, when ex-
amined by the stethoscope, or by the ear merely,
is heard either very imperfectly even on the most
forcible respiration, or to a small extent only, or
its sound may be but little impaired. The chest,
during the paroxysm, sounds ill on percussion.
These phenomena indicate that there is an im-
perfect entrance of the air into the air-cells. ]\I.
Laennec states, that if the patient after holding
his breath nearly as long as he can, breathes
(|uietly, the spasm will often be overcome as it
were by surprise, and the entry of the air into the
cells will be heard in a clear or even puerile
i-ound. This, and various other circumstances,
independently of the jiroof furnii-lied by the struc-
ture of the air-tuiies, indicate lliat the obi"tiuclicn
to the entrance ot air into the cells is owing to
sjiasm of the muscular fibres.

35. Dr. Williams believes that spasmodic

— Spasmodic.

asthma may be partial, affecting one lung only«
or one more than the other ; but this is very sel-
dom the case, unless when it is occasioned by,
or complicated with, dry catarrh, which is some-
times partial ; or when the spasmodic constriction
is excited by a collection of a pituitous fluid in
some of the bronchi, — a complication of not in-
frequent occurrence, but falling more strictly
under the next form of the disease. Although
the paroxysms of the primarily spasmodic asthma
are sudden, and generally of short duration, yet
the disease is often of long continuance, and may,
to a certain extent, become habitual, as shown
by Dr. Bree and others.

36. During the spasm, the lungs seem, from
an attentive examination of the thorax, somewhat
drawn together, owing to the constriction of the
air-tubes; and the parietes of the chest, being
necessarily pressed inwards at the same time,
generally yield a less clear sound on percussion.
The scrobiculis cordis is also drawn inwards and
upwards, indicating the manner in which the
diaphragm is affected during the paroxysm. This
phenomenon, which was first pointed out by
Scheidmantel (Fr'dnkische Betriige, No. 5.),
arises either from the diaphragm being prevented
from contracting to its full extent by the spastic
constriction of the air-vessels, or from a temporary
paralysis of this muscle. That the latter state
should take place, and be followed in a short
space of lime by a perfect restoration of action,
and that repealed seizures of this description
should be always succeeded by a similarly rapid
return to the healthy state, cannot be admitted
by any person who takes an intimate and com-
prehensive view of the operation of the animal
economy in health and di=ea<e. That retraction
of the epigastrium, and even of the hypochondria,
is owing to imperfect descent of the diaphragm
from constriction of the air-cells, seems proved by
the circumstance, that the pleural cavity is per-
fectly closed, and forms nearly a vacuum, and
consequently the capacity of the thorax cannot
be enlarged by the action either of the diaphragm
or of the other respiratory muscles, without the
expansion of the lungs. But this organ is only
imperfectly expanded, owing lo the spasm of its
air-vessels ; consequently the diaphragm eithe r
cannot assume its usual place, or does so im-
peifeclly, nolwiihstanding its efforts to accomplish
this end ; and the parietes of the thorax are every
where pressed inwards, following the retracted
slate of the lungs themselves, and are only
partially dilated alter the most energetic action of
the lespiraiory muscles, which at last overcomes
the spasm of the air-tubes, as the want of respira-
tion throws the former into spasmodic action,
and lends to relax the spastic state of the
latter.

37. This condition of the air-vessels, and the
antagonising action of the respiratory muscles
during the paroxysm, have a necessary tendency
to foim a vacuum in the thoracic cavity ; but this
can take place to a veiy small extent only, as the
action of the respiratory muscles is insufficient to
overconie both the pressure of the atmosphere
suriounding the chest, and the spastic strictuie
(jl'tlie air-lubes, as long as this stricture continuis
in hill loice. The consequence, however, of this
antagonising action and tendency to form a
vacuum is, that a larger quantity of blood is

ASTHMA— Humid.

14!

drawn into the large veins within the thorax, and
into the venous sinuses antl auricles of the heart,
occasioning congestion of those cavities, impeded
circiihition through the lungs, congestion witiiin
t!ie liead, an 1 inordinate and irregular action of
the heart, with various other injurious effects
upon tlie central organs of circulation, as well as
upon the cerehro-spinal centres.

38. In addition, also, to these efTects, v^diich
take place during the antagonising struggle cha-
racterising the paroxysm, rupture of one or more
of the air-vessels or cells sometimes takes place,
in consequence of the violent action of the inspi-
ratory muscles on the one hand, and the unyielding
state of constriction of the air-vessels on the other
(§ 136.); and emphysema of the lungs is super-
induced, forming one of the most common lesions
found upon dissection of fatal cases, and in the
opinion of some pathologists the proximate cause
of the disease. (See Lungs, Emvhiisema of.)

39. 3d, Common or Humid Aithina. — Svn.
Catarrhal Asthma ; Continued .'\sthma; Humoral j
Asthma; Pituitous Asthma. Spitting Asthma,
Ftoyer. Asthma Huniidum, Biverius and Mus- j
grave. A. Pneumaticum, Willis. A. Humidum, '
liiglivi. Pituitous Catarrh, Laeniiec. — Char.
Gradual accession oj the paroxysms, ivhich increase
in severity, are protracted, and attended with heavy
and laborious constriction of the tliorax, severe
suffocative cough, and with expectoration, often
cummencing early, at first viscid and scanty, but
becojning copious and affording relief.

40. This common form of asthma may present
various pathological states and relations. It
may, as stated by Cullen and Good, be cha-
racterised by plethora of the vascular system ge-
nerally, and of the pulmonary tissue especially,
particularly when it supervenes to the suppression
of some accustomed evacuation. It may also be
associated with a relaxed or atonic state of the
txhalants of the bronchial surface, particularly
when it takes place after chronic catarrhs, and
ill aged or phlegmatic subjects; and it may be
attended with both these states, namely, with
plethora of the sanguineous system, and atony of
the exhalent pores of the respiratory mucous
surface. Besides these states, it may vary in the
acuteness and clironicity of its symptoms and
progress ; it being either acute or chronic, or
presenting grades intermediate between both.

41. The chief characteristic of this variety of
asthma is the copious discharge of viscid mucus
accompanying it. But the questions with several
modern pathologists have been, v\hether the phe-
nomena of the disease are to be imputed solely to
the accumulation of this fluid in the air-passagts,
or in part only ; and whether the spasm of those
passages also exist in conjunction with an in-
creased secretion of mucus, or not. I believe that
an attentive observation of the phenomena of the
disease, with the assistance of auscultation and
percussion, — which, however, occasionally furnish
but little information,and thatof a negativedescrip-
tijn, in this disease, — will lead to the inference
that it depends upon both those morbid states.
'J he limits of our inquiry are now narrowed to
the question of the priority of their existence, and
the relation which the one holds to the other. As
to these points it may be remarked, that the early
occurrence of expectoration, as well as its abun-
dance, forbid the inference that the production of

viscid mucus is the consequence of relaxation of
the spasm ; whilst they favour the idea that the
spasm is occasioned by this secretion in the irri-
table and morbid air-tubes ; the severity and
duration of the paroxysms being occasioned by
these double states of disease, — an abundant se-
cretion of viscid mucus in, and a spastic constric-
tion of, the air-passages,

42. But it may be further inquired, are not
those morbiil changes the effect merely of a cer-
tain condition of the air-passages still more in-
timately connected with the disease than they are?
I do not deny the po-sibihty of lesions antecedent
to those now specified ; but the difficulty of ascer-
taining their exact nature must be conceded. It
would certainly be advantageous to obtain this
information, inasmuch as on it would be based
the means of cure which might be employed
early in the disease. That it is not inflanima'ion
is proved by concomitant anrl symptomatic phe-
nomena, by the course of the paroxysms and of
the disease, by the terminations usually charac-
terising it, and by observation of ihejuvantia and
Ledantia during its progress. It seems, however,
extremely probable that the morbidly increased
secretion and spasm are preceded by a congestive
state of the mucous respiratory surface ; this stale
disposing to the spasm, and being, as well as the
spasm itself, at last relieved by the copious effu-
sion of mucus; the mucus tirst effused tending,
however, for a time, to increase the spastic con-
striction of the air-passages, and the consequent
struggle of the respiratory muscles to overcome it
(^§36, 37.), and to procure a fresh supply of air
in the lungs. This antecedent state of vascular
turgescence of the mucous surface of the bronchi
in asthma, is perhaps most marked in that form
of this variety, in wliich little or no expectoration
accompanies the cough, at least early in the attack,
and which, from this circumstance, and the causes
which induce it, has been called the dry catarrhal
asthma.

43. If it be still further asked to what cause are
we to impute this congestive state of the respir-
atory surfaces? I can only answer, to a certain
primary change of the vital energy of the organic
nerves supplying the blood-vessels, and actuating
the muscular fibres of the bronchi ; and hence,
as the morbid changes of the circulation, secre-
tion, and calibre of the air-passages, are merely
efl^ects of one cause, — of a previous change of the
vital manifestations of the nerves of the organ, —
it becomes of the utmost importance to ascer-
tain the nature of tliis primary change with as
much accuracy as possible, in order that reme-
dial agents may be directed with precision to
its removal ; but the prosecution of this very
interesting topic falls under another division of
my subject. In estimating, however, the nature
of this, as well as the other varieties of asthma,
the difficulties opposed to expiration by the
spasm of the air-tubes, and the accumulation of
viscid mucus in them, have been too generally
overlooked in our eagerness to ascribe all the
morbid phenomena to impeded inspiration. But
I believe that the disease, particularly this va-
riety of it, is as much occasioned by the obstacle
these states of the air-passages present to free
expiration ; the air, by the greater power of the
inspiratory over the expiratory muscles, being
diawu in sullicient abundance into the lungs.

142

from which it is imperfectly expelled. From
this circumstance the lungs are often kept in a
state of inordinate dilatation, and the respiratory
muscles excited to convulsive actions, occasioning
dilatatioa or rupture of the air-cells, and conse-
quent emphysema of the lungs. In the more
advanced stages of the disease, in old and debili-
tated subjects, this struggle to dilate the thorax
siill further, proceeding from the wants of the
system for respiration, and to expel the air from
tlie lungs through the obstacles placed in its
way, generally terminates unfavourably to the
latter part of the respiratory actions ; conse-
quently expectoration is impeded or suppressed,
and life is terminated, with the air-tubes and cells,
and even the substance of the lungs, loaded
and infiltrated with mucus, air, and serum. It is
in this state that active stimulants and emetics, by
rousing the enerfiies of the frame, and by exciting
the expiratory efforts during the process of vomit-
ing, prove so frequently beneficial.

44. This form of asthma may be partial, af-
fecting one lung only, or one more than another ;
but it is more commonly general ; and in some
constitutions, particularly in aged persons, and
when it has supervened to repeated attacks of
catarrh, the quantity of viscid mucus expectorated
is very great.

45. Its anatomical characters are, slight swell-
ing, or thickening, and softening of, the mucous
membrane, with a slight appearance of redness in
parts, and with marked congestion, and purplish
tint of portions of this surface in the more severe
or protracted cases. Sometimes these lesions are
accompanied with slight oedema of the membrane,
and the development of miliary tubercles in the
lungs.

46. As the majority of cases of this disease is
characterised from the commencement by copious
expectoration, it becomes a question how far it
deserves to be considered as a variety of asthma ;
but taking all its phenomena into consideration,
particularly the spasm of the air-passages, and
convulsive action of the respiratory muscles, as
well as the circumstance of its having been usually
considered as a species of asthma, and the dif-
ficulty of arranging it otherwise, I was unwilling
either to assign it a different place, or to make
it a distinct disease, to which it scarcely can lay
claim. M. Laknnec has placed it amongst ca-
tarrhal inflammatory affections of the bronchi :
but I conceive that it is seldom inflammatory
either in its origin or progress ; and that, although
occasionally commencing in, and always aggra-
vated by, catarrh, it is not necessarily a catarrhal
disease. Besides, inflammations of the bronchi
and catarrhs are not identical aBections, although
the latter frequently pass into the former.

47. But, besides these considerations, many of
the phenomena essentially characteristic of asthma
always attend it to a greater or less extent. Upon
an attentive examination, however, of the chest
of a person afflicted with this affection, by auscul-
tation and percussion, these phenomena are found
to vary, in different cases, or even in the same
case, at different periods of the attack ; yet they
are essentially the same as those which mark the
preceding varieties, ulihojgh not so evident to the
senses as in tlnin, inasmuch as they are obscured
by a more prominent symptom — the copious mu-
cous secretion and expectoration. Sonielimes it

ASTHMA — Diagnosis.

is manifest that certain parts of the air-tubes are
differently, or even oppositely, affected at diflerent
periods of the attack. When the viscid mucous
secretion proceeds from, ani is still present in,
the smaller ramifications of the air-vessels, this
condition, together with some degree of spastic
constriction of their circular fibres, either in a
part only, or more or less throughout the organ,
occasions many of the symptoms which charac-
terise the second or spasmodic variety of the
disease. But in proportion as the secretion rises
to the larger air-tubes, and leaves the smaller
ramifications clear ; or when the mucous secre-
tion proceeds chiefly from the former parts, and
excites, or is accompanied with, spasms of these
canals, but not to the extent of preventing the
passage of air into the parts of the lungs which
they supply ; these parts generally expand freely,
owing to the vital activity of the oryan, the wants
of the system for the changes effected on the
blood by respiration, and the active contraction
of the inspiratory muscles during (he convulsive
efforts of the paroxysm. Hence the part of the
lungs thus affected generally furnish the puerile
respiration, and a clear sound on percussion, with
a full and prompt performance of the inspiratory
actions, — phenomena characteristic of the Jirst
or nervous form of asthma.

48. III. Diagnosis. — From the foregoing ac-
count of the symptoms and forms of asthma, it will
appear obvious that the distinction of it from
every other disease cannot be difficult, particularly
if we carefully bring auscultation and percus-
sion to our assistance. The sudden attack of
the paroxysms, the short period of their duration,
the violence of their symptoms, their returning
after intervals of ease and of tolerable health,
are sufficient to characterise the disease. It is
only when asthina is complicated with, or has
induced, other diseases — as chronic or acute
bronchitis, pneumonia, tubercular phthisis, or-
ganic changes of the heart and large vessels, or
effusions of fluid within the thorax — that difli-
culty can arise in determining the exact state of
parts ; and here we have it in our power to resort
to auscultation and percussion, which, if this
disease be simple and uncomplicated, will furnish
us with no very unnatural sound, at least with
none which will exist with any permanency in
any particular part of the chest j and if it be
complicated, the nature and the extent of the
organic changes will be ascertained by these
means, as pointed out under their respective
heads,

49. A. Spasmodic affections nf the larpix moy
be mistaken for iisthma ; but they may readily be
distinguished from it by the sound occasioned by
the passage of air through the narrowed passage,
which is very diflerent from the wheezing sound
of the asthmatic respiration. Besides, in all the
affections of the glottis, the patient readily points
to it as the seat of his sufferings. The patient
also betrays much more alaim of impending suf-
focation ; whereas in asthma he is seldom appre-
hensive of the result, however severe the attack
may be.

50. U. Severe cases of acjUe bronchitis, owing io
the viscid and copious expectoration accumulated
in the bronchi and trachea, and to the spasm ex-
cited in these parts and in the glottis during its
expulsion, are often accompanied with fits of

difficult and spasmodic respiration, so severe as to
approacli nearly to the character of the asthmatic
paioxysiii. But the presence of inflammatory
tever in broncliitis ; and the copious, albuminous,
thick, and glutinous expectoration ; the absence
of the distressing sense of stricture of the chest
and dyspoena which attend asihma; the gradual
accession and increase of bronchitis; its continued
character, and slow subsidence ; and the varying
appearance of the expectoration, with thediflferent
siages of the disease; will be suflicient to distin-
guish it from the humoral form of asthma, unless
both afl'ections are associated, or the one passes
inlo the other, vvliich sometimes occurs, as when
bronchitis seizes the asthmatic subject.

51. C. Angina pectoris may also be mistaken
for a severe lit of asthma. But the circumstances
inducing an attack of both affections, and the
periods of their accession, are dift'erent. Besides,
the fit of angina pectoris is attended with a feeling
of impending dissolution — a sensation which
never accompanies the asthmatic paroxysm. The
peculiar pains, also, under the sternum, and pain
and numbness of the left shoulder, arm, &c., cha-
racterising the former, are not present in the latter
aiFection. When asthma becomes assoc^ted with
disease of the heart and targe vessels, these sen-
sations may accompany it, which will render the
diagnosis more difficult. But still the accession
cf tlie asthmatic fit in the evening or night ; the
comparative immunity from it during the day.
and in the open air ; the history of the case ; and
the antecedent or attendant disturbance of the
gastric functions ; will still continue, and serve to
point out the nature of the disease.

52. D. Hiidrothorax is frequently attended with
suffocating paroxysms of difficulty of breathing
occurring during the night. But it may readily be
distinguished from asihma by the scanty urine ;
by external oedema, particularly of the extremi-
ties ; and tiie dead sound furnisiied by percussion,
and the absence of the respiratory murmur. It
must not, however, be forgotten, that hydro-
thorax is not infrequently consecutive of chronic
asthma, particularly when the valves and cavities
of the heart have become diseased in the course
of the asthmatic attacks. — I'he affection deno-
minated ihe Acute Asthma of Infants _ by RIii.lah ;
False Croup, by GuERstNT ; and the Spasmodic
Croup, by Wichmann, Michaelis, Double,
&c., is nearly allied to spasmodic asthma ; one of
tiie chief differences being its occurrence in in-
fants. Its diagnosis, &cc., will be found in the
article on Cuoop — Spasmodic. The practitioner
should also be careful not to confound the disease
with the difficulty of breathing which sometimes
accompanies hysteria, hypochondriasis, and the
passage of foreign bodies into the trachea.

53. IV. PuoGNosis. — There are few diseases
which continue longer without shorlening life ;
and which, therefore, admit of a more favourable
j)iognosis in respe<;t of a fatal result, or a more
unfavourable opinion as regards a perfect re-
covery. It is chiefly from the consequences of a
severe or protracted state of the disease that we
are to apprehend any danger ; and these are to
be asceriaiaed by auscultation and percussion,
and our opinions formed accortUngly. — a. The cir-
cumstances which warrant a favourable prognosis
as to recovery are, a recent attack, and its occur-
rence from a decided cause ; the constitution of

ASTHMA — Prognosts — Causes of. 143

the patient being but little impaired ; the absence
of deformity and malformation of the chest; a
free and easy stute of the respiration, and a toler-
ably healthy condition of the various functions,
during the intervals between the attacks. If the
occupation of the patient be not injurious to the
lungs ; or, if so, can iie readily relinquished ; if
the attacks are not extremely severe, nor of very
long duration; and more particularly, if auscul-
tation and percussion, as well as the rational
symptoms, indicate an uncomplicated state of the
disease, we have still greater reason to give a
favourable opinion as to its issue.

54. b. On the other hand, an unfavourable idea
must be entertained, especially as respects the
perfect recovery of the patient, and his immunity
from future attacks, if the fits be very severe ; the
cough difficult, suffocative, and attended with
great expectoration mixed with blood and puru-
lent mucus, — a state of the expectoration gone-
rally indicating rupture or dilatation of the small
air-vessels, or the existence of tubercles in the
lungs. If the occurrence of hasmorrhage from
the lungs, of epistaxis, of hiemorrhoids, or of the
menses in females, be not followed by a com-
plete solution of the attack: — if the disorder be
of long standing, and present remissions merely,
or imperfect relief in the intervals, the attacks
continuing for several days ; — if the means of cure
furnish but little or no relief; — if the patient be
far advanced in life, and his constitution have
suffered much either previously to, or from the
malady ; and if the body evince signs of cachexia ;
— if he has neglected his disease, or has been
injudiciously treated; — and if the symptoms
characterising any of the organic changes which I
have stated to proceed from, or to be associated
with, asihma (§j 20—24.), present themselves,
particularly drop'^ical effusions in the pleura or
pericardium, and the nature and extent of these
changes are determined by means of auscultation
and percussion, an unfavourable result must be
looked for sooner or later ; yet may this result be
often deferred for a long period by judicious ma-
nagement. The exact degree of proximity of
danger will depend entirely upon the nature and
extent of the existing organic lesions, and the
state of the vital energies of the frame.

55. If the expectoration become purulent,
round, and globular; if hectic fever be present,
with irregular or intermiitent pulse ; if palpita-
tions occur, and alternate with leipolhyrnia or
syncope ; if the urine be in small quantity and
high coloured, the hands and ankles being oede-
matous ; if the countenance continue bloated or
livid during the imperfect intervals between the
attacks; if the patient become restless, with
slight wandering or low delirium ; a fatal termin-
ation is not very far distant, unless under the most;
favourable circumstances of regimen and medical
treatment, when life may be occasionally pro-
tracted for some time.

56. V. Causes. — lst,Predisposing causes. Asthma
is not a disease of early life, in its primary or idio-
pathic form. 1 have seldom or ever seen it before
the 23d year of age. Some authors state that they
have met with it in infancy and childhood ; but I
believe that they have confounded this affection
with other diseases of the respiratory organs, and
particularly with those to which young children
are liable, and which has been termed spasmodic

144 ASTHMA — Causes or.

ci'oup, Millar's asthma, &c. by several modern
writers, and its nature very generally misunder-
stood. The reader will find them treated under
other articles. (See Larynx — Spasm of ; Croup —
^Spasmodic ; and Catahru — Suffocative.) I be-
lieve that affections of the respiratory apparatus
in children, which are not connected with inflam-
mation, are generally" symptomatic of disease of
some other organ.

57. Asthma is evidently sometimes dependent
'upon hereditary disposition and conformation.

It invades all temperaments, but especially the
melancholic, the sanguineo-melanchoiic, the ner-
vous • and irritable. The male sex is much
more disposed to it than the female, particularly
tliose of the former sex who are of a full habit of
body and advanced in life. Joseph Frank
suiely reckons the proportion of cases in males
somewhat too high, when he states that six are
affected to one ftmale. So far, however, as my
own experience enables me to judge, the propor-
tion is not much less. Persons endowed naturally
with great sensibility of the nervous system, or who
liavg acquired this state from indulgence of the
passions — from masturbation, venereal excesses,
ihe immoderate u^e of warm bathing, long con-
tinued mental exertions, want of the requisite
•sleep, frequent excitement of temper, nu ntal de-
jjression, and exhausting discharges, are much
more disposed tiian others to be aft'ecleJ by the
exciting causes of the disease.

58. The spasmodic form of asthma attacks most
fiequently persons of a spare habit, and who have
been weakened or emaciated by the foregoing
causes ; or who have passed a laborious and
anxious existence; wliilst the humoral variety of
the disease is commonly met with in those who
aie gross, phlegmatic, corpulent, robust, or full
of blood, and who have been long exposed to the
causes of chronic and general weakness, and have
led an indolent, luxurious, or sensual life.

59. In addition to the foregoing causes, san-
guineous pl'jthora; malformation and injuries of
the lungs, chest, or spine ; peculiarities of forma-
tion of the air-passages, of the cavities of the
heart, and large blood-vessels ; constitutional
irritability of the air-passages and lungs; narrow-
1,'ess of the glottis, and morbid sensibility and
irritability of the nerves and muscles of the
larynx ; congestions, enlargements, habitual dis-
tensions, or organic changes, in the large viscera
adjoining the diaphragm, as of the liver, stomach,
pph'en. and colon ; previous disease of the lungs
iind air-passages, particularly frequent attacks of
catarrh, and neglected winter cougiis ; and adhe-
.sions of the pulmonary pleura to ihe costal or
diapliragmalic pleura, may be ranked amongst
the predisjjosing causes of the disease. It should
not, however, be overlooked, that the foregoing
do not only dispose tlie system, and particularly
the lungs, to the 0[)eration of the exciting causes,
but are also of themselves capable of producing
the disease, when they act intensely, or when their
0])erntion is of long duration.

60. Neglected or confirmed f/_ys/)f7)s/« ; erratic or
metastatic ^mtf ; suppressed eiuplions, discharges,
and habitual perspiration of the feet, are also
j)redis])()sing and concurrent ( auses of the disease.
Jn ad<lition to these, I may add, tiie warnilh and
closeness of our apartments, luxurious habits,
and previous diseases affecting the lung8 in a

particular manner — as whooping-cough, measles,
small-pox, and typhoid fevers — as having a
marked influence in predisposing to asthma.

61. 2d, The occasional or exciting causes are,
various mental emotions and aflTections ; parox-
ysms, of anger, vexation, disappointment, anxiety,
and all the violent or depressing passions ; great
fatigue; prolonged watchings ; strong exeitions of
the voice, reading long aloud, or long speaking;
terror, or surprise ; sudden refrigeration of the
surface of the body ; or exposure to, and the
respiring of a cold or hot, or a too moist or too
dry air, — these states of the atmosphere acting
ditierently in different persons and varieties of
the disease. Thus, the third and Jirst varieties
are generally relieved by a dry and pure air,
whilst the second variety is occasioned or aggra-
vated by it ; and a very moist and cold air, or a
humid, close, and warm air, whilst it frequently
relieves the latter, always augments the former;
but It is not infrequently observed, that states of
the atmosphere, which cannot be referred to grades
either of temperature or humidity, act very diflfer-
enily on different persons labouring under the dis-
ease, although the form may be the same. It
seems to me extremely probable that this is owing,
in a great degree, to the electrical states of the
atmosphere, and the electro-motive condition of
the frame ; as we sometimes see the disease occa-
sioned by close and oppressive states of the air,
particularly when these states precede a thunder-
storm,— thunder and lightning being less in-
fluential in its production than the electrical
states of the atmosphere which terminate in these
phenomena.

62. There are, perhaps, few causes which more
frequently produce asthma, than those which
act directly on the air-tubes through the medium
of the respired air, as various kinds of dust and
irritating particles floating in it (see article on
Arts, as productive of disease); common coal
smoke, the vapour from lime or brick-kilns,
metallic fumes of every description, mephitic
gases, every kind of acrid vapour, the fumes from
chemical manipulations; hydrogen, nitrogen,
carburetted hydrogen, carbonic acid gas, and all
other gaseous productions floating in the atmo-
sphere ; employments which lead those prose-
cuting tiiem to breathe an air charged with minute
particles of vegetable, animal, or mineral produc-
tions, as manufactures of cotton and wool, fur-
riers, grimlers, needlepointers, &c. Odours of
every description occasionally excite the disease,
particularly odours acting differently in difl^erenl
persons ; those occasioning it in some, allevi-
ating it in others — as the aroma of various
flowers and plants, the smell of tobacco, ipe-
cacuanha, &c,

63. The disease may also be produced, or rather
a paroxysm may be occasioned in those subject to
the disease, by v\hatever deranges the healthy
funclion of the digestive organs, and particularly
if it occasion acid or acrid eructations, which
irritate the epiglottis and glottis, or cardialgia,
flatulent or inordinate distension of the stomach
or colon, or impedes the free descent of the
diaphragm (Asl. Slomachicutn, ]5A(ii,ivi ; Ast. Fla-
luleiiluni, Fi.dVi'.R, Sciiiukdeh, 15ai. dinger), and
by iriitation and spasm of the glottis and trachea,
(Wilms, LiiiUTAtin, Uesghanges, &c.). It is
also son.etimes occasioned in the female by hys-

ASTHMA -

terical affections (Ast. Htjstericum, Hdrstius,
Baglivi, Salvages, &c.) ; by misplaced, sup-
pressed, or metastatic gout {Ast. Arthi-iticum,
JMusGRAVE, Hoffmann, Stoli., &c.) ; by tiie
syphilitic poison {Ast. Venereum, Juncker); by
the slow mtroduction of lead into the system
(Williams ; Ast. Metallicinn of Ettmulleh and
Ilsemann) ; by great obesity (Flover); the
suppression of accustomed discharges and evacu-
ations, and from vascular pletiiora proceeding
from liiis cause (Ast. plelhoricani, Dover, Cul-
LEN, Sauvages; ylst. Saiiguiiieiim, Hoffmann) ;
by the repulsion of eruptions, the retrocession of
exanthemalous diseases, and the drying up of
issues and eruptive discharges (Ast. Eianthe-
malicnm, Cullen, et Var. Aucr.). It may
also proceed from a cachectic habit of body (Ast.
Cachecticitm, Hoffmann, Sauvages, &c.) ; from
excessive impregnation of the sj'stem with mer-
cury (ScnENCK, Bonet) ; and from chronic ca-
tarrh and bronchitis (Laennec, Boisseau, &c.).

64. 3d, Symptomatic Astltma. — But little is re-
quired to be added under this head, further than
to specify in a general way some of the organic
lesions that sometimes excite phenomena which
either closely resemble, or are the same as,
those which accompany the idiopathic disease.
Amongst those, the disturbance of the pulmonary
circulation, and the nervous and muscular irrita-
tion, occasioned by organic lesions of the heart
and large vessels ; by aneurismal tumours ; by
tumours affecting the diaphragmatic and pul-
monic nerves (Beclard, Andhal, and Parry);
enlargement of the cavities of the heart, and ob-
stacles to the circulation through the openings
into the ventiicles or arterial trunks; by ossific
deposits in these situations, or in the coats of
these vessels, or in the external surface of the
heart, or pressing on the pulmonic plexus of nerves
(Ferrus) ; by polypi in the cavities of the heart
and large vessels (Diem eh brock, FLOVEn, Ros-
tan) ; by adhesions of the pleura, and organic
changes of the parietes of the chest, diaphragm,
or spine ; by curvatures of the spinal column, and
lateral contraction of the chest, &c. ; by hernia
of the diaphragm (Hecker, Bonet) ; by tumours
and effusions within the chest and pericardium ;
by organic changes in the vicinity of the larynx
and trachea ; by enlargement of the lymphatic
glands within the chest and the glands of tiie
bronchi ; by tumours developed in the mediasti-
num (Sch.effer) ; by foreign substances which
have escaped into the trachea and bronchi; by
organic changes of the lungs, themselves, espe-
cially miliary tubercles, or similar productions in
advanced stages of growth and change ; by oedema
of the lungs, or sero-sanguineous infiltration of
their substance; and frequently by emphysema
of the organ, and pituitous collections in the
bronchi, the emphysema being a very common
consequence and complication of the severer
forms of the disease (Baillie, Laennec, &c.).
Besides being sometimes induced by one or more
of the above lesions, it may also be symptomatic
of congestions and organic lesions of the liver
and spleen ; but, although those, and various
other organic lesions enumerated under Dvspncea,
produce spasmodic and convulsive stales of im-
peded rtspiralion in some rare instances, yet they
are more commonly productive of continued or
remittent dyspncEa. Asthma is, moreover, some-

VUL. 1.

•Causes or. ' 145

times symptomatic of lesions affecting the medulla
obtougatji and spinal chord, of hypocJwndriasis,
and of diseases of the colon and rectum.

C5. V'l. Complications 'of' Asthma. — From
the foregoing statement, it will be readily admit-
ted that asthma very frequently presents itself ia
practice in complicated, forms.- Indeed, when
the disease occurs in' consequence of any of the-
states of the system described in §§ 60—64., or
of any of the previously existing diseases and
organic lesions of which I have stated it occa-
sionally to be consecutive and symptomatic, it
should be viewed as complicated with such lesion,
and our attention directed to the whole of the
morbid association, both pathologically and the-
rapeutically. Our inquiries should likewise be
extended even to the functions of distant organs,
as it will occasionally have an intimate relation
even with them, particularly to the functions of
the dijjestive, assimilative, and generative organs.
Amongst the most common complications of the
disease, I may mention the various forms of
catarrh, dyspepsia, hypochundriasis, hysteria, em-
physema and adema of the lungs, hicmopfysis,
chronic bronchitis, and disease of the heart, as
especially requiring our attention during the treat-
ment. (See the articles Lungs and Bron-
chitis.)

66. The paroxysm of the third variety of disease
is of en occasioned by a common catarrh ; and
owing to this circumstance, as well as the pre-
sence of many of the symptoms of this affection,
it has often been denominated catarrhal asthma.
It is sometimes also complicated with active con-
gestion of the lungs, particularly of their mucous
surface. Dr. Parry conceived that this state of
the respiratory organs constitutes the disease ; and
instances the case of a person, who died in about
twenty minutes with all the symptoms of spas-
modic asthma, and in vs'hom the only lesion was
complete suffusion, of a darpask rose colour,
amounting in parts almost to a blackness of the
mucous membrane of the trachea and bronchi.
Dyspepsia not only accompanies asthma, but
very generally precedes an attack. The compli-
cation with broncliitis and haemoptysis is chiefly
observed in the third variety ; whilst the associ-
ation with hysteria and hypochondriasis is most
commonly met with in the nervous and spasmodic
forms of the disease.

67. Organic diseases of the heart, and large ves-
sels are very frequently complicated with asthma.
The former seems to be most commonly a con-
sequence of the latter ; but, in some cases, aa
opposite order of causation obtains. In all such
states of disease, either too little, or too much
blood enters the lungs, and the healthy relation
between respiration and the pulmonic circulation
is changed ; if either too much, or too little blood
passes, it is imperfectly purified, and the wants of
the system occasion a sense of anxiety and an-
helation. But I believe that the phenomena of
associated disease of the heart, and of the pul-
monary functions, may be more correctly ex-
plained by referring them to the state of the
nerves supplying the organs. These nerves are
so intimately related, anatomically and physiolo-
gically, that disease originating in, or affecting,
any one part of them, will frequently influence
the functions of the whole, or of such of them as
are most intimately connected with the originally

146

ASTHMA — Causes of.

diseased part. When, therefore, we find a per- '
tion of the particular order of nerves, wiiicli
supplies the respiratory and circulating organs,
remarkably affected — whether such portion in-
fluence the state of the bronchi, or the circulation
through the lung«:, or the actions of the heart — can
it be a matter of surprise that an analogous dis-
order should extend to parts so intimately related
anatomically and functionally as are the air-
passages, the pulmonic circulation, and the heart
and large vessels?

68. Upon taking a review of the causes of this
malady, we shall perceive that it may be occa-
sioned, like several other chronic diseases of the
respiratory organs, — 1st, By whatever lowers the
vital energies of the frame, particularly as they are
manifested in the lungs, and increases the suscep-
tibility of the organ to the impression of external
agents, or to internal morbid associations (§ 57.);
— 2d, By mental or moral states deranging the
nervous influence actuating the respiratory and
circulating organs (^§ 61.) ; — 3d, By agents which
disturb the equilibrium existing between the cu-
taneous and respiratory functions (^61.); — 4th,
By causes acting, during respiiation, directly on
the seat of disease, either by depiessing the vital
and nervous influence of the organ, or by irri-
tating its mucous surface, and thereby exciting its
fibrous structure to undue contraction ($62.); —
5th, By causes acting during respiration, espe-
cially aerial vicissitudes and states which modify
or impede the respiratory functions, and favour
congestion of the pulmonary mucous surface, or
of the substance of the lungs ; — 6th, By whatever
impedes the action of the respiratory muscles, or
embarrasses the motions of the parietes of the chest
(§ 63.) ; — 7ih, By lesions of the circulating organs
deranging the circulatory function of the lungs
or heart (§ 64.); — 8th, By the extension of
irritation from adjoininjj viscera or parts (§ 64.);
— 9ih, By the destruction of the equilibrium be-
tween absorption and excretion (§ 58.); — lOtli,
By the transference of morbid action fnm o'her
parts of the frame (§ 63.); — 11th, By affec-
tions of the respiratory nerves and plexuses, either
at their origins, or in any part of their distribu-
tions ($$57. 64. 67.). Hence the propriety of
dividing asthma not only into the nervous, .s/jas-
modlc, and humid vaiie'ies, but also into two divi-
sious, as respects its relations to its causes, and to
other diseases; viz. into Idiopathic and Symp-
tomatic

69. VIT. Proximate CAiisr.. — The majority of
writers on this disease, fiotn Wh.ms down to the
times of Hofi-mann and Cullf.n, have referred it
to spasm of the bronchial tubes; and the same
opinion has been espoused by many contem-
porary authors, particularly Laennic, W'ii.iiams,
&c. Rostan and several Fieiich pathologists
consider the disease as altogether symi)lomalic of
organic changes seated chiefly in the heart and
large ve-sels ; but although this may be con-
ceded to be the case occasionally, 1 conceive
that they substitute the effect for the cause; le-
sions of these organs necessarily supervening in
the manner already explained ($ 67.), after re-
peated attacks. 'J'lic doctrine, moreover, has
been completely overturned by the post mortem
examinaiicm of ca«es of the disease by Con-
visAnx, Feurus, Geohget, Laennec, Andrai.,
Dei-ens, and IJriciieteau, in which no such

changes were found. Bree, PAnnv, and Bnous-
sAis ascribe asthma to inflammatory congestion and
irritation of the mucous meinbrane lining the air-
passages ; and this doctrine is at present adopted
by many British and continental pathologists.
L do not mean to dispute the existence, to a cer-
tain extent, of irritative congestion of the respir-
atory mucous surface, particularly in the third
variety into which I have divided the disease ; but
still I believe that it is a pait only of the changes
from the healthy state, which constitute this ma-
lady. M. Georget contends that it proceeds
from irritation about the base of the brain, and
particularly at the upper part of the medulla ob-
longata, and origin of the respiratory nerves,
occasioning convulsive paroxysms of the inspir-
atory muscles. iMM. Roche and Sanson ( E/e-
mens de Pathalogie, S^-c. t. ii. p. 642.) ascribe it
to irritation of the nerves supplying the respir-
atory surfaces, occasioning convulsive actions of
the respiratory muscles ; Zallony to suppressed
influence of the pulmonary nerves, and imperfect
change of the blood in the lungs; Dupuytren
to an afiection of the par vagum ; and Horn,
Henke, and many otiiers, entirely to spasm of
the bronchi. That the disease, in a great mea-
sure, depends upon the morbid state of the nerves
supplying the lungs and respiratory muscles, is
evinced by the case which occurred to M. Ferrus,
who found, on the dissection of a female who
had been subject to spasmodic asthma, a con-
siderable ossific deposit in the centre of the pul-
monic plexus, and compressing part of its nerves.
There can be no doubt that iriitalion of the
nerves, or impeded or interrupted nervous in-
fluence will produce spasm of those mu^^cular
parts, which they supply, and interruption of those
functions which are dependent on their healthy
influence.

70. The proximate cause assigned to the dis-
ease by Ci'LLEN, Parr, and other modern au-
thors, differs but little from that contained in the
writings of Wii.lis, Bagi.ivi, Hoffmann, Boeh-
HAAVF, Sauvages, and others of their predeces-
sors, excepting that it is stated by them with
greater precision. It seems to me so correct, in
the majority of cases, as not to admit of dispute.
Doubtless the researches of contemporary pa-
thologists have tended to show that many cases
closely resembling this disease, and which would
have been imputed to the same pathological slates
as thev were imputed by our predecessors, depend
on other conditions of the respiratory organs, and
those differing widely in their nature from each
other ; thus abridging the number of purely asfh-
matic cises, and consigning to different organic le-
sions many that present nearly similar functional
derangements to those which are strictly asthmatic.

71. 1 theiefore conclude, with many of my
predecessors, some ot them unmeiitedly overlooked
at the present day, that asthma depends on a pre-
ternatural or spasmodic constriction of the air-
pass;iges, accompanied in many cases, especially
in the humoral or catarrhal variety, and particu-
larly when it assumes what M. Laennic has
called the dry catarrhal form, with lurgescence
of the vessels of the lungs, particularly those sup-
plying their mucous surface, and an increased
secretion of mucus: and 1 would add, that, in
this form of the disease, the spasmodic constric-
tion of the air-tubes, the turgescencc of their mu-

ASTHMA ITS TitEATMENT.

147

cous lining', and tlie accumulation of mucus in
them, present an obstacle, not only to inspiration,
but also to expiration ; the lungs being' thereby
often kept in a state of inordinate dilatation, and
the respiratoiy muscles excited to convulsive
efforts, occasioning, in some cases, dilatation of
the air-cells, or their rupture, and consequent
empliysema of tiie organ, wiih effusions into the
air-tubes, and otlier consequences described in
the article on Organic Dheases 0/ the Lungs.

72. Vlll. Treaiwent. — The treatment of
asthma is generally directed to the fulfilment of
two intentiims ; viz. to shorten or alleviate the fit ;
and to prevent its return, and thus remove the
disease. The means of cure may therefore be
divided, 1st, Into those which are to be resorted
to during the paroxysm, with the view of attain-
ing the first intention ; and, 2il, Such as may be
employed during the interval, for the accom-
plishment of the second. I shall notice succes-
sively the measures which may be resorted to for
the fulfilment of these ends, with as strict a re-
ference to the forms and complications of the
disease as my limits will permit.

73. 1st. Treatment of the paroxysm. — In treat-
ing the fit of asthma, the practitioner will take
cognizance of certain particulars, which should
materially influence the choice, the combination,
and the extent of the means which are to be put
in operation. The duration of 1 lie paroxysm ; the
age, temperament, and habit of body of the pa-
tient) the period he has l)een subject to the
disease, the frequency of the attacks, and the
particular form they a-^sume; the state of health
in the interval ; and the presence or absence of
concomitant, functional, or orgaoic lesions of the
lungs, heart, and digestive organs, are all of the
utmost importance to be known ; and, without
toler;)bly accurate ideas respecting thern be enter-
tained, the disease cannot be judiciously treated.
As individual cases vary greatly as to each of
these circumstances, it would be impossible to
describe \u connection all the measures which
may be employed in a paroxysm of asthma, so as
to be appropiiate to each of its numeroi s states
and complications. Such descriptions, although
they would be sometimes perfectly suited to a
case, would as often be inappropriate, or even
altogether inapplicable. 1 shall, therefore, detail
separately the means of cure which have been
found most beneficial, and point out the states
and circumstances of the disease to which each
of them seems best suited, at the same time ar-
ranging them in such a manner as to fulfil inten-
tions of cure, based on the pathology of the
di'iease.

74. A. To remove congestion or repletion, when
present. — There are various symptoms which
frequently present themselves during the asth-
matic paroxysm, which would suggest tlie pro-
pric ty of blood-letting. But it is often either of
little service or positively prejudicial, especially
in the first two varieties of the disease. In the
third variety, liowever ; and in the younsr, robust,
middle-aged, and plethoric subj ct ; or when the
paroxysms are very severe, and are attended with
signs of much congestion of the lungs and brain,
as liviiliiy and fulness of the countenance, stu-
por, extreme dyspnoea, &c. ; blood-letting is in-
dispensable, and should be performed either from
the feet, or by cupping between the shoulders.

Yet, even in these cases, bleeding will seldom do
more than relieve the more urgent symptoms: it
will seldom or ever put a stop to the paroxysm,
and it should be practised always with much
caution.

75. J3. To moderate or relieve spasm by anti'
spasmodics, anodynes, and narcotics, S^c— These
medicines may be viewed in connection, as a
cornbinaiion of them are more suited to the asth-
matic fit, than the exhibition of them singly.
They are beneficial chiefly in the first and secund
varieties of the disease, and in the third, when at-
tended with severe convulsive and spasmodic fits
of cough. When the di-ease occurs in hysterical
females, or is associated with organic change of
the heart or lartje vessels, these medicines are
generally of much service. In the humoral form
of the disease, and particularly when it com-
mences, or is complicated with catarih, they are
less serviceable, although sometimes beneficial
when judiciously employed. The particular re-
medies belonging to the above classes, which
have received the approbation of the best authors,
are camphor, aisafatida, valerian, castor, musk,
ammonia, athers, coffee, opium, stramonium, to-
bacco, belladonna, Irqoscyamus, cojiiiim, hydrocyanic
acid, colchicum, digitalis, loctnca sativa, &c. &c.,
in various forms, and n,odes of combination.

76. a. Camphor is one of the most generally
beneficial of any of this class of remedies, and is,
when judiciously exhibited, applicable to nearly
all the forms and complications of the disease.
In the nervous and spastic varieties it is most ser-
viceable when given in Idrge doses (from three to
ten grains), and combined with musk, castor, assa-
fcelida, and the preparations of cether, opium, or
hyoscyamus (see F. 25. 186. 423, 493.), and the
following : —

Nn. 34. R Camphorie rasa?, gr. iij.— vi.; Ammon. Ses-
qui-Carbon. gr. iij.; Pulv. Ippcacuantiae gr. j. ; Extr.

Hyoscyami gr. iij v.; Miicilag. Aca ise q. s. RI. Fiant

Piliil* iij. statiiii surnenda cum f^austu sequente, et
horas post binas repetendte, si sit o])Us.

No. 3i. R Magiies. Ciirb 3 j. ; Aq. Anethi 3 x ; Spirit.
.Etlier. Sulph. Comp. 3j.j Tiiict. Castorei 3j.; Olei Anisi
tUiv. M. Fiat HaustJS.

77. In the pituitous or catarrhal form of the
disease, or in cases where blood-letting may be
practised, and where we suspect active congestion
of the mucous surface of the air-tubes, camphor
is best exhibited in moderate doses, and combined
with nitrate of poia-h, ipecacuanha, kermes mi-
neral, James's powder, and other anlimoniais
(see F. 494—496.).

No. 36. R Pulv. Jacobi Veri gr. iij—vj ; Camphorae
raseegr. ij. — iv ; Pulv. IpccacuanhaB gr. j. ; Ext. Hyos-
cyami gr. iij — vj.; Syrupi Papaveris q s. M. 11 int Pilu-
l^e iv., quanim capiat binas statim, et alceras post lioram,
vel omiies hora decubitus.

No. a7. R Campliorae rasas gr. j.— iij.; Antimonii Pot.-
Tart.gr. ss ; Potiissse Nitratis gr. v. — viij ; Moschigr. ij ;

Extr. Upii gr. ij — iv. (vel Ext. Lactiicas gr. iij v.); Olei

Anisi q. s. ut fiant Pilula; iv., quarum capiat binas sta-
tim. et alieias pust horani, vel sumat omnes hora somni.

78. b. Assafa^tida, castor, mu!,k, valerian , myrrh,
ammonia, the balsayns, the trisnitrate of bisrnulh,
the preparations of zinc, and the (ethers, may be
severally exhibited in the same states of the dis-
ease. They are more beneficial in the nervous
and spasmodic varieties, when unassociated with
inflammatory irritation, particularly in chronic
ca^es, in the debilitated or aged ; and in the
third variety, occurring in pervons of a re-
laxed and leucophlegmatic habit of body, — a
conclusion which is conformable to the experience

L 2

148

ASTHMA — ITS Treatment.

of IMlLLAnpIlENARD, ScHLEGEL, WOLFF, DoVF.n,

Reidlin, Bang, Schmidtmann, Wichmann,
Lentin, Kuetschmar, Loebel, Hufeeand, and
Berniiard, and which will be juslifieJ by future
observation, notwithstanding the doubts of their
efficacy which have been entertained by some
writers, who consider asthma as merely a form of
inflammation of the mucous surface of the air-
pa-^sages. They may be conjoined with one
another, or with narcotics ; and may be advan-
tageously administered, particularly assafoetida
and valerian, in the form of clyster.

79. Altiiough these antispasmodics are indi-
cated chiefly in the forms of the disease above
alluded to, they need not be restricted to them
entirely. When combined judiciously, as either
with anthnonials, or with colchicitm, opium, digi-
talis, nitrate of potash, camphor, ipecacuanha,
hyoscijamus, conium, &c., and given in suitable
doses, according to the peculiarities of the case,
they will be productive of much benefit, in other
states of asthma, both in the paroxysm and in the
intervals. Tlie external application of them,
especially of camphor, assafoetida, galbanum, am-
moniacum, &c., in the form of plaster, and par-
ticularly in conjunction with opium or with
belladonna, will sometimes prove of much ser-
vice, (See F. 112, 113.)

No. 38. R Extr. Opii, Camphorae, aa 3 ij.; Emplast.
Galbani Comp. 3iijss.— 3 ss. Fiat Emplastrum secundum
artem, scuto pectori admovendum.

80. c. Besides the beneficial eflFects ])roduced
by it as an emetic, ipecacuanha is, when used
with this or other intentions, one of the best
medicines that can be resorted to in asthma, as
being suited to all the states of the disease, par-
ticularly when judiciously combined with other
substances. It may be associated with nitre, or
colchicum, or digitalis, or with antimony, camphor,
and narcotics, in the more febrile and catarrhal
slates of the disease (see F. 39. 394.) ; and with
assafoetida, or with castor, benzoin, the spirits or
oil of aniseed, valerian, opium, &c., in the more
nervous or spasmoiiic varieties. (SeeF. 857.900.)

81. d. 'i'he distilled iuHj-ei water or the hydro-
ci/anic acid, particularly the latter, is often pro-
ductive of much benefit in the paroxysm. I have
found it of great advantage when given in from
two to four drops at the accession of the paroxy-m,
and in small doses in the inti^rvals, particularly
when the disease is attended wiih mucii irritability
of the stomach and flatulence. It may be con-
joined with camphor, ipecacuanha, a;ther, capsi-
cum, &c., or, indee<i, with any of the medicines
already mentioned. (See F. 344.)

82. e. Of the narcotics, opium, hyoscyamiis,
conium, stramonium, and belladonna, are the
most commonly used. 'I'he best preparation ol
opium in tliis malady is the compound tincture
(see F. 729.) ; and it is most advantageously
combined with camphor, aniseed, any of the
a;thers, or the wine of antimony or of ipecacu-
anha, according to the circumstances of the case.
I have tried ihe acetate of morphine in this dis-
ease, as a substitute for opium, but with no bene-
fit, unless when combined with stimulating anti-
spasmodics ; in which form, cither the sulphate or
the htjdrochlorate of mm-phine may occasionally
be employed. Ilifoscyamus and conium are often
uncertain remedies; i)ut when their preparation'^
are genuine, they arc very useful adjuvants, par-

ticularly the former; and, if judiciously pre-
scribed, applicable to every state of the disease.
The combination of hyoscycraus with the inj'usioii
of valerian has heen much praised by Loebel in
the spasmodic form of asthma.

83. f. Belladtmna has been found serviceable
when combined with stimulating antispasmodics,
particularly camphor, valerian, or assafoetida ;
but it requires caution. In conjunction with
ammonia, galbanum, or assafoetida, &c. in the
form of plaster (§ 79.), it will sometimes be
productive of much benefit. The lactuca sativa
will be also employed with advantage, under
similar circumstances to those in which the above
narcotics are beneficial. Schi.esinger and Wolff
advise two or three grains of its extract to be
given, either alone, or with half a grain of digi-
talis, every two hours.

84. It may be observed generally, that nar-
cotics can seldom be productive of any effect
under a certain space of time, which will vary
with the susceptibility of the patient. In many
cases they will have no marked influence under
two, or even three or four hours, at which time
the severity of the fit will often subside without
medicine. When given by the stomach, there-
fore, this circumstance should be kept in recol-
lection ; and should induce the practitioner to
a-certain the period of accession or aggravation
of the paroxysm, and to regulate the periods at
vi'hich these, as well as other remedies, are to be
exhibited, in such a manner as that their antici-
pated action may be contemporaneous with the
commencement of the fit. As the attack consists
generally of a series of paroxysms or exacerba-
tions, medicines siiould be continued in suitable
doses, and with reference to this circumstance,
until it terminates. It will be found always ad-
vantageous to prescribe a full dose of the narcotic
at once, in order that its eflFects may be secured
as soon as possible. When any one or more of
the stimulating antispasmodics, particularly cam-
phor, ammonia, or musk, are combined with
narcotics, a very large dose of the latter may be
exhibited. Narcotics are most quick in tiieir
operation, when their vapour or smoke is inhaled
into the lungs. Their effects are longest delayed
when they are applied to tiie external surface ;
unless the cuticle has been previously removed,
as in the '' en lermic^' method of medication. The
inhalation of the vapour of certain of this class of
remedies, either alone or in conjunction with some
volatile vapours, is one of the most certain and
quick modes of obtaining relief in the asthmatic
paroxysm.

85. g. Stramonium is one of the best remedies
tiiat can be prescribed in the spasmodic form of
asthma. It is piincipally used bj' smoking it as
lol)acco. During this jirocess, the patient may
either draw a portion of the smoke into the lungs,
or swallow some of it, or the saliva which has
become impregnated with it. Stramonium is
very advantageously smoked along with aniseed,
or with a small portion of tobacco. It may also
be emjjloyed internally during the asthmatic
paroxysm, as follows : —

No. 39. R Pulv. Fol. Stramonii gr. j iij. ; Soda; Car-
bon, exsic. gr. vj.; Olfi Anisi q. s. ut fiant Pilulae ij.
staf.im sumenda;.

No. 40. B Succi Inspissati Stramonii gr. rs. — gr. j. ;
Potassa; C:arl). gr. vij.; Oloi Cajiiputi q. s. M. J''iaiit
J'iluliv ij. pro Jose sumenda;.

ASTHMA —

86. The smoking of tobacco is one of the most
generally employed and efficacious remedies we
possess tor this disease ; but it is productive of
marked benefit only when it excites a free ex-
j)ectoration. The tobacco may be used in this
manner along with aniieed, or with stramonium,
or both. The internal use of preparations of to-
bacco, as of its infusion, tincture, wine, &:c., soi
as to excite nausea, has also been recommended
in the paroxysms of asthma by Ettmuller,
MicHAELis, and several German writers.

87. h. Lobelia injiata, or Indian tobacco, has
been much employed in America in asthmatic
cases. It is nearly allied in its operation to
stramonium and tobacco ; and often succeeds in
checking the paroxysm, when given at its invasion,
or very siiortly before. It sometimes, however,
fails of having any good effect, unless it be taken
to the extent of producing nausea and vomiting.
From six to fifteen or twenty grains of its powder
may be prescribed for a dose, or from half a
drachm to two drachms of a saturated tincture
of its leaves (5J. to O ss.)

88. i. Inhalution of emollient and medicated
vapours, gases, &c. - Next and, perhaps, equal
to smoking, is the inhalation of simply emollient
or of medicated vapours into the lungs. 'J his
method of treatment was recommended by C/elius

AURELIANUS, AlBERTI, MuDGE, BeDDOES, Tlll-
LENIUS, ZALF,ONy,HuFELAND, CrICHTON, FoRBES,

Gannal, Scudamore, and jMurray. It is chiefiy
indicated during the paroxysm, or shorily before
its accession. The vapours arising fjom pouring
boihng water upon camphor, any one of the
narcotic extracts or tinctures, or the balsams,
are of great advantage when properly managed.
Thus the vapour from a pint of boiling waler
poured upon half an ounce of balsam of to'.u ; or
that from a solution of camphor, balsam of tolu,
and extract of lettuce, or of conium, in sulphuric
asther ; or the fumes proceeding from camphor,
hyoscyamus,and aromatic vinegar, mixed together,
and quickened by the addition of some boiling
v/ater, may be employed. A solution of balsam
of tolu in sulphuric aether, the vapour of boiling
tar diffused in the air of the patient's chamber,
chlorine gas much dilated with common air, and
various other medicated vapours, may be tried;
but these act chiefly by removing the viscid
phlegm which collects in the bronchi, and by ex-
citing the extreme exhaling vessels. I have pre-
scribed the vapour of the sulphntet of iodine in
two cases : in one of spasmodic asthma, with no
benefit; and in one of humoral asthma, with only
temporary advantage. Sir C. Scudamore re-
commends this formula for the inhalation of
iodine — R lodinii gr. viij. ; Potassii lodidi
gr. v.; Alcoholis 5 ss. ; AquaB Desiil. 5 vss.
M. Fiat JMislura. To this he adds tincture of
conium. But his directions as to quantity and
mode of inhalation are, notwithstanding several
attempts to unravel them, perfectly beyond my
powers. I believe, however, that portions only
of the above mixture should be employed for
each inhalation. But the observing practitioner
will generally be able to apportion the quantity,
as well as to direct the particular materials, for
inhalation, according to the peculiarities of the
case ; bearing in recollection that the combination
of narcotic and anodyne vapours with volatile
fumes and gases will geneiidly be of more service

ITS Treatjiest. 149

in asthma than the use of individual substances
belont;ing to one only of these classes of medi-
cines ; and that the more irritating substances of
this description, such as iodine, chlorine, and tar
vapour, should be ventured upon only in a very-
weak or dilute state.

89. C. To remove viscid phlegm, and to prevent
its formation. — a. By expectorants, &;c. Squills are
amongst the most frequently prescribed medicines
for this purpose, in asthmatic att.icks; but they
are certamly not ajiplicable to all iis states, al-
though they, as well as ummoniacum, inula hele-
nium, and senega, are very generally recom-
mended by some of the best medical writers.
The good eflects of these medicines in certain
manifestations of asthma cannot be doubted ; but
1 have seen them productive of much mischief in
several cases in which they had been employed.
It should be kept in recollection, that they are
amongst the most active excitants of the respira-
tory mucous surfaces we possess, and are ex-
tremely apt to change active congestion of the
bronchial lining into inflammatory action, espe-
cially in young, plethoric, or robust subjects ; and,
by their effect upon the expectoration — particu-
larly by increasing it, rendering it thinner, Itss
viscid, and more readily expectorated — to occa-
sion a deceptive appearance of benefit, even when
they are increasing morbid action, with all its ill
effects. In relaxed and leucophlegmatic habits,
however, or when the expectoration is viscid, and
excreted with difficulty ; the skin cool, soft, and
nioist ; the pulse soft, slow, or weak, and the
urine scanty ; these medicines may be given with
great benefit (see F. 66,67. 74. 353.) : but when
the pulse is either hard, quick, or lull ; or the ex-
pectoration at all puriform ; they cannot be exhi-
bited without risk. They will often, doubtless,
even in cases of active congestion of the respira-
tory mucous surfaces, aflTord real benefit, by
exciting the capillaries to secretion, and thereby
unloading them ; but they miiy as readily kindle
up inflammatory action. When combined, how-
ever, with antimonials, refrigerants, diuretics, or
anodynes, the risk of mischief from them in
doubtful cases is much reduced. Alberti,
Flover, Wagner, Schulze, Lentin, and Bree
advise squills in the pituitous form of the disease,
and found them most serviceable when they pro-
duced nausea or vomiting, — the benefit being,
pel haps, more to be attributed to this operation,
than lo the medicine which occasioned it. Under
the circumstances in which I have admitted the
use of ammoniacum, squills, inula helenium,
benzoin, and senega, — namely, in the chronic
pituitous asthma, — the Formulae in the Appendix
above referred to, or the subjoined, may be pre-
scribed : —

No. 41. B Scillae exsic. gr. xij. ; Mvrrlije 3 ij. ; Extr.
Hjoscyami 3 ss.; Olei Anisi q. s. M. Fiant Pilula; xviij.,
e quibus sumaiitur binae quartis vcl sextis horis.

No. 42. B Scillae Pulv. gr. vi. ; Pulv. Ipecaciiantiffi
gr. vj.; Campliorae rasae gr. xv.— 3j. •, Pulv. Antimon.
Comp. gr. xij.; Extr. Hyoscyanii ,3ss.; Syrupi Toliitani
q.s. Fiat massa aequalis, et divide in PiliiLis xviij, quarum
capiat binas tertiis vel quarlis horis ex cyatho decocti
AUiiaeae.

No. 43. B Tinct. Scillje in xij.— 9 j.; Acidi Nitn'ci dil.
HI viij. — 111 xxiv. ; Aquae Pulfgii 3 jss ; .Spirit. /Ether.

Nit. 3 ss j. ; Spirit. Pulegii 3 j.; Extr. Hyoscyaini (vel

Conii) gr. iij; Syrupi Tolutani 3 j. M. Fiat Haustus ter-
tiis vel quartis lioiis capieiuliis.

No. 44. B Mist. Ammoniaci 3 ivss. ; Vini Antimonii
Pot. -Tart. 3 iv. ; Tinct. CampliorK Comp. 3 ss. ; SyrupJ
Tolutani 3j. M. Capiat cochleare unum pro re nata.

150

ASTHMA — ITS

No. 4'i. R Mist. Ammoniaci, Aquas Destil, Lauro-
Cerasi aa 3 >jss. ; Tinct. Castorei 3 iij- ; Tinct. Opii Co.
(F. 7i9.) 3ss.; Syr. Tolutani.5 j. Fiat. Mist., cuj us sumat
cochleare uniim am|ilum subiiide.

N.I. 40. R Balsaiiii Tolutaiii 3jss ij.; Mucilag. Aca-
cias 5 j.; teie beiiS et artde, mlscendo, i'inct. Benzoiiu
Comp., Tinct. Opii Camplioratce Prist, aa 3iij.; Olei
Anisi 111 S.X.; Aquae Piilegii et Aq. Anetlii aa 3 i'j-; Sy-
rupi Simp. 5ij. M. Capiat locii. ainpla duo, quater in die

90. I). Emetics are amongst the most promptly
beneficial remedies that can be resorted to during
the paroxysm, with llie intention of removing
both phlegm and spasm ; and they have been
justly recognised as such by C/elius Auuelianus,
HoRisTus, Mayerne, Floyer, Aken'side, Bang,
Kerbs, Hufeland, Weuel, Sioll, Bree,

LOEFFLER, and SCDMIDTMANN. IfltCUCUaU is,

upon the whole, the best meilicine that can be
employed to produce this effect. The philoso-
phical Akenside recommended a scruple of it to
be given at the commencement of the paroxysm,
and five grains every morning during the intervals,
for some time, so as to occasion nausea. When the
paroxysm is excited by an overloaded or deranged
state of the stomach, emetics are particularly in-
dicated. It is in such i;a.ses that Sciimidtmann,
one of the most practical and experience<l of
moilern writers, recommends them ; whilst Stoi.l
and IjOeffler advise them principrlly in the
humoral form of the disease. In the asthma to
which several classes of artisans, particularly
pearl-turners, &c. (See Arts, and tlie Causes of
DtSEASE), are liable, emetics have been found the
most succe.s.sful remedy in the paroxysm. But,
besides this operation, ipecacuanha has an espe-
cially beneficial efl^ect in asthma, as 1 have
already particularly noticed. Next to it, and
even superior to it in the very humid states of the
disease, are the preparations of zinc, paiticularly
the sulphate, in suitable doses and forms of com
bination (see F. 582—587.).

91. c. Nearly allied to emetics are Jifluseanfs and
diaphoretics. Thesi? are sometimes of service, either
at the commencement, or shortly before the fit.
The substances that may be employed to produce
this effect are ipecacuanha, and the different pre-
parations of antimony, particularly the potassio-tar-
trate and kermes mineral. These latter are praised
by Bang, Vicat, and Hufeland. Ipecacuanha,
in from one to five grains, or the antimoiiials in
full doses, may be combined with nitre, camphor,
opium, or hyoscyamus, according to the circum-
stances of the ca^e (see F. 393. 854.).

92. d. Refrigerants. Of this class of medi-
cines the most useful is tlie nitrate (f potash, in
conjunction with camphor; ipecacuanha, and
hyoscyamus (F. 279. 431. 436.), particularly in
the humoral variety of the di.sease ; in the state
described as requiring blood-letting ; or when the
attack has been induced by, or is complicated with,
catarrh. Either of the following rlraughts may Ite
taken at the commencement oi the ])aroxysm, and
repeated in two hours, if necessary ; —

No. 47. li I'otassa; Nitrati.s Rr. x — xx.; Spirit. jT"-lhor.
Nit. 3j.; Vini Ipccacuanli* 3 j. ; 'I'inct. Ilyoscynmi 3 j. ;
Mi t. Camphorffi 3j.; Syriipi Tolutani 3j. M. Fiat
Ilaustus stariiii suin(Mi>fus.

No. 4K. R Potassa! Nilritis pr. x. — xvj. ; Vini Ipecacu-
anha;, I inct. Uyobcyaini, aa 3j.; Liquor. Ainmc/n. Ace-
tat.3iij.; Mist. (J iinphoroe 3 vj. ; Syr. Tolutan. 3 j. M.
Fiat Ilaustus statim ca])icndus.

93. Besides the internal use of refrigerants,
LoEFFLEu recommends cold e])iihems to be placed
on the chest, in the spasmodic form of the disca.se|:
and several Continental writers advise clysters of

Treatment.

cold water to be administered when asthma seems
to be connected with hysteria. In such cases,
clysteis of assafoelida or of infusion of valerian are
preferable. Refrigerants act both by diminishing
inordinate secretion, and by allaying spasm ; and,
when the disease is connected with active conges-
tion, or excitement, are, with depletion, the safest
measures that can be employed to remove, or to
prevent the formation of phlegm.

94. D. To transfer irritation to other parts, or
to recall the disease to its original seat, when it
has arisen from the metastasis of gout, i heumatism,
or the suppression of discharges, is often an
important indication. The usual means of revul-
sion and deriration, or counter-irritation, particu-
larly those which produce this effect with the
greatest celerity, as sinapisms, stiniuktting pedi-
Inviu, and t\ie vapour balii, are the chief revulsants
that are admissible under such circumstances and
at this period. They may be accompanied with
diaphoretics, aperients, diuretics, or even em-
menasogues, in particular cases. They have also
occasionally been found succes.sful in preventing
the accession of the fit; particularly if employed
when the premonitory signs first appear; and if
internal derivatives, especially a purgative com-
bined with antispasmoflics and carminatives, have
preceded then), and if they have been followed by
gentle diaphoretics. Warm turpentine epithems,
placed on the chest, are often remarkalily bene-
ficial. The turpentine liniments {¥. 300. 311.)
may also be employed in a similar manner.

95. E. To remove Jialulence, by means of gentle
aperients combined with carminatives, is often
necessary during the course of the paroxysm. I
have observed much benefit derived fiom the
exhibition of a purgative, combined with anti-
spasmodics and carminatives, shortly before the
expected accession of the attack, particularly
when the premonitory signs begin to appear, and
the digestive organs evince disorder — such dis-
oriJer often acting as the efficient cause of the
.seizure. (See F. 28. 181. 266. 379.) The com-
bination of diuretics, alro, with the medicines pre-
sciibed during the paroxysms, or of carminatives,
in order to relieve the distressing flatulence with
which they are very generally accompanied or
preceded, will be often found of service.

96. F. Besides the means noticed above, there
are several which have been recommended in the
fit — some of them most deservedly, others in a
very indiscriminaling, and hence not a very bene-
ficial manner. Of the former of these, warm coffee
is tlie most important. This dietetic remedy was
used by Floyer in this disease, and more recently
by TiiiLENitJS, Peucival, and Biiik. Itgenerally
iiflbrds much relief when made sufficiently strong ;
and it seems to resen)ble the stimulating anti-
spasmodics, particularly camphor, in its action. I
have also observed the paroxysm checked by strong
green tea.

97. JMy limits oblige me merely to enumerate
the other medicines which may be revolted to in the
paroxysms of asihma. The chief of these are, dry
cupping between the shoulders, a weak solution of
phosphorus in aither, the trisnitrate of bismuth and
oxide of tine, nux vomica, Ike, by several Conti-
nental writers; galvanism, as recommended by Dr.
W. I'liii.ii' ; electricity, by ]\I. Sigaud Lafond;
the chenopodium ambrosioides, byJIuFEi.ANi);
the infusion or spirits of juniper, by Ukkker ;

ASTHMA —
guaiacum, by Aaskow, particularly when the
attack occurs iu the gouty or rheumatic diathesis ;
cajeput oil, in the spasmodic form of the disease,
by Wickmann; the veratrum album, by Mijller ;
the hydrochlorate of ammonia, by JMAmius; and
the external application of garlic, by Portal.

98. 2d. Treatment during the interval. — Our
chief object during the interval is to prevent liie
accession of the attack, by avoiding die remote
causes, and removing (he morbid slate of tiie
digestire and respiratory organs wliich dispose to
it, and whatever disorder of function or of struc-
ture vviili which the disease may have become
associated. We shouhl, therefore, endeavour to
form a correct opinion respecting the sidte of the
bronchial mucous surface, the morbid associations
of the atfection, and the consecutive lesions which
may have already supervened to it. The state ot
the dige-tive functions, of the alvine secretions
and excretions, should receive the utmost atten-
tion ; and the means which may be most appro-
priately used for their promction, in particular
cases, ought to be assiduously employed.

99. A. Evacuations, S;c. — Under this head I
win briefly consider blood-letting, emetics, pur-
gatives, blisters, issues, and diaphoretics. — a . Bleed-
ing is seldom of service in the uncompliL-ated
state of the disease. But when it is accompanied
with vascular plethora, or pulmonary congestion ;
or when the attack seems to liave been produced
by the suppression of an accu-tonied discharge,
whe'her sanguineous or of any other description ;
a moderate tjlood letting or cupping between the
shoulders, will be of advantage.

100. b. Emetics during the intervals are only
required when the disease is characterised by con-
gestion of the mucous surlace of the lungs, obstruc-
tion of the bronchi by a viscid secretion, or torpid
and loaded state of the liver and biliary apparatus.
AVhen prescriberl shortly before the expected fit,
they often succeed in preventing its acce-sion.

101. c. Purgatives are often necessary ; but
they may also be detrimental. Those substances
whicli irritate the digestive mucous surface, with-
out producing a full feculent evacuation, ate
always prejudicial. Purgatives also are hurtful
when they are employed so frequently as to lower
the vital enerj^ies, and cany off a portion of the
chyle which should be absorbed into the circula-
tion. On the other hand, stomachic aperients
and purgatives exhibited in combination with
tonics and antispasmodics, and to the extent merely
of promoting the digestive, assimilating, secreting,
and excreting functions, are particularly benehcial.
Either of Formula; 266. 4.30. to 456. 462., cun-
tained in the Appendix, or the following, may be
prescribed : —

Ni). 49. B Aloes Socot. gr iv. ; tere ben& cum Gum.
M;\stich. gr, ij., el adde Exir, GentiaiiiP Conip. et Mass.
Pllul. G.ilbani Comp. aa gr. iij. ; Olei Anisi q. s. Fianl
Pilulee iij. Iiora sumui quoiiiiie sumenda".

102. d. Diaphoretics in small doses, in con-
junction with anodynes, deobstruents, or anti-
."pasmodics, are of service merely in as far as ihey
may preserve a regular state of an important
function, and prevent the determinations to inter-
nal organs which frequently follow any inter-
ruption to it. But proluse perspirations and
icarm bathing are more generally prejudicial than
otherwise. Indeed, whatever relaxes the cuta-
neous surfaces beyond a certain degree has an
injurious effect upon affections of the lungs which

ITS Treatment.

151

are not acutely inflainmatory, and particularly
in the pituitous chronic asthma. When the
paroxysm is associated with the dry catarrh,
diaphoretics inay be carried further with advan-
tage ; and when combined with expectorants and
antispasmodics (§ 91.), they are more generally
applicable.

103. B. Expecto}ants, alterants, attenuanls, and
deobstruents, or substances supposed tc have sotne
one or more of these effects, h.ive been very
generally recommended in asthma. Several of
tliese have little or no effect, and others may
even be injurious. — a. The expectorants most fre-
quently employed are those already noticed ; but
1 believe thjt they are seldom productive of
much advantage, given in the interval. When
the disease is complicated, as it not iiifrequently
IS, with dry catarih, or irritation of the bronchial
mucous surface, those substances whicn have the
effect of sootliing irritation, relaxing spasm, and
softening the pulse, as James's powder, kermes,
ipecacuanha, camphor, antimonial wine, are in
(act the best expectorants ; inasmuch as ihey tend
more to render the bronchial secretion less tena-
cious, where it is glutinous and obstructing the
bronchi, and to dnninish its quantity when too
copious, than those which are of a heating or sti-
mulating kind.

104. b. Amongst those medicines which are
considered as atteiiuants, deobstruents, and alter-
ants, there ate none which possess greater claims
to consideration in this disease than the pure
alkalies and their carbonates, or their combination
with oils, and antispasmodic or narcotic sub-
stances. However the propriety of applying the
above terms to certain medicines in this disease
may be cavilled at, thee cannot be the smallest
doubt, in the minds of those who closely ob-erve
the operation of remedies, that certain substances
produce effects, on the respiratory surfaces and
on their seci-eiions, that justify the use of these
terms. The alkalies in various forms of combina-
tion, but particularly with oi7s,'have been much
praised by Wolff, Bachf, Sargonk, Mascagni,
and Laenmc. Either in the pure state or in that
of carbonates, combined with tlie oils of aniseed,
or of almonds, with ipecacuanha, small doses of
blue pill, and hyoscyamus, the /lafprf alkalies are
amongst the best remedies to wliich we can have
recourse, particularly in the catarrhal cr b onchial
complications, and when the disease is connected,
as it very often is, with irritability or other disorder
of the digestive organs. 1 have experienced the
greatest service, in practice, from the following,
and from Formula ]So. 348. 457.

No. ."iO. B Sodae Carbon, exsic. 3ij.; Pulv. Ipecacu-
anhiEgr. vj.; Piiul. HydrarL-. gr. vj. ; Olei Ani»i ill xij.
vel q. s. ut liant Pilulte xviij., quarum sumantur duo,
bis terve quotidie.

No. ; 1. H Potassae Carbon. 3ij.; Pilul. Hvdrarg.
gr iv. ; Extr. llyoscyami (vel Extr. Papaveris Albi) 3 j. ;
Olei Amydal. Diilc. q. s. ut fiaiit Pilulae xviij., quarum
capiat biiias ter quotiilie.

105. Under this head, I may make further
mention of the balsams, combined with small
doses of rhubarb, or with the addition of mag-
nesia ; of a combination of assafcetida, or myrrh,
wiih galbanum, ipecacuanha, and soap, or the
fixed alkalies (F. 503 — 510.); frictions with sti-
mulating or antispasmodic liniments in the course
of the spine (see the Li.mmems in the Appendix) ;
the nitro-hydrochloric acid wash, in a tepid stale,

L 4

152

over the chest, night and morning, or either the
one or other only ; warm clothing, &c.

106. C. blisters, issues, and artificial erup-
tions are often extremely beneficial, particularly
when asthma lias supervened to suppressed dis-
charges, to exantheiiiatous diseases, or in the
gouty and rheumatic diathesis. A large blister,
applied between the shoulders or on the chest, a
smaller one kept open, and issues and setons,
have been recommended by the majority of wri-
ters. Zacuti's Lusitani's and Sevi.rinus ad-
vise the actual or potential cautery to the nape of
the neck. The production of artificial eruptions
over the chest by the ointment of tiie potassio-tar-
trate of antimony, appears to me, from consider-
able experience of its effects for many years (see
Loud. Med. Repository, vol. xvii. p. 302.), pre-
ferable to any other mode of counter-irritation in
asthma, particularly when the use of it is com-
menced during the interval.

107. D. Tonics and astringents. — a. The use
of the preparations of bark during the intervals has
the support of the best writers on the disease.
Amongst these I may notice Fi.oyer, Bang,
Chapman, Htberden, Feldmann, Ranoe,
Frank, Withers, Rya\, Bree, and Laennec.
The states of the disease in which tliey recommend
it, are, 1st, When the disease assumes a periodic
type, or when it is connected with malaria ; 2d, In
the pituitous form of the disease, when the habit
is relaxed and leucophlegmaiic ; and, 3d, When
the stomach is mucii debilitated. There can he no
doubt of the preparations of hark or the sulphate of
quinine being indicated in such cases. Indeed,
wherever the powers of the constitution require
to be rallied, and where there exists no inflam-
matory initation to contra-indicate it, bark and
other tonics are frequently beneficial. In these
cases, the decoction or the infusion may bj given,
with the liquor ammonise acetatis, and vini ipeca-
cuanhae, or with the carbonates of the alkalies.

108. b. I have derived great service from the
sulphate and aide of zinc in the humoral form of
asthma, particularly under the circumstances now
desciibed. Either of tliese preparations may be
combined with ipecacuanha, camphor, myrrh,
hyoscyamus, conium. opium, &c., according to
the peculiarities of the case. Where it is desir-
able to produce a nauseating or emetic operation
during the fit, or in anticipation of it, tiie suliihate
of zinc is the next best medicine to ipecacuanlia
that can be employed.

109. c. The preparations of iron have met with
the approbation of Biiee and Stanoer, particu-
larly the sulphate. It may be employed in similar
cases to those for which bark and the sulphate of
zinc are prescribed. I can only allude to the
recommendation of the mineral acids with opium,
by Floyer, <kc. ; of the sulphate of hariites, by
Keik and Hufkeam); of arsenical fumes, l)y llie
Arabian physicians, and Eitmulleii; of i'owlrr's
solution, by Alexander ; of the nitrate of silrer,
by Zai.lony ; and of a solution of phosphorus iri
alher, by several German writers. These very
active medicines are admissible otdy in the most
obstinate cases, particularly when occurring in
relaxed or debilitated habits, and when other
active tonics and antispasmodics are indii'ated.
Saiiil Ignatius's bean, and tUaei tract ofnux vomica,
have also been mentioned by Stein and Hahne-
UANN. Strychnine, the active constituent of tiiese

ASTHMA — ITS Treatment.

substances, seems deserving of a fair trial in
asthmatic cases.

110. d. Sulphur and its preparations have
been advised by Diemerbroeck, Gasser, Mar-
tins, and Bang ; and from a few opportunities
whieh have presented themselves of trying them,
I consider them, particularly the buhamum sul-
phuris, — a combination of sulphur with the oils
of aniseed, &c. (see F. 21. andi2.), — and thesu/-
phurets of potassium and sodium, as medicines of
no mean efficacy in sc-eral states of the disease.
The sulphur precipitatum or subhmatum, taken
in the form of an electuary (see F. 82. and 89.),
is one of the best aperients to which we can re-
sort in cases of asthma or continued dyspnoea.
It may also be taken as follows : —

No. fi2. R Sulphur. Praeci|i. J ss. ; Semin. Anisi con-
tus. 3ijss. ; Coiilect. SenuEe et Syr. Tolut. aajvj. M.
Capiat cocli. ij. minima pro dose.

111. There are various medicines which have
been recommended in the paroxysms, which may
also be occasionally employed in the mterval,
particularly shortly before the expected accession
of attack, and upon the first intimation of ils ap-
proach. Of lhe.se, the most important are the
antispasmodics and narcotics already mentioned
{§ 75.), with the suioking of tobacco, stramonium,
and aniseed, and the iidialation of ihe vapours of
narcotic sulistances, and certain gases ($$ 85. 88.).

112. Flatulence is a very frequent attendant
upon asthmatic cases, chiefly before the invasion
of, and during, the attack. It seems connected
witli irritation of the digestive mucous surface,
and deficient vital power. The relief of this
symptom is often a matter of importance. For
this purpose i have sometimes prescribed the
following : —

No. 53. R Olei Anisi TTl viij xij.; Sodae Carbon.

gr. XV.; Satchari Alb', Magnesiae Calcinat. aa 9 j.; tere et
adde I'inct. Castorei jj.; I'inct. Capsici III iv. ; Tinct.
SeiiiiEE Comp. 3 ij. ; Aquae Menth. Viriil. et Mist. Cam-
phor« aa .5 v.; Syrupi I'olutani Sts. M. !• iat Haustus,
3tiis ve 4tis horis, ad tertiam aut quartam vicem sumendus.

113. 3d. Of ihe treatment of the various sym-
ptomatic and complicated stales of the disease. —
But little is required froin me on this subject, after
the detailed account of the treatment now given.
When the disease is associated with either of the
usual forms of catarrh, diaphoietics, consisting
ciiiefly of ipecacuanha, aniiinonials, &c., com-
bined with narcotics or anodynes, are ciiiefly in-
dicated ; and, if inflammatory irritation .seems to
exist in the bronchial lining, local depletions, col-
chicum, or digitalis, counter-irritants and revul-
.sants, gentle aperients, and the inhalation of the
vapour of warm water, in which a little camphor
has been tlirowD, may be added to tiie above.

114. In the frcipient complications of inflam-
matory irritation of the di<;^estive mncous surface,
and disorder of the hiliary apparatus, or of de-
rangement of the functions of tiie heart, it will
generally be advi.-<able to commence the treat-
ment with five grains of blue pill on alternate
nights, for three or four times, and with an ape-
rient draught on the following morning. By these
the .secretions will be excited, and the bowels eva-
cuated. Afterwards the healthy state of action
of the capillaries of the mucous surfaces gene-
rally will be promoted by exiiibiting half a grain
of blue pill, three or four times in the twenty-
four liouis, combined with two or three grains
of the extract of hyoscyamus, or of extract of
liop ; vegetable tonics, with the fixed alkalies, or

ASTHMA — ITS Theatment.

153

other stomacliic medicines, being taken through
the day. If we have reason to suspect the ex-
istence of organic change within tlie chest, par-
ticularly inflammatory congestion in the lungs,
enlargement of the structure of the heart, &c.,
the insertion of issues, or keeping up an abundant
eruption on the external surface of the chest by
the tartar emetic ointment, should be added to
the above means. This treatment ought, with
occasional variation according to the circum-
stances of the case, to be perseveringly continued
for weeks, or even months ; and it will often suc-
ceed, even in the most unfavourable complica-
tions. The trisnitrute of bismuth, combined with
tonic or bitter extracts, will also be found of
service in the gastric associations of the disease.

115. When tiie disease is associated with affec-
tion of the head, or curvature of the spinal
column, setons, issues, or moxas in the nape of
the neck, or in the course of the spine, may be
tried. If it be attended with disease of the liver,
external irritation, the nitro-hydrochloric acid bath
or lotion, small doses of mercury, and the plaster,
ForiTi 117., may be prescribed. Organic lesions
of the heart and large vessels, and dropsical
effusions, require a combination of these measures
with the use of alkalies, digitalis, opiates, &c.
When hysteria, and generally increased sensibi-
lity and susceptibility, attend the asthmatic afTec-
tion. Ionics with antispasmodics are principally
indicated. In the other complications of asthma,
the treatment recommended in Dyspnoea will be
generally appropriate.

116. 4th. 0/ the regimenal treatment. — Much
advantage will be derived in asthma from strict
attention to diet and regimen, — comprising bath-
ing, exercise, air, and climate, the use of mineral
waters, &c. A. Cold sponging the surface of the
chest, and cold bathing, are amongst the most
approved means that can be resorted to during
the intervals of asthma. They tend both to
diminish the sensibility and susceptibilily of the
patient to the impression of cold, — one of the
most frequent exciting causes of the attack ; and
to give a salutary tone to the respiratory mucous
surfaces and vessels ramified in them ; and hence
they prove the be'-t means which can be resorted
to for the prevention not only of the asthmatic
attacks, but of catarrhs, and all other affections
and diseases of the respiratory organs. The
patient should commence this practice with the
following lotion, with which the whole of the
chest and upper part of the abdomen should be
sponged, or rubbed with a towel or piece of flannel
wetted with it, and afterwards be dried, using
smart friction at the time : —

No. 54. R Acidi Acetici Pyrolignei vel Vini Albi, Liq,
AmmoniEe Acetatis, aajijss. ; Aq. Rosae 3 v. ; Spirit.
Vini Tenuioris 3 ij. M. Fiat Lotio.

This should be used every morning upon getting
out of bed ; and if the patient commence with it
during the winter, a fire may be kept in the
dressing room, ana the chill taken off it for the
first few days of using it. Instead of the above
lotion, a solution of common salt in water, in the
proportion of two table-spoonfuls to a pint, or
one part of vinegar to two of water, may be em-
ployed. After these have been continued for
some time, or as long as the patient may please, and
the system has been thus prepared for it, the
shower-baih may be substituted with advantage,

particularly if the patient be in that state of health
which will allow him to bear the shock without
risk. Sea or salt water bathing may also be
resorted to all the summer and autumn ; and the
shower bath, or at least cold sponging the surface
of the trunk of the body, all the winter and spring ;
for it will generally be advisable not to discon-
tinue this practice for any considerable time after
it has been fully adopted and found of service.
In addition to the cold bath, the patient should
have recourse to regular exercise in the open air ;
and attend to the state of his digestive organs, and
the regular functions of the bowels.

117. If along with the asthmatic affection the
patient have complained of palpitations, irregula-
rity of the action of the heart, oedema of the ankles,
severe dyspeptic symptoms, and disorder of the
liver or bowels, these ought to be removed, before
commencing with cold sponging and bathing, by
local depletions when they are indicated ; by very
small doses of blue pill, or the hydrargyrum cum
creta, with the carbonates of the fixed alkalies,
and hyoscyamus given at bed-time, a gentle ape-
rient draught the following morning, and bitter
tonics, with the alkalies through the day. The
recommendation of cold bathing in asthma inay
startle some ; but when all associated disorder of
an inflammatory kind has been removed by ap-
propriate treatment, and the means now specified,
and when the system has been duly prepared for
it, cold bathing is actually one of the most salutary
measures, and the most permanently beneficial,
that can be prescribed. It has, moreover, re-
ceived the sanction of C.ti.ius Avrelianus,
Floyer, Withers, Millar, Ryan, Bree, and
IluFELAND, — names which should claim our
respect for whatever they recommend, even if our
own experience did not altogether confirm their
opinions, which, however, is in accordance with
theirs as to this practice.

118. B. Mineral waters. — The waters in this
country, which are best suited to asthma, are
those of Cheltenham and Leamington ; and of
Buxton and Bath, to some of its complications,
particularly the arthritic. Dr. J. Clark very
justly remarks (The Influence of Climate, &;c,
2d ed. Lor.d. 1830, p. 371. et seij.), that when
asthma is accompanied with chronic irritation of
the bronchial membrane, or with disorder of the
digestive organs, and an unhealthy state of the
skin, a course of warm mineral waters will often
prove of benefit. The springs of Ems on the
Rhine, of Carlsbad, of ISonnes and Cauterets
in the Pyrenees, and of Mon] d'Or in Auveigne,
are those chiefly esteemed on the Continent. The
great difficulty generally is, that the climate and
degree of elevation of these places will often not
suit particular asthmatic cases. Where the cli-
mate of a valley is likely to suit the patient. Ems
and Carlsbad will be pieferred ; and where an
elevated situation is required, the Pyrenees and
iMont d'Or will be chosen. The artificial waters
of Ems and Carlsbad, prepared at Brighton, are
but little inferior to the natural springs. In a
case of this disease, where 1 directed those of
Ems, great benefit was obtained from them.

119. C. Change of air and climate. — It is im-
possible to point out the particular climate or
locality which will best suit the asthmatic patient ;
for the state of air or climate which will suit one,
will distress another, and without any very evi-

154

ATROPHY,

dent cause to explain tlie different effect. In
nearly all cases, however, changes of air are
beneficial, chiefly as respects the general health
of the patient, and the disorders with which
asthma is associated. Upon the whole, a temper-
ate, equahle, and moderately moist state of the
air is best borne : but even in this, theie is much
uncertainty. The physician must be guided in
his choice by the kind of asthma with which the
patient is afflicted, and by the ascertained effects
of certain seasons and localities in his particular
case. In general, a moist and warm, or mild
climate, as the south-west extremity of this island,
will suit the spasmodic or dry form of the disease,
and that most commonly associated with the dry
citarrh, much better than any other in this
country ; whilst the piiuitous or humid variety,
occurring in the debilitated or aged, and in those
of a relaxed and leucophlegmatic habit, and
attended with much expectoriition, will recjuire a
dry and a somewhat bracing state of the air.

120. D. Diet. — Very little is required to be
stated nn this topic. 1 he food should be always
light, digestible, in small quantity, and chiefly
farinaceous ; particularly in those cases which
indicate general or local plethora, inflammatory
irritation, and disorder of the digestive organs.
Fi.ovER particularly insisted upon abstinence, as
to both eating and drinking ; and later wriieis,
and experience, have confirmed the justice of his
injunction. When the disease is accompanied
with lowered energies of the powers of hfe gene-
rally, the diet should not be so poor as to furnish
insufficient means whence the mischief may be re-
paired ; but it ought, notwiihstanding, to be light
or digestible, and not exceeding the powers of the
digestive organs to manage with facility.

BiBMoo. AND Refer Galen, De Difficult. Respirat.

1. i. li. iii. ; et Uel»cis Affictis, l.iv.cup.T.—Are/ofus, De
Morb. Dint.. 1. i. cap. 9. — Ci'hiis, l.iv. c. 4. — delius Aure-
lianus, De Morbis Chron. 1. iii cb. 1. p. 431. — Avtcenna,

Canon. I. iii. tr. 1. c. 7—1'-' Ferntlnis. Consil. xxii

JBaglivi, De Pract. MeJ. 1. i. cli. 9. p. M.—Severinus, De
Efficac. Meilicam. p. 220. - Zacuti/s Lusitanus, Prax.

Uistor. 1. viii. ob. 2f>.\ et Prax. Ailmir. I. iii. ol)s. \'1&

Mai/erne, Praxis, &c. p.|184 — »>'//«, Pathologia Cerebri,
rap. 12. ; et de Mnrb. ( onvuls. cap. xii. p. 94. — Floi/er,
(Jii rhe Astlima. (.ond. ifJyS —Dicmcrbraeck. Observ. et
Curat. C. n. Ki.—Pun/hul, Ergo Astlimaticis Tahella; de
.Siil|)liMre. Monsp. \t^->:i. — Duver, Legacy, c. p. 4(1 —
ILiff'mann, De Astlini.ite Cunvul.s. Opera, vol. lii. ]). 10.'.

— ^^■|T/,'^^(?r, Diss, de Asthma' e. Hafn. \1W\. — Ettmullcr,
Diss, de .\sthrnate. I.ips. 1710; et Opera, a Ztvhigtwro, t ii.
p. 109 y^/irrt/. Diss. deSpirandi Difficultate. Hal. n->C<.

— jHiickcr, De Astlunatis Vera Patho!. ct I'lierapia Hal.

17i'2 Uanuii, in Act. Reg. Soc. Med. Haiin. vol. ii.

p. 1()3., vol. iii. p. 362., el vol. iv. p. 'ID'.), — Bang, in Il]id.
vol. i. p. 10. 1(2. WQ.—Aiiakou', in Iniil.. vol. i. p. 30S._
Knhs, Medicin. Keob^cli. I), li. Ii. iii. Mo. 7 — Akensidc.
Medical Transac. of Col!, ol Phys. vol. 1 . No 7. p 93.—
ly/ii/tt. Works, p. Wl.— lVithcrs, Treatise (jn the Astlnna.
Loi'id, \lxr,. — SMl. Rat. Medendi, p. iii. p. 3G., et p. vii.
p. 2M. — '/'/ii/rni>ts, Med. and Chirnrg. Remerk. i. p. I(i4.

— AW/nr, Observations on the A.slhiria,&c. Lond, 1709. —
Nei/cr, De As-thmate et i jus Spec. Got. m'J.—Jiyan, On
the llisiory and Cure of Asthma. 1/ nil. 1793. — Krctsch-
mar, Ilorii. .Arcliiv, 1>. i p. i27. — Chapman, in Med eal
Communications, Ike. vol. i. No, T/.—JIeberdi'ti, Coni-
jnent. Ue Morb. &c. cap. II. — Monro, in Kdin. Mid.
Essavs, vol. iii. p. 31(i. — .S'(»/sora, in Ibid. vol. vi. p. 121. —
Jivs/i. in Edin. Med. Conimenr. vol. iv. p. 198. _ I'uthrr-
gill. Works, vol. ii. — Aleiamlcr, in Kdin. Med. (Joni-
ment. vol. xv. — J'ercivul, Medical ^'s^ays, vol. i. p. 209.
and vol. iii. p. 270. — Mnc/tride, Med. Obser . and Inquiri>-8,
vi. No. 2 Michaaiis, in Riehter Cliir. Bibl. b, v. p. 127.

— Mciicdgni, .Suit' Uso di Carboiiato di Potas.sa, i\c. Mem,

dell Soc. Ital. Rom. xii. 1H(M llrfc. Practical lni|iiiry

into disordered Respiration. Lond. \HI)';.—ZiU/m/>/,'Vr:i\tO

de rAslhnie, Hvo. Paris, 1H()9 Slaiigir, in Med, and

Chirnrg. 'I'rans. vol. \. — Scliiiii'lliiiaitii, Anlciumg zu
Criindongeiner M»dicinalverl'assung, tli.i p. W.K—llmn,
Arcliiv (iir Pract. Mod. Jan. \v,\\, p. H7, — lienke, Ibid,

b. vi. p. 271. — Loebel, and Heinecken, in Ibid. July, 1810,
p. 187., et May, 1812, p. bl\. — Heitiecker, Huleland,

Journ. der Pract. Arzneyk. b. vi. p. 74 IVickmann, in

Iliid. b. i. p. 18. — Hahnemann, in Ibid. b. iv. p. 755. —
Hujeland, in Ibid. b. iv.—Heil, Fieberlehre, b. iv. p. 820.
p. 02. — iVolJf', Hufeland Journ. der Pract. Ueilk-xviii.
b. 1st, p. AS. — Loeffler, in Iliid. xxi. b. Kst, p. (0. — r,7-

bfrg, in Ibid, xxvi, b. 3d, p. 26 Portal, Mem. sur la

Nat. et le Traitement des Plus. Maladies, t. ii. p. 70. —
J. Frank, Praxeos Medicse Univ. Preecept. P. ii, vol. vii.
p. 379. — Roslan, Journ Gener. de Med. Sept. 1818; et
Nouv. Journ. de Medecine, t. iii. p. \.— Chiistie, in Edin.
Med. and Surg. Jouiri vol. vii. p, I5S Schlesirigir, Hufe-
land nnd Himly, Journ. der Pr. Heilk. Jan. 18i0, p. 1 15.
— Lacnncc. De {'Auscultation Mediate, 2 t. Paris, l^26.
— ly. Philip, Philos. Tr.ms. 1817-22. — /iewscmem, Ueber
den Ban der Lungen-Fol. Berl. 1822. — Andral, Revue
Med. t. iii. 1824, p. 3 '0.; et Clinique Medlcale, t, ii p. 72.
— J. Forbes. Me i. and Phys. Jouin. Oct 1822. — Georfiet,

.Sur le Systenie Nei veux, t. ii. Pans, 8vo. 18i:2 J. Hem

gin, in Journ. Compl. t. v Ferrus, Diet, de Medeciiie,

t.iii. art. Astlime, p. 101 Cruveilhi^r, Nouv. Bibliotli.

Me 1. t. T. p. I7i). — Bricheteau, Archives Gener. de Med.

t. ix. p. 534 Jolly, Diet, de Med. et Chir. Prat, t.iii.—

Parry, Elements of Pathology, § 474., and Posthumous
Works, &c, vol, ii. p. 19. — Andrews, in Glasgow Med.
Journ. vol. i. p. 177 Gannal, On the Inhalation of Chlo-
rine. By Potter. Loud, 1830. — Kreyssig, Encyclopadisches
Worterl). der Med, Wissenscli. b. iii. p, i;7o. — Forbes,
Cyclop, of Pract. Med, vol, i.

ATROPHY. — (From the privative a, and Tpo(p]i,
nutrition, or rpocpiai, I nourish.) — Svn. Atro-
pine, Coiisompiion, Fr. Uiigedeiben, Hchwiud-
sucht, Aiisiehruiig, Ger. Voedeloosheii, Dut.
Atrojia, Soinma MagrezM, Ital, Wasting, Eng.
Clasjif. — Pathology — Morbid Structure,

1. Uefin. Dejicient nutrition of a part or of
the whole J'rame, owing to which its natural dimen-
sions are neceisnrilii reduced.

2. The healthy pioportions of the various parts
of the frame are preserved by their vital endow-
ment, and are intimately dependent upon the
conditions of this influence. When it preserves
its due relations throughout the frame, a con-
tinued vital attraction of molecules from the
blood takes place, to an extent sufficient to sup-
ply the place of those particles, which, having
h)st their vital affinity, are removed by absorption,
1 his slow process, by which animal particles are
taken away, for a time, from the curient ot the
circulation, assimilated in the various tissues,
afterwards detached from them when they no
longer ar-e suited to the purposes of the structure,
and carried back to the circulating current to be
partly eliminated from the fiame, and partly
changed into ditferent conditions, is not ml're-
quently liable to bedistuibed in some one of its
parts or steps. Thus, when the vital influence of
an organ, or of the whole frame, is in a state of
activity, the attraction of molecules from the
blood, similar to those constituting the different
tissues, is energetic and extended to a greater
number of such molecules, — they are held in
closer affinity, and the bulk of the part is in-
creased. But wiien the state of the vital endow-
ment is reversed, when it is weak or depressed,
this attraction proceeds slowly and languidly,
and, llie existing affinity being also weak, the
molecules comjiosing the tissues are soimer re-
moved by the jirocess of absui-jition than in health,
and the \rorl tlius circumstanced is wasted, from
a more rapid loss ol its molecules than can be
supplied by the low state of vital affinity. 'Thus,
as in the former case, a double condition of the
oiganisation, but of opposite natures, actually ob-
tains ; namely, the attraction is extended to fewer
molecules, and the affinity between them is more
languidly exerted, they being more rapidly carried.

by the process of absorption, back into the blood,
from whence they came, in order to be p'li'tly
changed and partly eliminated from it; and the
part thus affected, instead of retaining; its healthy
proportions, becomes wasted, deficient in its con-
stituent molecules, or atrophied. Thus we per-
ceive tliat there is a continued circulation of
nutritious particles in the very tissues which they
compose; that this circulation, and the affinity
which preserves them in their spheres, is vital,
influenced by, and fluctuating witii, the various
conditions of the vital endowment of tiie frame,
the nutrition and bulk of a part being intimately
dependent upon it.

3. Nuirition being, then, the result of a vital
attraction extrled between the molecules of mat-
ter constituting the elementary tissues, and those
which are similar to them in the blood, and
being co-ordinate with the strength of that at-
traction, atrophy necessarily proceeds from a
diminution of this affinity, and the more rapid
transit, consequent upon this diminution, of the
particles which have been attracted, back into the
current of the circulation. The healthy propor-
tion of tiie tissues is therefore continued by a due
equihbrium being preserved between the attractive
influence on tlie one hand, and the continuance
of vital affinity on the other. When eithtr the
attraction is active, or its duration long, the bulk
of the structures will be increased ; but wiien the
former is wenk, or the latter of short continuance,
atrophy will naturally result,

4. The truth of these propositions is evident
from a due consideration of the various pheno-
mena of health and disease, and by the numerous
contingent circumstances which influence the
conditions of the different structures of the body.
At this place I will briefly describe, Jint, the
appearances which atrophied structures assuiie;
secondly, the various causes and circumstances
which, influenced by the vitality of the frame,
produce this change ; and, thiidli/, the treatment
that m;iy be employed to remove it. 'Thus I will
confine myself, at this place, entirely to the con-
sideration of atrophy, in its generic acceptation ;
the species being treated of under distinct and
separate heads.

5. A. States or appearances of atrophied parts. —
Atrophy may he confined to particular structures;
it may affect only a particular constituent tissue
of an organ, whilst its associated tissues are
hypertrophied, and it may extend to various
contiguous structures or unconnected oigans. A
particular constituent tissue may, however, be
wasted, and yet its associated structures may be
augmented in bulk, as I have shown occasionally
to occur, vvhen describing the morbid states of the
liver. When this takes place, either no diminu-
tion, or an actual increase of the whole organ, is
observed. When a compound organ, or pait
formed of various elementary tissues, is atrophied
in all its constituents, the diminution of volume is
then very remarkable; although, in some cases,
as when the atrophy consists chiefly of a rare-
faction of the internal structure of an organ, as of
the lungs and bones, the external surface presents
little or no change.

6. The earliest and most essential change in an
atrophied part is diminution of the quantity of
blood sent to it ; and next to this, and chiefly
owing to it, is greater paleness of colour. Sub-

ATROPHV. 155 .

sequently the organisation is still more completely
changed; so much so, frequently, that all traces
of its original conformation are lost, and the part
is reduced to the staie of cellular or fibro-cellular
tissue, generally of small size. In some cases,
the part is not only extremely atrophied, but at
last disappears altogether. When membranous
structures are atrophied, they become much
thinner and more diaphanous than natural, or
even perforated.

7. The atrophy of certain organs or parts is a
natural or healthy change, as respects the foetus
in utero, and the newly-tjorn infant. The parts
which experience those changes are too well
known to require noiice. Several structures,
especially muscular parts, sometimes have preter-
natural quantities of tat deposited on their surfiices
during the progress of atrophy. This is often
observed in respect of the heart, and appears to
result from the same causes; namely, diminished
vital energy, occasioning insufficient nutrition or
assimilation ( 6 j 2, 3.), and a morbid secretion of
fat, which olteu is as much a consequence of
diminished viial energy, as insufficient nutrition
of the different structures is the result of this
state ; both changes being, in some cases, merely
grades, in others modifications, of the same vital
manifestation.

8. Various parts of the body naturally undergo
marked atrophy during advanced age. Of these
the most remarkable are the generative organs,
particularly the ovaria, mammaiy glands, testes,
the thyroid gland, the bulbs of the hair, adipose
tissue, the luuiis, and bones. Atrophy of the«e
and other parts has received a more particular
notice under their respective heads. I may, how-
ever, remark, respecting the atrophy which results
from age, that it is very evidently the result of
diminished vitality, especially as those parts which
first expeiience a loss or diminution of their func-
tions, either from age or exhaustion, are the first,
to be atrophied ; and that it 'often differs from
other forms of atrophy, in consisting meiely of a
deficiency of the fluid constituents of the struc-
tures— in a condensation and dying of the organs,
and not of a loss of the molecules constituting
their solid parts.

9. B. The secondary catises uhich, nnder the
iyijluence oj' the vitalitif of frame, produce atrophy,
are, 1st, Original deficiency of development, con-
stiiu'ing congenital atrophy. This state of atrophy
may exist in every grade, and may amount to a
total absence of an organ or pari. When it takes
place to this extent, it has evidently arisen from
an arrest of the formative process, or of the deve-
lopment of the tissues, in consequence of disease
of the embryo. If llie disease affect the nervous
centres, the parts supplied with nerves from them
are sometimes either much atrophied or altogether
wanting, as RliM. Rostan and Serres have shown.
But this is only an occ isional occurrence ; for
parts of the brain or of the spinal chord have
merely consisted of a serous sac, and yet the
organs of sense and the limbs have been fully
developed ; and there have occurred many cases
in which both brain and spinal chord have been
entirely wanting, and yet the nerves proceeding
from them and the organs which the nerves supjdy,
have been fully formed ; evincing the truth of ilie
doctrine stated by the writer many years since
(see London Med. Repos. vol. xvii. for May, 1822 ;

15«

and Notes to Richehand's Elements of Physiology,
1st ed. 1824), tliat the nerves are first lormeil,
and the cerehro-spinal centres subsequently de-
veloped.

10. 2d. A diminution of the influence of those
nerves which preside over the circulation of a
part, and its assimilative and proper functions,
rapiflly reduces its volume. It is chiefly owing
to this cause that the organs of generation waste
in old persons. The ganglia which supply these
organs, in both sexes, become, in old age, small
and indistinct ; and the nerves which issue from
them to these parts can scarcely be traced. 1
have no doubt that a similar result follows in-
jury or change of the ganglia or ganglial nerves
in other parts of the body. The paralysis attend-
ant upon painters' colic is generally accom-
panied with great wasting. In cases of unre-
duced dislocation, when the head of the bone
presses upon the nerves, wasting is a frequent
consequence, chiefly owing to the incapability of
exerting the voluntary muscles, which are rapidly
atrophied when they remain inactive. Injuries of
nerves, of whatever description, that interfere with
their functions, will, as shown by Bell, Lob^tein,
and several others, occasion atrophy. But I may
add, that whilst injuries of ganglial nerves will
produce it directly, by arresting the nutritive
actions, injuiies of voluntary nerves occasion it
indirectly only, and chiefly by depriving the
muscles of their contractile powers, and reducing
them to that state of inactivity which is more or
less rapidly followed by atrophy. This is proved
in the numerous instances which come before us
of paralysis originating in the brain. The wasting
of the paralysed limb in these cases is seldom
great, and it is chiefly limited to the muscles ; the
other structures, particularly the cellular and
adipose, being unaffected.

11. 3d. Diminished supply of blood is a very
frequent cause of atrophy. This may be local, as
in cases of obliteration of a large arterial trunk,
and when the functions of an organ cease. In
many such cases, however, the obliteration may be
the consequence of injury of the ganglial nerves
which supply the ariery, or of the cessation of
the functions of the part. The general state of
atrophy which occurs after tubercular formations
in the mesenteric glands, or in the lungs, is gene-
rally partly owing to the diminution ot the entire
mass of blood, together with lowered vital in-
fluence ; the nutritious molecules, and the assimi-
lating or attractive power being both deficient.
A similar inference may also be extended to the
wasting accompanying idiopathic anaemia.

12. 4th. When the funciions of a part or
organ are arrested, atrojihy always results. This
is remarkably the case in respect of the voluntary
muscles (§ 10.). On the other hand, increased
function of an organ contributes to augmented
volume. The urinary and generative organs
furnish well-known proofs of tho^e positions, and
illustrate tlio^e with which 1 commenced, namely,
that nutrition, and consequently atrophy, most
intimately depend u|)on the states of vital mani-
festation of an organ or part. Other organs,
incapacitated from acting also undergo a marked
diminution of their size. Even the lungs, when
the principal bronchial tube of one lobe is ob-
Hinictcil, will experience atrophy of that lobe, as
JVIM. IIlynauu and Andiial l.ave shown. In

AUSCULTATION.

cases of death from hunger, the stomach and large
bowels appear wasted.

13. 5th. Atrophy will also present itself as a
consequence of inflammation ; and, in some cases,
will amount to obliteration or disappearance of
the part. Such changes are not infrequent in
blood-vessels and excretory ducts. It is some-
times observed in the spleen, liver, and gall-
bladder; the last of which has been observed to
be wanting or entirely obliterated from this cause.
In the majority of such cases, the atrophy has
proceeded from obstruction to an artery or vein
having occurred during the disease, probably
from the extension of inflammation to them, or
from the pressure of some of the usual products
of the inflammatory state.

14. C. Treatment o/" atrophy. — In all these
circumstances under which atrophy occurs, it will
always be observed that the vital energies, in
some one or other of its manifestations, are dimi-
nished or perverted — most frequently the former.
This fact furnishes us with the most rational indi-
cation as to the removal of the morbid state which
it occasions. Having first ascertained the circum-
stances and pathological states of the atrophied
organ, we are to direct our attention to remove
them as far as may be possible. We are next to
endeavour to restore the natural vital energy of
the organ by exciting its functions, and promoting
the constitutional powers. Knowing that, by in-
creasing the natural actions of a part, we thereby
increase its nutrition and bulk, we should en-
deavour to apply this principle to the removal of
atrophy, but wiih a caiiiioiis avoidance of fatigue
or exhaustion being occasioned by the means we
use for this purpose. When the atrophy seems
to depend upon the development of tubercles, or
upon engorgements of lacteal glands or tumours,
pre-sing upon nerves or large vessels, the prepar-
ations of iodine are indicated, on account both
of their influence in removing these tumours, and
of their excellent tonic powers when judiciously
administered. In many cases the functions of
the digestive organs — stomach, liver, and bowels
— are torpid, and consequently the nutritious
fluids are not sufficiently prepared to be assimi-
lated in the different tissues. Healthy chyle is not
supplied in the requisite quantity, or, if supplied,
is not converted into healthy blood for the iiouiisli-
meiit of the structures. In these cases, although
the energy of the whole frame is deficient, yet our
principal means of medication are to be directed
to these organs. (See art. Tublrcular Con-
sciMi-iioN, Marasmus, JMesentlric Disease, and
Tabis Dorsalis.)

BiBLioG. AND Refer. — Desmou/fns, in Journ. de Phy-
sique, t. xc. i> 142. — Rihcs, in Bullet, de la Faciilte de
Mc'il. t. vi. p. 2ii!». — Fi'rrus, Atrojiliie, in Diet, de Med.
t. iii. )i. 143. — A7i(l)al, Clinique Medicale, t. iv, p. 11.; ct
I'reiis d'Anatom. Pathol, t. i. sect. ii. cl). ii — Buuiilaiid,
Diet, (le Med. et Cliiruig. Prat. t. iii. p. i.Vi\i. — LubiUin,
Trailc d'Aiiatomie Pathologique, t. i. p. GO.

AUSCULTATION. — (From auscuho, I list-
en.) Classif. — Pathology, Semeiology.

1. This term is applied to the methods used
to ascertain the seat and nature of disease,
by the signs which may be recognised by
the sense of hearing. It comjirises the study
of all sounds indicative of disease, whether
heard by the unassisted ear, or through the
medium of instruments; and whether arising
naturally, or produced artificially. The observ-

AUSCULTATION -

ations, I have to offer upon this mode of investi-
galing disease may be arranged in the following
manner , but 1 s'lall confine myself at this place
to the consideration of tlie^'rst class of signs, and
devote to the second class a distinct article. (See
Pehcussion.)

2. I. Signs FURNnsHED by Sounds produced

NATURALLY WITHIN THE BODY.

A. Sounds hdving their seat in the chest. — o.
Depending upon the passage of air during respir-
ation, b. Proceeding from the action of the vocal
organs, c. Depending upon the action of the heart.

B. Sounds hacing tlieir origin in the arteries.

C. Sounds seated ivithin the abdomen. — a. Pro-
ceeding from air in the digestive tube, b. De-
pending upon the foetal circulation.

II. Signs furnished by Sounds produced
ARTIFICIALLY. (See Percussion.)

3. Hippocrates remarked that the existence
of fluids in the thoracic cavity might sometimes
be ascertained by applying the ear for some tune
to the side of the chest ; and our countryman
Hook (^Posthumous JVorks, p. 39. &c.), in
several very pointed observations, not only stated
the importance of attending to the sounds pro-
duced by the " internal motions and actions of
bodies," but also of rendering them sensible so as
to distinguish between them ; for the doing of
both which, he thinks, " it is not impossible but
that in many cases there may be helps found."
M. Double, also, was in the habit of applying
the ear closely to all parts of the chest, in order
to examine the signs furnished by tlie action of
the heart, and by respiration ; and published his
recommendation to cultivate this means of diag-
nosis, in his able work on Semeiology, two years
before the appearance of M. Laennec's celebrated
production. Although, therefore, M. Laennec
may not have been the discoverer of the import-
ance of auscultation in the investigation of disease,
yet is he clearly entitled to the honour of dis-
covering medmfe auscultation — of inventing the
stethoscope — and not only of bringing both tiiese
modes of examination into general use, but also
of strongly recommending percussion, and of im-
proving, in a very remarkable manner, our know-
ledge of the patiiology of pectoral diseases.

4. It is unnecessary to occupy my limits with a
description of the instrument teimed the stetho-
scope, as its construction, with the improvements
of iM. PioRRY, and the acoustic principles on
which it assists the sense of hearing, have been
frequently described, and are so simple, as to be
readily understood, even by those who are not
already acquainted with it. I may remark at
this place, that auscultation, like every other
method of investigation, requires practice for its
perfection. The young practitioner should there-
fore early commence the study of the sounds of
respiration and of circulation, at first with the
unaided ear upon the healthy subject, and pre-
ferably on children, from five to twelve years of
age, as in tliem all these sounds are distinct, and
seldom modified by organic disease. Having
made himself familiar with these sounds, by fre-
quent recourse to this practice, he may provide
himself with the cylindrical stetlioscope in gene-
ral use, and with the one called Piorry's ; and,
with their aid, continue his study of the sound
produced within the living body,

5. Having limited myself at this place to the

-OF Respiration. ' 157

consideration of the Signs furnished by Sounds
PRODUCED naturally WITHIN THE BoDY, whether
heard by the unassisted ear, or by the aid of the
stethoscope, I proceed, Jirst, to notice the sotinds
having their seat in the chest and throat. 1'hese
sounds are chiefly produced by the natural move-
ments of the parietes of this cavity and of the
organs contained within it, and consist of, 1st,
those of respiration; 2d, tho^e of the voice; and
3d, those of the heart. These will be successively
considered.

6. I. Auscultation OF Respiration. — A. Of
the healthy and simple respiratory sounds. The pas-
sage of air into, and out of, the lungs occasions a
somewhat different sound in various parts of the
chest, owing to the difference of size of the tubes
through which the air passes. Hence the respira-
tory sound has one character in the small
bronchi and air-cells, another in the large bronchi,
and another in the trachea. These sounds have
been respectively denominated, by Laennec, An-
dral, and Williams— the best writers on auscul-
tation— vesicular, bronchial, and tracheal. The
tracheal sound is heard in the anterior and lateral
parts of the neck, the upper portion of the
sternum, and the sternal part of the subclavian
regions. The bronchial respiration is heard in
the middle portion of the sternum, and paits of
the mammary regions contiguous to it, and in the
axillary and intei scapular regions. Vesicular
respiration is perceptible over the remaining parts
of the chest in health. These sounds are double ;
the one being that of inspiration, the other of ex-
piration. The former is much stronger than the
latter, which is often scarcely to be heard by the
unpractised ear, unless assisted by the stethoscope.

7. It is difficult to describe these sounds with
accuracy. The vesicular sound is a dull and
diffuse 1 murmur, or a feeble oieathing, resem-
bling that proceeding from the passage of the air
through the nostrils in a healthy and quiet sleep.
The bronchial respiration is fnore tubular and
blowing, and is chiefly confined in health to the
situation of the largest bronchi. The tracheal
sound merely conveys the idea of air passing
through a tube of larger calibre, and is more
hollow and blowing.

8. The lespiratory sounds vary in their in-
tensity, not only in different persons, but also in
the same person, at different epochs of life, and
at various limes. The thickness of the parietes
of the chest does not materially diminish their
intensity ; but the activity of the lespiratory func-
tion affects them niost materially ; this function
presenting different grades of activity in different
persons. Dr. Williams has remarked that they
are more distinct afier meals and moderate exer-
cise. After excessive exertion they are diminished.
Fear, and the depressing passions, have a similar
effect.

9. The respiratory sounds are greatly modified
by age. From birth to the period of puberty,
they are much louder and shrillei' than in after
life, and the whole respiratory function more
active. This state of the respiration has been
called puerile by Laennec ; and occurs sometimes
in adults, either generally or partially, from mo-
mentary excitation, or the presence of disease in a
part or parts of the lungs. At puberty the respir-
ation is less noisy ; and in a few years becomes
much deeper, and assumes the adult character.

158

AUSCULTATION — OF Respiration.

10. The vesicular sound being the result of I other diseases in which it occurs, the crepitation

the perfect penetration of tlie air into the lungs,
its equal and simple presence is a sign of the
healthy performance of the function. But this
sound may vary in degree. It may be feeble in
all parts, owing to constitutional peculiarity, or
only in particular parts, when we should suspect
disease; but it is no proof of disease, unless it
lie associated with certain peculiarities of sound
hereafter to be noticed. The total absence of
respiratory sound in a part indicates either the
exclusion of the air from the part of the pulmo-
nary tissue underneath, or effusion of fluids, or the
introduction of air into the pleura. Here we
must have recourse io pemission , in order to give
precision to the information. (See Percussion.)
In some cases the n:itural vesicular sound is
al)sent, and a bronchial respiration is heard. In
these we must infer that the vesicular murmur is
suppressed by a condensation of the pulmonary
structure, which, owin^ to this change, becomes
so good a conductor of sound, that the bronchial
respiration eitlier becomes louder or is heard in
unusual places. In other cases, a sound re-
sembling the tracheal is heard in situations where
vesicular respiratiim alone exi-ts in health. 'J'his
is caused by the passage of air into an ulcerated
cavity or cavern communicating with the bronchi,
and from this circumstance is called cavernous
respiration.

11. B. Of the morhid respiratory sounds. — The
respiratory sounds are not only varied in degree,
but also in kind, or they are mixed with different
adventitious sounds. These variations of kind
are produced, 1st, by changes in the parietes
and vicinity of the tubes, and in their secretions ;
and, 2d. by morbid states exterior to the pul-
monary tissup. Under the FmsT of these are
ranked the different I'arieties of sound produced hi/
the presence of morhid secretions ivithin the air-
tubes, and the lesions producing these secretions.
'J'his class of morbid sounds have been variously
denominated. By the French they have been
named rule ; by some of our own writers the word
rattle, and by Dr Johnson the word whee'^e,
have been used. As we have no English term
which so fully expresses the idea, to which this
morbid sound gives rise, as the word rhonchus,
adiipted by Dr. Williams, and some trench
pathologists, 1 shall use it here.

12. a. Moist crepitans rhonchus, the rale crepi-
tant of Laennlc, the crepitant rhonchus of Dr.
Whliams, has its seat in the air-cells and
minute bronchi. It resembles the sound from
rubbing a lock of hair between the finger and
thumb when held c'ose to the ear; or the crepit-
ation of a piece of lung ilistended with air when
compiesseil. It is generally unitoim, and con-
tinues to the end of inspiration, and seems to
ari»;e from diminished (alii)re of the minute
brimclii, owing to interstitial effusion, and the
admixture of the respired air with the secreted or
effusefl fluids in the air-cells and tubes. It is
characferisiic of incipient hepati-ation of the
lungs from pneumonia, and of its resolution ; of
fcdema and apoplexy of the organ ; sometimes
of early phthisis, of pulmonary catiirrh, and
bronchitis. I'jut it is only pathognomonic of the
first stage of pneumonia ; and the more viscid the
mucus that is secreted, the more distinct is the
cnpitant character of the rhonchus. In the

is less perfect.

13. 6. Dry crepitans rhonchus, the craquement
of Laknnec, resembles the sound produced by
blowing into a dried bladder, and conveys the
impression of air distending lungs that have been
more or less dried, and whose cells have been
unequally, but much dilated. It is only heard
during inspiration, and occurs only in pulmonary
emphysema.

14. c. Drq bronchial rhonchus. — Tliis is either
sibilous, rale sibilant sec ; or so7iorous, rale sonore
sec, of Laennec. The former is a low or loud,
shrill or bass, and prolonged whistle, such as may
be produced by air passing through a small ci^,_
cular aperture, and is owing to some contraction
or constriction of the bronchi. The latter is a
dull, prolonged, snoring sound ; sometimes very
loud. It occasionally resembles the bass note of
a violoncello, or bassoon, or the buzzing of an
insect. It seems to be produced by a flattened
contraction in a bronchus of considerable size,
leaving very little aperture ; and arising from
external pressure of the bronchial tube, from
local thickening of its mucous lining, or from
tenacious mucus within its canal. In a modifi-
cation of the rhonchus, which Dr. Williams calls
the dry inucous rlumchus, the sound lesembles
that of a click-wheel, and is produced by a portion
of very adhesive mucus attached to tiie bronchial
lining, which, yielding with a jerking resistance
to the air forcing its passage, thereby occasions a
ticking sound.

15. d. The mucous rhonchus, the rale muqueux
of Laennec, the mucous rhonchus of Dr. Wil-
liams, takes place in the bronchial tubes, and is
produced by the passage of air through a thickish
fluid, giving rise to a kind of buhhting within the
air-tubes. It is most frequent in bronchitis and
pulmonary catarrh, accompanied with mucous
secretion ; in hjemoptysis, in phthisis, in pneumo-
nia, and in other diseases which are attended at
any period with expectoration. This rhonchus is
more gurgling, loud, irregular, and coarse, the
larger the bronchi in which it is seated, the
bubbles being there larger and more unequal.
In the trachea, these characters arc particularly
marked, and have been denominated tracheal
from this circumstance, by M. Laennec. In the
smaller bronchi, on the other hand, this rhonchus
is more ef|ual, and its characters less remarkable,
the bubbles being of much smaller size. The
bubbles producing the mucous rhonchus must ne-
cessarily vary in their characters with the varying
fluidity of the secretion, and thus the rhonchi will
differ accordingly. If the fluid lie very thin, the
bubbles will be numerous, readily formed, and
rapidly break : but if it be viscid, they will be
fewer in number, and will often pass along the
tubes for some way before they break, the sound
being diffused, more regular, and rare. Also the
continuance of the rhonchus will be an indication
of the quantity of rK|uid present in the bronchi,
as justly remarked by Dr. Williams. If this
rhonchus accompany only the hr>t pare of in-
spiration and the end of expiration, the secretion
must be scanty. But if the whole of the respir-
atory act be attended with this sound, then we
mny conclude that the quantity of fluid is con-
siderable, hud extends to the smaller bronchi.

16. e. The cavernous rhonchus, or gnrgouille-

AUSCULTATION — OF the Voice,

159

ment, llie mucous rhonchus of morbid excavations
in the lungs, occurs when these cavities contain a
fluid, ami communicate with tha bronchi. It
generally exists in the advanced stage of tuber-
cular phthisis, in abscess, and partial gangrene of
the lungs. This rhonchus is characterised by
a strongly marked mucous gurgling or bubbling
sound, confined to a small spot and fleterminate
situation, and is particularly markeil upon the pa-
tient taking a full inspiration, or afler coughing.

17. It may be remarked that this class of
morbid respiratory sounds — proceeding from
changes in the parietes of the tubes, and in their
secretions — will sometimes be more or less ob-
scurely henrd through ellusions in the pleura,
when not very large. I proceed to consider the
second class of morbid sounds, or those arising
Jrom lesions exterior to the pulmonary tissue.

18. a. Metallic resonance, tintement metallique
of Laennec, is observed only when a quantity ol"
air is accumulated in the pleural cavity, as in
pneumothorax ; or rarely in cases where very large
tuberculous excavations are formed in the lungs.
It is most commonly heard when both air and
fluid are effused in the pleural cavity, and when
there is a communication between this cavity and
tiie bronchi. It is most di>tmctly heard upon
roughing, Laennec has distinguished two va-
rieties of this sound, namely, metallic tinkling,
and amphoric bussing or resonance. These sounds
are occasioned by the impulse given to the air
accumulated in the pleura, by the vibrations of
air rushing through a fistulous opening in the pul-
moniiry pleura, or strikmg against a condensed
part of the pulmonary tissue, or of the pleura
itself.

19. 6. Rubbing sound, the sound of friction, the
bruit de froitement ascendant et descendant of
Laennec. This sound has been particularly in-
vestigated by M^I. HoNORE and Reynaud. It
is an obscure, dull sound, perfectly distinct from
the respiratory sounds, but synchronous with the
motions ol the parietes of the chest during inspir-
ation and expiration, and resembling that pro-
duced by the rubbing of two soft and somewhat
rough bodies on each other. It is loudest, or
only heard during inspiration. It is sometimes
present in interlobular emphysema, but is more
frequently and sensibly heard in pleuritis, with
partial albuminous exudation, and with little or
no effusion of serum.

20. II. Auscultation of the Voice. — The
voice, although produced chiefly in the larynx,
lias its sound partially propagateil inwards i)y the
air in the trachea and bronchi, occasioning, in the
smaller ramifications of the latter, a vibratory sen-
sation or fremitus, rather than a distinct sound to
the ear through the stethoscope ; but, in persons
with a large chest and strong voice, a more dis-
tinct vocal resonance. When the instrument is
applied in the situation of the larger bronchi, as
between the scapuhe and under the axillae, the
voice is heard much more distinctly, and the arti-
culation may even be distinguished ; but the sound
does not seem to enter the cylinder, or to traverse
its tube. If we place the stethoscope on the
trachea or larynx, when the pati.nt is speaking,
we hear the whole of the words, loudly and arti-
culately, and as if passing through the instrument
to the ear. I'hese sounds have been called, from
their site, bronchophony and laryngophony ; and

arise from the vibrations propagated through the
air contained in the trachea and bronchi, and
which become weaker as they extend in the di-
rection of the air-cells.

21. The degree of vocal resonance in the chest
differs in different persons. It is loudest and
most extensive in those who are thin, and have a
strong, sharp, treble voice ; so that natural bron-
chophony will extend further in young subjects
and in females, particulaiiy through llie upper
regions of the chest. In fat persons with a deep
voice, the natural bronchophony is confined and
obscure, especially during the deeper notes. In
all the lower parts of the thorax, particularly
during the deep tones of the voice, there is either
no resonance, or merely a slight thiill or vibratory
fremitus, which may likewise be felt upon ap-
plying the hand to its parietes. Such are the
healthy sounds of the voice in difl^eient parts of
the chest ; but in certain states of disease they are
very materially altered, and both the bronchial and
laryngeal sounds are developed in places where
they never exist in health. Of the various ma-
nifestations of these sounds in disease, I now
proceed to take a brief notice,

22. a. Bronchophony is developed in disease by
the same causes that render the bronchial respir-
ation audible, viz. condensation of the substance
of the lungs in the vicinity of large bronchial
tubes, without diminishing their calibres, as in
hepatisation or induration from the formation
of tubercular matter. Fiom this circumstance
bronchophony is an important symptom in pneu-
monia and phthisis. When the condensation is
seated near the surface of the upper portions of
the lung, and near a large bronchus, the sound
may nearly approach laryngophony. The bron-
chial respiration is generally present with bron-
chophony, excepting when the hepatisation is ex-
tensive,

23. h. ^gophony (from at^, alyhs, a goat, the
sound resembling the cry ot" this animal,) is
merely a modification of bronchophony ; and
occurs when, with the circumstances which pro-
duce it, there are superadded the existence of a
thin layer of fluid between the surface of the
lungs and the pleura cosialis. The bleatino'
sound of the voice to which the term a^gophony
has been applied is variously modified in dif-
ferent persons, according to the natural tone of
their voice, and the different modifications of the
diseases which produce it ; thus it will resemble
the squeaking of Punch ; or pos-ess a shriller or
sharper key, and sound more like the echo of the
patient's voice than the voice itself, ^l^gophony
only exists in pleurisy or slight hydrothorax,
when the quantity of fluid effused is no more
than forms a thin layer beween the luncs and
parietes of the chest, Laennec states that he
has found this symptom present in almost every
case of pleurisy ; and considers it to be owing to
the natural resonance of the voice in the bronchial
tubes, rendered more distinct by the compress'on
of the pulmonary texture, and modified by its
transmission through a thin layer of fluid in a
state of vibration, l)r, Williams ascribes it to
" the successive undulations of the liquid, the
result of an irregular transmission of the so-
norous vibrations." ^Tgophony often co-exists
with bronchophony, and the one passes into the
other.

160

AUSCULTATION — or the Heart,

24. c. Pectoriloquy. — The existence, in disease,
of vocal resonance in any part of the chest, to
the extent of laryngophony, has bt^en termed
pectnriloquij by Laennec. It may be either im-
perfect or perfect. It is the result of a morbid
cavity, formed in the substance of the lungs, and
communicating with the bronciii ; to which cavity
the sound of the voice, or vibrations of the air in
the tubes, is propagated. When the stethoscope
is a])plied to a part of the chest, under which one
of these cavities is situated, the words vvhich the
patient utters seem to proceed from that spot ;
aad hence the term pectoriloquy. " The distinction
between perfect and imperfect pectoriloquy is, as
in the case of natural resonance, whether the
voice seems to traverse the tube, or remain at the
end ; and the physical difference producing the
two modifications consists in the size and situation
of the cavity. The most perfect pectoriloquy is
produced in cavities of moderate size, which are
situated near the surface of the lung, and freely
communicate with a large bronchial tube. If the
cavity be deep-seated, or if its communication with
the bronchi be imperfect, the resonance of the voice
will not amount to perfect pectoriloquy. True
pectoriloquy produced by a cavity, is generally
abruptly circumscribed, so that its limits can be
distinctly traced." — (Williams's liational Exposi-
tion, &;c, p. 43.). Andral appears to be correct
in considering perfect pectoriloquy as not com-
mon, and that the imperfect state of this sound, or
bronchophony, is very frequently mistaken for it.
When present in any part of the chest where
there is naturally no bronchial resonance, it may
be considered as a certain indication of the ex-
istence of a morbid cavity, generally tubercular ;
and when heard in situations of natural bronchial
resonance, although more doubtful, yet, if it be
perfect, distinctly circumscribed, and heard on one
side only, the some conclusion must be come to.
It may be further added, that an empty state of the
cavity, its rounded and regular shape, and natural
sh:irpness of the voice, particularly in women and
chilclren, tend to render pectoriloquy perfect.

25. III. Auscultation of the Heart. — A.
In its healthy state. I have always viewed Laen-
nec s explination of the sounds proceeding from
tiie heart's contractions as the most defective
part of the exposition of his system ; and a similar
opinion seems to have been entertained by Mr.
TiiRNER, Dr. Williams, and several others. The
observations of IMr. Turner, and of Drs. Stores
and Corrigan, first shook the staoility of the views
of Laennec on tiiis sul)ject ; and the recently
published researches of JJr. Hope have almost
altogether overthrown them. A.s I consider the
exposition of the actions and sounds of the heart,
given in Dr. Hope's work, to be ihe most accu-
rate, I shall follow it on this occasion.

26. Tst. Of the Contractions of the Heart in the
order of their occurrence, i^c. — 'l"he first motion
of the heart following the interval of re|)0se, is
the systole of the auricle. It is a very bi'icf and
slight contractile movement, most considerable in
the auricular appendix, and propagated toward
the ventricle, in the systole of which it terminates,
by a nearly continuous aciion. 'l"he systole of
the ventricle commences suddenly and diminishes
considerably liie volume of the organ. " Syn-
chronous with the systole are the first sound,
the inipul.-,e of the apex ygainst the ribs, and the

pulse of the vessels near the heart ; " the pulse at
the radial arteries following at a barely appre-
ciable interval. The diastole of the ventricles
follows their systole ; and these compartments
return, by an instantaneous expansive movement,
to the same state as during the previous interval |
of repose. The diastole is accompanied with the ■"
second sound, with a rush of blood from the au-
ricle, by a contractile motion of this cavity most
observable at its sinus, and by a retrocession of «
the apex of the heart from the ribs. " Next I
succeeds the interval of repose, during which the %
ventricles lemain at rest in a state of fulness,
though not of distension, through the whole
period intervening between the second and the
first sounds ; but the auricle remains at rest
during the first portion only of that period, the
remainder being occupied by its next contraction,
with which recommences the series of actions
described." — (Hope on the Dis. of the Heart,
^c. p. 40.)

27. The rhylhm of the heart, or the duration
of the several parts of this series of actions, con-
stituting what may be called a beat, is the same
as described by Laennec : — 1st, The ventricular
systole occupies half the time of a whole beat ;
2d, The ventricular diastole occupies a fourth, or
at most a third ; 3d, The interval of ventricular
repose occupies a fourth, or rather less, during
the latter half of which the auricular systole
takes place.

28. 2d. Causes and mechanism of the motion,— ~
The auricles, being always in a state of fulness,
arrive, during the first half of the period of repose
of the ventricles, at a slate of distension, on which
they react and propel a small additional quantity
of blood into the full but not yet distended ven-
tricles, in order to bring them to this state, and
to cause them to react, and thus expel a greater
or less portion of their contents. During the ex-
pulsion of the contents of the ventricles, Dr. Hope
considers that the apex of the heart is tilted
upwards and forwards, and occasions the impulse
against the ribs, in consequence of the retraction
of the ventricles upon their base, and on the
auricles, which, being in a state of extreme dis-
tension, serve as a fulcrum beneath them. The
diastole of th.; ventricles appears to be occasioned,
1st, by the relaxation of the principal part of
their muscular structure, assisted by an elastic
prooerty ; 2d, by the distension of the auricles,
which has arrived at its height, and brings into
action ceitain layers of ventricular fibres having a
powerful influence in distending these cavities;
3d, by the width of the ariculo-ventricular open-
ing, which allows the blood to rush instantane-
ously, and with facility, from the auricles into the
ventricles. 'I'he blood expelled from the former
cavities into the latter being instantly replaced
from the venaj cava', distension of the auricles
immediately recurs, and the same seiies of actions
is continued.

29. 3d. Causes of the sounds. — There can be
no doubt that the snunds of the heart's actions
are not produced by the mere contraction of its
muscular structure. To what other cause can
we impute them ? I conceive that they can only
be referred to the action of the parietes of the
cavities on the fluid circulating through them,
and to the motions of this fluid. According to
this view, which has been very diligently invcsti-

AUSCULTATIOX —

gated by Dr. Hope, the systole of the ventricle is
the cause of tlie first sound, by the impulse it
communicates to the blood, and the diastole of
the ventricle is the cause of the second sound ;
owing;, in the opinion of this writer, to the rush
of blood from the auricles, produced as already
explained (§ 26.), and the succession of the
stream against the walls of the ventricle, when
abruptly arrested by the completion of the dia-
stole.

30. I consider that it is cl.arly made out, 1st,
That the impulse, the pulse, and the first sound,
coincide ; 2d, That the ventricle is concerned in
the production of the second sound, although the
exact manner in whicii the motions of the ven-
tricle and tiiis sound are connected has not yet
been conclusively ascertained ; and, 3d, That the
actions of the auricles are insufficient to produce
either impulse or sound, and that neither the one
nor tiie other result from them. With respect to
the production of the second sound, I think that
the opinions of Mr. Turner. Dr. Corrioan,
and Dr. Williams, are untenable, and therefore
may not be stated ; and that the explanation of
Dr. Hope requires further confirmation. From
the third of these facts I believe that it may be
legitimately inferred, that the physical signs of
disease of the auricles are very imperfect, and
therefore uncertain.

31. B. Auscultation of the morbid sounds and
impulse of the heart. — 1st, Of the impulse of the
heart. Although, strictly sjieaking, the sounds of
this organ are the only objects of auscultation,
yet, as the impulse or shock it communicates to
a part of the chest is usually made a matter of
inquiry, although by a different sense, during the
time that auscultation is being performed, I will
briefly notice it at this place. The impulse ne-
cessarily varies, even in health, in different per-
sons, with the state of the heart's action, and the
liabit of body. It is also greatly modified by
mental emotions, and by various affections of the
digestive and otiier organs. It is always syn-
chronous with the first sound of the heart ; but,
in rare cases, a slight second impulse also accom-
panies the second sound ; but this is felt deeper
in the cliest ; is more of an obscure tremor, much
slighter in degree than the chief impulse or shock,
and is only met with in cases of hypertrophy with
dilatation.

32. W^hen the impulse is prolonged, strong, and
characterised by an extensive heaving movement,
thickening of the walls of the ventricles may be
inferred. It shc.ild, however, be recollected, that
whatever excites the feelmgs of the minil, or
hurries the circulation, will occasion a strong
impulse; but, in such cases, the actions of the
heart are also unusually frecjuent. Morbid im-
pulse of the heart is present in the states of both
mental and corporeal repose, and is often un-
connected with increased frequency, as in hyper-
trophy of the ventricles.

33. The impulse may be diminished, even in
health, as by the depressing passions. It is often
constitutionally so small in amount, as scarcely to
be felt. It is also lowered by diseases of remote
organ-!, as diarrhcea, &c., and by abstinence and
blood-letting, and whatever depresses the energies
of the system. It is generally weak in congestion
of the cavities of the heart, in cases of thinning
of their parietes, in the asthmatic paroxysm, in

Vol. I.

OF THE Heart's Sounds. 161

congestion of the lungs, in some cases of pneu-
monia, and in the advanced states of various
diseases; and it may even, although very rarely,
accompany certain states of hypertrophy of the
heart, particularly during the operation of debili-
tating causes.

34. In health, the impulse is usually limited
to the immediate region of the heart, and chiefly
in the situation of the cartilages of the fourth,
fifth, sixth, and seventh ribs. Its sphere is ex-
tended by increased action of the organ, whether
the result of mental or corporeal excitement or of
disease ; by hypertrophy, and by certain organic
changes of organs in the immediate vicinity.
When the muscular parietes of the heart are
increased without any dilatation of the cavities,
the sphere of impulse is not extended far beyond
its healthy site ; but when dilatation is conibined
with hypertrophy, the impulse may often be felt
on the right side of the sternum, below the clavi-
cles, and even on the back. Diseases of adjoining
organs, as hepatisation of parts of the lungs in
the vicinity, effusions of fluids in the pleural or
pericardiac cavities, tumours in the mediastinum,
close adhesions of the lungs to the costal pleura,
adhesion of the pericardium to the heart, dis-
placement of the heart, and even an enlarged
liver or spleen — when rising into the thoracic
cavity, and pressing the diaphragm upon the pe-
ricardium— will extend, often to a considerable
distance, the impulse of the heart, owing to the
increased density of parts which receive the shock.
Much discussion has arisen as to the manner in
which the heart's shock is produced. Further
than that it is occasioned by the muscular actions
of the organ, I believe that the phenomenon has
not been satisfactorily explained, at least in such
a way as accords with the various conditions it pre-
sents in health and disea e. The explanation given
by Dr. Hope has been already stated (§ 28.).

35. 2d. Of the chunges produced in the natural
sounds of the heart bij disease. — The sounds
of the heart vary in different persons, even in
health. In some they are loud and distinct ; in
others, the reverse : they may also be dull or
clear, in respect of their key. They are generally
distinctly lieard by the unaided ear, but more
accurately by the stethoscope. The impulse
and sound are never both present in health, to
a great degree, as they depend upon opposite
conditions of the ventricles; the impulse being
great in proportion to the thickness of the pa-
rietes of the ventricles, the sound to their thin-
ness. The sounds of the left side of the heart
are strongest at the junction of the cartilages of
the left fourth, filth, sixth, and seventh ribs, with
the sternum : those of the right side, under the
sternum, and towards its right edge. The sphere
of the heart's sounds is, in a very few persons,
nearly limited to the sphere of impulse; but it is
generally far more extended, even in health. It
should not be overlooked, that the sphere of
sound is much larger in children and young per-
sons, in females, in the lean, and in those who
have narrow or small chests ; whereas, in persons
whose thoracic cavity is large, and its parietes
thick, muscular, or fat, the sound is heard much
less extensively.

36. The sphere and loudness of the heart's
sounds are increased by the same moral, physical,
and morbid causes, which have been stated (o

M

162

AUSCULTATION

augment its impulse (§ 31.). Therefore, when
frequency of pulse accompanies increase of sound,
no actual disease may exist ; but when a natural
or slow state of the pulse is attended with an
augmented range of sound, disease may be mucli
more certainly anticipated. The circumstant;e of
the sphere of sound being extended by the or-
ganic lesions already noticed as conveying the
impulse of the heart (§ 34.), and by tuberculous
excavations in (he lungs, should not be over-
looked. In taking account of the heart's sounds,
we should also be aware that the sounds of re-
spiration will occasionally mask them, as the
heaving of the chest during inspiration will, in
a slight degree, mask some of the shocks of the
heart. Generally, the sounds of the heart are
strongest in the left anterior part of the chest ; and
progressively weaker in the sternal, in the right
anterior, the left posterior, and in the right pos-
terior parts successively. If this succession be
deviated from, or in any way altered, disease
exists ; and the degree, state, and order of devi-
ation, become signs of some importance. It has
been remarked by Laennec, that, when the sounds
are heard beyond the healthy sphere, in persons
with the chest vvell formed, and presenting none
of the causes alluded to as giving rise to such
extensive ranue, these persons will be found to be
subject to palpitations, to shortness of breath upon
the slightest exertion, to attacks of asthma, and to
congestions of the internal viscera.

37. 3d. Of the adventitious sounds of the heart.
— The sounds of the heart may not only be
changed in degree, in extent of sphere, and in the
succession of intensity, but entirely new sounds
may be superadded. The most common of these
are the bellows-sound (^brnit de soujfiet), the saw-
sound (bruit de scie), and the rasp-sound {bruit
de rape). These may eitiier take the place of the
natural sounds, or may be conjoined or super-
added to them ; and they may be present with
either the first or second sound, or with both.
The bellows-sound resembles the puffing of a
pair of bellows, and conveys the idea of smooth-
ness. The saw and rasp sounds are so named
from their similarity to the sounds occasioned by
the sawing or rasping of wood, and convey the
idea of roughness. But the bellows-sound may
insensibly pass into the others; and they all vary
greatly in loudness. They may occupy the place
of the first or the second of the heart's natural
sounds, but more frequently that of the first than
of the second. 'The saw and rasp sounds are
generally louder, and present a wider range of
intensity than the bellows-sound, which is more
closely limited to the part which occasions it.
'I'hey may all be heard in arteries at a distance
from the heart, more particularly the belio«s-
souiid ; ami often when they do not exist in the
region of the heart. When tiie saw-sound pro-
ceeds from the heart, it may generally be traced
along the arch of the aorta to the subclavian and
carotid arteries.

38. The causes of these sounds, and the exact
site of the chan;^es which produce them, are ob-
viously the important considerations attached to
them, 'i'hey have been accounteil for in various
ways, even by their eminent discoverer; and, in
general terms, they may be said to arise from
unnatural or morbid motions induced in the cur-
rent of blood circulating through the iieart, in-

OF THE Heart's Sounds.

stead of those natural motions which contribute
to the healthy sounds of the organ. Hence, what-
ever produces the morbid ciiange of the motions
of the fluid, will occasion the adventitious sounds ;
and we have reason to infer that such change is
produced either by a permanent alteration of the
apertures and canals through which the blood is
propelled, or by a spasmodic or nervous state of
the same parts.

39. The simple bellows-sound is more com-
mon, and arises from slighter changes than the
saw or rasp sounds, and is less to be depended
upon in diagnosis. Pressure on an artery will
occasion it ; and when present in the heart, it
will sometimes be removed by blood-letting.
When even existing permanently, although it is a
very strong indication of organic change in the
heart, it cannot be iiupliciily relied on ; but
when only occasionally present, although such
change may be its cause, yet it deserves no re-
liance. The saw or rasp sounds are much less
frequent than the other ; are much more con-
stantly found in connection with contracted orifices
of the heart ; and are very frequently indications
of an increased degree of the same causes that
produce the bellows-sound. It may, however,
be generally inferred, 1st, That these sounds arise
from some change in the orifices of the heart's
cavities, produced by nervous or temporary
causes, or by alteration of structure ; more fre-
quently the latter. 2d, That these sounds,
therefore, although they indicate the existence of
organic disease, are not conclusive evidence of
it, as they sometimes arise from other causes.
3d, That in proportion as these sounds possess
more of the rasping character, the greater is the
probability of organic change. 4th, If the sounds
disappear after depletions, upon repose, or without
sufficient reason, their dependence upon func-
tional distuibance maybe inferred, although not
implicitly relied on; their continued absence,
however, strengthening the conclusion. 5th, The
continuance of these sounds, notwithstanding the
means now mentioned, or their diminution merely,
is nearly conclusive of organic change. 6th, In-
tensity of the sounds is no indication of the degree
of valvular disease, or extent of the contractitm of
an orifice ; as they may be weak, when these or-
ganic changes are extreme. A moderate contrac-
tion and size of current seem to be requisite to
their lull production. The relation of these sounds
to the particular changes which occasion them is
considered in connection with these changes. (See
1 1 E A nx — Diseases of, )

40. The rasp and saw sounds are often accom-
panied with a phenomenon resembling a species
of impulse, and which can be estimated by the
sense of touch only. This is the thrill or purring
tremor, termed '^ bruissemenl" by CouviSAnr,
and "freinissementcataire" by I.aennec, which
is felt when the fingers are placed upon the
heart, or on an artery. When existing in the
heart, the feeling excited upon applying the
hand to the region of this organ, is analogous to
the sensation occasioned by the saw or rasp
sounds. The fact is, that the same pathological
condition gives rise merely to modified sensations
as perceived by the medium of different organs,
the object exciting the sensations being one and
the same ; the only dilFereoce being that a
stronger current is required to produce the pur-

BARBIERS — Symptoms — Treatment.

163

ring tremor, than is necessary to the production
of the sounds. It is owing to tills circumstance
tiiat it is stron^iest in hypertrophy of tiie ventricle,
or when liie circuluiion is iiuiried. A firm pres-
sure of I he hand on the region of tiie heart is
necessary to feel it well; and a moderate pressure
to feel it in tiie arteries.

41. The last adventitious sound that I have to
notice is that which Laennec has termed the " cri
du nu'r," and which resembles the creaking of the
leather of a new saddle. It seems to be chiefly
observed in cases of per. carditis, when tiie oppos-
ing surfaces of the pericardium lose their lubri-
city, and when tliey are rendered rough by the
exudation of coagulable albumen, or are in an
unusual state of diyness ; and to be occasioned
eitiier by their friction wiiilst in this state, or by
the motions produced in tliat part of the peiicar-
dium reflected over tiie heart during the systoles
and diastoles of the ventricles.

It is unnecessary to add any thing at this place,
to what has been stated respecting the ausculta-
tory signs in diseases of arteries, and particuhirly
of tiie aorta. The employnient of auscullation of
the abdomen, in order to ascertain the existence of
pregnancy, is comprised in the article Pregnancy.

BiBnoG. AND Refer Double, Semeiologie Generate,

t. ii. p. 31. Pans, 1S17 — Laeimcc, He I'Aiisoultatioii Me-
diate, t. ii. Ire edit. Paris, 1819; Sine edit. Pans, 1^30 —
Berlin et Botii/laud, Sur les Maladies du Coeur, &c.
Paris, 1824. — j7irf;v//,Clinique Medicate, t. ii. et iii. Paris,
1824, passim. — Turner, in Trans, of Med. and Chirurg.

Soc. of Edin. vol. ii P. Colin. Sur I'Exploratinn de la

Poitrine, &c. 2d edit. Paris, 1830. — C. J. H. IVilliams,
Rational Expos, of the Pliysical Signs of Diseases of the

I.nngs and Pleura, &c. 8vo. Lond. 182s Rcynaud,

Joui n. Hebdomad. No. 65. t. v. p. 57(> Stokes, in I'raiis-

actions of Irish College of Pliysicians. vol. v. p. 305. —
TuWiiseiid, Ibid. p. 137 — Corrigan, in Dub. Med. Trans.

New Series, vol. i. pp. 1 \!>l Ferguson, in Ibid. p. 11.

— Hope, in Lond Med. Gaz. \&2^,passitn ; and Diseases
of the Heart and Great Vessels, 8vo. 1831, p. 28. et seq.—
Forbes, and Williimis, Cyclop. Pract. Med. vol. i. p. s\i),
and vol. iv. art. Slelhoscope, Brit, and For. Med. Rev.
No. 5.,' p. 1S+. (See also Bibliog. and Rijer. to arts.
llEiKT and Lungs.)

BARBIERS. — Classif. 4. Class, Nervous
Diseases; 3. Order, Affecting the ftluscles
(Good), I. Cr.ASS, V. Order (Author).

1. Defin. Tremor, tvith pricking formicatin'r
pain ; numbness of the extremities, principaliif of'
the lower, folUnved by contractions and paralijsis
of the limbs, inarticulation or hoarseness of' voice,
emaciation, and sinking of ail the vital powers,

2. This disease has been described by various
authors since the appearance of the worli of
BoNTius. But we have had no satisfactory ac-
count of it until IVIr. Marshall furnished it in
his interesting work on the diseases of Ceylon,
and distinguished it from Beriberi, with wiiich it
had been confounded by Bontius, and recently
by Dr. Good. Dr. J. Clark had, however,
noticed it briefly as a distinct disease, many years
previously ; and the definitions of it given by
Saovages, L1NN.EITS, Sagar, and Aikin, seem to
indicate that they were not altogether unacquainted
with it-i nature. I shall here follow the accounts
of it by Dr. Clark and Mr. Marshall, as they
seem to be the most precise, and to have been the
result of much experience.

3. 1. Symptoms. — The disease generally com-
mences with a lormicative pricking pain in the
muscles of the lower extremities, with numbness,
tremors, and an imperfect command of the powers
of locomotion. Both lower limbs are always

equally afiected. In some cases the forearms
and hands, and the powers of articulation, are
subsequently similarly seized. As the disease
advances, the patient is unable to walk steadily.
Standing or walking aggravates the uneasiness of
the limbs, aEd either is impossible without sup-
port. The superior extremities become incapable
of performing their usual offices ; and want of
sound sleep, great sluggishness, and inactivity,
are complained of. The limbs afterwards are
deprived of all feeling, and lo^e their natural
temperature ; the extensor muscles become quite
paralytic, and the limbs contracted. Loss of ap-
petite, indigestion, emaciation, &c. soon follow, and
the pulse gradually sinks to a frequent, thready,
or fluttering state; all tiie vital powers become
depressed, and death supervenes. As respects its
duration, it may be protracted for many months,
and it may present various grades of seventy. Its
forms are frequently more mild, the above de-
scription applying to the severer cases. The
diagnosis of barbiers is described in the article
Beriberi, to which disease it is closely allied, and
with whicii it may be associated.

4. Mr. Marshall observed many cases of this
disease, in 1812, amongst the Caffres composing
the 4th Ceylon Regiment. He never noticed it
amongst the indigenous inhabitants of this island ;
and, fiom every information he could collect, it
was only known amongst Africans who had arrived
in the island ; and he believed that late comers
were more disposed to it than acclimated resi-
denteis. Mr. ]Marshali, also met with it in
Europeans in Ceylon: and he has observed an
analogous affection in horses and dogs ; from
which, however, he never knew them to recover.

5. Dr. LiND states that barbiers is a species of
palsy frequent in India, aflfecting chiefly tlie lower
classes of Europeans, who frequently sleep, when
intoxicated, in the open air, exposed to the land
winds ; and that its attack is sudjen, depriving the
limbs of motion, &c. It appears also to prevail
in Java. Dr. Bostock has described a case
which seems to be nearly allied to this affection :
and I have been occasionally consulted by pa-
tients, whose complaints were very nearly the
same as those now described ; and who have been
seen by several medical men, A very remarkable
and extreme case of it, in a gentleman from Ja-
maica, was lately attended by Dr. Roscoe and
the author.

6. II. The REMOTE Causes of this affection
are cold and moisture applied to the body ; intoxi-
cation, irregularities, and excesses consequent
upon inebriety ; violent exercise in the sun ; lying
down in the open air during the heat of the day ;
exposure to the cold chilling dews of the night, or
sleeping when thus exposed ; suddenly obstructed
perspiriition, by currents of air ; long fasting, and
whatever exhausts the energies of life. The
translator of Bontius's work states that barbiers
is frequent on the Malabar coast, where it attacks
those who unwarily sleep exposed to the land
winds, paiticularly in the months of January, Fe-
bruary, and March ; and that it is seldom cured
till after the shifting of the monsoon, unless the
patient changes the climate.

7. III. Treatment. — This affection appears
to oiiginate in depressing and debilitating causes;
to be characterised by a gradual and chronic sink-
ing of the nervous energy ; and therefore to require

M 2

164

BERIBEUl — Symptoms— Cause?.

a tonic, restorative, and stimulating treatment.
Frictions, with stimulating liniments along the
course of the spine, and on the limbs ; attention
to tlie due performance of the secreting and ex-
creting functions ; tonics, combined with warm
cardiacs, gentle aperients, and antispasmodics ;
vesication ; stinging with nettles ; electricity, the
internal use of the extract of nux vomica, or of
stiychnine; the application of external warmth,
and the use of warm clothing ; a nourishing and
digestible diet ; regular habits, and change to a
healthy air or locality ; are the chief means ot
cure. Dr. Joiis' Clauk states, that the few Eu-
ropeans whom he saw ill with this disease were
cured by a change of climate, and a sea voyage.
In otiier respects the treatment is the same as that
recommended in the article Palsy, particularly
palsy from lead. (See Colic — Jroni Lead, and
Palsy.)

BiBLioG. AND Refeu Bont>us,'De Medicina Indoium,

c. i. — Lind, On the Diseases incidental to Europeans in
Hot Climates, !xc. 4th ed. Lond. 1788. — JoA« Clark, On
tlie Diseases which prevail in long Voyages to Hot
Countries, and on those in the East Indies, &c., vol. i. p.

91t. Lond. 1792, 8vo Marshall, Notes on the Medical

Topography of Ceylon, &c. 8vo. IHi'i, p. IGl Bustock,

Trans, of the Med. and Chirurg. Society, vol. ix. art. i.

p. I Good, Study of Medicine, vol. iv. p. 493.

BERIBERI. Syn. Beriheria, Synclonits Beri-
beria. Good. Hydrops Asthinaticiis, Rogers.
Classif. 4. Class, ])isea^es of the Nervous
Function ; 3. Order, Affecting the Mus-
cles {Good). I. Class, V. Order (Au-
thor).

1. Defin. Oppressed breathing ; paralytic
weakness, numbness, and stiffness of the lower
extremities ; general oedema, with a swollen and
bloated countenance.

2. I. Symptoms. — i. The attack is in some cases
gradual ; in others sudden and severe. When it
is the former, wliitdi is more commonly the case,
the patient complains for several days of weakness,
and inability or unwillingness to exert himself.
To these feelings, pain, numbness, and stiffness ot
the lower extremities, accompanied with oedema ;
muscular weakness, and dyspnoea, particularly
upon motion ; a feeling of numbness, fulness, op-
pre-^sion, and weight at the scrobicuius cordis;
extension of tlie oedema over the body, and leu-
cophlegmatic tumescence of the countenance, su-
pervene. As the disease advances, the dyspnoea
increases, and the face is more svvollen and bloated.
The lip'^, which were at first pale, become bluish
and livid; and the lower extremities more numb
and feeble, or even paralytic. The stomach is
ol'ten irritable, especially in the advanced stages of
the disease, when it ol'ten rejects all ingesta ; the
bowels constipated ; the uiine scanty, high-co-
loured, and sometimes almost suppressed ; the
pulse is at first either more or less (juick, small,
and hard, or but little iifTectcd ; subse(|uently ir-
regular or intermittent ; and the dyspna-a at last
becomes distressing and attended with great anxiety,
and sometimes with a pi culiar fluttering about the
lieart, and sinking or leipothymia, succeeded by
palpitations. \n the more advanced stages of
the disease the patient cannot lie down ; his sleep
is uneasy, interi uplc-d, and always unsound ; and
the recumbent posture induces violent palpitations,
sense of suffocation, and anxiety. The ofipression
at the pra;cordia and weight at the scrobicuius
cordis increase, and are attended with spasms of
the muscles of the thorax anil abdomen; the
countenance becomes livid, and the extrciriiiies

cold ; vomiting is either frequent or nearly inces-
sant; the pulse sinks, and the patient dies nearly
in a state of suffocation.

3. In tills, the most common form of the dis-
ease, it usually runs its course in about three
weeks or a month ; but sometimes, in slighter
cases, the patient experiences several relapses,
and is at last carried off unexpectedly, when the
anasarcous symptoms have nearly disappeared,
and he has been judged convalescent. In some
of the milder attacks, several of the above sym-
ptoms are extremely slight, and the disease is
altogether of much longer duration, or consists
apparently of several distinct seizures. Such seem
to have been the form of the majority of cases
which Mr. Maushall has given in his work. In
the most sudden and severe attacks, however, the
pain, numbness, stiffness, and oedema of the lower
extremities; the dyspnoea and anxiety, and all the
more urgent .symptoms, are either present from
nearly the commencement, or they rapidly super-
vene to each other, and the patient dies in a few
hours, or in a day or two. Such cases appear to
be not so frequent as those which are more mild.

4. ii. Appearances on dissection. — There is always
a leucoplilegmatic appearance of the surface,, with
cedt matous effusion to a greater or less extent
in the sub-cutaneous cellular tissue, and paleness
of the muscles; sometimes with a watery obesity
and deposition of fat in the abdominal regions. Oc-
casionally there is fluid effustd between the mem-
branes of the brain, and in the ventricles ; with
vascularity of the encephalon, and slight appear-
ances of congestion in the spinal canal. Serum
is always found effused in the pleural cavity, and
very frequently in the pericardium. 'J'lie lungs
are gorged with daik blood, and their structure
more or less oedetnatous. Old cellular adhesions
are sometimes found connecting the opposite sur-
faces of the pleur.-E. The heart is generally soft,
enlarged, and flabby. The peritoneal sac often
contains much serum ; and the liver is always
found engorged with daik blood, is unusually
large, and of a very deep colour. The spleen is
generally very soft, large, and is, as well as the
laige veins, loaded with black blood. Sometimes
intlammatory appearances are observed in the dia-
phragm and serous surfaces; but these are only
occasionally and very loosely noticed. (Chrisiie,
Rogkhs, Marshall, and Hamilton.)

5. II. Diagnosis. — The paralytic symptoms,
constant dyspncea, universal oedema, and leuco-
plilegmatic intumescence of the countenance,
characterise this disease sufificiently, and distin-
guish it from the cachexia AJricana, with which
it has been considered as being allied. (See i.l\-
ciiicxY — African.) It has been, however, more
commonly confounded with harhiers ; but the
history of both diseases shows various differences
between them. liarbiers is a chronic disease, in
which the paralysis, tremors, spasms, and cen-
tral tions of the limbs, and emaciation, are the
most remarkable symptoms; whilst the present
malady is acute, often of very short duration, and
is characterised by general udenia, dyspna'a, the
suddenness of its fatal termination, and the fre-
(juency of its occurrence. The former seems to be
a species of iniralysis ; and the latter to be a form
of acute dropsy, very generally diffused through-
out the body, and com[)licated with paralytic
symptoms. But it must be admitted that the one
is often associated with the other, either of them

BERIBERI — Diagnosis — TiiEATsir.NT.

105

being tlie primary affection. Mr. ]Malcoi.:i1=o>:,
who has had extensive experience of boih forms of
disease, states that ca-es commencing in the form
of barbiers, often suddenly take on the more fatal
and acute form of beriberi; and that the latter
frequently present the symptoms characteristic of
t!ie former. He further remaiks, that the two
classes of cases prevail in the same places, seasons,
and circumstances, and require the -^ame remedies.

6. in. Causes. — This disease is nearly pecu-
liar to India, and is most prevalent in various parts
of Ceylon, on the Malabar coast, and in that tract
of country which extends from Madras to Gan-
jam ; being, according to Mr. Hamilton, confined
to these parts, and extending no further inland than
forty miles. It is most prevalent during the de-
cline of one mon«oon and the setting in of another,
when the air is damp, cold, and loaded with va-
pours, and the vicissitudes of temperature greatest.
Captain PEiinvAi,, in his " History of Ceylon,"
ascribes it to low diet and bad water, and partly
to the dampness of the climate. Mr. Ridley,
however, states that the worst cases he had of it
at Trincomalee, where it was remarkably prevalent,
occurred during the change from wet to dry wea-
ther, when a strong and hot land wind prevailed ;
and that its severest prevaletice at Pulitoopane
was during dry weather. In the Indian peninsula
it seldom extends further inland than sixty miles ;
but in Ceylon, particularly at Kandy, it has pre-
vailed under very different circumstances, as re-
spects season, states of atmosphere, and topo-
graphy. It seems to have been much more prevalent
in particular districts, where it may be said to be
endemic, in one year than in another; and to have
assumed, at distant period-;, a nearly epidemic
form. Dr. Christie states, that a residence of
several months in the district where it prevails
is necessary to its production ; and Dr. Rogers
never observed it in any person who had not re-
sided six months or upwards in Ceylon. Dr.
Hunter has met with it also in Indian seamen,
particularly Lascars, after exposure to a moist
and variable atmosphere and privations of food.

7. Opinions respecting both the remote and prox-
imate causes of the disease differ very materially
among those who have had opportunities of ob-
serving it. Mr. Dick found it most prevalent
amongst soldiers who had taken much mercury
for venereal complaints, and who were addicted to
spirituous liquors. He never met with it in the
officers. Mr. Ridley, on the other hand, states,
that, in 1804, " both officers and privates fell vic-
tims to it." Drs. Christie and Rogers view it
as a consequence of deficient and poor diet, im-
pure and moist air, and of prolonged exposure to
niar-h exhalations; and consequently as a disease
of debility, — an opinion which is in accordance
with that of Mr. Dick and Mr. Ridley. Mr.
CoLQuiiouN found it to prevail notwithstanding
prophylactic measures founded on these views ;
and Mr. RIarshall did not observe it to occur
amongst ilie troops in Ceylon, when exposed to
the causes to which Drs. Christie and Rogers
impute it; and from that circumstance, as well
as from the effects of medicines, thinks it a disease
of increased vascular action ; in which opinion
Mr. IIasiilton agrees with him.

8. Niitiire of tbe disease. — It is evident that
the nature of this disease can be inferred only from
what \i known of its exciting causes, and the ap-

pearances presented after death. Of the former
we have imperfect, loose, and conflicting inform-
ation : of the latter no precise and minute ac-
count. It is difficult to explain the early occur-
rence of the paralytic symptoms. The spinal
chord, brain, and nerves supplying the lower ex-
tremities, have not been sufficiently investigated
to warrant a positive opinion as to the particular
state of the parts, to which these symptoms may
be referred. The palsy, however, may depend upon
congestion of the veins and effusion of fluid within
the spinal canal.* The dyspnoea is evidently
owing to congestion of the lungs, and oedema of
their structure ; and the feeble and irregular action
of the heart may be imputed to the weakened vital
energy and structure of the organ, in connection
with effusion of serum in some cases into the
pericardium. The effusion of fluid within the
serous cavities may, like other effusions, depend
upon very different slates of the vessels and se-
rous membranes. By Mr. INIarshall and JMr.
Hamilton it has been viewed as the result of
inflammatory action. But where there is merely
an effusion of a limpid serum, without either al-
buminous flocculi or adhesions, there evidently
can exist no actual inflammation. Viewing the
antecedent symptoms in relation to the post mor-
tem appearances, as far as both have been de-
scribed, it may be infeired that the disease is
more dependent upon active congestion of the
lungs, liver, and spinal chord, than upon any of
the usual states of inflammatory action ; and that
this congestion is intimately connected with
weakened power of the nervous and circulating
systems ; manifested chiefly in the heart and ex-
treme capillaries of the cellular and serous struc-
tures, with imperfect function of the liver and
lungs, and with effusion of serum to a greater or
less extent into the shut cavities and cellular
structures of the body; giving rise to a nearly
universal acute dropsy, and complicated with
more or less of paralysis of the lower extremities.
9. IV. Treatment. — According to this view
of the disease, the discordant accounts given of the
success of treatment will be readily accounted
for. When the disease prevailed very generally
in the Carnatic, during 1782 and 1783, Mr. Dick,
who appears to have treated a very great number
of cases, found most advantage, during the former
of these two seasons, from a pill, containing a
quarter of a grain of extract of elaterium com-
bined v\'ith extract of gentian, given every hour,
until copious watery evacuations were procured ;
and this plan was repeated every third or fourth
day, till a cure was accomplished. In the fol-
lowing season this treatment was not so suc-
cessful. He found most advantage from large
doses of spirit of nitre, antimonial wine, frictions
with warm camphorated oil, aperient medicines,
and wine to support the strength. Bleeding
and mercury were ttied without benefit. Dr.
Christie recommended mercury, to excite pty-
alism, combined with squills; cordial liquors,
consisting chiefly of gin punch; stimulating pedi-
luvia, with warm liniments; and when the
patient was convalescent, tonics, composed of
bark, wine, and porter. In more urgent cases,
he prescribed blisters to the chest, and brandy,

* Since this was written, Mr. Malcolmson's work on
the dispase has appeared, and proved the correctness of
the above remaik.

M 3

166 BLOOD — Healthv Relations of.

aetlier, and laudanum, to relieve the vomiting,
dyspnoea, and spasms. He found digitalis of no
service. Mr. Hamilton's first cases terminated
fatally under the plan recommended by Dr.
Christie; and Rlr. Coi.quhoun trusted to mer-
cury, but found that many of the patients who
died in hospital of the di-^ease were in a state of
salivation Irom this medicine.

10. This want of success led later writers on
the disease to have recourse to other means.
Dr. Hi'NTER had tried bloodletiing in one case,
without any apparent effect either one way or
another. Dr. Rogers stated, in his thesis on the
disease, that blood-letting hastened the fatal ter-
mination : but, according to IMr. Hamilton, he
has since prescribed it successfully. Mr. Mar-
shall appears to have been the first to employ-
blood-letting in a decided and successful manner
in the treatment of beriberi ; and the same prac-
tice was adopted by Dr. Paterson (Marshall,
on Ceylon, &;c. p. 161.), and by Mr. Hamilton.
The bleeding was large, and repeated; and fol-
lowed with the internal and external use of mercury,
laudanum, and the vapour bath. To these were
added purgatives of calomel and camboge.

11. i'he practice of Mr. Ridley, who expe-
rienced, himself, two very severe attacks ; and
wlio, excepting only Mr. Dick, has had the most
extensive experience as respects this disease,
liaving treated almost a hundred case^ in one
year (1814) ; recommends a nearly similar treat-
ment to that advised by Mr. Dick. In the early
stage, he directs purgatives of calomel, jalap,
and crystals of tartar ; the lower extremities to
be well bathed, afterwards rubbed with camphor
and oil of turpentine, or with the mercurial lini-
ment, and then rolled in flannel bandages. He
subsequently prescribes a pill, composed of one
or two grains of calomel and two or three of
powdered squills, every third hour; and a solu-
tion of crystals of tartar, as common drink, or
made into punch with geneva or arrack. In the
more advanced stages, he advises blisters to the
back of the neck, or to the seat of pain and tight-
ness ; the warm-bath; frequent fomentations of
the legs and abdomen, followed by frictions with
mercurial ointment, camphor, and oil of turpen-
tine ; and clysters with aether, and ptirgatives.
When the dyspnoea, spasms, and vomiting are
urgent, he states, that he has given large doses of
opium, aether, and brandy, with stimulating diu-
retics. When llu^y could be retained on the
stomach, small and repeated doses of camboge
were also exhibited.

12. From the above statements, as well as from
the varying chancier of the disease in I'^uropeans
and natives, in different seasons, as observed by l\lr.
J)i( K, and Mr. M ai.coi.mson, and in various local-
ities,— judging also from the nature and combina-
tion of the remote causes, and from the pint mortem
appearances, — 1 should infer, that a ilepletory
treatment may sometimes be required amongst
i^uro|)eans; and that the means of cure should be
modified according to the characters of the ma-
lady and tlie state of the vital energies; that, on
some occasions, general blood letting — in others,
cupping in the course of the spine ; blisters ; free
purging with calomel, camboge, jalap, elaterium,
&c. ; antispasmodics, consisting of opium, ajthers,
brandy in some cases, camphor, &c. , diuretics,
such as squills, cream of tar;ar, juniper, tere-
bialliinule preparations, &c. ; the vii])our bath,

or fomentations, followed by frictions with sti-
mulating liniments, mercurial or camphorated
liniments, with oil of turpentine, camphorated
oils, along the spine and lower extremities ; ex-
pectorants, consisting of ammoniacum, ipecacu-
anha, camphor, &c. ; constitute the chief means
that are likely to remove the internal congestions,
to reduce the circulating fluid to a nearer equality
with the vital power, to restrain effusion, and to
restore the various secretions and excretions of
the body. After these means have been judi-
ciously administered according to the peculiarities
of the case, or when circumstances seem to re-
quire them earlier in the treatment, stimulating
and restorative medicines may either be conjoined
with the above, or be exhibited alone ou such oc-
casions as may require them.

BiBLioG. and IIefer Bontius, De Medicina Indorum,

&c — Dick, in Duncan's Edinb. Medical Commentaries,
vol. X. p. 207. — IV. Hunter, Diseases incident to Indian
Spamon on long Voyagfs. Calc. 1804. — Hvgcrs, Diss, de
Hydrope Asthmatico, Kdin.1808 — Hidley, Dublin Hosp.

lleports, vol. ii. p. 2.'7 Mnrshall, Notes on the Medical

Topography and Diseases ot' Ceylon, p. IGl. 8vo. Lond.
Wl'i. — Hamilton, in Transac. of the Medical and Chir.

Society of Edin. vol. ii. p. 12 Good, Study of Medicine,

vol. iv. p. 4'.i3. — J. G. Malcolmsou, A Piact. Essay on the
History and Treatment of Beriberi, 8vo. Madras, 1835.

BLOOD. Syn. AT/xa, Gr. Sanguis. Lat. Sdng,
Fr. Das Blut, Gehtut, Ger. Sangiie, Ital.
Classif. General Pathology — JEtio'.ogy,
Semeinlogfi, — General Therapeutics.

1. States OF THE Blood IN health. — 1. A. Of
the states of the chyle. In order to acquire ac-
curate ideas respecting the blood in disease, it
is necessary to be acquainted with the varying
conditions and appearances of the chyle, accord-
ing to the food, from which it is chiefly ela-
borated. To these, however, I can only briefly
refer. This fluid, when removed from the tho-
racic duct, is usually of an opaque white or opal-
escent appearance, and separates into a serous
portion, and more or less firm clot. The former
resembles the serum of the blood, the latter con-
si'^ts chiefly of fibrine. If the animal have been
fed with fat animal food, the chyle at the time of
coagulation assumes a rose colour, and, in addi-
tion to the separation of the clot, which falls to the
bottom of the vessel, a thin liquid oily layer forms
on the surface of the serum. In animals fed on
vegetable food, the chyle is generally opaline and
nearly transparent, and separates into a serous
fluid and a small fibrinous clot only. According
to MiM. Prevost and Dumas the chyle contains
globules, similar to those contained in the blood,
but of a smaller size. The fibrinous coaguluni
seems to be formed from their aggregation. The
serum of the chyle also contains albumen, and the
saline inpjedients found in the serum of the blood.

2. Ii. The globules of the blood, particularly in
respect of their relation to the other constituents
of this fluid, and the changes they experience
when icmnvcd from the blood-vessels, excite the
utmost interest in the mind of the pathologist. It
is evident that they are suspended in the serum
hy means of the vital influence which the blood
derives from the vessels and organs in which it
circulates. According to the microscopic re-
S(!arches of Sir V,. Home, Mr. Bauer, and of
MM. Phevost and Dumas, they consist of a
central colourless sj)heroid ; and of a species of
membranous sac of a red colour, surrounding this
spheroid, from which it readily separates after
death. 'J'he central bodies are transparent and
spherical in the niammalia; and, when deprived of

BLOOD — Healthy Relations of.

167

tlieir colouied envelope^, are generally disposed
to n?sume ranges or fibrous meshes. The co-
loured portion appears to be a kind of jelly, easily
divisible ; but insoluble in water, from which it
may be separated by repose. It is likewise trans-
parent ; but much less so than the central cor-
puscle ; and the fragments arising from its division
are not susceptible of regular aggregation.

3. C. State of the blood in the vessels. — Ac-
cording to tiie observations of Kolk.Treviranus,
and others, the globules of the blood possess a
rotary motion during life, independently of the
motion an-ing from the impulse of the heart ; and
this motion continues till coagulation takes place.
More recently, this subject has been investigated
by Professor Sciiuitz, of Berlin, who has con-
firmed the fact respecting the intestine motion of
the globules, by virtue of which they move on by
themselves, surrounded by envelopes of colouring
matter, and keeping at a distance from one
another. 'J'his force, with which the globules of
the blood are endowed whilst circulating in the
vessels, I have, in my physiological notes, im-
puted to the influence exerted by the ganglial
nerves on the interior of the vessels, which they
every wliere s-o abundantly supply, as stated in
the article on the pathology of the Arteries.
But, besides this force of mutual repulsion, to
which the fluidity of the blood is evidently owing,
under the vital influence exerted by the organic
nerves on the vessels, there is evidently another
force also in action, by which the globules are
attracted by the tissues, when they are brought
more intimately in contant with them during their
circulation in the minute vessels. Whilst, then,
the former force keeps the globules in a state of
constant motion and repulsion, and is exerted in
the stream of the circulation, the latter tends to
bring the globules to a state of repose, and is
exerted in the organic structures themselves, at the
point of contact of the solids and the globules.
I'his latter force, which was first very minutely
examined by Profes-or Schui.tz, and briefly stated
by M. Andral, in his Pathological Anatomy,
■without acknowledgment, may be compared to a
vortex whence globules constantly pass from the
arterial or terminal capillaries, and are lost in the
different tissues. So that, although the vital en-
dowment of the blood is manifested by its fluidity
in the vessels, it assumes an opposite manifest-
ation in the capillaries, where this fluid is brought
■within the sphere of the vitality of the difl^erent
structures ; each one attracting from it those con-
stituents of which itself is formed, and which are
always present in healthy blood.

4. Thus we see organisation commencing in
the chyle, advancing further in the blood, and
reaching its acme in the vital attraction of the
constituents of the tissues from the blood circu-
lating in the capillaries which supply them. At
this part of the circle, where the arterial capil-
laries, with the fluid circulating through them,
become, as it were, confounded with the tissues
in which they are distributed, there appears, ac-
cording to Professor Schultz, to be not only a
constant attraction of particles by the tissues from
the blood, but also an equal extrication of other
particles from them into the blood received by the
radicles of the veins. I'lius it appears, that as
the proximate constituents of the different tissues
exist in the blood, as was first shown by Dr.

Prout, and subsequently insisted on by Ma-
JENDIE and Andrai, ; and as these become iden-
tified for a time with them, are afterwards de-
tached, and flow back into the current of the
circulation ; the intimate connection and mutual
dependence of the blood and the diflferent solids,
both in health and disease, ought not to be over-
looked. But it is at the same time manifest that
these constituents are kept in solution during cir-
culation, and attracted during nutrition, by the
vital influence; that the various parts into which
the blood separates on removal from the vessels
are only indications of its condition when cir-
culating through the frame; that no such se-
paration occurs in the healthy body, and never,
excepting very partially, in disease ; that this
change proceeds from the loss of vitality sustained
by the blood when removed from the frame, and
that the phenomena connected with it have an
intimate relation to the vital endowment of this
fluid, derived from the vessels and the nerves
supplying them.

5. D. Coagulation of the blood. — 'J'his process
is modified by numerous circumstances, and by
various disea^^e*. Generally, however, the blood
soon separates into two portions — the serum, and
the coagulum or clot ; and in this separation the
red globules are principally concerned ; it being
chiefly the result of the loss of the vital motion
which these globules possess in the vessels, and
of the attraction existing between the colouring
envelopes and central bodies. As the vital at-
traction, which keeps the red substance fixed
around the whitish corpuscles, ceases soon after
the removal of the blood from the vein, these
bodies can then obey the force which tends to
unite them, and they then form a network, in
whose meshes the liberated red particles are en-
tangled, and thus produce the phenomena of co-
agulation. If the coagulum be exposed to a
stream of water, the colouring matter is washed
away, while the aggregates formed by the colour-
less corpuscles remain in the form of filaments,
in which may be recognised an analogous struc-
ture to muscular fibre, and constitute the fibrine
of the blood.

6. It seems extremely probable, that the co-
lourless globules observed in the chyle form the
central corpuscles, &nd, when they have acquired
their coloured envelopes in the progress of san-
guifaction, constitute the red globules. And it
appears equally reasonable to infer, that both the
suspension of the globules in the serum, and the
attraction between their coloured envelopes and
colourless corpuscles, are entirely vital, inasmuch
as both phenomena cease soon after the blood is
removed from its source of vital endowment : and
that vital manifestations become first apparent in
the chyle, and still more so in the blood ; coagu-
lation being the result of the lossof this endowment,
and taking place with a celerity in proportion to
the rapidity of its departure. In cases where the
vital energy, or that manifestation of it exerted
by the organic nerves on the vascular system,
is unexhausted, or is in a state of healthy excite-
ment, coagulation is perfect and somewhat slow ;
but where it is depressed orjexhausted, this process
is quicker, but much less complete. Besides
these, it presents various other phenomena, which
are intimately connected with the nature of mor-
bid actions, and which J shall notice immediately.

M 4

168 BLOOD — Excess

7. E. Chemical relations of the blood in health.
— The analysis of the blood given by M. Le
Canu, who obtained the prize given by the Aca-
demie Iloyalc de Mcdecine of Paris, is extremely
minute; and, as respects the principal ingredients,
agrees very closely with the results stated by
Bekzelius and Marcet. The oily matter first
delected in the blood by Dr. Trail, and subse-
quently found by Dis. Christison and Babing-
TON, has likewise been recognised by him as con-
stantly present in the serum. The results of the
analysis of the serum by Le Canu, Berzei.ius,
and MAncET, are as follow • —

Water
Albumen
f Animal matter sol.
I in water and alco.
I Alhumen, com-
*-i, bined with soda -
I Crystallisable fat-
I ty matter
LOily matter
*Muco-extract. mat.
*Extractive mat. sol.
in alcoh. and acetate
of soda

Hydrochlorate of
soda and potash
Sub-carb. and phosph
of soda and sulph.
potassje

Phosph. of lime,mag.,

and iron, with sub-

carb.of lime and mag.

Loss -

Le Canu.
1st Anal. 2ci Anal

906-00
78-00

f69
210

1-20
1-00

GOO
2-10

0-91
1-00

1000-00

901-00
81-20

2-05
2-. 5.5

2-10
1-30

5-32

2-00

0-87
1-Cl

iro(i-oo

90.5
KO

loon

90000
HG-80

6- GO

2-00
0-60

lono-no

8. The blood, according to M. Le Canu, con
sists of the following constituents: —

Water 780-145

Fibrine 2-100

Albumen 65-090

Colouring matter - - -133000

Crystallisable fatty matter
Oily matter . - - .

E.xtractive mat. soluble in alcohol and

« ater - . - - -

Albumen combined with sod-i -
Chloruret of sodium and potassium,

alkaline phosphate, suli)hate, and sub.

carbonates - . - -

Subcarbonate of lime and magnesia,

pho.spliates of lime, magnesia, and

iron, peroxide of iron - - -

Loss . . . - -

2-430
1-310

1-790
l-liGS

78G-.590
3-565
69-415

119G2G
4-300
2*270

1-920
2-010

8-370 7-304

2-100
2-400

1-414

2-586

1000-000 1000-000

According to some chemists the blood also con-
tains carbonic acid (Vogei, and others) ; a yellow
colouring matter, resembling that of the bile and
the urine (Ciievreul, Lassaigne, &c.) ; and a
substance analogous to urea (Puevost, Dujias,
Vauquei.in, and Segai.as). Vauqvelin and
Ciievreul consider the fatty matter to be similar
to that of the brain and nerves.

9. a. The quantity of water in the blood of a
healthy person vanes, according to M. Le Canu,
in 1000 parts, from B.'J3-13.'), the maximum, to
778-62 J, the minimum. He found tl)e medium
(juantity in males to be 791-944, and in females
821-764. The quantity also appears to vaiy
with the temperament ; as the tiimphatic tem-
perament in the male furnished 830-566, in the
temale 803-716 ; and the sanguineous in the male
786-.'i84, in the female 793-007.

10. 6. The albumen contained in 1000 parts of

« I'robably tlic same coiistitMonts, differently named,
and more minutely examined, by M. Le Canu.

OF — Plethora.

blood varies from 78-270, the maximum, In
57-890, the miuimum. It is nearly the same in
the male as in the female, being only about one
part more in the former. The difference in the
quantity appears to have no relation to the tem-
perament, nor to the age of the subject, from
twenty to sixty years.

11. c. The quantity of Jibrine contained in the
coagulum vaiies extremely. According to Ber-
zELius it is only -75 for 1000 of the blood. M.
Lassaigne states, that the fibrine of the blood of
a young vigorous man is only .fg'y'L of its weight.
In the researches of M. Le Canu, who has in-
vestigated the subject more closely than his pre-
decessors, the quantity of dry fibrine contained
in 1000 parts of blood varies from 1-360 to 7-236
— the medium of twenty-two experiments being
4'298. It appeared to be greatest in the young
or middle-aged of the sanguine temperament, and
in the inflammatory state ; and least in the lymph-
atic constitution, the aged, and those suffering
under congestion or hasmorrhage.

12. d. The proportion of glohules varies much
more remarkably in the blood of a healthy per-
son, than that of the albumen; the maximum
being 148-450, the minimum 68-349, and the
medium 108-399, in 1000 parts of blood. The
medium quantity in males was 132-150, and in
females 99-169. The periods of life intervening
between twenty and sixty years had no influence
on its quantity, but it was found to vary with the
temperament. The medium quantity in the
lymphatic temperament was 117-300 among fe-
males, and 116-667 among males; and in the
sajjg-in'/iWMi temperament, 126-174 in females, and
136-497 in males ; giving 19-830 more globules
to the sanguine temperament in 1000 parts of
blood. M. Le Canu found the globules of blood
greatly diminished in females subject to a copious
flow of the menses. The quantity of globules is
also, relatively to the other constituents of the
blood, greatly diminished by blood letJlng, whilst
ihe albuinen is not sensibly affected. Thus, a
first bleeding furnished in 1000 parts of blood
792-897 of water, 70-210 of albumen, 9*163 so-
luble salts and animal extractive matters, and
127-73 of globules ; but a third bleeding a few
days afterwards in the same patient (a female),
gave 834-053 of water, 71-111 of albumen, 7*329
of soluble salts and extractive matters, and 87-510
of globules.

BiBLioG. AND Refer.— Marcel, in Transact, of Medico-
Chir. Society of Lond. vol. ii. p. 365. — Bcrzclius and
Marcel, in Ibid. vol. iii. pp. 199.231. — I'rout, Inquiry
into the Origin and Properties of the Blood, in the An-
nals of Me<l. and .Surg. vol. i. pp. 10. 13i. et '277.— /7o»«(?
and Bauer, Phdos. Trans, for 1820. — //w«<-, in Ibid, for
18-26, p. 189. — I'revost et Dumas, Memoircs do la .Soc. do
I'hysiq. et d'llist. Nat. de Geneve, t. i., et Biljliotheque
Univers. Juillot, \»2\.— Atillior, Appendix to M. Itichc-
raiuCs Elements of Physiol. 2d edit. p. (i31. — Scudat/iurc,
I'Issay on the Blood, &c. 8v(). Lond. 1H24. — Schullz,
Ifevue Mtdicale, t. i. 1825, p. 136., et Journ. de Prog, des
Se. Med. t. v.—Boslock, in Edin. Med. and Surg. Journ.
vol. xxxi. p. 114. — Adelon, Physiol, de I'llomnie, t. iii.
p. 110, ct seq. — Iji' Canu, Nouvelles Hecherches sur le
Sang, in .lourn. do Pliarmacie, Sept. et Oct. 1831.

11. Exuberance or Bi.nou, Plethora (nX-qOupTi,

repletion). Svn. Polycemia (Auct. Var.).

Ilypera:mia; pUthore, Fr. Die Vollbidtigheit,

GeriT). Pletora, Ital. Excessive Fulness of

Blood.

Classif. Pathology. — JEtiology. IV. Class,
II. OuDia {Autlwr, fiee Cbissif. in Pre.
face).

BLOOD — Excess of — Plethora.

169

13. Df.fin'. Greater fulness of the vascular
sustein than is compatible xuilh the continuance of
health )• or repletion of this system.

14. The importance of attending to the vary-
ing stales of the circulating system, in respect of
both exuberance and deficiencii of the fluid con-
lainud in ii, has been acknowledged since the
time of Galen. After the doctrine of nervous
influence iiad superseded the humoral pathology,
tiie state of tiie blood in disease experienced a
more general neglect, than the part actually per-
formed by this fluid in the causation and perpe-
tuation of morbid actions ougiU to have procured
for it. Yet have there always been a succession
of able observers and writers, who have never lost
sight of the influence of the quantity as well as
qnaiiiy of the blood in producing, as well as in
modifying, disease ; and more recently the subject
has deservedly received an increased and an in-
creasing attention. Plethora is the opposite of
aiiicmia : both may be, to a certain extent, com-
patible with health ; but both predispose more or
less to disorder, and, beyond certain limits, con-
stitute distinct and opposite states of disease.

15. i. General Plethora. — A, Slates of.—
Galen, Bailloii, Fernel, Riviere, and others,
considered plethora to be of two kinds ; to which
subsequent writers added two more. As the^e
distinctions are still, in several respects, founded
in truth, notwithstanding the neglect into which
they had long fallen, I will here briefly notice
them. 1st, True or absolute plethora — plethora
ad vasa ; 2d, Apparent, or false plethora — ple-
thora ad vol u men ; 3d, Plethora relative to space
— plethora ad spatium ; 4th, Plethora in relation
to vital power — plethora ad vires. It will be ob-
served that the first and second of these, the spe-
cies recognised by the earliest writers, are still
upon the whole the most important. In ihefrst,
the blood is permanently increased beyond the
wants of ttie system. In the secotid, plethora is
merely a passing occurrence, arising from tempo-
rary causes, as the general turgescence occasioned
by sudden or high ranges of temperature, &c. In
the third, the blood may not be increased, but its
relative quantity may be too great, as is observed
after amputations of one or two limbs. In the

fourth, the quantity may not be too great, if this
fluid were actuated by a healthy state of the vital
energy : but it may be excessive in respect of the
influence by which it is circulated in all pnrts of
tlie body. Now, those distinctions are actually
founded in nature; and although they may all be
resolved into one pathological proposition, viz.
greater repletion of the vascular system than the
wants and conditions of the economy require, still
they must have become matters of experience to
every one whose range of observation has been
such as entitle his opinions to respect. I shall
merely remark upon such of them as admit of
dispute.

16. False plethora is very generally observed
to occur in persons suddenly exposed to elevations
of temperature, and depends more upon the efl^ect
of heat in exciting the vital turgescence of the
capillary vessels, whereby a craving for fluid is
created, and a larger quantity is absorbed, than
upon the expansion of the fluids themselves,
owing to the increase of temperature. A state of
false plethora is very frequently occasioned, — and
is often productive of more serious consequences

than have generally been imputed to it, — by in-
gurgitation and increased temperature conjoined ;
and it should not be overlooked, that tliese com-
bined influences not infrequently affect those who
are already permanently plethoric. This will be
more forcibly and truly shown by what must
have fallen under the observation of many. A
red faced, full veined, and robust looking person,
of from forty to sixty, sits down to dinner with a
t'ood appetite. He eats three times as much as
his body requires, and he excites the stomach to
digest it by drinking stimulating fluids to six times
the quantity that is necessary. All this, moreover,
is done in a close and overheated apartment. The
vital turgescence and expansibility of the capil-
laries and veins are excited to the utmost; (he
whole surface is full and plump, and the ex-
tremities even swollen. Now, a person thus
circumstanced, particularly from four to eight or
more hours after such ingurgitation, actually has
the quantity of his circulating fluids increased
from one sixth to one third, at a moderate calcu-
lation ; but the increase is generally soon di-
minished by the pulmonary exhalation; the
urinary, the perspiratory, and intestinal secretions,
which are all greatly augmented, and are thus
the safety valves of the circulation. But how
often, notwithstanding, do we observe the vessels
at last yield before the mass which distends or
overloads them, and apoplexy, and various other
haamorrhages, and congestions, result ; particularly
when any one of these safety valves are ob-
structed or tardy in their action — when the ner-
vous or vital influence is either depressed or much
exhausted by the previous excitement, and the
vessels are irritated, or their actions otiierwise
changed by the state of their contents.

17. That plethora is a not infrequent result
of amputations cannot be disputed, although the
privation of sufficient exercise, which is thereby
occasioned, will partly account for the occur-
rence ; at the same lime we generally oi)serve
that the same quantity of food is taken, and the
same quantity of blond is prepared for the body,
when deprived of one fourth part of the structures
requiring support, as was provided for its nourish-
ment when it was in a state of integrity.

18. That plethora may exist in conjunction
with deficient vital or nervous power, and that,
although the quantity of blood in the system may
not exceed that of health, and yet be too great
for this power to control, cannot bj doubted.
We are constantly observing such pathological
conditions, both at the commencement and in the
progress of disease, and frequently remark their
influence in its advanced states and terminations.
(See article Congestion.)

19. B. The causes of plethora are so manifest as
scarcely to require enumeration. They may ope-
rate either singly or in conjunction. They con-
sist, 1st, Of the introduction into the vascular
system of a greater quantity of the nutritious
elements than is necessary to the support of the
organisation : and, 2d, Of the retention in the
blood of those parts which are usually removed
by the secreting and excreting organs. It muse
be evident that the former is owing to excess of
nourishment and stimulating fluids, whilst the
latter proceeds most commonly from insufficient
exercise, suppressed natural secretions and ex-
cretions, or accustomed morbid discharges, llow

170

BLOOD — Excess of — Plethora.

remarkably the habits, indulgences, luxuries, and
refinement of modern life contribute to these, ia
sufficiently apparent. At the same time it should
not be overlooked that there are certain consti-
tutions, and particularly those of a lax fibre, more
disposed to plethora than others, even indepen-
dently of temperament ; that this disposition is
often hereditary, and that it is frequently so
strong, notwitiistanding precautions to overcome
it, as to constitute a distinct diathesis. Plethora,
particularly in conjunction with a rich state ot
the blood, is generally most remarkable in those
•who live highly, drink much, and are very often
in the open air, without taking active exercise.

20. riiere are also certain epochs of life at
which it is most apt to occur, particularly when
the energies of life are beginning to wane, and
when the balance between sanguifaction and se-
cretion preponderates in favour of the former (see
article Aoe). Plethora is also more frequent
in females than in males, owing to their more
sedentary occupations, and to the wants of the
female economy, particularly during the period of
utero-gestation, and subsequently to the cessation
of the menses. It is justly remarked by various
writers, that the plethora of early life is generally
arterial and capillary : that of advanced age alto-
gether venous.

21. Plethora has been too generally considered
as always existing in fat persons, and as occurring
at least in them most commonly. But obesity is
no sure criterion of plethora ; it may even co-
exist with a deficiency of blood. I have known
the supposition, that obesity indicated at least a
suflSci ncy of this fluid, lead to dangerous results.
Indeed, the opinion entertained by several of the
older writers, that fat persons do not bear deple-
tion, is quite as well founded as its opposite. There
are other circumstances besides this which must
be taken into consideration, when we estimate
either the simple exi-tence of plethora or its ex-
tent. This state of the vascular system is some-
times associated with leanness; but when this is
the case, the pulse is also full and strong, and the
veins very large, full, and rapidly filled upon
being emptied by friction. It is more generally
observed in persons passing middle age, who, with
a ruddy, flesh-like, or lively surface, are beginning
to assume greater fulness of the frame without loss
of firmness, and in whom the pulse is full and the
veins well marked.

22. C. S>pr>ptnms. — Pleihora, in its slightest
grades, is generally productive of little incon-
venience. 'I'here are usually observed merely a
greater disposition to sleep than in health ; less
quickness and aptitude to ni ntal or corporeal ex-
ertion : and a more marked disposition to suffer
from and to be affected by the more energetic
causes of disease. In an advanced degree it occa-
sions lassitude, indolence, vertigo, or weight or
pain of the head ; heavy, snoring, dreamy, and
often unrefreshing sleep ; lurgescence of the
countenance; suffusion of tlve eyes ; fulness of the
veins, and of the pulse ; occasionally palpitations
of the heart, and slight amaurosis. Such are the
usual signs of ple'hora, short of actual disease,
at least of such as may alarm the patient. When
it proreeds further, it assumes eillier the features
of inllatniriatoiy fever, with excess of action in
Bome organ or part, or passes into general visceral
congestion, ac<oidiiig to the stales of vital action

and power. It may moreover occasion, or ter-
mhiate in, haemorrhage, visceral inflammations,
congestions, and obstructions, active drop-^y,
morbidly increased secretions, convulsions, spas-
modic diseases, morbid states of the vessels, Ike,

23. ii. Local Plethora. — The vessels of an
organ or part may be loaded with blood, and yet
the state of their vital action may be neither
generally or locally exalted to the pitch of active
determination, nor reduced so low as that of passive
congestion. There are, perhaps, few such cases
that are entirely independent of some degree of ex-
citement, arising eittier from the condition of the
nerves of the organ, or from an irritating cause
of some description influencing the state of the
capillaries. I'he best exemplifications of this
state are the plethoric states of the ovaria and
uterus previous to the menstrual discharge ; of the
generative organs during the venereal orgasm ;
of secreting glands and parts when their func-
tions are unusually active ; of the brain during the
exciting passions and emotions (see Local deter-
minations of Blood), and various internal viscera,
particularly the spleen, during the cold stage of
an ague, &c. These last, however, more nearly
approach to congestion than to simple local
plethora. It should not be overlooked, that what-
ever excites the nerves and irritates the tissues of a
part, will occasion turgescence of the capillaries,
increased flux of blood through the arteries supply-
ing them, and a quicker return of this fluid through
the veins. If the part thus excited perform
secreting functions, these will be augmented ;
and thus Increased flux and local plethora will
both exist, and constitute local determination of
blood, — a state which will be considered hereafter.
But still this is not inflammation ; for as soon as the
cause of excitement ceases, this state disappears,
without terminating in any of the ways in which
inflammatory action terminates, and without
having assumed any part of the formative process
which in some state or other follows upon in-
flammation occurring in a previously sound
frame. It cannot, however, be denied, that
although local plethora does not constitute either
inflammation or passive congestion, it will often fa-
vour the production, not only of these, but also of
haemorrhages, convulsions, &c. according to its
seat and extent, the state of vital power, the na-
ture of the exciting causes, and other contingent
circumstances. It is evident that local plethora
may occur either with or without general plethora.
It may even coexist with insufficiency of blood
(§34.).

24. iii. The Treatment of general and local
plethora consists almost entirely of avoiding its
causes. Simple plethora does not require, and is
selilom permanently benefited by, vascular de-
pletion alone; indeed, it is more generally in-
creased alter a time by this practice, unless more
efficient measures be also employed. Abstinence,
and a free state of the secretions and excretions ;
active and regular exercise ; abridging the period
of repose ; early rising ; a moderate use of
diluents, and abstaining entirely from malt and
spirituous licjuors ; cooling and acidulous bever-
ages, when thirst requires to be (juenched ; are
the chief means both of prevention and cure.

HiBLioo. AND Kefgr Galen, De Plenitudine, vfile

Opera. Fischer, De I'lethora Mult. Morli. CaUba. Erf.

\Tl'.\ IIiiffinann,Y>e Plethora iiisufficiento Morbnnim

Uausa, Opp. sup. ii. pp. 1. 506 Stahl, Theoria Meilica

Vera, Juncker's ed. Halfc, 1737, t>P- 303. 483, &c. ; et
De I'leiliora. Erf. 1736.— y««rie)', Consiiectus MiHliriiia'.
H.ilae. 17'i4, p. 7. el seq. — Nicolai, De .Singular, quiliiisd.
ad Polyeemiam Spectantibus. Jengc, XTiQ.—Kitdjlsti'llcr,
De Morb. ex Abund.intia Sanguinis oriiinilis. Helms,

1777 IVcickiird, Veruiischte Schriften, b. iii. p. 89.—

Gregory, Conspect. Med. Theoret. ed. vi. p. \W2.—Horn,

Bcitra;ie zur Medic. Klinik. vol. 11. p. 88 Calemard,

I.atuyctle. Essai siir la Plethore ou I'olyemie, 4to. Paris,
18'JO.— Vi.idfi, Diet, des Sciences Med. t. xliii. p. 178 —
Parry, Kli-ments of Pathology, '.'d ed. p. 30. A-^.—Rochoux,
Dot. de Med. t. xvii. p. 123 —P. S. Denis, Reclierches
Experini. sur le Sang Humain. 8vo. Paris, 1»30, p. 350.

III. Local DETERMiNAxroN of Blood.
SvN. Alflux of Blood; increased Momentum
of Blood. Fluxion, Fr.
Classif. Pathology. Therapeutics —
( Derivation, Bevuhion.)

25. The determination of a larger proportion of
the circulating Jlnid to an organ or part, than is
u^ualtti sent to it in health, not infrequently takes
place independently of inflammation. This state of
the local circulation has been, singularly enough,
doubted by some writers, and too much insisted
on bv others, more particularly by Dr. Parry,
who assigned to it a greater importance in pa-
thology than it is entitled to, and overlooked the
fact that it is a part only or link in the chain of
morbid causation.

26. i. Pathologigal Doctrine. — Determin-
ation nf blood is intermediate between inflammation
and local plelhoi'a. Inflammation is an actively
morbid slate of the capillaries ; congestion a passive
conilition of both them and the veins ; whilst deter-
mination isa simply active or excited, but not other-
wise diseased, state of both the arterial branches
and the capillaries, the veins being unaffected, and
re;idily returning the blood conveyed by the arte-
ries. More or less determination of this fluid
accompanies acute and sub-acute inflammations,
and ha>morrhages; but it never attends congestion,
unless this state pass into either of the former
diseases, or be followed by augmented secretion
from the congested organ. Local plethora (^23.)
is a lower grade of local determination, or rather
an intermediate state of the vascular system be-
tween determination of blood and congestion. In
other words, (a), Congestion ot blood is repletion
of the veins, attended by depressed vital power —
(/)) Local plethora, increased fulness of the vessels
gener:dly, with integrity of viial power — (c)
Local determination, augmented circulation and
vital functions of the vessels — (d) Inflammation,
an actively morbid state of the vessels, and or-
ganic nerves supplying them, tending to change
of structure and to disorganisation. As these
pathological stales are often referred to, and are
sometimes improperly confounded, it is therefore
necessary to attend to the distinctions now drawn.

27. That determinations of blood actually oc-
cur, and may even be excited at pleasure for a
short lime, are matters of daily observation even
in heallh ; und that such changes in the circula-
tion of a part are occasioned by the influence of
the nerves, particularly of the organic nerves sup-
plying the vesseN, seems an equally well esta-
blished fact. When these nerves are exciter),
whether by heat, stimuli, friction, or irritating
bodies, the capillaries experience a degree of ex-
pansion,— a property with which they are na-
turally, or rather vitally endowed. The eretliysin,
expansibility, or slight erectility, which is evinced
by the capillaries of certain organs in a very re-
markable manner, exists more or less throughout

BLOOD — Determinations op. 171

the frame, especially in mucous or cellular parts.
When, therefore, this property is influenced by
any agent possessed of the power, the diameter
of the capillaries running between the arteries and
commencement of the veins being increased, an
enlarged stream of blood will necessarily pass
through them, and a correspondent demand will
be made upon the arteries supplying them, owing
to the less resistance opposed to the current, and
freer circulation in the part ihus circumstanced,
provided that the return of blood by the veins
be not impeded. If the circulation be thus in-
creased as respects the volume of blood passing
through the vessels, and continue thus facilitated,
the demand thereby made upon the larger vessels
and the heart will ultimately tend also to accele-
rate it, and hence "ill result augmented volume
and quickened circulation — the slates constituting
determinations of blood.

28. The circulation of an organ or part may
long remain in this state, particularly if its vital
manifestations do not become exhausted, and if
its nervous power continue excited by the agent
or cause which first occasioned this condition, or
by other influences operating in a similar manner.
But if the vital or nervous power become de-
pre.ssed, or otherwise changed, either congestion,
or some form of inflammation, will generally ensue,
or even haBinorrhage may supervene — a result
which is not infrequent when ihe determination
takes place to membranous viscera or parts, and
to mucous surfaces. These being, therefore, not
unusual terminations of simple determination of
blood, means should generally be employed to
remedy this state. The agent or cause exciting
the vessels should be removed, and other iineasures
directed that may equalise the circulation and di-
minish its fulness, when the determination is con-
nected with plethora, as it not infrequently is.

29. Determinations of blood to an organ are
very frequently occasioned by whatever rouses its
natural actions. If the part thus excited perform
secreting functions, the increased secretion, in ad-
dition to whatever excitement of the vessels may
be produced, will of itself determine a greater
flow of blood to it. Numerous proofs of this are
furnished us by the progress of various diseases,
and the appearances presented by others after
death ; and endeavouring to follow nature, we
attempt to remove determination or inflammations
in vital organs, by inducing artificially an afflux
of blood to parts and surfaces where it cannot be
injurious, as to the skin, mucous digestive surface,
extremities, &c., with the view of assisting other
agents in soliciting or recalling it from the seat
of disease. The exercise, also, of orafMns which
possess not secreting functions, will likewise fa-
vour an augmented flow of blood to them. Thus,
exertion of the mental faculties and the passions
determine an afflux of blood to the brain ; and of
the muscular organs, to the spinal chord, muscles,
and heart. It is of importance to be aware that
the irregular distribution of the blood, whelhtr
of this or of other kinds, may take place either
when this fluid is more abunilant and richer thaa
natural, or when it is deficient as well as poor;
and that the change from the healthv state of the
circulation is to be imputed primarily to ihe state
of influence exerted by the organic class of nerves
distributed to the vessels, whudi.thus influenced,
control the volume of the blood circulating through

172

BLOOD — Deficiency of — An/ewia.

them (§ 27.)-> fis well as modify its states and the
rapidity of its circulation. The particular deter-
minations of blood are noticed in their respective
articles.

BiBLioG. AND Uefep..— St a /il, De C'lnmotionibus San-
guinis Activis et Passivis. Halse, 1698 ; et De Motu Shiu
guinis et pendentibiis Vitiis, &c. Halae, 1700. — Fischer,
Be Motu Sing. Natural!, Non-iiaturali, et Mixto. Erf.
1720.— Barthcx, Memoire sur les Fluxions, qui sent les
Elemens essentiels dans divers Genres des Maladies, in
Mi^inoires de la' Societe Med. d'Emulation, t. ii. p. 1 —
Parry, Elements of Pathology and Tlierapeutics, 2d ed.
I^ond. X'i'i.'b.—Authnr^m Lnnd. Med. Repos. vol.xxiii. p.

409 Barry, Exp. Researclies on the Blood. 8vo. Lond.

1826.

30. ii. Therapeutical DocTniNE. — Deriva-
tion.— Revulsion. The doctrine of determination
of blood sufficiently indicates the propriety of
liaving recourse to means in the cure of various
diseases, calculated to solicit a fiow of blood to
parts where this may be done safely, and thus
to diminish the quantity sent to tiie seat of dis-
ease. This mode of practice was well understood,
and very generally employed by the older physi-
cians, upon the well-known pathological principle
that, " ubi irritatin, ihi Jiuxiis." It must not,
however, be overlooked that irritation will not
always procure afHux of blood ; and that it is
therefore not altogether identical with derivation
either in a pathological or a therapeutical point
of view. It does not come within my limits to
point out the difference ; l)ut they are so far alike,
that, in order to produce the latter, we frequently
have recourse to the former. At the same time
we must recollect that irritation will sometimes be
of service even independently of any afHux of
blood that may accompany it, or even although it
should fail of producing this etTect.

31. It is almost unnecessary to enumerate the
means, which we occasionally have recourse to
in order to occasion a local determination of
blood, and thus derive it from the seat of disease.
These consist of numerous agents ; — a. Such as
increase the circulation in the rete mucosum, as
rubefacients, sinajiisms, external heat, &c. : b.
Those which, in addition to augmented circula-
tion, procure a discharge from the surface or part
to which they are applied, as scalding water,
blisters, irritating ointment, &c., purgatives and
cathartics, &c. : c. Those which, by procuring a
flow of tlie natural secretions, solicit an afHux of
blood to the secreting organs, as certain purga-
tives, diuretics, and diaphoretics : d. Those which,
evacuate ihe viscera, increase the discharges from
their mucous surface, and augment the secretions
in adjoining organs, as emetics, cholagogue pur-
gatives: e. Those whicii influence the circulatinn
in the limbs and extremities, as frictions, the semi-
cupium, various forfus of pediluvia, and manu-
luvia ; abstraction of blood from llm feet or hands,
by vena?section, leeches, or cuppin?, stimuhumg
or scalding pediluvia, kc. ; ai)d,_/'. 'i'liose which
permanently iriiiale and procure a coiiliiiued dis-
charge, as deep scarifications, incisions, setons,
issues ; caustic applications, as the alkalies, the
inner bark of mezereon, moxas. &c.

32. All these occasion, in the first place, irri
tation in the i)arl to which they are ap])lied, and,
conse(]uent to this, an afHux of the circulating
fluid. Some of them produce the primary, more
remarkaldy than the secondary, ed'cct ; and when
this is the case, ihe pain which is lelt is often an
index of tiic extent of the former. This is the

case with blisters, rubefacient epithems, sinapisms,
and scalding applications ; and, therefore, much
advantage is obtained from them in various dis-
eases, independently of their secondary operation,
particularly when we wish to rouse the torpid or
oppressed functions of an adjoining or subjacent
organ. When derivation is, however, our prin-
cipal object, they cannot always be depended
upon, particularly in irritable habits, and in the
early stages of acute diseases. 1'hey ought never
to bo employed in the stage of excitement in
tever, unless this stage be irregular, imperfectly
developed, or inefficient ; nor in inflammations,
until acute action is subdued by dei)letions, eva-
cuations, and other means, — when only artificial
derivation can be expected to have any influence
in diminishing the remaining disorder, and lessen-
ing the risk of effusion. This caution is especially
deserving of attention in respect of blisters, — the
cantharides of which, particularly if improperly
allowed to remain too long on a place, as
they often are in diseases of excitement, being «

often absorbed into the circulation, thereby in-
creasing the general as well as local vascular
action. These applications, also, ought not to be
directed to the vicinity of parts suffering from
vascular excitement. I have often seen mischief
produced by blisters having been directed to the
head and throat in acute diseases of the subjacent
parts.

33. The means usually employed in order to
derive the flux of blood from diseased parts are
variously combined, and much discrimination is
requisite both in the choice and in the combination
of them, appropriattly to the state and nature of

the diseased action at the time. The scope and >

limits of this work preclude my entering upon ■
this important branch of the subject ; but it has I
received attention when discussing the treatment I
of those diseases in which the various means of I
derivation are required ; and the appropriation of
those means to the diffijrent states of vascular
action is there attempted with some degree of
precision.

"BiiiLiOG. AND Refer. — Dumas, Nova Constitiitio Artis
Revellendi et Derivandi per Venaesectionem, 4to. Tig.
Vi^T. — Sciuiert, De RevuUione et Derivatione, 4to. Vit.
\CtO\. — Bcilin, Do Revulsione Crueuta, 4to. Leip. 1704 —
Fiklar, De Revulsione. Lugd. Bat. 1731. — Segner, De

Derivatione per VeniESPCtionem. Goei. 1749 Bolten,

Do Revulsione, Generatim. 4to. Hala;, 1750 Mrnxer,

I)c Lege UevuLsionis Virium S) stematis Nervosi. Pragflp,

17S4 Gt'jvWiC, Derivationis et Revulsionis HIstor. et

Proesid. 4to. Jenfe, 1787. — J. //. F. Atiienricth, Ob.'erv-
ationes Veritatem Mcthodi Rtvulsoria; Spectantes, 8vo.
Tul)ingo:, ls()2. — (Recommends the tart, antimonial
ointment, tlic fir.st employment of which has been incor-
rectly attriluted lo Dr. jKNNiiii. It was first recom-
mended by the late Dr.MoNHo, in his Lectures on Morbid
Anatomy. I attended these lectures, and employed it
long before the publication of Dr. Jennkk's letter on the
suliject. See cases adduced by me illustrative of its good
cllucts, in Lond. Med. Repos. vol. xvii. p. 310.) — I'inrl
ft Urichcteau, in Diet. Sciences Medicales, t. xlviii.
p. 'AM. — Jennfr. Letter to C. It. Parry On the Inlluence
of Artificial Eruptions in certain Diseases, &c. 4to.
Lond. 1822.

IV. Deficiency of Bi.ood. Syn. Antrmia
(from the privative a, and a'i/xa, blood).
Bloodlessness. Ancmie, I'V. JJer lllut-
manf^el, Ger. Dyspepsia Anwmia (Young).
Marasmus Auhainia (Good).
Cj.assif. 3. Class, Diseases of the San-
guineous Functions; 4. Order, Cachexies
(Good). I. Class, V. OiiuKii (Anlhor).

34. Defin. a deficiency of blood in the whole

BLOOD — Deficiency or — An«mia.

173

body, or in some important organ, not firoceedtng
from natural or artificial hemorrhage, giving rise
to a waxii, bloodless state of the countenance and
surface, einaciaticn, feeble quick pulse, and great
languor and debilitii.

35. Defect of blood, bloodlessness, or anfemia,
ahhoiigli not of frequent occurrence, is yet occa-
sionally met with, particularly in its less remark-
able, or local forms. In connection with chloroiis
it is ofiener observed. Cases of anjemia have
been recorded by Keieelius, Swiienke, and
others ; and the disease fully described by Becker,
Albert, Jaxson, Hoffmann, De Haen, Isen-
FLAMM, LiEUTAUD, Hallk, Andral, and several
pathologists, and practical writers of the present
day. 1 shall first ofler a few general observations
on local anamia ; and afterwards describe more
fully geneial ansniiu and its complications. The
deficiency of blood, occasioned l)y natural or ar-
tificial losses of it, is considered under a distinct
head.

36. i. PATHOtoGY OF AnjEmia. — Ist, Local
anizmia. Deficiency of blood in an organ or
part is evidently the result of one or more of the
following pre-existing lesions : — a. Of dimin-
ished influence of that portion of the ganglial or
organic class of nerves which supplies the blood-
vessels of the organ ; h, Of defective vital ex-
pansion of its capillaries, probably owing to the
depressed state of the influence exerted on the
vessels by the nerves supplying them ; c, Of
mechanical impediments in the way of a sufficient
supply of blood ; d. Of imperfect development,
or diminished calibre of tlie arteries by which blood
is conveyed to the organ; e, Of disease of the
organ or part, or an imperfect exercise of its
functions; and, f. Of unusual fiux of blood to
other quarters, causing a proportionate diminution
of it in others. It is evident that these states are
merely local, and are capable of co-existing with
other changes affecting the whole mass of the
circulating fluid, as respects both its quantity and
its quality ; and that various disorders of func-
tion, accoiding to the particular state on which
the anaimia depends, and the extent to which
it may exist, will be the consequence.

37. I'lie organs most subject to this condition
of their circulation are, according to M. Andral,
the lungs, the brain, the liver, the substance of
the heart, the stomach and alimentary canal,
and some of the voluntary muscles. To thefe I
would add, the spleen, the ovaria, and the gene-
rative organs of the male. In many of the~e,
as in other parts, atrophy is associated with the
anaimia; and may lie considered, in the majority
of cases, as the consequence of it. The symptoms
of local anaemia are not always manifested during
life ; but they frequently are, as I shall have
occasion to point out, when considering the mor-
bid conditions of those organs most subject to
this change. Thus, in the completest of all the
stvites of local anasmia, as when the obliteration
of an artery cuts off all supply of blood to the or-
gan, gangrene will result ; frequently vvheu anffi-
inia is seated on the brain, a form of convulsion
is the consequence, with other symptoms stated
in the article on this subject (see Brain — Amnnia
oj ) ; and when the ovaria, at the period of pu-
berty is not supplied with the requisite quantity
of blood, owing to deficient influence of the gan-
glial nerves distributed to the organs of generation,

chlorosis, sometimes with more or less of general
anaemia, is the constant effect.

38. 2d. General anainia. — The blood circu-
lating through the body may be most remaikably
deficient, in respect both of its quantity, and of
the relative proportion of red particles. In many
•cases in which the absolute quantity of blood in
the body is diminished, the globules are still more
remarkably deficient, they being insufficient to
give the blood its usual deep colour. General
ancemia presents itself in practice, 1st, as a pri-
mary disease ; 2d, as a consequence of pre-exist-
ing lesions of some one of those organs which are
concerned in conveying the nutritious fluids into
the blood, or in the processes of sanguifaction ;
3d, associated with other diseases, resulting
equally with it from some antecedent affection,
the nature of which cannot, perhaps, be readily
recognised.

39. A. The primary forms of ansmia, whea
closed analysed, seem to proceed, 1st, from de-
ficient nourishment ; 2d, from deficient vital
power, — from a torpid or depressed state of the
influence of the organic class of nerves on the
digestive, assimilating, sanguifying, and circulat-
ing organs which they supply. — a. The influence
of deficient supply of nourishment in producing
angemia may be readily imagined, and instances
showing it are numerous ; I will merely allude to
one : — iM. Caspar d, whose researches have tended
much to advance the state of the pathology of"
the fluids, has illustrated this part of the subject
by observing the remarkable degree of anjemiu
which existed in a large proportion of the inha-
bitants of a district devastated by famine, who
lived upon grass. A more or common and less ex-
pected form of general anjemia is ihat which
arises from the injudicious restriction of diet and
regimen, during convalescence from acute dis-
eases, particularly those which liave required
large depletions. Several instances of this state
of disease have come before me, and would, I am
confident, have terminated in dropsical effusions
(^ 44.) or in death, if a different system had not
been adopted.

40. b. A torpid state of the organic class of
nerves, is one of the most influential, if not the
most frequent, antecedent affections to which we
can impute this state of the circulating fluid. It
is extremely probable that those instances of its
occurrence from being shut out from the sun's
influence, and the constant respiration of an un-
wholesome air, arise from the continued privation
of salutary stimuli to this important class of
nerves, upon which the sanguifying processes
depend.

41. 'J"he influence of the sun's rays in promot-
ing all the vital actions, particularly those of or-
ganic life, probably from modifying the electro-
motive state of the frame, must be evident to all.
The good efl'ecls of light and air are shown in the
vegetable kingdom, the circulating fluids of which
cannot be duly formed without exposure to both.
The sun's rays diffuse a genial influence through
the frames of the aged, and excite the organic
and generative lunciions of the young. It has
been observed that those peisons who are en-
tirely excluded from tiie light of the sun, and
breathe the close air of mines, are paricularly sub-
ject to general anaemia. JNl. Chomel has given a
very interesting account of the disease which

174

BLOOD — Deiicien'cy of — Anemia.

affecteil the workmen employed in a coal mine at
Auziiin. It commenceil vvitli colicky pains, me-
teorismus, blackish green stools, dyspnoea, palpita-
tions, great prostration of strength, followed, in
ten or twelve days, by a yellowish or waxy and
bloodless appearance of the countenance. The
capillary vessels disappeared from the conjunc-
tiva and mucous surface of the mouth ; and the
pulsation of the arteries could scarcely be felt.
The patients complained of palpitaiions, anxiety,
oppression and suffocation on exertion, paroxysms
of fever, profuse peispirations, oedema of the coun-
tenance, and rapid emaciation. This state con-
tinued for six months or a year ; and in some cases
terminated fatally, with the reappearance of the
invading symptoms. Four of these patients were
sent to Paris for treatment, and were ordered light
nutritious diet, bitter infusions, &c. One of them
died; and on dissection, the arteries and veins
were found almost void of blood, containing
merely a little sanguineous serum ; and little or no
blood floweil from the parts divided during the
inspection. The appearances in this case led JMr.
Halle to prescribe iron filings in the dose of a
drachm daily, with tonics and opium; and, under
this treatment, all the symptoms gradually vanish-
ed, the capillary vessels reappearing on the surface.

42. -B. It is probable that general anseniia
will not take place, unless consecutively of re-
maikable torpor of the vital influence, or of some
other morbid condition of one or more of the or-
gans which contribute to the formation of blood.
Where the digestive powers and the functions of
the liver are weakened, anaemia to a slight degree
is not infrequent. Its connection with chlorosis is
merely that of an associated effect of pre-existing
depression of the influence of the system of organic
nerves. (See Chlorosis. ) The lungs have been
considered by some authors as the organ which
is chiefly concerned in the production of anamia,
and consequently have been viewed by them as the
seat of hajmatosis, or at least the place where t^iis
process is completed. Without disputing that
such is the case to a certain extent, I am dis-
posed to view the liver as being equally, if not
more, concerned in this function, — an opinion
long since contended for in my Physiological
Notes (see Appendix to M. Riciiirand's Elements
of Physiologq ) ; and consequently as being in
many cases very influential in the production of
general anemia. It is probable, however, that
other viscera or parts may also give rise to it.
Thus it inay be admitted that totnl obstruction of
the thoracic duct will occasion it; and I have
repeatedly observed it in children affected with
various chi'onic di-eascs of the viscera of oiganic
life ; being here, as in most cases, one of the re-
sults of imperfect digestion and sanguifiiclion, as
well as of obstruction to the passage of chyle into
the blood. One of the most remarkable cases of
general anajniia was recorded by Dr. Combe.
In it all the viscera were found nearly bloodless,
excepting the spleen ; but not diseased in other
respects, at least not to the extent of impeding
their functions. The thoracic duct and absorbent
system were not examined.

43. The siimiitoms of luui'mia have been neatly
all alludeil to in the foregoing remarks. 1 may,
however, enumerate them briefly at this place.
'J'hey consist of a i)ule, waxy, or blanched appear-
ance of the countenance and integuments, in

which the cutaneous veins are scarcely seen ;
and those which appear are pale, apparently
empty, do not hll quickly, or scarcely at all, upon
pressure made upon them ; and, when emptied,
fill very slowly. The conjunctiva has lost its red
vessels ; the lips, tongue, and inside of the mouth
are pale ; the pulse feeble, small, irregular, and
readily made still quicker or fluttering upon
mental emotion ; the patient is languid and very
weak ; complains of flatulence, borborigmi, and
an irregular state of the bowels, with want of
appetite, and an occasional nausea ; a sense of
sinking and syncope, particularly upon assuming
the erect posture, followed by palpitations ; op-
pressed, shoit, hurried, and sometimes gasping
lespiration ; irregular convulsive or spasmodic
movements ; tremors ; oedema of the ankles ; and
in some cases the more severe symptoms described
as following sinking after large depletions (§ 54.),
In the more unfavourable cases the patient may
be carried off by a fit of syncope upon assuming
quickly the erect posture ; or by a convulsion ; or
sink with the symptoms of exhaustion, or with
those of effusion on the brain, or in the pleural or
pericaidial cavities. It most commonly runs into
one or more of the complications about to be
noticed.

44. 3d, Complicated anccmia. — Deficiency of
blood, as respects both its diminished quantity
and its poor quality, or the defect of red globules,
is often associated with visceral disease, of which
it is generally the consequence ; but it also may
give rise to various affections, both functional and
organic. That aneemia should be complicated
with certain chronic diseasLS of the liver, mesen-
teric glands, and absorbent system, chlorosis, &c.
may be expected ; but that it should give rise to
diarrhoea, and to dropsic.d effusions in various
parts, particularly in the shut cavities and cel-
lular tissue, without any alteration of the solids,
may not appear so obvious, although admitting of
explanation. 1\1. Andral states, that he has ob-
served an;umia in the bodies of persons who had
died dropsical ; and in persons who had com-
plained of diarrhoea, profuse perspirations; and
very justly considers both the dropsical effusions
into the shut cavities and into the cellular tissue,
and the exhalation from the digestive mucous
surface and skin, as perfectly independent of any
local congestion or irritation, and to be analo-
gous to the profuse diarrhoea and perspirations
which occur in persons who are brought near to
dissolution by long protracted disease. In all
such cases, whether attended with effusion into
shut cavities or cellular tissue, or with increased
exhalation from mucous surface*, we may con-
sider nearly the same pathological conditions to
exist as their principal sources; viz. diminished
tone of the exhaling orifices, with lessened vital
cohesion of the tissues in which they open ; a
poor and thin state of the blood, the crasis of
which is much lowered ; and a more rapid circu-
lation of the remaining fluid.

45. Anasmia, when existing even in a moderate
degree, will often give rise to various functional
disorders, which are, however, of no constant
character, but differing with the temperament,
hahilof body, &c. The chief of these are hysterical
and epileptic convulsions, palpitations, leipothy-
mia or syncope and palpitations alternately, ir-
regular or anomalous convulsions and spasms,

chorea, and various nervous tremors resembling
chorea, dyspnoea, sickness or vomiting, cedemn,
of the ankles, diarrhoea, headach, &c., with weak,
small, quick pulse; pale, waxy, or doughy state
of the countenance ; listlessness, flatulent state of

BLOOD — Morbid Effects of its Loss. 175

aloes, the aloes and myrrh pill, the compound iron
pill, &c.

49. When the anaemial state of the system is at-
tended with hysterical, convulsive, and other ner-
vous afTections, a combination of chalybeates and

the abdomen, gastralgia, colic pains, very weak tonics, with antispasa odics, as the preparations of
digestion, vermination, and irregularity of the ' '

fascal and urinal evacuations. It will aNo be
followed by atrophy and softening of several of the
internal viscera, and general emaciation.

46. In ca<es where general anaemia is not ex-
cessive, it may be admitted that both inflamrnation
and hjEinorrhages may still occur, particularly
the latter, from the causes usually producing
them; and that they will have a remaikable
tendency to terminate unfavourably, owing to the
state of the system causing the deficiency of
blood, to this defect itself, and to the want of
yital resistance, as well as to the incompatibility
of most of the means of cure with the state of the
constitutional powers and of local action.

47. ii. Causes. — Several of the causes of anae-
mia have been already alluded to (§ 39 — 42.).
There may be others which have not yet been
ascertained. I may stale, however, briefly and
generally, those which have been usually acknow-
ledged. They consist of insufficient and poor
food ; excessive secretions and evacuations ;
masturbation practised early in life, and long
continued ; long exclusion of the body from the
direct influence of solar light and rays ; protracted
confinement in crowded apartments, in the stag-
nant and impure air of manufactories, especially
when affecting children or very young persons ;
and the constant respiration of a moist, impure, and
miasmal atmosphere, from which the sun's rays
are shut out. All these e.xhaust or depress the
vital and nervous powers ; whilst some also either
cut off the necessary supply to the circulating
fluid, or waste its richer constituents. To these
causes inay be added certain malignant organic
diseases, as carcinoma, &c., which, in the latter
stages, is always attended with more or less of
ansemia; impeded development of organs, par-
ticularly those belonging to the generative func-
tions, whose perfect evolution is requisite to the
salutary excitement of all the organic actions,
especially those of digestion and sanguifaclion ;
and lesions which either impede these litter func-
tions, and interrupt the passage of chyle into the
blood, or vitiate these fluids.

48. ill. Treatment. — T!ie most rational and
the most successful means that can be employed
consist of such as are calculated gently to excite
and permanently to promote the organic functions.

valerian, ammonia, zinc, myrrh, extract of hops,
galbanum, aether, strychnine, and various others,
is indicated. If we have reason to suspect that
the antemia is a consequence of obstruction or of
torpor, combined with an enlargement of some
organ or part concerned in the formation of blood,
the prejiarations of iodine, the liquor potassae
alone or combined with tonics, the subcarbonate
of soda, the boracic acid, and bi-borate of
soda, are the best medicines with which I am
acquainted.

BiBLioG. Axu TiEFEJi..— Ueisi'liiis, Miscell. Curios, dec.
ii. an. 7. obs. xiv. — Strhenke, in Hnller's Disput. &c. vol.
vii. — Seeker, Diss. Resol. Casfls I'rart. Anaemiae. &c.

Leid. l6Ki. — Albert, Diss, de Anaemia. Hal. 1732

Janson, De Morbis ex Defectu Liquidi Vitalis. Lugd.
Bat. 1748. — Lieulaud, Precis de la Medecine Pratique, p.
71. Paris, 1761. — Halle, Journ. de Medecine, &c. par M.
Corvisart,ii.c. t. ix. p. 3. — Gnspard, in Journ. de Physiol.

Experiment, &c. t. i. Octobre 1821 C/iotnel,an. Anemi'e,

Diet, de Med. t. ii. p. iiS.—Hoc/ie, art. i;?;^^!?. Diet, de
Med. et Chirurg. Pract. t. ii. p. 372. — Andral, Clinique
Medioale, t. iii. p. .558. ; also his Pathological Anatomy,

translated by Tutrnsend, and West, vol. i. p. 91 Combe

Trans, of the Med. and Chirurg. Soc. of Edin.vol. i. p. 194.

V. INIonBiD Effects of Loss of Blood.

50. This is a subject of greater practical im-
portance than has generally been attached to it ;
and one which I have had numerous occasions to
contemplate, particularly from the years 1816 to
1823, — an epoch during which blood-letting was
either more generally adopted, or carried further,
than the nature of several diseases, and the con-
stitutions of many patients, warranted. The effects
of large depletions have been well illustrated by
the experiments of Dr. Seeds, which have shown,
what indeed might have been anticipated from
the physical condition of the circulation within
the cranium ; viz., that we can tiever hope by de-
pletion alone to materially di.minish the quantity
of blood in the vessels of the brain. Dr. M.
Hall, and the Author, have also shown that
several morbid states may be occasioned by large
losses of blood, or by too large a proportion of
this fluid circulating in the head, relatively to the
rest of the body, as a consequence of large blood-
letting ; and M. Piorry has illustrated the same
subject by numerous experiments, and has offered
many instructive and practical observations on it,
particularly in relation to diagnosis.

51. The morbid effects of loss of blood may be
advantageously considered in relation, Jint, to a

Of these, the most appropriate appear to be the ' person previously in health, or not affected by
various preparations of iron, bark, sulphate of ' dangerous disease ; and, secondly, to persons la-
quinine, camphor, ammonia, small doses of iodine, bourmg under different diseases in which loss of
aather, &c. combined occasionally with opium,
hyoscyamus, extract of hops, conium, &c. when
the disease is attended with colicky pains. Con-
joined with these, the chalybeate mmeral waters,
cod-liver oil, stimulating frictions of the surface,
light and digestible food, gentle exercise in the open
air, particularly on horseback, and change of air,
will be found of much service. During the em-
ployment of tonics, due attention should be paid to
tlie state of the secretions and excretions ; and,
when the bowels are constipated, the more tonic
and less irritating aperients shouM be resorted to.
Of these, perhaps, the best are rhubarb, and

blood may occur, either naturally or from inju-
dicious practice. INly observations on both these
branches of the subject must necessarily be brief,
more particularly on the latter, as the topic is not
overlooked in the consideration of the treatment
of those diseases in which such losses are most
likely to be met with.

52. i. JMoRBiD Effects of Loss of Blood im

PERSONS not previously AFFECTED WITH SERIOUS

DISEASE. — These effects will naturally vary with
the suddenness or rapidity of the loss, the extent
to which it has proceeded, and the habit of the
person, especially as regards vascular plethora, at

176 ' BLOOD — Effhcts

the time when it occurreil. It is evident that an
evacuation vvhicli has been rapid will have a
more marked and serious effect than the same
quantity removed at several times, or in a slower
manner ; and that, when blood is discharged at
intervals, a much larger quantity may be lost
without producing the morbid effects often re-
sulting from the sudden loss of a smaller quantity ;
or, if th^y occur, they may be of a different kind
from those wiiich follow rapid discharges. 'I'he
subjects, therefore, which chiefly require con-
sideration are, 1st, The immediate effects of large
loss of blond ; 2d, The more remote consequences ;
and 3d, 'J'he slow and insidious effects super-
vening on repeated losses, each occurring to a
small or moderate extent.

53. A. Of the immediate effects of large losses
of blood. — a. These are vertigo, leipothymia or a
sense of sinking, syncope ; feeble and slow, or
sometimes quick fluttering pulse ; slow or ap-
parently suspended respiration for shoit periods,
interrupted by deep sighs ; eructations from, and
sometimes sickness of, stomach ; a cold, pale, and
bedewed countenance and general sui face ; irre-
gular sighing and yawning, generally followed by
a return of liie pulse and of consciousness ; and,
if the haemorrhage is not renewed upon the re-
storation of the circulation, recovery soon follows.
Where, however, the loss of blood is greater, the
above symptoms are more marked ; the syncope
is more profound ; the respiration, which is car-
ried on during this state entirely by the diaphragm,
is nearly imperceptible, until it suddenly returns at
intervals, with deep sighs : sickness and vomiting
occur, and restore consciousness for a tmie, but
the patient again relapses into syncope, which is
broken in a similar manner ; and, it the loss of
Llood has ceased, a more permanent restoration
follows the sighing and sickness, and recovery
slowly takes phice.

54. When, however, the loss is still greater
either absolutely or relatively to the energies of
the patient, or if it continue after the above effects
supervene, the return of consciousness is often
attended with some degree of delirium ; a diffi-
cult stertorous breathing; dyspnoea ; gaspings for
breath; occasionally retchings, and discharge of
the contents of the large bowels ; an irregular,
intermittent, feeble, or impejceptible pulse ; loss
<.f animal heat ; great restlessness, violent shud-
derings, or general tremors, and jactitation, some-
times so violent as to shake the bed upon which
the patient lies ; a sense of sinking through the
floor; convulsions, or tetanic spasms, and con-
tractions; terrible gaspings for breath, and death.

55. Such is the common grouping of the mor-
bid effects ; but some of them are more niaiked
than others. Thus, when the loss of blood is
very large, the patient may suddenly and unex-
pectedly expire in one of the fits of syncope which
occur, or he niay sink more gradually, without
any a[)pearance of delirium or convulsion, some-
times with the faculties entire to the last. The
former may occur after excessive blood-letting or
lircmorrhage, when the patient has been incau-
tiou-'ly raised up, or when he has not been
instantly placed in the recumbint posture when
syncope otcuri'ed ; the latter has taken place un-
expectedly wluiU bluod-lelling has been carried
too far, 01 too often repealed, in the recumbent
posture.

OF LAnOE Loss OF. '

56. b, Cmwulsions are often the most marked
effect, either of excessive haimorrhage, or of large
and repeated venisection in the recumbent posi-
tion ; particularly if it be carried to leipothymia
or syncope in this position, which ought always to
be avoided. This symptom is very common after
puerperal hiemorrhagy, or any large losses of
blood occurring in females, particularly those of
an epileptic or hysterical diathesis, and in children
or young subjects.

57.0. Delirium is another prominent effect of ex-
cessive evacuation of the vascular system ; but it
usually presents something peculiar. The carotids
are often neither full nor strong, the countenance
is pale, and the head cool, • — symptoms indicat-
ing, with the character of the delirium, impaired
vital energy of the brain. In some cases the
delirium is associated with convulsions, and both
may ultimately be followed by coma or lethargy.
Delirium more rarely occurs in children or young
subjects from excessive loss of blood, than in
adult or advanced age ; but coma, as will be
shown hereafter, is not infrequent in the former,
particularly when the loss of blood has occasioned
convulsions, which in them usually terminate iu
coma.

68. B. Of the more remote effects of large loss
of blood. — When the patient is not carried off by
the more immediate effects of excessive loss of
blood, reaction generally supervenes, and often
becomes excessive. It usually commences with
palpitations, and throbbings through the body,
but particularly in the carotids and arteries of the
head, giving rise to the peculiar noises, of which
patients so often complain after large depletions.
The pulse now becomes quick, sharp, and soft ;
and there is sometimes distressing nervous puls-
ation of the aorta. In the more marked cases of
reaction, the patient complains also of pain of the
head ; intolerance of light and of noise ; a sense of
tightness or pressure around the head ; hurry of
mind, and sometimes delirium, particularly in the
night ; restlessness, agitated sleep, often accom-
panied with a sense of sinking or impending disso-
lution, fearful dreams, &c. The arteries throb;
and the pulse ranges from 110 to 140, is jerking,
sharp, open, and bounding, but readily compressed.
The respiration is hurried, panting, and frequent ;
often attended with sighing, a desire of fnsh air,
great restlessness; and in females for aromatic
perfumes, or the smelling-bottle. The mouth and
throat are dry ; there is much thirst; and the skin
is u-ual!y hot, but the extremities, particularly the
lower, are generally cold.

59. 'I'his state has not infrequently been mis-
taken for one reijuiring depletion; and 1 have
met with cases in which the idea of inflammatory
action had so taken possession of the mind of the |
practitioner, as to induce him to employ large or i
repeated depiction, which lia<l been loHowed by
this state of leaction, for whicli he vvas proceed-
ing again to deplete, mistaking the morbid effects
of the previous excessive loss of blooil lor a re-
turn of the inflammation. If this state of reaction
be not judiciously managed, exhatistion rapidly
supervenes; and almost as soon as it occurs death
may take place, freipienlly upon some muscular
ellort, or upon getting up from the recumbent
posture. In some cases, particularly in children
ami young subjects, the delirium or morbid sen-
sibility of the brain, characterising the leaction.

BLOOD — Effkcps op large Loss of.

177

passes rapidly into a state of lethargy and coma,
which on numerous occasions I have seen mis-
taken for effusion of serum within the cranium,
or iiydrocephalus, particularly when it has been
preceded by convulsions, as is often the case in
children. In many sucli cases, either no effusion
is found, or the effusion is to an extent insuffi-
cient to account for the comatose symptoms.

60. Under more favourable circumstances the
reaction is gradually followed by returning health,
or lapses into a slate of chronic exhaustion or as-
thenia, which is variously characterised. In some
cases it is attended by somnolency, alternating
with slight delirium, &;c. : in others, by fits of dys-
pnoea, palpitations, frequent cough ; hurried, la-
borious breathing ; a flatulent, tympanitic state of
the abdomen: in several, by pale, emaciated,
or discoloured countenance and skin ; amaurosis,
nervous tremors, or jactitation ; delirium, or
mania : and in puerperal females by a form of
mania which requires to be carefully distinguished,
and which is particularly noticed under the
article on Puerperal IMania. In addition to these
functional disorders following reaction after large
losses of blood, organic changes may supervene;
such as effusion of serum and extravasation of
blood upon the brain, effusion into the bronchi
and air-cells, dropsical effusions in various parts,
and flatulent distention of the stomach and bowels.
When recovery takes place, the pulse always con-
tinues small and frequent for a long time, owing
to the remarkable diminution of the fluid in the
vessels.

61. C. Of the insidious effects produced ty
S7nall but often repeated losses of blood. — Loss of
blood occurring in this manner produces effects
different from those now described. They gene-
rally, as may be expected, advance slowly, and
often exist either altogether, or a long time, with-
out detection. They are extremely various, ac-
cording to the age and constitution of the person.
They most frequently occasion a pale, leuco-
phlegmatic, and lax appearance of the countenance
and surface; a very quick, weak, and irritable
pulse; hurried, and oppressed respiration; fre-
quent palpitations, and sense of sinking ; borbo-
rygmi, and hysterical symptoms ; flatulent dis-
tention of the colon, and colicky pains; swellings
of the ankles, and dropsical effusions in other
parts: in females, difficult and scanty menstru-
ation, chlorosis, deviations of the spinal column,
epileptic convulsions, pains in the loins, and
various anomalous affections of a painful or spas-
modic kmd ; tremors and irregular action of the
muscles ; chorea ; paralysis ; dyspeptic disorders,
with irregularity of the bowels; a disposition to
syncope ; amaurosis ; and all the symptoms of
anjemia, which indeed is the primary or real state
of disease produced, and constitutes the chief
change detected upon examination after death ;
together with serous effusion in some situations,
and a pale bloodless state of the viscera, and of
the heart itself.

62. ii. Of excessive Loss of Blood in the
COURSE OF VARiovs DISEASES. — There are two
important considerations which should not be over-
looked in practice ; viz. that in many diseases,
apparently attended with excitement, we shall
meet with cases in which the actual quantity of
blood in the body is much less than usual ; andi
in various others, blood-ktling will often not be

Vol, I.

borne, although seemingly indicated, and although
the quantity of blood in the frame be not lessened.
In illustration of the former of these, I may state
that many years ago I had an opportunity of re-
marking minutely the appearances on dissection
of a man of middle age, and somewhat fat,
who had complained of an acute and painful
disease, obviously functional, fur which lie had
been blooded only twice on successive days, and
on neither occasion to above thirty ounces; and
yet the symptoms of excessive loss of blood ap-
peared, from which he died in twenty-four hours
after the second dep'elion. The mo-t careful
examination could delect no organic change,
excepting the remarkably bloodless and pale state
of all the viscera. Even the brain was less
vascular than usual. That in various diseases,
unattended by diminution of the circulating
fluid, depletion will produce marked symptoms of
depression and sinking, ov\ing to the state of the
vital power being insufficient to accunmodate the
vessels, by their tonic or vital contraction, to the
reduced bulk of the blood, is well known, and
has been fully discussed in the articles on Adii-
luimic Fevers, Erysipelas, and Puerperal Ferers ;
in which, as well as in puerperal mania, and va-
rious other acute diseases, large vascular depletion
is often most injurious.

63. A. Of excessive loss of blood in diseases of
excitement. — The morbid effects of large deple-
tions will necessarily vary with the nature of the
disease in which they are employed. When
carried too far, in cases of excitement, where the
nervous or vital power is not depressed, and the
blood itself rich or healthy, reaction generally
follows each large depletion, and thus often ex-
acerbates or brings back the disease for which it
was employed, and which had been relieved by
the primary eflfects of the evacuation. This is
more remarkably the case in acute inflammations
of internal viscera, particularly of the brain or its
membranes. Thus, every obsefving practitioner
must often have noticed, that a large depletion,
when carried to deliquium, will have entirely re-
moved the symptoms of acute inflammation when
the patient has recovered consciousness; and that
he expresses the utmost relief. But it generally
happens that the inordinate depression — the
very full syncope that is thought es-ential lo the
securing of advantage from the depletion — is fol-
lowed by an equally excessive degree of vascular
reaction, with which all the symptoms of inflam-
mation return; and the general reaction is ascribed
entirely, but erroneously, to the return of the in-
flammation, instead of the latter being imputed to
the former, which has rekindled or exa>perated
it, when beginning to subside. The consequence
is, that anotlier very large depletion is again pre-
scribed for its removal ; and the patient, recollect-
ing the relief it temporarily afforded him, readilv
consents. Blood is taken to lull syncope — agaiia
relief is felt — again reaction returns — and again
the local symptoms are reproduced: and thus,
large depletion, full syncope, reaction, and the
supervention on the original malady of some or all
of the phenomena described above as the conse-
quence of excessive loss of blood, are brouoht
before the practitioner, and he is astonished at
the obstinacy, course, and termination of the
disease ; which, under such circumstances, gene-
rally ends in dropsical effusion in the cavity in
N

178

BLOOD — Effects of large Loss of.

which the affected organ is lodged ; or in con-
vulsions, or in delirium running into coma; or in
death eitlier from exhaustion or from one of the
foregoing states ; or, more fortunately, in partial
subsidence of the original malady, and protracted
convalescence. Sucii are the consequences which
but too often result — which I have seen on
numerous occasions to result, when blood-letting
has been looked upon as the only or chief means
of cure — the " sheet anchor" of treatment, as it
has too frequently been called and considered
during the hist twenty years.

64. B. Of the mode by which excessive loss of
blood in disease may be best avoided. — Method if
conducting blood-letting. Frnm the above it will
appear obvious, that if blood-letting were better
managed, and directed so as to make an impres-
sion on the local ailment, but in such a manner
as to avoid being so readily followed by the
reaction which reproduces the malady for which
it was employed, great advantage in practice
would result, and much less blood require to be
removed even in the most acute cases, a. In order
to accomplish this, I have long been in tlie habit
— and have inculcated it in my lectures on the
practice of medicine, from 1824, — of directing the
following mode of practice when large blood-
lettings were required in the treatment of visceral
inflammation: — The patient should be either in
bed, or on a sofa, and in the sitting or semi-
recumbent pQ:-ture, supported by several pillows.
The blood it to be abstracted in a full-sized
stream, and the quantity should have some re-
lation to the intensity and seat of the disease, and
the habit of body and age of the patient, but
cliieHy to its effects ; it should flow until a marked
impression is made upon the pulse, and the
countenance begins to change. Further deple-
tion must not now be allowed ; but the finger
should be placed on the orifice of the vein, the
pillows removed from behind the patient, the
recumbent posture assumed, and the arm secured.
Thus a large quantity of blood may be abstracted,
when it is required, without producing full syn-
cope, which sliould always be avoided ; and
when a large loss of this fluid is either unnecessary,
or might be hurtful, the speedy effect produced
upon the pulse and countenance by the abstrac-
tion of a small quantity will indicate the impro-
piiety of carrying the practice further. In this
manner I have often removed about forty ounces
of blood, where large depletion was urgently
required, befoie any effect was produced upon
the pulse, but always carefully guarding against
syncope ; and by the subsequent means used to
prevent reaction, no further depletion has been
retiuired.

65. b. In order, however, to obtain this object,
a treatment varying with the nature of the disease
is required. Repeated doses of the potassio-tartrate
of antimony, eitlier given in small quantities at very
short intervals, or in large doses, combined with
opium ; full doses of calomel, antimony, and
opium ; of camphor, nitrate of ])Otash, and col-
chicum ; or of ipecacuanha, nitre, and opium, &c.,
particularly the first of these, exhibited so as
to excite nausea, but guarding against retching,
us ijcing liable to induce reaction ; and the in-
dividual antiphlogistic remedies, appropriately
directed, and combined according to the cir-
cumstances of the case, arc the chief means

which I have employed to prevent the return of
increased action after blood-letting conducted as
now stated. The particular measures which may
follow blood-letting are fully explained in the
articles on Injiammation of the different Organs;
but. I may now mention, that when opium is
given with the view of preventing the recurrence
of reaction, it ought to be exhibited in a large
dose at once (two or three grains), either with a
full dose of James's powder, or any other anti-
monial, or with two or three of ipecacuanha, con-
joined with some one of the other substances above
mentioned.

66. It should be kept in recollection, however,
that reaction after large depletions is chiefly apt
to occur in idiopathic inflammations, and other
diseases of excitement, in which the constitutional
or vital powers are neither remarkably lowered
nor depraved ; and when the circulating fluid is
not vitiated by the retention of those substances
in it which require to be eliminated, nor by the
absorption of matters which are foreign to its na-
ture, and injure its purity. Reaction is very opt
to follow large losses of blood in acute rheuma-
tism ; in inflammations of the membranes of the
brain ; and, indeed, of all serous or fibro-serous
membranes; and by its recurrence to re-animate
the local action ; so that a person may be blooded
to that state which has been described as the
extreme result of large loss of blood (§ 54.),
and yet, trusting to this practice alone, the local
disease has either not yielded, or has passed into
one or other of the unfavourable terminations
it is liable to assume, particularly dropsical effu-
sion. In the course of practice 1 have frequently
seen persons who had experienced attacks either of
pleuritis, pneumonia, peritonitis, enteritis, or of
some other inflammation, and who had recovered
with great difficulty, and after a long convales- ~
cence. Upon inquiry, I found that they had
always been blooded largely, and to syncope, —
some of them four, five, or even six times, but
scarcely ever less frecjuently than thrice ; and yet,
upon a subsequent attack of inflammation in its
most acute form, in the same or some other organ,

a single depletion, practised as I have recom-
mended above, and followed by the means most
likely to prevent the return of reaction afterwards,
to subdue the local action, to solicit the flow of
blood to other parts, and to equalise its distribution
over the body, has been sufficient; or, at most, a
single repetition of the venesection has been all
that has been required.

67. c. When the chest is dull on percussion,
the heart congested, the liver large, and the veins
distended ; or when the circulation is full and
strong, the capillaries injected, the lips and mu-
cous surface red, the muscles firm and large, or
the respiration oppressed, blood-letting is generally
reciuired, and is well borne. It is also necessary
even when the pulse is languid, the external
venous circulation diflicull, and the surfaces pale,
if these symj)toms be conjoined with those in-
dicating internal congestion. (See Congestion.)
On the other hand, persons with an open, soft,
full pulse, florid countenance, lax muscles, &c.,
although they may bear moderate loss of blood,
yet suffer more from large depletions than those
of a pale, dry, thin, but muscular and rigid habit
of body.

68, Under no circumstances ought a patient to

BLOOD — Effects of large Loss of — Treatment.

179

be blooded whilst his head is nearly on the same
level with the trunk ; and the utmost care should
be taken in having recourse to venesection in
cases of dilatation of the cavities of the heart, par-
ticularly those of a passive nature. It is seldom
necessary in such cases : and if circumstances
should arise to require it, the blooil should be
taken, in the position I have inculcated (j 64.),
from a small orifice and to a small extent. In
the majority of cases, the state of the venous
circulation, if duly examined, furnishes some in-
formation as to the quantity of blood in the sys-
tem, and therefore sometimes becomes a valuable
guide to blood letting in some doubtful cases.

69. \Vhen the superficial veins are distended,
of a deep or daik colour, and the blood flows
(juickly, and the veins fill rapidly on applying
friction and pressure — indicating that their usual
state of fulness does not depend upon interrupted
circulation about the right side of the heart, or
in any part of their course — we may infer that
tiie system is sufficiently supplied with blood.
But if the veins are small or pale, the body not
being fat ; if they swell slowly upon a liga-
ture being applied above them ; or are readily
emptied by friction, and very slowly refilled,
we must infer the existence of a feeble state of the
circulation, and a deficient as well as poor state
of the blood: and the inference will be further
verified if we find this slate associated with a pale
sickly appearance of the countenance and integu-
ments ; a small, feeble, and quick pulse; and
paleness of the lips, conjunctiva, tongue, and
gums. (See § 43.)

70. C. Of loss of blood in relation to diseases oj
depressed vital power, S;c. — There is a numerous
class, or rather classes, of diseases, in which
blood-letting, either in small quantity, or carried
too far, is especially injurious. All those in
which the circulating fluid is poorer and thinner,
or less pure, than in health, particularly chronic
and malignant diseases presenting more or less
of the symptoms of anaemia, and disorders occur-
ring in ill-fed and emaciated subjects; those in
which the vital endowment of the blood-vessels,
or their tonic contractibility, is partly lost, or ma-
nifestly reduced, as various forms of fever, puer-
peral and other diseases in which hurtful matters
are apt to pass or to be absorbed into, or not to
be eliminated from, the blood ; all those in which
the vital cohesion of the soft solids is diminished,
and the fibrine of the blood is incapable of coher-
ing in the inanner necessary to form a tolerably
firm coagulum, are injured by large bleedings, or
even by depletion to any extent. In the first of
these, it is obvious that blood cannot be spared : in
the second, although its loss might not be felt in
other respects, the vessels cannot accommodate
themselves to the state of their contents when any
considerable quantity is abstracted ; and in the
last, as well as in them all, the vital manifest-
ations of the circulating system, and of the solids
generally, of which cohesion is one, is so far in-
jured, that the primary morbid condition from
which they all proceed is increased by the oper-
ation ; and, moreover, a greater disposition lo the
absorption of morbid matters is imparted to the ab-
sorbing function, when such matters are within the
sphere of its operation, by the vascular depletion.

7L 1 may, in conclusion, remark, that all dis-
eases essentially spasmodic, and coipsisting of

irregular action of muscular parts, or of altered
sensibility of nerves, or of morbid exaltation of
their peculiar sensibilities, even when affectino-
internal organs or the heart itself, and when no
conclusive evidence of inflammation exists, will
either be aggravated by loss of blood — in some
cases even to a moderate extent — or be leadily
followed by the efTtcts which have been described
as consequent upon an excessive evacuation of
this fluid. But I may further add, that, in many
cases where the above reasons for abstaining from
large or repleted depletions, or from venesection,
strictly apply, local depletions, umler due restric-
tions, may be resorted to with advantage.

72. iii. Treatment of the Effects of large
Loss of Biood. — This will necessarily vary with
the particular effect produced, and the state of the
patient, and of the disease in which excessive loss
of blood occurred. The more immediate effects
of the loss are the Jirst to claim attention ; the
other morbid conditions which result from it more
remotely, will be considered in succession.

73. A. Treatment of the primarii effects of loss
of bhod. — The more immediate effects (§ 53.)
generally require the recumbent posture, free ven-
tilation, and airy apartments ; in the extreme cases,
stimulants, sprinkling the face with volatile and
fragrant fluids, and even the transfusion of blood.
In the worst cases, and particularly when the
loss of blood has occurred from the rectum or
vagina, the head and shoulders should be placed
lower than the pelvis ; and care should be taken
to ascertain whether or no internal hEemorrhage
is going on, as far as this m.ay be accom-
plished (see Uterine Hemoi-rhage). In all
cases of hajmorrhage, the involuntary discharge
of urine and evacuation of the bowels ought to
be considered most dangerous symptoms — even
more so than the occurrence of convulsions —
and the most decided measures should be instantly
adopted. Where we have reason to suppose that
transfusion will be required, it s'hould not be de-
layed too long, as the risk from delay is infinitely
gieater than that from the operation performed
by an expert surgeon, and with a proper appara-
tus. In cases where convulsions or delirium oc-
cur, or when these pass into coma or lethargy, it
will be necessary lo exhibit, internally, stimuli, as
£ether, spirits of ammonia, and camphor, with a little
tincture of hyoscyamus ; to sprinkle a;lher, or laven-
der water, or eau de Cologne, over the face and
head ; to apply a blister to the nape of the neck,
or on the epigastrium ; to support the animal
heat in the trunk of the body and extremities;
and to administer the lightest and blandest
nourishment. Recovery fioin large loss of blood
is usually quick, when the functions of digestion
and assimilation have not been greatly injured
by it; but when they remain imperfect, or remark-
ably disordered for some time afterwards, we may
dre.id the formation of visceral disease, and should
direct change of air, voyaging, and travelling,
with the use of tonic and deobstruent mineral
waters, and appropriate internal medicines.

74. B. Treatment of reaction nj'ter large loss of
blood. — Careful reference ought to be had by
the inexperienced practitioner to the symptoms
indicating this state (§ 58.), so as to distinguish
between them and the general excitement conse-
quent upon internal inflammation. 'I'his state
will require means modified according to the fea-
N 2

li

BLOOD — ITS Alterations in Disease.

tures it assumes. But generally tlie morbid re-
fiction existing- in the head, and rendering all the
senses reniarkahly acute, and the system suscep-
tible of impressions, as well as the distressing
palpitations of the heart, require the utmost quiet,
and small doses of hyoscyamus, or extract of hops,
Aviththe preparationsof ammonia, and mild nourish-
ment. Where the throbbings or pains in the
head are urgent, the surface of the head warm, or
delirium exists, cold spirituous lotions, applied
over the head, and full doses of hyoscyamus with
ammonia, or moderate doses of the acetate or the
hydrochlorate of morphia, with weak brandy and
water, and warmth applied to the lower extremities,
will be required.

75. C. Treatment of consecutive exhaustion, or
sinking. — Here stimulants are required in larger
doses ; and should be administered by the mouth,
in the form of enema, and externally. It is pos-
sible that transfusion would also be of service in
this state of the system. If coma be present in
this stage, large do«es of camphor, aether, and
ammonia are required, with the tepid effusion on
the head ; blisters, or mustard cataplasms to the
nape of the neck, or epigastrium, or to the feet.
In more chronic cases of exhaustion or sinking,
gentle nourishment, in small quantities and often ;
warm tonics, combined with gentle aperients, in
order to remove morbid secretions, and relieve
flatulence ; nutritious enemata, or injections of
gruel or mutton broth ; and small quantities of
weak brandy and water ; are the best means that
can be adopted.

76. -D. Treatment of certain effects of depletion
in relation to disease. — a. Large loss of blood
during diseases of excitement (§ 63.) requires a
treatment but little modified from that already re-
commended. \\'hen it has occurred during in-
flammation, a certain degree of irritative action
may stdl continue, notwithstanding the excessive
loss of blood, occasioning dropsical effusion into
shut cavities ; and, when the disease is seated in
the lungs, effusions in the bronchi or air-cells,
which the powers of life are insufficient to throw
off, or to expel. In such cases exteinal deriv-
atives, and a combination of gentle stimuli, with
diuretics, anodynes, and diaphoretics, in order to
equalise the circulation, and to lower the irri-
tative action in the part affected, often prove of
service. When the primary disease is seated in
the head, the tepid or cold effusion, cold lotions
to the head ; external revulsants applied to the
nape of the neck, or to the lower extremities ;
anodynes, camphor, with hyoscyamus, or with
acetate of morphine ; and the promotion of the
alvine and cutaneous secretions and excretions,
constitute the principal measures, together with
those already enumerated (§§ 74, 75.).

77. li. Loss of blood occurring during diseases
of vital depression {§ 70.) requires the most ener-
getic means. The objects very generally are to
restore, as far as may be, the vital endowment —
the tonic contractility, of the vascular system, and
to enable it to act with sufficient energy on the
fluid circulating through it; to increase the vital
cohesion of the soft solids; and to excite the
secreting organs to remove the hurtful ingredients
that may have passed into or accumulated in, the
remaining fluiil, and which tend to vitiate the
whole of the structures, and to sink still lower
the already depressed powers of life. U'liese ends

can be attained only by exhibiting, in frequent
doses, the various tonics and stimuli ; particularly
those which tend to arrest or to counteract the
morbid changes going on in the frame, and to rally
the powers of life. Of this kind are the prepar-
ations of bark, or quinine, combined with camphor,
the asthers, particularly hydrochloric aether, the
preparations of serpentaria, spirits of turpentine,
wine, opium, and various remedies of the same de-
scription, combined according to circumstances,
and generally exhibited in small or moderate doses
frequently repeated. External stimuli, rubefa-
cient cataplasms and liniments, stimulating and
tonic enemata, injections of mulled port wine, with
opium and camphor, are often of great benefit.
When the secretions require to be carried off,
rhubarb and other tonic aperients may be em-
ployed. When the disease is attended with coma,
blisters or sinapisms to the nape of the neck, epi-
gastrium, or the feet, may be employed ; and either
of the following formula, in the Appendix, ex]uh\t.e(l
(see F. 423. 496. 845. 906.). If low muttering
delirium be present, the same treatment as is recom-
mended for this state in typhoid fevers is required.

BiBLioG. AND Pepeb Montn'n, Des Effets des Diffe-

rentes Especes d'Kvacuatioiis Sanguines, &c. Lyons,
18111 — Seeds, in Lond. Medical Gazette, vol. v. p. 433.—
M. Hull, On tlie Effects of Loss of Blood, in Trans, of
Med. and Cliiiurg. Society, vol. xiii. p. 121.; and Re-
searcties relative to the Morbid and Curative EfTects of
Loss of Blood. 8vo. Lond. 1830.— T/ie Author, in Lon-
don Medical Repository, vol. xx. p. \5 — Piorry, Mfe-
moires sur la Circulation, &c. Paris, 1831.

VI. Alterations of the Blood in Disease.
78. It will be necessary to the accurate estima-
tion of the causes and results of the various changes
of the blood in disease, briefly to consider the
relation in which the different functions of the
body stand to the blood. These functions are of
the following kinds: '^\z. d^ sun guif action, nutri-
tion, depuration, and secretion; one organ per-
forming, or contributing to two, or even three, of
these offices. We know that digestion, absorption,
arterial circulation, and respiration, are necessary
to the formation of the blood, and to the nourish-
ment of the tissues, we also know that absorption,
nutrition, secretion, and venous circulation, are
concerned in rendering the blood impure, by con-
veying hurtful ingredients into if, or allowing
others to accumulate in it, or by destroying the
relative proportion of its constituents ; and that
various organs, particularly tho^e of secretion and
respiration, are actively concerned in eliminating
such matters as become injurious by excess, or
pass into the circulation from the various sources
of impurity which suiround it. Hence it must
be evident, that changes in the solids, and particu-
larly in those viscera which are concerned in the
supply and waste of the blood, as well as in its
depuration, must be followed by changes in the
state of this fluid ; unless when one or two organs
merely have their functions interrupted, and
others performing analogous actions to lliese dis-
orders assume a vicarious office. It must be
evident, therefore, from this, that the doctrines of
solidi^m and humorism are, to a certain extent,
both coirect , that, although disorder may origin-
ate in either, it cannot be long limited to one or
the other, but must extend more or less to both,
according to the nature of the causes, and the
organs or parts where their impression is made.
We observe in the course of practice, that certain
morbid 0|^ poisonous ingcsta make but little im.

BLOOD — ITS Alterations in Disease.

181

pression on the system, until they are absorbed into
tlie circulation, and by their presence there dis-
order various organs or parts ; whilst other sub-
stances make an immediate impression on the
nervous system, and, through its medium, impede
the I'unclions of secretion and depuration, and
thus the blood itself is rendered impure, and tlie
source whence all the frame is more or less viti-
ated. Various feveus furnish most satisfactory
illustrations of this position.

79. Having already considered changes in the
quantity of the blood, alterations in its (jualilies
are next to be viewed. The facts winch have
been observed, connected wiih this subject, are
few and deficient in precision ; and the majority
of tiiose who have directed their attention to it,
have merely described chemical conditions and
combinations presented by this fluid after it had
been for some time removed from the body, and
had lost whatever vital endowment it may have
received from the vessels and tissues in which it
circulated, or had undergone important changes
incidental to this state ; instead of describing at
tlie same lime such vital manifestations as it may
have presented upon its removal, and the relation
of its chemical states to the pathological conditions
of the body.

80. As we have seen that organisation com-
mences in the chyle, and that this fluid is the
chief source whence the blood itself is formed, the
importance of studying the alterations of the blood,
in connection with the stale of this fluid, is evi-
dent; but the difficulty of the investigation gene-
rally precludes many from engaging in it. At the
same time it must be admitted, that very important
changes may take place, not only in the blood,
but also in the fluids which supply it, and are
secreted from it, without being made manifest to
our senses upon the most careful examination.
1 shall now, Jint, furnish proofs of important
changes in the constituents and state of the blood
in various diseases; and next consider the causes
of such changes, and the results to which ihey
usually lead.

81. i. Proofs of Change. — A. In the propor-
tion of the chief constituents of the blood, a. The
quantity ot alhumen varies considerably in disease.
It is not sensibly diminished by large or repeated
blood-letting, unless the quantity ot blood, in rela-
tion to the bulk of the body, be much diminished.
In many inflammatory diseases, and in a large
proportion of ca~es of active dropsy, the relative
proportion of albumen is often very much in-
creased. This has been shown by Blackall,
Trail, Gendrin, Bright, and several authois.
I have always found it remarkably increased in
most of the exanthemata, particularly before the
eruption has come out. Gendrin shows that, in
inflammatory diseases, the serum of the blood often
contains twice as much albumen as in the healthy
state. When this is the case, the blood feels
remarkably viscid to the touch. In diseases of
debility, and when the blood is apparently de-
ficient in quantity, and poor in quality, the al-
bumen is generally very much diminished, being
sometimes less than half its usual proportion.
M. Gendrin and M. Andral think that it may
also be altered in its nature as well as quantity ;
and I believe, from appearances which I have
observed in the advanced stages of several dis-
eases, thdt their opinion is correct. In these cases.

the albumen seems either precipitated to the bot-
tom of the serum, or suspended in it like a cloud,
giving it a turbid opacity.

82. b. The proportion of the watery part of the
blood has been shown to vary in health; but it
varies still more in disease, and even in different
stages of the same malady. This change is not,
however, limited to one, or even a few, of the
constituents of this fluid ; but sometimes is ex-
tended to the most of them. Blood-letting, in
acute diseases, diminishes the proportion of coa-
gulum ; and, if diluents be supplied, increases
greatly the proportion of serum, without lessening
the quantity ot albumen, unless the depletion be
carried very far. In several chronic diseases of
debility, in the stages of excitement and exhaus-
tion in fevers, and in the last period or decline of
the acute exanthemata, the proportion of serum
is very considerable, ov\ing to the interruption of
the secreting functions; but in acute inflamma-
tions, and the early stages of some of the exan-
themata, the blood is of a deep colour, and rich
in cruor, with an increased proportion of albumen
and of fibriiie. In the advanced stages of disease,
attended with fluid evacuations, the watery part
of the blood is diminished. This is remarkably
the case in the pestilential cholera, dysentery, and
in some forms of diopsy.

83. c. The colouring matter of the blood evi-
dently undergoes some alteration during febrile
and malignant diseases. It has recently been
supposed that such change has an intimate connec-
tion with the proportion of the saline constituents
of this fluid, — a diminution of these rendering the
colouring matter dark coloured, whilst an increase
of them has an opposite effect ; and certainly va-
rious facts seem to confirm the opinion. But
this alteration is one merely in relation to colour,
which is unquestionably rendered much more
deep or black in the last stages of the diseases
now alluded to. But besides alteration of colour,
there are others which may be termed dyna/nic,
inasmuch as they relate to the vital endowment
of the globules, or, if not of the globules, of the
fluid generally. In the diseases referred to, and
after the operation of virulent poisons, the con-
dition of the colouring matter is remarkably
changed : it separates readily, and almost before
dissolution, from the central corpuscles which it
surrounds; and, passing through the exhalant
vessels of mucous surfaces, with the serous or
v\aiery part of the blood, gives lise to the sanious
cruor, and the dissolved blood, which we some-
times observe issuing from these parts shortly
before or after death ; and probably to the black
vomit in yellow fever. In cases of infection by
animal poisons or morbid secretions, this separation
of the colouring matter, and solution in the serum,
take place very early, indeed almost immediately
after death; and it is evidently owing to this
change of the blood, that the interior surface of
the blood-vessels becomes so deeply coloured,
without any other appearance of inflammation.
Indeed, the evidence adduced by I\l. Trousseau
fully proves this to be the case. (Archives Gen.
de Mid. t. xiv. p. 321.) 'I his further accounts
for the coloration of the interior of arteries in
fatal cases of adynamic or malignant fevers, — an
appearance first paniculaily noticed by J. P.
Frank, and subsequently by many others, and
by some incorrectly ascribed to inflammation.

N 3

182

BLOOD — ITS Alterations in Disease.

84. d. The jihrine varies greatly in its quan-
tity, and as to the states in which it presents itself
in the blood removed from the body. Its con-
dition will be somewhat modified by the manner
in which blood-letting is performed ; but generally
it soon separates from the serum, and, with ihe
red particles, forms the crassamenlum or clot,
which will vary in its appearances with the de-
gree of nervous energy exerted by the organic
nerves on the vascular system, and the quantity
of fibrine, o. First, the fibrine and red globules
may be in much greater proportion relatively to
the water and albumen, and sldl thecrassamentum
formed therefrom will be very different, according
to the state of vascular action and nervous energy
at the time wiien tiie blood was abstracted. If
the vascular action be increased, or in a healtiiy
state, and the vital energy unexhausted, the fibrine
will contract into a firm and large coagulum. If
the fibrine retain its relatively large proportion,
and vascular action be exhausted, it will contract
so imperfectly or loosely, as to enclose a large
portion of the serum, and to leave but little of
this fluid surrounding it. In the former case the
coagulum possesses much density : in the latter,
extremely little ; indeed, sometimes not sufficient
to separate it sensibly from the serum. In such
cases the blood is rich, although otherwise very
different in appearance, owing to the stale of
action and vital power.

85. ;3. In the second place, the fibrine may be
in small quantity, and yet present a state of firm
attraction, fbrniing a small coagulum in the midst
of a larger proportion of serum than is usual in
health. Or the proportion being still small, the
cohesion of the fibrine may be so weak as to form
a tolerably large coagulum ; whilst, in other cases,
it will scarcely separate from the serum, owing
either to its diminution, or the weak attraction of
its corpuscles. I have met with it in several
cases so nearly wanting, and so delicient in at-
traction in other instances, as not to form any
coagulum ; the red particles having been, as it
were, precipitated to the bottom of the vessel in
a dark or blackish sediment, without any cohesion
in the form of clot. From this it will be inferred,
that the quantity of fibrine cannot be reckoned
from the apparent size of the coagulum merely,
but from the size in connection with densitv or
degree of cohesion. When the bloud is deficient
in red globules, and fil)rine, it has usually re-
ceived the appellation of poor blood ; the degree
of cohesion existing between the particles of fibrine
in it, as well as in rich blood, being the general
index of the degree of nervous power. But there
are apparent exceptions to the indications it pre-
sents. Thus, in acute rheumatism, alter repeated
depletions, injudiciously resorted to, — injudi-
ciously, because a frecjuently injurious, and seldom
a beneficial practice — and during the reaction con-
sequent upon repeated blood-letting, the fibrine,
although much reduced in quantity, will often still
continue to adhere firmly, or even to form, in some
cases, a buffy coat, and yet the powers of life are
reduced very far beyond what the state of the
fibiine would seem to indicate. In these cases, the
cohesion of the coagulum, and the formation of the
buir, are, as well as in many other circumstances of
disease, princqially the result of vascular reaction,
occasioned by morl)i(l excitement of the nervous
influence; and as long as these states exist, this

condition of the coagulum will occur, although
depletion be carried to the utmost extent.

86. y. Whilst the blood is still circulating in
the body, particularly in the last stages of various
chronic diseases, the repulsion existing between
its existing globules may be so far destroyed as
to admit of the fibrinous corpuscles adhering to
each other, in some part of the vascular system,
or even in one of the cavities of the heart. The
fibrinous concretions thus formed are attributable,
1st, 'J'o retarded or obstructed circulation of the
blood in the part. Van Swieten and H aller state
that flocculent and fibrinous coagula have formed
in the blood of the pulmonary artery during syn-
cope and the cold stage of agues ; and they, as
well as numerous later observers, have found these
productions after exposure to extreme cold, and
when death has been preceded by a very languid,
obstructed, and irregular state of the circulation,
2d, To effusions of a small portion of coagulable
lymph from the inside of a part of the vascular
lining, during a state of inflammatory irritation;
which lymph may have become the nucleus around
which the fibrinous particles may have collected, or
the bond of cohesion between them in the first in-
stance : and, 3d, Particularly as respects those fibri-
nous concretions, in the centres of which purulent
or tubercular matter has been found, as in the in-
stances adduced by MiM. Legroux, RIaiuchai,,
and subsequently by others, to the absorption of
these matters, or to their passage into the blood
from the internal coats of the vessels on which
they may have been formed ; and from becoming
nuclei around which the fibrine has concreted.
In some instances, in which these fibrinous
masses have been found, little or no connection
with the surrounding vessels can be traced. M.
Andral supposes that these concretions are pos-
sessed of a separate vitality, and that the matter
detected in their centres is a product of vessels
previously formed in them. This opinion, how-
ever, cannot be supported, inasmuch as the mat-
ters formed in their centres have no relation to,
nor have they been found often surrounded by,
blood-vessels ; and, when vessels have been de-
tected, the firm attachment of the concretions to
the inner surface of the vessels attests the manner
of their formation to be identical with that of other
productions of a similar kind.

87. S. But the attraction between the particles
of fibrine, which is usually observed when the
blood is removed from the sphere of vital endow-
ment, in which it participates, instead of being
exerted, as now stated, within S(^iiie part of the
vascuhir system, n^ay be entirely lost, or be very
irregular or imperfect. In such cases, the blood
either remains altogether fluid ; or its fibiine, and
some part of its albumen, form grumous paiticles,
or minute fragments, which are either suspended
in the serum or mechanically mixed with it,
forming a sanious cruor in the vessels. This
latter state is observed sometimes locally, and
often generally,' immediately alter death; as in the
veins of the spleen, liver, of the extremities, &:c.
A thick, dark, and treacle-like slate of the venous
blood, and a vcnousappearance of the arterial blood,
are not inrrtciuent during life ; particularly in pes-
tilential cholera, in asphyxia, hydrophobia, &c.

88. f. 'i'Uc l>it£'ii coat observed to form the upper
part and surface of the coagulum, most frequent-
ly, in cases of inflammation, consists of fibrine,

BLOOD — ITS ALTEUAxroN's in Disease.

183

according to Deyeux and Parmentier ; of
fibrine, and especially concrete albumen, in the
opinion of Fourcuoy, Vauquelin, and Tiie-
NAiiD ; of fibrine and gelatin, according to Or-
FiLA ; of fibrine, containing serum between its
fibres, and albumen, or very albuminous serum,
according to Dowler and Gendrin. Berze-
Lius considers that it may contain all the elements
of the coagulum. It manifestly is produced by
the concretion of the fibrine, which, parting from
the colouring matter, forms a whitish yellow, or
slightly greenish layer, varying in thickness fiom
a Ime to one or two inches; and giving rise to
the cupped appearance of the clot, by the firmness
of attraction between its particles. The form-
ation of the buff may be somewhat favoured by
the size of the orifice from which the blood has
been drawn, the rapidity with which it lias fiowed,
and the form of the vessel in which it has been
received ; but the buff itself entirely depends upon
the state of the fibrine, which, in conjunction with
a portion of serum and much albumen, not only
chiefly constitutes it, but modifies it in the man-
ner already noticed, according to the state of vital
influence and vascular action. (See § 84. and
art. Inflammation.)

89. e. Respecting changes in the saline con-
stituents of the blood, we are provided with but
little information, and that by no means of a pre-
cise character. So much difl^erence has existed
amongst chemists respecting the actual saline in-
gredients of heahiiy blood, and their state of com-
bination in this fluid, that a standard has not
been furnished for comparative observation. Ac-
coniing to Dr. Stevens, they are very sensibly
diminished in the blood of patients aflfected by the
fevers of warm chmates ; and Dr. O'Shaugh-
NESSY has shown that the blood of those suflTering
from pestilential cholera contains much less saline
constituents than in health.

90. f. The electrical condition of the blood may
also be changed by disease. Bellingeri states
the electricity of venous blood to be equivalent to
that of antimony ; that it is an imperfect conductor
of this agent ; and that its electricity is diminished
in inflammatory diseases. According to Rossi,
the blood presents, in severe fevers, modifications
of its electrical states. That electricity, when act-
ing energetically on the frame, afl^ects the blood
(probably through the medium of the nerves sup-
plying its vessels) in a most intense manner, is
shown by the dissolution and decomposition of this
fluid after death from this agent. 'The evident
effect of light upon the blood, in rendering it both
more abundant and rich, may be attributed to the
electrical states of the solar rays.

91. g. The temperature of the blood has been
observed to vary, during the course of disease,
from 8G° to 104°. It has been observed as low
as the former grade in pestilential ciiolera, and the
cold stage of ague ; and as high as the latter in the
stage of excitement in fevers, and visceral inflam-
mations. Its temperature is evidently owing to
the degree of nervous power in connection with
vascular action.

92. B. Changes in the intimate nature of the hlood,
for which mere difference in the proportion of its

constituent'! cannot account ; and which are refer-
rible to the state of vital power. — Important chaiiges
of the blood, which are evidently not referrible
merely to alteration of the healthy proportion of its

constituents, although sucli alteration may be con-
sidered as often co-existing with those other in-
appreciable modifications upon which its morbid
eflfects chiefly depend, occur in the course of
various diseases ; and, when once induced, occasion
not only violent or fatal effects as respects the
individual subjects of tliera, but also similar
changes in healthy persons inoculated with this
diseased blood. Dr. Home communicated measles
by means of blood taken from persons afl'ected by
them. DuHAMEL records a case of a butcher, who,
having put in his mouth the knife with which
an over-driven ox had been slaughtered, had his
tongue and throat swollen a few hours afterwards,
and an eruption of blackish pustules over his body.
He died in four days. Another person, having
wounded himself in the hand with a bone of the
same ox, was seized with inflammation of the
arm, followed by mortification and death. Two
females experienced also gangrenous inflamma-
tion from a few drops of the blood of the same
animal having fallen upon the hand of one, and
on the cheek of the other. Inoculation with, or
even the simple contact of, the blood of diseased
animals, may produce in men the malignant
pustule. Of this numerous proofs have been
furnished. MM. Dupuy and Leuret introduced
into the cellular tissue and veins of a sound horse,
blood taken from a horse affected with malignant
carbuncle (pustule maligne), and thus produced
the disease. The serious effects also observed to
follow wounds in dissection, either of recently
dead bodies, or those in which decomposition has
commenced ; the changes which take place in the
blood, either primarily or secondarily, in various
maladies ; the septic influence of certain animal se-
cretions and poisons on the tissues to which they are
applied, on the blood, and on the frame generally ;
are among the most important phenomena of dis-
ease. I sliall, therefore, proceed to a more minute
examination of this department of pathology than
it has recently received. Thai these changes are
of a most important nature ; that they may arise
from various causes, or from spontaneous alter-
ations taking place in the blood while circu-
lating in the vessels of the animal, even whilst
those changes are so slight as to escape detection
by our senses ; and that the blood, when thus
changed, will be the cause of disease presenting
a malignant character, when applied to or in-
serted into the tissues of healthy animals, are
facts which the preceding, as well as other evi-
dence about to be adduced, fully demonstrate.
The chief of these changes, to which I attach the
utmost importance, having observed them to exist
more or less in a large proportion of cases where
blood has been removed, or escaped from a vessel,
in malignant or adynamic diseases, or in the last
stages of vei'y acute and dangerous maladies, are
the following : —

93. a. The blood has generally a somewhat salt
taste in health, evidently depemling chiefly upon
the quantity of chloride of sodium contained in
it. In various maladies, particularly those which
are malignant, and in tlie advanced st:iges of
fevers, the taste is not so remaikable, particularly
when the blood assumes a darker hue than na-
tural, b. The peculiar odour of this fluid upon
emission from a vein is also very remarkably
changed in these maladies. Haller has ad-
duced numerous instances of this in his great
N 4

184

BLOOD— ITS BuFFY Coat.

work ; and various authors — and amongst these,
Van SwiETEN, Hoffmann, Sen WENCKE.Huxii AM,
Linings, &c. — have noticed a remarkable I'oetor of"
the blood in adynamic fevers and pestilential ma-
ladies. I liave observed a peculiar odour of the
blood in cases of malignant puerperal fever. We
are informed by Louis de Castro, that the blood
of two plague patients infected the air of their
apartment with a fcctid odour; and Zacutus
mentions, that three persons were struck dead by
the odour exhaled from the blood drawn from the
vein of a person infected with plague. Muhalt
also states that a cadaverous fcetor emanates from
the blood of persons afTected with this malady ;
and Baglivi mentions that a nearly similar phe-
nomenon was observed in the blood of patients in
the advanced stages of a very fatal epidemic
fever. IIali.er prognosticated a fatal issue,
chiefly from this symptom, in a case to which he
refers. Zurinus, Alprunner, and Vater, allude
to cases where physicians were dangerously in-
fected by the foetor of the blood, upon its abstrac-
tion from the veins of persons in malignant
and contagious diseases. Boisseau states, that he
has been very disagreeably affected by the
odour of the blood just abstracted from the veins
of persons attacked by severe disease of the chest
or abdomen. Pringle relates, that an individual
■was seized with dysentery, after inhaling the
odour from the blood of a dysenteric patient,
kept for a long time. The blood taken from a
vein in the arm of a woman in a malignant fever,
was, according to Mouton, so offensive, that the
surgeon and assistants fainted in consequence.
It may be therefore inferred that both the odour
and the taste of the human blood may be very sen-
sibly changed in the advanced progress of various
adynamic, infectious, and malignant maladies.

94. c. Softness or firmness of the coagulum
has been already noticed, in connection with the
condition of the fibrine ; and stated to be often
independent of the quantity of this constituent,
and to be chiefly owing to the degree of nervous
influence and vascular action. In the class of dis-
eases now alluded to, the coagulum is not only
remarkably soft, but, from the want of adhesion,
and fiom the solubility of the colouring matter in
the serum, is sometimes readily converted into a
reddish fluid by slight agitation with it. In other
cases no coagulum forms, the fibrine being sus-
pended in small albuminous-like fragments in the
serum, and the colouring matter precipitated to
the bottom of the vessel. In several instances,
these constituents are not separated from the
serum, but seem combined with it ; the whole
mass remaining more or less fluid, and presenting
a reddish, reddish black, or blackish colour, from
the time of its emission till it furnishes evidence
of decomposition. I have met, in other cases,
with the blood changed into two parts : the upper
and serous part consisting of a remarkably soft
gelatinous ma^s, sometimes almo-t fluid, resem-
bling very weak or uncoagulated calves- foot
jelly, and forming from two thirds to four fifths of
ilie whole; the colouring matter being spread
over the bottom of the vessel, and presenting a
dirty, black, and muddy appearance. I have also
oljserved, and very lately, in two cases to which I
had bc('n called by neighbouring practitioners,
the colouring part of the blood, with a portion of
the fibrine and albumen, deposited on the bottom

of the vessel, of a colour between a deep brown
and dirty dark grey, the serum being very abun-
dant and turbid.

95. d. -Appearances analogous to the above
are also observed whilst the blood is in the veins
of the dead body. In many cases, it is either
fluid or semifluid, treacly, and of a dark colour.
In others it is apparently decomposed and gru-
mous ; and in some, either consisting of perfectly
fluid blood, or resembling water coloured with
a reddish brown matter. In some cases, where
the blood has been partially coagulated or sepa-
rated into a grumous state, the more fluid parts,
generally in the form of a bloody or sanious
serum, have percolated the tissues, and escaped
through the relaxed exhaling pores and extremi-
ties, and passed into the shut cavities ; but more
fiequently flowed out on the mucous surfaces,
leaving the moie consistent parts of the blood in
the vessels in larger proportion than in heahh.
In all these cases, the blood, whether that drawn
from the veins, or found in them after death, seems
not so deficient of fibrine, as that its state is changed
owing to exhaustion or annihilation of vitality, by
virtue of the possession of which (derived from the
influence of the organic nerves on the blood-vessels
and internal viscera) its fibrinous corpuscles are
aggregated into a coagulum when removed from
the veins.

96. ii. Further Proofs of Change in the
Blood, and its relation to particular kinds
of disease. — A. The existence of a huff on blood
drawn from a vein has always been regarded by
practitioners as a sign, not only of disease, but
also of inflammation. Gendrin (following the
path of his predecessors) asserts that the blood is
in a verii iiijiummatory state, when it coagulates
quickly ; is covered by a thick, concave, dense,
elastic, buflF, of a yellowish white ; and separates
into a truncated, ovoid, dense, elastic clot, floating
in a serum, which bears a proportion to it of one
and a half or two to one; is slimy, colourless,
slightly turbid at the bottom of the vessel, and
without any trace of colouring matter. The clot yi
more rarely is of the shajjC of a truncated cone ;

is very dense at its surface, pretty soft at its base ;
does not float; and is more voluminous than the
serum, which is of a pale yellow : in this case the
blood is more than very inflammatory.

97. He observes that the blood is injlammatory,
when the buft' is thick, diaphanous, of a dull
white, and covers a rather dense c}lindrical clot,
beneath which is the serum, yellowish, and equal
at most twice the volume of the clot, a slight
colouring deposit being found at the bottom of
the vessel. If there be any bufl^ when the
blood is Uib-inflammatiiry, the clot does not float,
but is suspended in the middle of the li(|uid, or is
jirecipitated, and is less dense than in inflamma-
tory blood ; the serum is slightly tinted with red
at the bottom of the vessel, where a layer of
colouring matter may be seen. But usually
there is no buff; the clot is dense, ovoid, floating,
and presenting a red stratum on its surface ; the
serum is viscous, limpid, somewhat turbid at the
bottom of the vessel, where no colouring matter
can be observed. The blood in this slate coagu-
lates quickly, and yields serum of at least twice
the volume of the clot. When the proportion of
serum is less than twice that of the clot, and the
hitter is soft, cylindrical, voluminous, although

BLOOD — Changes of its Vital Relations.

185

floating, the blood is scarcely sub-hijUimmatory ;
it is so in a slight degree when the clot is dense,
ovoid, and pendant in the middle of the vessel ;
when, of those two last mentioned coagula, the
first occupies the middle, and the second the bot-
tom of the vessel, the blood is more injluinmatory.

98. This description is tolerably accurate, par-
ticularly as respects injiammcitions of serous mem-
branes, pneumonia, and other visceral injiamma-
tions, wlien the circulation is free and the pulse
not oppressed. But every one must have ob-
served, that there may be very acute inflammation,
and yet the blood is not bufTed, particularly in
children ; and on the other hand, that tliis ap-
pearance often exists to a greater or less extent
in plelhoric persons, in pregnant and puerperal
females, in those who resort frequently to blood-
Jetting, and in rlieuniatism even in its least in-
flammatory forms. i\I. Gendrin also ens as
respects tlie rapidity with which inflamed blood
coagulates. When the powers of life are unim-
paired, and the circulation quick, and particu-
larly during acute and general vascular reaction
and vital or nervous excitement, coagulation is
either longer in taking place, or, if it commences
soon, it is much later m being completed than in
other cases ; but much will depend upon the stream
of blood. If this be full, quick, and large, and the
temperature of the apartment high, coagulation is
delayed, and the buff more readily appears. If the
stream be small, slow, and the temperature low,
coagulation is rapid, and no bufi'is formed.

99. In some cases of intense iujlammalion, no
buff appears, the blood coagulates slowly, the
clot is less dense, and less serum is formed than
in health; but the coagulum is very distinct
from the serum, into which it does not at all
dissolve. This, although another condition of the
blood in a state yf inflammation, is observed also
in cases where the inflammation is not excessive,
as every praciitioner must have had numerous
opportunities of ascertaining. Two superimposed
layers of buf^'are sometimes seen — the one soft or
friable, the inferior more dense, more compact, —
but not (as is asserted) only when suppuration
has taken place in an inflamed organ ; still less
must we receive as a sign of suppuration the
dusky white or opacity of this buft', an^l the pre-
sence of a mucous stratum at the bottom of the
serum. In short, it does not always happen that
the bufl^ siiovvs itself on the blood in chronic
phlegmasia, until the subject has become en-
feebled, and the nutrition deteriorated. A repe-
tition of bleeding, and a tendency to syncope,
causes either a diminution, or the entire disap-
pearance, of the bufl^. According to Plenciz,
when the blood is not bufl^ed in inflammations,
the coagulum is always more firm than natural,
— an observation which is tolerably correct in
respect of the state of vital power, but not as
regards the presence of inflammation. It should
not be overlooked, that in many cases of very
acute inflammation, particularly in its early stage,
the nervous power may be so oppressed, and gene-
ral va-cular action consequently so imperfectly
developed, that the coagulum will neither be firm
nor exhibit any buff on the first and second
blood-lettings; and yet, when this oppression has
been removed, a firm and sizy coagulum will be
formed by the blood subsequently drawn. This
is particularly the case when the respiratory func-

tion has been oppressed at the commencement of
the attack.

100. Out of four and twenty cases of peripneu-
monia terminating fatally, Louis found the blood
of nineteen of these patients covered by a buflT,
which was firm and thick at each bleeding in
fourteen cases ; soft, and sometimes infiltrated, in
the other?. It was cupped only in two fifths
of the whole number of patients. The buff was
absent in oidy six cases out of fifty-seven, which
recovered. It was very thick, and cupped, in
twenty-three of them. The blood was covered
by only a slight buff in three cases out of five of
hydrocepluilus, softening of the brain, or apoplexy ;
and in another instance of softening of the brain,
the blood remained semi-liquid, without clot or bufF.

101. In four cases of scarlatina, small pox, and
measles, which terminated favouiably, the blood
was covered by a thin and not very consistent
buff; in one case of scarlatina it was firm and
thick; of the same character in five cases out of
seven of erysipelas of the face, and in four cases
of a/igina, while in a fifth it was soft ; in nine
tenths of rheumatic patients it was equally firm
and thick ; in two subjects afi'ected by zona it
was not present. It was somewhat thick in four
cases of erythema, where the circulation was con-
siderably accelerated ; and thin, in four out of
fifteen cases of pulmonary catarrh. According to
Gendrin, the buff never appears on the blood of
variolous patients, until after the eruptive fever
begins ; it is more strongly marked when the in-
flammation is more intense, and lasts even after
desiccation has taken place. When bufl!' appears
at the very first, Baglivi is of opinion that the
eruption will he considerable.

102. B. Other states of the blood in various
diseases. — i\I. Boisseau states, that he has seen
the venous blood of a lively red — now and then
of a clear rosy red — and spouting in a transparent
thread, in patients afflicted with inflammation of
the lungs, and sometimes in tliose with inflamed
joints. Among tliose with peripneumonia, but
who were otherwise of sound constitution, he has
noticed it covered by a greenish buff; yet the
greater part of these patients recovered after re-
peated bleedings. In a very fine young girl, who
had enjoyed good health, but was attacked by
pain in the side in consequence of a chill, the
blood was of a dirty grey, apiiroaching to violet,
and like lees of wine : after this bleeding she suf-
fered no more, although her skin continued yellovv
for some months. M. Boisseau has also seen
blood like turbid wine in several cases of pulmonary
inflammation, which were nevertheless cured, the
patient sufl^ering little more in consequence of the
unusual appearance in the blood.

103. In fact, the hicmorrhagic blood, as also that
taken from the veins of subjects attacked by in-

flammation, is not always consistent and buffed ;
it is sometimes found dissolved, thin, and serous.
The latter appearance is, indeed, less common
than the former; but sufficiently so to teach us
not to attach too much importance to the aspect
of the blood in inflammations, and aUo not to
forget that, whatever may be its condition, phleg-
masia will develope itself when the causes from
which it springs are sufficiently powerful.

104. A whitish appearance of the venous blood
has been long observed, arising from the presence
of white flakes or streaks. This has been ascribed

186

BLOOD — ITS MoBBiD Relations.

to various causes ; but wilh greatest truth to the
existence in it of a large portion of un assimilated
chyle. The separation of the blood into a soft or
natural coagulum, and a milky serum, is much
more common. This, as well as the foregoing
state of the blood, has been imputed to various
causes. Emwert considered that it was owing
to a substance analogous to buff. Some have
ascribed it to milk ; others to albumen ; a few
pathologists view it as owing to a matter analogous
to fibrine ; and several, as proceeding from the
admixture of liquid fat. IIaller imputed it to
liquid chyle. Of these opinions, tiie two last are
the most accurate. There can be no doubt that
both the mijkiness of tiie serum, and tiie whitish
streaks observed in venous blood, are owing in a
great measure to unas<imilated chyle ; and the
more accurate researches of modern chemists,
particularly CiiiiisrisoN, Babington, Le Canu,
&c., have detected in this kind of blood an un-
usual proportion of oily matter. Dr. J. Adam
found oil in a pure state, and in considerable
quantity, in ti)e blood of a corpulent man, who
had died suddenly in a state of intoxication.
(^Trans, of Med. and Phys. Soc. of Calcutta, vol. i.
p. 74. and Buhrows, in Med. Gaz. July 12th,
1834.) This state of the serum is occasionally
met with in various diseases, functional as well as
organic ; and seems connected with deficient assi-
milating power. Sydenham states, that he ob-
served the blood drawn from a young convalescent
to resemble pus, — an appearance probably owing
to the great quantity of chyle carried during con-
valescence into the blood, which had been poor
and defective, and to the circumstance of this fluid
not having then experienced the process of sangui-
faction. Nicolas and Guendeville have noted,
that the blood of diabetic patients contains an
increase of serum, and very little fibrine ; this
.serum contains, according to Rollo, a saccharine
matter; about the thirtieth part of what is found
in urine, according to Wollaston.

105. During tiie prevalence of scurvy in Ad-
miral Anson's fleet, the blood taken from the veins,
after the eruption had appeared, was marked with
dark or with vermilion streaks; on first issuing
from the veins it was dissolved and very black,
but after standing some time it thickened, and
assumed a dark colour ; no regular separation of
its serum took place, and its surface was greenish
in several places. When the disease had arrived
at its third stage, tiie blood was as black as ink ;
and although it was kept several hours in a vessel,
its fibrous pait precisely resembled wool or hairs
floating in a muddy substance. The blood issuing
from the moutii, nose, stomach, intestines, or any
other part, in the last stage of this malady, was
entirely di composed, black, or yellowish. It was
found after death entirely dissolved in the veins,
so that by cutting some branch of a rather large
vein, it was possible to cm)>iy all the neighbouring
brandies with which it communicated of the yel-
lowish black fluid they contained. The extrava-
sated blood was of the same nature. In a scorbutic
patient, opened by order of Cahtieu, the cavities
of the iieart were stated to have been entirely filled
with corrupted blood.

106. In four cases of scurvy, Rouite lias found
the right cavities of the heart filled with black and
coagulated blood ; and a greenish jellow polypus-
like matter filling the kit cavities of this organ,

the aorta, and the pulmonary artery and vein.
Amongst the scorbutic subjects opened at Paris in
1699, by PouPART, it was found that in those
who had died suddenly, the auricles of the heart
were dilated by coagulated bload, the muscles
loaded with black and corrupt blood, and the
cellular sub-cutaneous tissue infiltrated by extra-
vasated, black, coagulated, and congealerl blood,
in some cases, and by red blood in others.

107. BicHAT found in a dead body, instead of
venous blood, a greenish sanies, which filled all
the divisions of the splenic vein, the trunk of the
vena porta, and all its hepatic branches ; so that
when cutting the liver, he distinguished by the
flowing of this sanies all the branches of the vena
porta from those of the hepatic vein, which con-
tained blood in a natural state ; this body was
remarkable for such an excessive obesity, that
BiciiAT never remembered seeing any thing equal
to it. Unfortunately he does not give us the sym-
ptoms of the disease of which this person died.

108. According to Covter, Gendi;in, and
many others, a black pulverised-like substance
deposits itself at the bottom of the vessel containing
blood taken from persons affected with typhoid,
malignant and gangrenous diseases; the clot
being often either completely dissolved, or not
formed at all. I have seen these appearances,
and various modifications of them alluded to
above (§ 94.), not only in these diseases, but also
in htrmatemesis, dysentery, severe infectious erysi-
pelas, phlebitis, the dangerous forms of puerperal
diseases, puerperal mania, and in purpura hmmor-
rhagica.

109. Remarkable fluidity of the blood is always
observed after death from severe blows on the
epigastrium, and from lightning. J. Hunter
states, thit he has also found it fluid after death
from a violent fit of passion. Mciigagm observed
it in a similar slate after death from hunger ; and
jM. Audouard relates that it was uncommonly
fluid in a man who died from coup de soleil,
voiding blood from the mouth and nostrils. In
two cases of hydrophobia I found the blood black ;
so fluid in the heart and veins, that it flowed out
abundantly from the vessels of the head and neck,
presenting an infinite number of oily points or
particles on its surface ; and when removed from
the vessel, it did not afterwards coagulate. The
same appearances were observed in a large pro-
portion of the numerous cases descriijed by IM.
'I'rolliet, and other authors on this disease.
M. Troi.i.iet states, that in several of his cases, a
considerable quantity of gas escaped from the
heart and aorta.

110. iii. The Causes of Changes in the

HEALTHY STATE OF THE BLOOD. TllB CaUSCS whicll

occasion morbid changes in tlie state of the blood,
are either such as are confined in their operations
to individuals, or such as influence whole classes,
or the communily generally. They may ihus be
sporadic, endemic, or epidemic. Jn respect to
their mode of operation, they may be arranged,
1st, Into such as vitiate the fluids from which the
blood is formed ; 2d, Into those which impede
the functions of secretion and depuration ; 3d,
'1 hose putrid or septic matters which contaminate
the li'-sues and fluids to which they are api)Iied,
and act chiefly by absorption ; 4lh, Those which
act upon the vascular system, cither directly or
indirectly, tluough the nerves which supply it ; and,

BLOOD — ITS MoRDiD Relations.

187

5ih, The passage into the blood of morbid matters
formed in the same body that is the se;it of disease.

111. A. Of vitiation of the blond by the fluids
ichich form it. — I'lie fluids which supply tlie
waste of tlie blood are not infrequently vitiated,
and thereby change the state of the circulating
mass. Tlie chief sources of this vitiation are
hurtful or unwholesome ingesta. Many articles,
even of food, will be hurtful when too long con-
tinued. The injurious effects of salt provisions on
the blood, whtn exclusively employed, and par-
ticularly if depressing causes cooperate with this
diet, are evident, and are fully illustrated in the
article on Scuiivv. The influence of diseased
rye, in first changing the condition of the blood,
and inducing a state of chronic arteritis, termin-
ating in gangrene of the extremities, is also well
known ; and the effects of diseased or putrid flesh
upon the system have been often noticed, al-
though not always correctly traced to the quarters
where the principal changes are produced. M.
Bertin states that a number of negroes in Gua-
daloupe, having eaten the flesh of some animals
dead of an epizooty, were seized with fever, and
violent ileus, of which the greater number died :
and numerous cases are on record, where persons
shut up in besieged towns, having partaken of
putrid animal matter, or of the flesh of animals
that have died, have been seized with malignant
states of disease ; and the blood has been found
fluid, dissolved, blackish, grumous, &c. upon ex-
amination after death. In these, and numerous
similar instances which might be adduced, al-
though the state of the blood has been alluded to
in general terms, the information has been de-
ficient in precision, and has been furnished inci-
dentally, the attention of the observer having been
directed to other quarters.

112. ]M. Magendie adduces, in his Journal,
the instance of a man, who, after a long use of
vegetables in which the oxalates abounded, un-
derwent the operation of lithotomy, and a large
oxalate of lime calculus was removed from him.
AVe know that a large proportion of both our mi-
neral and vegetable medicines operate by being
absorbed into the circulation (see art. Absorption,
&c.) ; and there is every reason to suppose that
various morbid or foreign matters may pass with
the chyle into the blood, and modify its condi-
tion. The excessive or long-coutiuued use of
alkalies, or of alkaline salts with excess of base,
has the eft'ect of diminishing the cohesion and
the viscosity of the blood, and of preventing it
from coagulating after it has been removed from
the vessels ; and while these substances thus, as
it were, dissolve, or attenuate this fluid, they also
diminish the vital cohesion and ionic contractility
of the extreme vessels, and of the tissues, and cre-
ate a disposition to extravasation of blood in the
parenchyma of the organs, and to exudation of it
from the mucous surfaces. On the other hand,
the acids — particularly the mineral acids — tur-
pentine, the acetate of lead, and all the salts,
— especially those with excess of acid — have
the effect of increasing the healthy crasis of the
blood, and of producing an opposite change to
that now stated. When used in excess, however,
or injected into the veins, tliey have been con-
clusively shown to give rise to fibrinous concre-
tions in the vessels, to coagulate the albumen of
the blood, to darken its colour, and thus to render

it grumous, and unfitted for circulation through
the minute capillary vessels, particularly those of
the lungs. The influence of salted provisions,
long and exclusively employed, in which the
soda is generally in excess, in attenuating the
blood, in preventing its coagulation when removed
from the vessels, and in relaxing the soft solids ;
and the effect of acids in removing these morbid
stales, are well illustrated by the nature, progress,
treatment, and prophylaxis of scurvy.

113. That the nature of the food materially
affects the state of the blood is further shown by
the general character of the diseases most pre-
valent in various communities, living chiefly on
certain kinds of aliment. The inhabitants of se-
veral places in the north of Europe, who live
principally on fish, a large proportion of which is
usually kept until it has become remarkably stale,
or even ammoniacal, from incipient decomposition,
who seldom partake of flesh meat unless in a simi-
lar state of change, and who dry or smoke both
these kinds of food, instead of salting them, are
generally subject to diseases which arise from, or
are connected with, an impure state, or weak
cohesion, of the circulating fluid. It should not,
however, be overlooked, that the more complete
changes which respiration efl'ects on the blood in
cold climates, and the active exercise of the func-
tions of depuration, under the influence of the
vital energies, serve to counteract the morbid al-
terations which this cause would induce. Yet
still the prevalence of disorder in these eliminating
organs, particularly the mucous and cutaneous
surfaces, which preserve the purity of the blood ;
and the marked disposition, which all febrile dis-
eases evince, in persons thus circumstanced, to-
wards vitiation of the circulating fluid ; and the
consequently low or adynamic symptoms whicfi
characterise their progress and termination ; are
sufficient indications of a change in the consti-
tution of this fluid. It is worthy of notice, that
communities which live in the manner now al-
luded to, generally employ remarkably acid be-
verages, usually consisting of the fermented whey
of butter-milk, and a fermented farinaceous in-
fusion. I believe that noihing could be used as
common drink better calculated than these to coun-
teract the ill effects of their diet on the blood. Be-
sides the acid existing in these beverages, they also
contain much carbonic acid gas, which likewise con-
tributes to their wholesome influence on the blood.

114. The effects of living upon much fresh
animal food, in increasing the quantity of fibrine,
in rendering the blood rich and abundant, and in
disposing to inflammatory diseases, are too well
known in all their relations to require illustration.
But when we consider the influence of various
kinds of aliments in modifying the state of the
blood, we ought never to overlook that, as its or-
ganisation and vi'al manifestations, commence
with the chyle, ami depend upon the vital con-
dition of the vessels and tissues, and upon the
perfect discharge of all the functions which con-
tribute to its formation and purification, the extent
of mischief produced by unwholesome food will
be commensurate with the deficiency of vital en-
ergy, and the imperfection of the various or-
ganic functions. A person of a robust consti-
tution, breathing a pure air, and assisting the
eliminating functions by regular exercise, will
sufl'er much less, than the debilitated, the indolent

188

BLOOD — ITS Morbid Relations.

and lliose placed in unhealthy localities, from either
unwholesome food, or from the accidental ingestion
of injurious substances. A person thus circum-
stanced will also suffer less from the habitual
indulgence in too much animal food ; but more
commonly such indulgence will give rise to a
superabundant secretion of uric acid, and favour
gravel. In such persons, also, there is reason to
suppose that urea, or uric acid, may exist in the
blood, and be deposited from it in various parts of
the body, particularly tlie small joints. The uric
acid, which becomes thus abundant, is a highly
azotised animal principle, obviously formed from
llie excessive use of food which abounds in azote ;
and when its appropriate emunctory, the kidneys,
fails of carrying it out of the blood, it and its com-
binations are secreted in other parts.

115. B. Imperfect performance of the functions
of depuration , a chief cause of morbid states of the
blood. — The evident influence of this class of
causes renders it a matter of surprise that it has
been so long overlooked in our estimation of the
causation of disease. When the facts which
have been brought to light by the successful in-
vestigation of the animal functions are duly weigh-
ed, and estimated in connection with the sources
of impurity to which the circulating fluid is ex-
posed, the importance of assigning a due rank
to this kind of morbid agency will become ma-
nifest. When we consider the important changes
that take place in the lungs — the quantity of car-
bonaceous fluids constantly discharged through
this organ, and of watery vapour loaded wiili
various inipuiities continually exhaled from its
surface, and passing out with the expired air; or
the abundant perspiration, sensible as well as in-
sensible, constantly issuing from the cutaneous
surface, and holding dissolved in it substances
which require to be eliminated from the circula-
tion, owing either to tiieir excess or their foreign
and hurtful nature ; or the varying state of the
urinary secretion, the quantity eliminated and
the changes it manifests from variations of tem-
perature, atmospheric moisture, and especially
from the abundance and nature of tiie ingesta ;
or the discharges vvhicii the female experiences
during the greater part of her average duration of
life ; or the secretions formed by tiie liver, the
internal suiface of the bowels, the pancreas, &c.
out of elements wiiich, if not combined into these
new forms, and destined to ulterior purposes,
would become poisonous to the frame, by vitiating
the blood ; it must be evident that an interruption
to any one of these several functions, if not com-
pensated for by the vicarious increase or modifi-
cation of some others, must be followed by alter-
ations of the cjuantity, of the (juality, of the relative
proportion of the constituents, and even of the
vitality of this fluid.

IIG. a. Under tlie due dominance of the vital
energy of tiie system — and particularly of that
influence exerted by the organic nerves on the
great secreting viscera, and on the whole vascular
system — no sooner does any substance, which may
have been cariied into the circulation, or accu-
mulated in it, become injurious, than it is elimi-
nated by the appropriate action of some organ,
vihich often evinces a kind or degree of disorder,
either in its actions, or in the state of its secretions,
according to the natuic of the substance which
iflTtcts it. Thus, we perceive various substances

and kinds of food, even in health, affect the ac-
tions and secretions of tlie kidneys, of the skin,
and of the bowels ; certain of tlieir constituents
becoming sensible in the halitus of the expired
air, in the perspiration, or in the urine, where
they could be transported through the channel
of the circulation only. The foe,tor, &c. of the
breath, and of the perspiration, &c. consequent
upon interruptions of the abdominal secretions,
also indicates that impurities have accumulated
in the circulation, and that they are being elimi-
nated by means of the lungs and skin. So long
as the vital energy is sufficient for the due per-
formance and iiarmony of the functions, injurious
matters are seldom allowed to accumulate in the
blood to the extent of vitiating its constitution,
without being discharged from it by means of one
or more organs ; but as soon as tliis energy lan-
guishes, or is depressed by external agents and in-
fluences, and the blood is thereby either imperfectly
formed, or insufficiently animalised and depurated,
some one of its ultimate elements or proximate con-
stituents becomes excessive, and the chief cause of
disorder, which terminates either in the removal of
the morbid accumulation, or in a train of morbid
actions and organic lesions. These very important
pathological facts are so fully proved by the his-
toiy of the most prevalent and serious diseases,
and by their terminations and results, and are so
perfectly unopposed by accidental or occasional
exceptions, that proofs or illustrations of their value
and uniformity are superfluous.

1 17, Thus it will appear that, although changes
in the secretions and in the blood itself are most
influential in the production, perpetuation, and
aggravation of disease ; yet such changes are
prevented, controlled, and even in some cases
promoted, by the state of the nervous energy and
vital actions of the frame; to which influence
they are always more or less subject, unless when
the causes of the disorder are so intense, in re-
lation to its state, as entirely to annihilate it, as
is occasionally remarked in respect of the most
pestilential diseases, and of the operation of some
virulent poisons. Thus, also, will it appear, not
only that hurtful matters carried into the circu-
lation, and ultimate elements, or proximate con-
stituents allowed to accumulate in it, owing to the
imperfect performance of some eliminating func-
tion, will be removed from it, when the vital in-
fluence is sufficient for the task ; but that both
kinds of injurious agents will, according to their
natures, become productive of a vitiated state of
the blood, of the secretions formed from it, and
even of the various tissues themselves, when the
state of vital manifestation, particularly as dis-
played in the organic nerves, is insufficient to
remove them from the frame, or to control their
combiniitions,or to direct them to salutary changes.

118. Before leaving this iinportant subject —
important in as far as it involves the fundamental
doctrines of disease, and points to rational indi-
cations of cure — 1 may briefly illustrate it by a
reference to two or three facts, which are of every
day occurrence. It has been long known tiiat af-
fections impeding the functions of the lungs are
fjcquently attended with an increased secretion
of bile. This I have shown to depend upon the
liver being excited to increased action bj' the car-
bonaceous and other elements accumulated in tiie
blood, owing to their elimination by the lungs

BLOOD — ITS RIonniD Relations.

189

being interrupted ; and thus we readily recognise
the cause of the frequent complication of biliary
disorder with puhuonary disease, particularly in
some hot countries. In cases also, where, owing
to asphyxia, or to disease, as pestilential cholera,
&e., the requisile changes by respiration are not
effected in the blood, if recovery take place, the
diseased states of the secretions of the liver and
bowels indicate that the favourable result has
been chiefiy owing to the increased performance,
under tlie influence of life, of the functions of
these organs. When death occurs from asphyxia,
and particularly if it be occasioned by the vapour
of charcoal, the black, fluid, or dissolved state of
the blood, the presence of yellowish globules like
oil, sometimes observed on its surface, and noticed
by M. Rayer, sutHciently indicate the changes
produced in ihis fluid, and the influence these
changes exeit on the chief functions; and if re-
covery is effected, the evacuations evince that the
principal secreting organs have been the means of
removing the morbid matters from the blood. A
strict inquiry, also, into the changes which pre-
cede a favourable termination of the latter stages
of malignant diseases, manifestly detects the in-
fluence of the secreting and eliminating organs in
bringing about this result, and chiefly by their ope-
ration, under the influence of life, upon the blood.

119. 6. That high ranges of temperalure occa-
sion very important changes in the state of the
blood, had been remarked by several of the an-
cients, and by some of the best writers of the
eighteenth century ; but the chief mode of its
operation was first pointed out in a thesis written
by me in 1815. I there showed that increased
atmospheric warmth, particularly when accom-
panied with moisture and miasmal exhalations,
greatly diminish the changes effected during re-
spiration on the blood in the lungs ; and that the
carbonaceous, and other elements and impurities,
are imperfectly discharged from the blood through
this channel. I further showed, both in that
production, and in my physiological notes, that
these materials are partly combined to form bile,
thus occasioning an increased as well as vitiated
secretion of this fluid, and partly excreted by the
mucous surface of the intestinal canal, and by
the skin ; and that, if the functions of these organs,
—the liver, skin, and intestinal mucous surface, —
which thus compensate the diininished actions in
the lungs, be at all iinpeded under such circum-
stances, the elements, which they should have
eliminated from t!ie blood, necessarily accumulate
in it, and influence the functions of the nerves
ramitied on the blood-vessels, and of the principal
secreting organs and surface^, ultimately vitiatmg
the blood and all the soft solids of the body, when
the vital energies become depressed or exhausted,
and the train of morbid phenomena experiences
no change tending to health.

120. Thus, we perceive that, during high ranges
cf temperature, particularly when the air is loaded
with miasmata, and the liver is inactive, the ele-
ments of the bile will accumulate in the blood,
sometimes even to the extent of giving the coun-
tenance a darker or more dusky tint than natural,
and the blood will be changed, 1st, by the super-
abundance of the materials whence bile is se-
creted ; and, 2d, by the passage of this fluid, or of
certain of its constituents, into the blood, after its
secretion has taken place. In the foregoing man-

ner (§ 119.), I explained the prevalence of biliary
disorders, particularly bilious cholera, diarrhoea,
dysentery, increased secretions of bile ; and, in
warm climates and seasons, and when vegetable
and animal miasms are superadded to this in-
fluence, the occurrence of fevers of various kinds
— remittent or continued, simple or complicated,
biliary or malignant, inflammatory or dysenteric,
endemic or epidemic, sporadic or pestilential —
according to the ciicumstances of individuals, the
kind of locality, the nature, combination, and
source of the miasm, and the state of the atmo-
sphere. This doctrine, now many years since
contended for, later experience, and the concur-
rent opinions of more recent observers, have fully
confirmed. (See Fever.)

121. c. Several states of disease, which occur
in the puerperal slate, may be referred to the ar-
rest of the secretions or discharges incidental to
it. The secretions from the internal surface of
the uterus, and which partly consist of the bloody
serum poured into the uterine cavity from the
open mouths of the vessels which communicated
with the placenta, are not infrequently arrested
or impeded. In such casts, the blood does not
undergo that salutary depuration which this eva-
cuation occasions; and, consequently, either expe-
riences further disorder, or it creates a disposition
in the system to the invasion of other causes of
disease. Besides, the fibrinous and albuminous
parts of the blood, which are generally in excess
during pregnancy, not having been discharged by
this route, determine the occurrence of inflamma-
tion of the uterus, peritoneum, &c. upon the co-
operation of exciting causes. Or, if such causes
have protluced these diseases, the obstruction or
interruption of the secretions and discharges, which
is generally thereby occasioned, aggravates the
mischief, and the pnst mortem appearances often
furnish more or less evidence of the suppression
having been concerned in modifying the results ;
the matters poured out froin the diseased parts
frequently resembling, or containing constituents
of, the secretion which was suppressed. How are
we to account for this? We find it demonstrated,
that the materials of both bile and urine, owing
to obstruction of these secretions, may be mixed
with the blood, and give rise to certain well
known symptoms. We may therefore extend the
same principle to suppression of the puerperal
secretions; and infer, that the matters which con-
stitute thein, having accumulated in, or not been
eliminated from, the blood, are discharged along
with those effusions of albuminous serum which
frequently follow the di-eases of this state, even
although they may not actually be the causes of
these diseases.

122. Graeffe of Berlin (llev. Med. Jan. 1827)
states, that a female, in a favourable state, and
suckling her child, experienced a fright on the
eighth day after delivery, which occasioned a
complete suppression of her milk. Febrile ex-
citement followed, and effusion took place in the
peritoneal cavity and cellular tissue. I'pon
tapping a few weeks afterwards, a bucket of fluid,
resembling whey, and exhaling an acidulous
odour, was drawn oflT. Upon being boiled with
dilute sulphuric acid, it furnished a substance re-
sembling caseum. When tapped six weeks after-
wards, the fluid was of a greenish yellow, and
without the least trace of caseum.

190

BLOOD — ITS Pathology ix Fevers.

123. That changes in the composition or state
of the blooiJ are also followed by alterations of
the natural secretions, is fully shown by both
physiological and pathological facts. It is not,
therefore, unreasonable to suppose, that modifi-
cations or changes of morbid secretions will be
occasioned by a similar cause. Indeed, alter-
ations of the latter are quite as likely to be the
consequence of pathological conditions of the
blood, as changes of the former.

124. d In cases, where the functions of the
skin, or of the kidneys, are interrupted, not only
are the watery parts of the blood frequently in-
creased, but also various irritating matters accu-
mulate in it, unless eliminated by other organs.
These excite more or less disturbance of the whole
vascular system ; and if the cause continues, or
is assisted by concurrent causes, the blood itself
becomes very evidently changed, in respect both
of the state of its cruor and of its serum. The
effects of obstruction of the bile on the blood, and
mediately on the tissues, are sufficiently apparent
to the sight; and the actual presence of this fluid
in the circulation, or, at least, the peculiar matters
which characterise it, has been shown by several
modern chemists, and completely demonstrated by
the recent researches of RIM. Proust, Orfila,
Gmelin, and Le Canu. But it is unnecessary
to prosecute the subject further, as I consider the
grand pathological inference to be fully established
— that the interruption or obstruction of anii im-
portant secreting or eliminating function, if not
compensated by the increased or modified action of
some other organs, vitiates the blood more or less ;
and, if such vitiation he not soon removed, btf the
restoration of the function primarily affected, or
by the increased exercise of an analogous function,
that still more important changes are produced in
the blood, and ultimately in the soft solids, if the
energies of life are insufficient to expel the cause of
disturbance, to oppose the progress of change, and
to excite actions of a salutary tendency.

125. e. Illustrations. — The importance of
this conclusion will become still more manifest, if
we illustrate it by reference to the pathology of
fever, and observe the train of morbid phenomena
produced by its causes. The.se, although modified
even still more infinitely than the combination of
causes in which they originate, present the fol-
lowing almost unvarying characters and mode of
procession : — A person exposed to the miasmata
generated from vegetable or animal matter in a
state of decay, or from persons affected with fever,
inhales such miasmata into the lungs, where they
produce a morbid impression on the nerves of
organic life, followed l)y depression of the vital
influence : the functions of digestion and secre-
tion languish, and, owing to the imperfect perform-
ance of secretion and assimilalion, the necessary
changes are not fully eflPected in the blood ; and
thus irritating or otherwise injurious matters accu-
mulate in it. These phenomena generally proceed
gradually, until, owing to the continued and
augmented depression of the vital |)owers through-
out the frame, and the increasing change in the
state of the blood, marked disorder is occasioned.
The vascular system becomes excited by the
quantity and the ([uality of its contents; and,
when the viial energies are not too far depressed
for its production, the excitement becomes general.
The accelerated circulation tends still more to

disorder the state of the blood ; but it also has
the efl'ect, in the majority of cases, of exciting the
organic functions, of restoring the secretions which
were impeded or interrupted, and thereby of re-
moving the morbid state of the circulating fluid;
after which the return to health is rapid. When,
however, salutary reaction of the vascular system
is not brought about, owing to the morbid depres-
sion of the vital energy, and to changes which had
taken place in the blood ; or, if reaction occur, but,
owing to the state of this fluid, and of the nervous
influence to which it is subject, it is irregular,
imperfect, or excessive ; the vitiation of the blood
proceeds; the secretions are also vitiated; the
solids aflTected ; one or more vital organs suffer in
an especial manner ; the energies of life are ex-
hausted ; and various organic lesions are induced,
having reference to the previous state of the system,
the kind of change produced in the bloo<l, and the
agencies in operation during the progress of disease.

126. Such is the general procession and cha-
racter of the morbid phenomena ; and we observe
in them certain prominent features, by means of
which the various species of fever are recognised.
They may be briefly stated to be, — Isi, The im-
pression of the causes on the nerves of organic
life, the depression of their energies, and imperfect
performance of all the functions which they in-
fluence: 2d, fllore or less vascular excitement or
change in the slate of vascular action, and of the
circulating fluid : 3d, Frequent predominance of
disorder of some one general system, or vital or-
gan : 4th, Consequent exhaustion, with either a
gradual restoration of the functions, followed by
a return to health ; or more marked vitiation of
the blood, of the secretions formed from it, and of
the solids of the body, often terminating in or-
ganic changes, or death.

127. Here we observe three diflTerent states of
vital action, in each of which the blood generally
presents very different appearances. 1st, 'i"he
state of depression and invasum of fever, in which
the blood taken from a vein is of a very deep or
dark colour; flows with difficulty; frequently oc-
casioning syncope, or great depression upon the
loss of a few ounces; and generally coagulates
rapidly, and separates into a very dark, large, and
soft coiigulum, which falls low in the serum — the
quantity of which is extremely small in propor-
tion to the clot. Not infrequently the separation is .
very imperfect, and the coagulum extremely large •«
and soft. 2d, The state of reaction, or febrile |
excitement, in which the blood flows more freely
from the vein, and of a brighter colour, occasion-
ing little immediate depression until a more con-
siderable quantity is abstracted ; is apparently
thinner than natural ; coagulates much more
slowly, and separates into a somewhat more firm
coagulum, than in the former state of disease;

and occasionally exhibits a thin fibrinous layer on
its surface : in several malignant cases, however,
even in this stage, either the separation of serum
is very im|)erfect, consisting chiefly of a deep ge-
latinous layer, beneath which the colouring mat-
ter is deposited in an extremely loose state, and
dark colour ; or the blood remains imperfectly
coagulated, and of a gelatinous consistence. 3d,
i'lie state of exhaustion, in which the blood ge-
nerally flows readily ; but is uncommonly thin,
dissolved or attenuated, and dark coloured ; occa-
sions great increase of exhaustion ; and either

BLOOD — ITS Pathology in Fevers — Contamination of.

191

scarcely coagulates, or separates into a remark-
ably loose coagulum, which lies at the bottom of
tlie vessel ; the serum varying much as to quan-
tity and colour; being often turbid, clouded,
watery, or slightly viscous, and less saline in its
taste. Sometimes the coagulum which falls to
the bottom of tiie vessel is so loose, that it appears
as a precipitation of the colouring matter, of a
very dark, colour, and is readily stirred up into
the supernatant serum (§§ 94. 108.). In nearly all
the cases where I have seen blood taken, either
in the state of depression or in that of exhaustion,
but particularly in the latter, either little or no
fibrine could be collected from the coagulum ; or
what was obtained was scanty, remarkably loose,
and even flocculent, and nearly albuminous.
Throughout the progress of typhus, the venous
blood is generally watery, and without consist-
ence,— a fact to which my attention was called
many years ago by the late Professor Hildex-
BRAND, at Vienna. In the latter stages of typhoid
or malignant fevers, it seems nearly altogether de-
prived of fibrine. In two or three cases, the blood
was abstracted in these states chiefly with the
view of examining its appearance. But several in-
stances have occurred to me, in which I have found
that blood had been drawn, although the nature of
the symptoms, and the state of this fluid, equally
contra-indicated the propriety of the practice.

128. With respect to the post mortem appear-
ances of the blood in the vessels, I stated, many
years ago, when describing the symptoms and
morbid appearances of yellow fever, several cases
of which 1 had an opportunity of examining within
five hours after death, in the years 1816 and 1817,
that it is generally half dissolved, or fluid and
grumous, daik coloured, and speedily undergoes
complete decomposition. (Qiwrterlii Jour>t. of
Foreign Med. vol. ii. 1820, p. 446.) A similar
state of the blood has been noticed by Arfjula,
Bally, Palloni, and others, in the epidemic
yellow fever of Spain ; and more recently by Dr.
Stevens, who has described the appearances of
the blood in tropical fevers with greater minuteness
than his predecessors, has referred to most im-
portant changes of the saline constituents of this
fluid, and has fully confirmed some very detailed
observations adduced by myself several years
previously (Appendix to M. Richerand's P/ii/-
siotogy, p. 640. et seq.), cotnprising the general
results obtained from noting the appearance of the
blood in a number of febrile and malignant dis-
eases. Dr. Stevens states (Paper read to the
College of Physicians in May 1830), that the
blood, in these fevers, loses its property of coagu-
lating, because more fluid, and thin or watery, of
a much darker colour, and has its fibrine and saline
ingredients exhausted, — changes which I have
ascertained to obtain in a greater or less degree
in the fevers of this country, particularly in their
latter stages, and have described in my lectures
since 1825. (See Fever.)

129. Besides other proofs of the diseased state
of the blood in fevers, I may adduce the follow-
ing : — In those who were victims to malignant
fevers, Chirac found the blood in the ventricles
of the heart, and the vena cava, more or less
clotted ; and all the ramifications of the vena porta
were filled with grumous blood. In those who died
of typhus, at Brest, in 1757, the blood was found
grumous, unnatural, black, and decomposed, par-

ticularly in the liver. Soulier observed blackish
blood coagulated in the vessels ; and extremely
foetid black blood in the stomach, of those who
fell victims to tlie plague at INTarseilles. Larrey
found the blood black and liquid in those who
died of the plague in Egypt. After intense fevers,
Andral has found the blood contained in the
heart, and in the larger arterial and venous ves-
sels, remarkable for its great liquidity, and its
black and deep colour : in some subjects it pre-
sented a clear rosy tint, and was like water
coloured red ; some small fibrous grains were then
dispersed over the internal surface of the vessels.
In one individual, the liquid "contained in the
larger vessels was no longer really blood, but a
matter the colour of wine lees, sanious in some
parts, nearly resembling the ill-elaborated fluid
contained in unhealthy abscesses.

130. M. BouiLLAuu found, in two or three
cases, the blood clear and rosy, after putrid fevers ;
but it nearly always appeared blacker and more
liquid than in its normal state : this alteration
varied, from the degree in which the clot was
simply flabby, to that in which the blood formed
only a blackened and liquid mass, without any
trace of clot. This blood, being put into a basin,
was brilliant, shining, and full of n)icacious specks;
in some cases it has been found mixed with puru-
lent matter, or pure pus ; at other times it was so
altered and disorganised that it resembled a pu-
trid mass, BouiLLAUD justly adds, that in such
instances it is not rare to meet with a quantity of
gas, more or less considerable, in the circulating
canal ; and also that, although it be diflicult to
describe these changes, they should nevertheless
be taken into consideration, if we wish to explain
satisfactorily the phenomena attendant on putrid
fever.

131. The malignant febrile diseases which very
frequently attack horses and cattle are always
attended with a remarkable alteration of the blood,
even early in their progress. -These diseases are
less frequently met with in this country, than in
marshy and warm climates. In some of the most
pestilential of these climates, horses cannot be
reared ; and when brought thither, they generally
experience a febrile attack, with adynamic or
malignant symptoms, and speedily die. This is
constantly the case in some parts of Africa,
where the vegetoanimal miasms from the soil are
abundant and concentrated. I had an opportu-
nity of observing the exainination of a horse
brought from the interior to an unhealthy situ-
ation on the coast, where it died, as all others had
done, a few weeks afterwards. It was not much
emaciated ; but the blood was black, decomposed,
fluid, and sanious ; and the liver, spleen, lungs,
heart, and, indeed, all theinternal viscera, softened,
ecchymosed, and lacerable with the utmost ease.

132. C. Conlainination of the blood by putrid
or septic matters applied to the tis'iues. — These
substances were not inappropriately said, by the
older writers, to occasion a putrid ferment in the
part to which they were applied. The ferment
may be disputed, but that they produce change
of the blood is undeniable. If we examine the
subject closely, we can arrive«at this conclusion
only,— that the substance applied changes the part
to a state somewhat similar, as respects sensible
properties, to itself ; and that this contamination
soon extends, either by its immediate eflects upon

192

fBLOOD — Contamination of — Poisoning of.

the organic nerves supplying the vessels, and con-
secutively on the blood, or by the direct introduc-
tion of the contaminating matter into the divided
vessels, or by its imbibition or absorption, or by
one or more of these channels, to the whole body,
affecting, more or less, the blood, the secretions,
and the solids. That these changes take place is
undeniable, although the precise channel of pri-
mary infection cannot be easily demonstrated ;
and is sufficiently proved by the facts already
adduced (§ 92.), and by those which follow
(§ 133.). The instances of gangrenous or diffu-
sive inflammation of the cellular tissue, arising
from contact or inoculation of putrid animal mat-
ter, as recorded by numerous writers, and recently
by Drs. Butter and Duncan ; the not infrequent
instances of it from injury in the dissecting-room
(see Cellular Tissue, Diffusive Ivjiummation of);
and the occurrence of putrid fever, with gan-
grenous pustules and carbuncles, particularly
amongst farriers, flayers, and knackers ; furnish
proofs and illustrations of the blood being one of
the chief, although, perhaps, not the primary or
only, channel through which the whole frame
becomes more or less infected in a large and
important class of diseases. A most remarkable
instance of this, and at the same time showing
to how great an extent the fluids and solids of the
body may be contaminated, and yet the patient
recover, is recorded by ]\I. Gendrin.

133. A flayer was affected with putrid fever,
and gangrenous pustules and carbuncles. His
breath, evacuations, and whole body, were hor-
ril)ly foetid ; and blood taken from a vein was,
three hours and a half after its emission, unusually
dissolved and black ; and gave out an odour
resembling that of putrid flesh. A spontaneous
discharge of a black, dissolved, sanious blood,
also occurred from his mouth and nostrils. ]M.
Gendrin introduced some of the blood taken
from the arm of this person into the cellular tissue
of a cat, and into the femoral vein of a dog. Both
animals evinced symptoms of putrid fever, and
died in a few hours. The blood throughout their
bodies was dark and fluid ; the heart soft and flac-
cid ; the viscera congested, and ecchymo<ed with
dark spots, and speedily began to exhale a foetid
odour. M. Gendrin also details some experi-
ments, in which he injected into the veins of
different animals, the blood of persons affected
with confluent small pox. Very violent effects,
rapidly terminating in death, followed ; and, upon
inspecting the bodies, several viscera were found
highly inflamed and congested.

134. D. Contamination of the blood from causes
infuencing the stale rf the vascular system, either
direclltj, or mediately through the nerves xvhich
supply it. — Under this head maybe comprised
a very numerous cla^s of causes; and, indeed,
many of those which were alUnled to in preceding
sections may also act in this way. a. Infectious
and contagious miasms and secretions may cliange
the slate of the blood in a more or less direct man-
ner, as well as by first aflTtcling the organic nervous
system generally, and thereby impeding or chang-
ing the action of vital and secri;ling organs. In-
ordinate acceleration of the circulation appears
to be frequently 'followed by serious alterations
of tlie blood. Ihe experiments of M. Dui'uy
on several animals show that the fdirine is either
very much dimiuished, or otherwise changed, by

their being coursed or hunted ; as the blood re-
mains fluid, or becomes dark coloured and gru-
mous subsequently : M. Ciiaussier found that a
portion of blood altered by this cause produced
gangrenous pustules and malignant fever, when
inserted into the cellular tissue of sound animals ;
and the striking instance recorded by Duuamel,
and already alluded to, further proves that a
morbid state of the blood is occasioned by over-
driving animals. Haller and Buchner remark,
that vehement exertion renders the urine foetid,
acrid, and scalding; the perspiration foetid and
disagreeable ; the blood very fluid, acrid, anrl
vitiated ; and, if long continued, occasions most
ardent fever, terminating rapidly in death, and
dissolution of the fluids and solids. Haller refers
to two cases where he observed these effects pro-
duced by intense acceleration of the circulation
by running ; and adds, that the blood of hunted
animals is often not only fluid, but foetid ; the
flesli becoming quickly putrid. The attenuation
and subsequent alteracion of the blood observed
in ardent or other fevers, attended with inordinate
vascular action in their early stages, and the
ecchymosis, petechias, softening of the mucous
tissues, &c. may doubtless be attributed, in part,
to the rapidity of the circulation, or increased
motion to which it is subjected. If we continue
to agitate healthy blood as it flows from a vein,
it becomes thinner than natural, a small portion
of fibrine collects around the stick with which
it is stirred, and the blood remains fluid, as must
be familiar to every one, and long since demon-
strated by Schwencke.

135. h. If any of the neutral alkaline salts,
particularly those with excess of base, be added
to blood as it is discharged, the coagulation will
either be entirely prevented, or imperfectly pro-
duced ; little or no fibrine will be formed, and its
colour will become more florid. These facts
have long since been noticed by Verhevn, Eller,
Rutty, Haller, &c. The injection of acids, or
the metallic salts, particularly those with any
excess of acid, renders the blood dark coloured,
and changes it into a grumous fluid, from partially
coagulating its albumen and fibrine. The expe-
riments of Eller, Gianella,Duhamel, Friend,
CouRTEN, Rutty, De 11eyde,Sproegel, Aalsem,
BoRRicH, Petit, and various others, prove this
effect ; and further show, that when these sub-
stances are added to blood taken from a vein
they either accelerate its coagulation, rendering
the coagulum firm ; or, if strong solutions are
employed, the coagulation is irregular, the sepa-
ration of the watery portion is more perfect, and
the coagula are of a dirty black or dark brown
colour. Tiie attenuating effects of the fixed and
volatile alkalic s, and of their carbonates, both
upon the blood and the secretions formed from it,
pnrticularly when long employed, will be con-
sidered as proved by any one who will peruse
the experiments of Schwencke, Friend, Eller,
Rutty, Courten, Pitcairne, Tiiackrah, and
ScuDAMORE, without the bias of system ; and they
are confirmed in my mind by some observations
1 have made of the results when these sub-
stances are mixed with blood immediately after
venaiseclion, or when exhibited internally in large
doses for some time previous to abstraction of the
blood : whilst directly opposite effects are ob-
served to follow the internal use of acids. In the

BLOOD — Nervous In

latter case, the coagulum is firm, the blood of a
deep or dark colour, and the fibrine abundant:
in the former, the blood is thin, of a brij;hter
colour, the coagulum much less firm, and the
quantity as well as the cohesion of the fibrine
dimmislied.

136. Tiie effect of the fluid extract or tincture
of opium, alcohol, tonic or astringent tinctures,
and of spirits of turpentine upon the blood, is to
increa'^e its coagulability; and, whon injected
into the veins in sufficient quantity, to produce
death, as in similar experiments with acids and
the metallic salts, chiefly from this mode of ope-
ration. The experiments of Courten, Fhiend,
YouNGE, Schwencke, De Heyde, SpnOEGEL,
Sii.BEitLiNG, and FoNTANM, fully prove these
facts. The accuracy of the results as to one of
these sub>tances, has been confirmed by the ex-
periinents of the writer. That both alkalies, acids,
and salts, act upon the system chiefly from their
being absorbed and carried into the blood, has
been satisfactorily demonstrated by Magendie,
TiEDEMANN and Gmelin, RIeyer, Westrumb,
and various otiiers, and will not be now doubted,
although the active exercise of the eliminating
functions, which their very presence in the blo;.d
generally promotes, prevents their accumulation
there to any considerable or deleterious extent,
unless they have been taken in poisonous doses.
They have, nevertheless, been absorbed in such
quantity as to be detected both in the blood and
in the various secretions by means of chemical
agents, as demonstrated by MM. Grognier,
Chausster, Orfila, and by Bi'chner, Krimer,
Bennerscheidt, Schubartu, and Dr. O'Sh augh-

NESSY,

137. c. The interesting researches of MM. Gas-
pard and Magendie, in order to ascertain the
effects of putrid vegeUible and animal matter
when introduced into the cellular tissue or in-
jected into the blood, further illustrate the im-
portance that is to be attached to morbid states
of this fluid, as well as the origin and nature of
various diseases. These physicians have fully
proved that such substances, when thus em-
ployed, produce symptoms very similar to those
of yellow fever, and typhus ; and that, after death,
this fluid is found remarkably altered, being
nearly altogether fluid, of a very dark colour, and
partially exuded from the capillaries, both into
the parenchyma of the viscera, and from the mu-
cous surfaces. That the blood is really altered
in Its nature by this inoculation, is proved not
only by those changes, but also by the circum-
stance of its having lost the power of coagulat-
ing upon removal from a vein soon after it has
been thus infected, and by its speedy putrefaction.
'J'iie more recent experiments of MJM. Leuret
and Hamont furnish the like results ; whilst those
performed by M. iMagendie show that dogs con-
fined over, and breathing the effluvium proceeding
from, animal and vegetable matters undergoing
decay, experience similar symptoms to those now
referred to, and the same alterations of the blood,
of the secretions, of the execretions, and of the
viscera, as observed in yellow fever : and, in all
these cases, the morbid changes also extend more
or less to the soft solids, and particularly to the mu-
cous surfaces, the lungs, the liver, the heart, &c.

138. A most interesting fact has been stated
by M. Leuret, and one which fully illustrates

Vol. I.

FLUEXCE ON THE. 193

the views I have entertained respecting the nature
of certain forms of puerperal fever. This phy-
sician injected some blood from an artery of a
living horse affected with gangrenous boils (pus-
tula? malignae) directly into the veins of a mare
five months with foal. She died five days after-
wards. 1 he heart, lungs, and intestinal canal
were studded with dark ecchynioses, the uterus
was gangrenous, and the blood dissolved and
dark-coloured. But, in all the cases where poi-
soning has resulted from the injection of septic
or putrid matters into the circulation, or from
virulent, and rapidly fatal poisons, it must not
be overlooked that, although the more manifest
lesions are often observed in the blood, the injuri-
ous agent affects also the organic nerves terminat-
ing in the vessels, and consequently the vitality of
the vessels themselves, altering the blood they con-
tain, and thereby ultimately contaminating all the
secretions and solids of the body ; and that the
mode of operation of the greater number of these
septic agents, whether applied in an aggregrate or
palpable form, or from being dissolved in the
moisture of the air, is very different from that of
the saline and mineral substances considered
above, which affect the blood more especially.
(See Infeciion.)

139. d. The direct influence of the nervous
system upon the blood was long since contended
for by Barthfz, and admitted by several physio-
logists, the chief error, or rather mischievous
fallacy in their theory, however, being, that this
inHuence was imputed to t he cerebro-spinal nerves,
and not to the ganglial nerves, to which it almost
entirely belongs. This great mistake also vitiates
the opinions promulgated on the subject by Mr.
Brodie and Dr. W. Phillip. The opinions
which I have entertained, and frequently ex-
pressed, that the power exerted by the nervous
system on the blood is limited to the organic or
ganglia! class of nerves, and that their functions
are very distinct from those performed by the
cerebro-spinal class of nerves, the influence of
the former having been loo generally and errone-
ously imputed to the latter, have been already
alluded to. Since their promulgation many years
ago, numerous proofs of the accuracy of these
views have been furnished in different countries.
That the effects produced by the organic nerves
take place chiefly in the minute vessels may be
safely assumed ; ami that a reciprocative influence
is exerted by the blood upon these nerves will
not be denied ; but it may also be inferred that
the effects produced by the organic nerves ate
not limited to the small vessels. Professor
Meyer's experiments support this opinion. He
found that, when both pneumogastric nerves
were tied, the blood coagulated in all the pulmo-
nary vessels, the colouring matter having sepa-
rated from the fibrine; and that this change was
not the consequence of death, but its antecedent,
since it was uniformly found upon opening the
bodies the moment they expired. IM. Dupuvtren
had previously ascertained, that a simple division
of the pneumogastric nerves prevented the venous
from being converted into arterial blood in the
lungs.

140. M. DupuY' found that, when the pneu-
mogastric nerves were divided in the cervical
region, in horses, the quantity of fibrine in the
blood became progressively diminished to a very

O

194

BLOOD — Operation of Poison on the.

remarkable extent ; and that a similar result fol-
lowed laborious breathing in disease. lie fur-
ther states, that the blood throughout the animal
was entirely dissolved after the pneumogastric
nerves had been divided ; and he adds that,
when a portion of this blood is injected into the
jugular vein of another horse, a gangrenous af-
fection is produced (§ 92.) But iliese eflects
are comparatively slow ; for, in order that they
may take place, tlie division of these nerves must
previously affect the ganglia and plexi supplying
the lungs and heart, and with which they are in
intimate connection. When, however, these
ganglia are immediately impressed, the effect is
much more rapid. Such impression cannot, how-
ever, be readily made upon the ganglia them-
selves, owing to the protection tlieir situation
affords them from experiments of a conclusive
kind. But as we find that agents, which do not
affect the system when applied to the voluntary
nerves, or the brain itself, will act rapidly when
brought in contact with parts which are especially
provided with the other class of nerves, and mani-
fest the effects of this mode of operation upon the
parts more immediately influenced from this
source, we must necessarily conclude that the
moibid impression of poisonous substances is pri-
marily exeited upon the latter, and not upon the
former; and hence the rapidity of their efl^ects
upon the blood, — effects which are productive, no
doubt, of most important consequences through-
out the economy, which I am endeavouring to
estimate fully and fairly, but which should not
altogether obscure our perception of earlier changes,
which alone can account for all the phenomena.
A severe blow over the ccBliac ganglion will pro-
duce instant death, and the blood will remain
dissolved, and exhibit the same appearance as
after death by lightning and the most virulent
poisons. Here we can attribute these remaikable
chan es only to the sudden concussion, and an-
nihilation of the influence exerted by this im-
portant part of the organic or ganglial class of
nerves — by this central source of vital power —
upon the vascular system, and to the effect thereby
pioduced upon the blood.

141. Seeing, therefore, that the organic or
ganglial nerves are chiefly distributed to the very
internal membrane of the blood-vessels for the
purpose of tiansmittmg their vital influence to
the blood itself, it must be inferred that, although
various substances or poisons may seem to act
more particularly and immediately upon the blood,
and oiliers more dyrectly on this class of nerves
according as they are applied within or without
the vessels, the action cannot be restricted to
either ; hir whatever changes the state of the one,
must affect the other. 'I'iiat poisons, when intro-
duced into the blood, will have an almost instan-
taneous effect, but not in the manner usually ex-
plained, may be readily granted and accounted
for. The views upon the subjei:t fr{(|iiently
Stated by the Aulhor in the Aledical Repo-
sitory, and in his Physiological iXoies, seem more
in accordance with tlie resulting phenomena ; and
are moreover confirmed by experiments and ob-
servations recently made by others; for when the
jioisoii lias been applied to the cerebro-s])inal
nerves, it has been found by Oiiiti.a, Foniana,
and others, to have no further ojieralion, or even
less, than when applied to other tissues, because

it is not directed to that particular organisation,
upon which the functions of life more imme-
diately depend. But when injected into the blood,
it is applied to the terminations of the organic
nerves in the blood-ves-sels — to that particular
quarter where the life of the tissues and of the
blood is either generated or supplied, — to tlie
seat where the influence of these nerves aftects,
even if it does not vitalise, the circulating fluid, and
the operation is instant and most manifest. The
reader, who, possessing an intimate acquaintance
with the healthy relations of the organic nerves
to the blood-vessels on the one hand, and to the
cerebro-spinal system on the other, examines the
numerous experiments which have been perform-
ed, — by one class of experimenters to show the
action of poisons upon the nerves, confounding,
as all have done, the ganglial with the cerebio-
spinal nerves, — and by another class to demon-
strate the operation of these substances on the
blood solely, both sides leaving reciprocity of ac-
tion, or rather the rapid change occasioned by one
system on the other, too much out of the question ;
and is able to detect the fallacies with which they
nearly all more or less abound, chiefly from con-
founding distinct functions, and even different
systems, with o.ie another; will entertain but few
doubts that the influence of various poisons, al-
though more manifestly indicated in the blood, is
chiefly exerted upon the nerves which terminate ia
the blood-vessels ; and that the alterations in the
contents of the vessels arise principally from pre-
vious changes produced upon these nerves, however
rapid the succession of the phenomena may be.

142. The celebrated and accurate experiments
made by Fontana on the venom of the viper and
the ticunas can be justly estimated only in ac-
cordance with this view ; for when these sub-
stances were applied to the cerebro-spinal nerves
no more rapid eflfect was produced by them than
upon any other tissue : but, when injected into
tlie veins, a fatal result was almost instanslaneous ;
tlie blood, in the words of this able experimenter,
being suddenly changed to a livid black, and
soon afterwards coagulated in the lungs, heart,
auricles, and liver, as well as in the large veins,
with violent disease of the structure of the lungs.
Now, as these substances, when added to blood
as it is drawn from a vein, preserve its fluidity,
they must produce, on the organic nerves ramified
to the blood-vessels, a most intense effect ; the
alteration in the blood resulting evidently from
antecedent change in the vital influence of these
nerves, since no such alteration is occasioned by
them when added, even much more abundantly,
to blood as it flows from a vein. And tliere can
be no doubt that virulent poisons introduced into,
or having access to, blood contained in the vessels
of a living animal, however the vessels may be in-
sulated from surrounding nerves, must come in
contact with its interior, and thus have an occa-
sion given them to act upon the independent
class of nerves which is especially devoted to
the blood-vessels. That the very instant and
intense effects which I have, in three intances,
seen produced upon the blood of the human
subject from the bites of serpents, and which
have been minutely described by Orfii.a, Fon-
tana, and many oilieis, cannot arise fr m the
diffusion of the poison in the blood, must be evi-
dent from the rapidity with which they occur, but

BLOOD — SrGNS

from the morbid Impression made by tliem upon
the vital or ganglial nerves, and instantly propa-
gated tlirouuhout the frame ; the eft'ects of this
impression first appearing as a manifest lesion in
the part where the injury was inflicted, and in the
blood, which, as a part of the vascular system, is
co-ordinately affected with the class of nerves
supplying both it and the vessels which contain
it, with vital influence. From the mode of ope-
ration, therefore, of all the most virulent poisons, as
hydrocyanic acid, the venom of the viper, ticunas,
Ike., I infer that, as the organic system of nerves
may be intensely affected, without altering the
state of the brain more than that of any other im-
portant organ, and then secondarily merely, so
may those poisons destroy life by their effects
upon this system of nerves primarily and chiefly,
other lesions being consecutive, amongst which
the alteration of the blood is the next mo!^t imme-
diate, and the next most important in its relations
and consecjuences. (See Poisons.)

143. E. The pussiige into the blood of morbid
matters formed in the same body that is the seat of
disease, has been paiticularly noticed in the arti-
cles on Absorption and Inflammation of Veins,
I have shown, when treating on these subjects, as
well as of certain organic and malignant diseases,
that vitiation of the blood, and ultimately of the
soft solids, more or less, is a very frequent occur-
rence ; that it is hastened or promoted by depres-
sion of the vital energies; and that this fact, as
well as the vitiation of the blood, should be taken
into account in treating these maladies, parti-
cularly in their more advanced stages. It is
probable that morbid matteis may sometimes exist
in the blood without very materially affecting its
condition ; but they much more frequently occa-
sion very important changes in its constitution, as
must appear from what has been stated, particu-
larly when the powers of life begin to languish.
Pus has been often detected in the veins which
convey blood from parts undergoing tlie suppu-
rative process, both by the older physicians and
by recent writers, particularly Bighat, Fizeau,
Vei.peau, Rochoux, GENnniN, Andral, Danck,
BREScnET, and Ribes ; and it seems very pro-
bable that, when thus absorbed, and not mixed
with, or eliminated from, the circulation, it gives
rise to various changes of the blood in the vessels,
not only from attracting the fibrinous corpuscles
in the manner already noticed (§ 85.), but also
from combining with albuminous or other consti-
tuents of this fluid. I further believe that the
sanies which flows from chronic ulcers, or from the
inside of veins when affected with spreading in-
flammation of their internal surface (see Veins),
and from the internal surface of the uterus in
ceitain states of puerperal disease; and that the
tubercular and encephaloid matter which often
forms in internal viscera ; may all be carried into,
and most sensibly affect, the circulating fluid, and,
through it, all the functions and structures of the
body.

144. M. Andral states, that he has often
found in the blood-vessels, instead of blood, a
curdy friable matter, of a dirty grey colour, and
resembling either the semi-concrete pus of chronic
abscesses, or the sanies of malignant ulcers, or
encephaloid matter broken down and mixed with
blood ; and similar instances are recorded by
BicHAT, Beclard, and Veipeau. In all these

OF ITS Disease. 195

cases, abscesses, tubercles, or other morbid form-
ations, also existed in some pai ts of the body. (See
arts. Absorption, Abscess, &c.) In many of
such cases, it is diflicult to determine what may
have been the state of the general mass of blood
in the latter stages of the disease, owing to the
peiiod which had elap-ed from the dissolution of
the patient to the examination ; but it is very
probable that the morbid matter found in the
vessels had mateiially affected, either directly or
mediately through the organic nerves, the consti-
tution of the whole fluids and soft solids of the
body.

145. iv. Phenomena materially depending
UPON a vitiated state of the Blood, and

SERVlNCf TO indicate ITS EXISTENCE. I haVe

contended that the functions of depuration are very
frequently concerned in occasioning, as well as
in removing, a morbid condition of the circulating
fluid. These functions will, therefore, evidently
present some modification, when performing this
latter purpose, inasmuch as the stale of the blood,
and of the impurities requirmg change and elimin-
ation, will excite in them, as well as throughout
the soft solids, more or less disturbance. In the
slighter cases, the disorder of function will be less
apparent ; but even in \hese, and still more re-
markably in the more severe cases, the particular
function most disturbed will generally evince
some relation to the kind of change existing in
the blood. This relation of the change or im-
purity of the blood to the functions of the viscera is
very similar to the mode of operation and effects
of very many medicinal substances, which, having
been carried into the circulation by the function
of absorption, act upon particular organs accord-
ing to the circumstance of their exciting or other-
wise changing the vital condition of these organs
while they are being circulated through or elimin-
ated by them.

146. As respects, however, this relation of the
pathological slates of the blood,' much requires to
be ascertained, or rather but little is yet known
beyond a few facts evincing that such relation
sometimes actually exists. Thus we observe that
excess of carbonaceous elements in the blood is
removed chiefly by means of the liver, occasion-
ing an abundant and vitiated secretion of bile.
We may frequently remark, that an imperfectly
elaborated chvle, or the partial absorption of sordes
from the intestinal canal, renders the breatli foetid,
and the urine loaded, or otherwise changed ; that
accumulation of the materials usually eliminated
by the kidneys produces copious urinous perspira-
tions, and the exhalation of a copious foetid halitus
from the lungs ; and that putrid vegetable and
animal matters, or morbid secretions carried into-
the circulation, derange the digestive mucous sur-
face and secreting organs in a somewhat greater
degree than other parts.

147.^. It obviously becomes most important
to inquire if the phenomena resulting from change
in the blood slowly brought about, or proceeding
from pre-existing disease of important functions,
are different from, or are nearly the same as, those
which arise from the introduction of putrid or
morbid matters directly into the circulation. We
observe in the last stages of malignant diseases,
when the blood undoubtedly becomes changed,
that all the secretions are reniaikably offensive,
acrid, and even excoriating. The breath, per-
O 2

196

BLOOD — Signs of its Disease.

spiration, urine, and stools, are foetid ; and the
surfaces and parts with whicii the secretions and
excretions come in contact, experience more or
less change in tiieir vital actions, and are disposed
to undergo rapid disorganisation. All the cir-
fulating and secreted fluids have acquired septic
and irritating properties ; and discharges of san-
guineous, or black, grumous, fluid matters some-
times take place Irom the digestive canal. The
whole soft solids also lose their vital cohesion and
tonic contraciility, and are rapidly destroyed upon
accidental injury and pressure. Hence the fre-
quency and severity of the excoriations, ulcers,
and sphacelating sores, which affect the promi-
nent parts, sustaining the weight of the body in
bed ; and to this cause, in some measure, are to
be imputed the ill effects sometimes following the
use of blisters in the last stages of adynamic
diseases. The whole surface of the body and
countenance also presents more or less of the
characteis wiiich distinguish change of the other
structures from this all pervading cause; they
lose their vital and animated hue, and become
lurid, murky, or of a dirty pale lint ; in some
cases of a dirty or muddy pale yellow ; in others
slightly livid, or even altogether purpli'-h ; and in
many instances, besides assuniing a lurid and
unhealthy colour, they are dotted with pelechiai,
ecchymoses, and blotches of various shades, from
a reddish tint to a reddish brown and deep
purple. In numerous cases, particularly in the
last stages of yellow fever, the skin is of different
shades of yellow, frequently disposed in large
patches, some of which are deeper than others,
but the whole surface being more or less changed
from its healthy tint. All these appearances
arise from the state of the colourless pirts of the
blood, transmitted by the minute vessels of the
integuments ; and the admission, wdiere ecchy-
mosis, &c. occur, of colouring uiatter into vessels
which did not circulate red blood in health, and
the extravasation or escape of minute portions of
a reddish serum, or attenuated or semi-dissolved
blood, from the poies or extremities of the capil-
laries of the 1-ete miirosnm, — a change, iiowever,
which is not limited to the teguments, but which
often exists still more remarkably in the mucous
and submucous surfaces, and parenchymatous
organs {§ 149.)

143. B. The rapid or direct introduction of
vegetable or animal putrid matter, purulent sanies,
or animal poisons, into the circulation, geneially
occasions, not only changes in the blood, destroy-
ing its properly of coagulating, and imparting to
it a temlency to (juick decomposition, but also
most intense disease of ihe principal organs: —
a. The nervous centres are remarkably impressed,
giving rise to great prostration of strength, deli-
rium, convulsions or dealh, according to the
intensity of ihe cause : — h. The digestive organs
are affected by vomiting of morbid, brown,
grumous, or other fluids: wiih purging of san-
guineous, dark, putrid, or black matters ; or dis-
tended with ffEtid gaseous secretions : — c. 'J'he
respiratory and circulaii-ig functions are remark-
ably deranged — the respiration is quick, difK-
cult, or panting ; the action of the heart quick,
weak, or fluttering, and llie impulse deficient;
and iht: pulse, at first full, open, broad, and un-
usually soft and compressible, soon becomes un-
commonly quick, weak, and ultimately small,

thready, or fluttering: — d. General disease of al!
the functions and soft solids, accompanied with
speedy death whon the cause is intense; but
with the symptoms of adynamic, typhoid, or putrid
fever, when acting more slowly, or to a less extent,
and occasioning sphacelation or gangrene of vari-
ous parts, gaseous exhalations, or secretions, and
various serous, sanguineous, or sanious exhalations
and infiltrations.

149. C. The effects upon the fluids and soft
solids have been already mentioned incidentally,
and may, indeed, be inferred from what has been
staled. These chiefly consist : — a. Of a foetid, de-
composed, remarkably morbid, acrid, and dark
or unnatural colour of all the secreted fluids : — b.
Of diminished cohesion of the tissues generally,
but most remarkably of the mucous, cellular,
muscular, and glandular parts, — liie heart is
soft and flaccid, the blood dissolved, and the in-
ternal surface of the heart and blood-vessels tinged
of a more or less deep red colour, owing, as M.
Trousseau has fully proved, to the altered state
of the blood ; the muscles are easily torn, the mu-
cous and cellular tissues are soft and pulpy ; all the
structures have lost their vital and physical elas-
ticity, and they all undergo decomposition more
rapidly than usual: — c. Congestions, infiltrations,
extravasation, &c. of fluid dark blood, into the pa-
renchyma of the lungs, liver, kidneys, and into the
cellular, mucous, muscular, and other parts, with
gangrenous spots, and a foetid odour.

150. Such are the consequences of putrid or
morbid matters conveyed into the circulation,
and the result, in respect both of the phenomena,
and of the temote organic lesions, of changes
produced by these matters in the constitution of
the whole fluids and structures of the body.
When these matters are in a less concentrated
state, or enter the circulation in a more gradual
manner, they will then act in a relatively slower
and less intense form, and their effects will more
nearly approach those described as consequent
upon a diseased state of the blood in malignant
fevers (§§ 125 — 130.) Yet their operation will still
retain nearly the same distinctive characters, the
symptoms varying chiefly in degree, but not ma-
terially in kind, unless the nature of the cause has
also varied. Whetiier we contemplate, therefore,
the character and progress of the phenomena fol-
lowing infection of the blood from these various
sources, or the nature of the lesions which ulti-
mately result, we shall be equally struck by the
maiked similarity existing between them.

151. That the blood is changed in various
other maladies, although to a much less extent,
may be infeired from the phenomena which are
observed either essentially or contingently in their
course. 'i'he secondary fever in small pox is
apparently connected with the partial absorption
of the more fluid parts of the matter contained in
the pustules, and the change thereby produced on
the blood, and through it upon the economy. In-
stances have come before me, where, upon the
rapid disappearance of the small pox eruption,
puiulent matter was secreted suddenly and in
large (luantity in the capsules of the joints, and
without any previous or coexistent inflammation
of these parts. In such cases, the purulent mat-
ter liad evidently passed through tlie current of
the circulation. (See Aiisciss — Consecuti tie, znd
AiisonrTiON.) Similar occurrences are not in-

I

BLOOD — Treatment

frequent in cases of inflammation of veins, and in
puerperal metritis. (See Veins, &c.)

152. V. Therapeutical Indications and Mea-
sures IN diseased states of the Blood. — The
facts and observations now adduced in iiiustralion
of the pathology of the bipod must appear suffi-
cient to attract greater attention to the state of
this fluid in the treatment of diseases, than has
been directed to it in modern times. However
scanty well ascertained facts connected with this
subject may seem, they are at least sufficient to
justify us in directing our means of cure to the
removal of those changes which may be presumed
to exist in this fluid. This indication is the more
safely entertained, as those means are often at the
same time the most efficacious in removing pre-
existing or concomitant disorder of the nervous
or other systems of the frame. And it should not
be overlooked, in our anticipations of the benefit
resulting from curative indications founded on
these views, that the most certainly beneficial
means of prevention and cure of a most danger-
ous disease admitted to depend ciiiefly on the
blood, viz. scurvy, is a remedy which acts princi-
pally on this fluid, — the citric acid.

153. There are certain facts, which a review
of the foregoing observations will lead us to en-
tertain as useful data for our guide, both in the
recognition of changes in the blood, and in devis-
ing means for their treatment. It will be appa-
rent from what has been adduced, that remarkable
diminution or exhaustion of the vital manifest-
ations of the organic nerves, or of the vital energy
generally, renders the blood dark coloured, pre-
vents its fibrinous particles from adhering into a
coagulum when removed from the vessels, dis-
poses the colouring matter to separate from their
central corpuscles, and occasions a diminution of
its saline ingredients. The effects of various
matters, vegetable, animal, and mineral, when
gradually and circuitously conveyed, or directly
introduced, into the blood, have been particularly
described, not merely as evidence of the very
important changes produced by them on this
fluid, but also as furnishing indications for the
removal of similar alterations, when they are the
results, immediate or remote, of diseaseil actions.

154. A, Treatment of blood abounding with
fibrinous and albuminous constitui'nts — of bnffii
blood, i5)T. — In various disease-:, particularly
those which are inflammatory, in the early stages
of the exanthemata, especially in certain epide-
mic occurrences of these maladies, the blood
abounds in these constituents ; and hence partly
the copious albuminous and fibro-albuminous
exudations which are thrown out by the blood-
vessels in their progress. The knowledge which
we have already obtained as to the effects of cer
tain substances on the blood, indicates the pro-
priety of having recourse to such as possess the
property of diluting and attenuating these con-
stituents, at the same time that they diminish the
vascular action which is instrumental in secreting
them ; and experience fully proves, by its success,
the propriety of the treatment. Blood-letting, and
afterwards the free use of diluents hokling in solu-
tion the alkaline carbonates and salts, more particu-
larly the citrates of potash and magnesia, cream of
tartar and borax, or the potassio-tartrate of anti-
mony, digitalis, large doses of calomel, or other
substances which have been shown to produce an

OF ITS Morbid States.

197

attenuating effect upon the blood, are especially
indicated. Blood-letting in those cases is of the
utmost service, as it diminishes general action, and
removes a portion of the fibrine and albumen,
which are replaced by the thinner fluids absorbed
from the prima via and tissues.

155. B. Treatment of blood with a loose coagu-
lum, S^c. — Rapid coagulation and deficient ad-
hesion of the clot have been shown to arise from
weak nervous influence and vascular action; and
indicate the propriety of having recourse to stimu-
lating tonics, particularly when the smallness of
the coagulum, and whey-like, milky, or turbid state
of the serum, evince a poor and imperlectly elabo-
rated blood. In this case, chaljbeates, the sul-
phate of quinine, and the more permanent tonics,
with the mineral acids, and the metallic salts, are
especially required. When in addition to this
state, the blood is of a very dark colour, the com-
bination of stimulants with tonics and the alkaline
salts, especially iheclorides of potassium or sodium,
will be found most advantageous. In cases of this
description, however, the preparations of ammonia,
excepting the hydrochlorate and acetate of ammo-
nia, although stimulating, will not be found so ser-
viceable as other saline preparation*. When,
however, the hydrochlorate and acetate of amrnonia
are combined with excess of acid, the use of them
will be advantageous. Camphor, serpentary, and
arnica, the essential oils, the turpentines and
balsams, are all beneficial in this state of the cir-
culating fluid.

156. C. The treatment in other morbid states
of the blood will necessarily vary according to the
particular appearances it may present — a. When
the blood coagulates imperfectly, is daik coloured,
is readily decomposed, or is thin and dissolved, as
in scurvy and various malignant and adynamic
diseases, especially when the vital cohesion of the
tissues is also impaired, the use of most of the
remedies recommended above (§ 155.), particu-
larly the chlorides, the preparations of biirk, an-
tiseptic vvines, the oil of turpentine, camphor, the
chloric and hydrochloric acids, with vegetable
tonics, the niiro-hydrochloric acid, vinegar, citric
acid, &c. The influence of ac'ids in restoring the
state of the blood, particularly when morbidly at-
tenuated, and deficient in fibrine, ajipcars to have
been well known to the ancients, and the indica-
tions thereby offered put in practice by them. Vine-
gar was adopted by the Carthaginians and Romans
in all their campaigns as the chief beverage, as
may be gathered from Virgil, Martial Pliny,
Galen, &c.; and its advantages have been ad-
verted to in modern times by Linnsus. There
cannot be a doubt that both it and citric acid
are particularly serviceable in preventing the at-
tenuation, and tendency to dissolution, of the
blood, generated, as has been shown, by excessive
fatigue and exertion, — causes which have often
been proved (§ 134.) powerfully to concur with
unwholesome food, and vegeto-animal miasms, in
the production of scurvy, dysentery, and typhoid
fevers. It appears that the scurvy, which was
found so destructive in Admiral Anson's fleet, was
in no small degree promoted by the excessive
labour of the men at the pumps, — a species of
exertion which tends more than any other to ac-
celerate the circulation, and exhaust nervous
power, and consequently to produce a dissolved
and incoagulable state of the blood, and to dimi-

O 3

198 BLOOD — Treatment of its Morbid States

nish its fibrine. When, however, the blood is

11)01 bill ly thick and carbonaceous, when the re-
spiratory functions are imperlectly performed, and
when there appears lo be a deficiency of saline
constituents in the blood, as in the advanced
stages of fevers, the fixed alkaline saUs, and chlo-
rides, are much to be preferred to acids.

157. b. Since the general neglect into which
the humoral pathology has fallen, antiseptics have
almost been discarded from practice ; at least,
medicines have seldom or never been given with
an intention of preventing a tendency in the fluids
and solids to dissolution. It must have been long
known to every person who considered attentively
the operation of remedies on the frame, that many
of them, either directly or indirectly, produce this
efTect, in conjunction with other operations; and
that they act in this manner, 1st, by exciting the
organic nerves, and increasing the vital cohesion of
the tissues, to which they are immediately applied ;
and, 2dly, by their passage, to a greater or less
extent, into the circulation, and operation on the
blood itself, and, through its medium, on the
nerves supplying the vascular system, and on the
structures generally, — the antiseptic efTect being
the sum of those actions. Amongst the various
antiseptic remedies with which we are acnuainted,
there is none more energetic than the chlorides or
chlorurets, the spirits of turpentine, camphor, the
barks, mineral and vegetable acids, the spices and
aromatics, metallic, earthy, and alkaline salts,
spirits, and balsams ; and observation has proved
to us that these are actually the means which,
when appropri.itely employed, are mo^t suc-
cessful in removing morbid states of the blood,
secretions and solids. Needham and Paulet
found salt most successful in combating an epi-
zooty characterised by a morbid state of the
blood ; and 1 had an opportunity of ascertaining
that, without a necessary supply of this substance,
the natives of the more insalubrious districts in
intertropical Africa are carried off in great num-
bers by a putrid and liquiscent dysentery, for
which salt, lime-juice, and cayenne pepper are
their principal means of cure. It should, liow-
ever, be remembered, that all stimulants are not
also antiseptic in their operation on the blood.
The preparations of ammonia have even an oppo-
site effect, except the hydrochlorate combined
with an excess of acid.

158. c. During the treatment of all diseases in
which he blood becomes more or less changed,
it will be reiiuisite to have strict reference to the
causes from which the change has arisen. Un-
wholesome food, vegeto-aniiniil miasms, imperfect
secretion and depuration, and deficient nervous
and vital power, have been shown to be the chief
of these. That the first and second of these should
be avoided, need not be stateil ; and that the
secreting and eliminating functions ought to be
promoted, in order to purify the blooil, is ecjually
manifest. The hervous and vital energies must
be not only supported, but also promoted and
excited, in order that the power of secretion may
be afforded to the torpid and weakened viscera ;
and that the crasis and vital condition of the
blood may be thereby restored, and the tonicity
of the capillaries, and of the tissues generally, be
increased. In addition to these, also, morbid se-
cretions should be frequently evacuated, in order
that vital power may not be further reduced by

their morbid impression on the nerves and mucous
digestive surface, and that the possibility of the
absorption ol any part of them into the circulation
may be thereby avoided. But, in carrying this
indication into execution, care ought to be had as
to the measures which we employ. Gentle means
are generally requisite, as rhubaib, &c. But
those substances, which, with an aperient opera-
tion, possess also a stimulating and antiseptic
operation, as the oil of turpentine, should be se-
lected ; or, if other substances be prefeired, they
should be combined with tonics, antiseptics, and
stimulants. Formulae 266. 437. 572. in the Ap-
pendix, are good examples of this combination.

159. d. In all the alterations of the blood re-
sulting from the introduction or absorption of
morbid matters from parts previously diseased,
whatever tends to lower nervous and vital power,
or to promote absorption — more particularly blood-
letting, which operates in both these ways — ought
to be guarded against, and a diametrically oppo-
site plan of cure adopted ; not neglecting at the
same time the promotion of the depurative and
excreting functions.

160. e. In diseases where it seems evident that
the watery and saline parts of the blood are
drained off, by the continued exudations from the
mucous surfaces, as in cholera, particularly epi-
demic cholera, diarrhoea and dysentery attended
by dangerous symptoms, much advantage might
accrue from the injection of warm water into the
veins, holding a very small proportion of saline
matter, particularly the chloride of sodium and
carbonate of soda, with a minute quantity of some
mdd stimulant and astringent, in solution ; care
being taken that the latter ingredient be not in
nearly such quantity as to effect the albumen of
the blood. Spirit of wine, ammonia, sulphate of
quinine, &c. may be thus employed. (See Poi-
sons, for treatment of Puisiming of the Blood.)

161. D. Prophylaxis, or the prevention of mor-
bid states of the blond. — The extended inquiry
which has been entered into respecting the
causes of the alterations which take place in the
blood, furnish the chief indications for preventing
their occurrence. The primary influence of the
organic nerves upon the blood, and the effect
rapidly produced upon this fiu:d by a diminution
or vitiation of this influence, having been con-
clusively shown in respect of changes directly
produced by this class of nerves, both on the
blood circulating in the vessels, and on the func-
tions of secretion and depuration, it becomes a
matter of the first moment to preserve the vital
manifestations of this important part of the ner-
vous system from experiencing depression or ex-
haustion ; especially where causes having this
effect are in operation, and where there is any
risk of those morbid matters, which have been
shown in this article to be the chief sources of
vitiation, being carried into the blood ; particularly
those vegeto-animal, or animal efliuvia, which,
floating in a moist atmosphere, act both by de-
pressing these vital manifestations, and by in-
fecting the blood itself. Persons exposed to those
sources of disease sliould live on a due proportion
of farinaceous and other vegetable substances,
with a moderate proportion of fresh animal food,
and preserve the energies of the digestive and
assimilating organs: always attentively promoting
the functions of secretion, depuration, and excre-

BLUE DISEASE.— Pathology op.

lion. At the same time many of the substances
mentioned above may be employed as beverages,
condiments, or preventives ; more particularly the
medicines f'ormeily denominated antiscorbutics, the
citric acid, lenions, lemon-juice with sugar ; spruce
beer, vinegar in which tlie warm spices, as capsi-
cums, have been infused ; the cliloi ides, camphor,
quinine, &.c. As it has been satisfactorily shown
tliat great excitement and acceleration of the
circulation, besides exhau>ting nervous and vital
power, have also the eH'ect of changing and even
of corrupting, the stale of the blood, such excite-
ment should be prevented, and aliased when
present, by appropiiate evacuations, and by refri-
gerant saline medicines and beverages.

BiBLioG. AND Refer — Jcssenms, De Sanguine ex
Vena Misso Judicium. 4to. Prag. 161« — A/. Uqtfi/iann, De

Sanguine, et ejus Observatione.4to. Altd. IdGO It. But/if,

Anatoin. dbserv. on Milk tound in Veins instead of
Blood, Phil. Trans. Ki-W, |)p. 100. 13'J. ; and Natural His-
tory of the Human Blood. 8vo. Lond. I(j84 — Cnurten,
txpernni-nts on the Blood, by injecting various sub-
stances into the veins, Pliilos. Trans, vol. xxvii. p. 48.i.
(Abounding: in important facts.) — Albinus, De Pravitate
Sanguinis. 4to. Franc. I'iJsy. — i)e 6'a«(/;'?i, De Naturali
et PriEternaturali Sanguinis .statu. 4to. Bon. llinij. —
Jlit'irtns, De Sanguinis Pravitate. 4to. Ultraj. 1702. —
Sicuerlin, De Morbis ex Crasi Sanguinis Alterato oriundi?.
Ualas, 1706. — F. Hvjfmann, De Judicio ex Sangume
per Venaescctioneni emisso. Halje, 1727. — Friend,
Eramenagogia, Opera Omnia, p. 130. lol. Loud. 1733.
{Co}itaiits a fiumber oj important experiments). — Schuri-
gius, Hajmatologia Histoiico-Medica. 4to. Dresd. 1741. —
Schivenckc, Haeniatologia,sive Sang. Hist.4to. Ilagae, U43.

— A'/cutez, De Spissituiiine Sanguinis. 4to. Halae, 1749. —
Bucchuer, De nimia SanguiuisFluiditate, et Murb. inde
oriundis. 4to. Halie. 1741). — Meyer, De Signis ex Sang.

per Venesect, petend. Halse, 1753 Haller, Elementa

PhysiologiEe, 4to , vol. ii. p. 17. et seq. {Acullcctiunojmt-
■merous facts, with impurtant new observations.) — Hciv-
son. Experiment. Inquiry into the Properties of tlie Blood.
8vo. Lond. 1771. ; and Philos. Trans. 1773, p. 303 — Bor-
deu. Analyse Med. du Sang. Paris, llTb. — Milman, in
Trans, of Lond. Col. of Phys. vol. ii. p. 478. — Lind, On

Diseases of Hot Climates. 3d ed. 8vo. Lond. 1777

Pring/e, On Diseases of the Army, &c. 8vo. Lond. 1775. —

Hci/, Observations on the Blood. Lond. 1779 Ferris,

De Sanguinis per Corpus vivu u Circul. Putredine. 8vo.
ICdin. 1784.— Gr((«(r;-, DePathologia Sanguinis. Jen. 1791.
■ — Deyeitx, et F armentier , Meinoire sur lis Alterations du
Sang. 4to. Paris, \~i\)ii . — Lertlin, Beytrage, &c. b. iv.

pp. 182—225 /(VrMti/?; Opera, p. 748.— J. Hunter, On

the Blood, Inflammation, &c. 4to. Lond. 179-5. — Wells, On
the Colour ol the Blood, Phil. Trans. 1797, p. 416.—
Beale, Of the Diseases arising from vicious Blood. Lend.
IHiiO.— Bostock. Medico-Chirurg. Trans, t. i. p. 47.—
Thackrah, On the Properties of the Blood, &c.8vo. Lend.
1819. — Wilson, Lectures on the Blood and Vascular Sys-
tem, 8vo. Lond. I819.;pp. 24. 50 Autenreith, Physiologic,

5§ 880. 922. 1034 Wolff, in Ilufeland's Journ. der Pr.

Hellk. ix. b. 4 st. p. 97 Mickaelis, in Ibid. xiv. b. 3 st.

p. 65 — J. Copta?id, in Appendix to M liichtrand's, Ele-
ments of Phy^iology, 2d edit. p. 636. — Belhomme, Obser-
vations sur le Sang'. Paris, 1823. 4to. — Home, in Philos.
Trans, for 1826, p. 189. — Gendrin, Recherches sur les
Fievres, &c. t. ii. p. U5. ; et Traiie Anat. ries Inflam. t.

ii. p. 565, &c Bellengcri, in Annali Universali di Med.

Ap. \Wn. — Schultx, in Meckel's Archiv fiir Anat. und
Physiol. 1826, No. iv. p. 487. — Trousseaux, in Archives

Gen. de Med. t. xiv. p. 328 Leuret, Archives, &c., xi.

p. .3c3. — Segalas, in Ibid. t. xii. 103. — Dupuy, in Ibid, t.
xiv. p. 289. — Bayer, Ibid. t. xv. p. 136 — Uaspard, in
F. Mogcndie's Journ. de Physiol. Exper. t. Ii. p. 1., ei t. iv.
p. h — F.Magcndie, in Ibid. t. iii. — Bochoux, in Nouv. Bib-

liotli. de Med. Sep. et Nov. 1823 Diet, de Med. t. xvi.

p. 206. ; et Journ. Hebdom. de Med. t. ii. p. 630. — Bois-
seau, Nosographie Organique, t. iii. p. 175. — Velpeav,
Recherches sur les Alterations du Sang. 8vo. Paris, I82G.

— Christisim, in Ediii. Med. and Surg. Journ. No. ciii. p.

274. — Babington, in Trans. Med. Chir. Soc. t. xvi.

Hibes, Anatomic Pathologique, &c. t. i. p. 308. — Andral,
Pathological Anatomy, by Townscnd and West, vol. i. p.
638. — Piorry, Procede Operatoire, &c., et Collection de
Memoires sur Pathologic, iSic. Paris, 1831. j sur la Cir-
culation, p. 208.— J. Duvy,m Edin. Med. and Surg. Journ.
vol. XXX. p. 249.

BLUE DISEASE. Syn. Cijanosis (xuavo?,
blue, and voVor, disease), Beaumes. Morhm
C(eruletis, Cyanopathiu,'^ JNIarc. E.uingia Cy-

109
Die Blausucht, Gcr.

aiiia, Good. Cyanose, Vr.
Blue Skin, Blue Jaundice.

Classif. 3. Class, Sanguineous Function ;
4. Older, Cachexies {Good). IV. Class,
II. Ohder (Author, see Vrejace).

1. Defin. a blue violet, or purple, colour of the
integuments, particularly of parts usualiv pre-
senting arose or Jiesk tint, as the cheeks, lips, mu-
cous surfaces, &;c,

2. A blue or purple colour of the integuments
of paits, or nearly the whole of the body, may
occur as a symptom in the last stage of various
acute diseases. But it is present from the begin-
ning of this affection, is frequently connected with
comparatively litile disturbance until some sudden
change takes place, and generally results from
chronic organic lesion. In other maladies this
colour is an accidental, occasional, and not the
most important symptom ; in this affection it ap-
pears as the only, or the most remarkable, change
observed during life.

3. I. Its Patholooy. — According to M. Gin-
TRAC, who has directed much atieniion to this
affection, it always proceeds from organic chaiioe
of the heart or large vessels ; the admixture of
venous with arterial blood, and the distribution of
it to the sui faces of the body, being the immediate
or essential cause of the alteration of colour. 'Iliis
pathology agrees with the opinion of Senac and
iMoBGAGNi : it has, however, been disputed.
J\l. CoRVisART first threw out doubts of the con-
stant oiigin of cyanosisin this source; and more
recently MM. Ferrus, Breschet, Marc, Louis,
fouQuiER, and Crampton, have adduced facts
which seem to militate against it, while it has re-
ceived the able support of INI. Bouillaud.

4. M. Ferrus contends, 1st, '1 hat cyanosis
sometimes has existed to an intense degree, and yet
upon post mortem examination no lesion could
be detected admitting of the admixture of venous
blood ; nor any organic change of the heart or
respiratory organs: 2d, That the opening of
Botal may continue unclosed for many years
without blueness of the surface being occasioned :
and, 3d, That the admixture and circulation
of venous with arterial blood have been demon-
strated to occur in some cases, without giving
rise to this peculiar appearance. 1 hat the second
and third objections are well founded seems al-
niost incontrovertible. Numerous instances have
been recorded by Louis, and others, which fully
prove these facts. 1 have met with cases in
children, where the communication between both
sides of the heart seemed very free, and yet no
alteration of the natural colour existed : and others,
in which the change was evident during the pa-
roxysms of suffocation only. But I must agree
with Corvisart, Hicherand, Cloquet, Gintrac,
and Bouillaud, that the existence of this opening
is no certain proof of admixture of the venous and
arterial blood ; for if the contractile powers of
both ventricles are nearly equal, in relation to the
resistance to be overcome, and if the natural
openings of the cavities be not obstructed, no ad-
mixture of the blood in both sides of the heart
could take place.

5. The principal force of the objections, there-
fore, urged by M. Ferrus, evidently rests upon
the fact of the non-existence of organic diseases of
the heart, large vessels, or lungs, in some cases
of the disease, — a fact which is still not satis-

O 4

200

factorily established. I believe that it may be
safely concludeil, that the blue disease of infants
and children is very generally dependent upon a
communication between the opposite sides of the
heart, or some malformation of the heart or large
arteries, particularly contraction of the origin of
the pulmonary artery, or some other change af-
fecting the circulation through the right cavities
of the organ ; vvhilst in older and aged persons, a
similar colour of the surface may proceed from
whatever obstructs the circulation through the
large-veins, lungs, or heart, and even from simple
congestion of the venous capdiaries from loss of
vital power ; and in these latter cases the affec-
tion more nearly approaches the blueness ob-
served to occur as a dangerous symptom of various
acute diseases of the lungs and heart, as of as-
phyxy, and of pestilential cholera.

6. i. Symptoms, progress, and terminations of blue
disease. — Tlie bluish tint of the external surfaces,
whence this malady derives its name, is net equally
deep in every part. It is usually deepest over
the whole of the face, and the lips in particular,
on the hands, feet, and genitals. During any
effort, or wiien crying, this symptom ismuch more
marked than during repose: at the same time
the parts presenting a bluish colour, or a violet
of the darkest shaile, are more or less puffed.
The circulating and respiratory functions are
rarely without derangement. The disordered cir-
culation is characterised by palpitations more or
less violent ; sometimes accompanied by a very
distinct bellows sound, and by a purring tremor,
tendency to fainting, and serious effusions. 'J'he
breathing is laboured and panting after the slightest
effort. The warmth of the body is considerably
diminished, and patients are very sensible of cold.
'J'he functions in general, and principally those of
locomotion, are more or less languid, and, as it
were, benumbed.

7. The sym[)toms just described do not always
exist in the same degree, during the continuation
of the malady. It may even be said that the
disorder is made up of a succession of paroxysms
and remissions. In the paroxysms alone we ob-
serve these frequent faintings, that tumultuous
palpitation of the heart, and suffocations, which
endanger the life of the patient. No rule can be
relied on as to the recurrence of these paroxysms ;
in fact, if it be certain that they are often brought
on by over-exertion, fatigue, and violent mental
agitation, it is equally certain that they occur
without any assignable cause, and are more fre-
([iient in winter than in summer. The length of
the paroxysm vaiies : it sometimes lasts several
hours, and generally abates gradually. The
termination of cyanosis is fatal to most patients ;
but some appear to recover entirely ; otiiers live
for many years. Cases of this kind have been
recorded by MoitOAfjNr, SANnii-oiir, and Kuiu;-
HAND. The death caused by this disorder is
sometimes very sudden ; but in the majority of
cases it is preceded by an intense suffering, cha-
racterised by the most acute anguish, difficulty of
breathing, fainting fits, and cold sweats. In a
case of remarkable blueness from birth, in a girl,
who was for some time under my care, the colour
changed in the course of two or three years, to a
dirty yellowish, chlorotic tint, which is still re-
tained up to the thirteenth year. The disorder
ol the heart's action and resjiiration, in this case.

BLUE DISEASE,— Pathology of.

although more or less considerable, was never

very severe ; but the child was always remarkably
delicate, and incapable of any bodily or mental
exercise.

8. ii. Lesions observed after death : and their
connection with the symptoms. — 1st, The most
common lesion is the persistence or the re-esta-
blishment of the opening of Botal, This com-
munication of the two auricles is generally
accompanied by an obstacle to the passage of
the blood from the right auricle into the corre-
sponding ventricle, or from the latter into the
pulmonary artery. Twenty-seven cases out of
fifty-three reported by M. Gintrac, presented
such an obstacle. In twenty-six of these cases
the circulation on the right side of the heart was
impeded either by a contraction or by a total
obliteration of the orifice of the pulmonary artery,
and in only one case by the contraction of the right
auriculo-ventricular orifice. Co-existent with
these lesions is usually a hypertrophy of the right
ventricle and auricle, or of one only of these
cavities, wither without dilatation. Sometimes the
ventricular cavity is itself contracted. 2dly, The
ventricular partition has often presented a solu-
tion of continuity of more or less extent. 3dly,
The arterial canal remained open in some sub-
jects. 4thly, In one of the cases reported by
iM. Gintrac, the two auricles (imperfectly di-
vided) opened into the right ventricle: the latter
being very large, communicated freely with the
left, which (narrow and without auricular oiifice)
gave origin to the aorta. 5thly, In another case,
the aorta and pulmonary artery sprung from the
lett ventricle, the right being almost obliterated,
and the inter-auricular partition perforated,
bthly, In another instance, the opening of Botal
was preserved ; the aorta disappeared after having
supplied the cephalic and brachial trunks; the
pulmonary artery, receiving the blood from both
ventricles, formed the descending aorta. 7thly,
Such a tiansposition of the larger arterial trunks
has been witnessed, as the aorta springing from
the right ventricle, and the pulmonary artery from
the left ; the opening of Botal and the arterial
canal still remaining, or only the latter. 8thly,
In some cases the heart consisted only of one
auricle and one ventricle. 9thly, Two superior
venaj cavas were seen, the one opening into the
left auricle. It is unnecessary here to enlaige
upon the other lesions noticed in persons afHicted
with this complaint, because they do not neces^arIly
belong to the subject.

9. iii. As respects the relation hetiveen ihesynt-
ptoms and lesions, M. Bouillaud remarks, that the
alterations pointed out in the central organs of
circulation have usually the effect of perniilting
the black blood to mingle with tiie red ; but
some of these lesions, as previously observed,
such as the opening of Botal, do not necessarily
entail this admixture ; for which reason they are not
invariably accitmpanied by blueness of tiie integu-
ments; either the black blood not having mingled
with the red, or the mixture being insufficient to
jiroduce the bluish colour. Hut when the arterial
canal remains upon ; when the aorta s|>rings from
both ventricles jointly ; or when, to the commu-
nication between the right and left cavities, is
superadded an obstacle to the free current of
blood in the former ; a considerable quantity of
black blood must necessarily mix with the red.

BRAIN — Alteratio

Whenever an abnormal communication between
the cavities of the right and left divisions of the
heart co-exists with an obstacle to the circulation
of the blood in the right ventricle or in the pul-
monary artery, the mixture of the blood is not the
sole cause of the discolouration of the skin, the
puffing of certain parts, of various serous con-
gestions, &c. In fact, it is evident, that the
impelled circulation contributes mainly to the
production ol these phenomena. Should we not
also attiibute to the contraction of the auriculo-
ventricular, or ventriculo-pulmonary orifices, the
bellows sound and the purring tremor remarked
in some patients? However this may be, some
of the lesions coincident with blueness of the
teguments are invariably congenital ; while others
(such as the communication between the right
and left regions of the heart) may be either con-
genital or accidental.

10. iv. The causes which develope most of the
congenital lesions, from which blueness may
ensue, are not easily determined on. But a com-
munication between the right and left cavities of
the heart may be occasioned by ulceration of
the auricular and ventricular partitions, or by the
rupture of these partitions, especially of the au-
ricular, in violent and lengthened efforts. An
obstacle to the course of the blood through the
right auriciilo-ventricular, or the ventriculo-pul-
monary orifice, may also, particularly in the early
stages of life, induce an abnormal communication
between the two auricles, by ungluing, as it were,
the valvular laminae, which, by their agglutin-
ation, have obliterated the opening of Botal. The
existence of a similar ol>stacle at an intia-uterine
period of life, when the opening still remains,
may be also deemed a sufficing cause for its ulti-
mate non-obliteration. (^Dict, de Mtd, et Chiruig.
Prat. t. vi. p. 7.)

11. J am of opinion, not only that such ob-
stacles have very generally existed during intra-
uterine life, and been the cause of the blueness
observed afterwards, but that they have also
occasioned, during foetal existence, a permanent
state of distension ; and thence, in some respects,
malformation of the capillary system, particularly
in the cutaneous and mucous surfaces, favouring
congestion, and languid circulation through them
after birth, and the consequent blueness, and the
puffiness that generally attends it. 1 may add, as
a matter of diagnosis, that very intense and ge-
neral blueness is not uncommonly produced by
the incautious and internal use of the nitrate of
silver. I have observed two or three such cases,
and others are recorded by Ai.bers, Roget, &c.
(JMed. Chir. Trans, vol. vii. p. 284.)

12. II. Treatment.- — Art is of liitle avail in
this malady. We must chiefly depend upon the
efforts of nature in bringing gradually about a
change in the lesions on which it depends; and
attempt to assist her efforts, by directing bodily
and mental repose, and a pure, mild, dry, equable
and somewhat warm air ; by attending strictly to
the stale of the biliary and other secretions, and
the digestive functions; and by recommending
gently tonic medicines, with an easily digested
and nutritious diet. During the paroxysms, INI.
BouiLi.Ai'D recommends blood-leiting, — a prac-
tice which is by no means warranted by my
experience. Depletions, and all other lowering
means, aggravate the symptoms, and seldom or

NS IN ITS MEJIBBANrs. 201

never succeed in removing the severity of the par-
oxysms, for which he advises them. I have
derived more advantage from stimulating pedi-
luvia, frictions of the surface of the body and
lower extremities, and the administration of gentle
antispasmodics and stimulants. (See F. 348.424.
663.) In one or two instances, I conceived that
some advantage was derived from the preparations
of iron combined with the fixed alkaline carbo-
nates. (See also F. 94. 662. 718. 920.)

BiBLiOG. AND Refer. — Hunter, Medical Obsprvat. and
Inquiries, vol. vi. p. 299. — Ferrus, in Diet, de Med. t. vi.
p. 29(5. — Good, Study of Med. t. iii. p. 482. — Gin/rac,
Observat. et Rerhe.ches sur la Cyanose, &c. Paris,

1824 Louis, Mem. sur la Commun. des Cavit. Droites

du Coeur avec les Cavites Gaiiches, Archives Gen. de
Med. t.iii. pp. 32?. 48.5. ; et Mem. et Hecherches Anat.
Pathol. p.SO\. — Buvillau(l, Diet, de !Vled. et Chirurg.
Pratiques, t. v. p. 1. — Crampton, in Trans, of College
of Phys. Dublin, N. S. vol. i. p. 34.

BRAIN AND MEMBRANES— Diseases OF,

SvN. '£yx£<(>aXoj, Gr. Cerebrum, Eiicephalnn,
Lat. Cerveaii, Eticephate Fr. Das Him, Ge-
hirii, Ger. Cerebro, Ital.

Classif. Special Pathology and Mor-
bid Structures. IV. Class, III. Order
(Author, see Preface).

1. With the view of avoiding unnecessary re-
petition, and of furnishing a complete account of
the changes and morbid phenomena connected
with the parts contained within the cranium,
alterations of structure will be considered in the
first place, and in systematic connection ; and, af-
terwards, inflammations affecting either the brain,
or its membranes, will receive attention. As
similar lesions develope themselves in the brain,
or its membianes, in the course of a variety of
diseases ; and as many of those v\ hich are most
commonly found upon dissection give rise to very
different phenomena during life; their arrange-
ment in a separate form will facilitate reference
to them, when those specific states of disease,
which they either originate in, or occasion, are
being discussed. I'hus tumours formed in the
brain, or purulent matter secreted there, or in-
duration or softening of the cerebral substance,
&c. are not infrequently found in cases of either
palsy, epilepsy, insanity, or encephalitis, without
limitation to any one of them. Instead, however,
of describing these and various other lesions,
when considering each of these diseases, I shall
here give a minute description of the morbid
structures observed in the brain and its mem-
branes, and refer merely, when discussing these anrl
other diseases implicating the cerebral functions, to
those clianges most commonly found on dissection
of fatal cases, as they are described in this article.'

2. Of all the organs of the body the brain is
the most exquisitely and incomprehensively form-
ed, and presents the least intiniacy of connection
between the results of dissection and the pheno-
mena of disease. The most violent symptoms
rtferrible to this orj^an often exist during life ;
and yet, on the most careful examination, after
death, either no appreciable lesion, or none sufli-
cient to account for the phenomena, can be de-
tected. Whilst, on the other hand, many and
most (important changes are frequently discovered
in both the brain and its membranes, in cases
which betrayed either no cerebral disorder, or
none calculated to excite suspicion during life of
any organic change. It is extremely important
to be awaie, not only of this fact, but of the cir-

202

BRAIN — Alterations in its Membranes.

cumstance just alluded to, that the same irorbid
a|-vpearances, or, at least, states so nearly alike
that they cannot be distinguished, will frequently
be found after maladies very dissimilar as regards
their cause, nature, and consequences, 'i'hus,
irritation of the brain occurring in the progress of
fevers, and the exanthemata ; convulsions, in-
sanity, drunkenness, puerperal derangements, me-
tastasis of gout, and various other diseases, will be
attended wiih congestions, injection of the blood-
vessels, secretions of lymph or serum, or of air
between the membranes, &c. — states in every
respect similar to those proceeding- from idiopa-
thic inflammation. Nor should it be forgotten,
that the kmd of death, the particular circumstances
attending it, and the positions and changes to
■which the body is subjected immediately after-
wards, tend very materially to influence the ap-
pearance and slates of the parts within the cranium.
Jn the view which I am about to take of the
principal lesions of structure afFecting the ence-
phalon, I shall /i'rst notice the morbid states of
its membranes ; next, the lesions presented by its
sinuses and other blood-vessels; and, lastly, the
diseased appearances of the different parts of the
encephalon itself.

3. I. Morbid States of the Membranes of
THE Brain. — 'I'he intimate connection which the
membranes of the brain have with the cranial
bones on the one side, and the brain itself on the
other, and their expansion between both, render
them extremely liable to participate in all the
malformations, diseases, and external injuries of
those parts. Whilst they most commonly, with
the limpid fluid exuded between them, separate
those parts, and facilitate the motions of the lat-
ter, they also often prevent the extension of mor-
bid action from the one to the other. But they
do not always succeed in thus limiting disease ;
for they frequently become secondarily affected
during maladies commencing either in the skull
or the brain ; and, when thus involved, they, in
some measure, become the medium of mutual
infection. But the membranes are not only thus
secondarily affected ; they are also not infre-
quently themselves the primary seat of disease ;
and when such is the case, the parts on each side
of them, particularly the brain, seldom fail of
participating more or less in the disturbance. Thus
we often find them the primary seal of congestion,
and of inflammation, with their consequences, as
efl^'u'sion between them of various kinds of fluids;
and the source whence disea-^e has extended to
the brain itself. I'hose changes are presented to
our view, not only in the primary inflammations
of the membranes, but also in several forms of
fever ; in morbid afl^ections of the mind, tetanus,
delirium tremens, convulsions, epilepsy, apo-
plexy, palsy, and other diseases, wherein we have
reason to sup])ose that the brain itself is either
primarily and principally affected, or participates
largely in the morbid states of its envelopes.

4. i. The Dura Mater is often found un-
iianalUj adherent to the cranium, even when the
brain and its membranes have been quite fr(^e from
change, but more commonly when chronic disease
lias existed in either the one or the other. It is
aUo sometimes slii^lulji adherent to the skull, and
occasionally this want of adhesion is very remark-
able. In some instances, the dura mater is sepa-
rated entirely from a portion of the cranial bones.

In some rare instances, the space is filled with a
icatery Jiuid ; but this has only been met with in
hydropic children. The separation is generally
the result of external injuries ; and either blood or
pus, or even both, is usually found in the space
between the bone and the membrane. Jn some
cases, these effused fluids, particularly blood,
either fluid or in coagula, are in considerable
quantity, occasioning the usual symptoms depend-
ing upon pressure. Lymph, in various degrees of
firmness, is also found between a part of the dura
mater and the skull ; and this, as well as jms,
with which the lymph may be partially mixed,
are generally the result of inflammations conse-
quent upon external injuries. These appear-
ances have been sometimes observed in fatal cases
of epilepsy, but only when the patient has re-
ceived some injury during the paroxysm. They
are often connected with a pufl'y swelling of a
corresponding portion of the scalp.

5. The dura mater itself may be here viewed
as two membranes, closely united throughout by
means of fine, close, cellular tissue : the exterior,
or that applied to the cvanial bone-:, resembling m
structure, and performing the office of, perios-
teum ; the interior, or unattached, being a reflec-
tion of the arachnoid, and having, as respects its
functions, a more intimate relation to the included
organs : the former being a fibrous, the latter, a
serous membrane.

6. A. — a. The Jihroiis structure of the dura
mater is frequently more than usually vascular,
particularly in fatal cases of apoplexy, paralysis,
fever, with cerebral symptoms, epilepsy, and in the
congestions which occur in the last stages of
whooping cough, pulmonary diseases, asphyxia,
and poisoning by narcotics. This state is, how-
ever, very different from inflammation, as the
minute capillaries do not present the same degree
of redness, particularly in the unattached or arach-
noid surface. This structure is sometimes tinged
with bile, and of a deep yellow colour through
its whole extent, as in cases of acute jaundice,
which are attended with comatose symptoms.
After contusions, or when suppurations exist be-
neath or exterior to it, it is either yellow, dusky,
bluish, brownish, or even blackish. It is also
occasionally spotted with black, in some cases of
melanosis. In some instances, this membrane
seems distended from fluids effused in the cavities
of the brain, or between the membranes ; in others
it is apparently corrvgated or collapsed. This latter
state generally proceeds from it having been
punctured during the separation of the calvarium,
the fluid which it had contained having thereby
escaped. Bat it is sometimes noticed where no
such accident occurs, particularly in extremely
emaciated bodies, or in the very aged, when little
or no water is collected beneath it. A more than
usual dryness and iraiispurency is occasionally
observed in this as well as in similar structures.
Unusual dryness is also sometimes conjoined with
a shrivelled state, and deficient transparency.
Otto thinks that this is one of the remote efTects
of inflammation.

7. h. It is but rarely inflamed, excepting from
external injuries, and then generally in circum-
scribed patches of greater or less size. In these
cases, the injection and redness are very remark-
able, particularly in the vicinity of purulent form-
ations and injuriesof the bones, or where ulceration

BRAIN — Alterations in its IMembranfs.

203

tliscoloration, fractures, abscesses, &c. exist in
its vicitiity. Suppurations, in which tlie pus is
found between its lajers, or on its outer surface,
are very rare. Cases, however, are referred to by
Otto of this occurrence. When suppuration
does occur, it is g;enerally seated in its inner sur-
face. In some of these cases, the purulent matter
has eroded, and perforated the skull and layers of
the dura mater exterior to it. Thickening of the
dura mater is not an u usual result of chronic
Slates of inflammation. It varies extremely in
<legree, and it is sometimes so great as to occasion
symp oms of pressure and irritaiioii. It is some-
times found in fatal cases of epilepsy and paralysis ;
and is occasionally conjoined to induration of the
thickened part. Ossijication of the fibrous struc-
ture of the dura mater is a comparatively rare
occurrence, whilst ossific deposits in its free or
arachnoid surface_are very common. In tlie former
case, the bony matter follows the fibrous arrange-
ment of the membrane, and involves its substance.
Two interestmg specimens of this change are
referred to by Dr. Bright (Report of Medical
Cases, 6;c. vol. ii. p. b63.). Ossific deposits may
likewise be ascribed to slight, or chronic states
of inflammatory action.

8. c. Tumours also form in the dura mater.
Those wliich are most intimately connected with it
have ajibrous structure ; whdst ihefungnid tumours
s onetimes observed seem to be common to both
this membrane and .he arachnoid lining it. Nor
are they limited to the dura mater, as supposed
by Louis and the Wenzels ; but they may arise
also in the bones of the skull, as shown by Wal-
THER, GuAAFF, and SiKBOLD ; and even in the
pericranium, as contended for by Otto, Eber-
MAiER, and Cruveilhier. Osteosarcoma orj'ungiis
cranii, therefore, as stated by Vox Wai.ther,
and fungus duriB mutris, are merely difterent,
although often simultaneously occurring forms of
the same disease. (Se ■ § 17.) When fungous
tumours originate in the dura mater, they not in-
frequently perforate the skull, by occasioning ab-
sorption of the superincumbent portion of bone;
but they also often involve the bone in a similar
change, giving rise to fungus cranii as now stated.
They occur in every part of the dura mater,
commencing more frequently in its inner coat,
and are found oftener in this situation, than in
the bone itself, or the pericranium. (See Cra-
nium.)

9. d. Other kinds of tumour are occasionally
found in the dura mater. But those of a con-
stitutional origin usually commence either in the
arachnoid covering the dura mater, oi in the fine
connecting cellular tissue. They, however, gene-
rally soon involve, not only this latter membrane,
but also occasionally the cianial bones. Of these
tumours, comprising the scroj'ulous, scirrhous, car-
cinomatous, and the hiEmatoid, 1 shall make more
particular mention in t! e sequel. Although some-
times found in the inner surface of the dura mater,
they are met with only consecutively upon their
original manifestation in some other part of the
body. Rlore rare than any of the foregoing, is
the occurrence of futtii and enciisted tumours on
the exterior surface, or between tie layers of the
dura mater. They have been found in this situ-
ation by JMoRGAGNi, Fricke, and Otto ; imd, in
very rare instance*, have been observed to contain
hair. Scroj'ulous tumours ar^ less frequently found

exteriorly to, and between the layers of, the dura jn

mater, than in its internal surface. ^^-^''^

10. c. Unusual thinness has been observed in
some parts of this membrane ; and some of its pro-
cesses have been wanting, owing to their absorp-
tion; in some cases, without any obvious cause,
but more frequently from the pressure of a tumour
of the brain, or some other morbid enlargeu.ent.
" The falciform process, and a part of the tento-
rium, have been wholly removed, and large portions
of the dura mater and its processes have been
found as thin as silver paper." (Hooper, Morbid
Anatoinij of the Brain, S^c. p. 29.) When portions
of the dura mater are d.slroyed by any internal
cause, or even by external injury affecting the
bone, they are rarely or never reproduced, and
never otherwise than by a thick or dense cellular
tissue closely connected wi h the newly formed
bone ; or, if the bone be not produced, after having
been destroyed, it assumes a fibro-cartilaginous
state, and becomes consolidated into a common
cicatrix with the integuments. Rupture, or lacera-
tion of the dura mater is gen; rally the consequence
of fractures of the cranium and concussion. It
has, however, proceeded fiom violent coughing,
after the superincumbent bone has been removed
by fracture, or by trepanning, &c.

11. B. Morbid states of the arachnoid covering
the dura mater. — a. The internal surface of the
dura mater is lined by a reflected portion of the
arachnoid membrane, the unattached surface of
the dura mater thus consisting of a true serous
membrane, intimately attached to, although dif-
ferent in its nature from, the fibrous structure
which it covers. Inflammation, whether originat-
ing in the dura mater itself, or in this surface,
chiefly manifests its distinctive characters and
efliiects on this lining : and generally presents, es-
pecially in the early stages of the acute disease,
a minutely injected state of the capillaries, with
a bright red tinge of the whole surface. This
appearance has been beautifully illustrated in the
first of Dr. Hooper's plates of lesions of the brain.
When acute inflammation attacks this part, it is ^
generally confined to one side, the longitudinal
sinus or the falx furnishing the boundary of the
disease. In very acute attacks, and in the ad-
vanced stages of inflammation of the dura mater,
the internal surface becomes covered by a layer of

Jihrinous lymph, into v\ hich, as I have shown in
respect to serous membranes generally, minute
vessels may be traced, when the exudation of this
substance has been proceeding for some days. It
is usually diaphanous, very delicate, and loiTning
a complete adventitious membrane. In other
ca--es, a much thicker, opaque, and albuminous-
like membrane, of much firmness, less vascular
and less intimately adherent to the dura mater, is
formed. Although the fibrine and albuminous
matter exuded may be both abundant, and thus
provided with vessels, it is seldom the medium of
adhesion ; or, indeed, at all adherent, to the
arachnoid cov ring the convolutions: and if ad-
hesions have formed, they are very slight in respect
of this latter duplicature of the arachnoid, unless
very acute inflammation also exists in the pia mater,
directly opposite to the inflamed surface of the dura
mater.

12. /). In more chronic forms of inflammation,
this surface not infrequently assumes a spongii
appearance, with more or less redness and marked

204'

BRAIN — Altehations in its Memdranes.

injection of the vessels. la some cases it has
a villous aq)ect, from a slight exudation of albu-
• minous matter, and interstitial effusion of serum
.in the texture of the arachnoid lining. Purulent
matter is seldom formed to any considerable ex-
tent ; but, when it is secreted, it usually spreads
thinh' over the membrane. It seems generally
to proceed from the inflamed surface, without any
distinct appearance of ulceration. In some cases,
however, owing to adhesions of the membranes
around it, circumscribed accumulations of pus are
met with ; and these may cause the erosion of the
dura mater and bones exterior to them. Although
the productions now noticed sometimes are observed
to follow idiopathic inflammations of this part, they
are more frequently tlte results of external injuries ;
and are more commonly met with in the parts
whicii cover the hemispheres, than in the basis of
the skull, unless there be a very general state of
inflammation of the parts within the cranium.

13. c. :4(i/(esio7is of the lining membrane of the
dura mater to the arachnoid and pia mater are
chiefly observed when both reflections of the
arachnoid are inflamed, particularly in chronic
aflfections of the cranial contents. The medium
of adhesion varies considerably. It is frequently
found to consist of a firm but thin exudation of
fibrinous lymph or of albuminous matter : in some
cases, delicate, diaphanous, and vascular ; in
others thick, opaque, and less intimately adherent
to the internal surface of the dura mater than the
preceding. In a few instances it is formed of fine
filamentous bands passing through a more than
usually copious efl^usion of serum ; and occasion-
ally the membranes are intimately and firmly
joined, even without any very apparent medium
of union, particularly at the centre o^" the part
adherent. This is chiefly seen immediately over
or near the situation of severe organic disease of
the brain itself, as abscess, tumours, superficial
ulcerations, &c. In some cases, the adhesions
are so firm that, in attempting to raise the dura
mater, the subjacent membranes, with a portion
of the brain, are removed along with it.

14. d. Ecchiimusis and purple spots arising from
the eflTusion of blood, in minute patches, beneath
its arachnoid lining, are sometimes observed in
the unattached surface of the dura mater, and
partake of the character of purpura. They are
most commonly found in ca-^es of cerebral dis-
ease, which has been complicated with chronic
change of the biliary organs and deficient energies
of life, — or with general cachexii. Carhonaceous
depnsiis, or melawisis, have also been sometimes
observed in the situation. Dr. liniciiT believes
them to be the result of extravasated blood. (See
the art. ISIelanosis.) O.-si/jc deposits, generally
disposed in plates, or much thicker in the centre
than the circumference, and varying much in
number and situation, are also fre(juently found
towards the surfac of the duia mater. 'J'hcy
seem covered by the arachnoid, are closely ad-
herent to the dura mater, and formed between
them. They occasionally present an irregular
surface, or assume a nearly conical form, and are
often connected with nervous diseases, particu-
laily epilepsy. 'J'liey are most fretiuently met
with upon the falx, and near the p;irt where the
dura mater se|)arates to form the longitudinal sinu-*.

15. e. Tumours not infrequently proceed from
the internal surface of the dura mater. 3Iany of

those productions are actually formed in the
arachnoid lining this surface ; being only adherent,
and often very slightly, to the proper structure of
the dura mater, and in no way changing its cha-
racters. As these tumours" increase in bulk, they
gradually produce debility of both mind and
body, particularly the former. Much of the
severity and rapidity of these effects will, how-
ever, depend upon the rapidity of their formation.
When small, and sources rather of irritation than
compression, convulsive affections are oftener oc-
casioned by them th-in paralysis: when large,
they more frequently give rise to paralysis than
convulsions: but either of them may be followed
by any of those affections ; mental weakness
being the more constant, and often the most re-
markable efTect. JNlany, also, of the tumours de-
veloped in the dura mater can scarcely be said
to originate either in its fibrous membrane, or in
its serou-j or arachnoid lining: but should ra-
ther be referred, at their commencement, to the
cellular tissue uniting those layers. Amongst
those which seem more frequently at least to ori-
ginate in this latter situation, — although often
involving, and in a very short time, all the layers
of the dura mater, and even the parts adjoining,
— the scrofulous, the cartilaginous, the haimato-
matoid, and the encephaloid or fungous tumours,
require the most parti ular notice.

16. a. The scrofulous tumour is found on the in-
ternal surface of the dura mater, having an organ-
ised, fleshy, solid, and humid appearance ; and is
but rarely met with, and only in connection with
scrofulous disease in some other part of the body.

B. The cartilaginous tumour is generally seat-
ed in close connection with the dura mater, and
under its arachnoid lining. It varies as much in
the peifection of the cartilaginous state, as in its
size. It is sometimes perfectly carlilayinous ; at
other times merely grisiJy. It is oftenest met
with in the falciform process and tentorium ; and
is occasionally attended with ossific deposits in
the same situations. Indeed, as remarked by Dr.
Hooper and Dr. INIoNno, some of those tumours
are partly ossified, so that the cartilaginous state
seems to be often an intermediate slate between
that of gristly firmness and complete ossification.
A case is described, by Mr. Watson, in Dr.
Monro's work, of a cartilaginous tumour, the
size of a walnut, containing bony matter towards
its centre, growing from the dura mater, 'i'he
suh-cartilaginiius tumours are often tuberculous,
of a dirty white colour, always distinct, but often
numerous, and varying from the size of a pea to
that of a hazel-nut. They generally are found
between the dura mater and its arachnoid lining,
have a broad base, present a clean smooth sur-
face when ilivided, are firm, and devoid of vas-
cularity. They seldom affect much the superin-
cumbent dura mater and bone, but deeply indent
the substance of the brain.

17. y. The mulignant tumours, which are oc-
casionally met with in the dura mater, assume the
sarcomcito)is, the curcinomatous, and the Jiingoid
characters. The fungoid disease may be either
e)icepb(iLoid, or haniatoid. The encephaloid tU'
monr is not common. Its divided surface is cel-
lular and spongy, and gives out a pap-like matter
when ])ressed. Its structure is more generally
approaching to the fungoid, than to the tubercu-
lous. It seems to be entirely produced from the

BRAIN — Alterations in its Memdhanes.

205

lining membrane of the dura mater, and is almost
always connected with sciniious or malignant
diseases originating in some other part of the body.
The hamatiiid tuinimr is of the colour of venous
blood, has a broad base, and a fungous, some-
times a tuberculous, structure. It is soft to the
touch, is covered by a delicately lamellafed
tissue, thinner than silver paper. When divided
it appear-! spongy, and extremely vascular. It is
very rare, and is always connected with the
primary occurrence of the disease in some other
part of tiie body.

J. The simple ci/st, or watery tumour, the hy-
groma oi T>t. HoorER.is seldom or never observed
in this situation,' although frequently in other parts
of the encephalon. A case of it, however, oc-
curred to Dr. Duncan. The u<;ephalocyst, or
headless hydatid, has been found connected with the
arachnoid of tiie dura mater, in a very few cases.

18. £. The CAi'SF.sof malignant, or constitutional
tumours in the dura mater, are generally external
wounds or contusions, concussions, the scrofulous
or syphilitic taint, and most commonly previously
existing di-^ease of a similar nature in other parts
of the body,

19. ^. The Symptoms by which their existence
may be inferred are extremely equivocal. At
the early periods of their growth, they frequently
give rise to little or no disturbance. JMuch, how-
ever, will depend upon the rapidity with wliich
they are formed, and their situation. When they
grow slowly, the portion of brain becomes gra-
dually accustomed to, and as it were, insensible
of, the pressure ; it seems to waste ; and if this
compressed and atrophied part be not indispen-
sable to the free exercise of the sensorial, intellec-
tual, and locomotive functions, the disease pro-
duces no evident or sensible indication of its
existence. But sooner or later the compression
produced by them on the brain, or the irritation
occasioned in the membranes, gives ri«e to effects
of the most serious nature. These chiefly consist
of paralysis, epileptic convulsions, and apoplexy,
occasionally occurring as suddenly as in the san-
guineous forms of these diseases ; but frequently
in a more or less gradual manner. When the
tumour is situated in or near the base of the brain,
the symptoms, whether those of compression or
of mental disorder, generally supervene rapidly.
jMost commonly, however, sensation and volition
gradually disappear from the limbs which corre-
spond with the compressed portions of brain ; the
intellectual powers are obscured, and the patient
soon becomes hemiplegic and idiotic. The gra-
dual accessions of hemiplegia, and of the other
symptoms of compression, generally indicate that
the paralysis arises from the developement of a
tumour, rather than from the formation of an
apoplectic effusion of blood. The .frequent oc-
currence, also, of acute pain in the paralysed
limbs, of epileptic movements, antecedent cepha-
Lxlgia of a violent character, with obscuration of
the intellectual powers, somnolency, a cachectic
iiabit of body, or the occurrence of disease in
other parts of the body calculated to taint the
system, as the scrofulous, syphilitic, carcinoma-
tous, or fungoid diseases, are also circumstances
indicating the formation of tumours in the mem-
branes of the brain.

20. These tumours usally give rise to further
disease of the brain, or its membranes, before

terminating life ; such as inflammation of the parts
adjoining, effusions of fluid beneath or betweefi
the membranes, adhesions of their opposite sur- •
faces, destruction of the bones, softening and.
pulpy destruction, &c. of the cerebral substance;
sanguineous effusion in this situation : and these
increase the severity of the symptoms, and hasten
the fatal termination. It should, however, be kept
in recollection, that the effects produced by these
tumours have in general no relation to their bulk.
One of the circumference of one or two inches
will often occasion (the situation and nature of the
tumour being the same) as violent effects as an-
other of four or five inches. It is, moreover, not
to the tumour'itself that the symptoms are to be
imputed, but to the effects it produces on the
brain and membranes. ^

21. ii. Morbid Changes of the Arachnoid
and Pia INIater. — A. The Arachnoid is kg
delicate, perfectly transparent, and so intimately
adherent to the pia mater, except at the base of
the brain, as to admit with difficulty of separation
from it. That lesions, therefore, of the latter
membrane should aflfect also the former, cannot
be a matter of surprise. Indeed, the greater
number of changes which I shall have to notice
in this section generally invade both these mem-
branes simultaneously, although either of them
may be affected in a more or less marked de-
gree.

22. a. Infiammatory action gives rise, though
very rarely, about the optic nerves and between
the lobes of the cerebellum, to small patches of
beautiful vascularity in the arachnoid; the sur-
rounding portions of this membrane being opaque,
and adhering to injiamed parts of the pia mater.
It is, however, very uncommon to find, even in
the most intense inflammation of these mem-
branes, red vessels in the arachnoid. The most
frequent results of inflammation in this situation
are, thickening, and the effusion of a watery
or serous jiuid under it, raising and separating
it, in places, from the pia mater, particularly
in the intergyral spaces. The fluid secreted in
this situation is generally transparent, but it is
sometimes turbid and albuminous, occasionally
opaque, and tinged with bile in jaundire. In
rarer cases it is tinged with blood. Thickening,
and opacity of the arachnoid vary much in degree.
They are occasionally so great as to obscure the
vessels and membrane underneath it. Less fre-
quent than the foregoing is the secretion of a
pnriform matter, under the opaque and thickened
membrane, giving the appearance of a diffused
suppuration ; and still more rare is the deposit of
Jihrinous lymph unless in a state nearly approach-
ing to an albuminous substance, or a puriform
fluid.

23. h. The effusion of a serousjluid, in excessive
quantity, exterior to the arachnoid of the pia
mater, and in the bag of the arachnoid coat,
around the encephalon, forming dropsy of the
cerebral membranes, is sometimes observed. It
has been fully demonstrated by M, Magendie,
and confirmed by other inquirers, that this mem-
brane secretes a fluid in health, varying some-
what in quantity with the state of the brain, and
of its circulation ; that this fluid cannot be mate-
rially diminished, or entirely deficient, without
morbid phenomena being produced ; and that it
may, in disease, not only be secreted in too large

206

BRAIN — Alterations in its Membranes.

^ quantity, but also in modified quality. In some
cases of chronic and congenital hydrocephalus,
particularly when accompanied with spina bifida,
the effusion is chiefly in this situation. In those,
it is usually pellucid, and the arachnoid is not
materially changed in its appearance. In more
rare cases, however, this fluid has been observed
somewhat turbid, as well as excessive in quan-
tity ; and the arachnoid opaque and thickened.
In these, it would seem to have proceeded from
increased vascular action iiffecting this membrane
and the pia mater. Effusion of a watery fluid, how-
ever, in this situation, is much less frequent than
in the ventricles. It is commonly congenital and
chronic in these latier cases ; and it sometimes
protrudes the membranes, in large watery tu-
mours, through apertures in, or between, the
bones of the head. Several cases of this kind
have occurred to me in the Infirmary for Chil-
dren. In dropsy of the ventricles, which is most
common, producing almost all the large watery
heads, the fluid is collected in the bags of the
arachnoid and vascular membranes Iming the
cavities of the brain, so that it is contained, either
in all, or the greater number of them, at the same
time, which is most frequently the case ; or in one
cf them only. Serum effused from the arachnoid
and vascular membrane (pia mater) may thus be
situated : — 1st, In the sub-arachnoid cellular tis-
sue ; that is, between the arachnoid of the pia mater
and this vascular membrane : 2d, In the great
cavity of the arachnoid around the encephalon:
3d, In the different ventricles, and even in the
cavity between the two folds of the septum luci-
dum (Breschet). The quantity of serum effused
in these situations varies remarkably. In cougeni-
tiil and chronic cases, it is sometimes uncommonly
great, filling uj) and distending enormously the
cranial cavity ; impedins' or arresting the de-
velopement, altering the form, and even injuring
or destroying the texture, of the cerebral sub-
stance, which is expanded in the form of a sac;
that part of it above the ventricles sometimes con-
sisting of the meninges merely. In acute ln/dro-
cephaliis, the effusion takes place in a few days,
and to a much less extent; and in serous apoplexy
it may occur in a few hours. In these latter dis-
eases, however, it is often a matter of dispute,
whether the symptoms are more the result of the
effusion, or of diminished vital endowment, and
the state of circulation of the brain. (See Dropsy
of the Kncephalon.)

^ 24. c. Drijness of the arachnoid is occasionally
found after cases of excessive cerebral irritation,
and where inflammatory action has been sus-
pected. 'J'here can be no reason wherefore defi-
cient secretion should not sometimes occur here,
as well as in other serous membranes, as a result of
inflammation. Aminctuous state of the arachnoid
is j?ometimes observed, particularly after erysi-
pefas, absce.ss of the brain, discharges from the
ear, paralysis, &c., and other states of disease, in
which there was reason to infer the existence of
inflammatory irritation of the membranes of the
brain. Adhesion of the arachnoid to the opposite
surface of the dura mater, by means of a cellular
or firm albuminous false membrane, &c. have
been already described (§ 13.). Dark carbon-
aceous deposits, similar to those noticed (§ 14.)
in 'he iTilernal liriinj? of the dura mater, are also
rarely observed in lire arachnoid and pia mater.

Osseotts deposits also occur in the arachnoid, and
are likewise rare.

25. B. The Pia Mater partakes in all the
inflammatory states, and their consequences now
described in respect of the arachnoid. — n.The vas-
cularity of this membrane varies greatly. Some-
times it consists chiefly of engorgement of its
veins, imparting to it a dusky or purplish hue,
without any sign of inflammatory or other change.
Occasionally this congestion is attended with in-
jection of the arteries, and increased redness only,
or with these in conjunction with one or more of
the lesions now referred more immediately to the
arachnoid.

26. b. Slight effusions of blood', and patches of
ecchymoses, varying from the size of a split pea to
that of a half-crowt), are occasionally found lying
upon the suiface of the convolutions, and retained
between the meshes of the pia mater. This state
arises from concussions of the brain, and conges-
tions consequent upon suffocation, poisoning by
narcotics, and the advanced stages cf disease ;
also from obstructions in the vessels returning the
blood from the brain. A layer oifihrine is some-
times, but rarely, observed as a consequence of
effusions of blood between the pia mater and brain ;
the serum and red particles of the effused blood
having been absorbed, and its fibrine remaining.

27. c. Thepi'a mater a.nd arachnoid are occasion-
ally separated from the convolutions in consequence
of concu.ssion ; and in some cases, particularly
after acute or recent inflammations, they may be
removed from the cerebral substance with scarcely
any force, or with much less than in health, the
vessels being loaded with blood. Otto thinks
that the easy separation of the vascular membrane
from the brain originates in the effusion of lymph
beneath the membrane, loosening its connection
to the cortical substance. On the other hand, after
chronic inflammation, occurring without effusion
under the membranes, but with a considerable
effusion into the ventricles, they are often found
so closely adherent to the convolutions, that they
cannot be separated, but in very small frag-
ments, and then not without bringing away with
them portions of the cineritious substance of the
brain.

28. rf. Patches of yellow albuminotis, oralhumino-
purij'orm matter, are sometimes found on the up-
per surface of the pia mater, between it and the
tunica arachnoidea. These patches are usually
small; but they are occasionally very large, and
diffused over nearly the whole of one hemisphere.
Dr. Hooi'Eu has observed them covering nearly
the whole of the base of the brian, so as to en-
velope most of the nerves. 'i'his appearance
seems to result from a more than usually inten.se
state of inflammation, as all the membranes are
found inflamed, and the blond-vessels loaded
with dark blood, and to differ but sliglitly from
the effusion of pus and lymph already described
in connection with changes of the arachnoid.
Ulceration and mortification are very rare conse-
quences of inflammation of the pia mater. They
may, indeed, be rather considered as superficial
ulceration and gangrene of the brain. Cases,
however, have biicn met with, sometimes con-
nected with superficial suppuration, aifecting
chiefly this membrane. (Buzzi, Morgagm, Du-
nn i:vii,, Ottj.)

29. e. Tumours often grow from the ^pia mater.

BRAIN — Alterations in its BIembranes.

207

The scrofulous kind of tumour or tubercles are
not very rare ia this situation. When they occur,
they sometimes reach a large size, and break
down into a puriform fluid, forming circumscribed
or encysted abscesses on the surface of the brain.
Leiveille found them as large as an egg, in an
idiot. Cases are also described by Earle, Aber-
CROMBiE, Otto, and others. Tumours •>/ a sub-
curtilaginous structure are very rarely met with in
the pia mater, although occasionally in Ihe choroid
plexus. They are usually of the size of q pea,
round or oval, laminated cartilaginous, in the
centre, exteriorly tuberculous, and covered with a
delicate vascular membrane.

^ 30. True encijsted tumours are also sometimes
met with in the pia mater. Otto describes one of
immense size, — six inches long by three broad, —
found on the right hemisphere of the brain of the
Duke of Saxe-Gotha. Esquirol met with a tu-
mour of this kind containing fat ; and similar in-
stances have been recorded. Ossijic deposits and
eurthii concretions have been rarely ob^erved on
the internal surface of the pia mater, dipping down
into the structure of the brain.

31.J'. Serous cysts, the hygroma of Dr. Hooper,
consist of a delicate and transparent membrane,
filled with a clear, limpid serum. There is in
some cases only one, in others two, three, four, or
even more. When solitary, they vary from the
size o£ an orange-pip to that of a walnut ; but
they are seldom much above the bulk of a large
pea. When numerous, they are usually much
smaller. They are very rare in the membranes of
the exterior surfaces of the brain ; but they are
very common in the choroid plexus, where they
are frequently in clusters. They have been mis-
taken for hydatids, but are merely simple cysts,
containing a serous fluid. J'hey have likewise
been found in the adventitious membranes formed
on the surface of the brain. They generally fur-
nish no symptom by which their existence can
even be suspected during life. — The acephalo-
cyst, or headless hydatid, is seldom or never found
in the pia mater. Five species of the Cysticercus,
or the bladder-tailed worm, namely, the C. tenui-
coUis, the C. Fischerianus, the C. dicystus, C. punc-
tatns, and the C. Finna, have been discovered re-
spectively by Brera, Fischer, Laennec, Treut-
i.er, and Werner, either in the pia mater or
choroid plexus. (Art. Cysticercus, Diet, de M£d.)

32. g. Fungoid, hxmatoid, and other malignant
tumours, are sometimes found in the pia mater
and arachnoid ; but I believe they are seldom or
never met with as a primary disease, but asso-
ciated, as a consecutive change, with fungoid or
malignant disease in some other part of the body.
When they grow to any considerable size, they be-
come deeply indented into the convolutions; pro-
ducing at fiist irritation, and afterwards, as they
increase, symptoms of pressure. When, there-
fore, such phenomena present themselves, in per-
sons with fungoid disease, we may suspect its de-
velopement also in the brain.

33. C. The Choroid Plexus, and the vascular
pleius of the fourth ventricle, which are all pro-
ductions of the pia mater, are often found remark-
ably distended with blood, and their vessels varicose,
particularly when the pia mater has its vessels
overcharged. The choroid plexus is also some-
times uncommonly pale and exsanguine. This ge-
nerally occurs when consideiable effusion of serum

has taken place in the ventricles, especially when
the eflTiision is connected with debility. Some-
times the plexus contains a number of transpa-
rent vesicles (see §30.), and it occasionally pre-
sents a granulated or Jieshy appearance. This
has been ascribed to a morbidly enlarged state
of the glandular apparatus, with which, in the
opinion of some anatomists, this structure is
naturally provided. Gelatinous tumours about the
size of a bean, and surrounded by a cyst, have
also, though rarely, been observed in this situ-
ation. Tumours of a cheesy or sub-cartilaginous
consistence, the size of a pea, are likewise found,
in some rare cases ; and occasionally these tumours
contain ossijic deposits in their centres. Bony and
earthly concretions are still more rarely met with in
the choroid plexus than in the membranes. All
these morbid changes have been most frequently
observed in apoplectic, epileptic, and paralytic
cases; but they have also been frequently de-
tected where no particular symptom referrible
to the nervous system had manifested itself during
life.

34. The membrane ivhich lines the ventricles is
naturally extremely thin and transparent. No
blood-vessels, excepting those which ramify over
the corpora striata and thai ami from their trunks,
which pass by the side of the tagnia semicircularis,
are usually observed in it. The vessels, however,
of this membrane are sometimes found much en-
larged, and gorged with blood, particularly when
afluid is collected in the ventricles, so as to distend
them beyond their natural capacity. In this state
the membrane is not only more vascular, but also
much firmer and thicker than natural. The sep-
tum lucidum is sometimes as thick as the dura
mater, and very firm ; but more commonly, those
parts of the membrane which are thickened and
rendered opaque, are also soft and pulpy.

35. Coagulated albumen is occasionally found
on the surface of the ventricles. It is sometimes
met with in layers on the corpus striatum and the
thalamus. I have found it of great thickness: and
in one case, which recently occurred to me at the
Children's Infirmary, it nearly filled both ven-
tricles. Ulceration proceeding from inflammation
is occasionally met with in this surface, particu-
larly in the corpus striatum. It seems generally
to arise from the formation of a small abscess or
purulent collection under the membrane, which it
ruptures, the fluid thus escaping into the ventricle.

36. D. Injlamed states of the Pia JNIater, with
or without ulceration, puriform secretion, &c., are,
as well as other lesions of this description in other
parts of the brain, most frequently occasioned by
external injuries. Inflammatory irritation, affecting
the arachnoid and vascular membrane either of the
periphery of the brain or of the cavities, is not an
unusual consequence of injuries of a serious cha-
racter sustained in other parts of the body, as after
compound fractures and contusions of the limbs
and joints, severe burns, 6lC. In these cases, a
similar state of the membranes, as well as a nearly
simdar kind of delirium to that which has been
called delirium tremens, sometimes occur. Inflam-
matory states, either with dryness of the membranes,
but more frequently with effusions of various
kinds, often taken place in the progress of acute
diseases, particularly fevers, and the exanthemata ;
from drunkenness, accidents, concussions, or men-
tal excitement J whiUt congestions, effusions, and

208

BHAIN — Morbid Anatomy ok its Sinuses.

infiltrations of blood, proceed generally from in-
terrupted circulation through the heart and lungs,
narcotic poisons, asphyxia, &c., and frequently are
attended with convulsions, stupor, coma, para-
lysis, &c. The adventitious formations are usually
the result of a cachectic habit of body, as scro-
fula, deficient vitiil power, and the vitiation of
the system by syphilis, and the cancerous or car-
cinomatous taint.

37. iii. Lesions of the Sinuses of the Dura
Mater, and Vessels of the Brain. — a. Inflam-
mation of the sinuses is sometimes observed, in its
advanced stages and consequences, and but rarely
at the early periods. In this latter case, they ma-
nifest chiefly increased vascularity, and ledness of
their internal lining, with slight tliickening and fri-
ability, sometimes with softening, and occasionally
with abrasion, and give rise to the following
changes, seated immediately within the part of the
vessel which is inflamed : — 1st, To the coagu-
lation of the blood in contact with, and its ad-
hesion to, the inflamed surface of the vessel : 2d,
Subsequent discoloration of the coagulum, and
its conversion into a state nearly resembling that
of coagulated lymph : and, 3d, The presence of
pus, which is usually found in the middle of this
coagulum, though not always. Thickeni)ig of the
membranes forming the parietes of the sinuses is
occasionally remarked, and is evidently a result
of a slow stale of inflammatory action, aflPecting
chiefly the fine cellular (issue connecting the se-
rous lining to the fibrous membrane. Sometimes
their parietes are remarkably thick and dense,
almost approaching to cartihge, this morbid
change being chiefly seated in their connecting
cellular substance. Firm Jihrinmis formations, or
coagulated lymph, are also occasionally formed in
these vessels ; in some cases, conjointly with
marks of inflammation in them ; the internal tis-
sues of the vessels being red, injected, congested,
and of a dark colour; and in others without any
very marked appearance of such disease, but with
evident thickening of their parietes. In several
instances I have observed these formations dis-
posed in the form of false membranes within the
sinuses, and adherent to their serous lining.
While the more exterior surface of these false
membranes, or that next the vessel, is generally
firm, the interior of the canal which it forms is
soft, and contains a purulent-like matter mixed
with a concrete albuminous substance.

38. In other instances, no fibrous concretions
are formed, nor is the vessel perceptibly inflamed,
and yet pus is found in parts of the sinuses, either
distinct and in considerable quantity, or mixed
with firm coagula, or with clots of blood, and in
small quantity. In these cases there is reason to
suppose that pus has been carried by the veins
into this situation from an adjoining part. In
some cases it occurs accompanied with an albu-
minous-like eflTusion, more or less concrete, or
with firm fibritious coagula, and an inflamed state
of the internal membrane of the vessel. In many,
the presence of pus is coimected with an apparent
abrasion, and even ulceration of the internal
surface of the sinus; but in others, increased vas-
cularity, with patches of deep redness, or of con-
gestidn, with a deep lividity, and occasionally
slight thickening with diminished cohesion of the
parietes of the vessel, are most remarkable. In all
these, there can be no doubt that the puriform

fluid is deposited in this situation from the sur-
rounding inflamed parietes of the vessel.

39. The lesions now described are most fre-
quently connected, in adults, with chronic disease
of the bones of the cranium ; and, in rarer in-
stances, with disorganisation of the brain itself and
of its membranes. They are most frequent after
fractures of the skull, and external injuries : and
I believe that they are occasional consequences of
the worst forms of erysipelas of the head ; a case
of this description having occurred to me, in which
inflammation of the sinuses of the dura mater was
found upon dissection. They are more common
in children, according to my experience, than in
any other class of patients; particularly from the
age of one and a half or two years to ten or
twelve. I have observed the appearances now
described in several cases of cerebial disease;
or, at least, of cases terminating with the usual
symptoms of pressure on the brain, following
severe states of porrigo, ulcers of the scalp, and
chronic diseases of this structure, particularly in
scrofulous, weak, and ill-fed children. The ob-
servations of M. ToNNELLE and of M. Rinis fully
agree with my experience as to the pathological
relations of these lesions of the sinuses. The
sinuses also present a vermilion colour of their in-
ternal membrane, like that which is sometimes
found in the arterial system. This appearance is
most probably caused by a morbid state of the
blood ; and it may be, on some occasions, a post
mortem change, arising from the staining of the
internal surface of the vessels by the colouring
part of their contents.

40. h. In respect of the state of the hlood itself in
the sinuses, much diversity exists : the quantity
contained by them also varies greatly. More fre-
quently they are empty, or nearly so. When
they contain blood, it is in some cases dark, semi-
fluid, or thick ; in others, less dark, and more
fluid ; in the greater number, either altogether or
partly coagulated. In a few, it is separated into
a serous or sero-sanguineous fluid, and a fibrinous
coagulum having no connection with the parietes
of the vessel, the coagulum consisting entirely of
the fibiine of the coagulated blood, and not of the
albuminous fibrine, or coagulated lymph, already
described (§36.). In some cases, one or more
of the sinuses is filled with a dense, firm, and
brown coagulum, peifectly continuous through-
out ; branching even into the veins which open
into the sinuses ; and not interrnpted, soft, and
forming variously-sized clots, such as are often
found after death. This state of the contents of
the sinuses is seldom or never connected with in-
flammation of its parietes, unless the inflamma-
tion has occasioned, by means of the albuminous
matter effused, a complete obstiuction of the
vessel, and, consequently, the accumulation and
gradual coagcliition of the blood beyond it ; being
a change in these fluids independent of organic
lesions of the parietes of the sinus, unless such
lesion occasion obstructed circulation through it.

41. 'I'he firm, dense, and continuous coagulum
now described is evidently the result of a slow
coagulation proceeding in the sinuses previous to
death ; and, in every instance in which 1 have
observed it, has arisen from obstruction in the
return of blood from the sinuses, owing to com-
pression of the jugular veins, by tubercles, scro-
fulous tumours, or other organic changes obliter-

BRAIN — Alterations of its Substance.

209

ating the canals of these vessels, or of the sinuses
themselves; or from a stasis of the blood, fol-

owed by coagulation in these vessels, arising in
consequence of great cerebral congestion, joined
with the utmost general adynamia. There is no
doubt that the effusion of lymph, in any of its
states, or even of purulent matter, will, while in
connection witii the internal surface of an inflamed
vessel, or mixing with the blood in it, dispose this
fluid to coagulation; forming a nucleus around
which coagulation will proceed, or a point from
which it may depart. And such seems to be the
source of the more or less extensive and continu-
ous eoagula, which we frequently find in connec-
tion with inflammatory lesions and formations in

he sinuses. But such is not the case here. In
the course of an extended experience at the In-
firmary for Children, I have observed, in several
cases, that this state of dense coagulation of the
blood in the sinuses manifestly supervenes before
Jealh, owing to the general and local conditions
now stated, and gives rise to all the symptoms of
more or less complete and sudden compression of
the brain, owing to the consequences I am now
to notice as arising from it, in common viith other
causes of obstruction in the sinuses. In cases of
'his description, if no effusion of blood have
occurred, the veins are found generally engorged
wiih dark blood. In some ca>es, the distension
of the veins had given rise to an exudation of

ilood, or rupture of several of their minute dis-

ributions, with copious extravasation of this fluid ;
And in many, the distension of the veins was
accompanied with copious effusions of serum in
the ventricles, between the membranes, or in both
situations.

42. c. The glandulce Paccliioni are sometimes so
much increased in number and size as to obstruct
the passage of blood through the sinuses; give
rise to the appearances now described ; and thus,
IS the other changes in the sinuses, terminate in
some one or other of the apoplectic states. JMr.
Earle (Medico-Cliirtirg. Trans, vol. iii. p. 66.)
has observed these glands changed to the ap-
pearance of grumous blood, in connection with
fungoid disease in the brain. I'hey are more
frequently enlarged and hardened ; and, occa

and the vessels departing from it, as well as the
arterial ramifications which appear between the
convolutions, and come out upon the suiface,
often participate more or less in this morbid state.
CurtiUiginoiis degeneration is still more extensive,
and seems to ))recede the ossific deposits. Car-
tilaginous, ossific, and atliercnnitous formations in
the coats of the arteries of the brain occasion irre-
gular distributions of blood, and interrupted or
imperfect supplies of this fluid to some parts of
the organ ; disposing to aneurismal dilatations, to
rupture, and, consequently, to the production of
apoplexy and paralysis. In most instances of ex-
travasation of blood in the substance of the brain,
these conditions of the arteries exist; and are,
most probably, the causes of the extravasation, by
disposing to congestion, and rupture from in-
creased action of the heart.

46. g. Aneurismal dilatations of the arteries of
the encephalon are by no means very uncommon :
they are most frequently met with in the carotids
after they have entered the cranium, in the large
blanches, and in the basilar artery. They may de-
range the circulation of the brain, or may occasion
effusions of either blood or serum, without them-
selves having been ruptured ; but they more
frequently break, occasioning apoplexy. I'he ar.
terics, particularly those about the base of the
brain, and some part of the branches forming the
circle of Willis, are also occasionally obliterated
and reduced to a thin chord.

47. II. Lesions of the Substance of the
Brain. — The morbid states of the brain have
been investigated in modern times with the greatest
success and advantage to practical medicine. The
labours of Reii., Serres, Lallemand, Wenzel,
Gall, Rostan, Aeercombie, Hooper, Craigie,
and Duncan, have chiefly tended to this advance-
ment ; whilst a number of other enquirers have
added much of importance, as well as confirmed
the observations of more original enquirers.

48. i. Inflammation of thf. Substance of the
Brain, — Encephalitis, — Cerebritis — A. Acute
inflammation of the brain does not frequently occur
as an idiopa'hic or primary and uncomplicated
malady. It is in consequence of previous disease,
as fevers, the exanthemata, inflammations of the

sionally, they cause an absorption of the dura j ears, extravasated blood, tumours and tubercles

mater, with corresponding depressions in the supei
incumbent bone.

43. d. The hands which cross the longitudinal
sinus are occasionally more numerous than natu-
■al ; and they are sometimes thickened, particu-
larly in connection with a similar change of the
parietes of the sinus.

44. e. The veins on the surface of the brain

of the brain, of poisons, and external injury, that
it comes most frequently before the pathologist.
Resulting from injury, it is generally limited in
extent, although intense in degree. The whole
brain is rarely or ne\ er afl^ected at the same time,
but only a part of it; and the disease is seated
either in the vascular membrane, or in the cor-
tical substance, or in the medullary matter of

sometimes contain a few bubbles of air; but it is the interior parts, of the brain, or in them all
doubtful whether this is a morbid state or a post simultaneously. 'J he part aflfected first becomes
mortem change. They are occasionally filled with I vascular, and the injection of the vessels proceeds
fibrine, particularly in those cases which presented \ till the cerebral substance displays a red tint,
a corresponding state of the sinuses. Pus has deepening, as the disease advances, until it assumes

also been observed in them, especially in cases
of inflammation, with secretion of pus under the
'■rachnoid.

45. f. Ossification is detected only in the arteries ;
but it occurs in them veiy frequently, and to a
very great extent, particularly in advanced life.
The early stages of this change have also been
discovered in youth, although rarely. 'Jhe arte-
ries most commonly found ossified are the internal
carotids and the basilar; but the circle of Willis,

Vol. I.

a reddish brown, and, occasi<maIly, even a brown-
ish or green shade. With this increased intensity
of disease, the part becomes softer than natural.
The formation of matter, however, is not so fre-
quent a consequence of this form of inflammation
as of that of a sub-acute or chronic kind, occur-
ring in persons of a scrofulous diathesis, and
unhealthy habit of body, unless when a foreign
substance, or piece of bone, has been diiven into
the brain. Somewhat similar to infiummation

210

BRAIN — Alterations of its Substance — Abscess.

although decided])' different from it, is that state
of morbid irritation frequently met with in fevers,
especially lypiius, eruptive diseases, epilepsy, de-
lirium tremens, tetanus, convulsions, hydrophobia,
nostalgia. In these diseases, vascular turgescence
and red injection of the brain are usually seen ;
but not the general red colouring, the spot-like
effusion of blood, and the change of consistence,
whicli characterise acute inflammation of this
structure.

49. Acute cerebritis occasions violent headach,
intolerance of light, acuteness of all the senses,
delirium rapidly succeeded by convulsions, coma,
and deatli. When it arises from morbid poisons
affecting the system, as in gaol and camp fevers,
purulent formations are more frequently met with,
as stated by Pringle and others. In these cases
the symptoms are somewhat varied ; the prostra-
tion of the powers of life being much greater, and
the delirium of a much lower grade. In those
diseases, the post mortem inspections, when nume-
rous, will furnish examples of the various stages
of lesion, from the first appearances of injection of
the vessels to the formation of matter, or complete
de-.truction of the part chiefly affected.

50. B. Suppuration of the brain, — Abscess of the
brain, — Apostema cerebri. — Collections of puru-
lent matter have been often found in the biain,
generally as a consequence of inflammation of a
sub-acute or chronic kind. Of this the writings of

BONET, MORGAGNI, LlEUTAUD, BaADER, StOLL

(Rat. Med. i. p. 285.), Frank (Acta Inst.
Clin. Viln. Ann. 1. p. 75.), Prochaska (Anat.
Acad. Fasc. part. ii. sect. ii. cap. 2.), Schaeffer
(Hufelitnd und Himli/. .Journ. der Pr. Heilk.
(1809), Portal {Mtmoires de I' Acad, des Sci-
ences, 1780, p. 315.), Lallemand, Baillie, Bro-
DiE, Powell, Hooper, and Abercrombie, furnish
numerous examples. The situations of these
aljscesses vary considerably, as well as the kinds
of abscess formed. — a. Sometimes the purulent
collection is lodged in an irregular cavity, and
appears unsurrounded by any distinct cyst. These
take place to a greater or less extent, and consist
most commonly of purulent matter mixed with
flakes of lymph, giving it a slight curdly appear-
ance. They are most commonly found in the
anterior lobe of the cerebrum, or in the centres of
the hemisphere. Some of the abscesses of this
kind seem to consist of several small cavities com-
municating with each other: these are usually
found also in the anterior lobes, the centres of the
hemispheres, or near the striated nucleus of Reil.
— b. The next species of abscess consists of a dis-
tinct, firm cyst, or even cysts, as observed by Lal-
lemand, and seems to have been the result of a
slower process of formation, and of a less acute
form of iijflammation : it contains purulent mat-
ter, and is most freijuently found in the centre of
the hemispheres, particularly just above the cen-
tral oval of ViEussENs, or at its margin. Ai)sccss
of the biain has also been met with immediately
below the cornu ammonis ; likewise near the pari-
etes of the small posterior cornu of one of the lateral
ventricles, and just below the unciform eminence
which rises into the interior of this cavity. In
one instance only (North Amer. Med. and Surg.
Journ. 1818.) have the tubcrcula quadrigemina,
and |)ineal gland, been the s::at of abscess.

51. c. I'uiulent matter is also found in some part
of the bruin, infiltrated, as it were, into the cere-

bral substance in the form of a number of minute
drops, and occupying a considerable extent, but
not lodged in any single distinct cavity : the parts
surrounding the purulent infiltration presenting
scarcely any other appearance of change, except-
ing more pr less softening, which is always pre-
sent, and seldom any sign of augmented vascular
action. This morbid state is frequently observed
as the consequence of the transit of purulent
matter into the circulation, which, in some cases,
is secreted from the vessels in the substance of
the brain, giving rise to the infiltration. This
phenomenon takes place much more frequently
in the parenchyma of other organs, as of the
liver, lungs, and spleen, than in the brain. The
infiltration, whether proceeding from this source
or not, often passes into the condition of distinct
collections, varying in number and size ; and
sometimes they nearly or altogether communicate.
In such cases, the cerebral substance separating
these collections seems as if it were softened,
or broken down into the purulent matter, and
often processes of the cerebral structure, still ad-
hering to the surfaces surrounding these collec-
tions, are floating in them, appearing as the debris
of a portion of the disorganised brain. In these
cases an approach is made to the formation of
a regular cavity. In other instances, if the dis-
ease is less rapid, or does not destroy life before
further local changes take place, a distinct cavity
is effected, which, at first, consists of the cerebral
substance merely, softened, discoloured, and vas-
cular. M. Andral thinks that the following
characters presented by the cavities containing
purulent matter are the result of subsequent
changes which the surfaces of these cavities un-
dergo, and not the result of an original dissimi-
larity of structure. As to this point, I think his
reasoning inconclusive, and his proofs insuf-
ficiently strong. It, however, should be admitted,
that the purulent infiltrations, and collections in
either of the forms now noticeil, are those vvhich
take place most rapidly, and which are generally
observed in post mortem researches, in cases of
death taking place soon after the symptoms of
cerebral disease had supervened ; whilst the en-
cysted form, as I have already stated, are those
which manifestly form most slowly.

52. d. The different kinds of parietes sur-
rounding the collections of matter in the brain,
according to this able pathologist, are, — 1st,
The cerebral structure itself, which, in recent
and acute cases, forms the only envelope of the
purulent collection ; but which may assume the
following appearances successively, according to
the duration of the disease. 2u, A cellulo-vas-
cular substance, extending over the whole of the
internal surface of the cavity, or merely in parts.
3d, A true membrane, which is as yet soft, and
flocculent, but yet admitting of separation from
the adjoining nervous substance. 4tli, A fine
membrane, presenting a distinct organisation, and
capable of being detached either in pieces or
entire. Once arrived at this stage, their internal
surface often has the appearance of villosities,
whilst sometimes the cyst is composed of two or
more distinct layers, which may be detached from
each other. In these cases, the cysts are thick,
as remarked by I'rofessor Lallemano; the in-
ternal layer, or cyst, being of a reddish white,
and presenting the aj)pearuace of a mucous sur-

BRAIN — Alterations of

face slightly inflamed. In a case noticed by this
author, in wKich three distinct layers, or cysts,
were observed, the exterior was cellular, adhering
to the cerebral substance ; the middle one thick
and firm ; the interior layer closely resembled a
mucous surface. Meckkl, however, espouses a
different opinion from Andral, as to the form-
ation of abscesses contained in distinct cysts.
These are not, according to him, owing to ad-
vanced changes in the organisation of the walls
of the purulent collection; nor are they to be
ascribed to suppuration of the cerebral texture
itself; but to intlammation and suppuration of an
adventitious structure, developed in the cerebral
substance. His reasons for this opinion are, —
1st, That those cysts adhere but very loosely to
the surrounding cerebral texture : 2dly, That this
texture is not hardened, but, on the contrary,
softened, immediately around them.

53. Tiie cerebral substance in which the puru-
lent infiltrations and collections of the first grade
are found, is generally softened, and, excepting
when they arise from the absorption of purulent
matter into the circulation, more or less injected.
In cases of purulent collections contained in
more or less distinct cysts, or membranes, the
surrounding structures are often but slightly
altered, and occasionally not even perceptibly so.
But when the collection has much increased, or
continued long, the nervous substance surround-
ing the cyst becomes irritated, inflamed, dis-
coloured, and softened ; and then only supervene
those symptoms which evince, unequivocally, the
existence of abscess or serious organic lesion :
for, up to this period, the abscess may have been
proceeding, but so slowly as not to disturb the
functions of the organ, until, owing to some de-
termining cause, in conjunction with the changes
taken place in the cyst or its contents, or with
its size, the substance of the brain surrounding it
becomes diseased.

54. Abscesses, whether immediately surrounded
by the cerebral structure, or contained in more
or less distinct cysts, may vary in number from
one to six or seven, each distinct from the other,
and seated in various parts of the brain. 1 hey
may present appearances of ulceration in their
parietes ; and they may be accompanied by a
variety of other lesions of the brain and its mem-
branes, generally in different subjects, but occa-
sionally even in the same case. Inflammatory
appearances of the membranes ; eflTusions, serous
or albuminous, in either the external or internal
surfaces of the organ ; softening of the structure,
tumours, occasionally hardening, &;c.; are their
usual attendants.

55. e. In respect of appearance, the pus found
in the brain differs in no way from that formed in
other textures of the body. IM. Lallemand
(Rtcheiches Anatimiico-Pathotog. sitr VEnceph. &c.
let. iii. p. 361., let. iv. p. 41.), whose numerous
observations of purulent collections in the brain
have enabled him to give much interesting inform-
ation on this topic, states, that he has observed it
of a yellowish green tint, yellowish, yellowish
white, greenish, greyish, yellowish grey, whitish
grey, dirty white, and altogether white. lie, as
well as Abercrombie, has frequently found it
extremely fcetid. This foetor of the pus I have
cbserved in several cases of abscess occurring in
young subjects, from the extension of inflam-

iTS Substance — Abscess. 211

mation of the ear to the brain. In a case of this
description, reported in the Medico-Chiitirgical
Revieiv for Dec. 1830, the foetor of the purulent
collection was extreme ; and the cerebral sub-
stance surrounding it greenish, disorganised, and
broken down into the contained matter. Ab-
scesses formed within the substance of the brain
occasionally make their way to some part either
of the external or of the internal surface of the
organ : thus they sometimes break into the ven-
tricles, as in the case just now alluded to : when
they open upon the periphery of the cerebrum,
they occasionally destroy the bone and inter-
vening membranes in its immediate vicinity, be-
fore death is occasioned. ]\I. Andral says, that
he has observed an abscess of the brain destroy
the cribriform plate of the ethmoid bone, and
escape externally through the nasal fossa; : and
RIM. Itard, Lallemand, and others have shown,
that abscess of the brain, from an extension of
inflammation from the ear, may destroy the
petrous poition of the temporal bone, so far as to
admit of the evacuation of the abscess by the ear.
In cases originating from this source the matter
is frequently contained in no distinct cyst, the
cerebral structure suiTounding it being generally
discoloured, softened, and often appearing as
broken down into it. Sometimes the meatus
externus and internus are shut up by means of
fungous granulations preventing the external exit
of the purulent secretion, and hence probably, in
some cases, diverting it internally. In some cases
more than one abscess, in some instances four or
five, seated in distinct parts of the brain, have
been observed.

56. f. Collections of purulent matter have like-
wise been found by Bianchi, Stoll, Weickard,
J. Plancus, Frank (De Curand. Homin. Morb.
lib. ii. p. 49.), Nannoni, Perrault {Journ. de
Med. t. vi. p. 389.), and Abercrombie, in the
cerebellum, generally contained in more or less dis-
tinct cysts, " the walls of which were membranous
and vascular." ]\Iatter, indistinctly defined, has
been found also in the medulla oblongata, generally
in small irregular cavities, " especially in that part
of the olivary body which contains the corpus
dentatum." {Craigik, in opus. cit. p. 386.) Dr.
Abercrombie mentions a case where it was met
with at tlie junction of the protuberance.

57. g. These collections are evidently the result
of inflammation, but of a peculiar and slow cha-
racter, probably owing to the constitution of those
in whom they are most frequently found, and who
are generally of the strumous diathesis. The en-
cysted abscess seems to take place very slowly, and
to be analogous to what has been commonly called
chronic or cold abscess. The purulent infiltrations
occasionally met with in the large nervous masses,
as well as in other viscera, from the absorption of
purulent matter into the circulation, evidently take
place with great rapidity, and are a result rather
of morbid secretion, than of inflammation.

58. h. Abscess of the brain is very frequently
met with as a consequence of purulent discharne

from the ear. This affection of the ear, when it
has not apparently proceeded from inflammatory
sore throat, and the extension of the inflammation
along the Eustachian tube, is very generally con-
nected with a sub-acute or chronic inflammation
of the dura or pia maler of the brain ; and is thus
frequently extended to the substance of the biaia
P 2

212 BRAIN — Altetiations OF

itself, terminating at last in abscess in this situ-
ation. This has been satisfactorily shown by

MORGAGNI, ItARD, PoWtLL, LaLI.EMAND, DuN-

CAN, Abercrombie, Craigie, and others. Bonet,
and, more recently, Sir B. Brodie, supposed tliat
the affection of the ear was consequent upon that
of the brain, or at least coeval with it; and iience
they ascribe the discharge from the ear to the in-
flammation of the membranes iiaving extended
itself from the dura mater of the temporal bone to
the tympanal cavities. When abscess of the brain
takes place owing to the affection of the ear, they
consider it an exiension of the inflammatioti from
the membranes internally to the substance of the
brain, in consequence either of the unhealthy
habit of the patient, or of improper treatment, by
suddenly suppressing the discharge, " and con-
verting a chronic external inflammation into an
acute internal disease ; " the external discharge
liaving been, as it were, arrested and turned in
upon the cerebral substance. The only question
here is in respect of the particular parts in which
the inflamnia;ion originates; as to the consecutive
phenomena, there seems to be no difference of
opinion: and this point can be decided by the
symptoms only, and the order in which they
occur. If the purulent discharge take place
without any previous internal and deep-seated
pain, and the dangerous symptoms follow upon
tile suppression of the discharge, we may infer
that the disease has commenced in the ear, and
extended itself to the membranes and brain itself.
This is, perhaps, the most frequent procession of
the morbid phenomena. But, occasionally, a
different course is manifest, especially in delicate
children, and patients of a strumous diathesis.
In these, symptoms of disease of the brain or its
inembianes are very manifest before the discharge
takes place; and when it does take place, either
the patient recovers, under judicious management,
or, upon the di'^appearance or suppression of the
discharge, a sudden exacerbation of the symptoms
is observed, with delirium, coma, convulsions,
&c. followed by death. Such is the result of my
experience in a very great number of cases which
liave come before me ; so that 1 am led to con-
clude that, whilst the opinion adopted by Mor-
CAGNi and his followers, on this question, is often
correct, tliat espoused by Bonet and Brodie is
not wholly without foundation.

59. But it is not infrequently observed, (and
I have met with several instances in grown up
persons,) that patients have been occasionally
liable, for years, to a puriform dischnrge from the
car, — occasionally from childhood, with little
remission, and with little or no furl her ailment.
This sometimes gradually diminishes, or sud-
denly disappears; when either soon afterwards,
or not until several months subsequently, or even
after a year or two, dangerous symptoms of dis-
eased brain supervene, and rapidly advance to a
fatal termination ; and upon dissection, inflam-
mation of the meml)ranes of the brain of the
wime side of the body with the affected ear is
observed, and in the substance of the hemisphere
is foutid a large purulent collection with inflam-
mation and softening of the cerebral matter sur-
roundinfj; it, the cavity presenting on irregular
Soft surface.

GO. 'I he following cases strongly illustrate this :
r— Ist, A young gentleman iiad, from childhood, a

ITS Substance — Abscess.

slight purulent discharge from the right ear, until
nearly the period of puberty ; about which time
it gradually disappeared. lie had nearly lost the
sense of hearing on that side. He went into the
public service, in which he continued for several
years, until, about the age of thirty, he was sud-
denly seized with intense pain of the head, fever,
followed by paralysis of the whole left side of the
body, insensibility, involuntary motions, coma,
shortly terminating in death. On examination,
thickening of the membranes of the right side of
the brain, with adhesions, softening of the cerebral
structure, and a purulent collection nearly in the
centre of the middle lobe of the hemisphere, were
found. I very recently witnessed a nearly similar
case, to which I was called by a neighbouring
practitioner ; and a third case, in which I had
ventured to predict similar lesions in a person
advanced in life, but which we were not permitted
to verify by a post mortem inspection.

61. Abscess of the brain consecutively on pu-
rulent discharge from the ear, is most frequently
observed in young subjects, particularly in those
of a strumous diathesis. From what I have said,
it must not be inferred that abscess of the brain is
the only unfavourable consequence, or even the
most frequent one, owing to an extension of the
inflammatory action from the ear or cerebral
membranes ; for other lesions accompany it.
But, whether the abscess proceed from a gradual
extension of disease, as now slated, or be a vi-
carious result of the suppression of the external
discharge, — in which liglit it may sometimes be
justly viewed, — there are generally found, upon
examination of the surrounding parts, increased
vascularity, softening of the cerebral substance,
and an irregular, soft, and vascular cavity, con-
taining the purulent matter. Added to this, there
are also inflammation, thickening, and suppuration
of the membranes; the pia mater being injected,
and covered with lymph; the dura mater thick,
opaque, dark coloured, more readily torn, and
detached from the bone underneath it, which is
also discolouied, and sometimes carious.

62. Abscess of the brain is very often a conse-
quence of external violence ; but it is one which
takes place at extremely indefinite periods from
the receipt of injury, and wliich often has little
or no relation to the extent of the external mis-
chief. I'lie period which elapses from the ex-
ternal violence to that full development of the
abscess which is incompatible with the duration
of life, according to the observations of Bigrav,

JVIORAND, PrOCUASKA, ThII.ENIUS, HoME, DeN-

MAHK, and others, varies fiom two or three months
to as many years. A case which I had an op-
portunity of observing in a public institution, and
in which the operation of trephining had been
performed, presented a laige abscess in the hemi-
spheie, underneath the seat of injury, between
three or four years froin the time at which it
had been sustained. The perf)ration made by
the trephine was completely filled with ossitic
matter, which extended in a radiated manner
from the edges of the perforation towards its
centre.

63. Dr. Bah.lie says, tliat when suppuration
of the brain takes place from internal causes, it is
generally in the substance of the organ ; but
when it arises from external violence, it affects
only the surface. But as Dr. Craigie has \{;Ty

BRAIN — Ai.TERAiioNS OF ITS Substance — Abscess.

213

justly remarked, lliis dibtinction docs not always
hold good, and requires modification. — " Ist.W here
a long interval elapses after the infliction of the
injury, the collection of purulent matter is almost
invariably deep seated. 2d, In like manner,
when the injury operates in the manner of coun-
terstroke, the collection is also often within the
substance of the organ." 3(1, In some instances
of suppuration after injury, the collection does
not take place at the part where the blow struck
the skull, but either in the line of the force

passing through the brain, or in some of the lines 1810), Anderson Transact, of Roi;ai Snc. nj

into which this force may be resolved. 4th, It
is chiefly when this force has been diiectly ex-
pended on the part, i. e. when the bone has been
immediately broken, and its membranes injured,
that suppuration takes place on the surface of the
brain: it is tlien the result rather of the injury of
the membranes, especially of the pia mater, than
of the cerebral substance itself.

64. Suppuration may occur in any part of the
brain; but it is most frequently met with in the
hemispheres, as shown above {§ 50.). Its effects
vary exceedingly, according to the situation and
extent of the purulent collection ; but are not es-
sentially different from those which follow upon
the slow effusion of blood, the presence of tumours,
or other morbid formations. I have already hinted
at the occurrence of suppuration in parts of the
brain in the course of fevers, especially those
which are of a malignant character, or which are
complicated with inflammatory action of the
brain. Such occurrences have been observed
by Pringle, BonsiEia, Eisfield, Ploucquet,
Clutterbuck, JMarcus, Jackson, and Mills,
and many others. But this falls under the patho-
logy of, and morbid appearances in fevers, where
the subject has received due attention.

65. C. Ulceration. — To ulceration of the brain
authors have attached no precise idea, they flif-
fering widely as to what should constitute ulcer-
ation of the cerebral texture. According to the
opinions of some, those solutions of continuity,
sometimes observed in the most advanced de-
grees of pulpy destruction of the brain, about to
be described (§ 72.), are nothing else than ulcer-
ation ; and ceitainly, if there were appearance of
any considerable loss of substance by absorption,
the lesion would be legitimately ulceration. The
case recorded by Morgagm {De Sed. et Cans.
Morb. ep. xi. pars ii.), in which he descibed the
corpus striatum ab reliquo cerebro omnitto separa-
tum inventum est, which is so singular, may be
referred to ulceration. By ulceration of the brain.
Dr. Craigie understands destruction of part of
either of its surfaces, "so as to present a hollow or
depressed surface, rough, irregular, and covered
partially either with bloody or albuminous exu-
dation." This seems sufficiently precise; and
excludes those doubtful cases of ulceration some-
times consequent upon effusions of blood, the ad-
vanced stages of softening of the organ, and the
formations of abscesses existing in the substance
of the brain, where, although a breach of con-
tinuity of structure is produced, yet the removal
of it by absorption cannot be demonstrated. Cases
of this description are more legitimately examples
of pulpy destruction, or suppurative disorganisa-
tion, than of ulceration. With this limitation of
ulceration and erosion to the various internal
and external surfaces of the brain, M. Andral

agrees with Dr. Craigif. This species of lesion,
although not of frequent occuirence, is yet occa-
sionally met with. Besides the case given by
Morcagni, and already referred to, another is
mentioned by him in the same epistle. Instances
of this disease have also been recorded by Ho-
NtT {Hist. Amit. Med. part iii. Ob. 108. 138.),
VVepfer (p. 212.), MoiiGAGNi (Epist. Auut.
Med. iv.), LiEi'TAUD {Hist. Aiiat. Med. let. iii.),
Senac, Valsalva, Portal (Anat. Med. t. iv.
p. 98.), IlowsHip {Med. and Phys. Journ. March,

Edinburgh, vol. ii.), Ridley, IIaller, Stoll
{Ratio Med. pars iii. p. 122.), PowrLt {Case 6.
Transact, of College of Physicians, vol. v. p. 96.),
and ScouTETTEN {Archives Gen. t. vii. p. 31.),
who have met with it on the convoluted surface
of the brain, on the foliated sui face of the cere-
bellum, and in the surface of the ventricles, — parts
in which this morbid change is chiefly found. As
shown by Haller (t. iv. p. 351.), Sroi l, anrl
ScouTLTTEN, ulceration of any part of the brain's
surfaces is always attended with an inflamed,
or otherwise unsound state of the pia mater, and
occasionally with softening of the parts under-
neath, sometimes limited to the grey substance,
but at others proceeding further. In the two
cases recorded by M. Scouteiten, the adjacent
brain was somewhat softened, and in one of
them of a wine lees colour. The ulceration
in the first case existed on the in'^erior surface
of the right anterior lobe, and presented a hard,
dry, irregular, yellowish surface, thirteen lines
long and eleven broad, with singularly indented
edges. This patient died w}th symptoms of
irritation of the digestive canal, and of the
brain. He experienced a constant acute pain
at the bottom of the orbits. In the second case,
the extremity of the posterior lobe presented
two small ulcerated patches, one much larger
than the other, and of an oval form. They pe-
netrated no deeper than the cortical substance.
This patient had been seized with gastro-intestinal
irritation, and complained of no pain in the head.
During the latter stage of his disease, he became
delirious. In both these cases the surrounding
pia mater was injected, and somewhat erofled ; so
that we may infer from these, and other cases
upon record, that ulceiation of the biain is a con-
sequence of circumscribed inflammation of the pia
mater.

66. The existence of ulceration of the brain is
indicated by headach, partial convulsions, some-
times epilepsy, palsy, loss of memory, hebetude,
coma, and exhaustion. In some cases the head-
ach is intermittent, and the palsy is generally on
the side opposite to that in which the lesion is
found. In the case recorded by Dr. T. Ander-
son, and in which most of the symptoms now
noticed were present, there was a superficial
loss of substance from ulceration, two and a half
inches long, one and a half broad, and nearly
an inch in depth, situated on the upper part of the
right hemisphere of the brain. In the bottom of
this cavity were found some thin laminae of a
brownish matter, with stony concretions, some
of which broke into sand upon the slightest
touch.

67. D. Sphacelation or mortif cation of the cere-
bral substance is rarely met with, and chiefly as
a result of external injury, when it has been
P 3

214

BRAIN — Alteratioks of :ts Substance — Softening.

bruised and acutely inflamed. In this state of
disorganisation, ihe cerebral substance is dis-
solved, of an orange brown colour, or of a greyish
black, and foetid. This alteration seems to be
rarely produced by internal causes, and is to be
distinguished from the pulpy softening of the
organ. Dr. ABEncuoMniE, however, considers
this latter change to be identical with gangrene.

68. ii. Softening of the Brain. — A. From
serous infiltration, — (Edema of the brain. Infiltra-
tion of ihe substance of the brain with a watery
fluid has been noticed by Guersent and An-
DRAi,, — by the former in children, by the latter
also in adults. In these cases the serum may be
diffused in the nervous substance, or contained in
more or less di-tinct cavities. This change is
most frequently observed in the white central
parts of the organ. It has not generally been
remaiked in connection with any particular sym-
ptom ; but it has, in a few instances, co-existed
with dropsy of the ventricles; and, in adult
subjects, with general leucophlegmasia and ca-
chexia.

69. B. Simple diminished consistence of the
brain, without change of structure, — Malakence-
phalon (Craigie), — seems to be a different state
of the organ from that which constitutes the ra-
moUissemeiit —-sohernng, or pulpy destruction of
the brain. In this latter more or less disorganis-
ation is manifest, and generally some change in
its colour ; but the former is merely diminished
consistence, greater flaccidity, and decrease of its
natural firmness, toughness, or tenacity, and of
that clamminess or viscid feeling which it usually
communicates to the touch. This state is com-
monly attendant on low or malignant fever, and
on chronic diseases, particularly pulmonary affec-
tions, marasmus, diabetes, dropsies, mesenteric and
visceral affections. It generally aflfects the whole
organ, and, indeed, the whole cerebro-spinal axis ;
whereas the pulpy destruction of the brain is more
or less limited in extent, aflfecting parts of the or-
gan in a particular manner.

70. In dropsies, the brain is often flaccid, more
easily lacerated, and of diminished consi'^tence
throughout. This state proceeds either from di-
minished nutrition of the organ, or from an inter-
stitial deposit of serous fluid with its minute atoms,
and defective vital cohesion of its substance. The
proper texture of the part is not otherwise changed.
Diabetes sometimes occasions a similar state, and
most probably from diminished nutrition added to
a deficient vital cohesion of the structure. In
jndmonary consumption, and in chronic bronchitis,
the brain is very commonly found softer than
natural throughout; and this softness is the more
marked, the more chronic the pulmonary affection
has been, and the more complete the emaciation.
Blay not this state be considered as analogous to
emaciation of other parts ? the molecules of matter
removed by interstitial absorption of the texture
of this organ being replaced by a serous effusion,
owing to the cranium being a shut cavity, which
must necessarily, during the life of the subject,
always be in a sta'e of repletion. In such a case,
the density of the brain is actually diminished.
]Mi;cKET, states, that he found a cube of six lines,
taken from the brain of a man dead of jihthisis,
l:j- grain lighter than the same bulk of a sound
br;iin. Dr. IMomio has found the bruins of con-
demned felons extremely soft, particularly inter-

nally (The Morbid Anatomy of the Brain, vol. i.
p. 35. and 100.). Littre, however, states, that
the brain of u felon, who committed suicide, was
extremely dense and firm {Histoire de I'Aca-
dtmie Eoyale des Sciences, Ann. \105.), Tulpius,
Kerkringius, King, Scheide, INIorgagni, Grf-
ding, &c. have found the brain frequently soft
and flaccid in fatuous persons, as well as in epi-
leptics, and epileptic maniacs. Gbeding (On
Ludwig's Adversaria, t. ii. part iii. p. 633.) found
in about one half of tlie last named class of sub-
jects, the brain very soft throughout, particu-
larly in its central parts; and Dr. Haslam's
observations (Observations on Madness and Melan-
choly, 2d edit. Cases, 4. 10. 18. 25. 28. 30. 37.)
in some degree confirm these statements. But
it should not be overlooked, that the brain of
epileptics and maniacs is found also more than
usually firm. The diminished consistence of the
brain of condemned felons has been attributed to
confinement, inactivity, and low diet. Whether
these may have a greater influence in causing it
than the mental distress to which these persons
are reduced, it may be difficult to determine ; but
if the former be the cause of this state of the organ
in felons, it may be equally so in maniacs, who
are generally also subjected to confinement and
low diet. The diminished consistence now de-
scribed is more or less universal, although more
remarkable in particular parts, and it generally
aflfects the whole cerebro-spinal axis. Whereas
the morbid softening, or pulpy destruction, about
to be described, is generally limited in extent.
The former also seldom presents any very sensible
change from the natural colour of the part ;
whereas with pulpy destruction there is a more or
less evident discoloration.

71. C. Pulpy destruction, — Softening, — Ra-
mnllissement, — Encephalitis snb-acutns, — Cere-
britis sub-acutus et chronicus. — Softening of the
substance of the brain has generally been ascribe<l
to a sub-acute inflaminatory action, especially by

RIORGAGNI, IloSTAN, LaI.LEMAND, }5oU1I.I.A UD,

PiNEL, Olivier, and Velpeau, to whom we are
chiefly indebted for having directed attention to
this particular lesion. There are others, however,
as IIecamier, who consider this change as the
eflfect of a morbid nutrition of the part, rather
than as a result of inflammatory action. By
softening of the brain, must not be understood that
soft state of the organ which is always present in
early infancy, nor the less consistent stale of the
organ sometimes observed in some chronic dis-
eases, and in certain forms of fever, and already
described. It should also be recollected, that all
parts of the brain possess not the same degree of
firmness ; for, if the mesocephalon be as soft as
a lobe of the cerebellum, it is undoubtedly in a
morbid state.

72. Softening of the brain presents various de-
gree?. The least change of consistence of the
part can be recognised only when it is touched.
In a more advanced degree, the softening is ob-
vious to the sight. In a still farther advanced
grade, the cerebral substance is nearly liquid,
and has almost entirely lost its organisation ; and
in its place there is a mere loose cellular sub-
stance, soft and gelatinous, appearing as the
original matrix of the structure; and in the last
and most advanced stage of all, there is a perfect
dissolution of the part, and breach of continuity.

I

BRAIN — Ai.TF.nATioN's of

In the cases of this description published by MM.
Kullieu and Vei.peau, the disorganisation was
so complete, tliat the filaments of the delicate
cellular substance, forming, as it were, the matrix
of the structure, were suspended in the n)idtlle of
the diffluent matter into which the cerebral sub-
stance was changed. In the case observed by
M. Velpeau, the solution of continuity was still
more complete. From the inferior margin of the
mesocephalon to the base of the pyramidal bodies,
a substance entirely liquid, which no longer re-
tained the appearance of nervous substance, oc-
cupied the place of the bulb of the chord ; and
through the whole of this space there existed nei-
ther arachnoid nor pia mater.

73. I'he softened portion of brain presents
various shades of colour. 1st, It may be of the
natural or healthy colour of the part, — even al-
though the softening has advanced to such a degree
as to form a diffluent pulp (ANDRAr., Lalle-
mand). 2d, It may be perfectly coloutless ; of
a dull white resembling milk; and occasionally
the whiteness of the part assumes a clear, or bril-
liant hue. 3d, The shades of colour soinetimes
are the following: — a rose tint, an amaranthine
red, reddish brown, the colour of wine lees, violet,
yellowish, greenish yellow, light grey, and dark
grey. Besides the above appearances, the softened
part of the brain may be, — 1st, The seat of effu-
sions of blood, which are sometimes small, rela-
tively to the degree of softening, or to its extent ;
at other times very considerable compared with
the softening itself: 2d, Pus may be infiltrated
throughout the part which is softened ; or the pus
may exist in it in the form of one or more distinct
collections. M. Lallemand considers, that in
all softenings of the brain of a white colour, this
appearance is owing to the infiltration of purulent
matter through the softened structure. MM.
RosTAN and An oral espouse an opposite opinion,
on the grounils that, in many softened portions
of the brain of this shade, no pus could be de-
tected. The softened part of the brain is gene-
rally inodorous; but M. Billard has remarked,
in the case of an infant, the smell of sulphuretted
hydrogen. Softening, attended with the odour
observed by this author, seems to have constituted
what was called, by the older writers, gangrene of
the brain.

74. There is no part of the brain or cerebellum
in which softening has not at some time or other
been detected. Generally those parts which are
most obnoxious to hfemorrhage are most liable to
softening, such as the optic thalami, and the cor-
pora striata, and the parts in their vicinity. It
also as frequently affects the cortical substance,
as the medullary texture. In the cerebral hemi-
spheres, the softening may be seated in the corti-
cal suhsttince of the convolutions, the white me-
dullary structure remaining unchanged, where it
may often escape detection, owing to such limita-
tion ; and it is usually an attendant upon active
inflammation of the membranes of the brain.
When the grey part is softened, it geneially sepa-
rates along with the pia mater, on attempting to
raise this membrane. When softened, this por-
tion is commonly also redder than natural ; some-
times, on the coiiiiury, it is paler than common.
The meduUiiry structure situated above the lateral
ventricles is very often the seat of this species of
lesion. This mass may be altogether softened,

ITS Substance — Softening, 215

or in a few small points merely, each point being
quite isolated from the other. The symptoms,
however, resulting from this smaller extent of
morbid change may be as severe as those arising
from the more extensive and more intense lesion.
When one of the hemispheres is softened near to
its external surface, the circumvolutions are flat-
tened, and often evince a species of fluctuation.
M. Andral has remarked, in some cases, tlie ex-
istence of softening of the parietes of the ventri-
cles, with the presence of a turbid fluid effused
into them. (Anat. Pathol, t. ii. p. 802.)

75. The optic thalami, the striated bodies, and
parts in the vicinity of these ; the cornu ammonis,
and the eminences in the interior of the digi-
tated cavities of the lateral ventricles, the com-
missures of the hemispheres (corpus callnsum,
septum lucidum, Sfc), have all been observed the
frequent seats of softening; sometimes limited to
one or other of them only, at other times extend-
ing to two or more, and occasionally co-existing
with signs of inflammatory action, or with effusion
of a serous fluid into the ventricles. Softening of
the other parts of the encephalon is not so often
met with, as of those now enumerated ; yet has it
been seen in the mesocephalon, in the various
parts of the cerebellum, in the medulla oblongata,
and spinal chord.

76. Softening of the brain may be limited to
one part, or it may exist in several parts, even in
both hemispheres, in the same case ; and it may
affect these different parts at the same time, or
successively, either as respects the brain merely,
or as regards the whole cerebro-spinal axis. In-
stead of being partial, which is its usual form, the
softening may be so general, and to so intense a
degree, that the brain is almost reduced to a pulpy
matter, evincing scarcely any appearance of or-
ganisation. So general and great a change is very
rarely met with in the adult ; but it is occasionally
observed in infants. M. Billard has met with
ten instances of it, and I have also found it in
some cases of young children : the odour of sul-
phuretted hydrogen, first noticed by M, Billard,
was sensible in these ; and he found it present in
all his cases, which were chiefly of infants only a
few days old.

77. Softening of the cerebro-spinal axis is met
with in patients of all ages. According to M.
RosTAN (liecherclies sur RumoUissement du Cer-
veau, 2d edit. p. 155.), whose attention has been
directed, at the Salpetriere, to this lesion in a
special manner, it is very common in old subjects;
even more so than sanguineous apoplexy. The
researches of Lallemand, Andral, and others
go to confirm this opinion, and to show that it is
also common during early and middle age, al-
though less so than in old age. And I perfectly
agree with JM. Billard in considering it common
in children, especially infants. He believes, and
I think with justice, that it commences in some
cases even before birth.

78. There still remains an important question
to be discussed, namely, what is the origin and
nature of the softening which has now been de-
scribed 1 ]M. Lallemand conceives that it is a
constant and necessary result of an acute, sub-
acute, or chronic inflammatory irritation of the
part. M. RosTAN, who has examined this sub-
ject with great care, and viewed it in various

. lights, as respects both the morbid appearances
P 4

216

ERAIN^ ALTEnATiONS of its Substance — HyEMonniiACE.

and the symptoms accompany ing them, concludes
at last by confessing its difficulty, and consider-
ing this change as iinalogous to senile gangrene.
Before the question can be entertained with pre-
cision, we should previously enquire with what
other morbid states of the sy^^tem generally, and
of the brain in piirticular, has softening been
found allied ? 1st, It has been observed by Je-
juna, Black, myself, and others, to supervene
during fevers, especially those of an epidemic and
malignant character. 2d, It has been seen con-
nected with puerperal disease of a malignant na-
ture; and with epidemic and infectious erysipelas.
3d, It has been found in cases of scorbutus, and to
occur in persons of an unhealthy and cachectic
habit ; also in those whose powers of life have
been exhausted by bad living and excesses.

79. As to its relation to other lesions of the
brain, I may state that it is often found surround-
ing edlravasated blood in the brain, and intimately
connected with this effusion. The softened part
is then generally of the colour of wine lees, of a
brownish hue, sometimes tending to green, or of
a grey or ash tint. But what is the nature of xhis
connection 1 M. Rostan contends, that the
softening precedes and is always the cause of the
effusion, owing to the destruction of the minute
capillaries at the point where the softening is
greatest ; whilst Ur. Craigie and others consider
the softening surrounding the effused blood as
the consequences of such effusion ; and chiefly
because, " in cases in which death takes place
early, the pulpy disorganisation is less comidete
than in those, in which it takes place at a later
period. In short, the extent of the disorganisa-
tion is proportionate to the interval which elapses
between the effusion of the blood and the pe-
riod of death," But is this the fact? It cer-
tainly is not in accordance with my experience,
for I have observed no such relation ; but have
found recent efl^usions surrounded by as great, and
even a greater, extent of softening as effusions of
an older date.

80. Pulpy softening may be the attendant
upon a coup de sang, or sudden congestion of the
venous capillaries of some part of the brain. 'J'his
is considered to be the case in softenings with
the reddish, amaranthine, crimson, or reddish
brown shades of colour. But is the softening
a consequence, or a cause of the injection 1 May
it not be a state of the vessels preceding that of
effusion ? These are questions which large ex-
peiience and deep thought will not readdy de-
cide. Dr. Craigie thinks that the softening is a
consequence of the blood-slroke ; but 1 cannot
agree with him, merely because the reasons for
a contrary opinion are quite as strong as those
which may be urged in its favour. It has been
often found accompanying hydrocephalic effu-
sions, by ROSIAN, IvAr.I.EMANl), I5lI,I.ARD, OtTO,

Andral, anil by the author. It is then gene-
rally of the lighter shades of colour, and not great
in degree. Js it here a consequence or a cause
of the serous effusion? It may be either. I am
more inclined to consider both lesions as being
often coeval, and, whether consecutive or not,
depending upon a similar state of the vessels and
vital manifestations of the organ and system ge-
nerally.

81. Softening, or pulpy destruction of a por-
tion of the brain, has likewise been found sur-

rounding tumours and abscesses, by Morgagni*
Sandifort, Meckel, Lallemand, Blane, Yel-
LOWLEY, PowEi.i., &c., and presenting almost
every variety and depth of shade already noticed.
In these cases, especially in those where puru-
lent matter is lodged in the substance of the
brain, without any intervening cyst or membrane,
the softening often amounts to disorganisation,
and is more clearly attributable to inflammatory
initation. When it is found subsequently to in-
jury of the brain, external violence, and inflam-
mation of the brain and its membranes, its nature
and origin are most manifest. That it does su-
pervene in this way, is shown by Fantoni, Mor-
gagni, Le Dran, Schmucker, O'Halloran,
Dease, Abernethy, Thomson, Hennen, Aber-
CROMBiE, and others. The apparently unequivo-
cal origin of this lesion in inflammation, under
these latter circumstances, induced Morgagni,
Lieutaud, Jemina, and more recently Baillie
and Abehcrombie, to consider it as analogous to
gangrene in other structures,

82. But it should be kept in recollection that
this state of the cerebral structure, although often
preceded by signs of inflammation, and exhibiting
in the paits surrounding it inflammatory appear-
ances, is often neither preceded by the one, nor
accompanied by the other, but, on the contrary,
with a directly opposite train of phenomena and
state of parts. In these opposing cases, what is
the origin of the disease? Are we to infer, with
Recamier, an entirely opposite origin to that of
inflammatory action, and that as the softenings
observed in the brain betray a variety of charac-
ters, therefore they ought not strictly to be re-
feried to a single unvai-ying source ?

83. From what I have seen of, or read concern-
ing, this lesion, I should infer, in respect of either
of its most manifest conditions, that it is an eft'ect
of different states of morbid action, but most fre-
quently of a form of sub-acute inflammation, cha-
racterised by deficient power and loss of the vital
tone and cohesion of both the vessels and the
sub-tance of the brain, — that it is the result of
deficient vitality of the extreme capillaries and
cerebral structure, occurring either primarily,
or in consecjuence of pieviously excited action.
The circumstances in which it is observed ; its
occurrence after injuries and bruises, from the
pressure of tumours, &c., and during the progress
of malignant diseases, show that it is not produced
by a sthenic or healthy form of inflammatory
action ; but by that unhealthy, disorganising and
diffusive kind observed in cachectic habits, or in
persons whose vital powers are much reduced.
At the same time, I think it cannot be denied,
that it sometimes originates in a different way,
is preceded by no signs of inflammatory irritation,
nor is attended with inflammatory appeariinces,
but is a consc<iuence of structural lesicnsof the
cerebral arteries, and of diminished, or altogether
lost, vital j)ower and cohesion of the part affected.

84. iii. Il/F.MORnnAGE. — Sdtiuui neons effitsion
may occur in a primary form, but more commonly
from some morbid state of the vessels, or of the
substance of the brain itself. It may take jilace
in any part of the organ, but much more fre
c|iiently in some situations than in others. — a.
iJlood is effiised on the external surface of the
brain, either in small quantities beneath the pia
mater, iij one or two aidVacluosities ; or in an

BRAIN — Alterations of its Suhstance — HYPERTiioriiY.

217

uniform layer, even extending over tlie whole of
an hemisphere in rare cases. — b. It is sometimes
found in large quantities in the ventricles; but il
generally has escaped into tiiem, owing to lacer-
ation of the cerebral substance in which the ex-
travasation takes place. — c. The haemorrhage most
frequently is in this substance. JNl. Andual
states, that in 392 cases of ha;morrhage in the
brain, its actual seat was in some part of the
cerebral substance in as many as 386. Of these,
202 occurred in the corpora striata, and thulami
optici, and parts in the hemispheres, on a level
with these places. The cavities formed by the
extravasated blood vary in size, from that of a
small pea, to the greater part of the extent of a
whole hemisphere. \\ hen the effusion is very
laige, it generally ruptures the parietes of the
lateral ventricles, sometimes tearing the septum
lucidum, and destroying the fornix. In otlier
cases it may make its way to the exterior of the
brain, and spread itself over the cavity of the
araciinoid.

85. The number of hsemorrhagic cavities found
in the brain vary from one to many. When
several are found in the same brain, they gener-
ally present different appearances, owing to their
having been formed at different periods. This is
generally the case when the patient has ex-
perienced several attacks of apoplexy or palsy.
JM. Andral remarks that eflFusion of blood sel-
dom occurs in the cerebellum without appearing
af^o in the cerebrum, whereas it may take place
in any part of the cerebral hemispheres without
occurring elsewhere, I have stated in the article
on Apoplexy, the periods of life at which hemor-
rhage in the brain is most frequently met with.
Instances have occurred to MM. Rocnoux,
liii.LARD, Seures, Guersent, and myself, in
which it has taken place at the unusual peiiods of
infancy and childhood. The changes that take
place in the effused blood, in the cavity contain-
ing it, and in the substance of the brain after
haemorrhage, comprising the reparative processes
consequent upon it, are fully de-cribed in the ar-
ticle Apoplexy (^35—39.). I have there shown
that the cysts remaining after the coagula have
been absorbed, sometimes disappear altogether by
adhesion of their parietes. Some pathologists
suppose that the cerebial fibres in those cases are
directly united, and refer to the expeiinients of
FoNTANA, IIaighton, JMiciiaelis, and Mayer,
who had shown, in opposition to Aunemann, that
the filaments of divided nerves are, after a time,
directly produced in the direction of their axis
across the cicatrix. But intimate examination of
the cicatrix of a lacerated portion of brain, or of
a hemorrhagic cyst, shows that this does not take
place in the medullary structure of the brain.
(See Apoplexy, § 53.)

86. iv. Hypertrophy and Atrophy' of the
Brain. — A, The brain occasionally presents
lesions evidently connected with a modification of
the niitritice process. In such ca-es, the con-
sistence and size, either of the whole, or of certain
of its parts merely, are altered. Changes of its
consistence are more frequent than of its size, and
both are occasionally conjoined. It should not
be overlooked, however, that the consistence and
size of the organ are modified from the usual
standard of middle age, at both the earliest and

. most advanced epochs of life ; and that these

modifications, as being its natural conditions at
those terms, are to be distinguished from the
alterations occasioned by disease. One hemi-
sphere may also difler fiom the other, in respect
both of its volume, and the form and size of its
convolutions, owing to original conformation,
without occasioning any appreciable disorder of
function.

87. The brain continues to increase in size
until manhood ; from this period until old age its
volume continues the same; but with extreme
age it somewhat diminishes in bulk. This is,
however, not an uniform occurrence, for disease
may have cut short existence before the period
had arrived, at which the organ would have un-
dergone this change. According to Cazau-
vieilh, the longitudinal diameter of the brain of
an old man, compared with that of one in early
life, is 6 inches 1 line French measure for the
former, and 6 inches 4 lines for the latter ; vvhilst
the transverse diameter is 4 inches 10 lines, and
5 inches respectively. M. Desmoulins (Anat.
des Syst. Kerv. &;c. t. ii. p. 620.) found that in
persons above seventy years of age, the specific
gravity of the brain was from one twentieth to
one fifteenth less than that of the brain of persons
just arrived at manhood.

88. 'Ibe co]ivolutioiis of the brain are scarcely
developed at birth, or even until the expiration
of the first year. In old age they again become
less distinct and prominent. In the brain of the
full grown young subject, they vary in thickness
from three to five lines, whilst they are usually
about two or three lines in old persons. They
present the greatest diversity in respect to their
number and length, and the depth of their an-
fractuosities in the adult : in general they are the
most marked and developed in the largest brains.
Several physiologists in France are of opinion
that the developement of the faculties of the
mind has a very intimate relation with the extent
and number of the convolutions' of the hemispheres,
and the depth of their anfractuosities.

89. But it is important for the physician to
know that not only may the wliole encephalon
experience a diminution of its bulk and specific
gravity with old age, but that this diminution
may be particularly apparent in certain parts < f
it in preference to others; and it is presumed,
that this change may sometimes commence in
one portion previously to others, or may afl'ect it
alone, so as to disturb its functions withcut being
so evident upon dissection as to attract notice.
The comparative length of the following parts of
the encephalon of subjects just arrived at puberty,
of those in the prime of life, and of aged persons,
is here given, as furnished by Rl. Cazal'vieili-
in French measure : —

Persons at Puberty.

Thai, optici
Corp. striata -
Corp. callosum

Mesocep/idloH i
Cercbcttmn f

in. linpf
1 ."Ji

2
3

lengtli 0
breadth I
len^tli 2
breadth 3

In the
Prime 01

Lije. '
ill. lines

1 G

In Old

.4ge.

in. lines,

2 4A
2 7

0 101

1 0

2 3

90. From these data it will appear, that the
cerebellum is the only pait of the encephalon
which is not diminished by old age. But it may
be asked, do the large nervous nn sses experience

218 BRAIN — Alteijations OF

any diminution of volume analogous to that
which the muscular textures and other parts ex-
perience in chronic diseases ? In answer to this,
M. Desmoulins states that the brain, although
atrophied in the manner stated above by old age,
suffers no diminution of its bulk, whatever may
be the degree of marasmus to which the indivi-
dual may have been reduced. In all such cases
he has also found the brain of the same specific
gravity ; and, to this predominancy of develope-
ment which the brain thus has acquired over all
other organs, he is inclined partly to impute that
nervous susceptibility and excitation, which are
common to the last stages of those maladies. It
ought, however, to be borne in recollection, that,
although the nervous centres may not undergo
any change in bulk or specific gravity in conse-
quence of those diseases, they often experience a
very marked diminution of their consistence, as
we shall have to show in the sequel. Having
been made acquainted with these modifications
of the nutrition of the encephalon which it un-
dergoes at the different epochs of life, we are the
belter able to recognise those which arff the result
of disease.

91. B. Hypertrnphy, or morbidly increased Imlk
of the brain, is very rarely met with. This state
of the organ is to be distinguished from the ap-
parently augmented bulk, arising either from in-
creased vascular action, or congestion of the
vessels. It appears to consist of an actual increase
of the molecules of matter composing the proper
tissue of the organ, and not of an injection of the
minute vessels distending its structure. Although
this condition of the brain seems to have been
known to Morgagnt, it is to Laennec that we
are indebted for precise information respecting it.
lie stated {Joum. de Corvisart, &;c. t. ii. p. 669.),
that, upon opening the heads of patients who had
been thought to have died of hydrocephalus, he
found no fluid effused ; but the brain presented
appearances of great compression, which he could
attribute to no other cause, thnn to a too active
nutrition of its structure, giving it a bulk too great
for the bony case containing it. In children es-
pecially, who had died in convulsions, or wlio
had been subject to epilepsy, this disproportion
between the capacity of the cranium and the
bulk of the encephalon has been witnessed by him
on several occasions, the convolutions of the hemi-
spheres being flattened, and apparently squeezed
against each other. M. Dance has also de-
scribed this state of the brain (R^pertnire d'Aiia-
tnmie, t. v. 1828.), and furnished some cases in
which it was observed. It is chiefly met with in
children or young subjects, and is, I conceive, of
very rare occurrence, since, from amongst the
great luany thousand cases of children's diseases
which have come before me, 1 have oidy remarked
three cases in which it was unc([uivocally present.
In tlicse it presented the following characters: —
The convolutions of tlie hemispheres were extremely
flat, and closely pressed against each other, so
that the separations between them were scarcely
apparent. 'J'he cerebral structure was firm, and,
when incised, was dry, and more tiian commonly
destitute of blood. The ventricles seemed small,
were closely pressed together, and almost dry.
The bones of the cranium were either natural or
thicker than u«ual, as if they had participated, as
regarded their thickness, in the increased nutiition

ITS Substance — ATnopiiy,

of their contents : the dura mater adhered closely
to the cranium. A similar augmentation of the
thickness of the cranial bones, but to a greater
degree than I have remarked it, has been recorded
by M. ScouTETTEN, who met with it in a giii five
years of age, who died of abdominal disease, and
who had never complained of any disorder of the
head, or of disturbance of the mental faculties,
which were those common to children at her age.

92. Rickety hypertrophy of the brain is more
frequent. It commences soon after birth, and often
attains a great extent. Otto supposes that brains
wiiich have been much expanded by dropsy in
youth, become subsequently, in rare instances,
cured by increased deposition of cerebral matter;
and thus retain their size and weight. The dis-
tension of the cerebral substance by the accumu-
lation of fluid in the ventricles, cannot be compre-
hended under hypertrophy of the organ.

93. M. Andual (Anat. Path. t. ii. p. 776.)
says, that, although hypertrophy of the brain is
tisuully general, and extends to the whole of both
hemispheres, it is sometimes «/si> partial: thus he
has seen the thalamus opticus of one side of its
natural dimensions, whilst that of the opposite
side was one fourth larger. This extraordinary
developement of the thalamus of one side was not
attended with any particular symptom during the
patient's life. Otto refers to a number of cases
of hypertrophy confined to a single part of the
bruin, chiefly to the thalami and the corpora qua-
drigemina. I am not aware that any well authen-
ticated cases of marked hypertrophy of the cere-
bellum are upon record. The spinal chord,
however, is not infrequently subjected to this
change.

94. Morbid enlargement of the pineal gland
has been observed by Drelincourt, Morgagni,

LlEUTAUD, DeSPORTES, SOEMMERING, AnGELI,

Greding, Meckel, and Blane. The pituitary
gland has also been found enlarged, inflamed,
and otherwise changed, by Greding, Baillie,
Chaussier, Oppert, Ward, Buli.ier, De
Haen, Rayer, Neumann, Abercrombie, Otto,
the Wenzels, and INIeckel.

95. C, Imperfect developement and atrophy of the
brain, — Agen^ne cerebrale (Cazauvieilh), — is
met with in every degree, from a slight diminution
of the usual bulk of the whole organ, or of any of
its parts, to their almost entire disappearance.
Atrophy, although occurring in all situations of
the cerebrospinal axi^^ is most frequently ob-
served in those wiiich are the last formed : thus the
sjiinal chord is formed before the brain, and atrophy
of it is much rarer than that of the encephalon.
Of the brain, the convolutions are the last de-
veloped, and they are most frequently atrophied.
It should, however, be noticed, tiiat the majority
of those cases which are denominated atrophy of
the brain by ANnuAi., and other French patholo-
gists, are, strictly speaking, imperfect or arrested
developement of tiie organ. The hemispheres
are most frequently the seat of atrophy and im-
jieifect developement ; and they may be thus
afl'ected, either jiarlialiy, or altogether. Imper-
fect growth of particular lobes, es|iecially the
anterior, is common in idiots, and may exist even
although the cranium is well formed, the void
being filled up with water, the congenital efi'usion
of which is the probable cause of the arrest of
developement. When the hemispheres are par-

BRAIN — Alteiiations of its Substance — Induration.

219

tially affected, the lesion is most commonly ob-
seivt'd in the convolutions.

96. a. Atrophy of the convfllinions. — These
parts are sometimes only smaller and less numerous
than usual, either in respect of one or both hemi-
spheres, or in a portion of a hemisphere merely ;
and they may be altogether wanting in one, or in
both. M. Jadelot lately found the hemispheres
of the brain of an idiotic child, aged six years,
without convolutions, and consisting of an uniform
layer of medullary substance covered by a thin
coat of cineritious matter.

97. b. Sometimes the greater part of the hemi-
spheres of the brain, especially their superior por-
tions, from tiie vault of the ventricles upwards,
are found in a state of atrophy, or altogether
wanting. Most of the cases of this description
which have been adduced by the French patho-
logists, as well as the case of Jadelot, are merely
instances of imperfect developement of the part.
Sometimes this portion of the encephalon is re-
placed by a sac containing a serous fluid, having
no communication with the ventricles. In other
cases, no such body replaces the deficient hemi-
spheres ; but the different parts of the anterior and
superior aspect of the ventricles, as the thalami
optici, corpora striata, &c., may be seen through
the membianes, no substance intervening between
them and those portions of the floors of the ven-
tricles. These occurrences are, however, not
cases of atrophy, but of arrest of the formative
process as respects the hemispheres of the brain.
Cases of diminished size merely, of one or both
hemispheres, are more common than those now
instanced ; and are generally to be con'-idered as
being congenital, or, at least, the result of a di-
minisiied nutrition of the part in the process of
the growth of the organs. Instances of extreme
smallness, or an entire absence of a part of the
hemisphere, are most frequently met with in its
posterior or anterior lobes: either of which may
be altogether wanting, in one or both sides of the
brain. Diminished size of the anterior or pos-
terior lobes are a inueh more frequent occurrence
than their entire absence.

98. c. The thalami optici, and corpora striata,
may be also much diminished in volume, either
sinuly or together. The diminution may proceed
from a defect either of the grey matter, or of the
while substance ; and from tliis cause of diminished
bulk, the accompanying symptoms will derive
their chief characters. Not only may those bo-
dies be simply diminished in volume, they may
be even altogether wanting, either bfing replaced
by a serous cyst, or having no other body as a sub-
stitute : in the former case, the hemisphere of that
side may be, or not, also entirely wanting ; in the
latter it is always absent, and, from the cerebral
peduncles, nothing more is found than a few scat-
tered fibres, which are spread out into a membra-
nous tissue, resembling that which, at the earliest
epochs of foetal existence, forms the rudiments of
the hemispheres. It is evident, that in such cases,
the wiiite central portions of the bram being absent,
and both sides of the cerebrum being liius circum-
stanced, there can scarcely be said to be any brain
in existence. This, however, does not prevent
the other parts contained within the cranium, as
the mesoceplialon, cerebellum, &c., from being
fully formed.

99. d The central white parts of the brain

may be imperfectly developed, even when no
alteration is remarked in the hemispheres. J a
some such cases the corpus callosum is so small
as to form merely a thin membrane. Hiil re-
marked its entire absence in a lemale idiot, who
died at thirty : the two hemispheres communi-
cated only through the medium of the anterior
and posterior commissures. It is remarkable, that
when the cerebral lobes are wanting, two small
masses of nervous substance, whence the olfac-
tory nerves arise, are sometimes found in the ante-
rior part of the cranium ; thus displaying in man,
in the morbid state, the independent existence of
the olfactory lobes, naturally shown in animals.

100. It will be seen from the above, that all
the parts of the brain may present a state of im-
perfect developement to a greater or less extent ;
that either of them may be entirely wanting,
while the others remain; and that all of them
may be absent, so that there exists no brain : a
circumstance not infrequently observed in foetuses,
and evidently owing to the process of develope-
ment having been suddenly arrested.

101. But not only may the brain be in part,
or entirely, deficient at birth ; it may be aho re-
markably small at advanced age, particularly in
idiots. It may be generally, but more frequently
only locally, diminished by external pressure, as
in meningeal hydrocephalus. Although the brain,
as well as the other parts of the nervous system,
wastes so little in general consumption, it is, how-
ever, somewhat diminished, although rarely, in
the course of certain dist^ases : Savaresy states,
tliat he has found it atrophied in yellow fever.
Horn remarked a similar state in diabetes; and
Otto, after venereal excesses. Atrophy is, how-
ever, more frequently observed in particular parts
of the brain. The lateral lobes of the cerebellum, have
been occasionally found atrophied. M. Hutix
observed the medullary centre of the cei'ebellum
reduced one third of its natural size. Morgagni,
VVenzel, and Biermaver have described atrophy
of the corpora striata. I'he crjUic beds have been
found greatly reduced in size after blindness, by
Soemmering, JMichaelis, Rudoepiii, &c. ; and
in idiots, by Otto, Ramsay, and Romberg. 1 he
quadrigeminul bodies and the tnherctes of the
brain, have likewise been severally found atro-
phied. The pressure occasioned by tumours,
collections of lymph, pus, or blood, or even
dropsy of the ventricles, gives rise to atrophy, in-
terstitial absorption, or destruction of particular
parts of the brain. Impaired supply of blood
owing to diseased arteries, causes both atrophy and
softening. The want of exerci.se of the functions
of the nervous system also occasions atrophy, by
diminishing nutrition, as an unexercised muscle
.soon wastes. Thus, the wasting of the brain so
generally observed in idiots, may be the effect
and not the cause of idiotcy. The pineal gland,
and the pituitary gland or appendage of the brain,
have both been seen remarkably atrophied, par-
ticularly the latter. According to Otto, this
change has been most frequently remarked in
idiots, and in hydrocejihalic cases.

102. V. Indiiration, or Hardening of ihe
Brain, — Sclerencephalia (Craigie). — The cere-
bro-spinal axis sometimes presents, either through-
out its extent, or in particular parts, a remaikable
increase of consistence. This increase varies in
grade. In its ^rst degree, it is nearly of the con-

220 BRAIN — Alterations of

sistence of a brain which has been kept some
time in dilute nitric acid. Tiie second degree of
increased liardness resembles tlie consistence of
cheese. In this state, the cerebral substance,
when exposed to the action of lire, instead of
swelling up, without emitting any marked odour,
and leaving a brownish light residue, assumes a
horny hardness, emits a strong heavy smell, and
leaves a compact blackish residue. Nitrous acid
also imparts to it a horny hardness, — circum-
stances evincing a great increase of the albumi-
nous constituent of the structure. 'J'he third
degree of iiardening equals the firmness of wax,
frequently also conjoined with elasticity, so that
the indurated portion resembles flbro-cartilage.

103. a. "J'heyi'rsi grade of induration may affect
the whole or the greater part of the cerebro-spinal
axis. The two greater degrees of this change are
commonly of more or less limited extent. General
hardening of the brain is usually attended with
augmented vascularity, numerous drops of blood
becoming effused when the cerebral structure is
incised. This increased vascularity, although
general, is not constant ; for, in some few in-
stances, little or no injection of the capillaries is
observed, the brain being rather exsanguineous
than vascular. Even in the general induration of
the brain, the hardening is not equal throughout
every part. It is least remarkable in the cortical
structure and convolutions; and more manifest in
the whrte, particularly the central medullary parts
than in the grey substance.

104. b. Partial induration of the brain is most
frequently found in its central parts, and some-
times in the convolutions. IM. Andral has ob-
served it in this latter situation, at as early an
age as three years, which is extremely unusual.
Sometimes the convolutions of the convexity of
the hemispheres are unaltered, whilst those of the
base are hardened ; occasionally in such cases,
especially when the induration is considerable,
the cortical can scarcely be distinguished from
the medullary structure. In a case recorded by
Lali.emand, the induration was limited to a cir-
cumscribed portion of cortical substance, and
under it, the medullary texture was manifestly
softened. M. Pinel found, in one of the hemi-
spheres of a female who had died in a state of
idiolcy, a portion of the medullary structure ex-
tremely hardened ; and, in the same individual,
there existed, in the whole posterior and inferior
border of the cerebellum, an induration of a fibro-
cartilaginous desciiption. The hardened portion
was yellowish, elastic, resembling a piece of
whitish yellow leather. JMr. Payin found, in
a girl six yeais of ane, near the posterior third
portion of the left hemisphere of the brain, a
depression, owing to Iiardening of one of the con-
volutions, which seemed externally as if it were
shrivelled. It was rose-coloured on its surface,
slightly yellowish in its substance, and almost
concealed from view by two convolutions, which
were hciilthy. 'I'lie mciTibranes covering this har-
dened convolution were white and thickened.
Hardening was here joined to diminution of vo-
lume; or, perhaps, the disease of this portion of
the brain was congenital, and, whil>t the growth
of the rest of the organ had proceeded, the de-
velojiemerit of this was interrupted. The intel-
ligence of this child was well advanced ; but she
had, from birth, a contraction of the right wrist

ITS Sl'dstance — Induration.

and foot, with slight atrophy, and incomplete
hemiplegia of this side. Similar cases of hard-
ening of portions of the lobes of the brain are
desciibed by JMonho, Laliemand, and IluicniN-
soN. In a case recorded by JoEGEH,the induration
was limited to the paiietes of the posterior cornua
of both lateral ventricles, and amounted almost
to that of cartilage. Bergman found both optic
beds hardened in a paralytic and squinting girl :
and Castellier and Anderson observed exces-
sive hardening of the lobes of the cerebellum.
Paitial induration of the nervous centres fre-
quently co-exist with other ksionsof those organs,
especially around old sanguineous effusions and
morbid productions formed in the cerebral sul)-
stance : they are also occasionally found accom-
panying the usual results of chronic inflammation ^
of the niembranes; these being firmly aggluii- ■
nated together, to an extent of surface more or *
less considerable, and closely adherent to a sub-
jacent hardened portion of brain. (Portal,
Anatomic Med. t. iv. p. 91.)

105, Caute nf hardening of the brain. — Thejirst
degree of induration has been frequently found
in persons who have died of fevers, generally of
an ataxic or typhoid type, and in maniacs. M.
Andral observed it in two paiienls afflicted with
convulsions from working in lead. JMiNLGAUDtx
{Recherclies sur I'Endurrissement gen. de I' Enreph.
coinme une des Causes des Fievres Ataiiqnes. Paris,
1825.) and Bouillaud (^Archives Geiter. t. iii. p.
477.) consider it as the consequence of acute in-
flammatory action of the brain and its membranes,
they having found it in persons who have died of
encephalitis occurring either primarily, or as a
complication in fevers; and RI. Andral (Auat. m
Futh. t. ii. p. 810.) seems to coincide with this I
opinion. Budoipiii observed it in thirty cases m
of typhus: and Otto found, during the epidemic
typhus of 1809 and 1812-13, hardening of the
brain frequent in those who died within the first
week; and softening in many who died at a later
period, but, in these cases, granting the induration

to have been the consequence of the disease which
destroyed life, it must have taken place in the short
space of a very few days; whereas, I am much
more inclined to impute it to inflammatory action
of a lower grade and of a much slower progress.
JM. BnovssAis regai'ds it as the result of meningo-
encephalic inflammation, of a sub-acute or chronic
nature. As being generally found in connection
wiih increased vascularity of the sub.-tance of the
organ, and with this and other signs of inflam-
matory action of the membianes, the relation of
this change to inflamiijation seems established;
but I am inclined to ado|)t the inference of Dr.
Craigie, in resptct of the opinions of JMJM. Gva-
DET and Boi'iLLAi'D, that, in tho^e cases in which
llicy cbseived this lesion, it had existed previous
to the acute disease which occasioned death.

106. Induration of the brain has been long
famili;ir to pathologists, in relation to mental de-
ningemcnt. 'I'he writings of l.ni iii , (i i oi frov,
ISoi'.hhaa VF, Lancisi, J\1orga(;ni (^Fpist. Anat.
Med. viii. 4—18.), J. F. JMickel {Mem. de
I' Acad. Hoy. de Berlin, t. vii. p. 306.), Lieotaud,
Santorini, CiREDiNG {Ludwig's Advcrs. Med.-
Fract. t. ii. pars 3. p. 533.), Portal, JMar-
siiALi, (Morbid Anat. of the Bruin, 6ir. Lond.
1815 ), Hasi.am (Observ. on Madness and Me*
lancholy. Loud. 1809.), Serres (Ann, Medico-

BRAIN — Alterations op its Substance — Tumours.

221

Chirurg. Paris, 1819.), Lallemand (Recherches
Aittt. Path. let. ii.), Lerminieu, Bouii.eaud
(Traite C Unique de VEiictphal'de. Paris, 1825.),
PiNEL, jun. (I?e'y. Mtd. t. vi.), Fovilee, and
Pinel-Grandchamp, furnish numerous instances
of it, thus related: and, from the history of the
cases, as well as the generally augmented vascu-
larity of the membranes and of the indurated
brain iiself, I infer that it is a consequence of
ciironic inflammatory action, conjoined with some
change in the nutrition of the cerebral substance;
and that it proceeds fiom a less intense and more
ciironic state of the vascular action than that
which occasions softening, or pulpy destruction
of the cerebral texture. That such is the case is
proved, not only by my own experience, but also
by the observations of the authors enumerated
above ; for, in the majority of those cases, even
wiien presenting the appearances and consequences
of cephalo-meningeal congestion and inflam-
maiion, tiie symptoms of cerebral disease were
of much longer duration than those depending
upon morbid softening of the organ.

107. It has already been stated, that indura-
tion of the cerebral substances, amounting to
either the second or the third degree, is generally
circumscribed in extent. Whatever doubts may
be entertained of the first degree of hardening
being the result of chronic rather than of acute
disease, there can be no doubt of the second and
third being always a chronic affection — perhaps,
of a still more chronic state of capillary action
timn that giving rise to the first form of increased
hardness ; the morbid action, afl^ecting in the
former cases a portion of the brain only, may be
compatible with a longer duration of life, and
hence give ri-e to ulterior or more advanced stages
of change than those presented when the whole
organ is affected, and all its functions and ener-
gies thereby involved. That this change is one of
the consequences of chronic irritation, or inflam-
matory action, may be conceded as well as the
supposition entertained by Anoral and Craigie,
tliat the morbid irritation is connected wiih a
perversion of the nutritive action. Indeed, the
numerous cases detailed by Portae, Serres,
Lallemand, Bouillaud, Pinel, and others, fur-
nish satisfactory evidence, both in the symptoms
during life, and in the co-existent lesions in the
membranes and other parts of the brain, of the
existence of a chronic inflammatory action, or of a
state of irritative erethysm of its capillaries. But
to say that this state is in such cases accompanied
by a perversion of its nutritive actions, is ascribing
to it what always is an attendant upon inflam-
iTiatory action, of whatever grade, or in whatever
texture it may be seated. It should, however, be
mentioned, that M. Lallemand considers partial
induration to occur occasionally as a favourable
termination of morbid softening of the brain ; but
this is a mere supposition.

108. As to the phenomena to which induration
of the brnin gives rise, every practical man must
feel considerable interest. I'he first and more
general induration of the brain generally occa-
sions loss of memory, confusion of thought, and
derangement of the mental manifestations — caus-
ing insanity without lucid intervals. When the
induration is advanced in degree, or considerable
as to its extent, or both, and especially when its
long duration has been indicated by continued

mental derangement, a complete obliteration of
the mental faculties, or fatuity, is frequently its
attendant towards the last periods of life, and may
therefore be considered as the consequence of the
most advanced degrees of this lesion. The signs
of partial induration of the brain, in any of the
grades to which I have referred, will vary accord-
ing to the extent and seat of the lesion. They
consist chiefly of a progressive defect of memory,
inattention, or an inability to pursue a long traio
of ideas, indifference to momentary impressions,
and to present or future occurrences, difficulty of
articulation, derangement of ideas, with partial
or total loss of the affections, appetites, and
desires; and ultimately increased loss of speech,
palsy, convulsions, or want of power over the
muscles, fatuity, general or partial wasting, and
death.

109. Lallemand found, in a patient who had
complained of fixed pain of the foreiiead, palsy of
the face, and confusion of memory, tiie membranes
firmly matted together, for the extent of a thirty
sous piece, at the anterior extremity of the left
hemisphere ; and the subjacent cerebral substance
hardened to a scirrhous or cartilaginous firmness,
and adhering closely to the membianes. Bouil-
laud states the case of a man, aged sixty-eight,
who, after symptoms of cerebral disease, had im-
paired memory, headach, diflicuity of expressing
his ideas, followed by muscular weakness, and
convulsions: the cerebral substance was found
injected, and induration was seen " passing from
the striated body of the left hemisphere, through
the nucleus, at the upper region of which it formed
a cavity with hard yellow walls : a similar hard-
ened portion also existed in the posterior lobe."
According to M. Pinel, induration confined to
the brain causes fatuity, with more or le-s of
palsy ; but, if it extend to the annular protuber-
ance, the crura cerebri, the corpora olivaria, or
chord itself, epilepsy, followed by palsy, and
death by marasmus, are generally superadded. In
these advanced degrees of hardening, which are
sometimes attended with a shrunk, depressed, and
condensed appearance, — a species of atrophic
hardening of the part, — there are usually re-
marked palsy and idiotcy, which are either con-
genital, or occurring subsequently to birth.

110. vi. Morbid Growths. — Tumours of the
brain. — Tumours of various kinds have been
found to originate in the substance of the brain ;
but as Dr. Craigie (Anat. p. 447.) has observed,
they have not been distinguished with suflScient
precision by authors, from those which, originat-
ing in the membranes, affect the brain only se-
condarily. The first form of tumour which he
has described, and denominated " cerebral tumour,"
entirely agrees with those partial intlurations al-
ready considered ; differing from them in no
respect, but in the extreme degree of firmness it
presents, which is similar to the second and third
(the latter particularly) degrees of hardening,
arising in the manner I have endeavoured to
explain (§ 104.), and affecting all parts of the
nervous masses, — the cerebellum and medullary
chord, as well as the various parts of the brain
itself. (See Hardening, &c.)

111. A, Tubercular secretion, — Tyroma
(Craigie). — Tubercles of the brain have been
(lesciibed in recent times with much accuracy by
Gendrin, Leveille, Ollivier, Abercrombie,

222

BRAIN — Alterations of its Substance — TuMOtms.

Andral, and Craigie. They are formed of a
white, or pale yellow, opaque, firm, cheese-like,
sometimes granular and Iriahle substance, con-
sisting of a large proportion of albuminous matter,
and varying in size, from that of a millet-seed to
the balk of a hen's egg. This substance is depo-
sited ill various forms in the brain, but usually as
follows : — 1st, One, two, or more, homogeneous,
distinct masses of considerable size; 2d, Several,
or many, separate, minute, spherical, or spheroidal
masses. Cases of the Jiit,t form of tubercular
formations are to be found in the writings of
Manget, Rocnoux (Recherches sur V Apoplexie,
p. 151.), Powell (Traiis. of Cull, of Phys.
vol. V. p. 222.), Blane (^Trans. of a Society, S]'c.
vol. ii.) Baillie {Fasc. of Eiig. No. 10. plate
vii.), Coindet (Mem. sur I' Hydroce-ph. p. 106.),
Bouillaud {Trau6, ^c. p. 161.), Abercromdie
{Dis. of the Brain, &jc. p. 428,) ; Chambers
(Med. and Pliys. Journ. vol. Iv, 1826, p. 5.),
Piedagnel (J()u)'n. de Phys. t. iii. p. 247.),
Berard {Ibid. t. V. p. 17.), and Hooper (Morbid
Anat. of the Brain, p. xi. and xii. fig. 1.). Tu-
bercles of this class vary in number from one to
five or six, and in size from that of a pea to the
Lulk of a hen's egg. In form they closely re-
semble tubercles in other parts of the body. Ac-
cording to LiiVEiLLE, they are often of an unequal
surface, so as to appear lobulated, particularly
when they are very large. If only one or two
are present, their size is generally considerable.
]M. Andral mentions their existence in the cere-
bellum, of so large a volume as to destroy nearly
tiie whole of one of its hemispheres. Even when
of this bulk, they consist of the opaque, cheese-
like substance already described, and are always
destitute of vessels, or any trace of organic struc-
ture. 'I'hey are albuminous, friable, and gene-
rally surrounded by a cyst. MM. Gendrin and
Lkveille are of opinion that they always have
cysts, but of variable thickness, which are some-
times remarkably thin, at other times, especially
in old tubercles, thick and fibrous. The cyst
adheres externally to the surrounding cerebral
structure ; and its internal surface sends off de-
licate filaments, which traverse the continued
tubercular matter, and, in the large and old tu-
bercles with thick cysts, seem like small fibres or
partitions passing between the lobules of the con-
tained subslance, which is disposed in cellules
formed by these filaments. In some large and
old tubercles, the cyst is fibrous, cartilaginous, or
even osseous (Gendhin), and is sometimes par-
tially separated fi'om the surrounding cerebral
siructure by a minute quantity of serous fluid.
In proportion as the tubercle softens, the cyst be-
comes more apparent.

1J2. The surrounding cerebral substance is
often perfectly natural, and sometimes variously
altered; — occasionally inliamed, or softened, or
atrophied, or even destroyed, especially when the
tubercles are very large. Upon these lesions,
the symptoms during life are often chiefly de-
jicndent. Very frequently, especially in children,
tubercles varying as to number and size may
exist in the brain, without occasioning any sym-
ptoms sufficient to lead to the susjiicion of cerebral
disease: but this seems to be the case only when
the nervous substance around them lias been but
little changed from the heallliy state. When
nervous Bymptoms have appeared without such

change, they have generally assumed an intermit-
tent character. •

113. It is very probable that tubercles are
formed in the brain, as elsewhere, at first in a
fluid state ; and that they afterwards either undergo
a slow coagulation, or have their aqueous por-
tions partly absorbed, the albuminous and otlier
more solid constituents forming the tubercular
substance. INI. Bouillaud believes that they
are the product of an inflammatory process ; and
the tendency of inflammation to produce an albu-
minous secretion certainly countenances this
opinion. Whatever may be the origin, they ap-
pear to experience in the brain a similar softening
to that which they undergo when formed in other
organs. When this is advanced to more or less
partial fluidity, tubercles may be mistaken for
otlier formations ; and when amounting to lique-
faction, the tubercular production can, with diffi-
culty, be distinguished from a small encysted
abscess. (See art. Tubercles.)

114. The second form in which tubercular
productions are found in the brain, is that of
spheroidal bodies, disseminated through its sub-
stance. Professor Reil (Memorah. Clinica, t. ii.
fas. iii. No. 2. p. 39.) describes them, in a case
which occurred to him, to have consisted of about
two hundred spheroidal bodies lodged in the grey
matter of the brain and cerebellum. I'liey were
a little firmer than the brain itself, mostly of a
pale yellow, some of a pale blue, of the size of a
lentil or pea, and consisting of an adipose-like
substance. From some, which were marked in
the centre with a dark point, and seemed covered
by a thin cyst, a slight incision discharged a mat-
ter-like vermicelli. These bodies were confined
entirely to the cortical substance of the brain,
chiefly near the deep anfractuosities, and but very
few were in the prominent parts of the convolutions.
They were most numerous in the superior aspect
of the hemispheres, less so in the cerebellum, and
least numerous in the base of the cerebrum. The
pia mater was remarkably injected with blood,
and the ventricles contained very much fluid.
This patient had never complained of pain in his
head, although long afflicted with scrofulous
sores, until eight days previous to death. In a
case recorded by M. Ciiomel (Nouv. Journ. de
M^d. t. i. p. 191.), similar bodies were found
disseminated through the brain of a woman aged
thirty, who died with symptoms of cerebral dis-
ease. Two such productions were also found in
the cerebellum, and one in the spinal chord.
Cases similar to the aliove have likewise been re-
corded by other writers. Tubercles, even in
the form now being considered, are seldom or
ever found in greater number than in the case
just quoted from Reil ; and, as Gendrin has
remarked, they are never found in the brain in so
very great numbers as in the lungs; nor, in my
o])inion, do they assume, in (he cerebral struc-
ture, the ag;ili)meraled form, in which they are so
often met with in other viscera, and in the lungs
especially.

115. Tubercles are often met with in the brains
of children, and those especially of a strumous
diathesis, and upwards of one or two years
of age. '1 hey occur most frequently from this
age to puberty; after which they aie rarely met
with, even in scrofulous and jihthisical subjects,
where tubercles exist not only in the lungs, but

J

BRAIN ^Altehations of its Substance — TuMouns.

223

also in other organs. They are most common in
the hemispheres of the brain, and there occupy
indifferently either the cortical or the medullary
texture : sometimes they appear, as it were, placed
between both. In some cases in which they have
been found in the more exterior layer of the
cineritious structure, they seem not to have been
originally formed in it, but to have sprung from
the internal surface of the pia mater, and to have
pressed inwards the cerebral tissue as they in-
creased in size, forming, as it were, a superficial
cavity in it, without any intimate union with it
beyond that of close contact. The parts of the
brain, after the hemispheres, where tubercles are
most commonly found, are, accordmg to ftl. An-
DRAr,, the cerebellum, the mesoceplialon, the
medulla oblongata, various parts of tiie spinal
chord, the peduncles of the cerebrum and cere-
bellum, the thalami optici, corpora striata, the
commissures of the thalami, and pituitary body.
According to the order of frequency here indi-
cated, it will be observed, that those parts of the
cerebro-spinal axis which are most frequently the
seats of inflammation, softening, or hasmorrhage,
are not those which are oftenest the seat of tuber-
cles.

116. B. Adipose tumour (yVK^zKi.'), — Fatti/ pro-
ductions (Andual), — Lardaceous degeneration
(Hebreart, Annuaire Med.-Chirurg. Paris,
1829. p. 579.), — Ceroma (Craigik). — This
morbid formation has been noticed, under the
above designations, by the authors whose names
are respectively noticed, and also by Rudolphi,
Braun, Cruveilhier, Meeat, Liprestre (Ar-
chives Gen6r. de Med. t. xviii. p. 19.), and Dal-
MAS (Journ. Hebdom. de Med. t. i. p. 332.).
BoRELLi states that he has found, behind the
upper part of the medulla oblongata, a fatty,
homogeneous, reddish, or rose-coloured substance,
the size of a nut, apparently traversed by reddish
lines, and contained within a thin envelope. A
similar tumour, though smaller, was found in the
left cerebellic hemisphere. Amongst the great
number of brains examined by the Wenzels,
only two presented this change ; which they de-
scribe as having been smooth, of a yellow colour,
and consisting of a solid, adipose, ash-coloured
substance ; and, although found near the exterior
surface of the hemisphere, penetrating deep into
the substance of the organ.

117. According to ]M, Hebreart, this disease
is not so rare as the Wenzels lead us to suppose.
He had met with four cases of it ; two in which
tiie tumour was seated in the brain, and two in
the cerebellum. " In the first of the former, a dis-
tinct tumour, consisting of matter of a yellow
colour, and lard-liiie consistence, the size of a nut,
in the anterior part of the anterior lobe of the
right hemisphere, gave rise to idiotcy. In the
second, a square inch of the posterior lobe of the
Lft hemisphere was converted into a yellowish
pulpy matter, which was separated from the con-
tiguous sound brain by hardened cerebral sub-
stance. This, in a man aged forty, caused epi-
leptic paroxysms, occurring once or twice a month,
which at last proved fatal, by causing asphyxia.
In the first of the cerebellic cases, in a young
man who had been idiotic for six years, tlie cere-
bral substance, forming the walls of the fourth
ventricle, had been converted into a yellowish
lardaceous matter. In the second, that of an

incurable maniac, a space, six lines in diameter,
of the lower part of the right hemispheie of the
cerebellum, had become hard, yellowish, and lard-
aceous, both in the grey substance, and also in
the white." The membranes also participated in
this change. IM. Hebreart considers that this
lesion may occur in two forms, — 1st, As a de--
generation of the cerebral structure into a matter
of a yellowish colour and lardaceous consistence ;
and, 2d, In the shape of a distinct tumour situ-
ated in the cerebral substance.

118. Closely allied to the above, although
materially different in some respects, yet still more
strictly deserving the term adipose, are the tu-
mours described by Leprestue and Dalmas.
M. Leprestre found, in the left side of themeso-
cephalon of an adult subject, a large tumour,
with a brilliant lobulated surface, consisting of
concentric layers, united by means of fine cellular
tissue, but without any trace of blood-vessels. It
was denser in its structure than the brain, and
closely resembleil a mass of adipocire. This
resemblance is remarkable, inasmuch as MM,
Barruel and Gmehn have demonstrated, in the
healthy human brain, a certain quantity of fatty
matter and cholesterine. The tumour found by
M. Dalmas nearly resembled the foregoing. It
was situated in the base of the brain, and was as
large as a hen's egg. It rose upwards into the
third ventricle, separated the parts which contri-
bute to the formation of this cavity, and disap-
peared in the medullary substance of the striated
bodies, the thalami optici, the anterior commis-
sure, &c. Its superior surface closely resembled
spermaceti. Its, inferior surface was transparent,
polished, and studded with a number ot pearl-
like granulations, from a line to a line and a half
in diameter, which were, like the whole of the
mass, perfectly homogeneous, and devoid of every
trace of organisation. When analysed by M.
Barruel, this tumour was found to contain a
very large portion of fatty matter, and a substance
which seemed to be cholesterine. The description
of a similar tumour is recorded in the first volume
of the Journal Clinique des Hopitaux. Otto
also found a fatty tumour, which contained hair,
protruding through an aperture in the hemisphere
into the ventricle, its cyst shining like mother-of-
pearl.

119. C. Flesh-like tumour, — Adenoidea (Crai-
gie). — This production has been described by
the vague names of scirrhous and scrofulous tu-
mour ; but it cannot be admitted to possess un-
equivocal characters of either. It is generally
stated to be similar to a mass of flesh, or an en-
larged absorbent gland. Its colour is light pink,
or pale flesli-colour ; its firmness is considerable ;
and, in some instances, it is compared to the
kidney. Cases of this description of lesion may
be found in the writings of Plater (Obscr. 1. i.
p. 13.), T. BoNET (Sepulchretum, t. i. p. 283.),
llnoDius (Cent. Obs. 1. No. 55.), J. J. AVagner,
(Miscell. Curios. Dec. II. Ann. 10.), J. G. Zinn
{Comment. Soc. Reg. kicient. Golt, t. ii. 1752.),
J. J. IIuBER (Nova Acta Physico-Medico Acad.
Cas. Leop. Cur, I. iii. p. 533.) ; et Comment, de
Rebus in Scient. Nat. t. xviii. p. 335.), Halleb
(Opusc. Path. Obs. i.), J. E. Greding (Ludtiig's
Advers. Med.Pract.t. ii.parlii. p. 492.), II. Earle
(Med. Chirurg. Trans, vol. iii. p. 59.), Powell
(Trans, of Coil, of Phys. vol. v. p. 241.), &c. Moit

zU

BRAIN — Alterations or its Substance — Tumours.

of (hose cases appear to have occurred in strumous
labits ; and, besides signs of glandular disease,
many of them were affected with palsy, apoplexy,
or mental derangement ; and otiiers with convul-
sions and epilepsy, shortly before death. ]M.
Andual (Aiiat. Pathnlog. t. ii. p. 848.) mentions
his having found, in the middle of one of the hemi-
spheres of the brain of a person who had died of
apoplexy, a fleshy fibrous tumour of the size of a
walnut.

120. D. Fibrp-curtilnginous tumour, — Scirrhtis,
Chondroma (IIoorER and Craioie), — is probably,
in itssliglitergrades of change, merely an advanced
state of tlie third variety of paitial induration of
the brain (j 103.). It is distinguished from the
surrounding cerebral substance by its great firm-
ness ; its irregular and lobulated form ; its yel-
lowish, hard, and fibrous structure ; and, in its
advanced stages, by the presence of a semi-fluid,
gelatinous matter, occasionally tinged with blood,
contained in small cavities, disseminated through
it ; and by a tendency to softening; death, how-
ever, generally taking place before complete soft-
ening, or cancerous ulceration, has surpervened.
This tumour is not often met with in the substance
of the brain, and very seldom as a primary affec-
tion. It seems to consist of a change in the
structure of thj part aflfected, rather than of a
deposition of adventitious matter ; and it is not
enveloped by any cyst; but gradually disappears
in the surrounding substance, which is sometimes
softened. All the cases which have been recorded
of scirrhus of the brain, are not in every respect
similar to the above description, but an approx-
imation to it merely ; some, according to the loose
accounts given of them, being intermediate be-
tween this and the cartilaginous conditions. The
best illustrations of this form of tumour have been
furnished by Cruveilhier (^Anut. Puthol. t. ii.
p. 80.), RosTAN (Recherches sur le Ramollisse-
ment du Cerveau, &;c. Ire ed. p. 80.), Andral
(^Jotini. de Physiol, t, ii. p. 105.), Bouillaud
(Trail£ CUnique de I'Eiictphalile, &;c. 1825.),
Lerminier (Ann. M^d.-Cliiruvg. 1819, p. 225.),
]\loNRO (Morb. Anat. of the Brain, p. 55.), Wade
( Medic, and Plii/s. Jour7i. vol. Iv. p. 369.), Bayi.e
( Rcch. sur la Plithisie Pulmon. &;c. p. 305.), and
Copland Hutchison (Trans, of Med. and Chir.
Sue. vol. ii. and iv.). All these cases were cha-
racterised by acute pain in the head, stupor,
palsy, idiotcy, convulsive movements, and, at last,
insensibility, coma, or complete apoplexy, and
death ; or by one or more of these symptoms ; and
several of ihem seemed to originate in external
injury received at a more or less remote period.

121. E. lionq tnynours and calcareous concretions,
-^Osteoma (II joper), — are rarely observed in tiie
substance of the brain. Cases have, however,
been furnisiied of their formation, in more or less
considerable masses, — near the right ventricle, in
an idiot, by KiuKRiNCiius (Ohs. Anat. p. 135.);
in the corpus striatum, by Deidier (Des Tn-
meurs, &ic. p. 351.), and Kentmann {De Calc.
in Ilominih. Tig. 1536.); in one of the corpora
quadrigemina, byTvsON (Phil. Trans. No. 228.) ;
in the union of the optic nerves, by ]5i,icny
(Zodiac. Gall. ()b<. xiv. p. 81.) ; where they were
attended by violent pain in the occiput, by Boyer
(Cruveilhier's Anat. Path. t. ii. p. 84.) ; in the
cerebellum, by Littre (Mem.de I' Acad. deParis,
1705, p. 55.); in the cerebellum of an epileptic.

by LiEUTAUD (Hist. Anat. Med. l.iii. Obs. 179.) ;
in the pons varolii, by Metzger (Ohs. Anat. Reg.
1792, p. 3.); in the optic beds, by Caldani
(Oimsc. Anat. Path. 1803, p. 51.) ; in one hemi-
sphere of an epileptic, by Otto (Comp. Anat.
Pa//i. p. 415.) ; in the cerebellic peduncles and
protuberance of an idiot, by Home (Phil. Trans.
1814. ); in the left hemisphere, by Anural (Journ.
de. Phijsiol. t. ii.p. 110.) ; in the cerebellum, with
violent pain at a determinate part of the occiput,
by Nasse (Abercrombie on Dis. of the Brain,
p. 426.) ; in the centre of the medullary substance
of the anterior lobe, with jnilpy destruction of
the surrounding part in one case, and in the
cerebellum in another, by Dr. Hooper (Morb.
Anat. of the Brain, p. 39.). Besides these,
other instances are referred to in the Repertorium
of Ploucquet, and the Compendium of Otto.
In more numerous cases, the chalky, calcareous,
or bony matter, is disseminated like sand in a
diseased portion of brain, and can be detected
only by squeezing or rubbing the part between
the fingers. In some cases the bony matter ap-
pears like minute spiculec, or particles; and Dr.
Hooper states that he has found each of them
attached to a filamentous vessel.

122. Sabulous concretions are so constantly
found in the pineal gland, or its peduncles, even
of those wiiose cerebral functions were most
healthy, that Soemmering conceived them to form
a part of its natural structure in adults. But
this part may be greatly enlarged, and contain
calcareous matter to an excessive amount. A
case of this description is given by Mancet
(Theai. Anat. 1. iv. c. ii. p. 309.) and Salzmann
(De Gland. Pineal. Lapid. Arg. 1733.).

123. /''. Hiigromatous tumours, or cifsts, contain-
ing a serous or albuminous Jluid, — Hygroma oi
Hooper, — are not infrequently found in some
part or other of the brain. Dr. Hooper has de-
scribed four varieties of these cysts: — a. That
consistin^j of a simple cell, or cavity, containing a
transparent, yellowish, or yellowish red, serous
fluid. Their sides are somewhat harder than
healthy brain, occasionally rough, and of a brown-
ish hue internally, but mostly smooth and shining.
They present no appearance of membrane bning
the cell, nor of vascularity ; are of the size of
peas or nuts, and are most frequently met with
near the external surface of the brain. They
appear to be the remains of cavities formed by
extravasated blood. — h. Another variety is a dis-
tinctly encysted tumour, consisting of a membran-
ous cyst, or vesicle, filled with a serous fluid.
This cyst is delicate, is formeil of a single mem-
brane, and is provided with vessels coming from
the surrounding brain, and which may sometimes
be seen ramified over it. The fluid which fill< it
is colourless and limpid. This variety varies
from a very small size to that of a small orange.
It is sometimes solitary ; but occasionally two or
more may be embedded close together. — c. Dr.
Hooper describes two other varieties, one of which
is formed of a cyst, which is opacpie in some
parts, and transparent in others, and distended
with a sero-albuminous fluid. The cyst is not
apparently vascular, but is much thicker than tho
preceding ; and its contents coagulate by heat :
d. 'i'lie other is characterised by the remarkable
tiiiekness of its cyst, and the thick albuminous
nature of its contents. It is generally found

BRAIN — Alteuations of

embedded in the medullary substance of the
brain.

124. G. Htjdalids. — The existence of <rMe /ii/rfa-
tids, — both the acephulocitst, or headless iiydatid,
and the ci^sticercus, or bladder-tailed Iiydatid, —
in the substance of the brain, has been doubted.
Several cases of hydatids in this part have been
adduced by autiiors; and instances have occurred
to Andral and Calmeii, (^Anat, PatlivL t. ii,
p. 779.), which they considered to belong; to the
latter of the above species of entozoa; but whether
they actually were such, or some one of the cysts
described above, rests upon the patiiological re-
putation of tiiese physicians, 'i hose adduced by
Home, HEADiNcroN, JNIorraii, and Uosxan,
seem to have been merely varieties of Iiugrflma.
Dr. Hooper never met with hydatids in this situ-
ation, in his numerous dissections. Brera states
that he has found them in the choroid plexus;
and Dr. jNIonro relates a case, where a cyst,
which he considered as a true hydatid, was found
in one of the ventricles. But their connection
with the membranes of tiie brain (§ 31.) has
already been shown,

125. H. The Hamatomatoiis tumour, — the He-
matoma of Hooper, — is not common. It is mostly
fungous, arising from a small base, separating ti;e
convolutions and cerebral substance about it, as it
enlarges and rises towards the surface of the brain.
It is soft to the touch ; is elastic, and covered
with a vascular and shaggy membranous tissue.
When divided, its inner structure is vascular,
mottled, of a whity brown, and, in some paits, of
a bloody colour ; and a humid substance adheres
to the knife like cream. Interesting cases have
been detailed by Ilocnoux {liech. siir I'Apo-
plexie, Ob. 38. p. 149.), Hooper (Op. cit,
pi. X.), Monro (Op. cit. p. 56.), and G. Gre-
gory (Med. and Phi/s. Journ. vol. liv. p. 462.),
in which these tumours were, exteriorly, of a red-
dish or reddish brown colour, lobulaied, and
surrounded by pulpy destruction of tlie cerebral
substance. In two of the patients, violent head-
ach and epilepsy, and, in one, palsy, followed by
coma, preceded dissolution. This tumour must
not be confounded with the solid nodules of ex-
travasated blood, often found after apoplectic
seizures.

126. /. Encephaloid or cerehriform tumours, —
3Iedullary sarcoma, — Fungus hcematoiJes — Cepha-
loma. Hooper. — These tumours are not frequent.
Delineations of them have been given in Dr.
Baii.ije's and Dr. Hoopke's illustrations. They
occur chiefly in young subjects; and are ency^^ted,
soft, compressible, and spongy, resembling the
grey cerebral substance, with a tinge of red, and
of the consistence of the foetal brain. They are
frequently divided into lobulated masses. When
cut with a knife, the surface is smooth, and the
knife is covered with an unctuous substance. I
have met with one case in a boy of eleven years
of age. JM. Bavle found it in the cerebellum of
a middle-aged xnnn. (Rev. Med. Avr. 1824, p. 77.)

127. A'. The Melanoid tumour, — Melanosis, —
Me/aHoma, of Hooper. — Rlelanosishas rarely been
found in the brain. Dr. Hooper has, however,
observed it in a tuberculous form, both in the
cineritious and medullary structure. These tu-
mours were of a jet black colour, soft, distinctly
circumscribed, and closely surrounded by healihy
brain. Dr. II. has found them of all sizes.

Vol. I.

ITS Substance — Rupture. 225

from that of a mustard seed to that of a walnut.
" I'liey are so soil as to lequire a very sharp
knife to cut them, which they soil. 1 liey are
easily taken out of the brain with a forcejis, and
leave a clean cavity, without any cyst apparent
to the naked eye ; and if shaken in water, they
colour it black, and a flocculent substance re-
mains. In one instance, in which there were
several of these tumours, some of them were of a
blood or liver colour, and resembled hasn.atoma
(§ 125.); others were perfectly melanomatous ;
and several were of an intennediate colour, — a
circumstance which is very much in favour of
the hasmatoma and melanoma having an intimate
connection, if tliev be not one and the same disease,
modified by particular circumstances." (p. 41.)

128. All the tumours now described occasion
alterations, generally of an inflammatory nature,
with softening in the substance of the brain con-
tiguous to them ; and until those alterations have
been in some measure produced, they often give
rise to but little disturbance of the functions of
the organ. However, when these changes be-
come developed, the usual symptoms of circum-
scribed ivjiammatioii of the substance of the brain
with softening; epilepsy; loss, or perversion of
one or more of the mental faculties — amounting
ollen to insanity ; idiotcy ; palsy; co??!a, and apo-
plexy; are the usual effects. (See the Articles on
these diseases.}

129. vii. Rupture of the Brain. — Hernia
cerebri, — Encephalocele, — is occasionally met
with. It consists of the protrusion externally of a
portion of the brain through openings in the cranial
bones. This lesion either may ,ba congenital,
or may arise siibse'iuently toh'inh. In ihe former
case it is generally connected with effusion of
fluid in the ventricles. Ihe protrusion of brain
varies with the size of the aperture in the skull,
and the quantity of effusion causing it. In some
cases a large portion of the sku'.l is wanting,
and the protruding part of the brain has a wide
base : in other cases, the opening in the craniun\
is small, and the protrusion is either very small,
or attached to a narrow neck. Otto states that,
in every case which he has observed, the lesion
was owing to effusion, and not to hypertrophy of
the substance of the brain ; and that the aperture
arising from deficient development of the bones
of the cranium was one of the consequences of the
effusion. This agrees with my experience, and con-
stitutes hydrencephalocele or waiery rupture of the
btain. In some cases large portions of the brain
are protruded, in others but small. Frequently
the protrusion consists only of the membranes
forming hifdrencephalocele meningea, and the water
which they contain. Otto describes this as a
rare occurrence. I have met with several cases
at the Infirmary for Children, and in unusual
situations, namely, through clefts in the parietal
bones. In rare cases of hernia cerebri, the water
is found both within the ventricles and between
the membranes.

130. Congenital rupture of the brain occurs
most frequently on the back of the head, through
the enlarged occipital foramen, and the cleft upper
cervical vertebra, or through a cleft in the upper
part of the occipital bone, or in the lambdoidal
suture. It is not fiequent at the top of the head,
especially at the great fontanel ; and Otto says
it is still more rare in the sides of the skull and

Q

226

BRAIN — Cerfbral Plethora.

forehead, and the rarest of all in the orbits and
sphenoidal sinuses. Two coses, however, of its
occurrence at the sides of the skull have come
before me. Rupture of tlie brain, occuninjj after
birth, arises from the expansion of the brain by
its own elasticity, or by increased deterrainalions
of blood, and its consequent detiusion through
apertures naturally or artificially made in the
cranium. I have met with cases, however, in
which no protrusion of the brain iiad been ob-
served after birth ; and yet apertures, tlirough
which it might have occurred, weie found in
the middle or squamous parts of the bones,
and must have been congenital. The inference
is, in these cases, that a watery tumour of the
brain had arrested the formation of the bone
immediately over it, and tliat this tumour had
subsequently disappeared, probably from the ab-
sorption of the aqueous effusion ; but that tiie
bone had not yet been formed in the situation
where the ossific process had been interrupted.

131. viii. Laceration. — The continuitij of the
brain may be destroyed by external violence, or
injuries penetrating the cranium, either with or
without loss of subjtance. Concussions also will
lacerate the brain, without the skull being pene-
trated or even fractured. The substance of the
organ, particularly the septum and fornix, may be
torn by large collections of water in the ventricles.
There is every reason to suppose that, when the
solution of continuity is simple, adhesions will
take place. When there is loss of substance, the
injury can be repaired only by granulation. If
the laceration be accompanied witii the effusion
of blood, so as to form a large coagulum, requir-
ing to be absorbed, the reunion of the opposite
sides of the lacerated brain is effected by nieans
of a fine cellular tissue ; permanent paral^ sis being
the usual consequence. When the granulations
of the lacerated brain protrude through the frac-
tured skull, owing to their luxuriance, or rather
to the elasticity of the brain; and when the pro-
trusion proceeds from the distention arising from
tlie fulness of its vessels, the morbid condition
lias been improperly called fungus cerebri, — im-
properly, inasmuch as tlie leim fungus is applied
10 a malignant and constitutional malady.

132. ix. ECCHYMOSES, AND ALTERATIONS OF Co-

i.ol'r. — Besides the lesions now described, there
are others of a less remarkable kind, of which a
brief notice may be taken. — a. The cineritious
substance may be extremely pule, and even ap-
])roxirnating to tvhile ; and it may al-o be ot a very
deep colour, and almost approaching \o black, par-
ticularly in some cases of asphyxia and fevers,
owing probably to the dark and imperfeclly de-
carbonised state of the blood. Tlie diffijrenl
layers composing this substance are sometimes
also more than usually distinct, and separate
easily from each other (INI. l'"ovir.r.E and J)r.
]3aicin). In other crises they arc very thin, as
if in a great measure absorbed. 'J'his part of the
cerebral substance likewise, in some instances,
presents numerous eccbifmosed spots of various
sizes and depth of colour. — b. The medullary
structure is also simetimes eccJnjinosed, particu-
larly after concussion; and variously ■tnarhlcd,
and prisenling blotch -s of a pink, luirplish, grcy-
i'-h.or of a greyish yellow. Tiiese changes seem
to pioceed from excessive injection of the minute
tapdlarits of the organs, and probahly fruin par-

tial extravasation of their' contents, "owing to
over-distention, or a morbid stale of the blood
which had circulated in them shortly before
death, and are most commonly observed after
death from convulsions and malignant diseases.

133. As respects the colour of the brain gene-
rally, I may state that it is sometimes found
unusually pale from deficiency of blood, in cases
of ana?mia and cachexia. But it is more com-
monly of a deep or pink colour, particularly in
those wlio have died from apoplexy, strangula-
tion, narcotic poisons, asphyxia ; and in the in-
sane, or those given to drunkenness. In some
cases resulting from those diseases, or attended
with cerebral congestion, dark red, bluish, or
purple-coloured spots, or even streaks, have been
found in both the cortical and medullary struc-
tures. In cases of inflammatory irritation, a red-
dish or pink hue is observed. A red colour is
rarely met with, but more commonly a pale rose
tint, unless effusion of blood have occurred. I
may also state, at this place, that if, in severe
diseases of the brain, the blood be decomposed,
or if the colouring particles be secreted in various
proportions, the brain will present different shades
of colour, both in its cineritious and in its me-
dullary substance : it will thus be either a pale
or dusky yellow, an orange, a brown, greyish
green, a slate colour, and even here and there
soot-coloured. Occasionally, also, in different
changes of texture, although even without these,
a deposition of a melanotic pigment takes place,
chiefly in the course of the larger vessels, in-
dependently of the melanoid tumour (^ 127.).
Otto never observed the brain generally tinged
yellow in cases of jaundice, and doubts it having
ever occurred, alihough Sioll says that he has
seen it. I should add, that the above changes of
colour are independent of maiked softening or
pulpy destruction of the cerebral substance.
Brain — Anemia of the. — See § 132., and

art. Convulsions.
Brain — Cerf.bral Plethora. — Determin-
ation of Blood to the Head. Clas^if. II.
Class, LOnucn (Author).

134. When the blood is determined in too
great quantity to the brain, although the patient
may not be altogether incapable of his usual avo-
cations, yet much disorder may be present, which,
if negltcted, may lead to serious diseases, more
especially to those which will be considered in the
seijuel of this article.

135. i. Causes. — The causes of general vascular
plethora likewise occasion this affection. 'J'liose
which are more peculiar to it, are inactivity of the
secreting and excreting functions, mental exer-
tion, retention of accustomed evacuations and
discharges, full living, sedentary occupations, and
want of exercise in the open air ; organic dis-
eases of the heart, particularly hypertrophy of the
left ventricle, and those causes which are enu-
merated under the article Apoplexy.

13G. ii. Symptoms. — Cerebral plethora, and de-
termination of blood to the head, differ in many
respects from cerebral congestion, or coup de sang
(§ 139.), but she symptoms accompanying them
vary chiefly in degree. ^V here the disorder consists
merely of plclhoi'a from local determination, som-
nolency, cephalalgia attended with scintillations,
and objects appearing of a red colour, vertigo, noises
in the cars, sometimes skeplcssness, moral and

BRAIN — Congestion of the.

227

physical excitation, intelleclual activity; or, on
the contrary, inactivity, inability of continued
attention, stillness, cramps, twitchings, &c. of liie
limbs; animation of tiie countenance and eyes,
wliich are sometimes red or injected, with strong
pulsation of tiie carotid and temporal arteries, full
and somewhat frequent pulse, and slightly in-
creased temperature about the head, are the usual
symptoms.

137. iii. Morbid appearances. — This state of
disorder never of itself occasions death ; but, as it
sometimes occurs in the advanced stages of fatal
diseases, it has been observed to consist of in-
creased vascularity in ths brain and its mem-
branes, wiihout further organic change ; but it
is sometimes accompanied with a slight serous
effusion into the ventricles and between the mem-
branes, particularly towards the base of the brain.
This effusion seldom amounts to more than may
be present in the healthy state of the organ, the
excess being probably rather a consequence of
death than its antecedent.

138. iv. Treatment. — Cerebral plethora may
generally be removed by avoiding the causes in-
ducing it; by promoting the abdominal secretions
and excretions by the usual means; by t!ieaff"usion
of cold water on the head, and the daily use of
the shower-bath, or by sponging the head with
cold lotions ; by clothing the lower extremities
warmly, and promoting the cutaneous perspiration ;
by regular daily exercise ; by due attention to the
quantity and quality of the food ; and by changes
of air in obstinate cases, and sea voyages,

]3rain. — Congestion of Blood in the. —
Cinip de Savg. — Cerebral Congestion, Clas-
siF. 11. Class, I. Order (Author^.

139. Congestion is an advanced as well as a
modified slate of cerebral plethora, and consists in
too great an accumulation of blood in the vessels
of the head, particularly in the venous capillaries
and sinuses, occasioned eiilier by too great a flux
of this fluid to the brain, an exluusted tone of the
capillaries and smaller vessels, or impeded return
of it by the veins. 1 his stale of ciiculalion in so
important an organ as this is, necessarily occasions
marked lesion, not only of the functions which it
performs, but also of other functions throughout
the system.

140. i. S^^mptoms. — Cerebral congestion is cha-
racterised by numbness, vertigo, noises in the
ears, somnolency, brilliancy or watering of the
e)es. cephalalgia, redness of the countenance,
beating of the carotids and temporal arteries, loss
of recollection, &c. These symptoms continue
for some time in different degrees, sometimes dis-
appearing, and after a while returning, accompa-
nied with cramps, twitcliings of the limbs, gene-
rally of both sides : at last the patient loses sense
and voluntary motion, in a more or less sudden
manner. But usually in the course of a few
minutes, or, at furthest, some hours, the more
urgent of these symptoms disappear; leaving,
however, numbness of the limbs, which generally
disappears in a short lime, or in the course of one
or two days.

141. In the more severe cases, and those which
more neaily approach complete apoplexy, the
attack is preceded by disorder of the stomach, or
accompanied by nausea, or vomitings ; and some-
times, during the loss of sense and voluntary
motion, the stools and urine are voided involun-

tarily ; respiration is more or less embarrassed,
but not stertorous ; the pulse is strong, frequent,
and full; the temporal and carotid arteries beat
strongly ; and the skin is generally warm and natu-
ral. Cerebral congestion is almost always gene-
ral throughout the brain, but it is also, although
rarely, local, affecting only one hemisphere ; and,
owing to the numbness and temporary paralysis
thereby occasioned being confined either to one
limb or to one side of the body, simulates apo-
plexy, or paralysis from hemorrhage in the brain.
That these local symptoms are, however, owing
to partial congestion, and not to hajmorihage, is
evinced by the celerity with which they disappear
under judicious treatment. When the cerebral
congestion is very great, it constitutes a form of
apoplexy, noticed in the article on that disease,
and may occasion death wiihout any further
lesion than congestion merely.

142. ii. Appearances on dissection. — The scalp,
and even the bones of the cranium, in some cases,
are of a red violet colour, and allow of a consi-
derable quantity of blood to escape upon being
divided. The vessels, and particularly the si-
nuses, are filled wiih dark blood. When the
arachnoid of the pia mater is separated from the
brain, a reddish patch, more or less deep, is
formed, the vessels running through it being
gorged with blood. The surface of the convolu-
tions are of a more or less dark colour ; and,
when the cortical substance of the brain is di-
vided, it is of a deeper hue than natural, the ori-
fices of the cut vessels giving out drops of blood
proportionate to their size. Upon dividing the
medullary structure, which is usually not so white
as in health, myriads of minute specks, becoming
small bloody drops, rapidly form on the surface.
The large vessels, and particularly the veins of
the brain, are gorged with blood. When a person
cured of repeated attacks of cerebral congestion,
dies of a different disease, njorbld appearances
are seldom delected in the brain.

143. iii. Terminations and Complications. — Ce-
rebral congestion may occasion meningitis ; or in-
JlammatioH and softening of the sabstance of the

brain ; or litcmorrliage in some situation within
the cranium, giving rise to complete apoplexy, or
palsy, or both ; and serous effusion in the ven-
tricles, or betvv'een the membranes ; many of the
cases of apopkiii, attended with extravasation of
blood, thus commencing in congestion, the extra-
vasation being a consecutive change. It may also
supervene on organic changes of the heart and
lungs, and in the progress of various fevers, and
thus be complicated with these diseases.

144. iv. Canses. — The causes of this state of
the cerebral circulation, are those wliich have been
already detailed in the articles Apoplexy and
Cerebral Plethora (§ 134.).

145. V. Treatment. — i)/()('(Z-/e<(iHo-j general, lo-
cal, or both, to an extent which the constitution,
habit, and symptoms of the patient indicate, are
requisite. iVext to blood-letting, active purging
by calomel, followed by a dose of senna, croton
oil, or some other active cathartic, and promoted
by strong cathartic injections, such as the oleum
terebinthinae, oleum ricini, extr. colocynth. comp.,
&c. are required, and should be repeated, so as to
procure copious evacuations, and keep up sufficient
action in the alimeutary canal. The effusion of
cold water on, or cold sponging the head, is gene-

Q 2

228

BRAIN — Inflambiation of its Membranes.

rally beneficial ; and when the temperature is
increased, and the countenance and conjunctiva
flushed, a thick oiiskin shouhl be placed under the
patient's head, which ougiit always to be kept
elevated, and covered with cold epithenis. Due
attention should be constantly paid to the state of
the evacuations. Accumulations of bile in the
gall bladder or hepatic ducts, and of faecal matter
and morbid secretions in tiie aimientary canal,
freijuently predispose to or induce an attack,
which will seldom altogether yield to the means
employed, unless these morbid collections are re-
moved by appropriate means ; and as long as the
evacuations continue unhealthy, we may infer
that the chief cause of disorder is not altogether
removed. (See Treatment it/' Apoplexy.)

IjIlAlN — iNFLAaiMATION 01' THE. ClASSIF.

1. Class, Febrile Diseases ; 2. Order, Inflam-
mations (Culten). 3. Class, Diseases of San-
guineous Function ; 2. Order, Inflammation,
(Good). III. Class, I. Order (Autlior, see
Preface).

146. NosoL. Defin. — Pain of the head more
or less violent, ivith suffusion or prominence of the
eyes; generally tumid or flushed countenance , de-
lirium, or sopor, or both, or a marked predo-
minance of either with sifmptomatic fever ; and

frequently with lesion of the senses and functions
of relation.

Pathol. Defin. — Inflammation of either the
membranes or the substance of the brain, or of both,
generally with predominating lesion <f either the
one or the other.

147. The recent researches of anatomists and
pathologists have tended to advance our know-
ledge of the phenomena of inflammations of this
important organ. The investigations of M. Ma-
gendie, who has shown tiiat Us membranes ex-
hale in health a limpid serum for the purposes of
protecting the parts they surround, of facilitating
the movements to which they may be subjected,
and of accommodating and imparting a certain
degree of superficial pressure, so tiiat they may
not sufter from the varying positions and states of
vascular plethora to which they are obnoxious,
have indirectly thrown considerable light on the
pathology of tiie brain. Much, however, is still
required to be known, not only as to the further
relations which these membranes iiold to tlie ce-
rebral organs, in the performance of their healthy
functions, but more particularly as respects tiie
connection which subsists between their organic
lesions and their symptomatic or functional dis-
orders.

148. We know that the more internal and the
most vascular of these niemi)ranes are chiefly
appropriated to the distribution of the circulating
fluid by means of the minute capillaries which il
transmits to the external surface of the brain.
We may thence infer that the functions, and
even the organic conditions of the brain, in these
situations especially, will be greatly modified, or
even altogether changed, by the varying condi-
tion of the circulation in this membrane. When,
therefore, it is the seat of indammation, disease
will be more or less extended to the substance of
the brain ; and will more or less influence the
functions of this organ, particularly in the
parts which it supplies with blood. 'I'lie mem-
branes, however, exterior to the ])ia mater, may
be itflecled to a considerable extent without this

latter participating mu-cli in the disorder : and
here our knowledge is both imperfect and de-
ficient in precision: for we are not enabled to
state that in such cases the functions of the brain
itself are undisturbed, or, if disturbed, in what
manner the lesion of these exterior membranes
afl^ects this organ ; and, being imperfectly informed
respecting all the offices of these membranes, we
are less able to trace the relation between healthy
function and the phenomena which inflamma-
tion of them present. Surrounded thus with
ditficulties, which the advance of science will
doubtless diminish, are we therefore to leave the
subject without investigation, or relinquish the
attempt to place in order and explain those facts
which we have already obtained, and which may
be made subservient to a further elucidation of the
subject?

149. In no other organ of the body is il so dif-
ficult as in the brain, to trace the relation between
demonstrable change of structure and morbid ma-
nifestations of function. This is partly owing, no
doubt, to the circumstance of its being a double
or symmetrical organ ; lesions seated only in one
half or side of the brain, when unattended by
absolute disorganisation, not occasioning a cor-
responding degree of disorder as long as the same
part of the other side is unaffected. Delirium
has been conceived to be a symptom indicating
the existence of inflammation of the membranes
of the brain ; yet delirium is a disorder of those
functions which we conceive to be performed by
the cerebral substance itself; and every expe-
rienced practitioner must have observed, and
numerous are the cases on record, in which in-
flammation to a great extent, and ail its conse-
quences— as thickening, adhesions, effusions of
lymph, or even of purulent matter — have been
observed, and yet there had been no delirium.
It is therefore to be inferred, that, when me-
ningitis is accompanied with delirium, the disease
extends more or less to the pia mater or parts
enclosed by it. 'i'his inference, however, might
lead to a conclusion which seems not well
founded, viz. that it is impossible to distinguish
meningitis as a disease independent of inflam-
mation of the substance of the brain. This,
doubtless, is often difficult, bfcause both dis-
eases frequently co-exist in difl'erent degree",
or co-orilinatily ; yet still an extensive expe-
rience will show that they often exist separate-
ly : and hence the necessity of ascertaining
what are the characters wliicii are proper to
each. In respect of diagnosis, the subject pos-
sesses inteiest ; and although the treatment
in both is, in its principal points, the same,
yet on some occasions it requires to be mo-
dified.

lillAlN iNFLAIVniATION OF ITS JMeMHRANES.

SvN. Meningitis, Paraphrenilis et Phrenitis,
Auct. Var. Recent. Arachnitis, Parent
and Martinet. Cephalitis Meningica, Good.
Phrcnesie, I'ineh i\.eningile, Vr. Die Hirn-
hautenlz'ilndung, Cler. J, rain Fever.
150. Deux. Acute pain in the head, ivith in-
tolerance of light and sound ; watchjulness, deli-
rium ; flushed countenance, and redness of the
conjunctiva, or a heavy suffused stale of the eyes ;
(juick pulse; frequently spasmodic twilchings or
convulsions, ]>assing into somnolency, coma, and
complete reUnalion of the limbs.

151. We are rarely enabled to distinguish
between inftHmmatton of the arachnoid membrane
and that of the pia mater by the sympioms during
life, I shall tlieiefore comprise under the head of
meningitis inflammations affecting one or more of
the membranes of the brain.

152. Symptoms. — As tlie u~es of the cerebral
membranes are not rendered sensible by manifest
functions, it may be concluded that diseases of
these parts may exist to a considerable extent,
without any distinctive symptoms. The justness
of this observation is but too frequently confirmed
by experience ; for there are few practitioners
who have diligently employed their opportunities
of post mortem research, and have not observed
appearances of inflammation, without much dis-
order of the intellectual faculties, or of the move-
ments of the body, having been manifested, almost
up to the moment of death. Such instances are
not rare, particularly in persons advanced in life.
JMore frequently, however, when the membranes
are inflame 1, the adjoining portions of the brain,
the functions of which they are probably intended
to facilitate, evince some sort of disorder, particu-
larly of iheir usual functions. Ihese symptoms,
although indirect, are generally similar to liiose
of the inflammation of the cerebral substance
itself, and are the chief guides to lead us to the
recognition of meningitis.

153. The symptoms vary according to the seat
of the inflammation, the stage at which it has ar-
rived, the severity of the attack, and the celerity
of its progress. The disease in its usual form
presents three periods : l^t, that of invasion ; 2d,
that of fully developed inflammation ; and, 3d,
that of compression. Some one of ihese periods,
however, does not always exist, particularly when
the inflammation is very general or very circum-
scribed, or when it is very acute or very chronic
in its progress. Meningitis afl'ects more I'requently
that part of the membranes which covers the
convexity of the cerebral lobes, in adult subjects;
and the portions about the base of the brain, in
young children.

154. A, Acute meningiiis of the convexity of
the cerebral lobes is aitended with violent pain,
which is exasperated at intervals, and often with
stupor or somnolency. It occupies various regions
of the cranium, the frontal, occipital, syncipital,
&c., and is augmented by motion, particularly
by rotation of the head, which, in children, is
often drawn backwards. In this class of patients
the pain is expressed, particularly upon being
roused, by a peculiar cry, which the experienced
observer recognises as a diagnostic sign of the
disease, and after utteiing which the intant sinks
into a somnolent stupor, in which it grinds its
teeth frequently. The functional derangements
occasioned by meningitis are usually of a general
character, although the inflammation is more
freciuenlly of limited extent. I'his is owing to
both sides being attacked at the same time ; cases
where the meninges are inflamed on one side only
being very rare.

155. a. Pain in the head is generally pre-
ceded by chills or rigors, wtiich may be viewed
as the result and indication of the formation of
the disease ; but cases not infrequently occur,
wherein the foregoing signs in a greater or less
degree precede the rigors even for a considerable
time. The face at first is often pale ; but, as the

BRAIN — Inflammation or its Memeiianes. 229

disease becomes fully developed it is more fre-
quently slightly tumid, flushed, and expressive of
pain, and the eyebrows knit or contracted ; the
eyes are heavy or brilliant, injected and watery,
generally nearly shut, incapable of bearing the
light, and the pupils contracted. The patient
thinks he sees fire, or scintillations of light; and
sometimes the colours of bodies appear diflTerenily
shaded. The slightest noise is insupportable, and
all the senses are in a state of morbid activity.
His answers are brief and quick, and there is an
evident activity of mind, but as yet no delirium.
His disposition, however, seems changed ; and he
becoxes impalient, irritable, abrupt, and quick in
his manner, and his countenance is expressive of
irritation and pain. The temperature of the head
is now greatly increased ; the pulse is frequent
and developed ; the tongue rather dry, its papillaj
more or less erect and distinct; thirst is com-
plained of; the urine is scanty and high-coloured,
and the bowels are obstinately constipated, but
•in some instances, in children, either relaxed or

irregular, and the evacuations morbid and ofTen-
sive. From the commencement of the attack
there is generally vomiting, particularly in chil-
dren, which recurs at intervals, is unattended with
tenderness or pain at the epigastrium, and is
manifestly sympathetic of disease within the
head. In adult subjects, vomiting is sometimes
absent. It is not infrequently remarked, that
this stage either does not occur or passes un-
observed in aged persons. The patient loses
suddenly his recollection, as in congestion only
of the brain ; but to this succeed febrile sym-
ptoms, distinguishing it from this latter affec-
tion.

156. b. After an indeterminate period, com-
monly varying from one to three or four days,
according to the intensity of the attack, violent
delirium comes on, but not constantly. If the
pain in the head continues, it is not complained
of by the delirious patient ; Snd the senses are
no longer intolerant of their natural excitants ;
the pupils commence to dilate or to contract, and
strabismus supervenes ; the countenance has a
convulsed appearance ; the lips are drawn some-
what to one or both sides; the pulse is more or
less developed, sometimes irregular and trem-
bling, and is rarely at this period feebler or slower
than natural ; the tongue presents the same ap-
pearances already noted ; the thirst, and fre-
quently the vomiting, still continue. The tem-
perature of the head continues excessive, but
occasionally fluctuates, whilst that of the rest of
the body is often not materially augmented.

157. c. To this state succeeds more or less
marked exhaustion, which should not be taken
for commencing resolution of the disease. The
patient ceases to scream ; and the symptoms of
violence subside ; but to these succeed slartings
of the tendons, carphologia, convulsive motions,
and sometimes cramps, chiefly in the upper ex-
tremities. The pupils are dilated, contract with
difficulty on exposure to light ; the eyes are rolled
in their orbits, become insensible, as well as
the other senses, to the ordinary excitants ; and a
complete calm takes the place of the violent
delirium ; the patient even not answering ques-
tions put to him. He has had no sound sleep
excepting a f.itiguing stupor; he is now plunged
in a profound coma. The limbs are, up to this

Q 3

230

BRAIN — Inflammation of its Substance.

time, rigid and contracted, but soon become
completely relaxed. This state is owing, gene-
rally, to the effusion of sciaun, which has now
taken place; but it sometimes may exist without
increased effusion ; injection and congestion of
the vessels of the brain, or compression, from
whatever other cause, also producing it. At this
period of the disease the face is pale, the eyes in-
expressive, dim, half open, and drawn upwards;
the cheek bones prominent, the temples hollow,
the nose pinched, the ears cold ; the lips dry,
applied closely to the teetli, which are covered
with a fuliginous coating at their base ; the tongue
is dry, hard, and brown; deglutition difficult,
the abdomen distended with flatus, and the ffeces
and urine voided involuntarily. The skin iseither
cold, or covered by a viscid sweat; the pulse is
small, unequal, or irregular; the respiration slow,
sometimes stertorous; the expired air is cold and
foetid ; and the patient dies generally in the
course of a very lew days, or fiom two to three
weeks, and but rarely later.

158. These are the principal symptoms of acute
meningitis of the cerebral hemisphere'^. They
present ii regular periods of exacerbation ; the
heat of skin and character of countenance vary-
ing at difTerent times without any evident cau>e.
The stages of the disease are not precisely marked ;
either of them may be wanting, and sometimes
they seem as if confounded with each other.
When the disease terminates favourabhi, the
symptoms sub-ide gradually ; resolution taking
place, sometimes with, but as frequently without,
critical phenomena.

159. According to the observations of MM.
Parknt, jMartinet, and Rostan, wdien the wc/h-
hraites of the base of the biain, or of the ventricles,
are the seat of the inflammation, the symptoms
are somewhat different. The patient then ex-
periences less delirium, or even preserves his in-
telligence almost entire ; his faculty of attention,
and some of the other intellectual powers, being
only diminished, lie answers slowly, but ration-
ally, to questions put to him ; somnolency is
almost continued, and coma more quickly super-
venes. In other respects the symptoms are the
same. Cephalalgia is complained of chiefly at
the bottom and above the orbits; in general, the
symptoms of irritation and excitement are less
strongly ]>ronounced than in the preceding form
of the disease.

lt)0. /i. Chronic meningilis differs from the
acute chiefly in the less intensity of the sym-
ptoms, and slow progress of the disease. In many
cases the functions of sense and locomotion are
but slightly disturbed, and usually the intelli-
gence is uniiiqiaired ; at least, as long as the
inflammation docs not aflect the iricmbranes of
the convexity ol the hemispheres. Wlien seated,
however, in this place, according to M. Rayle,
who has devoted considerable research to this
subject, delirium freciuently is also present, but it
is seldom violent ; sometimes it is taciturn ; and
the ))atient gimerally is engaged with lofty or
ambitious ideas.

161. ('Inonic meningitis commonly succeeds
to the acute form of the disease ; but it often
presents the chronic characters from the com.
inencenient. 1'here is generally continued head-
ach, vviiJi slight somnolency, sluggishness, in-
capacity and want of desiic for intellectual

exertion, nioroseness, irritability of temper, some-
times confusion of ideas, embarrassment of speech,
and delirium, terminating in confirmed mania or
maniacal idiotcy. The motions of the limbs are
slow, difficult, or painful ; and their muscles are
subject to involuntary motions and twitchings,
and sometimes are not under the control of vo-
lition, or are altog^ether paralytic. Vomiting and
convulsions are rarely present, excepting in in-
fants, where they are often the chief or almost
only signs. In children, the peculiar knitting of
the eyebrows, retraction of the angles of the
mouth, whining or peevish cry, stupor, grinding
of the teeth, scanty urine, obstinate cosliveness,
and the increased lieat of the head, are the chief
symptoms; these being s-imilar in kind, but much
milder in degree, than those accompanying the
acute or sub-acute states of the disease. In
many cases, both in children and adults, the func-
tions of organic life present but few lesions of a
marked description until towards the last period
of disease, or shortly before death. It will be
perceived that many of the phenomena here stated,
belong to disease of the brain, — a circumstance
which must necessarily obtain, for as the mem-
branes surround the whole of this organ, and are
one of the chief media of distributing the blood-
vessels to it, any disease affecting its structure,
or modifying the quantity or properties of the
fluid secretion furnished by these membranes, for
its protection, &c., must necessarily implicate the
state of its functions.

1G2. C. The duration of meningitis necessarily
varies with its intensity. In its ucnte form it
extends from three or four days to twenty-eight,
ami even thirty; but more fretjuently from seven
to fourteen days. In many cases it is difficult to
assign the period of invasion ; pain and somno-
lency having been complained of even for days
before the occurrence of chills or rigors. The
disease also not infrequently supeivenes on other
att'ections, and occasionally becomes complicated
with them, particularly in the course of honping-
congli, and diseases of the prima via, when its
invasion may be overlooked, or with difficulty
ascertained. The more chronic states of meningitis
have no determinate duration : they may proceed
gradually and in a slight form, when, unexpect-
edly, from some exciting cause, or even without
any evidence of such occurrence, they may as-
sume an acute character, and terminate more or
less rapidly.

163. i). The oro-(/7iicf/iaHn-es consequent upon
inflammation of the cerebral membranes are ob-
served chiefly in the jiia mater, the arachnoid,
and the reflection of the arachnoid covering the
dura mater, and not infrefiuently, also, in the
cineritious substance of the brain. 'I'hcse consist
principally of injection and impregnation of the
pia mater wit;h blood, &c. ; loss of the trans-
parency of the arachnoid ; effusion of serous or
sero-albuiniiious fluids ; and the vaiious lesions
pailicularly described in the preceding sections
{§ 22-28.).

Euain — Inflammation of its Substance. —
Svn. I'hrenesis, Phrenismus, Auct. Var.
Encephalitis, Enkephalilis, Hildenbrand.
Cephalitis, Auct. \'ar. Recent. Euctphalile,
Rouillaud and other French Pathulugists,
Ccrdhrile, Foville. Cephalitis Profunda,
Good. Cehirnenz'undung, Ger.

BRAIN — Tnflamm

164. Defiv. Pain nf the head ; vertigo ; altered
sensibility ; spasms or cmitractions, of one or more
iunhs ; excited or deranged Junctions (if sense and
intellectual power ; rapidly terminating in coma.

165. I have stated tlrat meningitis manifests
itself to our senses cliiefly by the lesion of the
cerebral functions ; and that tliis \i occasioned in
two ways, viz., by derani^ing and impeding tlie
functions of the brain, wliicii the^e membranes
are intended to facilitate; and by imparting the
inflammatory action to those parts of the brain
contiguous to them. But althougii tiie relative
connection of parts thus necessarily increases the
ditHeully of distinguishing tlie symptoms proper
to the membranes, or to the brain itself, still there
are certain signs which enable us to infer the
degree to which either may be separately affected.
We shall see in the seciuel, that, in cerebiitis, the
organs of voluntary mtition exiiibit frequently
morbid phenomena which are generally limited
in extent; whilst we have seen, in meningitis,
these organs are affected generally, and seldom
or ever partially, excepting when complicated
with inflammation of some portion of the brain ;
and if, in cerebritis, all the voluntary actions are
afiected, the inflammation has commenced in the
membranes, and extended itself to the sub'^tance
of the brain, — the disease existing as meningitis
and cerebritis conjoined, which is, perhaps, its
nio>t common state, and in which I shall presently
consider it.

166. Symptoms. — A. The more immediate
functional derangements. The functions of the

brain consisting of sensation, volition, instinctive
desires, intelligence, and moral sentiments, it is
evident that the phenomena of the d'sease should
be sought after in this series of manifestations;
and that they will vary, in respect of their par-
ticular states, their intensity, and progress, ac-
cording to the seat, the nature, and extent of the
organic change.

167. a. When cerebritis is general, it often
presents the same functional disturbances, and
the same progress and stages, as meningitis : it is,
indeed, very probable that both diseases co-exist,
and that the inflammation commences in the pia
mater. However, when the whole cerebral mass
is inflamed, coma, with relaxation of all the limbs,
lakes place much earlier than in meningitis ; and
the disease developes itself with extreme rapidity ;
the symptoms of vascular excitement scarcely
showing themselves, or, at least, for a very short
time; and being frequently altogether absent.
This difference is readily explained, when we con-
sider that, in meningitis, the brain being only
secondarily and slightly affected, it may still ex-
ercise its functions, although in a deianged man-
ner; whilst in general cerebritis, the change being
extensive, its functions must necessarily be sus-
pended. The patient, after a rigor, v/hich ushers
in this as well as the majority of other inflam-
mations, sometimes loses recollection; but he has
generally experienced other symptoms previously,
such as obstmate pain of the head, twilchings,
pricking sensation*:, slight numbness or diminu-
tion of the sensibility, with painful muscular
action, vertigo, sudden want of recollection, and
tinnitus aurium. Sometimes the sensibility is
morbidly increased at this stage, as well as the
functious of sense; the intellects are active, or
excited ; and there is watchfulness, with other

ATION OF ITS Sl'ESTANCE.

231

analogous symptoms, for a longer or shoiter
period before the patient is seized uith rigors and
insensibility,

108. b. These precursory symptoms M. Rostan
considers as tiie result of an incipient disorder,
which he conceives to be local congestion, and
that inflammation has not then taken pLice; but
they are, more obvious-ly, signs of an early period
of inflammatory action. These symptoms are
frequently accompanied witli general signs of
plethora or determination of blood to the head ;
the pulse, particularly of the carotids, is hard, or
full and developed ; the countenance is injected ;
the skin hot, &c. The same precursory si;^ns
are likewise observed in softening of the brain ;
but in this aflMsction the pulse is not augmeuied in
frequency or fulness, the skin is cold and pale,
and the countenance pale or shrunk. 'i"he sym-
ptoms now described indicate, at least, thatmorbid
action has commenced in the brain, and that it is
not so extensive or intense a^ not to subside
under judicious treatment. But when the pa-
tient has had rigors, the functional disturbance,
especially of locomotion, is particularly marked :
then ensue clonic or tonic spasms of the muscles,
such as starlings of the tendons, carphologia,
convulsions, cramps, rigid contraction of the
limbs, &c. At a more advanced period, par-
ticularly when efl^usion supervenes, paralysis or
relaxation, and loss of sensibility of a limb or
limbs, takes place.

169. c. When cerebritis is general (which is
never the case without the pia mater being in-
flamed), these symptoms afl^ect all the limbs
simultaneously ; when local, only som.e of them,
according to the seat of inflammation. Spasms,
convulsions, or paralysis, aflTect also the muscles
of the face ; there is a falling down of the upper
eyelid ; the eyelids are shut and contracted ; the
commissures of the lips aie drawn to one side,
either by their natural tonicity, when the an-
tagonist muscles are paralysed, or from a mor-
bidly increased action. Sometimes this exists on
both sides, producing retraction of the angles of
the mouth. A'ery frequently the muscles and limbs
are remarkably painful; so that, when attempts
are made to move them, or to straighten those
that are contracted, or upon attempting to move
himself, the patient screams out,

170. d. In partial cerebritis, the action of the
muscles and the sensibility of the surface are also
partially, but not permanently, afl^ected ; some parts
being less disordered, whilst the afi'ection extends
to others; or they all become more severely and
permanently disesised ; the spastic contractions,
wliich existed at first owing to inflammatory irri-
tation, giving place to paralysis, in consequence
of pressure or disorganisation. The intellectual
faculties are also frequently disturbed. Tiie
patient's answers are abrupt, rapid, sometimes
incoherent, and at other times made very slowly.
When merely one hemisphere is aflected, it has
been supposed that; the functions of the other
will proceed so as to prevent the appearance of
much disturbance of the mental faculties ; but this
may or may not be the case; and, at least, can
only occasionally obtain. The mental distuib-
ance, which is extremely various in its forms and
states, according to the part of the brain aflected,
exists only during the first days of the disease,
and is soon displaced by coma.
Q4

232 BRAIN — Inflabimatiok of the — Seat

171. e. At the commencement, particularly
■when cerebritis is general, or affects the periphery
or more superficial parts of the brain, as in me-
ningitis, or meningitis complicated with superficial
cerebritis, the functions of the senses are nioibiclly
increased, the least light or noise, or the slightest
touch, being insupportable ; but when the disease
is seated in the centre of the brain, where the
senses transmit their impressions, there is either
])erversion, or complete loss, of these functions.
'J'he pupils are then fiequently dilated and in-
sensible; the eyes unaffected by light, the ear by
sounds ; and the other sen^^es are similarly dis-
turbed ; the patient is either watchful, or is
oppressed by a somnolency intermediate between
sleeping and wakmg ; and numbness, with twitch-
ings, or local convulsions, are generally observed.

172. In the course of a period varying from
one to three or four days, or sometimes earlier,
and occasionally later, the symptoms are changed,
owing to the local aflfection having advanced to
disorganisation. At this period, copious eflusion
ot serum often takes place, occasioning symptoms
of compression. 'I'he spasms and convulsions are
replaced by relaxation and immobility ; and the
senses are paralysed, not only on the side oppo-
site to the cerebral lesion, but on both sides si-
multaneously, owing to the healthy parts of the
brain being compressed by the effused serum, or
by the tumefaction of the parts inflamed. Sensibi-
lity diminishes rapidly, and is at last abolished ; the
intellects are obscured, and at last overwhelmed,
and the patient becomes profoundly comatose,
or, in the less acute or chronic cases, hemiplegic,
and sometimes ultimately apoplectic, or epileptic.

173. B. The mediate si/mptoms. — During the
first days of the disease, the countenance is full
and coloured; the eyes brilliant and animated,
their expression unusual; the temporal arteries,
as well as the carotids, beat strongly ; there is no
appetite; the tongue is white, loaded, red at its
niaigins and point, and the papilla; developed ;
there are nausea and vomitinjf ; the bowels are
costive ; but occasionally in children there is a diar-
rhoea from the commencement, and the evacu-
ations are morbid and offensive; the skin is
varm, the pulse strong and frequent, and the re-
spiration accelerated. At a later period, a very
manifest change ensues ; the countenance is ex-
pressive of pain, irritation, and chagrin ; the fea-
tures begin to sink and become pale ; the eye* dull
and half closed ; and thirst is no longer complained
of ; deglutition is difficult, or cannot be aicom-
])lished ; vomiting is produced with difficulty; the
abdomen is distended with flatus ; and llie"f<x-ces
are passed involuntarily, as well as the urine,
which sometimes accumulates in the bladder from
paralysis of this organ ; the skin becomes cold,
or covered by clammy sweat ; the pulse is un-
C(]ual, iireguhir, or variable; the re-piiation la-
boured, or stertorous ; and the patient sinks. In
rare cases, at this stage of the disease, the sym-
ptoms diminish, and the functions gradually as-
sume their natural states, either with or without
the occurrence of phenomena which may be
regarded critical. The ulteruthms of strtcctiire
]>n)(luced III! cereliy'ilis are fully described in pre-
ceding sections ot this article (§ 4i). et seq.).

lillAIN InM.AMMATION 01' lUL RlKBUJItANES

AND SuiiSTANCE OF TIIF.. SvN. PIllC-

vilis (from (pi'V", the mind) ; Encephalitis,

Cephalitis (from Ke(pa\rj, the head), Fiunk
and Hii.DENnnAND. Phrenesie, Encephalite,
Fr. Hirneniz'undung, Ger.

174. Defin. Violent pain in the. head; pro-
minent suffused eyes; flushed countenance ; violent
delirium, followed by profound sopor.

175. Having described inflammation affecting
chiefly either the membranes, or the substance of
the brain, I now proceed to consider inflamma-
tion attacking these structures simultaneously, or
rapidly extending from the one to the other,
chiefly from the former to tiie latter. This is cer-
tainly the more common form in which inflam-
mation seated within the cranium manifests itself
in adults, particularly in hot countries, and in
temperate climates during hot seasons. In chil-
dren, however, a more or less evident limitation
of the inflammatory action to either the mem-
brane=, or the cerebral substance, especially the
former, is frequently perceived ; and the same re-
maik may be extended to aged persons, in whom
the substance of the brain is more liable to be
affected, chiefly in a sub-acute or chronic form.
That the division which 1 have made of inflam-
mations of the brain, is founded in truth, and
that their diagnosis may be established in prac-
tice by a judicious and experienced physician,
I have had numerous opportunities of proving at
the Infirmary for Children, where the cases ad-
mitted with inflammations seated within the head
have been entered as cases of meningitis, cerebritis,
or encephalitis, as the membranes, the substance of
the brain, or both, respectively, were considered
chiefly afi'ected.

176. It may be supposed, that the distinctions
argued for, granting their accuracy, tend to
little practical advantage. This is, however, a
veiy serious mistake ; and I cannot more fully
demonstrate it, than by the following fact: —
About ten years since, I was requested to see a
child, attended by an able and scientific practi-
tioner, who considered the case as meningitis,
which had terminated in effusion ; or, in other
words, of acute hydrocephalus in its advanced
stage, and perfectly beyond the reach of art.
Alter an attentive consideration of its history and
existing state, I expressed the opinion, that the
disease was inflammation, chiefly affecting the
substance of the brain, and that a decided treat-
ment founded on these views might still be suc-
cessful. Leeches applied behind the ears, and
around the occiput, with the means which will be
hereafter detailed, succeeded in restoring the child
to health in a lew days. Since this instance,
I have witnessed similar mistakes. The diagnosis,
prognosis, and the treatment adopted in these
cases proceeded on the impoitant fact already
slated (<5 167.), that cerebritis will, owing to the
turgescence of the inflamed organ, give lise at a
very early stage of the disease to the most ])io-
fouiid coma, relaxation of the limbs, and many
of the symptoms occasioned by effusion of serum ;
whilst the greater temperatiiie of the head, iintl
strength of the j)ulsation of the carotids in the
former, will often, inde))endently of other signs
connected with the history of the case, evince its
real nature.

177. Seat. — In the greater number of cases,
inflammation commences in the pia mater, and
extends itself to the arachnoiil on one side, and
to the cortical substance of the brain on the oilier;

BRAIN — Inflammation of the— Causes.

233

nnd not infrequently also to the arachnoid cover-
ing the dura mater, nm] the deep sealed strurtures
of the brain. It is also very probable liiat more
than one of these dlFerent structures may be
nearly simultaneously aflPected. It may, however,
originate differently when it arises from external
injury ; as in the dura mater, the substance of the
brain itself, or the arachnoid.

178. I. Symptoms. — A. Preyvoyiitnry. Ence-
phalitis generally commences with a sense of heat
and fulness in the head ; frightful dreanis, and
unquiet sleep ; forgetfulness ; confusion of ideas ;
dimness of sight ; vertigo ; turgidity of the face
and eyes, and moroseness of temper. 'I'iiese sym-
ptoms generally precede tiie occurrence of chills
or rigors, and are entirely absent when the dis-
ease proceeds from external injuries. In children,
unusual somnolency, or wakefulness ; startings in
sleep, or fretfulness ; aversion from sudden or
quick motion ; dryness of the mouth and nostrils,
and not infrequently a voracious appetite^ are the
chief precursory symptoms.

179. B. The invasion, or first stage of ence-
phalitis, is indicated by severe chills or rigors, to
which succeed a burning heat of the head ; ur-
gent thirst; sometimes, even thus early, an un-
natural absence of thirst, and violent delirium ;
jactitation of the body ; intolerance of light ;
fixed, pulsating, heavy, compressing, and most
severe pain of the head, alternating frequently
with stupor. Febrile heat rapidly increases, and
the head becomes more turgid and hotter ; the
eyes more prominent, suffused, watery, and in-
tolerant of light; the pupils are contracted ; the
eyelids are generally shut, or imperfectly open ;
the eyebrows are knit, and the countenance is
threatening and fierce. Hearing is quicker, is
attended with ringing in the ears, and intolerance
of sound. Epistaxis sometimes occurs, generally to
a small extent, and with only transitory benefit.
Insomnia, and delirium of various forms — morose,
taciturn, furious, &c. — supervene; and, in pro-
portion as the cerebral organs are excited, t*iose
viscera which are supplied with the ganglial nerves
are rendered torpid, the patient being insensible
to the wants of the digestive organs.

180. C. The second, or advonced stage, is ge-
nerally characterised by a marked diminution of
the sensibility which was in the preceding period
morbidly increased. The pulse, which was at
first frequent, hard, and full, becomes slower,
fuller, and softer, and, in some cases, quicker,
smaller, or harder. The skin is dry; the urine
scanty and high-coloured ; the tongue is dry, and
loaded at the root; the bowels constipated. In
some cases, particularly those in which the cere-
bral substance is early and generally inflamed
and turgid, instead of jihrenetic delirium, an
apoplectic sopor, often preceded by convulsions,
quickly supervenes ; with a slow pulse ; stertor-
ous, slow, or laborious breathing ; turgid or
bloated countenance; startings of the tendons;
involuntary evacuations ; torpor of the senses,
and flaccidity of the limbs. In those cases in
which delirium is present, and the pulse quick and
hard, a similar state of coma to that now men-
tioned takes place sooner or later, if not averted
by medical aid. In the one, the first stage is
short and indistinctly marked ; in the other, it is
long, and often continuing the greatest part of
the vviiole duration of the disease; the second

stage sometimes appearing suddenly, and ter-
minating rapidly. In both these states of the
disease, the difficulty of swallowing is great, so
that fluids are sometimes regurgitated by the nose ;
and when the substance of the brain is chiefly
aflected, deglutition is often nearly, or altogether
abolished in the most intense cases. In this stai^e,
the pupil becomes at first dilated, and occasionally
again contracted ; the patient, in some cases,
squints, or has double vision ; his speech is often
much afltcted, and his mouth is drawn to one
side. Deafness also comes on, or increases, and
the sopor, or coma, is more profound ; most pro-
bably owing either to incipient effusion of fluid,
or to greater turgidity of the capillaries and
veins, or to both these combined, in a part or the
whole of the encephalon. The comatose sym-
ptoms appear early or late, according to the inten-
sity of the disease, the extent to which the cerebral
structure is afl^ected, and the tone and energy of the
system. They sometimes partially subside, again
recur, or alternate with convul>ions. As the
disease advances to an unfavourable termination
the pulse becomes remaikably quick, irregular, or
mtermiitent.

181. D, Duration, — Encephalitis usually
reaches its acme about the third or fourth day.
It then continues in full strength for several days,
exhibiting slight remissions and exacerbations,
and simulating continued fevers. In favourable
cases, a. change is sometimes observed on the fifth,
seventh, or some other critical day, unless a fatal
termination occur ; and is generally attended with
either copious perspiration, or hemorrhage from
the nose, free evacuations from the bowels, or a
discharge of urine depositing a copious sediment.
The disease may assume a sub-acute or a chronic
form", presenting a diversity of symptoms, espe-
cially in its chronic state, according; to the par-
ticular part of the brain affected ; or it may proceed
in a very slow, slight, and insidious manner, and
escape detection until a dangeK)us or fatal chancre
has taken place. The more chronic states may
follow an imperfectly cured acute attack, and the
latter may suddenly supervene on the former.

182. II. Causes. — A. Predisposing. The san-
guineous and nervous temperaments; the epochs
of mfancy, childhood, and youth — particularly lo
meningitis; the period of dentition; advanced
age — especially to cerebritis in a sub-acute or
chronic form ; the male sex ; a large head and
short neck ; children of scrofulous parents, and
those who evince precocious talent or acquire-
ments; persons subject to perspirations or erup-
tions on the head ; early or iiabitual exertions
of the mental powers ; the indulgence of the
more active passions and affections ; encouraoe-
ment of vindictive feelings; anger; continued
watchings; venereal excesses; the use of spirits
and narcotics, as opium, tobacco, &:c. ; a too
warm state of the head ; suppression of epistaxis,
hemorrhoids, or of any other accustomed secre-
tion or evacuation ; the neglect of sanguineous
depletion after the habit has been established •
the healing up of chronic ulcers and eruptions,
and other disorders of the brain, aie most fre-
quently the predisposing circumstances and causes
of the disease.

183. B. The exciting causes. — a. Those which
act more directly on the encephalon, are blows,
fractures, falls, counter-strokes or concussions of

234

Ihe head, all v/Iiich may not be followed, for many
days, by any evident symptoms ; whirling chil-
dren in the air, or tossing them in order to quiet
them, or rocking them rudely in cradles ; the im-
proper use of narcotics and stimulants in order to
quiet tiiem ; the action of the sun's rays ; pro-
tracted study ; excessive joy ; violent fits of an-
ger ; excessive desire; jealousy, and all the ex-
citing passions ; unusual exertion or irritation of
the senses of sight and hearing; exostoses on the
inner table of the skull, and the absorption of
jmrulent or morbid matters into the circulation.
b. The causes which act more remotely or indi-
rectlii, are the diseases with which I have stated
encephalitis lobe sometimes complicated (§ 186.);
nervous or bilious headachs ; all painful affections ;
mania; inflammations of the ear; disorders of
the stomach, diaphragm, liver, and bovv-els ;
affections of the sexual organs; ingurgitalion and
intoxication ; the exanthemata, particularly when
imperfectly developed on the external surface, or
upon the disappearance of the eruption ; the me-
tastasis of gout, rheumatism, and erysipelas; sup-
pressed haemorrhages and evacuations, particularly
the menses and the urinary secretion ; the accu-
mulation of sordes and morbid secretions in the
prima via and gall bladder; the ingestion of irri-
tating and narcotic poisons ; indulging in cold
punch (Fuank); vinlent fits of coughmg ; long
exposure to great cold, and, according to Goelis,
the too free use of helUulmna, and other narcotics,
in the cuie of hooping-cough.

184. III. Diagnosis. — A. Characteristic sym-
pioms. a. Pain is an early sign, but the patient
often ceases to complain of it very soon, particu-
larly if the cerebral substance be chiefly inflamed ;
■when it is also gravative, and attended with stupor
from the commencement. It is most acute*when
the membranes are aflected, and is always aggra-
vated by shaking the head, and the erect position.
When the disease supervenes in the progress of
fevers and bronchial affections, pain may not be
complained of, owing to the impure state of the
Idood having blunted the sensibility, b. ]\'atch-
fnliicbs and slcp. — Insomnia is generally present
during the first days, when the membranes are
aflected, and, in children, starling from sleep, and
screaming. Heaviness, somnolency, sopor, or
even coma, often preceded by convulsions, are
early present when the substance of the organ
is the chief seat, or the mend)rane3 extensively
affected, and supervene early, but without con-
vulsions, when the disease occurs in the cour.-e
of fevers and bronchial affections; but a refresii-
ing sleep is never enjoyed, unless alter a favour-
able change, c. 'J'he senses, particularly sight,
hearing, an<l touch, are all morbidly active in the
first stacre, esp('Cially when the meninges are in-
flamed ; but they are nearly abolished at this
period, when the cerebral substance is chiefly
affected. The eye often indicates menial oppres-
sion, even when bright and staring. The sensi-
biliti) of the surface is unnaturally increased in
meningitis or superficial cerebritis, but is di-
minished when the substance of the brain is
deeply aflected, and in the advanced stage, when
the membranes generally are inflamed. In partial
cerebritis, the sensiblliiy of a limb, or part only,
is often lost, and it may be conjoined with S])astic
rigidity, or paralysis ol the same or of another part.
d. 'i'hi: ill telleclual and vinral faculties arc more

BRAIN — Inflammation of the— Diagnosis.

or less disordered ; they are unusually excited, or
violently deranged, early in the disease ; but sopor
frequently supervenes without being preceded by
this state, when the cerebral structure is inflamed.
Reverie or wandering of the mind during night,
is the least important form of mental disturbance,
indicating a slight aflection of the pia mater, ex-
tending to the cinerilious substance ; delirium
through the day, and watchfulness in the night,
are the most dangerous, and attend a severe affec-
tion of the membranes. e. The respiration is
often quicker in proportion to the pulse in the first
stage, and slower in the second ; and in the torpid
or somnolent state, when the substance of the
organ seems chiefly to be affected, is often attended
by deep-drawn sighs, f. The digestive organs are
much affected, particularly in children. 'I'here
are nausea and vomiting, especially at the com-
mencement, and torpor of the bowels. As the
di?ease advances, however, the bowels often be-
come free, or even relaxed. "■. The muscles and
limbs are more or less pained, contracted, con-
vulsed, particularly in the first stage, and when
the cerebral structure is inflamed. The convul-
sions are often general or severe, on the super-
vention of the disease, in young sul)jects. They
may be soon followed by coma, which may pass
off', and the convulsions again recur, and terminate
life. When the cerebral substance is partially
affected, the spasms and contractions may be
confined to one or more limbs, whilst the rest are
relaxed, or complete paralysis may ensue. In
the last stage muscular power is generally lost,
and the limbs are flaccid, h. 'Jhe pulse is ex-
tremely variable. At first it is not remarkably
frequent ; but it often becomes slower, and again
quicker than ever, and at the same time weak,
small, irregular, or intermittent. It may be at one
time either slow or frequent, and in a few minutes
the reverse ; but it is never natural in respect of
fulness, regulaiity, or strength. It is generally
stronger and fuller in the caiotids than elsewhere,
and in this situation it ought always to be felt.

185. B. Encephalitis may be mistaken for other
diseases ; but if attention be paid to the history of
the case, and the descriptions now given, this can
scarcely happen. It may, however, be confounded
with fevers, apoplexii, delirium tremens, mania,
and nervous lieudaclts. — «. In fevers, the disturb-
arice of the cerebral functions, when promi-
nently marked, generally occurs in their progress,
as a complication or consecutive affection. The
pulse is always more uniformly frerjuent and re-
gular than in encephalitis ; spasms, convulsions,
or paralysis, seldom occur, unless the brain be-
comes inflamed ; lespiration is not laborious, nor
deglutition diflicult ; nor are the eyes, coun-
tenance, and speech, affected, as in encephalitis.
In idiopatiiic fever, the muscular power is de-
pressed from the commencement, but is neither
generally nor partially alficted by spasms, (contrac-
tions, or paralysis, and the stom ich is less re-
markably disordered. There is not observed that
falling of the pulse from its former frequency,
afterwards followed by great rapidity, trembling,
or irregularity, which take place in encephalitis.
In fever, the general febrile symptoms arc the
earlii'St and most apparent disease ; in encephalitis
lire functions of the brain, of sense, and of the
organs of volition, are prominently and early dis-
ordeI^d, and the febrile symptoms much less re-

BRAIN — Inflammation of the — Terminations.

235

tnarkable in proportion to the severity of llie cere-
bral disease. ^VIlen ihe coma is profound in en-
ceplialitis, the iieat of the whole body, excepting
the liearl, is either not augmented or depressed.
The delirium in fevers also occurs at a remoter
period, and is much less violent in its character,
than in encephalitis. — b. The (Usturlunice of the
organic, and particularly the digestive functions,
the presence of fever, and the acute character of
the disease, distinguish it from maniactd insanity.

— c. The same symptoms, with the frequent addi-
tion of delirium, of disturbance of the senses and
general sensibility, spasms or convulsions, somno-
lency, sopor, and paralysis, preclude the possibility
of confounding it with bilious or nervous headaciis.

— d. Somnolency, sopor, convulsions, and slow-
ness of the pulse, distinguish it from delirium tre-
mens, in which the spectral illusions, the remark-
able tremors, timidity ; copious, clammy, ftrtid
perspirations ; and the specific cause of the affec-
tion ; sufficiently characterise tiie latter, wiien oc-
curring in a distinct and uncomplicated form. — e.
'ihe spasmodic or convulsive symptoms, antecedent
delirium, tiie mode of attack, and progress of dis-
ease ; the absence of paralysis, or its slower ac-
cession when tlie brain is inflamed, distinguish
encepiialitis from apopte.rii, in wliicii the invasion
is sudden, or more rapid, and the paralysis a simul-
taneous or consecutive symptom. The relation,
however, between apoplexy and encephalitis is
often intimate, particularly in cyses of partial in-
flammation, or inflammatory softening, of the sub-
stance of the organ.

186. IV. States, Forms, and CoMPr.iCATiONS.

— Besides the more or less perfect limitation of
inflammation to either the membranes or tiie sub-
stance of theencephalon, other states may present
themselves deserving of remark. — a. Encephalitis
may result from the 7netastasis of gout, rheu-
niatisin, and erysipelas, or it may arise from tlie
extension of the last named disease to the brain.
In these cases the membranes are chiefly affected ;
stupor and coma come on early, and are attended
with general flaccidity of the limbs, subsultus
tendinum, involuntary evacuations, and slowness
of pulse ; but local cramps, convulsions, or para»
lysis, are seldom present. — 6. The di'^ease may be
also consecutive of other diseases, as of inflamma-
tion of the ears (§ 58.), of the bones of the head
or pericianium. In these cases it is first extended
to the membranes, and afterwards to the sub-
stance of the organ ; occasioning contraction,
spasms, or paralysis of one or more limbs, or
muscles of tlie face, terminating in coma, or
alternating with stupor and general convulsions.
It may also be consecutive of severe ophthalmia,
of inflammation of the parotids or testes, of the
kidneys, of inflammation of the mucous surface of
the bowels, especially in infants, and of the dis-
eases of the lungs. — c. Encephalitis may likewise
supervene on, and be coinplicaied with, the ad-
vanced stages of continued and remittent fevers,
bronchial and pulmonary affections, hooping
cough, exanthematous fevers, particularly scarlet
fever and small pox. In all these cases the
membranes and superficial parts of the brain are
principally affected, generally in a more or less
diffused manner, occasioning first delirium, gene-
ral convulsions of young children, great pain in
the limbs, sensibility and soreness of the surface,
followed more or less rapidly by sopor, coma,

more rarely by local spasms and paralysis, invo-
luntary evacuations, rapid irregular pulse, &c.
The complication with typhoid, continued, and
exanthematous fevers, especially those of certain
epidemic coustitutions, is extremely fretjuent and
important; and has given occasion for the opi-
nions entertained by Willis, Chirac, Werl-
iiOF, Reil, Ploucquet, Cluttehkuck, and JMar-
cus, respecting the proximate cause of fevers.
To this complication also Torti attributes the
malignancy occasionally assumed by the remit-
tents and intermittents of the south of Europe.
When it thus supervenes on fe/cis and bronchial
diseases, the symptoms are often more insidious,
and of a less violent character, although the dis-
ease is equally rapid and disorganising. This is
probably owing to the depressed state ol the vital
manifestations, particularly of the organic nerves
and vascular system. Owing also to this circum-
stance, encephalitis, when thus complicated, re-
quires a modified and less depletory treatment.
Inflammation of the brain is also not infrequent
after apoplectic seizures, particularly in the part
of the organ surrounding extravasated blood. Iq
these cases the disease generally nccurs from five
or six to ten or twelve days after the attack, and
is attended with many of the symptoms of partial
encephalitis, particularly spasms, paralysis, deli-
rium, &c.

187. V. Terminations and TituoNDsis. — a.
This is always a dangerous disease, ami therefore
a very cautious prognosis ought to be given. The
termination of encephalitis in health occurs most
frequently in persons of a sound constitution, and
who have no hereditary disposition to the diseases
affecting the encephalon. This change often
occurs on critical days, when it is generally at-
tended by some favourable occurrence, as a co-
pious discharge from the bowels; a genial and
universal perspiration ; a copious discharge of urine,
depositing a sediment; hasmorrhage from the nose,
or the presence of the mensfes ; a more natural
state of the pulse and respiration ; a quiet un-
disturbed sleep, distinct from the oppressive som-
nolency or sopor which is one of the chief signs
of the severity of the disease; a more moist, na-
tural, and clean slate of the tongue and gums; a
decline of the temperature of the head, and of all
the other symptoms.

188. b. A fatal termination may take place,
1st, In the inflammatory stage owing to the very
general extension of the disease to the membranes
and substance of the organ ; the pressure and in-
terrupted circulation arising from the turgescence
of the inflamed organ annihilating its tunctions
(^§48.167.): 2d, In a fuither advanced stage,
from an effusion of serum, seroalbuminous fluid,
or the deposition of false membranes (J^ 21 — 28.):
3d, In the less acute cases, and at a still more ad-
vanced period, from suppuration or inflammatory
softening of a portion of the brain (i'i 51) — 76.) :
and, 4ih, This i>sue may pro(;eed from any two, or
the whole, of these changes being conjoined in the
same case. The indications of an unfavourable
termination are the persistence of the urgent sym-
pioms after treatment; violent delirium, watchful-
ness, and restlessness; profound lethargy or coma,
or the alternation of these states; violent general
convulsions, followed by coma, or alternating with
it ; a morose delirium ; retraction of the head ;
severe | ains of the limbs, followed by cramps.

236

BRAIN — Inflammation of the — Treatment
palsy ; hffimorrhaoje from tlie

contractions, or

ears; difficulty or impossibility of deglutition;
strabismus, or double vision; loss of speecli; slow-
ness of pulse, followed by a sudden increase of
frequency ; a trembling or irregularity of pulse ;
obstinate vomiting, particularly of a greenish
fluid; singultus, continued or recurrent; the ra-
pid healing of chronic ulcers; the appearance of
the disease in the course of other maladies, parti-
cularly pneumonia, the exanthemata, and after
apoplexy, and in the scrofulous habit, or in per-
sons having an hereditary disposition to cerebral
affections, or who have been recently affected by
other maladies,

189. c, 'liie disease may pass into an obscurely
chronic form, which together with the effects
produced by its antecedent state, may give rise to
paralysis, epilepsy, various states of mania or
mental disturbance, idiotcy, &c. In these cases,
many of the chronic changes which have been
described as occasionally found in either the mem-
branes or the substance of the brain, particularly
liiose wiiich affect parts only of these structures,
liave taken place, as softening, abscess, induration,
tumours,ossificformations,&c.(§50. 71.102,^c.).

190. d. When encephalitis arises from rheu-
matism {Encephalitis Rheumatica, J. Frank), the
membranes, particularly the dura mater and arach-
noid, are chiefly affected ; and the danger has been
considered, upon the whole, less than in other
states or relations of the disease. The disposition,
however, to effusion, and to many of the chronic
organic changes described as frequently found in
the membranes, is great. It often assumes a
sub-acute or chronic form, and is usually at-
tended with great distress, but is without delirium.
The goiitij form of encephalitis generally is ob-
served in older persons than the rheumatic; is
accompanied with much disorder of the stomach,
liver, and bowels, and with deficient vital power ;
and is hence a more dangerous state of the dis-
ease. The same remark is applicable to its oc-
currence from the extension or suppression of
erifsiiielus. In these, the re-appearance of rheu-
matism or gout in a joint or extremity ; the erup-
tion of the erysipelatous inflammation in any part
of the surface, even in the face (J. P. Fhank) ;
the supervention of diarrhoea, the hajmorrhoidal
flux, or any other discharge ; are favourable cir-
cumstances. Encephalitis, occuriing after the
rlisappearance of the erupiion in the exanthemata,
or duiing the course of typhoid or epidemic
fevers, or pulmonary diseases, or after attacks of
apoplexy, jjaralysis, epilepsy, or mania, is much
more ddngerous than when appearing in a primary
form, owing, 1st, to the depressing of the vital and
nervous powers; 2d, to tlie vitiated state of the
circulating fluids; and, 3d, to the silent and in-
sidious manner in which the di-ease of the brain
often advances to disorganisation in these com-
plications. According to llui j;i.ani), encepha-
litis, supervening on the disappearance of the
variolous eruption, is generally faial. The alter-
otiims nf structure occasioned hq encephalitis are
fully described in pieceding sections of this
article (§ 11. el seq.).

191. VI. TiiKA-iMiNT. — A. Of the idiopathic
and simple encephalitis. It must be evident that
the treatment siiould be the same, whether the
membranes or the substance of the brain be
chiefly, or entirely, the seat of disease. 'J he

cinaes, the age, the habit of body, and apparent
state of vital power, are circumstances which ought
to be duly considered when adopting the means
of cure, or determining upon the extent to which
they ought to be carried, a. The antiplilogistic
treatment, in all its departments, must be rigor-
ously enforced. Some discretion is, however,
required as to the extent to which it should be
carried, and the direction, choice, and adaptation
of the individual means of which it consists. In
ordinary cases, bleeding from the jugular vein;
cupping between the shoulders, nape of the neck,
behind the ears, or occiput; leeches applied in
those latter situations, and bleeding from the arm,
are upon the whole the preferable modes. Ar-
teriotomy 1 consider to be attended with no ad-
vantages ; and in this 1 am supported by the
opinion of Hildenbhand and others ; but bleeding
from the feet, from the hemorrhoidal vessels,
and from the groins and insides of the thighs, are
undoubtedly preferable when the disease arises
from metastasis or the interruption of discharges,
especially when conjoined with the treatment I
shall presently describe as appropriate to those
states. Hildenbhand, and several other German
physicians, recommend the application of leeches
to the insides of the nostrils, when the patient has
been subject to epistaxis, or if a disposition to criti-
cal epistaxis be evinced. As to the extent to which
depletion should be carried, no precise opinion
can be given. It should be regulated according
to the circumstances of the case, and its effects
upon the circulation, and be conducted in the
manner I have recommended in the article on
the Falhologif of tlie Blood (§ 64.). It ought
never to be relied on alone : other means should
be simultaneously, or subsequently employed,
with the view of diminishing local and general
action, and thereby preventing the removal of
more blood than may be indispensable.

192. b. The hair should be removed from the
head as soon as possible, and a stream of cold
ivater poureil upon it from time to time, or every
second or third hour, until the temperature be
reduced to the natural standard ; and, as morbid
heat soon returns, cold epilhems, or evaporating
lotions, or even pounded ice enclosed in a bladder,
should be constantly applied in the intervals be-
tween the cold affusions, and the head be kept
elevated, and phiced upon a thick oil-skin, or,
what is still better, upon a piece of common
painted floorcloth, as long as increased action
continues. Cold applications or affusions may,
however, be injurious if too long persisted in.
They ought never to be continued after the tem-
perature is depressed to the natural standard,
or a little below it, particularly if sopor or coma
be present; and as soon as the heat returns,
they should be again resumed. Simultaneously
witii the affusion, the feet and legs should be
immersed in warm water, or in warm water made
irritating by means of salt and mustard, and
the saphena vein be opened. In some cases, par-
lic.'uhirly when suppression of the menstrual or
haimorrhoidal dischnrge has preceded the attack,
semicupium or hip-bath, may be substituted for
pediluvia.

193. c. The immediate exhibiiion of r«(/i«r//f5
should not be neglected. From ten to twenty
grains of calomel may be given at once, and
three or four iiours afterwards, an active purgative

BRAIN — Inflammation of the — Treatment.

237

drauglit, which should be followed by cathartic
enemata, particularly the En. Ccithart. and the
Eh. Terebinth. (F. 141. and 150 ). By these, or
similar means, a copious action of the bowels
should be procured and continued. \\'itii this
latter intention, ])ill3 calculated to promote the
abdominal secretions may be «-iven each night, a
purgative drauglit the following morning, and an
enema subsequently, if it be necessary. Calomel
combined with digitalis, or with antimony, should
be prescribed in full and frequent doses, in addi-
tion to the above, so as to cliange the state of mor-
bid action, particularly when tiie membranes are
chiefly aflected. The following, or similar medi-
cines, may be used, and iheir effects carefully
watched : —

No. 55. R Calomel, gr. iij. — x. ; Piilv. Jacobi Veii
gr. iij. ; Pulv. Digitalis (vel Pulv. Colchici) gr. j. — ij. ;
Syrup. Simp. q. s. M. Fiaiit Pilute ij. vel iij. tertia,
quinta, vel sexta quaqup hora porrigciid^.

No. -56. R Hydrarg. Chloriiii gr. iij. — vj. ; Pulv. Jacobi

Veri gr. iij vj.; Extr. Coloeynth. Comp.gr. vj.; Syrup.

Simp. q. s. Fiant Piliilae iij. hora somni sumend;e.

No. 57. R Infusi Semite Comp. 3jss.; M.ignes. Sul-
phatis" 3ij. (vel Potassse Tart. 3j/>s.); Vini Aiitimon.
Pot-Tart. 3ss.; Tiiict. Jalap. 3 j. 'I'iiict. Cardam. Co.3j.
M. Fiat Haustus, prime mane sumendus.

194. d. In addition to these means, the fre-
quent exhibition of refrigerants and saline medi-
cines, especially those consisting of the liquor
ammna. acet., potasste nit., antimunials, &c., will
be of much service. 'J'iie preparations of anti-
mony, judiciously exhibited, have a remarkable
influence in diminishing determination of blood
to, and inHammatory action in, the brain ; and
I believe that the effect will be more decidedly
beneficial, if their operation as an emetic be
carefully avoided. Form. 24. 359. 406. 436. 456.
and 854. are of the above description, and, as
well as others of a refrigerant and diaphoretic
nature, may be employed, in small or moderate
and frequently repeated doses. I may state, as
the result of considerable experience, that I have
found the saline refrigerants and antimonials
most beneficial during the early stage of the
disease, and where the membranes were chiefly
inflamed. In the stage of coma, or when the
substance of the brain itself is alFected, and the
pulse is quick, weak, small, trembling, or iire-
gular, antimonials are not admissible ; the prepa-
rations of camphor, with liquor ammon. acet. and
spirit, tether, nit., being preferable. (See F. 405.
436. 441.)

195. e. Sedative and diuretic medicines, parti-
cularly colcliicum and digitalis, combined with
the liquor a]nmoniiE acet. and moderate doses of
camphor (F. 395.^00. 514.), are extremely
useful in the early stage of the disease, after de-
pletion and the free evacuation of the bowels.
In the advanced stage, however, much less ad-
vantage will be derived from them. After blood-
letting has been carried as far as may be tiiought
judicious, and if much restlessness and jactitation
be present, great advantage will be derived from
tiie exhibition of a moderate dose of camphor, hy-
oscyamus and James's powder, in this or any other
appropriate form : —

No. 58. R Pulv. Jacobi Veri gr. iij. — v. ; Camphorre

ras* gr. ij iv. ; Extr. Hyoscyami gr. iv. — vij.; Syr.

Papav. q. s. ut fiant PilulcB iij.stalim sumendas et li. s.
repetendjp.

No. -59. R Mist. Camphorse 3j. ; Liq. .'Immon. Acet.
3ij.; Si)irit. ^the'-. Nit. 3ss.; Tiiict. Colcliici Semin.
m xij.— XX. ; Syrupi Papaveris 3 j. Fiat Haustus, tertiis
vel quartis Ir ris capiendus.

196./. Derivatives and cininter-irritanis are
useful in many cases, when judiciously prescribed.
In the early stage of the disease, and whilst great
iiritability or delirium is present, they are often
prejudicial, excepting simple pediluvia, the semi-
cupium and hip-baili, employed simultaneously
with cold applications to the head. Great mis-
chief has arisen from ordering blisters and mus-
tard poultices too early in inflammations, but
more particularly in encephalitis, whun, instead
of deriving tlie circulation from the inflamed part,
they excite the nervous and vascular systems ge-
nerally, and thus react upon the disease. It is
chiefly in the latter stage, when sopor or coma is
present, that benefit is derived from them. Some
difl^erence of opinion has existed as to the part to
which they — particularly blisters — ought to be
applied. If the coma be profound, some writers
have advocated the application of blisters directly
to the scalp. Without denying the possibility of
circumstances arising to justify tliis practice, I
believe that they will seldom occur. The most
profound sopor, weak action of the carotid*, a
not remarkably frequent pulse, and a temperature
of the head mucii and permanently below the
natural standard, would only influce me to apply
blisters to the scalp. When deriration can be
attempted with safety, — when sopor is present,
and morbid sensibility and irritability has nearly
disappeared, and depletion has been carried as far
as seems judicious, — a large blister to the nape
of the neck or between the shoulders, or over the
epigastrium, mustard poultices to the insides of
the legs or thighs, or irritating liniments (seethe
Liniments in the Appendix) in the latter situ-
ation*, will often be used with advantage. The
sonicupium, icarm hath, or pediluvia, are seldom
of service when there is much general febrile
excitement, paiticuiarly in children, unless when
used simultaneously with cold aff"u-ion on the
head. But when the lower paits of the body
have their temperature reduced below the natural
standard, and when the disease has appeared
after suppressed discharges, &c., they are often of
service, and may be made more revuhive by salt
or mustard.

197. g. Various remedies have been recom-
mended in the treatment of this disease, in a more
particular manner than others. Amongst these,
the mo>t generally employed and most beneficial
is calomel, when given in large and repeated
doses, and judiciously combined, and until an
impression is made upon the disease, or state of
the circulation. In the meningitis of children,
this practice is particularly requisite, as, without
it, but little impression will often be made on the
disease ; and, with due attention, but little risk
will be run of experiencing unpleasant results
from it. Where we dread impending exhaustion,
the calomel may be combined with small doses
of camphor and ammonia, and a less restricted
regimen allowed. INI aucus recommends strongly
very large doses of nitre, which may be combined
with antimony, or with diuretics; IIkogewiscii,
the ])reparations of inercury carried to the extent
of salivation ; CiiAussiEn, the horacic acid, very
nearly as prescribed in F. 343. ; several phy-
sicians in Italy and in Switzerland, especially
Breua, ToMMASiNi, Pesciiieii, Laennec, &c.,
large and frequently repeated doseso( ihe potass io-
tartrate of unlimony so as to act upon the bowels j

238

BRAIN — Inflammation of the — Treatment.

LoEFLER (Htifelani.Vs Journ. der Pract. Arzneik.
b. iii. p. 694.), fiee iiicisimis of the scalp ; iinJ
AnF.T/Eus (Curat. Aciit. 1. i. ch. 1.), Cei.sus
(1. iii. ch. 18.), C/F.Lius Aurelianus (p. 30.),
and Zacutus Lusitanus (Med. Fr. Hiit. 1. i.
p. 85.), scarifications and cupping in the same
situation. All these are undoubtedly advan-
tageous, when judiciously prescribed. Besides
these there are remedies wliich are very generally
employed, and which are beneficial in certain
states of the disease only ; these are, camphor,
digitalis, hyoscyamus, opium, &c. In the early
stage, camplior, unless in very minute doses, is
])rejuilieial : but when sopor or coma is present,
when depletion has been duly practised, the heat
of the head has subsided, the energies of life are
depressed or exhausted, and the symptoms are ap-
parently the consequence of the lost tone of capil-
laries of the brain, moderate and frequently re-
peated doses of this medicine are almost indis-
pensable ; particularly in the complications of the
disease with typhus, or epidemic fevers, with gout
or rheumatism. Vigilalis as well as colchicum
are principally required in the early stage, when
either of them may be combined with cabmel : if
exhibited subsequently, they should be given with
camphor, and their eflects carefully watched.
Both these medicines may be advantageously
combined with aperients or with diuretics. Brera
recommends digitalis as follows in the earlier stages
of the disease : —

No. fiO. R Pulv. Fol. Digitalis gr. xvj. ; Hydrarg.
Chloridi gr. x. ; Pulv. Had. Gljcyrrli. 3j.; Olei Jiiiii|i.
q.s. M. Fiant PUuiae viij. Capiat biuas teitiis vel quartis
noris.

The combination of camphor with colchicum is
often of service in the gouty and rheumatic furms
of the disease. I found it recently of much ad-
vantage in a severe case of the latter.

198. Narcotics ought generally to be avoided ;
yet there are states of the disease, chiefly in adult
and aged subjects, which are benefited by them.
When lelhaigy or coma, or an obvious disposition
to either, is present, narcotics are injurious, par-
ticularly in cerebrilis; but when the membranes
are obviously most aftected, and the disease pre-
sents much of the phrenitic character; when great
iriiiability, mental excitement, or exhausting
watchfulness is present, particularly alter deple-
tions and other evacuations have been carried as
far as seems judicious, and the pulse has been
reduced, or become less febrile ; a full dose of
/((/osfyu)»ws,or even theprepaiationsofcii/iim, par-
ticularly the acetate or hydio-chlorate of morphia
(F. 315. 674.), the compound tincture of opium
(F. 723, 729.), or Battlers sedative li([Uor, may
be exhibited. In cases where the propriety of
having recourse to these medicines admits of
doubt, they should be combined with moderate
or full doses of camphor (F. 554. 787.), or the
Spiritus ^Elher. Sulph. Camp. (F. 375.)

No. 01. R Camphora: rasa? gr. j.— iv. ; Cum. Aoacix,
Sacchari Albi. aa .3 ss. ; IVlagiics. Caib. 3j.; Dcciicti Al-
thaea; 3jss.; .Spirit. 7I-;tli(T.Siil|ih Coirip.; Tiiict. Hyoscy-
aiiii.aa .3j. (vul Tinct. Opii Comp. F. 7-'J. 5sf.) M. Fiat
Ilaustus.

199. B. Treatment of the complicated billies. —
There are certain consecutive and complicated
forms of the disease which refjuire a somewhat
modified treatment. — a. The rheumatic ence-
phaliti-<, according to .1. Frank, does not admit
uf cold iq)plicationsto the head; in other respects,

the means of cure do not differ from those already
stated. I believe that, in its advanceil stage, the
application of a blister to the scalp is more likely
to be of service in this than in any other form of
the disease ; and the same remark may be ex-
tended to the use of colchicu7n a.nd camphor — the
latter of which may sometimes be advantageously
combined with the potassio-lartrate of antimony
or James's powder.

200. b. In the arthritic complication, after ge-
neral and local depletions, — the latter chiefly on
the right hypochondrium, ha^morrhoidal vessels,
and insides of the legs, — followed by active
purging, stimulating and irritating pediluvia,
sinapisms and blisters ajiplied to the lower extre-
mities, and colchicum combined with the car-
bonates of the fixed alkalies, and diuretics, are
chiefiy indicated.

201. c. When encephalitis occurs in the co»)se
of fevers, or when it is seated chiefly in the sub-
stance of the brain, and assumes a typhoid charac-
ter, from the depressed state of the vital povver.s,
either at the commencement or in consequence of
treatment, the infosions or decoctions of arnica,
senega, or serpenturia, have been recommended by
the German writers, after depletions liave been
carried as far as seems prudent. When the dis-
ease is thus complicated, depletions should be
employed with caution; and those which are local
and derivative ought to be preferred, reinilsants
being simultaneously prescribed ; cold applications
to the head require equal caution. In the early
stage of this complication, J. Frank recommends
a combination of camplior, cinnabar, and nitre,
every two hours. The first of these is amongst
the best medicines we possess in every stage of
such cases ; but it should, in the advanced periods,
be exhibited in larger doses than early in the dis-
ease ; and it may often be advantageously com-
bined with calomel. A similar treatment is ap-
plicable when the disease appeare in the course
of bronchitis and other pulmonary diseases.

202. (/. The eriisipelalous complication of en-
cephalitis often re(iuires a more antiphlogistic and
depletory treatment than the typhoid form of the
disease ; but such is not uniformly the case. I
conceive that deep and large incisions into the
scalp, particularly over the occiput, as recom-
mended by Loi FLER, would be more applicable
to this stale of the malady than to any other, es-
pecially if there be much tumefaction of the scalp
or counter.ance. When encephalitis follows, or is
complicated with apople.iy, the treatment diflTers in
no respect from that which has been recommended
for the primary form of thaakisease. Incisions or
scarifications of the scalp may be also practised
in this complication.

203. e. 'J he su])ervention of encephalitis on in-
flammations of the digestive mucous suiface is
not infre(;uent in children : and in diseases of the
liver in persons of middle age, or advanced in
life. In these cases the treatment is not mate-
rially different fiom that already advised. Local
depletions over the region of the liver ; full doses
of calomel, so as to affect the mouth ; cold af-
fusions on the head, particulaily in the former
state of complication ; external and internal revul-
sants and diuretics; are generally indicated.

204. f. 'I he appearance of the disease after
irrilaling and narcotic poisons, paiticularly after
cpium, aconitum, belludoiina, ike, is not iutre-

BRAIN — iNrLAMMATION OF THE TREATMENT.

239

quent. These occasion, first, congestion, and I decidedly on the abdominal secretions ; and was
atierwards inHammatory action. In encephalitis repeated eveiy hour until three were taken.

from these substances, vascular depletions, cold
affusion on the liead ; emetics, or the introduction
of the stomach-pump ; camphor or arnica, com-
bined with antimonials or aperients ; external
derivatives, and active purging, are amongst the
chief means of cure.

205. C. Of the treatment of the more unfa-
vourable and anoniaLms stales of the disease.—-
The practitioner, although he will very fre-
quently, or even generally, find the treatment
described above successful, may sometimes meet
with cases in which the symi)toms persist, not-
withstanding repeated depletions, and the other
remedies prescribed ; the energies of life being
more or less depressed ; the pulse becoming very
rapid, irregular, trembling ; the coma or stupor
more profound, and the temperature, even of the
head, much diminished. lie may or may not
have had recourse to derivatives, but in either
case tiiey may be continued or varied ; and
camphor, musk, valerian, ammonia, Hoffmann's
anodyne, and other restorative medicines, va-
riously combined, may be exhibited. If the
pulsation of the carotids and temperature of the
head be not in such cases increased — or if they
be diminished, and the energies of life be obvi-
ously depressed or exhausted, both in the affected
organ and throughout the system — the above dif-
fusible stimulants will often be inefficacious. In
this case, the infusion of the flowers of arnica, or
the infusion of serpentaria, either simply or com-
bined with cinchona ; camphor, in larger doses,
and given occasionally with calomel and small
doses of opium; active frictions of the surface
and lower extremities with rubefacient liniments,
and in some instances, particularly if effusions
between the membranes be suspected, with mer-
curial liniments, or inunction of the scalp, are
the principal means that can be adopted. But if,
notwithstanding those, the above symptoms con-
tinue or increase, — the evacuations being invo-
luntary, and the patient unconscious of them ;
a vomiting, or rather a pumping up, of whatever
is taken into the stomach, with singultus and an
intermitting, trembling pulse, that cannot be dis-
tinctly counted, being also present, — are we to
continue to give the medicines which we have
found inefHcacious, thus leaving the patient to his
fate, or are we to resort to still more active means 1
There can surely be no hesitation as to the part
which ought to be taken. In a case of this descrip-
tion, consecutive of bronchitis, in a robust man of
middle age, who was attended by IMr. Faxom, Dr.
Bree, and myself, after depletions and cold appli-
cations had been carried as far as it was judged
prudent, and blisters were applied on the epigas-
trium and nape of tlie neck, without benefit, lull
doses of calomel and camphor were given, the
following medicines prescribed, and their action
promoted by the enema terebinth. (F. 151.) : —

No. 62. R Camptiorae raSi-B gr. iij.; Aramoniae Sesqiii-
Carbon. gr. iv. ; Mucilag. Acaciie q. s. Fiant PiUil<E
ij., omni secunda hora, cum Haustu sequente, sumendae.

No. 03. R Mist. Camphoroe 3j-; Li'l- Amnion. Acrt.
Sijss. ; Spirit, jl^tlier. Sulph. Comp.3ss.; Tinct. Capsici
III "ij. ; Syrup. Croci 3ss. M.

The following draught was also given, four
hours after the exhibition of a large dose of ca-
lomel and camphor, with the view of deriving
the circulation from the head, and of acting

No. (54. R Olci Tereliinth., Olei Ricini. aii 3 ij. ; Tinct.
Capsici lllxii.; Olei Cajeputi Hlvj.; AquE JMeiilh.
Vind. 3jss. M.

The pulse soon afterwards became more distinct
an<l regular, tlie bloated cast of countenance
subsided, and all the symptoms improved. 'The
patient afterwards quickly recovered, and is now
in perfect health. At the time the above treat-
ment was suggested by me, his recovery was
considered almost impossible. Several years ago,
I was consulted by Mr. IlAnny Cox respecting
a very similar case, which was consecutive of ery-
sipelas. In this a similar treatment to that now
noticed was adopted, and the patient recovered
from an extreme state of danger. This case is
published in the twenty-third volume of the London
Medical Repositorii. In those states of the dis-
ease %vhich are characterised by profound sopor,
depression of vital power, and the symptoms
above referred to (^§ 180. 205.), other means
having proved insufficient, a judicious exhibition
of the oleum terebinthins has very frequently a
decidedly beneficial effect, particularly in the
typhoid, erysipelatous, and other complications
of the disease ; and, when suitably prescribed,
will generally allay the irritable state of the sto-
mach, with which the worst forms of the malady
are often attended even during their advanced
stages.

206. The experienced practitioner should be
aware that the existence of profound sopor or
coma does not contra-indicate sanguineous deple-
tions or cold applications to the head, if, conjoined
with this state, the temperature of the head be at
ail increased, or the pulsations of the carotids
strong or full. If these evidences of increased ac-
tion be present, those important parts of the treat-
ment ought not to be omitted; but the depletions
should often be moderate or local merely; and, in
my opinion, preferably from the scalp of the occi-
put or nape of the neck, by cupping, or by deep
incisions of the former. When the disease is con-
sequent upon suppressed discharges, a derivative
intention may be had in view, and the lower ex-
tremities, the groins, the vicinity of the anus, &c.,
may be selected as the situations for depletion.
In traumatic encephalitis, the fact that the dis-
ease either does not appear whilst the wound in
the scalp remains open, or is averted by a long-
continued discharge from it ; and that the worst
states of cerebritis often arise after injuries of the
head, when the external wound has readily and
prematurely healed, furnish a striking indication
of the propriety of having recourse to incisions of
the scilp in the other forms of the disease, and
to issues and setons in the same situation subse-
quently, when their sequelag indicate the pro-
priety of having recourse to ])ermanent irritation,
with puriform discharge, for their removal.

207. D. Treatment of the suh-acute and chronic
stales of encephalitis, particularly in children. —
a. One of the most frequent forms of sub-acute
inflammation of the brain is observed in infants,
principally aff'ecting the substance of the organ,
and often terminating in dropsy of the ventricles.
It is chiefly characterised by want of animation,
by slight sopor, indifl^erence to all objects, absence
of sound sleep, and a state that is diff^erent from
waking. The child is dull, but fretful and irii-

240

BRAIN — Inflammation of the — Treatment.

table upon being roused or handled. The head
generally droops, or reclines on one side ; the
countenance is usually pallid, but occasionally
irregularly flushed ; the eyes ure dull, rolled
about, or turned up ; the pupils sometimes di-
lated, at other times contracted; and the infant
often utters a plaintive moaning, and occasionally
starts soon after having fallen asleep, as if pained
or frightened. The hands are tossed about or
raised to the head ; the lower extremities alter-
nately extended and drawn up to the abdomen ;
the head thrown backwards ; and occasionally its
temperature is slightly increased, w hdst the heat
of the rest of the body is either natural, or some-
what diminished. This grade of disease may con-
tinue for a long time; sometimes fluctuating, at
other times passing into either a more acute or more
chronic form, or at last terminating in dropsy ;
the bowels being either relaxed or irregular, but
in either case with a nioibid and ofliensive state
of the motions. The shades of diflPerence observed
in this form of disease are numerous : the pulse
is very variable, as well as the appearance of the
tongue ; which is, however, most frequently red
at its point and edges, and white or loaded at its
middle and base : in some of the more chronic
cases, particularly when the disease is compli-
cated with chronic disorder of the digestive mucous
suiface, it has what may be called a strawberry
appearance, from the number of bright led dots
scattered over it. This variety of the disease is
often associated with torpor or imperfect func-
tion of the liver, with di.sease of the mucous sur-
face of the stomach or bowels, or with both ;
and occasionally with bronchitis, especially
during the period of dentition, when it often
supervenes.

208. b. Another variety of this affection is also
frequent in infants and children, and seems to be
chiefly sealed in the arachnoid. Dr. W. Nichoi.ls
has termed it sensitive erethism of the brain. It
is characterised by a morbidly increased sensi-
bility, which distinguishes it from the foregoing
variety. The child often ciies without any ob-
vious reason ; is generally wakeful, lively, but
irritable; all the senses, even that of touch, are
morbidly acute, paiticularly the senses of sight
and hearing: it frowns, winks its eyes, or closes
them upon exposure to light ; it sometimes shrieks,
clenches its hands with the thumb bent across
the palms, tosses backwards its head, and pre-
sents many of the symptoms of the preceding
foi m of disease ; and not infrequently terminates
in effusion ; but, more frequently than the fore-
going, between the membranes exterior to the
hemispheres.

209. c. The Treatment chiefly consists of leech-
ing behind the ears or on the occiput ; fre(|uent
scarifications of the gums; the affusion of cold
water on the head, or cold sponging ; calomel
purges, followed by castor oil or other cathaitics,
and occasionally promoted by terel)iiithinate en-
emala; frequent warm semicupia; the use of
saline aperients combined with diuretics, and
strict attention to diet and regimen, with change
of air. After the several active c^ilonul purges
have been exhibited, and the evacuations have
improved, and the more obvious symptoms are
abated, small doses of hydraig. cum crela may be
given iit night, either ahiiie or comliinud wilh a
Jillle of the carbonate of soda or potash, and a

weak saline mixture through the day, similar
to the following, or to F. 440. and 441.

No. G5. B. Magnesiae Sulpliatis (vel Sodte Sulpti.) 3ij ;
Potassse Siilpliatis 3 j. ; Aquae I'ceniculi 3i'ss. ; Spirit.
iEtlier. Nit., Vir.i Antimoiiii Pot-Tart., Spirit. Juniper.
Co.,aa3j.; Syrupi Scillae 3 ij. M. Capiat Infans 3 j —
5.iij. ter quaterve quoticlie.

210. When the morbid sensibility or irritability
continue, notwithstanding the above treatment,
and if the child be not very young, small doses
of James's power, and, if that fail of procuring
quiet, of the pulv. ipecacuan. coinp. may be eon-
joined with the hydr. cum creta, and given every
night ; or a little tinct. of hyoscyam., or of the
extr. conii, may be added to the above mixture.
In the soporose form of the affection, narcotics
must be avoided, but the rest of the treatment
strictly adhered to. Small doses of camphor and
nitrate of potash may also be exhibited, — if in
solution, with ihespirit. ffither. nit., and blisters ap.
plied either to the nape of the neck, or behind the
ears, or turpentine epithemsover the shaved scalp.

211. E. Treatment of the sequetct of encepha-
litis. — After an attack of this disease, the patient
may complain of veitigo, more or less torpor or
weakness of the menial powers, cephalalgia, &c. ;
or of increased sensibility, and marked erethism
of the brain and whole nervous system, watch-
fulness, incapacity for mental exertion, tinnitus
aurium, languor, and pain in the limbs, &c. In all
such or similar cases, the diet should be carefully
restricted to food of easy digistion, in moderate
quantity, and consisting chiefly of the farinacea-.
Change of air, easy travelling, avoidance of all
mental exertion and anxiety, and attention to the
secreting and excreting functions of the abdominal
viscera and of the skin, will generally bring about
perfect recovery. If these fail ; or if the patient
have irregular flushings, or increased heat of
head ; or if the carotids pulsate more strongly
than usual ; the shower-bath, cold sponging the
head ^night and morning, and wearing the hair
closely cut, occasional local depletions, the in-
sertion of a seton in the neck ; or keeping out an
eruption, in the same situation, with the tartarised
antimonial ointment ; or bli^ters kept open behind
the ears for some time ; may be prescribed.

212. When the more severe sequelae of the
disease are present, — such as cramps, pains, or
spasms of the extremities, hebetude or derange-
ment of the mental faculiies, obstinate headach,
&c., — we should suspect the existence of a chronic
state of the disease, and resoit to occasional
local depletions, cold aft\isions, or sponging of the
head ; followed by issues in the scalp of the occi-
put, or the inunction of the laitar emetic ointment
in this situation ; and to the mercurial preparation
at bed-time, wuh cooling and deobstruent aperients
on the Ibllowing moroinor; and to the other means
above recommended. AVhen we apprehend, from
the marked character of the above symptoii.s, or
from the paralysed state of particular muscles or
parts, that organic lesion has been produced, the
means now recommended should be strenuously
persisted in ; and the mercurial medicines may be
pushed to slight salivation, under the favourable
circumstances of pure air and mental quiet ; after
which, gentle tonics, and a more invigorating treat-
ment and Hiyimen, may be cautiously tried.

213. F. The regimen (luring the disease shou]d
be strictly anli|)hlo;;istic. The patient's drink
or beverage may consist of cither of thafonnulief

BRAIN — Softening of the — SyjiPTOMs.

241

No. 590 — 595. 915. contained in the Appendix ;
and attention should be paid to the state of the
urinary discharge ; particularly to the prevention
of accumulations of urine in the bladder, which
ought to be removed by the catheter whenever
any interruption of its evacuation occurs. The
diet, and reginieu generally, should be as care-
fully regulated during convalescence, as in the
progress of the disease; and attention ought to be
directed no less to the mental occupations, and
moral einotions, than to the natural functions,
and physical employments. Care should be taken
not to carry abstinence too far in the meningitis
or encephalitis of infants or children, particularly
after large sanguineous depletions and doses of!
calomel have been employed. The exhaustion |
arising from too great abstinence, and from the j
treatment, will often simulate effusion into the
ventricles ; and be mistaken for it, if the history
of the case be not carefully attended to in con-
nection with existing symptoms.

BR/iiN — Softening of the. — Ramollisseinent,

Fr. — Classif. IV. Class, IV. Order

(Author, see Preface).

214, I have considered this change, apart from
those proceeding from inflammation, although it is
frequently a consequence of inflammatory action,
occurring either in an acute, sub-acute, or chronic
form, and characterised by deficient vital power ;
chiefly because I agree with ftlM. Rostan, Re-
CAMiER, and others, in considering that it occa-
sionally is unconnected with inflammation, par-
ticularly in aged persons.

215. i. Symptoms. — This disease takes place
slowly, and we may distinguish in it two stages
the recognition of which is of much importance
in the diagnosis, inasmuch as when the first pe-
riod does not exist, or when the physician cannot
obtain a satisfactory knowledge of it, it is diflicult
to determine the particular kind of disease pre-
sent. 1st, The first period. — A. Direct symptoms,
a. of non-bijiammatory softening. — A continued,
and more or less severe, pain in the head is gene-
rally complained of. To some, the existence of
pain may appear pathognomonic of inflammation ;
hut, as M. Rostan has justly said, this is an in-
ference not borne out by close observation ; for
pains frequently occur, of a most severe descrip-
tion, unconnected with any form of increased
vascular action, or capillary injection. Cepha-
lalgia is, however, not always present. At this
period, vertigo is oftener complained of, and there
is generally a more or less marked diminution of
the intellectual and moral faculties. The per-
ceptions, attention, judgment, memory, and ima-
gination, are more or less enfeebled ; and the
patient sinks into a species of senile mental alien-
ation. Sometimes the mental disturbance is
partial or slight, owing to the seat and limited
extent of the softening. There are observed,
moreover, slowness in the answers ; some degree
of embarrassment in the motions of the tongue ;
dejection and sadness of spirits ; hypochondriasis,
or an extreme indifference as to events ; great in-
clination to sleep, with prickings, twitchings, and
numbness in the limbs; and much difficulty of
laying hold of objects, particularly those of small
size. The sensibility is generally diminished ;
vision is often afl'ected, being less distinct than
usual, or partially or altogether abolished. It
very rarely happens, that unequal dilatation of the

Vol. I.

pupils, or strabismus, occurs. The sense of hearing
is generally impaired. These are the chief symp-
toms of uon-injiammatory softening of the brain.

216. b. If the softening proceeds from infant'
matory action, this period is more acute, of longer
duration, and presents also certain important dis-
tinctions. The pain in the head is then more
acute and sharp ; the answers are abrupt and
quick, and there is frequently delirium : the sensi-
bility of the limbs is often increased, and the pa-
tient complains of pain in them, with stiffness,
contractions, and cramps. This affection of the
limbs may be mistaken for rheumatism, but is to
be distinguished from it by the existence of cere-
bral symptoms, and the absence of increased heat,
redness, or tumefaction. The senses evince ex-
cessive sensibility, and cannot tolerate their na-
tural stimuli. (RosTAN.)

217. JB. Indirect symptoms. — a. The functions
of organic life do not present undeviating symp-
toms, and assist but little the diagnosis; the ap-
petite may be diminished, the thirst somewhat in-
creased, and digestion more or less disturbed, and
the mouth and tongue white and clammy. Some-
times there is nausea, or even vomiting, with epi-
gastric tenderness ; and there may be either con-
stipation or slight diarrhoea ; micturition is more or
less difficult, or involuntary ; or all these symp-
toms may be absent. I'he following are more con-
stant in this non-inflammatory form of the disease :
the pulse is slower and feebler than natural, a sym-
ptom which is not observed in inflammatory soften-
ing of the brain ; the skin is pale, its temperature
is lower than natural, and the respiration slow and
gentle, h. In infantmatory softening the pulse is
strong, full, or frequent ; skin hot ; and there is much
thirst, with many of the symptoms described in the
section on Cerebritis (§ 164.), but generally in a
sub-acute or chronic and slight form. Thus far,
the syj^ptoms do not seem very urgent ; and they
may be so slight, or so obscure, that the patient is
not induced to have recourse to medical aid, or the
physician overlooks the nature of his ailments.

218. 2d, Second period. — A, Direct symptoms,
— a. The patient now loses the use of some limb,
or even one half of the body, either gradually or
suddenly, but generally the latter. The greater
part of the time his intelligence is but little dis-
turbed, but he answers with extreme slowness,
and is often incapable of making himself under-
stood, excepting by the aid of painful gesticulation.
In certain cases, either complete coma supervenes
on the paralysis, or both come on simultaneously.
If the latter, the patient often regains his recol-
lection in a day or two afterwards. This change
seems attributable to temporary congestion of the
brain. The symptoms, particularly the coma and
paralysis, are increased, the mental faculties and
the powers of sense become entirely abolished,
and the patient sinks under the most complete
coma. (Rostan.)

219. b. In the inflammatory softening, in the
place of paralysis, there exist pains, more or less
violent, shootings in the limbs, vvith contractions,
cramps, or convulsions, and severe headach. In
either the inflammatory or non-inflammatory form
of the disease, when the patient complains of
pain in the head, and is asked its situation, he
carries the unafl'ected hand slowly to his head,
and indicates generally the side opposite to that
paralysed. In encephalitis, there is generally the

R

242

BRAIN — Softening of the — Treatment.

delirium ; in the non-infiammatory form of soften-
ing, the intellectual faculties are enfeebled, or
much weakened ; the countenance is generally
pale, colourless, or sometimes even sunk ; whereas
in inflammatory softening it is red, or more or less
injected, or even tumid.

220. B. bidirect symptoms.'-^ a. In th\s second
stage of the disease, the organic functions are
more or less affected : there is no appetite ; the
teeth and gums are dry, the tongue rough, brown,
blackish, chopped or traversed by small fissures ;
deglutition is difficult : sometimes there is vo-
mitmg, first of the ingesta, and afterwards of bile :
all the excretions are involuntary •, frequently
there is constipation : respiration is laboured, and
at last stertorous : the pulse feeble, frequently
irregular op unequal, or even intermittent, and
the skin is cold. b. In inflammatory softening
there is great thirst, redness of the tongue, sensi-
bility of the epigastrium and abdomen, hot skin,
a strong and frequent pulse, &c. (See § 170.)

221. The second period may be of longer or
shorter duration. The morbid phenomena often
continue stationary for a considerable period, and
then make rapid progress ; at other times the
progress is slight, but constant ; in some cases it
is constant and remarkable. This disease very
rarely retrogrades or evinces much amelioration ;
its progress is essentially continued and increasing.
The anatomical characters of softening have been
already fully described (§ 70, et se<i.). It may
be stated in general, that when it is the result of
inflammatory action, as it most frequently is, 1st,
The colour of the softened part is, more or less,
deeper than natural, or of a rose tint ; 2d, It
contains a certain quantity of pus, sometimes
in6ltrated through the softened tissue ; and, 3d,
Febrile symptoms have existed previously to the
death of the patient.

222. ii. Treatment. — It is unnecessary^ito add
any thing to what has been already advanced
respecting the treatment of the inflammatory states
of softening, which are essentially the consequence
of partial cerebritis (see § 191, et seq.). When,
however, the disease does not present an inflam-
matory cliaracter, it becomes necessary, not only
to enjoin abstinence from all debilitating means,
but from tlie commencement to apply rubefa-
cients, to throw irritants info the great intestines
(see Enem. F. 141. 150.), and to have recour«e
to tonics, aromatics, &c., of which the sulpliates
of zinc, iron, or quinine, in small doses, with sul-
phuric acid, or the less heating astringent tonics
belonging to the vegetable kingdom, are the most
eligible ; preserving, at the same time, a regular
state of the alvine secretions and evacuations,
and of the other digestive functions.

223. Regimen. — The gently tonic, chalybeate,
and aperient mineral waters are of service in the
non-inflammatory form of the disease; wiiilst
those only which nie aperient and deobstruent
should be ventured upon in its iufliimmntory
states, when they may be tried and varied ; local
evacuations, revulsives, particularly setons, issues,
&:c., being kept discharging at the same lime.
In both forms of the dis ase, gentle travelling,
and change of air, and agreeable an<l (juiet amuse-
ment, without undue im-ntal excitement of any
kin<l, will be of much service. M. Kosi.in's in-
junctions under liiis head may be summed up as
follows: — Those alimentary and medicinal sub-

stances which exert a strong and speedy action
on the encephalon, should be strictly shunned.
Wine, spirits, coffee, and spices, are of this num-
ber. Excess at the table is dangerous. The diet
should be mild and moderate, and the food easy
of digestion, but not too nutritious. The impres-
sion of cold air on the head may be favourable :
sudden passage into a heated place must be
avoided : the patient should inhabit a cool situ-
ation. Whatever, by compressing the limbs or
the organs contained in cavities, may favour
cerebral congestion, must be rigidly proscribed.
Warm, as well as cold bathing, should be inter-
dicted : tepid bathing alone may be permitted,
although with much caution. Cold lotions to the
head are advantageous in the inflammatory form
of the disease, provided we do not permit reaction
to be established ; at the same time pediluvia
containing mustard may be prescribed. The
ordinary excretions should be kept up ; but sexual
indulgence, too violent exercise, strong emotions,
long study, and watchings, should be carefully
avoided. The age, strength, constitution, habits,
and state of the patient, and the character of the
symptoms, must modify these precepts.

BiBLIOG. AND ReFETI. — I. DISEASES OF THE MEMBRANES

OF THE Brain, c*tc — i. Alterations of the Duka Mater.

— Hallcr, Opera Minora, vol. iii. p. 8G3 Burdach, Bei-

trage, b. i. p. 87. — Gilbert, in Edin. Med. and Surg.
Journ. No. 95. {Dura mater absorbed and wasted.) —
Otto, Anat. Pathol. &c. ; and Bonetus, Sepulchret. Ana-
torn. vol. i. p. 41. {Dura mater thickened to half an
inch.) — Lieutaud, Hist. Aiiatom. Med. vol. ii. 1. iii.
obs. 3. 16. 76. 165.; et Trecotirt, Journ. de Med. t. vi.
p. 189. ; and B. Brouin, Lnnd. Med. Repos. edit, by Cop-
land, vol. xvii. p. 108. {Dura mater dry, shrivelled, Sjc.)

— Gendrin, Histoire Anat. des Inflam. 8vo. Paris, 1826.
{Meldnoid deposit iii ditra mater.) — Ludwig, Adversari.i
Med. Pract. vol. ii. p. 4.59.; et J. P. Frank, De Curand.
Horn. Morb. 1. vi. p. 161.; et Voigtel, Handbuch, &c.
1). ii. p. 9. ( IVater between the bones and dura tnater in
hydroinc children.) — Bierniayer, Museum Anatom. Pa-
tliolng. No. 94.; et Kilian, Anat. Untersuchung, he.
p. 127.; and Lobstein, Conipte-rendu sur les Travaux
Anatom. t. i. p. 56. {Layers qf dura mater separated by
blood, coagula, and pus.) — Stanley, Med. Cliirurg. So-
ciety's Trans, vol. iii. p. 24. {Dura mater hurst during
coughing seven months after trepanning.) — Boehmer, De
Ossificatione Dura? Matris, &c. 4to. Hala;, 1764. — Velten,
Casus aiiquot Ossificat. in Membr. Cerebri invent. Bon.

18'i5 Loder, Observat. Anatom. Tumoris Scirrhosi in

Basi Cranii, &c. 4to. Jena;, 1779. Pfranger, De Fungo

Dura; Matris, &c. Erf. 1801 A.B. llertel, Anat. Pathol.

de Cerel)ri et Meningum Tumoribns, 8vo. Ber. 1824

Otto. Selt. Beobaclituiigeji.t.ii. p. 86. No. 36. — Louis, Sur
les Tumeurs Fongeuses de la Dure Mere, in Mem. de
I'Acad. de Cliirurg. t. v. p. 1. Paris, 1774. -Meckel, Hand-
buch der Path. Anat. b. ii. 2. p. 324 Palletta, Exercitat.

Patholog. vol. i. p. 93-104.

ii. Alterations of the Arachnoid and Pia Mater.

— Piorri/.De I'lrritalion Encephalique des Enfans, &c.
I'aris, 1823 — Senn, Siir la Meningile.Aigue des Enians,
Ac. P.iris, 1825. — Parent-Duchatelet et Martinet, Sur
1' Inflammation de rAracimoid Cerebrale et Spinale, &c.
I'aris, XHIX. — Bai/le. Sur Meningitis Chronica, in Rev.
Med. Fev. 1825.; Meningitis Acuta, Ibid. 1827. — Cfrra-

drin. Hist. Anat. des Inflammat. 2. I. Paris, 1826 Ta-

cheron, Recherches Anat. Pathol, sur la Med. Prat. t. iii.

p. 4—36 Barl.hanscn, Bcobachtimgen iiber den Saiifer-

walinsiun, odor das Delirium Tremens. Brem. 18J8

I'ortal. Cours d'Anat. Meilicalo, t. iv. p. 7('. — Speranxa,
Anno Clinico-Medico. Parma, 1823, 1824.— iirf. Thomp-
son, in Lond. Mod. Repository, edit, by Copland, Nov.

1824. — Bnillie, Engravings, &c. fasc. x iye?txel, De-

I'eiiitiori Stnictura Cerebri, cai). i Pow'l, in Trans, of

("oil. of Pliys. vol. v. p. 234. {Karthy concretions in pia
tnater.) — Olfo, Selt Beoliaehtiiiigen, ^c., et Verzeich-
nis.s, SiC. passijii. ~ - K>iiiiinil, in Diet, des Seioiices Med.
t. viii. art. I)ri//,iirr. I Cysls conlaitii/ig li/iic in pia mater.)

— Asprcy, in Lond. Med. and I'liys, Jonrii. {Bony con-
cretions on each side.) — Nasse, Zeitsdirift f. Anthopo-
logie, 1823. p. II. <\\G. — Bnrdac/i, Beitriige, &c. b. ii.
p. 107. 2H7. (Hydatids, 8;c.) — Earle, in Med. Chirurg.

Trans, vol. xiii. No. 18. — Hooper, iVIorbid Anat. of the
Human Brain, 4to. London, 1828. — Abercromhie, On the
Brain, &c. Edin. 1828. — Monro, Morbid Anatomy of the
Brain in Hydrocephalus, &c. V.iXh\.\fi2^.— Bright, Medi-

BRAIN — Diseases of — Bibliog. and Refer.

243

cal Reports, vol. li. p. 680, et seq. — J. Davies, in Lond.
Med. Kepos. vol. xxiii. p. !.■>. — Piurry, in Med. Chir.
Rev. vol. xxviii. p. 252. — Pict,m Encyclographie des Sc.
Med. June, 1837. B. p. 177.— Lf?«o!nt', in Ibid. July,
1837. G. p. 100. — J. Qiuiin, Cyclop. Pract. Med. vol. i.
p. 282.

iii. Alterations of its .Simises and Veins Blasius,

Observat. Med. rarior. Ephemer. Nat. Cur. dec. i.ann. ix.

et X. obs. 25., et dec. iii. ann. i. p. 107 Stoll, Katio

Medendi, vol. i. p. 217 IVichinann, Idian zur Diagnos-

tik. b. iii. p. HI Lieutaiid, Hist. Anat. Med. 1. iii.

obs. \Gi.— Portal, Anatomie Medicale, t. iv. p. 22, et seq,

— Abercrombie, Edin. Med. and Surg. Journ. vol. xiv.
p. 577.; and Diseases of the Brain and Spinal Chord, 8vo.
p. 44. — M. Ribcs, Revue Medicale, t. iii. 1825. — .,1/. L.
Tonnelle, Memoire sur les Maladies des Sinus Veineux
de la Dure Mere, in Journal Hcbdomadaire de Med. t. v.

p. 337 Hooper, Morbid Anatomy of the Brain, 4t8.

Lond. 1828 Cruveilhier, Anatomie Fathologique,8ieme

livr. Paris, 1830.

II. Diseases of the Substance of the Brain. — i. Ce-
BEBRiTis. Inflammation, and its consequences, S;c. — J. C.
Brendelii, Resp. Ellenbergeri de Phrenitide. Goet. 1756.

— Schroeder, De Indole et Sede Phrenitidis et Para-
phrenit. Goet. \7G5.— Stoll, Ratio Medendi, par. iii. sect,
iii. — Fischer, De Cerebri ejusque Memb. Inflammat. et
Suppur. occulta. Goet. 1787 iV. Nicholls, Pract. Re-
marks on disordered States of the Cerebral Structures of

Infants, 12mo. Lond. 1821 Marcus, Entwurf einer Spe-

ciellen Therai)ie, t. ii. p. 554. — Z). A. G. Kichter, Die
Specielle Therapie, b. i. p. 44.5. — Hiidenbrand, Institut.

MedicEe Pract. t. iii. p. -^5 J. Fraiik, Praxeos Medicae

Univers. Prsecep. vol. i. p. ii. sect. i. p. 211. — J, C.Pritch-
ard, in Med. Gaz. vol. xviii. p. 871.

ii. Abscess ob Suppuration op the Brain. — Bartholin,
Hist. Anat. Med. Cent. ii. Hist. 34., et C. vi. Hist. 13.—
Camerariits, De Vomica Cerebri. Tiib. 1711 — Thoner,\n

Halter's Biblioth. Med. Pract. vol. iii. p. 22 Lieutaud,

Anat. Med. 1. iii. obs. 1131 Bianchi, Stor. Med. d' un

Apostemanel Cerebello. Rim. 1751 i{f««s, Repert. Com-
ment, vol. xii. p. 78., et vol. xv. p. 107. — Lallemand,
Letters ii. iii. and iv. passim. — Horn's Archiv f. Med.
Erfahr. 1813. March and April, p. 238. (Several instances
of, in the cerebellum, also with erosion of the bones.) —
Lajigier, Recueil de Med. et Chir. Milit. t. viii. p. 179.1820.
(Cerebellum.) — Bush, in Lond. Med. and Phys. Journ.
Dec. 1823. — Hamilton, in Trans, of Med. and Chir. Soc. of

Edin. vol.! Dickson.in Lond. Med. Repos., Oct. 1824. —

Cruveilhier, in Nouv. Biblioth. Med. Nov. 1826 — Frank,
Inter. Clin. vol. i. p. 142. — Itard, Traite des Malad. de

rOreille, &c. p. 70. Paris, 1821 Duncan, in Edin. Med.

and Surg. Journ. vol. xvii. p. 331. {Opened through the
sphen. and temp, bones.)— Otto, m Selt. Beob. part ii.p. 96.
(Six cases.) — Pretty, in Lond. Med. Repos. by Ccpla7td,
vol. XX. Sept. 1823. (Opened through the frontal bone.)

— C. J. Frank, in Ephem. Nat. Cur. dec. ii. an. vi.
obs. 193. (Discharged by the nose through carious sphen.
bone.) — Syme, in Ed. Med. and Surg. Journ. July, 1828.
(On the forehead.)— Raikem. Repert. Gen. d'Anat. et de
Physiol. Path. vol. i. No. 2. p. 295. (Discharged through
petrous and sphen. bones and nose.) — For various other
references to abscess in different parts of the brain, some
of them in connection with inflammation of the internal
ear, others passing through fistulous openings in the
skull, see the article Cerebrum, in Ploucquct's Medicina
Digesta, and Otto's Compendium of Pathological Ana-
tomy.

iii. Softening Roslan, Rech. sur une Maladie encore

Inconnue, &c. Paris, 1820. ; et Traite de Diagnostic, &c.
vol. ii. Paris, 1827. — Cruveilhier, La Med. Eclairee par
I'Anat. Pathol, cah. i. Paris, 1821. — Lallemand, Rech.
Anat. Pathol, sur I'Encephale, &c. lettre i. et ii. Paris,
1820. — A. G. Herbst, De Eniephalomacia. Halae, 1825.
— Burdach, Vom Baue des Gehirns, vol. iii. p. •'534. (Con-
tains numerous cases, original and quoted.)— Guibert, in
Rev. Med. March, 1828. — Foville, art. Encephale, in
Diet, de Med. et Chir. Prat. t. \\\.— Cruveilhier, Op. cit.

iv. Sphacelus. — Lyserus, De .Sphacelo Cerebri. Lips.
IG.56.— -W. Cristin, Revue Med. t. ii. p. 302. 1825.— G>e-
ding, Samnitl. Medic. Schrift. b. i. p. 306. Gangrene is ob-
viously a post mortem change, as death must take place
before it could supervene as a consequence of acute in-
flammation. It may however occur alter severe wounds,
or injuries of the head, particularly in hospitals, when
hospital gangrene is prevalent ; as in the case recorded
by iNIr. Copland Hutchison. See Pract. Observat. on
Surgery, 2d ed. p. 203.

v. Hvi'ERTUorHY. — Hallcr, Element. Physiol, vol. iv. p.

10 Hebenslrcit, in Halter's Coll. Dissert. .'\nat. vol. vi.

p. 335. — Penchienati, in Mem. de Turin, vol. iv. p. 118.

— MeckeVs Handbuch der Pathol. Anat. b. i. p. 298.—
Scoutettcn, in Archives Gen. de Med. t. vii. p. 31 — Otto,
in Selt. Beob. part i.p. 106. — Dance, Journ. des Progres
des Scien. Med. t. xi. p. 'ai.—Jadelot, in Journ. de Med.
t. vi. p. 3.—Hufeland, Rev. Med. t. i. p. 130. 1825.— i'or-
tal, Ohserv. sur la Nature et Traitera. de I'Epilepsie.
Paris, 1827.

vi. Htpertbophy of Pineal GtxtiD. — Mangel, Theat.

Anat. 1. iv. c. ii. p. 309 Morgagni, Epist. i. 14., x. 17.,

xxi. 24 Lieutaud, Hist. Anat. Med. 1. iii. obs. 177—210.

381. — Desportes, Hist, des Malad. de St. Domingue,
vol. ii. p. 209. — Angeli, Osservaz. INled. Prat, et Chir.
Imol. 1793. vol.i. p. •n. — Greding, Sammtl. Med. Schrif-
ten, &c. b. i. p. 318. — Blane, Trans, of Soc. for Improv.
&c. Lond. vol. ii. p. 16.

vii. Hypertrophy, S.c. of Pituitary Gland. — De
Hacn, Rat. Med. vol. vi. p. 211. — Grcding, p. 282.—
Horn's Archiv f. Med. Erfahrung, 1815, par. iii. p. 463.
— Baillie, Morbid Anatomy, 4to. ed. p. 460. — Oppcrt, De
VitJis Nervorum Organicis, p. W.—Ward, in Lond. Med.
Repos. p. 217. vol. xx. — Bullier, in Archives Gener. de
Med. Oct. 1823, p. 302. — Bayer, in Ibid. Nov. p. 350.—
Neumann, in Hufeland Journ. No. 45. p. 46. July, 1824.
— li'enzel, Beobacht. iiber den Hirnanhang fallsiichtiger
Personen, 4to. Mainz. 1810, p. 74. ; et de Penit. Struct.
Cerebri, p. 114.

viii. Atrophy Willis, Cerebri Anat., in Opera Omnia,

4to. Amst. p. 14. — Morgagni, Epist. ix. 20., xL 1 1., Ix. 4 —
Rocderer, Observ. de Cerebro, p. 5. Got. 1758 — Sandifort,

Museum Anatomicum, vol. iii. p. 305 Otto, Selt Beob.

part i. p. 106. — Kaltschnzid, in Halter's Disput. Pathol.

vol. vii. p. 484 Mier, in Samml. Auserl. Abhandl. b.xi.

p. 214. — Meckel, Anat. Phys, Beobach. und Untersuch.
&c. p. 135. 1822 — Glover, in Philad. Med. Journ. vol. ii.
p. 1 — Saveresy, De la Fidvre Jaune, p. 158. — Horn, Ar-
chiv f. Med. Erfahrung, b. xxii. — Biermayer, Mus.
Anat. Path. No. 247. — VVenzel, De Penit. Cerebri Struc-
tura, p. 102. et 136. — Cazauvieilh, Archives Gen. de Med.
t. xiv. p. 582. ; Edin. Med. and Surg. Journ. vol. xliv.
p. 527 — Cruveilhier, Anat. Tath. passi7n.
ix. Induration. — Morgagni, Epist. viii. el seq., Epist.

Ixi. 8 Meckel, in Mem. de I'Acadcm. de Berlin, 1766. —

Lallemand, Opus. cit. lett. ii. etiii Portal, Cours d'Ana-

tomie Medicale, t. iv. p. 90 P;MW,fils,Recherches d' Ana-
tomie Pathologique, sur rEiidurcissement du Systeme
Nerveux. Paris, 1822 ; et Recherches sur les Causes
Physique de I'Aberration Mentale, in Magendie's Journ.

de Physiologic, No. i. p. 44. 1826 Heusinger, in Zeit-

schrift fiir Organ. Physik. p. 382. April, imS. — Bouil-
land, Sur I'lnduration Generate de la Substance de Cer-
veau, consideree comme un des Effets de I'Encephalite
Generale Aigue, in Archives Gener. de Mtd. 1825. —
Abercrombie, On the Diseases of the Brain, &c. 2d edit.
Case 18. — Craigie, Elementsof General and Pathological
Anatomy, p. 438. Edin. 1828. — Andral, Anatomie Pa-
thologique, &c. t. ii Hooper, Morbid Anatomy of the

Human Brain, 4to. p. 16 l>oiid. 1828.— BrigAZ, Medical
Reports, vol. ii. ; and Diseases of the Brain and Nervous
System, p. 664. Lond. 1831.

X. Tumours. IniheSubstanceof the Brain. — Mo}-gagm',
Epist. Iii. 15. (Scirrhics in cerebellum.) — Meckel, in
Mem. de I'Acad. de Berlin, 1754, p. 74. (Scirrhus) ;
Ibid. 1761, p. 61. {Scirrhus cerebeUi) ; Ibid. 1764, p. 84.
(Scirrhus.) — Holier, Oper. Minora, vol. iii. p. 282. (Scir-
rhus cerebelli.)—Baader, in Sandifort's Thesaurus, vol. iii.
p. 38. (Fatty.) — Gendri7i, Sur les Tubercles du Cerveau
et de la Moelle, &c. 8vo. Broch. Paris. — Zinn, in Com.

Soc. Reg. Sclent. Gott. vol. ii. 1752 LeveilN, Recherches

sur les Tubercles du Cerveau. Paris, 1824. — Burdach,

Vom Baue u. Leben des Gehirns, b. iii. p. 643 Chomel,

in Nouv. Journ. de Med. Mars, 1818, p. 1 Rose, in

Lond. Med. Repos. No. Ixi. p. 12 — Latham, in Med. and
Physical Journ. July, 1826 Bouillaud, Traite de I'En-
cephalite. Paris, 1825. (Scirrhus.)— Cruveilhier, in'SoM\.
Biblioth. de Med. Nov. 1825 j et Anatora. Patholog.
liv. ii. pi. vi. (Fatty tumours.) — Hawkins, in Med. and

Pliys. Journ. July, 1826 i/orw, in Archiv f. Med. Erfah.

March and April, 1813, p. 23S. — Nyslen, in Bullet, de la

Facult. de Med. 1816, p. 183 Biermayer, Mus. Anat.

Patholog. No. 74. (Scirrhus.) — Meckel, in Archiv f. d.
Physiol, b. iii. p. 190. (Fatty.) — Tacheron, Rech. Anat.
Path. vol. iii. p. 45. and 381. (Tubercles.)— Ward, in
Lond. Med. Repository, vol. xx. p. 217., and April and
June, 1824. (Pituitary gland, and in cerebellum.) — Bcll-
mer, De CerebeUi Degenerationibus. Bon, 1825. (Tu-
bercles, ^c.) — Berg, De Tumor, et Ossificat. CerebeUi.
Lips. 1826. (Osseous, SiC.) — Bergmann, in Mende's Beob.
und Beinerk. &c. b. iii. Gott. 1826. (Calcareous.) —
Mayer, De Tumoribus Cerebri, 4to. plates. Berol. 1829.
— Otto, Selt. Beobach. part i. p. 107., part ii. p. 94. &c.
(Eight instances, scrofulous and steatomatous .) — Scheider,
De Encephali Destructione, kc. Berol. 1823. {Steatoma-
tous)— Fantoni, Opuscul. Med. et Phys. p. 22- {Hy-
gro7na.) — Berdot, Acta Helvet. Phys. Sled. vol. v. p. 183.
(Hygroma.) — Portal, Anatom. Meil. vol. iv. p. 41. (Hy-
groma.) — Ueiitdoif, De Hydatidibus in Corp. Human.

prses. in Cerebro rrpertis, p. 36. Bcr. 1822 Bailey,

in Lond. Died Repos. Feb. 1826. — Otto, \'erzeichn.
No. 2891. (Fatty tumour in the hemisphere, containing
hair.) — Ozanam, in Journ. Complein. du Diet, des Scien.
Med. t. xix. p. 189. (Tubercles.) — Wardrop, On Fungus
Haematodes, &c. passim. ( Fungus hwmatodes. ) — Hunter,
Trans. Med. Chirurg. Soc. vol. xiii. p. 1. and 88. {Medul-
lary sarcoma.)— Rambclli, Archives Gt'n. de Med. t. xvli.
R 2

BRONCHI AND AIR-PASSAGES — ALXEnATioNs of the.

244

p. 97. [Scirrhus.') — Btifour, in Ibid. t. xvii. p. 242. —
VVedemeyer, in Rev. Med. t. i. p. 134. ]S26. — Balli/, in
Ibid. t. Hi. p. 35. 1224. {Ci/sts in.)— Otto, Selt. Beobach.
part ii. p. 90 ; and Verzeichn. &c. (Three cases of fun-
g7is h(Ematodes.) — Bright, Medical Reports, vol. ii.
p. (i-if^.—Abercrombie, On the Diseases of the Brani, &c.
p. i2H. — Calmiel, Jouin. Hebdom. de Med. t. i. p. 44.
{Hydatids.) „. ^

xi. Rtji TOKE OF THE Braiv.— M'cAW, Vom Himbruche
in Handb. der Pathol. Anatoin. t. i. p. 302. ; Ibid, in Ar-
chiv fiir die Physiologie, vol. vii. p. 139. ; et Rathke, in
Ibid. t. vii. p. 481. — Walter, Museum Anatora. Berol.
1803, p. 275. — Osiander. in Gotting. Gelchst. Anzeiger,
1812, No. c\x\\x. — Beclard, Bulletin de la Faculte de

Med. t. iii. p. 292. iutenrieth, in Tubinger BUittern,

vol. ii. p. 273.— Palletta, Exercitationes Pathologicje,

t. i. p. 127 Ehrmann, in Repertoire Gen. d'Anat.

&c. Phys. Pathol, t. iv. \i.'lh. — Martini, in Repertorio
Medico-Chirurgico di Torino, No. lix. — Otto, in Selt.
Beobach. part ii. p. 157. - Billard, Traite des Maladies
des Enfans Nouveau-iies, &c. 8vo. Paris, \»•>f^.— Merye,
in Archives Gen. de Med. Jul. 1827. — Geoffroy St. Hi-
laire, in Ibid. July, 1827 ; et Philosophie Anatomique.
Paris, 1822.— WccArt"/, in Pathol. Anatom. vol. i. p. 292. ;
et Archiv f. d. Phvsiol. b. vii. p. 99.— EaW<', in Medico-
Chirurg. Soc. Trans, vol. vii. p. 427. — Stanly, in Ibid.

vol. viii. p. 12 Thompson, in Lond. Med. Repos. Nov.

1824 Workman, in Ibid. vol. iii. No. xviii. — Spalding,

in New. Eng. Journ.of Med. and Surgery. Jan. 1M20.

xii. LiACERArioN irnemann, Versucheiiber das Ge-

hirn und Ruchenmark. Got. 1787 — Burdnch, Vom Baue
und Leben des Gehirns, b. iii. p. 501.- Copland Hutchi-
son, Practical Observat. on Surgery, Treat. 4 — Brodie. in
Med. Chirurg. Trans, vol. xiv. Lond. 1828.— 0«o, Ver-
zeichn. No. 2891.

xiii. Alterations of Colour. — Sloll, Ratio Medendi,
vol. iii. p. 11. — Lallemnnd, Recherche; Anat. Patholog.
sur I'Encephale et ses Depend. Paris, 1821-29. — Billard,
in Archives Gen. de Med. t. ix. Dec. 182.5, p. 492.—
Bright, Medical Reports, vol. ii. part ii. p. 070.

BRONCHI, Diseases of the. — Syn. BpoVxos,
Gr. Bronchus, Bronchia, Lat. Bronche, Fr.
Die Luftrohreniiste, Ger. Bronchi, Ital. Air-
passages, Air-tubes, Eng.

1. Bronchi and Aiii-Tuees. — Their Altera-
tions. Under this hea'l, the alterations of .struc-
ture usually found in the air-tubes, from the la-
rynx to the suiallest subdivisions of the bronchi

.will be first considered, and subsequently the his-
tory of such of them as are more immediately

• seated in the bronchi, and are not treated under
distinct heads, where some of them are placed,
owing to their specific nature, and their relations
to other part-:.

2. I. Altedations of Structure in the
Bronchi. — As the same lesions are found in the
larynx and trachea, as in the bronchi, although
certain of tliem are more frequent in one part
than in another, no paiticular distinction depend-
ing on locality merely will be made, in order that
repetitions may be avoided.

3. i. Alterations of the Mucous INIkmbrane
OF the Air-passages. — These are the same in
kind from the glottis to the air-cells, whether the
vascularity, the structure, or the secretions of this
memlirane, be individually or collectively changeil.
A. Passive or simple, congestion of this surface
is not unfrequeiitly found after death; and there
is every reason to believe that it may take place
during life, or at the moment of death, or even
be a post mortem change. When occurring
during life, it is most frequently met with in the
debilitnteil, and when the return of blood to the
left side of the heart has been impeded. Simi)ie
congestion of this membrane may be either p:ir-
tial or general. When general, and at the same
lime suddenly and inteusf'ly formed, it may ter-
minate life with all the symptoms of asphyxy.
(See Conoesiion of the Bronchi.) In a slighter
form it aci'.ompanies various diseases, particularly
the febiile exanthemata; but it is seldom found
in a chronic form. Congestion of this membrane

presents various depths of shade, varying from a
dirty pale red, or a brick red, to a brownish or
purplish hue ; being sometimes equally deep
throughout, in others of a different shade in dif-
ferent situations.

4. B. Injiammatory injection, or active conges-
tion of the bronchial surface, is generally ptu-fw/,
or affects one part of the air-passages more than
another. It is also of a livelier colour, and is
usually attended with some of the changes here-
after to be noticed. Partial or inflammatory
redness of the mucous membrane is very much
more common than general congestion. It may
be limited to the trachea and larynx, whilst the
bronchi are pale ; and in this case it may be con-
fined to one side of the tube. M. Andral has
seen it cease abruptly at the median line, parti-
cularly when one lung was affected ; and then
the inflamed side of the trachea has corresponded
with the diseased lung. The redness may also
be confined to the large bronchi, the mucous
surface of the passages above and below its seat
being pale ; or it may be limited to the smaller
bronchi, where it often occasions great dyspnoea
and fever, with little or no cough. According to
M. Bkoussais, the bronchi of the upper lobes
are most frequently congested and inflamed.
Congestion and inflammatory injection of the
bronchial mucous membrane, alihough very often
connected with diseases of the substance of the
lungs, are not necessarily dependent on any of
them ; for this membrane may be pale from
the glottis downwards in cases of acute, and still
more in chronic, pneumonia. The same obtains
in respect of tubercles, previously to their soften-
ing. In many cases, however, where tubercles
exist in the lungs, the surfaces of the smaller
bronchi are more or less inflamed or congested ;
and when the tubercles have advanced to soften-
ing, the bronchi nearest them are almost always
red. VVh(ire tubercular excavations exist, the
redness is still more marked and extensive, some-
limes proceeding along the trachea to the larynx :
bronchitis thus supervening to tubercular phthi-
sis. In these and various other diseases, the
inflammatory state of the mucous surface com-
mences in the smaller ramifications, and spreads
upwards to the glotti.s. But in other maladies,
pariiculaily tiiose which first afl^ect the Schnei-
derian membrane, throat, fauces, pharynx, &c.,
ihe injection of the bronchial surface is chiefly an
extension of these ; inflammatory action more
frequently originating in some one of these situa-
tions, and extending itself more or less rapidly,
a(;cording to the state of the patient, along the
surfiice of the larynx, trachea, and large bronchi
successively, until it at last reaches the minute
bronchi, or even the air-cells and structure of the
lungs. This is the usual diiection in which in-
flammation of the mucous membrane of the air-
pas.sages commences and extends itself; but most
frequently without reaching the smallei bronchial
ramifications, and pulmonary parenchyma.

5. C Thickennig of the mucous membrane of
the air-passages is a very common le-ion, arising,
1st, from its congested or injected state; and, 2d,
from its iiicTcased nutrition or hypertrophy. — a.
'J'he former i-, most frequently observed in the
larynx and small bronchi : it is sometimes found
in children about the margin of the glottis, giving
rise to a form of croup. — /*. True thickening, or
hypertrojihy of this membrane, occurs in various

BRONCHI AND AIR-PASSAGES — Alterations of the.

245

situations, occasioning very different phenomena
accordingly, particularly in those who had been
affected with chronic coughs. This form of thick-
ening may extend througliout the larynx, or may
be limited to the epiglottis, to the entrance of the
glottis, to the chordee vocales, or to the ventricles.
In the trachea it may occasion no marked sym-
ptom ; but in the bronciii, particularly the smaller,
il gives rise to sensible alterations of the sound of
the pulmonary expansion. It may, when extensive,
very materially impede the changes produced by
respiration on the blood. Hypertrophy of this mem-
brane may also be confined to a circumscribed
point, forming thus a tumour rising above the sur-
rounding surface. 'I'his form of thickening may
assume a nearly cauliflower appearance, from ils
exuberance. These excrescences have been found
in the larynx by MM. Andral and Ferrus.

6. The mucous follicles may be enlarged inde-
pendently of the membrane in which they aie
seated. When this is the case, a number of
round granular bodies, of either a white, red, or
daikbrown colour, are found ou the internal sur-
face of the membrane, surrounded by two coloured
circles — one round the centre, the other roun<l
the base. M. Andrai. thinks that they have often
been mistaken for tubercles, and for the variolous
eruption.

7. C. Other alterations of structure in the re-
spiratory mucous membrane. — a. Atrophy is said
by Andrai, sometimes to be observed in this
membrane. — b. Softening is much more frequent j
and is most common in the larynx, especially in
the situation of the chordae vocales and ventricles,
where itis sometimes very remarkable, and has been
the only change of these parts observed in ])er-
sons who had either lost their voice or been hoarse
long before death. — c. Ulceration is not infre-
quently found in this membrane. Ulcers may
be seated in any pait of the air-passages, but are
more common in the larynx than in the trachea
or bronchi. They rarely, however, occur in the
larynx, without tubercidar ulceration existing also
in the substance of the lungs. They occasion
various modifications of the voice, according to
the parts of the larynx in which they are situ-
ated ; being found in every point of its internal
surface. Their size and number vary excted-
ingly. Sometimes only one very small ulcer is
found, the rest of the larynx being in all other re-
spects quite natural. In other cases, this part is
nearly destroyed by numerous ulcers of various
shapes and sizes ; and in some cases, one large
ulcer extends over one half or more of the larynx.
Ulcers, when seated in the trachea, are chiefiy
found in its posterior or membranous part. AI.
Andral states, that in some cases they are con-
fined to one side of the trachea, which invariably
corresponds to the diseased lung ; or, if both
lungs be diseased, to that which is most affected.
Ulcers are not so frequent in the bronchi as in the
larynx, but more so than in the tiachea.

8. Ulcers in the internal surface of the air-
passages sometimes extend no deeper than the
cellular tissue connecting the mucous membrane
to the subjacent parts. In this case the con-
necting tissue is much thickened at the bottom of
the ulcer. But they frequently proceed deeper,
destroying successively tlie different tissues, until
the parietes of the tube are at last perforated, and
a fistulous opening is formed between it aad some

neighbouring organ or part, as the oesophagus,
aorta, parenchyma of the lungs, large blood-
vessels, the pleural cavity, &c., or even the ex-
ternal surface ; forming, in this last case, a direct
communication betv-.een its interior and the ex-
ternal air. When a fistulous opening extends
into an excavation in the parenchyma of the lungs,
it is difficult to determine whether it produced,
or was itself occasioned by, the excavation. When
it is connected with a cavity arising from the
liquefaction of tubercular masses, there can sel-
dom be much difficulty in determining the pre(;e-
dency ; but every cavity found in the lungs has
not this origin. There can be no doubt that ul-
cers perforating a bionchial tube may excite in-
flammation of the substance of the lungs, and
occasion either small abscesses, or ulcerations,
which enlarge into considerable excavations.
But, iu the majority of cases, excavations com-
municating with the bronchi arise from the soft-
ening of tubercles ; the bronchi being perforated
from without inwards, instead of Ir^m within out-
wards, as in the case of ulceration commencing
in their mucous surface. The bronchi or trachea
may be also perforated from without inwards, I y
anturisms, &c. of the aorta, and not infrequently
by ulceration commencing in the oesophagus and
extending through the membranous part of the
tiachea ; an instance of which I lately had an op-
portunity of seeing in a patient of my friend, Mr.
BvAM. Suppuiated bronchial glands may also
perforate the bronchi which they surround, and
pour their contents into them. A similar result
may likewise occur fiom purulent collections, hy-
datid formations, &c. of adjoining parts, as of the
thyroid gland ; instances of which are recorded by
Portal and Andral.

9. D. Alterations of the secretions of the air-
tubes. — M. Andral has very justly stated that
alterations may occur, 1st, in the gaseous secre-
tion ; 2d, in the perspiratory exhalation ; and,
3d, in the mucous secretion.— ^ a. Changes of the
gaseous exhalations are but little understood, and
are more matters of inference than of demonstra-
tion. There can be no doubt, however, that not
only in various diseases, but also in certain states
of the system and of the atmosphere, a very ma-
terial alteration occurs in the proportions of the
different gases naturally exhaled by the mucous
surface of the lungs. That the successive changes
in the system, certain conditions of temperature
and of the air, different states of vital energy,
and the constitutional differences in the various
races of our species, modify very materially the
quantity of carbonic acid gas and of azote ex-
haled from the lungs, may be considered amoncrst
the surest established facts in physiology. (See
my Notes, &;c. p. 626.) Such being the case, it may
reasonably be inferred that marked alterations of
the gaseous exhalations al-o take place in disease.

10. 6. The perspiratory exhalations evidently
undergo changes in disease ; but their nature and
extent are but little known. The vapour exhaled
from the respiratory mucous surface very probably
may, when excessive, be condensed into a liquid
state, and increase the watery fluid sometimes
discharged from the lungs. AI. Alibert states
that he has seen, in certain diseases of the skin in
which the cutaneous transpiration is suppressed
the pulmonary vapour issuing like steam from the
chest, and descending again like an abundant

113

BRONCHI AND AIR-PASSAGES— Alterations of the.

246

dew. M. Andral adduces, in his Clinique Me-
dicale, the case of a person who suddenly dis-
charged, whilst suffering from hydrothorax, an
enormous quantity of a serous fluid from tlie
bronchi, at the same time that the fluid which
had been effused in the chest was absorbed,

11. c. Alterations of the mucous secretion of
the bronchi have been successfully studied by a
riuraber of modern pathologists, but more par-
ticularly by M. Andkal. This secretion is mo-
dified both in its quantity and quality. It is
often very greatly increased in acute and chronic
affections, particularly those immediately affect-
ing the respiratory passages ; under which heads
the principal changes of this secretion, with
the different states and stages of disease, are de-
scribed. The quantity of the mucous secretion
may be so excessive, as to nearly fill up the
bronchi, trachea, and larynx, and to suffocate the
patient. This sometimes occurs in adults ; but, I
believe, still more frequently in children, forming
in one of its states a species of croup intermediate
between true croup and bronchitis ; and, in an-
other state, the disease hereafter described as
asthenic bronchitis. M. Blaud considers the
former, or that seated chiefly in the large bronchi,
in which the secretion is consistent and glairy, a
" form of croup, and calls it croup myxagene."
This excessive secretion of mucus is sometimes
unattended by any alteration of the air-passages.
The mucous secretion may become so viscid as
to adhere to the sides of the bronchi ; where it
may accumulate so as to occasion a fatal dyspncea,
by preventing the passage of the air. In other
cases, the mucus is transformed into a puiiform
fluid ; sometimes without any trace of ulceration,
or even of redness, in any of the bronchi, the
alteration of the secretion being independent of
any perceptible change of structure. More com-
monly, however, patches, streaks, or points of
inflammatory injection of the mucous membrane
accompany this state of secretion.

12. d. Membraniform concretions, or false mem-
branes, form more frequently upon the internal
surface of the air-passages than in any other
raucous canal. Some pathologists have supposed
them to be consequent on the most intense states
of inflammatory action in mucous membranes;
but this is evidently not the case : they are rather
a result of a certain state of the system, probably
connected with excess of the albuminous con-
stituent in the blood, together with a disposition
in the inflamed vessels to secrete it (see art.
Croup). These membranes are generally un-
organised, and vary in thickness and consistence
in different parts as well as in different cases.
According to Schwilgue, they consist of albumen,
with a small portion of carbonate of soda and
sulphate of lime. M. Buetonnkau has detected
iibrine in them. They may exist in patches, or in
continuous layers, or in perfect tubes ; and ex-
tend from the larynx, where they usually com-
jnence, to the minute divisions of the bronchi.
Tiiey rarely originate in this latter situation, and
advance upwards ; but they often commence in
the pharynx, fauces, &c., and extend ,'through
the glottis, and down the trachea and bronchi.
They are most frequently met with in children
from two years of age to puberty; and are not
confined to, altiiough moht fre(|uent in, acute
diseases. In some cases they assume, in children,
a chronic character, but only when confined to

the trachea ; whilst a chronic state is most com-
mon in adults, when they are usually formed
in the bronchi. When, however, they occur in
the larynx, the tumefaction of the subjacent mem-
brane, the spasms of the muscles, and their own
thickness, often give rise to an acute or fatal dis-
ease. When seated in many of the small bronchi,
they may occasion asphyxy by interrupting the
changes produced by the air on the blood. It is
probable {haXjibrinous or polypoiis concretions may
sometimes form in the bronchi, from the coagulation
of a portion of blood exhaled from its mucous sur-
face. Laennec has described {Rev. MM. 1824,
t. i. p. 384.) a case which appears to be of this de-
scription. Such formations differ from the albumi-
nous exudations, in their containing much fibrine,
and being of a darker colour than the latter.

13. e. Earthy or calcareous concretions occa-
sionally are found in the air-passages, and are
sometimes coughed up. They consist chiefly of
phosphate of lime ; and are formed either in the
substance of the lungs, and escape into the
bronchi, or in the latter; but more probably in
the air-cells. They also have been found im-
pacted in the ventricles of the larynx. The cause
of their formation is not well understood. They
have been ascribed to chronic irritation of the small
bronchi and air-cells ; but this source is by no
means well established. I have met with them in
gouty persons, by whom particularly they are
often expectorated during life, recovery generally
taking place. Hydatids have also been found in
the air-tubes. In some cases they may have been
developed in this situation ; but they much oftener
escape into it from contiguous parts.

14. f. H(Em,orrhage from the respiratory surf aces
is amongst the most frequent changes to which it
is subject. In the greatest number of cases of hcc'
moptysis, the blood is exuded without any ulcera-
tion or breach of surface : a slight redness of the
mucous membrane being the only change that can
be detected. When the haemorrhage occurs in the
smaller bronchi, the blood sometimes accumulates
and coagulates in them ; imparting a blackish or
brownish black appearance to the lobules, and
constituting the pulmonary apoplexy of Laennec.
The occurrence of haemorrhage into the paren-
chyma of the lungs, is, however, more strictly
deserving of this appellation. The extravasation
and coagulation of blood in the small bronchi,
giving to portions of the lung a blackish and in-
durated appearance, are most commonly, but not
always, found in persons who have expectorated
blood, or died from an attack of haemoptysis ;
and are most frequent in those cases which super-
vene in the progress of diseases of the heart.
M. Andral considers, however, that the haemop-
tysis is not from those sources which have been
called apoplectic ; but from a larger extent of
mucous surface, and from larger tubes. (See art.
Lungs — Alterations of , and Hemorrhage from. ^

15. ii. Alteuaiions of tue other Structures
COMPOSING THE AfR-TUBES. — A. The fibroiis and
muscular tissues of the air-passages experience
various changes.— a. The fbrous structure of the
bronchi is sometimes found either softened or
hypertrophied. The thyro-arytenoid ligament is
occasionally softened. It has then lost its bril-
liant colour, become opaque, or even changed
into a cellular-like tissue, or an unorganised pulpy
substance, leaving the thyro-arlcnoid muscle
exposed. In this case the voice is remarkably

BRONCHI AND AIR-PASSAGES — Alterations of the.

247

altered. Wlien the fibrous tissue is hypertrophied,
increase of thickness is the chief appearance
(Andral). — b. The imiscular structure, as it
exists in the trachea, Sec, may be either atrophied
or hypertrophied ; it may also be softened and
destroyed partially or in points by ulceration
(§ 7, 8.). But it is chiefly where this structure
assumes a different state and function, as in the
larynx, that it undergoes marked alterations, giving
rise to the most formidable and fatal diseases. The
muscles of the larynx are, in some of those cases,
softened, more or less atrophied, or even alto-
gether destroyed ; and, in others, infiltrated with
either purulent or tubercular matter (Bouillaud,
Andral, and others). — ]M. Andral states, that
he has more than once observed, on examining
the larynx of persons who had been long com-
pletely without voice, the thyro-arytenoid muscle
either remarkably atrophied, or its fibres infiltrated
by different morbid secretions ; this being the only
lesion tiiat could be detected.

16, B. The cartiUigiiwus structures of the air-
passages are most frecjiiently diseased in the larynx.
The cartilage of the epiglottis sometimes loses its
natural form : it is scarcely ever ossified ; but it
is occasionally somewhat indurated, so that it
imperfectly protects the opening of the larynx.
It is not infrequently destroyed altogether by ul-
ceration, commencing either in itself, or in the
tissues enveloping it. Similar changes to these
sometimes take place in the other cartilages of the
larynx. Ulceration of these cartilages may be
superficial only ; or it may destroy more or less
of their structure. It generally commences in
the soft parts covering them ; but in some cases,
particularly of constitutional taint, there is reason
to suppose that it originates in inflammation of
the cartilages tiiemselves, terminating in the ulcer-
ative process, and the formation of purulent mat-
ter in the soft parts adjoining, which escapes by
a fistulous opening, generally through the mucous
surface into the larynx, and rarely externally.
Ulceration may also commence in the articula-
tions of the cartilages ; filling them with pus, and
destroying their ligaments and articulating sur-
faces. The thyroid and crycoid cartilages are
naturally ossified in old age; and in consequence
of disease, in earlier life. iVI. Axdral states, that
tiie arytenoid cartilages have never been ossified.
The rings of the trachea are sometimes ossified,
but seldom or ever otherwise altered. The car-
tilages of the bronchi are often hypertrophied,
becoming more apparent, and forming more com-
plete rings, than natural. They are also sometimes
ossified. MM. Reynauu and Andral found the
ultimate ramifications of the bronchi changed into
osseous spiculffi, with minute canals (the cavities
of the bronchi) running througii them, in very
old subjects. M. Andral states, that the bronchial
cartilages may become so brittle from disease, as
to break into fragments, project into the canal of
the bronchi, or become altogether detached, and
be ultimately expectorated.

17. C. The cellular tissue connecting the
above structures is often the seat of disease. In
the larynx, it is very frequently the seat of in-
flammation and congestion; and, in consequence
of a chronic state of inflammatory action, it some-
times becomes indurated and thickened ; diminish-
ing remarkably the calibre of the glottis, impeding
the action of the muscles, and affecting the form

and movements of the epiglottis. This tissue, in
the situation of the larynx and epiglottis, is occa-
sionally infiltrated with serum, which, when con-
siderable, constitutes the wdema of the glottis,
first accurately described by IUyle. The infil-
tration may distend the folds of mucous membrane,
surrounding the rinia of the glottis, so as to ob-
struct more or less the passage through it. This
change is generally consecutive of inflammation
of the mucous membrane of the larynx, or of
chronic aflections of this organ. In some cases
it is very chronic ; in others very acute, quickly
producing asphyxy. Instances of this latter form
are to be found in the sixth volume of the Archives
Generaks de Mcdecine, and twenty-second volume
of the London Medical Repository. Purulent
matter is sometimes found in the cellular tissue
of the air-vessels, either in the state of small abs-
cesses, or infiltrating it to a greater or less extent;
and either in the ventricles of the larynx, or in
any other situation in the course of the air-passages.
Tubercular matter has also been found in various
parts of this tissue. Different kinds of tumours
occasionally compress the nerves supplying the
air-vessels, and give rise to symptoms similar to
those caused by disease of their parietes. They
are sometimes formed in the larynx, or in its im-
mediate vicinity, occasioning more or less com-
plete occlusion of the glot:is. M. Ferrus has
recorded a case where this result followed the
developement of two fungous tumours in the larynx
(Archives Gtntr. Aout, 1824). Several writers
have made mention of a varicose state of the veins
of the air-passages amongst the causes of haemop-
tysis; but M. Andral states that he has never
met with this appearance in his numerous post
mortem inspections.

18. iii. Alterations of the Size or Calibre
OF THE Air-vessels. — The changes already de-
scribed very often cause marked change in the
air-tubes, either diminishing or increasing their
calibre. — A. Diminution of their canals are occa-
sioned,—o. by the formation of false membranes,
chiefly in the larynx and trachea of children, and
in the bronchi of adults ;— 6. by thickening of the
mucous membrane ; occurring principally in the
glottis and bronchi ; — c. by infiltration of fluids
into the sub-mucous cellular tissue, chiefly in the
larynx and vicinity; — rf. by various substances
formed in some part of these tubes, such as hyda-
tids, coagula of blood, concrete mucus, &c.; — e. by
compression by some tumour situated externally
to some portion of them, as by the thyroid gland,
an aneurismal tumour, or enlarged bronchial
glands. — f. Lastly, there is every reason to con-
clude, that diminution or constriction of some part
of these passages very often arises, althouo-h
seldom in so permanent a manner as to be ob-
served after death, from spastic contraction of
the fibres or muscles belonging to them ; particu-
larly when foreign bodies escape into the trachea,
or when it, the larynx, and even the bronchi, are
irritated by morbid pioductions — the larynx more
especially.

19. B. Dilatation of the In-onchi was first de-
scribed by Laennec, and afterwards illustrated
by Andral and others. It is most frequently
observed in the smaller ramifications ; and may-
be so great as to be mistaken for tuberculous ex-
cavations.— a. In some cases, the bronchi may bo
uniformly dilated throughout one or more of their

R 4

248

BRONCHI — Congestion of the— Treatment.

ramifications, some of those which could not na-
turally receive a fine probe, having attained the
size of a goose-quill ; and, in some instances, even
admitting the finger. These dilated branches are
sometimes visible on the surface of the lung, where
they terminate abruptly. They occasionally also
terminate, particularly near the top of the lung,
in an indurated black portion of its substance, or
in a cartilaginous mass, or in a calcareous concre-
tion, either exterior or interior to the dilated
bronchi. — b. In other cases, the dilatation is
limited to a particular point of the tube, and has
the appearance of an excavated cavity in the sub-
stance of the lung, for which it may be mistaken,
especially when it is met with in the upper lobe.
The size of cavities arising from this species of
dilatation varies from that of a hemp-seed to that
of an egg. Several of these may co-exist. When
they are placed near each other, they form, by
their communication, a complicated sinus filled
with puriform mucus, and closely resemble some
kinds of tuberculous excavations. — e. Occasion-
ally they present a third form, consisting of a
succession of dilatations, between each of which
the bronchus recovers its natural, diameter, the
walls of the dilated portion being generally thin
and transparent. One lung may contain a num-
ber of these dilatations. — d. The parietes of the
dilated bronchi are, in some cases, hypertrophied,
or more fully developed than in the natural state ;
in other cases they are reduced to a delicate
membrane, presenting neither fibrous nor cartila-
ginous tissue. (Andral.) The dilated portions
generally contain much mucus, or a puriform
mucus.

20. These changes of the bronchi are seldom
found, unless in persons who had suflFered attacks
of chronic bronchitis. They are most common
in persons of middle or advanced age. But they
are also someiimes met with in children who had
died of hooping-cough, particularly in its more
chronic states, and when complicated with bron-
chitis. I have occasionally found them in this
class of subjects; but only consequent upon this
disease. Dilatations of the bronchi, unless when
very considerable, seldom occasion any change of
the parenchyma of the lungs, beyond compressing
and condensing it : they are frequently associated
with either grey or dark induration of the adjoin-
ing pulmonary substance. (See Chronic Bron-
chitis, § 52. 61.).

II. Congkstion of the Bronchi. — Classif.
I, Class, III. Order (Author}.

21. Defin. Urgent continued difspnce a ; little
or no cough, and no expectoration ; with an anxious,
j)ale, or livid countenance. — This afl^ection is not
often seen in a primary, severe, and general form ;
but it is very common in more slight and partial
Etates, and as an attendant on typhoid, malig-
nant, and pestilential diseases, and on exanthe-
matous fevers, especially measles, scarlatina, and
small pox, either shortly before the breaking out,
or upon the premature disappearance of tiie erup-
tion, when it often assumes a very general and
severe form : and it not infrequently, in slighter
grades, ushers in other diseases of the bronchi,
particularly ha-morrluige, bronchitis, humoral
asihiria, Ike General idiopathic congestion of
the bronchi, to such an extent and degree as to
destroy life, although rare, is sometimes met with.
Several cases have been recorded of persons who,
without any apparent cause, were seized with

urgent dyspnoea, increasing until it terminated in
death ; and, on dissection, the only morbid ap-
pearance observed was general congestion of
blood in the capillary vessels of the mucous and
sub-mucous respiratory tissues. (See § 3. for a
description of its anatomical characters.}

22. i. The Symptoms of this affection have not
been sufficiently investigated ; but they may be
stated to consist of continued dyspnoea, more of
less urgent ; sometimes fever, little or no cough,
and no expectoration ; the sibillous or sonorous
rhonchus in the large tubes, and absence of the
respiratory murmur over the chest; diminished
resonance on percussion ; anxious, pale, bloated,
or slightly livid countenance ; purplish tint of the
lips and nails of the fingers; anhelation, &c.
When the congestion takes place in the course of
febrile or exanthematous diseases, in addition to
these, the pulse becomes very quick, small, irre-
gular, or intermittent, and the oppression at the
chest extreme.

23. ii. The Causes of these congestions are not
well known. They appear, however, to be most
frequently occasioned by the inhalation of poi-
sonous gases or effluvia ; by close, overheated,
and crowded apartments ; by the ingestion of
sedative or narcotic substances, or indigestible or
poisonous animal or vegetable matters ; by in-
ordinate distension or oppletion of the stomach j
and by the transition or metastasis of other dis-
eases, or by their determination to the bronchial
surface in a more especial manner, as in the in-
stances above referred to (§ 21.). When this
aflfection proceeds from poisonous or indigestible
substances, and not infrequently also when it
arises from other causes, it is evidently associated
with more or less congestion of the substance
of the lungs. It often precedes other pulmo-
nary complaints, as hajmorihage, and that mo-
dification of asthma, called dry catarrh, by
Laennec. Congestion of the bronchi sometimes
also occurs in the progress of several diseases of
the heart attended with obstructed or impeded
circulation through its cavities, particularly those
of its left side ; and is often one of tliose changes
which supervene in the advanced stages of several
acute diseases, especially the exanthemata, and
to which death is more immediately owing (see
§21.).

24. iii. The Treatment must depend upon the
state of the vital energies at the time, upon the
nature of the causes to which the congestion is
owing, and on the evidence of existing genera!
plethora. The state of the pulse in respect of
frequency and fulness, will indicate the degree of
activity characterising the attack ; but generally,
when the congestion is considerable, the changes
wiiich take place in the lungs during respiration
being impeded, the vital energies become propor-
tionately reduced, and the pulse weak, quick, and
small. Id the majority of cases, it will be neces-
sary, notwithstanding, to abstract blood either by
venajsection or cupping ; and if the tlepression of
vital power be ui'gent, to exhibit simultaneously
stimulants by the mouth, and in enemata ; to em-
j)loy frictions with irritating liniments (see ¥. 305.
308. 311.), and revulsants, such as sinapisms,
blisters, mustard pediluvia, &c. ; and to inhale, at
brief intervals, and for a very short time, stimu-
lating vapours, particularly those of ammonia,
camphor, aromatic vinegar, &c., with the view of
cxtiiing the nerves of the bronchi, and thereby

BRONCHI — Inflammation of the:.

249

removing the distension of the capillaries, and
accelerating the circulation through them. When,
however, the patient, in addition to the symptoms
indicating congestion, complains of a sense of
heat, trickling, &c. in the course of the trachea,
or under the sternum; and if tiie pulse retains
its volume, and still more especially if it be
sharp, full, or rebounding; we should infer t!iat
the fulness of the bronchial vessels is of an active
description, and most probably amounts to deter-
mination of blood; and, possibly, constitutes the
early stage of iiajmorrhage or of inflammation.
In cases of this description, full blood-letting,
either generally or locally, or both ; atid after-
wards, counter-irritation and revulsion, irritating
cathartic injections, the strict avoidance of inter-
nal stimuli, and the antiphlogistic regimen j must
be prescribed.

25. In every case a strict reference should be
had to the cause, associated circumstances, and
the complications of the attack, and the treatment
should be varied accordingly. When i1 seems to
have been induced, or aggravated, by hurtful sub-
stances taken into the stomach, the exhibition of
emetics, particularly No. 402. in the Appendix,
ought not to be omitted; and, if they fail of operat-
ing, the stomach-pump should be used. The
bronchial congestion preceding, accompanying, or
consequent on the eruptive fevers, is to be com-
bated by cupping, revulsants, rubefacients, stimu-
lating frictions of ihe surface, and by emetics.

III. H.EMORRHAGE FROM THE BrONXHI.

Hamoptysis (from ai/xa, blood, and tttvctis,
sputum) frequently occurs, and often consists, as
already stated (§ 14.), of a simple exhalation
from the mucous surface. It is seldom, however,
owing merely to the pathological stale of the
bronchi ; but it is either connected with some
change in the substance of the lungs, or with
impeded circulation through the heart , although
the bronchial surface is generally its more imme-
diate source. Being, therefore, intimately related
to various changes of the lungs themselves, and
often occurring in consequence of these changes,
it will be considered in connection with them.

(See HEMORRHAGE FROM THE LuXGS, &C.)

IV. Bronchi, Infammation of the. — Syn.
Bronchitis, Badham, Hastings. Erysipelas
Pulmonis, Lommius. Catarrhus pituitosus,
Angina bronchialis, StoU. Catarrhus snffo-
cativus, Auct. Var. Bronchitis Catarrhosa,
Hildenbrand. Peripneumonia, Bro7ichitis, J.
Frank. Bronchite,Fr. Die Entzandung der
Luftr'uhren'dste , Bronchialentzundting , Ger.

Classif. 3. Class, Diseases of the Sangui-
neous Function ; 2. Order, Inflamma-
tions {Good), ill. Class, I. Order
(Author, see Preface).

26. Defin. Cough, with or without rigors, often
preceded by coryza, and followed by expectoration of
a transparent, pale, glairy, and watery Jiuid ; more
or less febrile commotion, dqspnxa, and slight sore-
ness, heat, or tightness of the chest, which are dimi-
nished as the expectoration becomes more abundant
and opaque.

27. This important disease, until Dr. Badham
directed particular attention to it, was, according
to the particular form it assumed, confounded
with common catarrh, with pneumonia, under the
appellation of peri[)neumonia notha, and with
other diseases of the lungs and air-passages, more
especially tubercular consumption, dyspnoea, &c.

Dr. Young seems to have viewed it as a modifi-
cation or extension of inflammation of the trachea,
or even as synonymous with that disease, pro-
bably from their occasional complication, or suc-
cession to each other. J. P. Frank appears to
have been among the first who directed attention
to the frequency and importance of inflammation
of the bionchial surface. "Cum vero," he ob-
serves, " profundius per tracheam penetrat, ac in
bronchia descendit inflammalio; tunc in primo
casu tracheitidis speciem, in altero peripneumo-
nia imaginem refert, in qua ultima vix non con-
stantem internorum bronchiorum phh gosin in
centenis cadaveribus deteximus." {lute, p. Clin.
p. 110.) " Rectam habebis febrium catariha-
lium saltem fortiorem ideam, si eas pro inflam-
matione bronchiorum, sive pro bronchitide con-
sideies" (De. Cur. Horn. Morb. p. i. t. i. c. vi.).
BuoussAis also noticed the frequency and im-
portance of inflammation of the mucous surface
of the bronchi (Hist.des Fhlegemas. Chnm. t. i.
p. 75. Paris, 1800.). But it is chiefly to the
writings of Badham, Brocssais, Hastings, La-
ennec, Villerme, Alcock, Andral, and
Chomel, that we are indebted for our knowledge
of it as a specific disease.

28. Bronchitis commences variously, and as-
sumes different forms and states, according to the
intensity of the exciting causes, the severity of
the attack, and the constitution of the patient.
I shall consider it chiefly with reference to its
activity and duration, to the states of vital energy,
and age of the patient, to its forms and compli-
cations, and to its results. Its general prevalence,
severity, and not infrequent fatality, require for it
a more particular notice than it has received,
even recently, from several systematic writers.
This will appear somewhat singular, when I state
that I know of no disease that is more frequent,
or productive of a greater number of deaths, in
children, than it, in its different slates and com-
plications.

29. i. Acute Bronchitis assumes difl^erent
grades of severity, and a modified type, according
to the habit of body and vital energy of the pa-
tient, and the extent to which the inflammatory
action advances along the bronchial tubes. It
presents itself in practice, as a primary disease,
in three forms: — 1st, Common catarrhal bron-
chitis, in which only the mucous membrane of
the large bronchi and trachea are aflNected by the
specific and often infectious inflammatory irri-
tation constituting catarrh : 2d, Sthenic or true
bronchitis, in which the inflammatory action is
more acutely marked — is of a more phlogistic
description, probably from its further extension
along the bronchi, and from both the mucous
and the sub-mucous tissue of the tubes being
affected : and, 3d, Asthenic bronchitis, where,
owing to weak vital energy, the inflammatory
irritation assumes a lower and more asthenic
grade, and extends still more generally, or aflTscts
especially the minute bronchi, interrupting their
functions, and preventing those changes from
taking place in the blood which are requisite to
the support of the nervous and vital manifest-
ations.

30. A. Catarrhal Bronchitis (B. Catarrhalis) ;
Mild Bronchitis (B. Mitis) ; Pulmonary Catarrh,
Bronchial Catarrh, Catarrhal Fever; Bronchitis
serosa, S^c. — This is the most common form of the
disease, and generally commences with cory^o^

260 BRONCHI — Acute Inflammation op the

or with slight hoarseness or sore throat, and other
symptoms of catarrh extending down the larynx,

along the trachea, to the large bronciii ; the

affection of the former parts generally subsiding

as the latter become diseased. But it sometimes

appears without any signs of irritation, either of

the Schneiderian membrane, or of the tonsils or

fauces, evidently originating in the trachea or

large bronchi themselves, particularly in delicate

persons, or in those disposed to coughs, pulmonary

disease, and habitual expectoration.

31. A sense of roughness, with frequent

attempts to clear the throat, is generally the first

snmpto7n of the disease. This is accompanied

with, or followed by, tilillation of the larynx, ex-
citing a dry hard cough ; hoarseness of voice,

with a sense of tightness across the chest ; and

sometimes slight pain or soreness upon coughing

or bieatiiing deeply. Accompanying these local

symptoms, more or less constitutional disturbance

is generally present. The patient complains of

lassitude, pain in the limbs and back, slight

shiverings, or cold chills, quickness of pulse,

and increased warmth, witli dryness of the skin.

The cough, which was at first dry, is now ac-
companied with a slight expectoration of a some-
what saline, glairy, and tliin fluid ; and as it rises

towards the glottis, increases the cough, and

renders the fits more frequent, probably owing to

its irritating quality ; in this resembling the secre-
tion in coryza, with which it so often originates.
In the slighter forms of the disease, the expecto-
ration becomes in two, three, or four days thicker,

more abundant and tenacious, less irritating and

somewhat more opaque ; and with this change,

the constriction, pain, and soreness, are diminished,
or very much relieved ; the pulse also is less fre-
quent, the skin cooler and more moist ; the urine
less scanty, paler, and deposits a sediment ; and
the cough less frequent, although often in longer
paroxysms. As the amendment advances, the
sputum decreases in quantity, but is more opaque,
tenacious, and deeper coloured, being frequently
greenish white. This amelioration is most remark-
able at first in the morning, and, as convalescence
proceeds, continues throughout the day. At last
but little expectoration takesplace,and isobserved,
as well as the cough, only morning and evening.
In slighter cases, the chilliness continues through-
out, or alternates, with some increase of heat
and perspiration ; the pulse is scarcely affected un-
less towards evening ; the expectoration is neither
abundant nor very viscid ; the fits of cough not
severe, and chiefly in the night and morning. Such
are the usual symptoms and course of catarrhal
bronchitis, constituting what is usually named a
cold upon the chest. l>ut it sometimes assumes
other characters ; and then pulmonary catarrh is
no more applicable to it than to inflammation of
the substance of the lungs, in which, also, it occa-
sionally terminates.

32. 1 his form of bronchitis appears to consist
of catarrhal irritation extending to, or originating
in, the mucous membrane of tiie trachea and
large bronchi, to which it is chiefly limited, with-
out materially affecting the sub-mucous tissue.
It seems not to be actual inflammation, or, if in-
flanjmatory action be present, it is of a peculiar
or specific kind, probably owing to its being
seated in, or rather limited to, the mucous mem-
brane; in which li^jht it is viewed by IliLDtN-

Brand, who very justly considers catarrhal irri-
tation to be distinct from true inflammation. I'his
variety may assume an epidemic form, when its
symptoms become somewhat modified (see In-
fluenza); and repeated or prolonged attacks of
it often favour the developement of tubercles in
the lungs, or even originate them, in scrofulous
and delicate subjects. It may also pass more or
less rapidly into either true acute bronchitis, or
into the chronic form of the disease, owing to the
extension of inflammatorv action more generally
through the bronchi, and to their sub-mucous cel-
lular tissue.

33. B./frtoe Bronchitis (B. Vera); Sthenic
Bronchitis (13. Gravis Sthenica') ; the Actite
Miicous Catarrh o/" Laennec. — This more de-
cidedly inflammatory form of the disease is some-
times preceded by coryza or sore throat ; and as
these begin to yield, the morbid action extends
along the mucous membrane to the trachea and
bronchi. But it frequently also commences in
this last situation, particularly in those who are
liable to pulmonary disease, and to chronic
coughs, and assumes a severe form. After these
preliminary signs, sometimes hoarseness, or loss
of voice, and always a dry hard cough, with a
sense of soreness, rawness, dryness, and heat, are
complained of under the sternum, preceded by
marked chills or complete rigors. The chills at
first alternate with increased heat and dryness of
the skin ; and are soon followed by quickened and
somewhat laborious respiration ; dyspnoea or op-
pression at the chest ; sometimes a dull pain on
coughing ; quick, full, and often strong pulse ;
sickness or loss of appetite ; pain in the forehead,
back, and limbs ; loss of animal strength, with
an inability to leave the couch or bed ; foul
loaded tongue ; constipated bowels, and scanty
high-coloured urine. As the disease advances,
the frequency of pulse, the cough, expectoration,
and general febrile symptoms, increase, as well as
the tightness and soreness of chest : the latter
sensation often amounting to an obtuse pain ex-
tending between the shoulders to the back, and
to the attachments of the diaphragm to the false
ribs, sometimes with pale anxious countenance,
and great oppression and anxiety. As expecto-
ration comes on and increases, the sense of heat
below the sternum diminishes. The cough is
generally excited by a full inspiration ; and from
being short and dry, or attended by but little ex-
pectoration, becomes longer, more severe, and
convulsive, accompanied with a more copious
expectoration ; and subsequently, in some cases,
terminates in scanty vomiting, which promotes
the discharge of a watery or serous and frothy
mucus, sometimes in considerable quantity,
which had accumulated in tiie bronchi and
trachea. The febrile and other symptoms are
aggravated towards night, which is generally
sleepless and disturbed, the position of the body
being on the back ; but the posture is often
changed. ]n some cases, particularly those
which are not remarkably severe, each exacer-
bation of the fever is attended by chills ; and
throughout the disease, the sensibility of the sur-
face to cold is very great. In the more phlogistic
cases, especially in plethoric subjects, tiie dys-
pnoea and ojjpression are very urgent, the face is
flushed, and sometimes slightly tumid, and the
eyes injected. At a still more advanced period,

BRONCHI — Acute Inflammation of the.

251

the tongue is often red at its sides and point, and
deeply loaded in the middle and base ; the breath-
ing- becomes rattling or wheezing, owing to the
air struggling through the mucous accumulation
in the bronchi, and the exertions to expectorate
greater. In extreme cases of this description,
collapse, wltli diminished expectoration, purple
lips, orthopnoea, quick depressed pulse, cold
perspirations and extremities, with threatening
suffocation, occur as early as the sixth or eighth
day.

34. The chief characteristic of this true form of
bronchitis is the state of the sputum, which ought
always to be carefully examined. When the
disease attacks a person who never expectorates
whilst in health, the cough remains dry for a
considerable time ; and those who expectorate
habitually, cease to do so when the inflammatory
attack is very acute. If the disease be slight, the
sputum is often increased from the commence-
ment, and its quality changed. As long as the
cough continues dry, the disease may be said to
be in its first stage. In the course of a period
which varies with the constitution of the patient
and the treatment employed, each fit of coughing
is followed by the excretion of a clear, transparent,
serous or watery mucosity, which is at first
slightly saline, but afterwards becomes tasteless.
It is without odour. As the disease advances, it is
a glairy mucus, resembling white of egg. When
it is poured into one vessel from another, it flows
with extreme viscidity. The more it can be
drawn out into a fine thread, and the greater its
tenacity, the more marked is the irritation of tiie
surface secreting it ; the greater also being the
oppression, heat, and anxiety in the chest, the
violence of the cough, and the general febrile
symptoms. In these very acutej cases, it adheres
closely to the sides of the vessel containing it by
long striae. When the fits of coughing are severe,
there is a /roth or sort of lather on its surface ;
and, in some cases, it is streaked with a little red
blood, which, however, is not combined with the
rnucus as in pneumonia. Early in the disease,
whilst the expectoration is fluid, transparent, or
watery, it often contains small whitish flocculi,
proceeding from the mucous cryptae of the pharynx
and fauces.

35. In proportion as the inflammation advances
to resohuivn, the sputum loses its transparency,
and is mixed with opaque, yellowish, whitish, or
greenish matter, which increases until it forms
nearly the whole of the expectorated mass, and is
attended by a marked diminution of the symptoms :
its quantity also is lessened. The inspection of
the sputa thus not only serves to indicate the na-
ture of the disease, but also its various stages.
In cases of a relapse or aggravation of the in-
flammatory action, the sputum again becomes
transparent, frothy, more abundant, and viscid ;
and the other symptoms increase. In several
instances the disease will continue to fluctuate
for several days, exhibiting symptoms of slight
amelioration, soon followed by relapse or exa-
cerbations, often occurring on alternate days,
or at the tertain period, and assuming from this
circumstance a remittent character, until either a
more decided improvement takes place, or a more
marked aggravation, terminating in some one of
the ways hereafter to be detailed (§ 39.).

36. In the two forms of the disease now de-

scribed, the minute bronchi so far escape, during
the favourable course of the disease, as that no
material interruption to the functions of the lungs,
in respect of the changes effected on the blood
during respiration, takes place in them ; the air
still passing through them and reaching the air-
cells : but, in certain of their very severe forms
and complications, and of their unfavourable ter-
minations, and in the variety next to be noticed,
obstruction to the free circulation of air, and to
the changes produced on the blood, in the lungs,
occurs to a greater or less extent.

37. C. Asthenic Bronchitis (B Asthenica) ;
Peripneumonia Kotha* of Authors; Acute Suf-
focative Catarrh of Laennec. — This varietj' of the
disease generally occurs in very youn?, or in
aged persons, in those of a phlegmatic or cachectic
habit, and of lax fibres and exhausted powers of
constitution, or who have been liable to chronic
coughs, and to copious expectoration of a thin
watery phlegm. Severe paroxysms of cough, with
wheezing, and oppressed breathing; foul loaded
tongue ; scanty urine ; complete loss of appetite ;
very quick, small, or irregular pulse ; little or no
increase of heat, excepting at night; cold extre-
mities ; vertigo ; pain in the head ; exacerbating fits
of dyspnoea, with a scanty expectoration at the
commencement, gradually becoming abundant
and frothy ; are its chief symptoms in persons ad-
vanced in life. It is much less acute or phlo-
gistic in its character than the preceding variety ;
and its duration is longer. In the more severe
cases, the countenance is pallid and anxious ; the
oppression of the prascordia extremely great ; and
a full breath taken to relieve it brings on a severe
fit of coughing, which sometimes terminates in
vomiting, and relieves for a time the symptoms by
favouring the excretion of the accumulated mu-
cosities. The tongue is often dry, and brownish
red at its point and edges, and sometimes covered
at its base with a dark coating ; the breathing is
much more difficult ; the lips and nails assume a
blue livid appearance; the face becomes lurid or
dusky ; the patient cannot lie down in bed, or,
if he does, starts up, after falling asleep, with a
sense of suffocation ; and the symptoms indicate
either collapse, and obstruction of the air-passages,
or effusion of fluid in the thoracic cavities, or even
both : stupor or sopor ; weak, wiry, and very fre-
quent pulse ; marked diminution of the sputa,
cold extremities, orthopnoea, clammy sweats about
the face and neck, suppressed urine, &c., ushering
in a fatal termination.

38. This is, upon the whole, the most common
form of bronchitis which is met with in children,
particularly in the metropolis, and among the
children of the poor, ill fed, and ill clothed, and
those living in cellars, ground floors, and badly ven-
tilated lanes and apartments, and is often remark-
ably prevalent during the winter and spring. In
this class of patients its approach is often insi-
dious; and it usually commences with coryza,
but not infrequently also with chills, febrile sym-
ptoms towards evening, wheezing, quick breathing.

* " Peripneumonia notha fortiornobis bronchiorum ca.
tarrhus est, quo in pituitosis, obesis, senibus.cachecticis,
laxisque hominibus frigida et humida sub tempestate, ab
accedente menibranEe mucosae hos canales investieiitis
irritatioiie, copiosior, tenaxque pituitaceleriori passu se-
crpta bronchiorum fines oppleudo, suffotatiouera Eat cite
minatur." (J. P. Frank.)

252

BRONCHI — Acute Inflamm

and cough. There is at first little or no dyspnoea ;
but the tongue is loaded, the pulse accelerated
and full, the face pallid or tumid, and the child
has lost its animation. As the disease advances,
the breathing becomes more quick and laborious ;
and fits of dyspnoea come on, generally followed
by severe attacks of cough, which often terminate
in vomiting; on which occasion only the bronciiial
secretion is presented for examination, and is
found to consist at first of a viscid, watery mucus,
and afterwards of a yellowish while, or a tena-
cious matter. These exacerbations are followed
by remissions, during which the child dozes, and
appears relieved, and the pulse becomes less fre-
quent. Thus the disease may continue, with al-
ternate remissions and exacerbations, for many
days, until either a permanent diminution of the
symptoms takes place, or an increased frequency
of pulse, stupor, lividity of the lips and nails of
the fingers, convulsions, &c. supervene, and indi-
cate impending suffocation, with congestion or
watery tfTusion on the brain.

39. Terjiinations. — A. Duration. — The
sthenic variety of the disease usually runs its
course in about seven or nine days ; but it may
terminate either way as early as the fifth ; or it
may be prolonged to the 21st, or even the 28th
day. lis duration will, however, chiefly depend
upon the treatment employed, the complication it
may present, the severity of the symptoms, and
on the age and constitution of the patient. The
asthenic foim of bronchitis generally runs its
course in a slower manner; it seldom terminates
either way in less than fourteen days, and gene-
rally continues for several weeks (§ 37.).

40. B. In favourable cases, the sthenic form of
the disease begins to decline from the fifth to the
ninth day. Ihe change is first evinced by the
state of the sputum, as above described (§ 35.) ;
by an amelioration of the cough, dyspnoea, and
febrile symptoms : in rare instances, by copious
epistaxis ; by a more general and copious perspi-
ration than that which frequently terminated the
febrile exacerbations ; by a more copious dis-
charge of a paler urine, depositing a sediment;
and by a diminution of the dyspnoea, of the fre-
quency and severity of the cough, and of the
quantity of the expectoration, which becomes
pearly, opaque, thick, yellowish, or greenish
yellow ; at last febrile symptoms occur only to-
wards evening, and the disease disappears as in
the first variety (§ 31.).

41. C. This favourable change is not, however,
always observed, particularly when the attack is
very severe, when treatment has either not been
soon employed, or has not been sufficient to re-
move the disease, or when the secretion into the
bronchi has been very profuse, and expectorated
with much difficulty. In such cases, it either
lapses into the chronic state about to be described ;
or, owing to the extension of the inflammation to
the air-ceils and substance of the lungs, gives
origin to pneumonitis, and even to pneumonitis
combined with pleuritis, which is thus superadded
to the original disease ; or, from the great extent
of surface aflected, the consequent irritative fever,
and interruption to the pulmonary functions, and
the profuse viscid fluid filling up tiie bronchi, col-
lapse of the powers of life supervenes, and the
patient dies, either with cerebral affection, or
with the usual symptoms of asphyxy, consccjucut

ATION OF THE TERMINATIONS.

upon diminished discharge of the morbid secre-
tion, and its accumulation in the air-tubes.

42. a. When the disease thus terminates in
pneumonia, the sputum becomes more rounded,
thick, tenacious, and streaked with blood, which
is more or less intimately mixed with it, and some-
times of a dark colour, giving it a rusty appear-
ance; and the cough is more tight, hard, and
deep. The oppression also increases ; the cheeks
are flushed with circumscribed red ; the pain of
the chest is more severe, or is now complained of
for tiie first time ; the skin is partially covered with
moisture, sometimes very abundant in parts ; the
chest, which was hitherto sonorous throughout, is
dull, in some part or other upon percussion ; and
the auscultatory signs of severe and dangerous
pneumonia appear, on which delirium and other
unfavourable symptoms often supervene, and ter-
minate, with coma, the life of the patient.

43. b. Bronchitis, as it occurs either in the
sthenic or asthenic form, may also terminate in
chronic pleuritis, and in effusion of serum into the
pleural cavity, and in some instances also into the
pericardium, particularly in persons advanced in
life, and in those who have experienced difficulty
in the circulation through the cavities of the
heart. In some instances of this description, the
expectoration, and many of the other symptoms,
are suddenly or quickly diminished ; but the dys-
pnoea continues, and signs of effusion become
more apparent as those of bronchitis disappear.
In these, the consecutive effusion occurs in the form
of a translation or metastasis of the morbid action
from the mucous to the serous surface. In other
cases, symptoms of pneumonitis, or pleuritis, in-
tervene between the change in the bronchitic
symptoms and the occurrence of effusion, with
pain, more or less severe, loss of resonance in some
part of the chest, and other auscultatory signs,
indicating the extension of the inflammatory
action first to the small bronchi, and thence to
the substance of the lungs and the pleura.
Dr. Hastings has detailed some cases of this
termination in his work, and I have treated se-
veral instances at the Children's Infiimary ; but
it is ciiiefly the aged who are liable to this unfa-
vourable occurrence.

44. c. In other unfavourable cases, the disease
becomes, in the course of a few days, charac-
terised by failure of the energies of life ; oppres-
sion and uneasiness increase ; the cough is more
frequent, laborious, and convulsive ; the sputum
is either more abundant, frothy, tenacious, and
glairy, or gelatinous, and excreted with great dif-
ficulty, or much diminished in quantity from want
of power to excrete it ; the pulse is more rapid,
small, weak, and irregular, or intermittent ; the
pain of the head more distressing, the countenance
is pale, and the face and neck covered with a
clammy sweat; the respiration very frequent and
wheezing, sometimes with an audible rattle; and,
at last, delirium, lividity, at first of the lips,
afterwards of the countenance, great prostration
of strength, and coma, supervene, and the patient
sinks with all the signs of imperfectly changed
j blood. In some cases, cerebral symptoms come
I oil much earlier, with either violent or low mut-
[ lering delirium, which soon terminates in most
1 profound coma. In a few cases, this early acces-
! sion of delirium, or of violent headach, with other
\ symptoms of consecutive inflammatory action.

BRONCHI — Acute Inflammation of The— .Complications.

253

ending in serous effusion on the brain, altogether
removes the original bronchial inflammation, or
in otiieis moderates it greatly and masks it. I
have observed this in children, and once or twice
ia robust adult persons ; but in both classes of
subjects it is a dangerous occurrence. Rlore
commonly, however, the cerebral symptoms con-
tinue increasing, with those referrible to the bron-
chi, till life is extinguished.

45. In other cases of very acute bronchitis,
with very high fever and severe local symptoms,
particularly with quick, laborious, short respira-
tion, dyspnoea, anxiety, great sense of heat under
the sternum, and bloated countenance, collapse
takes place rapidly, particularly if an appropriate
treatment have not been early employed ; and
either delirium, coma, and other cerebral sym-
ptoms, or those more directly depending on the
circulation of venous blood, appear, and the
patient is speedily cut oflT. In weak and nervous
patients, and during unfavourable states of the air,
the inflammatory action sometimes seems to invade
nearly all the respiratory mucous surface, and is
soon productive of a copious mucous secretion,
which, either from its difficult excretion or rapid
secretion, in some cases, speedily suffocates the
patient.

46. In children, and rarely in adults, cases oc-
cur, in which the inflammatory action extends
upwards, to the trachea and larynx, occasioning
all the symptoms of laryngitis in addition to those
of bronchitis, and frequently terminating fatally
with convulsions and the signs of congestion in
the head. In many of the unfavourable cases of
bronchitis in ciiildren, the extent of the disease,
and the copious secretion, occasion suffocation
more or less rapidly, with somnolency, bloated,
or livid countenance, convulsions, coma, and, at
last, complete asphyxy : and, on dissection, con-
gestion of blood, with watery effusion, is found
within the cranium ; the bronchi are filled with
a muco-purulent matter, and the vessels of the
lungs are loaded vvith blood.

47. Complications. — The most common states
of complication, in which bronchitis presents it-elf
in practice, are, 1st, With catarrhal sore throat,
eoryza, &c. of which it is generally consecutive,
and with catarrhal inflammation of the pharynx
and oesophagus. 2d, With inflammation of the
trachea, or larynx, or both, of which it is most
frequently consecutive; but also sometimes ante-
cedent, as I have occasionally observed in chil-
dren. Indeed, we have seldom cruup m London
uncomplicated with bronchitis in some one of its
forms or states. 3d, With measles, scailatina, or
small pox, on which it very freq\iently supervenes ;
particularly in measles, sometimes very early in
the di-ease, and before the eruption breaks out ;
but oftener in consequence of its premature dis-
appearance, or retrocession. 4th, Very com-
monly with hooping-cough, especially during
certain seasons and epidemics. 5th, Not infre-
quently with continued fevers, particularly in its
asthenic form. 6th, Often with disorders, or even
sub-acute inflammation, of the digestive mucous
surface, and diarrhoea, in children, when it also
assumes this form ; the stools bying oflensive, and
the tongue red at its point, &c.* 7th, With dis

* During some seasons I have occasionally admitted in
one day, at the Intinnary for Ciiildren, several cases, in
which it was difficult to determine whetlier the digestive

ease of the liver, and accumulations of bile in the
gall-bladder, chiefly in adults; the tongue then
being very deeply loaded with a yellowi?h browa
crust, or fur; and the stools dark coloured, and
most offensive. 8th, In some cases with erysi-
pelas, particularly its epidemic and infectious
form. 9th, \\'ith pneumonia, or pleuritis ; these
beingeilher consecutive of the bronchitis, or simul-
taneous with it. lOth, With dropsical effusion
into the pleura or pericardium, especially in aged
persons; and, llih. With inflammatory irritation,
in the substance of the brain, or in its membranes,
with disposition to effusion, — a complication most
commonly met with in children.

48. All these diseases are greatly aggravated,
and their danger increased, from being associated
with bronchitis ; and they frequently terminate
fatally by one or other of the unfavourable states
which the bronchial affection assumes. Bronchitis
thus complicated, also presents, in consequence,
either a more acute character, or the asthenic
form ; and, being attended by a more marked
disposition to invade the smaller ramifications and
air-cells, or by a more profuse secretion of mucus,
and a rapid depression of the powers of life, the
unfavourable terminations above described quickly
supervene. In several of these complications,
particularly with pertussis, measles, scarlatina,
continued fever, cerebral affections, and diseases
of the lungs or pleura, bronchitis often escapes
detection, until it becomes either one of the most
important, or the most dangerous, or an actually
fatal lesion. When thus complicated with measles
or other exanthematous diseases, the eruption, if
it still continue on the surface, often assumes, as
the powers of life sink, adaik or purplish hue;
and a slight dirty blueness of the skin, particularly
of the face, hands, &c. is generally observed in
other cases, inilicating the impeded functions of
respiration, and the consequent changes in the
blood. The frequency and importance of the
complication of bronchitis with'measles, especially
before the appearance of the eruption, during its
progress, and after its decline ; and the occur-
rence of the former complaint, both during and
after convalescence from the latter ; are deserv-
ing of the careful attention of the practitioner.

49. ii. Sub-acute BnoNcniTis is characterised
by the symptoms of the sthenic form of the dis-
ease in a milder and more chronic form. The
cough continues longer dry, and the expectora-
tion scanty, or thick, visciil, gelatinous, or albu-
minous, with tightness of chest, and oppressed
breathing. In this form of the disease, a plastic
albuminous exudation sometimes forms in the
large bronchi, and lower part of the trachea, or
in the large bronchi of only one lung, and is
moulded in the form of the air tubes ; and is either
expectorated in fragments, or in large tubular
branches and ramifications. Cases of this de-
scription are detailed under the appellation of
bronchial polypi by the older writers, and figures
given of them by Tui.pius and others. Mr. Iliff
has published {Lond. Med. Repos. vol. xviii.
p. 207.) a case of this description, wherein this
production retained its ramified and tubular form.
I have met with two cases where the albuminous
exudation had been formed in the bronchi, and

or the respiratory mucous surface wasmost affected. This
complication is not infrrquent dining convalescence fn-ra
the exanthemata, particularly measles and scarlet fever.

254

BRONCHI AND AIR-PASSAGES — Alterations of the.

expectorated in fragments. It generally occurs
in an uncomplicated state.

50. iii. Chronic Bronchitis often follows se-
vere attacks of catarrh ; and is also frequently
consecutive of acute bronchitis ; but it sometimes
occurs primarily in the ciironic state, particularly
in aged persons. It differs in nothing from the
acute or sub-acute forms, excepting in as far as
the symptoms are altogether milder, and their
continuance longer ; there being no distinct line
of demarcation between its grades of activity and
chronicity. The chief means, by which we are
enabled to infer, that the disease has assumed a
chronic form, when it is consequent on the acute,
is the continuance of the sputum for several days,
in undiminished quantity, and the persistance of
the opaque, whitish yellow, or yellovvish green
appearance, which it assumed upon passing from
the transparent, fluid, and viscid condition charac-
terising the acute form.

51. Chronic bronchitis assumes various grades
of severity, and presents different phenomena,
according to the changes which have taken place
in the bronchi. In its slighter states, and primary
form, as it is often met with in persons advanced
in life, and as it prevails during winter and
spring, or variable seasons, it consists chiefly of a
frequent and almost habitual cough, with scarcely
any pain in the chest, continuing for weeks, or
even months, or recurring every autumn, winter,
and spring ; being most severe in the mornings,
and much easier through the day, with slight
dyspnoea on exertion, and copious viscid mucous
expectoration; but without any marked febrile
symptoms, excepting slight acceleration of pulse.
Its severer forms are met with in young or middle
aged persons, after catarrh or acute bronchitis ; and
are attended with fits of coughing, and copious
expectoration ; with oppression at the chest and
praecordia ; with febrile symptoms, particularly
towards night ; with copious perspirations in the
morning, which often seem to increase the cough
instead of relieving it ; with loss of strength, ema-
ciation, and slight disorder of the digestive organs.
The cough is increased after getting into bed, and
very early in the morning. The breathing is
quick and laborious, particularly on any exertion ;
and the patient complains of slight tightness of
the chest. The pulse generally ranges from 90
to 120 ; being the former whilst quiet in bed, and
the latter towards evening.

52. Attention to the expectoration is very im-
portant, in order to enable us to judge both of the
accession of tiiis state of the disease, or of its ag-
gravation or change into the acute form, which
is not infretiuent, and of tlie concurrent or con-
secutive alterations which often take place. The
sputum occasionally continues long in the state
now described. It is geneiully then inodorous,
and without taste. 15ut it oftener becomes green-
ish, or yellowish while, or muco-purulcnt ; is
mixed with a colourless watery phlegm, and is
more or less abundant. In cases of a worse cha-
racter, particularly when hectic symptoms are
present, it assumes a more purulent appearance ; is
sometimes streaked with blood, or mixed wilii daik
specks of blood, or consists chiefly of pus. These
changes, however, sehlom occur without much
antecedent fever, and attendant emaciation, niglit
sweats, occasional dinrrha',a, and the symptoms
of confirmed hectic. In rarer cases, the sputum

becomes remarkably foetid ; but this change can-
not be imputed to any particular lesion of the
bronchi or lungs, excepting sometimes to con-
siderable dilatation of the former. The whole of
the symptoms in this class of cases so very nearly
resemble tubercular consumption, as to be distin-
guished from it with much difficulty, and only by
attending to the appearances of the sputum, and
by examining the chest with the stethoscope.

53. The sputum generally partially swims on
the surface of water. When it is thin, trans-
parent, viscid, and frothy, it usually altogether
swims ; but when it is thick, in tenacious, opaque
lumps, or in fragments resembling portions of
albuminous exudation, it generally sinks. In all
these states it cannot be diffused in the water.
When it consists of yellowish white, or greenish
yellow matter, it partly sinks, and by agitation is
broken into ragged portions, and is partially dif-
fused ; and the more it approaches a purulent
state, the more completely and readily is it dif-
fused, imparting to the water, by agitation, a yel-
lowish white appearance.

54. Chronic bronchitis is also sometimes conse-
cutive of the eruptive diseases ; but tliese diseases
have generally altogether or very nearly subsided
before the bronchial affection supervened. It
occurs primarily from the irritation of minute par-
ticles of mineral or vegetable substances floating in
the air, as is shown in the article on Arts. It is
sometimes also complicated with other chronic
diseases of the lungs and pleura, more especially
with tubercles ; with diseases of the liver ; with
chronic inflammation, or other disorders of the
mucous surface of the digestive tube, particularly
of the oesophagus, stomach, and large bowels.
In all these consecutive and complicated states,
it presents no certain or unvarying forms ; its
chief character, its duration, progress, and ter-
mination, being modified by its severity, by the
constitutional powers of the patient, by his dia-
thesis, and by the quantity of expectoration. In
some cases, the secretion from the bronchial sur-
face is so profuse as to be the chief cause of the
exhaustion and death of the patient.

55. iv. Anatomical Characters or Bronchi-
tis.— A. When the body of a patient is opened,
that has sunk under any disease whilst affected at
the'same time with a inild and recent bronchitis,
some redness is found, generally in a circum-
scribed portion of tlie mucous membrane, and
usually towards the end of the trachea, and in the
first divisions of the bronchi. If tiie inflamma-
tion have been more intense, the redness extends
to a greater number of these tubes, and exists,
moreover, in the smaller ramifications. It some-
times happens that this redness is exactly limited
to the bronchi of one lobe only ; and it is the
bronchi of the sujicrior lobe which seems to be
more particularly disponed to inflammation. The
red colour of the bronciii presents itself occasion-
ally under the form of a fine injection, which
seems to exist both in the sub-mucous cellular
tissue, and in the mucous membrane itself, and is
usually attended by slight tumefaction. Some-
times the vessels cannot be distinguished, but
only a number of small, crowded, red points,
which are agglomerated the one around the other.
Finally, an uniform red colour is occasionally ob-
served. In some cases, the redness diminishes
progressively from the large bronchi to the

BRONCHI— Inflammation of the — Diagnosis.

255

small ones ; in others, an opposite disposition is
remarked. Occasionally the redness only exists
in intervals, in the form of bands or of isolated
spots, forming, as it were, as many circumscribed
phlegmasia;, between which the mucous coat is
white and healthy.

56. B. When the inflammation is chronic, the
mucous membrane generally loses its lively red-
ness : it presents a livid, violet-colouved, or brown-
ish tint. Finally, and what is very remarkable,
in individuals offering all the symptoms of inve-
terate chronic bronchitis, with puriform expec-
toration, the mucous membrane of the lungs has
been found scarcely rose-coloured, and even per-
fectly pale through its whole extent. Bayle and
Andral liave particularly noticed this fact. I
would not wish to conclude that there is not, and
least of all, that there has not been, inflammation
in these cases; but I tiiink a very copious secre-
tion will often take place from mucous surfaces,
and assume even a purulent appearance during its
retention in the bronchi, from lost tone of the
extreme capillary vessels, with, perhaps, an in-
creased flux or determination of the circulating
fluid in order to supply the discharge, all vascu-
larity disappearing with the cessation of circula-
tion. The other changes observed on post mor-
tem inspection, particularly in the more chronic
states of bronchitis, consist chiefly of thickening,
softening, ulceration, &c. of the mucous mem-
brane, dilalation of the bronchi, &c. (See § 7,
et seq.)

57. V. Diagnosis.— The characters of the coug/i,
and of the sputa, and the physical signs, are our
chief guides in the diagnosis of bronchitis. The
history I have given of the disease will be gene-
rally sufficient to enable even the inexperienced
to recognise it : but it will often be necessary to
arrive at more precise and certain information as
to the extent of lesion, and its existence either in
a simple or in a complicated form.

58. A. Of the acute. — a. By auscultation. — In
the first stage of the disease, the inflammation
causes tumefaction of the mucous bronchial sur-
face, and consequent diminution of the calibre of
the tubes. This state occasions a modification of
the respiratory sound in them : and, hence, either
with the unaided ear, or with the stethoscope, we
hear at first the " dry bronchial rhonchus ; " con-
sisting chiefly of a sibilous or whistling sound ;
occasionally with a deeper tone, resembling the
note of a violoncello, or the cooing of a pigeon,
particularly when the large bronchi are aflPected.
These sounds (see Auscultation, § 14.), deno-
minated the sibilous and sonorous rhotichi, are pre-
sent chiefly in the early stage, and before expec-
toration takes place ; and proves the accuracy of the
rational inference of Dr. Ba dh am, that the diflncult
breathing of this period is owing to the slate of
the mucous membrane ; and I would add, of its
sub-mucous cellular tissue also. To these sounds
is added the mucous rhonchus ; and in propor-
tion as the bronchial secretion, to which it is
owing, a)igments, this sound becomes predomi-
nant. When the inflammation is seated in the
large tubes, the bubbles of mucous rhonchus are
large and uneven ; and the respiration may be
stilT heard over the chest. But when the mucous
rhonchus is fine, and is heard constantly, it may
be inferred that the small bronchi are invaded.
When this is the case in a severe degree, there is

also slightly diminished resonance of the chiefly
affected part upon percussion. As the disease
proceeds, and the secretion passes into an opaque
and thickened state, the mucous rhonchus becomes
interrupted, sometimes with obstruction of the
respiratory sound in a portion of the lungs, and
passes into a sibilant or clicking sound. These
changes arise from the entire or partial obstruc-
tion of one or more tubes by the thickened mucus,
and are generally of temporary continuance :
occurring now in one part of the chest, and dis-
appearing ; and now in another. This state of
the bronchi fully explains the dyspnoea of this
stage.

59. b. Rational diagnosis. — a. The cough in
bronchitis is loose, diflfused, and deep ; in pa-
roxysms, and attended with fever, often with
wheezing. In pertussis, it is in severe paroxysms,
unattended by fever or wheezing ; is accompanied
with a distinct whoop ; and terminates in vomiting.
In croup it is sonorous, clanging, and harsh. In
laryngitis, it is suftocating, shrill, or grunting ;
and, on inspiration, attended with a drawing down
of the pomum Adami to the sternum, and retrac-
tion of the epigastrium and hypochondria. In
pneumonia, it is deep in the chest; frequent and
short, often hard ; and gives a metallic sort of
noise. And, in pleuritis, it is short, dry, hard ;
sometimes slight, but always suppressed and pain-
ful. — 0. The expectoration in bronchitis is abundant
after the second or third day, or even from the
first: in pertussis, it only follows the vomiting:
in pneumonia, it is more rounded, distinct, thick-
ened, purulent, rusty, and intimately streaked
with blood : in pleuritis, croup, and laryngitis, it
is scanty, thin, frothy in the latter; sometimes
with shreds or pieces of lymph, and entirely dif-
ferent in appearance from that of bronchitis. —
y. Pain in bronchitis is scarcely complained of ;
and consists merely of a sense of soreness, heat,
and tightness in the chest, particularly beneath
the sternum, and is not increased on full inspir-
ation : in pneumonia, it is more marked, especially
in certain parts of the chest, generally nearer the
lateral regions, and is increased on inspiration
or prolonged expiration : in pleuritis, it is very
acute, and a full inspiration is impossible : in
croup and laryngitis, the pain is increased upon
pressing the trachea and larynx. — 5. The conn'
tenance in bronchitis is more frequently pallid or
bloated; in p/zeumonin, it is generally flushed ; and
dyspnoea is greater in the former than in the latter.
The breathing is wheezing and hurried in acute
bronchitis; in pneumonia it is less so, and gene-
rally without the bronchial wheeze. The pulse,
in the former, is frequent, full, free, developed,
and soft; in the latter, full, hard, bounding or
vibrating, and sometimes oppressed and undeve-
loped. The general febrile symptoms are more
continued in pneumonia than in bronchitis; morn-
ing remissions, with free perspiration, being more
frequent in the latter than in the fornjer. The
physical signs in pneumonia, pleuritis, &c., are the
surest means of their diagnosis. (See art. Lungs
— Injiammalion of.)

60. Some cases of asthenic bronchitis may be
mistaken for humoral asthma; and occasionally
no very distinct line of demarcation can be drawn,
both aflfections either insensibly passing into each
other, or being complicated with one another.
But, generally, the slow accession of the former.

256

BRONCHI — Inflammation of the-

Procnosis.

the more continued and less urgent dyspnoea and
tightness of the chest, and the presence of febrile
symptoms, particularly great quickness of pulse,
will distinguish it from humoral asthma ; which is
commonly characterised by the sudden accession
of tiie paroxysms, their severity during the night,
and the attendant orthopncea, the more or less
complete and prolonged intermissions, and espe-
cially by the absence of fever, and by the much
more marked integrity of the vital and animal
powers than in asthenic bronchitis. In tliis
latter disease, the patient is incapable of leaving
his bed or his apartment : in asthma, he may
attend to his avocations ; or may, at least, chunge
his room in the intervals between the fits. 1'he
diagnosis between the sthenic bronchitis and
asthma is attended with no difficulty. (See
Asthma, $ 50.)

61. B. Of the chronic. — a. By auscultation.
—The physical signs of this form of bronchitis are
not materially different from the acute. The re-
spiration is extremely varied : being sometimes
louder, at other times more obscure than natural,
and generally accompanied with the mucous
rhonchus ; which, however, is not heard over the
chest, but now chiefly in one part and then in
another, and seldom during the whole of the
respiratory act. The occasional occurrence of
the sibilous and sonorous rhonchi indicates that
the tubes are sometimes partially obstructed ; but
this is much less frequent than at the commence-
ment of acute bronchitis ; and it rarely happens
that the respiration is entirely interrupted in a part
of the lung. Very often, also, when the dyspnoea
is considerable, or even urgent, the air is heard to
enter the lungs as well as usual, the respiratory
sound being either distinct or puerile. The re-
sonance of the chest on percussion is scarcely di-
minished. When the bronchitis is very chronic,
the tubes sometimes become dilated, from being
weakened by the inflammation and stained by
the paroxysms of coughing. When this state of the
bronchi exists, the sputum is often foetid, and
several of the auscultatory signs of tuberculous
excavations of ihe substance of the lungs are
present. If the dilatations be large and rounded,
it may furnish pectoriloquy and the cavernous
rhonchus ; but if, as is more generally the case, it
extend to several tubes, or if they be dilated along
a considerable portion of their axis, a loud hron-
cltpphonij is only heard. If this dilatation be exten-
sive, bronchophony, bronchi;d respiration, some-
times with a "veiled lAowing," and even slight
pectoriloquy, will be heard in corresponding parts
of the thorax. On percussion, the sound is often
somewhat less than natural, owing to the com-
pression of the surrounding pulmonary tissue ;
and owing, also, to this cause, the dyspnoea is
often great. Dilated bronchi remain long sta-
tionary ; tuberculous excavations generally in-
crease rapidly. The former are most fretiuently
situated in the sca|)ular, mammary, and lateral
regions ; the hitter in the sub-clavian and sub-
acromian regions of the client. (See the diagnosis

o/"I'uBEItCl'I.AH CONSUMl'TION.)

62. h. Rational diagnosis. — it is chiefly wilh
tubercles in tlie lungs that chronic bronchitis is
liable to be confounded ; and, indeed, without the
aid of auscultation, the diagnosis between them is
very difficult. When they both co-exist, and
especially when the latter is attended with dilat-

ation, we have seen that even auscultation does
not easily enable us to ascertain the exact state of
disease : however, by a careful comparison of the
physical and rational symptoms of both, we may
generally form a tolerably correct opinion. Early
in chronic bronchitis, the absence of pain during
inspiration, the capability of resting on either side,
the pallidity of the lips and countenance, the
appearance of the sputum (^§ 34, 35.), and the
wheezing noise on respiration, may readily distin-
guish it from tubercular phthisis. As the disease
advances, the symptoms more nearly resemble
tubercular consumption; but the pallor of coun-
tenance and absence of pain generally continue ;
or, if tiie latter be present, it is diffused over the
chest, and the patient can draw a larger volume
of air into the chest, and retain it longer, than in
phthisis. The dyspnoea is less on exertion, consists
more of a stuffing sensation, and is more relieved
by expectoration ; the sputum generally consists
of a more considerable portion of mucus, and is
more regularly abundant; and the perspirations
are much more partial, the emaciation less, and
the paroxysms of hectic much less regular, than in
tubercular disease. The cough is very different.
In chronic bronchitis, it is generally deep and
sonorous, and in paroxysms ; in phthisis, it is short
and tickling. When we find copious purulent
expectoration, but without broken-down portions
of softened tubercles or of the pulmonary tissue ;
night sweats ; hectic fever, with full deep cough,
and absence of the physical signs of phthisis ; —
if, after repeated examinations, there can be de-
tected neither a constant absence of the respiratory
murmur, nor gurgling cavernous rhonchus, nor
pectoriloquy, nor marked defect of resonance on
percussion, — we may safely conclude the disease
to be chronic bronchitis. When this disease de-
pends upon the inhalation of irritating substances,
as Dr. Hastings very justly remarks, the cough
and copious muco- purulent expectoration often
continues for months, or even years, without much
suffering, with pale countenance, slight lividity of
the lips, &c. In these cases there can be no
difficulty in the diagnosis.

63. vi. Prognosis. — A. In the acute. — When
the disease is slight, or limited to a few bronchi
only, the disease generally terminates favourably'.
The change is indicated by a more perfect apy-
rexia in the mornings, less severe and less fre-
quent cough, easier expectoration, and a thicker
and more opaque sputum ; which, however, gene-
rally assumes a more fluid and glairy appearance
for a few evenings during the febrile exacerbations.
A relapse of the disease is indicated by increase
of the fever and cough, and a more transparent,
fluid, and glairy expectoration. When the in-
flammation is very severe and general, as indi-
cated by high fever, dyspnoea, &c., the prognosis
should be unfavourable, or given with caution.
If symptoms of collapse have appeared, and the
mucous rhonchus be heard universally, and with
little or no respiratory murmur upon auscultation ;
if the pulse becomes very I'requent, small or weak,
irregular or intermittent ; and if the countenance
be at the same time pallid and anxious, slightly
livid, or the nnils of tlie fingers and lips tending
to purple ; the daniier from asphyxia is extreme.
When the disease occurs in the course of con-
tinued or exanthematous fevers, in some epidemic
states of liooping-cough, and in tlie other severe

BRONCHI — Acute iMr.AMMAiiox of tiii: — Tueatment.

257

forms of complication (§§ 47, 48.") ; and when the
signs indicating the unfavourable termiwitiims
already enumerated appear, the danger is also
great, although it may not be extreme. The
supervention of pneumonia or pleuritis, or of
tracheitis or laryngitis ; a sudden diminution of the
expectoration; tiie occurrence of cirebral sjnip-
tunis, of orthopnoea, or even continued dyspnoea,
with expansion of the nostrils ; a dark red colour
of the tongue ; are all unfavouiable circumstances,
and indicate imminent danger. On the other
hand, when spontaneous evacuations occur, with
a favourable change in the cough and expecto-
ration, particularly on one of the critical days,
although the attack has been extremely severe, a
favourable result may be looked for, more par-
ticularly if the disease proceeded from cold, and
was uncomplicated.

64. The asthenic form of the disease is veiy
dangerous, when occurring at the extremes of
age ; but less so when it is unattended by marktd
depression of the powers of life, and by signs of
the circulation of venous blood, — circumstances
wliich, in connection with the frequency, weak-
ness, and irregularity of the pulse, the quantity
and appearance of the sputa, and with the diffi-
culty of expectoration, constitute the danger,

65. B, In the sub-acute a7td chrcnic. — If it
have arisen from catarrhal affection, and be un-
attended by much einaciation or hectic, this form
of the disease will generally terminate favour-
ably, although the expectoration present a puri-
form appearance. The more purulent, how-
ever, this excretion, and the more marked the
symptoms of hectic, the greater the danger. But
when the sputum seems to consist chiefly of
mucus, although the quantity expectorated he
great, a favourable issue may take place ; and
this will be more frequently the case when the
chronic bronchitis has been consecutive of the
acute. When there are constant dyspnoea,
very frequent pulse, profuse sweats, and copious
purulent expectoration, with emaciation, hectic
fever, colliquative diarrhoea, associated symptoms
of disease of the liver, or of the mucous surface
of the bowels, with a smooth, glossy, or chopped,
a dark red, or raw appearance of the tonoue, a
most unfavourable piogiiosis should be given ;
and if to these succeed aphthous eruptions about
the mouth and tongi;e or fauces, little hope of
recovery can be entertained. Tiie causes and
complications of the disease should also mate-
rially influence our prognosis. When it has
ari-en from mechanical irritation of the bronchi,
patients often recover from a very unfavourable
state, when the irritating cause has altogether
been removed. The occurrence of bronchitis
in the scrofulous diathesis, and its association
with tubercles in the lungs, are dangerous cir-
cumstances. This complication is to be ascertained
chiefly by means of the physical signs. If these
indicate the existence of tubercles, or do not
establish with certainty their absence, a very cau-
tious opinion should be given. The mucous rhon-
chus, and dulness on percussion, with the rational
symptoms of tubercles, are indications of a very
dangerous malady. The rapid development of
symptoms of theacute, in the course of chronic bron-
chitis, must be viewed as an unfavourable circum-
stance. The extremes of age also increase the risk
in this as well as in the acute state of the disease.

Vol. I.

66. vi. Causes. — A. The predisposing causes are
— whatever lowers the energies of the frame, more
particularly too warm or crowded apartments ;
sleeping with too many clothes ; late rising, late
hours, and too great sexual indulgence; veryearly,
and far advanced age ; the lymphatic and sangui-
neous temperaments; relaxed habits of body ; fe-
brile and exjinthematous diseases, and the suppres-
sion of accustomed eruptions and discharges.

67. B. The exciting causes arc, exposure to a
cold and moist atmosphere, or to currents of air,
particularly when perspiring; rapid vicissitudes
of weather and season ; wearing (lamp clothes or
shoes; or sleeping in riamp beds or linen; con-
tinueil exposure to dry cold ; quick refrigeration
of the body after being over heated and fatigued,
or upon coming from crowded apartments and
assemblies ; vveai ing too low or very thin dress,
with exposure of the neck and chest; rapid at-
mospherical changes, parliculaily during autumn,
winter, and spritig, and especially from cold to
heat ; epidemic constitutions of the aimospliere ;
easterly and north-east winds; exposure to the
night air after rain ; the inhalation of iiritating
gases, vapours, or niineral or vegetable particles
(see Ams and Hmvloym^vts, as Causes if Dis-
ease, § 40.) ; sudden passage from- the cold air into
overheated apartments ; catarrhal infection ; mias-
mal exhalations in cold and moist states of the an- ;
the imperfect irruption or retrocession o( the exan-
thematous diseases ; and the translation or meta-
stasis of gout, rheumatism, erysipelas, &c.

68. viii. Treatment. — 1st, Of Acute Bron-
chitis.— A. In its simple states. — M. Broussais
gives a very concise view of the indications of cuie
in this form of the disease, which has been adopted,
verbatim, by Dr. Hastings; without, however,
referring to the original writer. M. Broussa.s
very justly recommends that the excitement of
the sanguiferous system should be moderated, by
general blood-letting, acidulated and mucilagin-
ous fluids, and abstinence fiorii stimulating food ;
that perspiration be favoured, by saline and an-
timonial medicines, and by emollients, both in-
ternally and externally employed; and that the
irritation and congestion of the diseased vessels
be relieved by local depletions and emollient re-
vulsants when erethysm of the capillaries pre-
doininates, and by rubefacients and vesicatories
when the nervous powers aie depressed.

69. a. In the first variety of the disease, blord-
letting is seldom requisite ; saline and antimonial
medicines, with demulcents, emollients, &:c. "being
generally sufficient. When, however, fever is
considerable, and the patient complains of sore-
ness or slight pain in the chest, a moderate bleed-
ing— preferably by cupping — will be serviceable ;
and the solution of the potasslo-tartrate of anti-
mony, in frequently repeated doses, will soon
remove all febrile disturbance. The following
mixture has generally answered this purpose in
my practice. (See also F. 393. 854.)

No. C6. I^ Mist. Campliorae, Mist. Am)'g(1;il. Dulc.
aa 5iij ; I^iq. Ammoniae Acet.5 jss. ; Spirit. xEtlier. Nit.,
Villi Antiraoii. Potass. -Tart., aa 3ijss. ; Syrupi Tolutani
5 jss. M. Capiat coch. ij. larga, secunda quaque hora.

70. In the tliird variety, or the asthenic form of
the malady, blood-letting is generally required;
but it ought to be resorted to with much caution,
and early in the disease, as recommended by Sy-

I DFNHAM and most practical writers of the present
S

258

BRONCHI — Acute Inflammation of the — Treatment.

day. From eight to ten ounces may be taken
from a vein, but, I think, preferably from between
the shoulders by cupping ; and afterwards, re-
vulsants, counter-irritants, and expectoranis, may
be employed. The admissibility of depletion, or
of antimonials, or the extent to which they should
be carried, and the propriety of having recourse to
stimulating expectorants, necessarily depend, in
this form of the disease, upon the degree of mor-
bid action and of vital power presented by indi-
vidual cases, and upon the quantity of the expec-
toration and the difficulty to excrete it. INIoderate
local depletions are more generally required when
this state of disease occurs in children, than when
it is met with in aged persons ; whilst the latter
are more benefited by expectorants, diaphoretics,
counter-irritants, and diuretics, than the former
class of subjects.

71. In the second variety of bronchitis, parti-
cularly when the patient is young,- plethoric, or
robust, blood-letting should be early employed,
and be directed as recommended in the art. on the
Blood (§ 64.) ; and a full impression made upon
the circulation, short, however, of syncope. Im-
mediately afterwards, the preparations of anti-
mony, combined according to circumstances,
should be given in frequently repealed doses, so
as to prevent the return of excessive local or
general action, and to promote a free and uni-
versal perspiration. The preparations of antimony
that may be selected for this purpose are the ant.
potass.-tart., James's powder, or the kermes mi-
neral (F. 637.) : and the first doses of them may
be advantageously combined with calomel. The
following may be exhibited ; or F. 24. 513. 530.
638., or other similar formulae, contained in the
Appendix : —

No. 67. B Hydrarg. Chloridi gr. vj. ; Pulv. Antimonii
Comp.gr. v.; CamphorEe rasse gr. j.; Extr. Hyoscyami
gr. V. ; Conservse Rosar. q. s. ut fiat Bolus statim post
Tensesectionem sumendus.

No. 68. R Mist. Camphors! 3j- ; Liq- Ammon. Acet.
3ij. ; Fotassae Nitratis gr. vj.— x.; Spirit. Mther. Nit.
Til XX. ; Villi Antimon. Potass. -Tart, (vel Vini Ipecacu-
anhae) HI XK.— XXX. ; Tinct. Hyoscyami ttlxv.; .Syrupi
Tolutani 3 j. M. Fiat Haustus, tertiis horis capiendus.

When antimonials are given in sufficient doses,
and frequently repeated after the first depletion, a
second will not often be necessary ; or local
blood-letting will be sufficient. But if the febrile
excitement and the state of the pulse and of the
blood drawn indicate it, venajsection may, in
robust subjects, be again repeated to the extent
already indicated. "When this variety of the
disease affects children, blood-letting, either gene-
ral or local, according to the age, should be pre-
scribed, with saline diaphoretics, followed by the
semicupium or pediluvia. In all classes of sub-
jects, hlond-leUiiig must be regulated according to
the state of the pulse, heat of .skin, the character
and quantity of the expectoration, the presence of
pain, and the prevailing character of distases;
attention to these circumstances being especially
required in children and aged persons.

.72. h. The choice of diapJwretics in this disease
is deserving of notice. Early in the first and secmid
varieties I have usually preferred the potassio-tar-
trate of antimony, generally in solution, anil con-
joined with the vin. ipecacuanha', or with the spirit,
aither. nit., small doses of camphor, &c. J5ut in
infants or very young children, in the aged, and
in the tliird or asthenic form of the disease, ipe-

cacuanha seems preferable, — in the latter class
of subjects particularly, combined with camphor.
In the more catarrhal, or less acute, forms of the
complaint, ipecacuanha, combined with nitrate of
potash and opium, and, in the more sthenic
states of the disease, the same medicines, in larger
doses, will often prove equally serviceable as the
preceding. While febrile excitement continues
much increased, diaphoretics or diuretics are often
exhibited with little advantage, as the restoration
of the cutaneous and urinary secretions is rather
the consequence, than the cause, of diminished or
exhausted febrile commotion. The object, there-
fore, should be, first to lessen the excitement by
depletion, alvine evacuations, and sedatives ; and
then to. employ those diaphoretics which produce
a lowering and refrigerant effect, until the strength
of pulse and heat of skin are reduced. Hence the
propriety of adopting the medicines already re-
commended, and combining them with the nitrate
of potash, and with each other.

73. c. Emetics are amongst the most beneficial
remedies we can resort to in certain states of
bronchitis, particularly in the t/iwd variety ; and,
in the second, after blood-letting : in children they
are often remarkably useful. They have the effect
of unloading the bronchi of the mucus accumu-
lated in them, of relaxing the surface, and after-
wards of promoting perspiration. For children,
ipecacuanha should be preferred ; and for aged
persons, and the third variety of the disease, the
sulphate of zinc. In the second form, and in all
other subjects, the potassio-tartrate of antimony is
the best emetic that can be prescribed, as it ope-
rates by vomiting, by lowering the vascular
action, and promoting perspiration. Emetics are
more particularly required when the expectoration
is difficult or suppressed, the cough severe and suf-
focating, and when the disorder depends upon the
inhalation of irritating particles. They moreover
tend to promote the operation of purgatives, which
are generally much required in this disease. In
cases of extreme depression, with suppressed ex-
cretion of the secretion, the stimulating emetics in
the Appendix ( F. 402, 403.) should be selected.

74. d. Purgatives and cathartics have been
considered by several writers as of doubtful
efficacy in pulmonary inflammations ; and, when
expectoration is established, as being even pre*
judicial. Such appears also to be partly the
opinion of an able reviewer in the Medico-
Chirnrgical Review for Dec. 1820. But it
is not quite in accordance with my experience,
which, at the Infirmary for Children alone, must
have amounted to some thousand cases of the
different forms of the disease. It should be kept
in recollection, that the expectoration in bronchitis
is not a salutary discharge from the lungs, the
promotion of which is a beneficial indication of
cure ; but that it is the product of a morbid state, of
the nature of which it is an index ; and that this state
is generally inflammatory, and always attended
with determination of the circulating fluids, thereby
keeping up the discharge. It is obvious, that
whatever tends to increase the morbid determin-
ation to the bronchial surface will increase the
disease, and, consequently, the expectoration ; and
that whatever derives from this situation will pro-
portionately diminish both. That purgatives or
cathartics, judiciously combined, have the effect
of deriving from the lungs, by increasing the se-

BRONCHI— AcvTE Infi.am

cretions of the liver [and digestive mucous surface,
must be evident; and I have accordingly founil
them serviceable when thus prescribed. Severe
attacks of bronchitis, moreover, are favoured by
congestions and accumulations of bile in the
biliary organs, and by sordes retained on the
mucous surlace of the bowels. In all those cuses
more especially — wherein the stools are generally
very offensive — and at the commencement of all
the forms of the disease, these medicines ought to
be exhibited, with the view not only of promoting
the abdominal secretions, and of removing fascal
matters and sordes, but also of deriving the circu-
lation from the seat of disease ; and the bowels
should be kept very freely open throughout the
treatment. It is, of course, understood that we
are not to prescribe cartharlics to the extent of
depressing the energies of the frame too low, es-
pecially when they are already weak. Indeed,
purgatives may be as much required, and as bene-
ficially employed, in asthenic cases, as in others
of a more phlogistic description, particularly if
the bowels have been neglected ; effects of a very
different nature from that of mere evacuation
arising from a judicious choice and combination
of them. Thus, when prescribed with bitteis,
tonics, stimulants, or antispasmodics (F. 266. 471.
572. 880, 881. 887.), in the asthenic or suffo-
cative states of the disease, not only will full
alvine evacuations be procured, but also a tonic
effect on the digestive organs ; and, consecutively,
a more moderate secretion in the bronchi, with an
easier expectoration, will be produced. I have
observed that the combination of purgatives, espe-
cially calomel, or those of the resinous class, with
camphor, antimony, and hyoscyamus, according
to the circumstances of the case, is particularly
serviceable in bronchial diseases.

75. e. Expectorants have been much abused in
inflammations of the bronchi ; chiefly from tiie
circumstance of the expectoration being too gene-
rally viewed as a salutary d'scharge which ought
to be promoted, instead of its being a product of
the inflammatory state, or of active determination
to the surface of the air-vessels. I consider them
quite inadmissible when there is much fever, or
heat of skin, or when the sputum is abundant and
fluid, the patient having sufficient strength to bring
it up ; and generally in the second variety of the
disease. On the other hand, in the third variety,
or when the expectoration is arrested evidently
from want of power to throw it off, or to excrtte
it, or from its great viscidity, expectorants will be
of much service. In such cases, ammonia and
camphor should be first tried, as being generally
least detrimental in doubtful cases, and most
quickly beneficial. Where the admissibility of
expectorants is evident, especially in the asthenic
form of the disease, and in aged persons, squills, am-
moniacam, galbanum, or senega, may be directed ;
with the precautions, and in the forms, recom-
mended when treating of them vi'ith reference to
humoral asthma (see Asthma, §§ 89. 103.; and
R No. 41 — 46.). When expectoration is rendered
difficult, and the cough suffocative, fiom the
tenacity and consistence of the sputum, as is
sometimes the case, attenuants and alteratives, as
the fixed alkalies combined with ipecacuanha, &c.,
or as prescribed in the article on Asthma (§ 103.
I^ No. 50, 51.), and exhibited with camphor or
ammonia, will be found of much service. In

MATION OF THE — TllEATMENT. 259

nearly all stales of bronchitis, camjyhor is a most
valuable mfdicine. Its virtues have been singu-
larly overlooked by the writers on this disea.-e ;
but, when combined wiih colchicum, or with anti-
mony, nitrate of potash, ipecacuanha, &c,, and
given in small doses, in the more inflammatoiy
and febrile states of the disease ; or when prescribed
in progressively larger quantities, with diuretics,
the spirit, ajther. nit., opium, &;c., as the vascular
excitement subsides, and febrile beat disappears ;
and in large doses (from five to ten grains), with
ammonia, ammoniacum, senega, opium, &c., when
exhaustion and difficulty of expectoration from
deficient power are urgent ; it is one of the most
valuable remedies we possess in this, as well as in
several other diseases.

76. f. The inhalation of emollient and medi-
cated vapours are occasionally of much benefit in
the sthenic form of the disease, but chiefly in its
first and second stages. The vapour arising tiom
a decoction of marsh mallows, or from linseed tea,
or from simple warm water, is the best suited to
this state ; and should be einployed from time to
time, the temperature of the apartment being duly
regulated through the treatment, and constantly
preserved from about 66° of Fahr. to 75°, Dr.
Paris recommends, during the dry easterly winds
of spring (when the disease is so prevalent), the
vapour of warm water to be diffused in the pa-
tient's apartment. In the early stage it may be
of advantage. In the case of the son of an emi-
nent medical writer, attended by Dr. Gordon,
Mr. Annesley, and myself, this was tried in the
state of the air alluded to, but with no benefit.
The case terminated fatally, from extension of the
disease to the air- cells and substance of the lungs.
When the expectoration becomes whitish, opaque,
and thick, the vapour may be rendered somewhat
more resolvent by adding a solution of camphor
in vinegar, and extract of conium or hyoscyamus
to the hot water, or to the emollient infusions now
mentioned ; and in the asthenic variety, particu-
larly when the difficulty of expectoration, and
the fits of dyspnoea, are distressing, or when the
excretion of the morbid matter is impeded or
suppressed from want of power, the medicated
vapours and gases recommended in the chronic
state of the disease (§ 98.), and in humoral
AsTiijiA (§88.), may be tried.

77. g. There are various medicines which are
occasionally useful, when exhibited in appropriate
states and periods of the disease. Amongst these,
narcotics and sedatives deserve an especial notice.
Opium should not be exhibited alone, as long as
febrile action is great ; but, in combination with
antimony, or ipecacuanha, and nitre, it is often a
most valuable medicine. It is best given in small
or moderate doses, in conjunction with camphor
and expectorants, where vital power is reduced
and expectoration difficult (§ 37.). In general,
when the skin becomes cool, the boviels are well
evacuated, and the air-tubes remain irritable,
opium, or some other narcotic or anodyne, is in-
dispensable. Opium, and others of this class of me-
dicines, particularly when judiciously prescribed,
are then of service, not only in diminishing the irri-
tability of the system and of the air-passages, and in
le-sening the cough, the frequency or severity of
which often aggravates the inflammatory iiritation
of, and determination to, the bronchial surface, but
also in ef[ualising the circulation, in determining to

S 2

260

BRONCHI — Acute Inflammation of the — Treatment.

the skin, and promoting perspiration. In the more
phlogistic states of the d:sease, and at its coni-
inencement, colcliicum or digitalis will be often
of advantage, in diminlsliing vascular action, lo-
cal determination, and morbid irritability. They
ought, howt'ver, seldom to be used at the same
time. In the more stlienic cases, (rigiUiUs is very
beneficially associated with tlie preparsitions of
antimony. When the sputum is thick and
opaque, colcliicum is generally less beneficial
than at an earlier peiiod, excepting in conjunc-
tion with diuretics and camphor. When the skin
has become cool, it is no longer of use. In the
Ihiid variety, it is seldom indicated, unless at the
commencement of the ilisease, or when combined
with ammonia and camphor. Upon the whole,
both colcliicum and digitalis are less to be de-
pended upon in acute bronchitis, than a judicious
combination of antimonials with anodynes, &c.
Hifoscifam,us, conium, and the extracts of Jioppii
and of lettuce, are also very generally serviceable
in the different forms of bronchitis. But with them,
likewise, the amount of alvaniage will entirely
depend upon the manner in which they are pre-
scribed. In the sthenic and febrile states of ihe
disease, and at its commencement, they should be
associate! with antimonials, ipecacuanha, refrige-
rants, demulcents, and emollients (F. 24. 208.
427. 554.); with diaphoretics (F. 394. 563. 809.);
and with diuretics (F. 818. 865. 893.); or in
other similar forms, of which there are several in
the Appendix. When the disorder assumes an
asthenic state, or when expectoration is difficult,
the cough distressing, and the skin cool, any of
the sedatives particular' sed maybe conjoined with
eitiier ammonia, camphor, or the fixed alkalies,
or with other attenuants (F. 835.), and with ex-
pectorants, .'kc. (F. 356. 555. 558. 811. 895.) ac-
cording to circumstances.

78. h. When the acute form of the complaint
seems to be about lapsing into the chronic, the
combination of gentle tonics with emollients and
diaphoretics is often of service, as was first pointed
out by M. BnoussAis, who allowed also red wines,
nfiuch diluted with water, in this state. The infu-
sion or decoction of cinchona, or the infusion of
uva ursi, may be thus prescribed : —

No. CO. R Decocti vel Infusi Cinchonje 3 iijss. ; Liq.
Amnion. Acet. 3 jss. ; Mucilag. Acacise 3 ss. ; Spirit.
TEtlier.Nit. 3 ijss. ; Tinct. Camptior.-c Coinp. 5 ss. ; Extr.
Conii gr. xx. ; Syru[)i Toliitani 3 ss. iM. Capiat Coctileare
iiiiuin amplum secunda vel tcrtia quaque hora, vel. Coc-h.
ij. quintis vel sextis horis.

79. i. External measures ought not to be over-
looked during the course of the disease. In re-
spect of local or general depletions, nothing need
be added to what has been already stated. The
former of ihe.-e should always be preferred when
doubts are entertaine<l as to the projiriety of taking
any considcraLle (juantity of blooil ; and, in the
sthenic form of tiie disease, may be resorted to at
an advanced stage, particularly when the change
in the expectoration, ancl other symptoms (§ 35.),
indicate a return or exacerbation of the inflam-
matory action. Blislcvs are not admissible in the
early stages of sthenic bronchitis. But, in the
asthenic disea-e, or when inflammatory action and
fei)rile heat have been subdued by repletions, &c.,
blisters are of much service, and may be applied
either between the shoulders or on the breast ;
and, in so ne severe cases, re-applied or kejit dis-
charging for some time. Jn young children, and
in adult or aged persons, when the secretion of

the bronchial surface is profuse, and the powers
of life much exhausted, I have derived moie per-
manent advantage from the use of the rubefacient
Uniaienls in the Appendix (F. 295. 296. 311.),
rubbed assiduously twice a dciy over the chest or
back, than from blisteis. When blisters are em-
ployed, much benefit will soratlimes arise from
removing thein as, soon as slight redness of the
skin is produced, and covering the part with a
large warm bread and water poultice, wliieh ought
to be (re(|uently renewed ; or by applying a suc-
cession of warm fomentations. In some extreme
cases of this description, I have seen much ad-
vantage derived from applying over the epigas-
trium and lower part of the chest, a flannel wiung
out of hot water, and immediately afterwards
soaked with the spir. terebinth., and allowing it
to remain uniil severe burning heat of the skin is
produced by it. If suflTocation be threatened
either by the profuseness of the secretion, by its
ditficult expectoration, or by exhaustion of the
vital energy ; and if we be, as we then unfortu-
nately are, at a lofs for any probable means of
success ; this will sometimes have a remarkable
effect, and save the life of the patient, particularly
when assisted by the internal use of camphor,
ammonia, &c. At the time of my writing this, a
case occurred, attended by Mr. Faxon and myself,
where immediate relief and a speedy recovery fol-
lowed tliis almost dernier ressurl. And I have
often witnessed a similar result, in other most
dangerous cases of this description, from the in-
ternal as well as the external use of this most
valuable remeily, particularly at the Infirmary for
Children, where 1 have for many years had re-
course to it in cases of danger.

80. The tepid hath, or semicupium, will often
be of service early in the disease ; and in its
course sponging the surface of the chest, or of
the whole trunk, with warm water and vinegar,
and afterwards with the warm nitro-muriatic acid
lotion (F. 834.), particularly towards the decline
of the disease, when we dread its lapsing into the
chronic, and in the asthenie variety, will often
prove of essential service. The common beverage
of the patient during the treatment should be
regulated according to the state of febrile action,
and its compatibility with the treatment directed.
Barley water, with any of the vegetable acids,
tamarind water, or any of the formulae or drinks
(vide PoTus), contained in the Appendix, maybe
directed.

81. B. Of the complicated states. — a. Bron-
chitis is not infrequently associated, particularly
at its coiTimencement, with sore throat : inflamma-
tion existing not only in the fauces, out extend-
ing to the pharipix, and tiirough ttie larynx down
the trachea and bronchi. 'I his state of disorder
sometimes obtains in sca?-/f(/'('(ic')-, forming a com-
plication of remarkable danger. I have also ob-
served it, in a very severe form, affect six members
of one family, and three of another, both living in
the vicinity of the metropolis, in a low damp situ-
ation, all of whom had long previously had scar-
hitina. In some of (hose cases the danger wiis
great, and all were severe and of the asthenic
type. Purgatives, first consisting of calomel and
•lames's powder, and subsequently combined with
stimulants and tonics, were actively exhibited. De-
mulcent linctuscs (seeLiNCTOs, in the Appendix),
or astringent, cooling, and antiseptic gargles ;
external revulsants, and rubefacients; the inter-

BRONCHI — CoBii'LiCATED IsFLAsniAxroNS OF THE — Treatment.

2G1

nal exlii'uition of camphor, coinbineil with anli-
monials, hvosc^amus, diuretics, and alttTwanls
with aniuionia, mild attenuants, expLctorunts,
and tonics ; tlie liijuor ammonia; acetatis, with
infus. cinchona;, spirit, asther. nit., or spirit, am-
nion, arom., iS>:c., formed also the cliief means of
cure. All the cases terminated favourably.

82. Ik When the disease is complicated with
scarlet fever, the treatment will altogether depend
upon the character of the prevailing epidemic,
and the circumstances of the case. I'^arly in the
complication, local depletions are sometimes re-
quired ; and afterwards, full doses of camphor or
ammonia, or of both, — particularly if the eruption
prematurely disappear, or present a dark tint, or
if the anginous afi'eciion assume an ash- colour,
or a dark red or brownish hue, — are amongst the
chief remedies to be depended on. I have met
with severe cases in which the bronchial disease
either preceded, or followed, the efflorescence and
decline of the eruption in scarlet fever ; and in the
course of this association most violent cerebral
symptoms have supervened ; thus forming a
double complication. These cases, although
extremely dangerous, are not necessarily fatal.
Local depletion, sometimes to a very con-ider-
able extent, may be practised, chiefly by leeches
ap|)lied over the sternum, behind the ears, or
below the occiput, or by cupping on the nape o
the neck; and calomel, antimony, revu'sants,
purgatives, camphor, ammonia, ficc, according to
the circumstances of the case, should be pre-
scribed. Counter-irritation by rubefacient lini-
ments is particularly required in complications
of the disease with scarlatina or measles. Formulae
No. 299. and 300. may be used for this purpose,
or the following : —

No. 70. R CamphorEE .3j. ; Pulv. Capsici 3ss. ; Oli'i
M icis m. XXX. ; Olei 01iva;3Jss.: Liq. Amnion. 3 vj.
Misce. Fiat Lininientum.

83. c. The appearance of the disease with
measles, either previous to, in the course of, or
subsequently to, the eruption ; or even its accession
during convalescence, is a very fiequent occur-
rence. This association was very common in the
winter and spring seasons of 1829, 1030, 1831,
and 1832; during which epoch, blood-letting was
not so generally indicated, nor so well borne, as in
former years, the bronchial affection being more
frequently of the asthenic type. In general,
however, local depletions are required early in
the disease, and, in some cases, may be carried to
a considerable extent ; often much further than
in its association with scarlatina. I have some-
times found it necessary to deplete locally in ijoth
these states of complication, at the very time
when I judged it proper to exhibit camphor or
ammonia in considerable doses. But in many
instances, particularly during the years above spe-
cified, patients have recovered as readily when
no sanguineous depiction has been employed, as
where it has. Bronchitis occurring either in the
cour.-e of scarlatina, inea^^les, or small pox, re-
(piires active counter-irritation and revulsion ; and
the means recommended for this purpose ($ 79.)
to be decidedly enforced. The observations I
have alrewdy made respecting the use of inhala-
tion (§ 76.) also apply to such cases. When
these exanthemata commence with bronchial
.•.ymptoms, emetics are then of decided advantage.
And, if they be accompanied vvith sore throat,

purgatives ought to be given in decided discs,
the bowels freely acted upon througliout, and
enemata occasionally thiown up, particularly
V. 140. 149. 784.

84. d. When bronchitis occurs in the course
of coiiiinued J evcrs, the same general principles of
treatment are lequired, as have been .specified in
respect of scarlatina and tDcasles. In all these
states of compile ition, this disease should be
viewed as a marked manifestation, in a particular
organ, of the morbid state prevailing more or less
throughout the frame ; and it should be kept in
recollection, that this affection always, in sone
measure, impedes the changes efi'ecled by respi-
ration on the blood, thereby increasing the morbid
condition of this fluid existing more or le.ss in all
severe cases of exanthematous fevers, and at least
the disposition to it that obtains even in simple
continued fever. I'he extent to which depletion
should be carried in this complication, or the
propriety of employing it at all must depend upon
the character of the fever, of the prevailing epi-
demics, and the particular symptoms and circum-
stances of the case. I have seen a strong, and
regular-living man, with fever thus complicated,
very dangerously depressed i)y a S'ngle small de-
pletion. Hurgiitives are, however, better borne,
particularly when combined with camphor or
ammonia ; and occasional large doses of calomel
combined with camphor, and followed in a few
hours by a cathartic draught, will be found of
much service in promoting the functions of the
liver, atid enabling it to remove those elements
from the blood, which so readily accnmnlaie in
it to a hurtful extent, when their elimination by
the lungs is impeded. Much advantnge will
also arisa from the use of blisters applied for a
few hours, and often repealed ; from the use of
the rubefacient liniments above specified ; and
from the inhalation of the vapour of warm water,
with a solution of camphor in vinegar added to it.

85. d. The association of 'the sthenic form of
bronchitis vvith tracheitis and lartfiigitis, either
afl^ection preceding the other, requires full deple-
tion, general or local, or both ; large and repeated
doses of calomel, with antimony ; the tepid or
warm bath, or semicupium ; internal and external
revulsion, by catliaitics, purgative enemata, &c.;
emetics, particularly when the paroxysms of suf-
focation and stridulous respiraiion are urgent ;
the inhalation of watery, emollient, and anodyne
vapours ; and a free use of diluents, emollients,
ficc, vvith the caibonate of soda, the sulphuret of
potassium, small doses of the sulphuret of am-
monia, or of the sulphuret of copper, in extreme
cases, until nausea or vomiting is occasioned, &c.
Blisters are seldom of much .service in this state
of disease, particularly whilst the symptoms of
croup are present, 'i'hey ought never to be ap-
plied over the throat, as occasionally directed,
and, in some cases, not without mischiet : although
recovery has taken place in others, notwithstand-
ing the risk they occasioned of increasing the local
irritation.

86. e. One of the most frequent complications
presented to us in practice is that of bronchitis
with hooping cough. In some cases, this com-
plication commences vvith the usual symptoms of
catarrh, on which those of bronchitis supervene ;
the characteristic signs of hooping cough, par-
ticularly the convulsive fits of coughing, with thu

S 3

262

LllONCm — Chuon'ic I>flammation of the — Treatment.

inspiratory whoop, and vomitings, not appearing
tor some days subsequently. In other cases — and
those, perhaps the most numerous — llie inflam-
matory affection has not appeared until after the
invasion of pertussis. Wiien thus associated,
bronciiitis may be either sthenic or asthenic ; the
one or the other being more generally prevalent
in some seasons tiian in others. During the
years specified above (§ 83.), the asthenc
state was most common ; and I have seen several
casps in which sanguineous depletion had been
injudiciously practised, particularly as respects
quantity. Cerebral symptoms are apt to occur
during this complication, and also infiltration or
hepatisation of a part of the substance of the
lungs. These unfavourable terminations should
be anticipated and prevented by sinall local de-
pletions,— by leeches applied behind the ears;
by the exhibition of camphor combined with ipe-
cacuanha, or antimonials, and narcotics, particu-
larly conium or hyoscyamus ; by diaphoretics
with diuretics; and more especially by the use of
tlie liniments and revulsants already recommended
{§ 79.). (See Hooping Coi'gii.)

87. f. The simultaneous occurrence of inflam-
matory action in both the digestive and respiratory
inucous surfaces is not infrequent, particularly in
children ; and means calculated to benefit the
one, generally aggravate the other, or risk the
accession of cetebral disease. I have found
small local depletions, followed by the pulv. ipe-
cacuanha; comp., combined with small doses of
calomel, or h^drarg. cum creta and camphor ;
the warm bath and frictions, with the stimulating
liniments already specified (§ 79.) ; the applica-
tion of blisters for a few hours only, and often re-
peated ; theliq. ammonia; acef., with spirit, aether,
nit., cainphor mixture, diuretics, &c., constitute
the principal means of cure.

88. g. The association of liepalic disorder with
bronchitis is not rare. But the affection of the
biliary organs does not always precede the bron-
chial disease: it often occurs in its progress ; an
increased, as well as a morbid, secretion of bile
supervening, probably in consequence of the vica-
rious increase of function of the liver, and its
irritation by, and elimination of, the morbid ele-
ments accumulated in the blood, owing to the
impeded function of the lungs. 'I'his complica-
tion requires the use of mercurial purges com-
bined with camphor and antimony, particularly
James's or kermes powder (F. 637.) ; external
irritants and revulsants, cathartic enemata (F.
151.), &c. A similar treatment is indicated when
the disease is connected with the translation of
erysipelas, gout, or rheumatism.

89. h. If the inflammation extend to the sub-
stance of the lungs or pleura, the antiphlogistic
treatment should be rigorously enforced : the so-
lution of the potassio-tartrate of antimony ought.to
be given in frequent doses, and carried as far as cir-
cumstances will permit; internal and external revul-
sants resorted to at the same time ; and diaphoretics
and diuretics suited to individual cases prescribed.
In some instances, either colchicum or digitalis, or
both, may be substituted for the antimony ; but
they answer better, particularly the digitalis, after
this medicine has previously been used. If we have
reason to suppose that effusion of serum has taken
place in tiie thoracic cavities, diuretics, and,
amongst others, digitalis, should be employed ; re-

collecting, however, that the accumulative and
sinking effects of either digitalis or colchicum
sometimesappear very rapidly, and in an alarming
degree, when they are given either at the same
time or after the exhibition of the potassio-tartrate
of antimony. Disease of the brain or its membranes
supervening in the course of bronchitis has been
considered in the article Brain (§ 186.).

90. The SUB- ACUTE form of bronchitis requires in
all respects the same treatment as the acute uncom-
plicated disease, but not carried so far ; the activity
of the means should have due relation to the acute-
ness of the attack, and the effects they produce.

91. 2d. Of Curonic Bronchitis. — M. Brous-
SAis has very justly staled the indications of cure
in chronic bronchitis to be, 1st, to diminish the
general excitability, and to keep the circulation
quiet ; 2d, to solicit the excitement and the fluids
to other organs, particularly towards the skin ;
and, to these I would add a 3d, namely, to re-
store the healthy tone and functions of the bron-
chial surface, by means which seem to have this
effect either directly or indirectly. It is obvious,
however, that the accomplishment of the first and
second intentions have an indirect influence in
bringing about the third.

92. a. General blood-letting is inadmissible in
this state of the disease ; and even local bleedings
should in many cases be employed with caution.
Cupping, however, to a moderate extent, is very
frequently required ; and it is evidently more ad-
vantageous to repeat the operation to a small
extent, than to abstract a large quantity at once.
When the disease has existed long, and is at-
tended with a copious discharge, much general
debility, and absence of pain upon full inspiration,
even local depletion cannot be ventured on. Next
in importance to depletion is counter-irritation ;
and for this purpose several means are presented
to us. When there is a tendency to acute action,
or when the cough is at all painful, and the spu-
tum puril'orm, either the tartarised antimonial
ointment, or a large issue or seton in the side, is
preferable : but when there is very maiked relax-
ation of the bronchial mucous surfaces, blisters,
and rubefacients, or a succession of them, seem
more appropriate. I have, however, found in a
number of cases, the Unimenls, No. 296, 297.
311. in the Appendix, productive of much greater
advantage, and more generally applicable, than
either blisters or the ointments. They may be
employed once or twice daily. The vapour arising
from tliem, and diffusing itself around, has also a
direct and beneficial effect, by being inhaled, upon
the diseased mucous membrane. JM. Broussais is
very favourable to the use of setons and issues ; and
1 have seen several instances of marked benefit
from them, particularly in the obstinate state of
the dis-ease which simulates tubercular phthisis.
He also reconmiends warm cataplasms to the
chest, made rubefacient by the addition of mus-
tard. I have seen advantage produced by warm
bread and water poultices applied over blistered
surfaces, and the seats of issues formed by the
mezercon bark, and by the same kind of poultices,
to each of which one or two table-spoonfuls of the
nitto-hydrochloric lotion (F. 834.) had been
added. l$ut it is chiefly early in the chronic disease,
or when it has recently passed into this state from
the acute, that issues and setons prove successful.
Tluy exliauit the energies of the system loo

BRONCHI — Chronic Inflam
much to be of service in the latter stages, or when i
the disciiarge I'rom tlie lungs is profuse, and tlie
vital energies much depressed.

93. b. Expectorants have been much em-
ployed in this state of disease ; and though more
appropriate in it, than in the acute, they are often
hurtful from their too exciting operation on the
vessels of the bronchial surface. This is especi-
ally the case with srjuills, ammoniacum, and se-
nega, which ought to be used with mucli caution,
and never whilst the sputum is purulent, and
pain or soreness complained of in the chest, with
fever, heat of skin, &c. The best expectorants
are those which are also astringent, or at least not
very heating : amongst . these, the sulphate or
oxide of zinc, with small doses of myrrh or gal-
banum, and extract of conium ; or small doses of
sulphate of quinine, or of the sulphate of i)0«, with
ipecacuanha and opium; or the sulphuret of po-
tassium, and the balsamum sulphuris (i\ 21, 22.),
are the most eligible, wiieu the state of the ex-
pectoration, of the skin, and pulse, indicates the
propriety of having recourse to tonic expectorants.
Opium has been too much reprobated in cases of
tiiis description, as well as in acute bronchitis,
owing to the dogma that it suppresses expecto-
ration. 1 believe, however, that, when judiciously
combined, particularly with ipecacuanha, with
the chloride of calcium, or either of the sulphates
of potash, of alumina, or of zinc; or with the
nitrate of potash; or with campiior, with kermes
mineral, or the compound powder of antimony,
according to the circumstances of the case, it is a
valuable medicine ; and tiiat the diminution of
the expectoration produced by it, and which has
been unaccountably dreaded, is, when it occurs,
a consequence of its changing the morbid slate of
the vessels forming tlie excreted matter. If it be
the object — as necessaiily follows from the doc-
trine of some writers — to preserve a copious and
free expectoration in this disease, how can it ever
be cured? Frequently have I seen this end pur-
sued, as if it constituted all that was required, and
squills, ammoniacum, senega, &c. given accord-
ingly ; and the more abundant and easy the ex-
pectoration thereby produced, the more rapidly
did the powers of life give way, or complete
hectic, with all its attendants, manifest itself. The
following have proved serviceable when the pulse
was soft, and not remarkably frequent ; the skin
cool and moist ; the sputum veiy abundant, and
consisting chiefly of mucus ; and the weakness
and emaciation considerable : —

No. 71. R Pulv. Ipecacuanhae gr. j. ; Camphorae rasse

gr. ss ^j. ; Extr. Conii gr. iv. — vj. ; Mucil. Acaciae q. s.

M. Fiant Pil. ij. ter die capiendae.

No. 72. R Zinci Sulphatis gr. vj.; Massae Pilul. Gal-
ban. Co. 9 j.; Extr. Conii 5 ss. ; Syrupi q. s. M. Fiant
Pilulae xij., quarum capiat unam tertiis horis.

No. 73. R Pulv. Ipecacuan. Comp. gr. xxv. ; Quininas
Sulphatis gr. vj. ; Pulv. Acaciae 9j.; Extr. Lactucse 3j.;
Syrupi Papaveris q. s. M. Fiant Pilulje xviij., quarum
capiat binas ter quotidie.

No. 74. R Quininre Sulphatis gr. vj. ; Pulv. Ipeca-
cuanhae gr. iv. ; Camphorserasaegr. iv. ; Opii Puri gr. vj.;
Pulv. Had. Glycyrrh. (vel Extr.) 3ss.; Mucilag. Acaciae
q. s. Misce bend, et fiant Pilulae xx., quarum capiat duas
ter quaterve quotidie.

No. 75. R Balsami Sulphuris 3 ss. ; Pulv. Ipecac,
pr. vj.; Extr. Conii 9ij. ; Pulv. et Mucilag. Acaciae q. s.
M. Fiant, secundum artem, Pil. xx., quarum capiat binas
quarta quaque hora.

No. 76. R Solut. Chloridi Calrii TTl xx — xxxv. ;
Mist. Camphors? 3 x. ; Tinct. Opii Comp. (F. 729.) "l x.
_xx.; (vel Tinct. Camphorae Comp. 3jss.). M. Fiat
Haustus ter die capiendus.

94. c. In cases of this description, any of the

jiATiON OF THE — Treatment. 263

formulse given under the head Balsams, in tiie
Appendix, may be employed. Dr. Armstrong
strongly recommended the balsam of copaiva ia
chronic bronchitis ; but it is seldom beneficial,
and is certainly inferior to the other balsams
and terebinthinates in this affection ( F. 486,
487. 53B. 571.). In the more advanced stages
of chronic bi'onchitis, particularly when colliqua-
tive sweats or diarrhoea occur, the most essen-
tial benefit has been derived from the following
mixture ; but even where the bowels are regular,
I have found it by no means productive of costive-
ness. At the time that I was giving this medicine
to the third patient on whom I had tried it, a case,
showing the success of a nearly similar treat-
ment, was published by Dr. Hastings {Midland
Med. Repos, vol. ii. p. 376.), — a coincidence fully
evincing the propriety of the practice.

No. 77. R Mist. Cretae 3 vjss. ; Vini Ipecac. 3 jss. ;
Tinct. Opii 3 j.; (vel Tinct. Camphorae Comp. 3 vj ) ;
Syrupi Tolutani oiij. M. Capiat Cochlearia duo larga
ter quaterve in die.

The cretaceous mixture will often be of service
when used alone, or with a little of the chloride
of calcium, or with the addition of mucilage, or of
hyoscyamus, or conium, or extr. lactucaj, or the
exir. papaveris, according to circumstances. In
this state of the disease, also, I have seen sulphur
given with advantage in mucilaginous electuaries.
Ur. L. Kerckuoffs states, that he has admi-
nistered it with success, in conjunction with the
powder of the while willow bark. M. Buoussais
relies chiefly upon mucilages and demulcents,
combined with ipecacuanha and opium, and cer-
tainly with great justice. (See F. 284, et seq.).
The extr. lactucae, as recommended by Dr. Dun-
can, may occasionally be substituted for the
opium. The decoctions of Iceland moss, and the
infusions of coniuiyi, or marruliinm, of the ura
ursi, or of the melissa ( F. 230. 237, 238.245.
267.), with mucilages, anodynes, and ipecacuanha,
are also very serviceable. 1 have given the pre-
parations of iodine in a few cases, in small doses ;
and in some instances, especially when there was
lilile or no febrile action, nor much emaciation,
benefit appeared to be derived from them.

95. d. When the disease is attended with dys-
pnoea, and profuse or difficult expectoration,
emetics are of great, although often of temporary
advantage, particularly in aged persons. Ipe-
cacuanha, or sulphate of zinc, with the addition of
diffusive stimulants (F. 402.), are the most appro-
priate in the majority of cases. After their opera-
tion, and if the strength be not very much re-
duced, the digitalis or colchicum may be prescribed,
in conjunction with diuretics and gentle astrin-
gents (F. 203.). These active medicines are
chiefly suited to the more febrile states of the dis-
ease, or when soreness or slight pain of chest are
complained of, with a puriform expectoration ;
and ai'e best combined with small doses of blue
pill, camphor, and opium, — with pectoral infu-
sions and mixtures (see App. F. 244. 426. 497.)
with demulcents (F. 389.), and with diuretics (F.
194, 195.236,237.). Dr. Hasti.ngs recommends
a combination of digitalis and colchicum ; but I
have seen more harm than benefit occasioned
by it in some cases of chronic bronchitis, — a
result which might, a priori, be expected from
the associated operation of two most depress-
ing medicines, given in a state of disease charac-
S 4

2'34 BROA'CHI— Chronic Inila

terir3ecl by iiiitative, rather than by acute, vas-
cular aciion. I have found thein most beneficial
when exhibited sinjily vviih diuretics, or diapho-
retics, in the chronic form of bronchitis conse-
cutive of exantheuialous fevers ($ 54.) ; sometimes
resorting also to the warm bath, followed by
frictions of the surface with the liniments F. 297.
or 311. Tlie combination of colchicum and
digitalis, in small or moderate doses, has proved
more serviceable, in my practice, in tubercular
disease of the lungs, or when bronchitis has been
complicated wiih tubercles, or with pneumonia.
In cases where tiie propriety of giving these medi-
cines is doubtful, a combination of them with the
alkalies, or their carbonate-;, and with tonic infu-
sions or decoctions, or F. 515 — 517., or the
following, may be prescribed: —

No. 78. R Pulv. Colchici(vel Pulv. Digitalis) gr.j ij.;

Massse Pilul. Hydrarg. gr. ij.; Massae Pilul. Galbani
Comp. gr. v.; Extr. Opii gr. ss.; Syrupi q. s. M. Fiunt
Pil. ij. bis terve quotidie sumendae.

No. 79. R Infusi Uvae Ursi 3 xij. ; Acidi Sulph. Dil.

711 XX.; finct. Digitalii 111 x xv. ; Tinct. Cainphorae

Comp. 3 j-; Syriipi Papaveris 3 ss. M. Fiat Haustus, bis
terve in die sumendu*.

No. 80. R Sodae Carbon, (vel. Liq. Potassie) 3 j. ;
Int'u.si Calumbse (vel Uecocti Cinchonas) 5vj.; Tinct.
Semin. Colchici 5j — 5jss. ; Tinct. Digitalis 111 xxx, M.
Capiat Coch. ij. larga ter in die.

No. 81. R Mist. Diosma; Crenatae (F. 396.) 3 vss.;
Tinct. Digitalis ITl xxxv. (vel Tnict. Semin. Colchici
3 j. — 3 ij.1 ; Extr. Conii gr. xxvj. (vel Extr. Lactuc£e
.3s£.) ; Syriipi ToUitani 3 ss. JVI. Fiat Mist., cujus sumat
Coch. ij. larga ter quaterve in die.

No. 82. iv Pulv. Acacia? 3 ij. ; Mist. Amyglal. Dulc.
et Mist. Camphora? aa 3 iijss. ; Acidi Hydrocyanici lllxj.
— xviij.; Spir. .Sther. Suljih. Comp. 3ij. — iij.; Oxy-
niellis Scillae 5 ss. M. Coch. ij. vel iij. larga ter in die.

96. Hydrocyanic acid is often of much service
in the chronic forms of bronchitis, especially in
their complications with disorder of the digestive
organs, and may be exhibited vsith demulcents,
gentle tonics, astringents, or expectorants, or as
prescribed in the Appendix (F. 344. 858.).
When the disease is associated wiih derangement
of the hepatic functions, or even of the stomach
and bowels, it will be necessary to give small
doses of blue pill, or of the hydrarg. cum creta,
with deobstruents and gentle tonics ; and, on some
occasions, full doses of calomel trom time to time,
either alone, or in suitable forms of combination,
foll(»wed by a purgative.

No. 83. B Pilul. Hydrarg. gr, vj. (vel Hydr. cum
Creta gr. xviij.) ; Pulv. Ipeciciiaidia; gr. viij. ; Extr.
.Sarzae et Ext. Taraxaci aa 3j.; Cum. Assafcetidae et
.Saponis Castil. a;T 3j. M. Fiant Pilulce xlviij., quarum
capiat binas, ter quatervo in die.

No. 84. R Hydrarg. Chloridi gr. vj.; Kermes Mineral,
gr. xij.; Campliorse ras£e gr. xij. ; Extr. Taraxaci 3 ijss. ;
lixtr. Hamuli 3jss. M. Divide in Pilulas Ixiv., quarum
capiat ij. vel iij. ter quaterve in die.

97. 'i'he treatment which has been already
recommended for Humoral Astfima (^see particu-
larly § 100, et omn. seq.), and the tonics and
astringents, especially the sulphates of zinc, iron,
or quinine, already noticed (§ 93.), are ajiplicablc,
with but little vaiiiition, to the more chronic and
humoral states of the disease, ])articularly in per-
sons advanced in life, and in childien, when it
has assumed a chronic form after hooping-cough
and the exanthemata. 1 have also occasionally
seen benefit derived, in the.se states of chronic
bronchitis, from the clilotale of potash, given to
iidul's, in from two to six grains, three or four
times a day. This medicine was often ])rescribed
by my.sell and one of my colleagues, at the Infir-
mary for Children, during the yeais 1826 — 1828,

MJIATION OF THE TbUATMENT.

and sub.sequently, in the more chronic forms of
bronchitis, and in vaiious disorders of debility;
in which latter it was generally beneficial : but
little advantage was frecjueiitly derived Irom it in
this disease, unless in those forms of it now men-
tioned, where it was often of great use, particu-
larly when the morbid action seemed connected
with deficient tone of the bronchial vessels, and
of the system generally. Mr. Murray, in a
recent publication,. states, that he has employed
it successfully in consumption, — a name which
has usually comprised most of the cases of this
form of bronchitis.

98. e. Inhalations of medicated or tar vapours
have been recommended by Crichton, Paoensif.-

CHER, HuFELAND, FoRBES, HASTINGS, ElLIOT.'^OX,

Gannal, and others noticed in the article on Asth-
wa, and been disapproved of by son:e. 1 believe that
they have frequently been used in too concentrated
a state ; or loo much of the vapour has been dif-
fused in the respired air, occasioning irritation of
the bronchial membrane, ins'.ead of a gently
tonic and healing effect. Whenever any of the
vapours advised in this disease produce an in-
crease of the cough, either its use should be left
off, or its strength greatly reduced. The manner
of having recourse to such vapours, as well as
the choice of substances emitting them, have not,
in my opinion, always been judicious. The tar
vapour is occasionally of service, chiefly from the
quantity of turpentine it contains ; while the acrid
empyreumatic fumes which it also emits, counter-
act whatever good efl'ect the former con,stituent
migiit produce. Would it not, therefore, be pre-
ferable to try the effects of the substance from
which the advantage is obviously deiived ? I have
done so in a few cases of this disease, and seen
marked benefit result from it ; and therefore re-
commend it to the notice of other practitioners.
In former times, medication by fumigations and
vapours was much resorted to ; and it is probable,
that the early use of incense and various balsamic
and aromatic fumes in religious rites had some re-
lation to their prophylactic efl'ect against disease,
or even to their curative influence ; the more espe-
cially as the p;iests of antiquity also exercised the
healing art. In several of the productions attri-
buted to IIiitocrates, the inhalation of vapours
and fumes of various resinous and balsamic sub-
stances is recommended ; and a number of writers
in the 16th, ]7tli, and 18th centuries, have ad-
vised a nearly similar method, and employed
camphor, benzoin, amber, frankincense, myirh,
storax, assafcetida, sulphur, cloves, the balsams,
&.C. for this purpose. This piactice was employed
by Benkdici' (see his Theuirnm Tabidorunt') in
consumptive diseafses : and 15oeriiaave gives
several formula;, in his Materia Medica, for fumi-
gations with the above substances. Mead, in
his Motiita el I'recepla, offers several judicious
remarks on this subject. He observes — "that
fumigation with balsamics, &c., is of vast service
in some cases : which is to be done by throwing
the ingredients on red coals, and receiving the
f'uines through a proper tube directed to the wind-
pipe." After noticing the undcseived neglect of
this practice, and the projiiiety of thus ajjplying
nudical substances directly to the seat of dis-
ease, he states, that the smoke of the balsam of
Toll! conveyed into the lungs, or (he smoking this
substance like tobacco is of signal service in

BRONCHI — Chronic Infla

diseases of ihis orgnn (|). 58.)- It appears from
tlie writings of FRACASioni ihat the fumes of
cinnabar were much employed by iiihiilalion in
the treatment of the constitutional forms of sy-
philis, at an early perioJ of the history of that
disease, when it assumed a pestilential form.

99. Notwithstanding the unsuccessful attempts
of Beddoes to revive tlie practice, by employing
the elementary and permanently elastic gases,
but according to views too exclusively chemical,
the practice of inhalation has long been neg-
lected or umleservedly fallen into the hands uf
em])iiics. Very recently, however, it has been
brought again into notice by RI. Gannai., !\Jr.
Murray, and Sir C. Scuda.moue ; and chlorine
giu, the fumes of iodine, and watery vapour
hohling in solution various narcotics, have been
recommended to be inhaled. I have tried those
substances in a few cases of chronic bronchitis ;
but in not more than two or three cases of tuber-
cular phthisis, i'he chlorine was used in so di-
luted a state as not to excite irritation or cough.
The sulphuret of iodine, and the liquor pota^sii
indidi concentratus (F. 328.) were also enij)loyed ;
one or two drachms of the latter being added to
about a pint of water, at the temperature of loO°,
and the fumes inhaled for ten or twelve minutes,
twice or thrice daily, 'i'he tinctures or extracts
of hyoscyamus and coniuni, with camphor, added
to water at about the above temperature, were
likewise made trial of; and, although the cases
have been few in which these substances have
been tlius used by me, yet sullicient evidence ol
advantage has been lurnished to warrant the
recommendation of them in this state of the
disease.

100. Inhalations also of the fumes of the bal-
sams, of the tsrehinlhinates, of the odoriferous
resins, &c., are evidently, from what I have seen
of their effects, of much service in the chronic
forms of bronchitis : and I believe that they have
fallen into disuse, from having been inhaled as
they arise in a column or curient from the sub-
stances yielding them, and before they have been
suflicient'y diffused in the air. When thus em-
ployed, thej' not only occasion too great excite-
ment of the bronchial surface, but also intercept
an equal portion of respirable air, and thereby
intertere with the already sufficiently impeded
function of respiration. M.NysTEN has shown
( D(ct. des Scien. Med. t. xvii. p. 143) that am-
moniacal and other stimulating fumes, when in-
haled into tl'.e lungs in too concentrated a state,
produce most acute inflammation of the air-tubes,
genei-ally terminating in death ; and has referred to
a case in which he observed this result fiom an
incautious trial of this practice. I conceive,
therefoie, that the vapours emitted by the more
fluid balsams, terebinthinates, the resins, camphor,
vinegar, &c., and from chlorine and the pre-
parations of iodine, should be more diluted by
admixture with the atinosphere, previously to
being inhaled, than they usually are. According
to this view, I have directed them to be diffused
in the air of the patient's apartment, regulating
the quantity of the fumes, the continuance of
the process, and the frequency of its repetition, by
the effects produced on the cough, on the quan-
tity and state of the sputa, and on the respiration.
The objects had in view have been gradually to
diininisli the quantity of the sputun), by changing

MMATION or THE TREATMENT. 265

the action of the vessels secreting it; without
exciting cough, or increasing the tightness of the
chest, or otherwise disordering respiration. From
this it will appear, that the prolonged re;.pira.
tion of air containing a weak dose of medicated
fumes or vapours, is to be preferred to a short
inhalation of them in their more concentrated
states. The want of success which Dr. Has-
tings and others have experienced, evidently
has been partly owing to the mode of adminis-
tering them, and partly to having prescribed
them inappropriately. When the patient com-
plains of acute pain in any part of the chest,
as in some of Dr. Hastings' cases, they are as
likely to be mischievous as beneficial. Where
benefit has been obtained, it will be found that
it was when the fumes of the more stimulating of
those substances were diffused, in moderate quan-
tity, in the air of the patient's apartments ; or
when he passed, at several periods daily, some
time in a room moderately charged with the
vapour or fumes of the substance or substances
selected for use. (See the remarks on Inhalation
in Humoral Asthsia, § 88., for an account of va-
rious medicines that may be employed in this
7nanuer,y

101. /. Sponging the surface of the chest, and
trunk of the body, first with tepid, ami afterwards
with cold lotions, has often been practi-^ed by me
with advantage in several states of this disease.
When the expectoration has been profuse, the
debility great, and little or no febrile heat pre-
sent, 1 have preferred for this purpose the nitro-
hydrochloiic acid lotion (F. 834.), in a warm or
tepid state, night or morning, or both. When the
disease is more ac'ive, the habit of body beino-
nevertheless, relaxed and debilitated, a solution
of common salt in water, or the lotion, l\. 54.,
seems preferable; and the directions given re-
Sjjecting this treatment in the article Asthma
(<J§ 1 16, 117.) should be strictly followed. 1 have
observed much benefit derived from the appli-
cation, for a considerable time, of one of the
plasters, F, 111. 115. 118, 119.. between the
shoulders; whilst cold sponging the anterior of
the trunk with the lotions referred to has also been
directed.

102. g. The complications of chronic bronchiiis
require generally no particular modification of
treatment from that now detailed : indeed, some
of them have been already noticed. I may, how-
ever, add, that, in the chronic asthenic states of
the disease frequently met with in aged persons,
and often occurring in children after exantheina-
lous diseases, hooping-cough, and bowel com-
plaints, the flowers of sulphur, the preparations
of s//ic, the trisnitrate of bismuth, ami the chlorates
of potash and of lime, have severally been of great
service, especially when combined with narcotics
— with opium in the aged, and conium in the
young, — their constipating effects upon the
bowels being duly obviated by the occasional
exhibition of purgatives. The chronic bronchitis
complicated with, or consecutive of, hoopino-.
cough, the characteristic cough of the latter
either still continuing, or having altogether dis-
appeared, is frequently attended \vnh dilatation
of the bronchi. In these cases, balsams, inha-
lation, the use of tonics, particularly the sulphate
of iron, quinine, the liniments already noticed,
frequent doses of s.ilpbur, or mcderate doses of

266

BRONCHI — Dilatation of the — Treatmekt.

the chlorate of potash, are required. If the child
be not very young, either of these latter may be
combined with belladonna, or with coniura, and
given in honey or syrup of squills ; or with simple
syrup, sugar, powdered liquorice-root, or with the
compound tragacanth powder. When the disease
is associated with chronic irritation of the mucous
surface of the bowels, the chlorate of lime will be
of much service, and will soon restrain the latter
affection ; the use of the liniments already recom-
mended (F. 296. 311.) in addition, generally con-
tributing to cure the bronchial disease. Either of
these liniments has often been sufficient of itself
to remove all disorder, both in the consecutive
states, and in the different complications noticed
at this place ; and, when bronchitis seems to have
a tendency to terminate, or has actually termi-
nated, in effusion, they have powerfully assisted
the treatment. When, however, dropsies super-
vene, in addition to them, colchicum or digitalis,
with astringent tonics; squills, with blue pill, ta-
raxacum, or extract of sarsaparilla ; the prepar-
ations of iodine, alone or with narcotics ; bi-tar-
trate of potash, with the bi-borate of soda, parti-
cularly this last ; and various other diuretic and
deobstruent medicines in different forms of combi-
nation— of which numerous examples are given
in the Appendix — and the general plan of treat-
ment recommended in the article Dropsy ; should
be employed.

103. C. The regimenal treatment of bronchitis
requires strict attention. — a. In ihe sthenic acute
disease it should be strictly antiphlogistic ; and, at
the commencement of convalescence, a farina-
ceous diet adopted, until out-of-door exercise may
be taken, or shortly before. In the asthenic states
of acute bronchitis, this regimen is chiefly appli-
cable to the commencement of the disease : sub-
sequently, nourishment in small quantities, suited,
in kind and frequency of partaking of it, to the
state of the symptoms, the powers of the digestive
organs, and feelings of the patient, should be
permitted; and even animal food of a digestible
nature, in moderate quantity, may in some cases,
particularly in the aged, be permitted once a day.
The decoction of Iceland moss, jellies, mucilagi-
nous and emollient soups ; shell-hsh ; the different
kinds of white fish, dressed either with sweet oil
or the oil obtained by boiling their fresh livers ;
the lighter kinds of animal food ; and, in the case
of infants, attention to the milk of the mother, or
a healthy wet-nurse ; are all occasionally of ser-
vice during early convalescence from the acute
forms of bronchitis, and in the progress of the more
febrile states of the chronic disease. In the more
asthenic cases of this latter, or when the expec-
toration is profuse, the skin cool and moist, and the
habit of body lymphatic, relaxed, or wasted, ani-
mal food, especially fresh beef or mutton, under-
done, and in moderate quantity ; new-laid raw
eegs ; or a due proportion of digestible and sti-
mulating food ; will be found most serviceable.
In nearly all the chronic slates of the disease,
particularly in their advanced stages, a light nu-
tritious diet is necessary.

104. h. The patient's beverage should receive
particular attention. Lemonade, imperial, barley-
water, and the cooling and aperient drinks pre-
scribed in the Appendix (F. 588 — 595. 916.),
should be employed in the sthenic form of the
acute disease. In the asthenic and chronic states.

the red Bordeaux wines, or the wines of Bur-
gundy— the former generally reduced by one
third or one half water ; or beer or ale, also
reduced, to which a little of the liquor potassfE, •
or of Brandish 's alkali.^e solution, has been added,
may also be tried at meals ; and either of these,
or of the more cooling beverages, adopted, that
may be found to agree best with the patient. If
tiie disease evince a disposition to terminate in
dropsy, the imperial drink, with the addition of a
little bi-borate of soda, or F. 590, 591., wdl be
most serviceable. In the advanced period of
chronic, or during convalescence from acute, bron-
chitis, the sulpliureous mineral waters will often
be beneficial. Those of Ilarrowgate, Leamington,
or Moffat, may be tried ; or of Enghein, Bonnes,
Bareges, or Cauterets (Roche) ; or the artificial
waters of Ems or Carlsbad.

105. c. Few diseases are more benefited than
chronic bronchitis by change of air. A resi-
dence on the southern coast, particuliirly at 'J'or-
quay, and in various other parts of Devonshire,
during the winter and spring months, guarding
against vicissitudes of climate, — which, how-
ever, is milder and less variable in this part of
the island than any where eL-e ; wearing Hannel
next the skin, especially during winter and sprmg ;
gentle exercise on horseback, or the use of the
swing ; arid constant attention to the state of the
bowels; are severally of great importance. During
the progress of convalescence, as well as in the
earlier stages of disease, particularly if the secre-
tion from the bronchi continue, it will be neces-
sary to resort occasionally to an emetic ; and in
a day or two subsequently, notwithstanding the
bowels may be freely open, to an active cathartic.
In these cases, the addition of a vegetable bitter
or tonic to a purgative medicine, — as the sul-
phate of quinine to aloes, or the infusion or ex-
tract of genti;m to senna, — will have a decidedly
cathartic operation, without lowering the energies
of the frame. There are few diseases more bene-
fited, either in their progress or decline, than those
now discussed, by active purging ; but it wdl
often be requisite to combine the purgatives with
stimulants or tonics, in order that an active or
continued operation on the bowels may not ex-
haust the patient. During convalescence, the
free use of purgatives requires a liberal and invi-
gorating diet.

106. V. Dilatation of the BnONcni. —
i. The anatomical characters and phifsical signs of
this change of the bronchi have been already
described (^§ 19.). It is almost entirely a con-
sequence of, or an attendant upon, the more
chronic cases of bronchitis, or of hooping-cough
complicated with bronchitis. The expectoration,
besides being copious and puriform,is often foetid,
— a diagnostic symptom of this alteration, with-
out which, M. Louis, and other pathologists, who
have devoted much attention to pulmonary dis-
eases, have sometimes failed of distinguishing it
from phthisis.

107. ii. The Tiieatment of this alteration is nearly
the same as that which has been recommended in
the more chronic states of bronchitis. The means
which are especially indicated consist of the inhala-
tion of balsamic and terebinthinate fumes ; of those
of creosote, chlorine, iodine, &c. (§§ 99, 100.) ; the
internal use of balsams, tonics, and bitters, particu-
larly the sulphates of quinine, or of zinc, or iron ;

BRONCHIAL FLUX — Diagnosis.

267

and other preparations of cinchona or steel ; with
the use of t lie liniments already noticed (^ 10"2.);
or tlie nitro-hydrochloric acid lotion on the chest.
The chlorate of potash, or of lime, seems indicated
in this form of the disease. An open state of the
bowels, an occasional cathartic, nutritious diet,
and change of air, are also evidently required.
In other respects, the treatment already det;iiled
(^ 101. et ieq.) may be followed; or modified,
according to the peculiarities of the case.

10(3. VI. ULCERAxroN OF THE Bronchi (scc
§§ 7, 8.) is another alteration which is produced
by, or is attendant on the advanced stages of,
chronic bronchitis ; most fre<|uently, however,
when complicated with tutjercular phthisis. It
is not infrequeutly met with, particularly after
bronciiitis occasioned by the mechanical irritation
of mineral, vegetable, or animal molecules. Tiie
existence of ulceration, when seated in the bronchi,
is not indicated by any sign in addition to those
wliicli accompany the most chronic states of bron-
chitis, or tubercular disease, when it arises from,
or IS complicati^d with, this change. When affect-
ing the Larynx or Trachea (see these articles),
it may frequently be suspected, or occasionally
prognosticated. In a case which occurred in the
trachea, a prognosis to this effect was given by rae
long before death.

109. The Treatment of this lesion, even
could its existence be ascertained during life, can-
not be different from that required in some other
stales of chronic bronchitis. I'liat ulceration may
take place in tiie bronchi, and heal, as evinced
by the appearance of cicatrices, has been ascer-
tained by jM. Laennec, and other pathologists.
In addition to the means of cure already de-
scribed, the establishment of local drains of the
most active kind is obviously required. Blisters
and is'ues applied to a distant part have not been
found of use by M. Laennec. He prefers the
repeated application of small moxas as near the
seat of disease as possible, and the preservation
of abs )lute rest and silence. The inhalation of
emollient, anodyne, and balsamic vapours and
fumes may likewise be tried; and, if the disease
be devoid of marked febrile excitement, the ex-
pectoration abundant, and the powers of life
consequently reduced, the treatment advised for
dilatation of the bronchi (§ 19.) may be em-
ployed in all its parts. (For the treatment of
other organic changes of the air-passages, see arts.
Croup, Larynx, hvy gs — H(emorrhage from,
and Trachea.)

VII. Bronchial T ws-.—Bronchorrhaa (from
BptJ^xoy and ^ea*.) — Syn, Bronchorrhee
(Roche); Catarrhe Pituiteux (Laennec);
Mticims Flux.
Classif. I. Class, III. Order {Aitthor').

110. Defin. Afiax of watery mucus, or phlegm,
from the chest, with more or less cough, but without
fever ; frequently occasioning exhaustion.

111. This affection varies considerably. It is
often a variety of chronic bronchitis ; being con-
secutive of it in persons advanced in life, or those
of a relaxed and phlegmatic or pituitous habit of
body. In other cases it appears from the com-
mencement, or consecutively of slight catarrh, as
intermediate between chronic bronchitis and
humoral asthma. This appellation may, upon
the whole, therefore, be viewed as applicable to
those cases which are attended with a more

abundant, fluid, and transparent expectoration,
than is observed in chronic bronchitis, and are
devoid of fever and all other signs of inflamma-
tory action ; whilst they are equally without the
severe dyspnoea, the paroxysms of suffocation
and cough, and the intermissions, characterising
humid asthma.

112. i. Bronchorrhcea proceeds generally from
similar causes to those which produce common
catarrh, or bronchitis, even although it be not
consecutive of some one of the forms of bronchial
inflammation. It is very frequently, either at its
commencement, or recurrence, connected with
cold and moist states of the atmosphere, or occa-
sioned by exposure to cold in some one or other
uf its forms. When it occurs ^as a sequela of
bronchitis, it may be viewed as arising from lost
tone of the vessels and of the bronchial surface,
the flux or determination to this part still con-
tinuing, from peculiarity of habit or some other
cause, after all inflammatory and febrile sym-
ptoms have been removed. Thus, it is very fre-
quent in aged persons of relaxed fibres, who
have experienced repeated attacks of pulmonary
catarrh.

113. ii. Diagnostic Symptoms, — Bronchorrhcea
may be distinguished from chronic bronchitis,
tubercular phthi.-i^, and humoral asthma, by the
iollowing characters: — The quantity of fluid
expectorated is very great; being, in some ca-es,
as much as four or five pounds in the twenty-
tour hours. The sputum is colourless, ropy,
transparent, slightly frothy on the surface, and
resembling the white of egg mixed with water.
It is without the thickened sputa generally ac-
companying chronic bronchitis. There is con-
siderable dyspnoea, but the chest sounds well
througiiout upon percussion ; and the cough is
slight comparatively to the quantity of the ex-
pectoration, being evidently no more than is
occasioned by the discharge of the secreted fluid.
The pulse and temperature of the skin are na-
tural, and there are no night sweats. The appe-
tite is generally unimpaired ; and emaciation is
not remarkable, or not at all observed, unless
the quantity of the sputum be extremely great.
M. Nauche states, that the expectoration in
this state of disease is always more or less acid,
and reddens litmus paper, whilst that proceeding
from inflammatory action restores the blue tint to
this paper after being reddened by acids. On aus-
cultation, the respiratory murmur is commonly
weak, but is very rarely suspended. The sibilous
rhonchus is heard more or less distinctly, and
often mixed with the sonorous, and occasionally
with the mucous rhonchus, the bubbles of which
seem to burst upon the surface of a fluid of less
consistence than in bronchitis.

114. Bronchorrhcea usually commences with
catarrhal symptoms, and frequently without fever.
In other cases, after bronchitis has continued
chronic for a longer or shorter period, the ex-
pectoration becomes less consistent and less
opaque, more abundant, and similar to that de-
scribed ; and the affection becomes established,
— aggravated at times by disorder of the stomach
or bowels, or by changes of the air, especially by
cold and moisture, or by arrest of the cutaneous
transpiration from any cause, — and ameliorated
at otiier times by a warm dry air, an open state
of the bowels, and light nourishing diet, taken in

268

moderate quantity. Viicillating iii this manner,
the disease may continue tor years if it be not
severe, without niateiially affecting the strength.
But more frequently the discharge iacreases,
after irregularly pirolonged, and more or less
slight intervals; the patient loses his flesh, and
becomes paler ; his strength is impaired ; dys-
pnoea increases; and, in some cases, the affection
either runs into humoral asthma, or the quantity
of expectoration is augmented so as to exhaust
his energies, and to occasion suffocating parox-
ysms of cough. In rarer cases, the quantiiy of
the bronchial discharge has been so great as to
occasion the exhaustion and death of the patient.
M. An DUAL has detailed two cases of tiiis de-
scri|ition, wherein, upon dissection, no evidence
of inflammation or congestion could be found in
the air-tubes. M. Roche has described, what
he has designated an acute form of this afftction,
wh;cli other French pathologists have named
cutarrlie siifocant ; but it diH'ers in no respects
from the mure humoral st:ites of asthma, described
in its more appropriate place, and presenting all
the symptoms of spasm of the air-passages, with
a copious viscid expectoration ; the spasm and
other symptoms subsiiling after the bronchi and
trachea are unloaded of the secretion accumu-
lated in them. IJronchorrhoea has, in rare in-
stances, been the means of removing otiier diseases.
M. Andrai, states that he has seen hydioihorax
disappear after the establishment of a copious
bronchial flux.

115. iii. TmcATMENT. — After the full exposltioa
that has been given of the means of cure in the
different states of chronic bronchitis, to some of
which bronchorrhoea is closely allied, it will be
sufficient to enumerate succinctly the various
mean; which are applicable to lliis affection. As
the di-ease esstntially consists of an increased
secretion and exhalaiion from the respiratory
mucous membrane, with a determination of tiie
circulation to that (juarter, and deficient tone of
the vessels distributed to it, the obvious indica-
tions are, to increase the secictions from other
surfaces and organs, thereby to derive from the
lungs, and to restore the lost tone of this mem-
brane and its vessels. In some cases, acconl-
ingly, it will be advantageous to commence with
an ii)ecacuan!ia or sulpiiate of zinc emetic, and
afterwards to act freely upon tiie secretions
and alvine excretions by purgative-^. I liave
never seen a case of the disease which has not
been much relieved by purgatives; taking care,
however, that they should not lower the enei-gies
of the constitution, by combining them witii
tonics, bitters, or stimulants, and allowing suffi-
cient light nouri>hmenl to admit of this mode of
deiivation being satisfactorily employed. In the
intervals between the (•xiiibitioii of ijurgatives,
diuretics and diaphoretics may be exhibited, and
the cutaneous functions promoted by wearing
flannel next the skin during the vvinler and spring
months.

116. Kipectonints are very much employed in
this afFection ; but some of this class of medicines
are seldom of benefit in it, unless combined
with opium. The balsams and teiebinlhinates
(F. 484— 4ii7. 48'J.); the sulphate of zinc, witii
iiiyirh, or the compound (^albanum pill ; and
either of ihesc, witli camphor and opium ; arc
often ol si.rvic.'. | „ adJiiion to these, inliaLninns,

BRONCHIAL FLUX — Treatment.

as recommended in another part (j§ 99, 100.),
may be employed. Altiiough astringents and
inhalations are often required, yet we should be
cautious in using them when the disease has been
of very long continuance, particularly in persons
advanced in age, or when there is any irregularity
of the action of the heart, or physical sign of
organic change about this organ, complicated
with it ; inasmuch as the arrest of an habitual
discharge will, in such circumstances, risk the
supervention of effusion in the cavities of the
thorax. It will be more judicious, in these cases,
to confide in purgatives combined with hitler
tonics ; in diuretics, and in diapiioretics, so as to
moderate the discharge, and prevent its increase,
or its exhausting effects upon the system. At
the same time tiie vital energies should be pro-
moted by a light nutritious diet, moderate exercise,
and cliange of air, with the sulphureous or gently
tonic mineral waters. In other cases, where the
age of the patient, the regular or healthy state of
the heart's action, the absence of leucophlegmasia,
and the circumstances of the case altogether, are
such as to preclude dread of the consecpienees of
suppressing this discharge, cold sponging the sur-
face of the body by the nilro-hydrochloric lotion,
6iC. (§ 101.), and the liniments already noticed
(K. 296.311.), with the internal use of the more
astringent Ionics, pariioularly the sulphate of iron
or of quinine, in addition to the measures already
recommended, may also be practised.

BiBLioG. AND Refer.— il/o>7io/, Priiiceps Medicus, 4 o.
Uost. 1GG5. — liwdcrer, Disser. de C'atarrlio l^luliisni
Meiitientc, 4to. Goet. 1758. — Ric/iter, On Mucous Con-
sumplion, in Miid. and Sui gieal Observations. Ediiibiirgb,
\1[H. — Jiecldues, On tlie Medicin^d Use of Fuctitious Airs,
&c. Brist. ITS)'. — Engleliart, Dt': CiiVdnho IiiHainmatorio,

4to. Lund. 1799 La Roche, Essai sur la Catarrlie I'nl-

nionaire Aigu, 8vo. I^aris, llf02 licrtraud, Sur la Dis-
tinction da Catarrlie, de la Pleuresle, et Feiipneum. iS;c.
■lio. Paris \%<M.-Cnbanii, Observ. sur Ics Att'ect. Catarrh.
8v(). Paris, 1k()7. — Bad/mm, On the Inflammatory Aftec-
tioiis of the Mucous IMemb. of the Bronchia^, 8vo. I...nd.
1H:U. — J. P. Frnuk. Iiiterp. Clinic, p. UO. Tub. 181-.'. —
J. Franii, Praxis AK-.lica, \c. part ii. vol. vi. p. 3"i9.— /■'<■)•-
liar. On the PUcits ot Pneumatic iVledicine, Medical His-
tories, ice. vol. li. p. '.iOl. Lond. 1 8 10. — JSruussais, llisioire
des I'hlenmasies, ou Inflammations Clironiqiies, &c. t. i.
p. Oil. 3d edit. Paris, Wn.—Chcyne. On the Pathol, of the
I-aryiixand Bron hia. Kdiii. iotiH. — Alarii,\iyi Siege »t

de la Nature des Maladies, 2 t. Paris, I82i fillcnite.

Diet, des Scien, Med. t. xxxii. p. WS.— Hastings, On In-
llim. of the iMucous Membrane of the Lungs, &c. 8vo.
Lond. 1820; ami Miiilaml Slcdical Reporter, vol. ii.

J). 3ii7 Roche el Sanson, Nouveaux Klemeiis dr Pathol.

Medico-Chirurgii'ale.t. i.p.riUO.; etDict.de Med et Chir.
Prat. t. iv. p. •lii^. — Arms/rong,On Scarlet Kever, MiMsles,
aiid.Consumiition, 2d edit. I,ond. 1818. — Buuillaud, in
Jouni. tloinplement de Diet, des Sciences Med. t. xix.
p. 0. — Duncan, Observations on Pulmonary Cnnsump-
tiun, 2d edit. p. 102.— /-«f«7/ec, Traite de I'AuscuUation
Mediate et des Maladies des Poumons, S:c. 'id edit.
Paris, 182(); el Uev. Med. t. i. p. 384. \%-H.— Anriral,
Cliiiique Medicate, &c. t. ii. p. 1.; et Anatomie I'atho-
logique, t. ii. p. 46-'). ; et Archives Geiier. de Mcdeciue,
t. iv. p. -Mi. — Hoyei-Collard, Nouv. Biblioth. Med. t. i.

p. lllii. \«2C,.— Savin, liev. Medic ,le, t. ii. p. .V20. 182(1

Mills, Aeconnt of Morbid Appearances Irom Disorders of
the Lungs and Heart, 8vo. Lond. 1830. — ///coc*. On lii-
Uainmatioii ol the I\Iu.;oiis Meinb. of the Organs of Ke-
.'liir.ition, .Medical Intelligencer, Nos.vii. and viil. p. 151.
— U. Ildiiisiin, in Medical and Physical Journ. July,

182U luhnson's Medico-Chirurg. Keview, Dec. 1820.

p. 31L- Chumcl, Diet.de Mud.t. iv. p. 417. (art. Catarrlie
J'ulnionairc.)—llildcnbrand, Institiit. Praetico-Mi'dica;,
t. iii. p. 170. — /•'«^'<■/l.s■/fcAt■>•, in llu/c/and'a Joiun. der

Pract. lleilk. Nov. 1827 Crichlvn, On the Xreaimentof

several Varieties of Pulmonary Consumptiiin, and on the
Vapour of Tar in that Di.sease, 8vo. Lond. 1823. — Elliot-
son, Loiul. Medical (iazette, vol. viii. p. 28'J. ; and Lancet,
vol. xvii. p. 4(17. — ISai/lf, liecherches sur la Phthisic (in
some cases of clinniiv hnmchilis found the bronchial sur-
face pale, and irillhiiil i/itiuae). obs. xlix. p. 31)2. Paris,
1810. — Abercroiiilne, iij laliii. Medical and SurgicalJourn-
nal, vol. xvii. p. 3'J. (t'lceralion of the bronchi.) — J-

BRONCHOCELE — Caus

Forbes, On Tar Vapour in Discnses of the Lungs, &c. in

Meiiical and Physical .Inurn. vol. xlviii. p. -2X1 tV/l-

liams. On the Physical Signs of Diseases of the l.ungs,
&c.p.G() 8vo. Lond. 1829 Foihfs, Original Cases, illus-
trating the Use of the Stethoscope and Percussion, 8vo.
JLond. IS24 Grndiin. Histoire Anatom. des Inflamma-
tions, &c. t. i. p. Mr\ Paris, 1H20. — fyn'ti/it, Keports of

Medical Cases, &c. p. 127. 4to. Lund. 1827 Graves, in

Hcns/iaw's Med. and .Surg. Journ. vol, vii. p. 1"J3.

HRONCIIOCELE (from Bpoyxos, ihroat, and
Kii\7], a swelling). Syn. Hernia Gulturalis,
Gossiiin, Liiitrohretibriicli, Kvopf, Ger. Goitre,
Fr. / roncncete, Gnzzc, Ital. Thifrophraria,
Aliberl. Ciimtitche Tliyroidea,ConTadi. Goitre,
'' JJerbiishire Neck."

Classif. 4. Cliiss, Local Disenses ; 6. Order,
Tumours (CitWeu). 6. Clnss, Excernenl
Function; 1. Order, Affecting the Paren-
chyma (^Good). IV. Cl.ass, IV. Order
(Author, see Preface).

1. Defix. CJirniiic enlargement of the thyroid
gland, sometimes wilh change in the snrrounding
parts, generally increasing stowlq, oj'ten continuing
for years, and depending upon constitutional
causes.

2. I. Cau«e=, and IMonniD Relations. — This
disease is endemicul in Derbyshire, and some other
parts of this country ; but most remarkably so in
Switzerland, various adjoining districts, and in
some places in South America. It usually occurs
during the early epochs of life, most frequently
about the period of puberty, in persons of a weak
and lax fibre, and generally in females; it very
seldom being observed in Great Britain in males :
but the comparative frequency of it in the latter
sex is greater in Switzerland, and other parts
where it is very prevalent, and is connected with
cretini<m. In a considerable number of cases
which have come before me in females, I have
never met with any before the period of com-
mencing pubeity, — not even at the Infirmary
for Children ; althongh the menses have often
been delayeil for a jear or two, or even longer,
when the tumour has appeared at this epoch ; and
I have seldom observed an instance in this sex
unconnected wilh some kind of irregularity of
the menstrual discharge, or disorder of the uteiine
functions. In two cases, occurring in married
females, who were under my care, unhealthy or
irregular menstruation had existed during the
continuance of the goitre ; in one case for eight
years, in the other for five: upon its disappear-
ance, pregnancy took place in both. Suppression
of the menses has sometimes caused its sudden
appearance and rapid development ; and it more
rarely has originated during pregnancy and the
puerperal states. Authors have adduced conclu-
sive proofs of ils occurrence hereditarily, inde-
pendently of endemic influence.

3. Dr. Good has attributed the disease, in a
great measure, to poverty, and the nature of the
food : the rich being exempt from it. This is,
however, very far from being the case. 1 have
seen several cases of bronchocele in the richest of
this metropolis. He is also wrong in attributing
it to the use, in Deibyshire, of oaten cakes. In
Scotland, where this article of diet is in general
use, bronchocele is rare.

4. That it chiefly depends upon certain phy-
sical causes is shown by its prevalence in certain
districts in preference to others, and by the cir-
cumstance of its disappearance when persons
aflected by it endemically have changed their

ES AND Mo a BID RELATIONS. 269

residence. M, Alibert mentions his having
seen it di>appear after a resilience in Paris. It
has been vi;iy generally imputed to the water
used by those afi'ictei!. Since the time of Pliny,
il has been attributed to the use of snow water.
But it prevails in several places where this cause
does not exist, as in Sumatia, and several parts of
South America. The Svvi~s who drink snow
water are free from the disease, while those who
use hard spring water are most commonly af-
fected. Captain Franklin states, that at a part
in his journey to the Polar Sea, where bronchocele
prevails, it is confined to those who drink river
water, and that those who use melted snow esca])e.
Mr. Bally ascribes ils frequency, in a district in
Switzerland, to the use of spiing water impreg-
nated with calcareous or mineral substances ;
and he states, that those who use not this water aie
free from both goitre and cretinism. Dr. Coindet
observed that the inhabitants of Geneva, who
drink the hard pump waters, are those most liable
to bronchocele. lis prevalence in Nottingham
is ascribed by Dr. Manson to the same cause ;
which also seems to occasion it in Sussex and
Hampshire, in the valleys of which counties it is
frequently met v\ith.

5. That this is, however, not the only cause,
may be inferred from other physical circum-
stances connected with its endemical preva-
lence. Its great frequency in low, moist, marshy,
and warm valleys, and the exemption of the
inhabitants of dry and elevated situations, have
been shown by Larry, FoDErtii, Sacssure,
Reeves, Clark, Valentin, Postiglione, and
J. Johnson, as respects various districts in Swit-
zerland, the Tyrol, Carinthia, the Vallais, and
the north of Italy. Similar facts have been ad-
duced by Dr. Gibson, and Humboldt, in regard
to the United States, and South America. It is
most probable, however, that the exhalations from
the sod of those localities are not the only, but
a concurrent cause, co-operating with others pos-
sessing equal influence in the production of the
disease, and particularly with the nature of the
water. But it as certainly sometimes appears
where neither of those causes can be traced, as
in London ; disorder of some kind in the uterine
functions being the most frequent morbid re-
lation it has presented, as far as my experience
has aone. Its connection with cretinism in the
districts on the Continent above alluded to, and
the occasional appearance of the disease at very
early periods of life — it being even somet'mes
congenital, in these countries, as well as being
more common there in the male sex than in
this country — are matters of some interest, and
not readily admitting of explanation ; since po-
verty, close, confined, and ill-ventilated apart-
ments, are not the chief causes of those phe-
nomena, as shown by their absence in the
poorest classes in this metropolis. Dr. Pai.ry
has seen goitre follow diseases of the heart, and
epilepsy. Flajani has noticed the common oc-
currence of palpitations and afltctions of th.e
lungs from the disorder it has occasioned of the
respiratory function, ^^'hen the tumour is very
large, or hard, or v\hen it has increased sud-
denly, it not infrequently occasions most urgent
sympton)s, by its pressure on the trachea, oesc-
phagus, and jugular veins.

6. As respects the external and internal appear-

270

BRONCHOCELE-

ances of this tumour, I may briefly observe tliat
it affects generally the whole gland ; but is also
sometimes confined to the lateral or to the middle
lobes : it is more rarely large on one side than
another. At first it is commonly compact,
rounded and equal ; but, as it increases, it is
either soft and flabby to the touch, or unequal,
irregular, hard, and obscurely lobulated. It is
usually free from pain, and is not discoloured.
When it is greatly increased in size, and is soft,
it appears pendulous, chiefly owing to its lower
parts being most enlarged. When the tumour is
divided, the cells of the gland are found, accord-
ing to Hunter, Baillie, and B. Bell, filled
with a more or less viscid fluid ; and are of various
sizes, generally from that of a pea downwards,
not only in different cases, but even in the same
f;land. In the older, harder, and more irregular
forms of the tumour, melicerous, sleatomatous,
cartilaginous, and ossific deposits have been met
with in parts of it, by Celsus, DeHaen, Fheytag,
GiRAUD, Hedenus, and others. The usual state
iu which this disease presents itself, obviously, is
that of an increased secretion into the cells of
the gland, distending them more or less ; the other
changes sometimes observed, being consequences
of obscure irritation induced in parts of it during
its continuance or growth.

7. II. Diagnosis. — It is necessary to be aware
that other diseases of either a more acute or ma-
lignant character may affect the thyroid gland
and its vicinity, and be mistaken for bronchocele.
1st, The gland may be either healthy, or but little
enlarged ; the tumour consisting chiefly of thick-
ened surrounding cellular tissue, sometimes con-
taining cysts filled either with a serous, albumin-
ous, or purulent matter. Large encysted tumours
may also form in the course of the trachea. But
these may be readily distinguished by tiieir situ-
ation, form, and fluctuation. 2d, The gland itself
may be the seat of chronic or acute wjlammation .
In this case the swelling increases more rapidly,
but seldom attains a large size ; and is generally
attended by redness of its surface, and increased
temperature. It is also painful, particularly on
pressure, and is very htird. I lately saw a case
of this description in a married female of about
thirty, who was also seen by Mr, Lloyd, where
the inflammation had proceeded to suppuration,
and had terminated in an external opening. I
believe that inflammation of the gland never
occurs but in scrofulous habits. 3d, The gland
may also be the seat of scirrlnis, which may
ultimately go on to carcinomatous ulceration ;
but this is a rare occurrence. In this case the
gland is very hard, seldom large, sometimes
scarcely increased in bulk, and is the seat of
sharp darting pains. It is only met with in
persons advanced in age. ALiiiEnx states, that he
has observed a case of goitre pass into cancer;
but I doubt tiie fact ; cancer having a very
wide and indeterminate signification with this
writer. The disease can scarcely be mistaken
for aneurism of any of the thyroidal arteries, if
any share of attention be directed to the subject.
Bronchocele has been considered in the light of
a Btrumous disease — as a form of scrofula. Dr.
I'osiici.ioNE, however, contends that no connec-
tion exists between these diseases. As respects
the slate of nioibi.l action in the tjlanci, the con-
con.itniil phenomena, and the respective tennin-

DiAGNOsis — Treatment.

ations of both diseases, there is certainly no inti-
mate relation between them.

8. Ill, Treatment. — Previous to the use of io-
dine in the cure of bronchocele, nunierous remedial
means were recommended by writers. Of these,
the most common were frictions with various
liniments ; dry rubbing ; stimulating and astrin-
gent lotions; cold bathing, and cold douches;
mercurial applications ; plasters with cicuta and
ammoniacum, or with ammoniacum and hydiarg. ;
repeated blistering; leeches applied to the tu-
mour ; electricity and galvanism ; moxas, issues,
and setons ; ligature of the arteries supplying
the gland ; and extirpation of the gland itself.
Amongst the internal remedies recommended, I
may notice the various preparations of mercury ;
digitalis combined with camphor (Ossiander);
sulphuret of potassium ; chloride of barium (Pos-
tiglione) ; cicuta or belladonna, either alone, or
with the chloride of barium ; the chloride of cal-
cium ; preparations of potash and soda ; various
mineral springs ; the use of sea water, and of dis-
tilled water; the ammonio-chlorideof iron ; burnt
sponge, given either alone, or with mercury ; and
the ashes of {hefucus vcsiculosus (Russell).

9. Of all these, the most celebrated was burnt
sponge ; and, after the discovery of iodine, this
substance, which, having been found by Dr.
Straub, of Berne, to be contained in oflicinal
sponge, was recommended by him in 1829, and
adopted by Dr. Coindet, of Geneva : and so suc-
cessful has this medicine proved in the treatment
of bronchocele, that of a hundred aud twenty
cases treated with it by Dr. INIanson, of Notting-
ham, seventy-nine were cured, eleven greatly
relieved, and two only were not benefited by
it. Of several cases of the disease which have
come before me since the introduction of this
remedy into practice, there has not been one
which has not either been cured or remark-
ably improved by it. I believe, however, that
although it has been found the most certainly
beneficial of any medicine ever employed in
bronchocele, some other practitioners have not
derived an ecjually uniform advantage from its
use. I can account for this only by considering
that it has been given in too large and irritating
doses, or in an improper form ; and without due
attention having been paid to certain morbid aud
constitutional relations of the disease during the
treatment. The cases of two females who were
lately completely cured by the remedy confirm this
inference. They had both had the tumour for seve-
ral years, one for nine years ; and had, on former
occasions, gone through long courses of iodine,
prescribed by judicious and eminent practitioners,
but without advantage. When this medicine
was ordered by me, it was, therefore, with great
difliculty that they were induced to have recourse
to it again. It was ordered in very small doses,
often repeated, and strict attention was paid to
the state of tiie secretions, and to the uterine
functions. In the course of a fortnight an im-
])rovement was manifest ; and of a few weeks
longer, a great decrease of the tumours had
taken place. One of these female-^, a married
woman, wiio had been once pregnant nine years
before, upon the disappearance of the tumour
came with child ; soon after which it somewhat
suddenly reappeared, but the resumption of the
iodine again clisjjcrsed it. Tiie preparations given

BULL^.

271

in the Appendix (F. 204. 277, 278. 302. 323,
324.) are those which an extensive experience of
its effects in various diseases, as vvell as in this,
has led me to adopt.

10. In respect of the use of iodine in bron-
chocele.the weaker preparations sliould be at first
preferred ; and care should be taken never to
exhibit ihem to the extent of irritating the stomach
or bowels: when this effect is produced, little or
no benefit will be derived from them. The suc-
cess which Dr. Manson and M. Lvgol have de-
rived from this valuable medicine, 1 know from
experience to be chiefly owing to the small and
Soluble doses in which they exhibited it. In some
of the more obstinate cases, it will be often requisite
to assist the operation of iodine by other means.
Sometimes the occasional use of emmenagogue
aperients will be of much service ; and when the
uterine functions evince disorder, as they very
frequently do in cases occurring in females, I
have usually directed either the bi-borate of soda,
or milk of sulphur, to be taken, in the form of
electuary, every night (F. 89. 281.). A calomel
purge will also be sometimes of service. I have
generally preferred the internal to the external
use of the medicine in this disease. In some more
obstinate cases, they may be both employed ; but
its external application should be of the mildest
kind. In some cases, a moderate blood-letting
may be premised ; and some writers recom-
mend that leeches should be applied to the tu-
mour itself. Nearly all the cases which I have
seen, having occurred in females, in whom it
appeared requisite either to promote the menstrual
discharge or to subdue uterine irritation, I have
usually directed the bleeding, when practised, to
be performed in the feet, or leeches to be applied
to the groins. Dr. Coster has adduced a case in
which galvanism materially assisted the iodine in
removing bronchocele.

11. Dr. KoLLEY has stated, that iodine should
not be exhibited where there is a disposition to con-
gestion in the head and internal viscera ; when
febrile and inflammatory symptoms are present;
when gastric, hepatic, or intestinal disorder exists ;
and when there is a disposition either to hydro-
cephalus or to pulmonary consumption. This is
in some respects just; but after depletions, and
when the more marked symptoms of these dis-
orders are subdued, iodine may, notwithstanding,
be exhibited, if its effects be carefully watched,
and if the mildest and weakest preparations be
selected, and these be combined with anodynes
and narcotics. I have observed that a continued
course of iodine has sometimes had the effect,
particularly during cold weather, of producing
pains in the limbs or joints resembling rheuma-
tism, which have continued to increase if the
medicine was not for a time relinquished. This
effect has never appeared during a course of less
than six weeks. It has generally soon disap-
peared after an aperient operation from sulphur,
and one or two warm baths. A change to warm
weather has also removed it.

12. If iodine fail of reducing the tumour, and
if its pressure occasion urgent symptoms, recourse
must be had to surgical aid. For a full exposi-
tion of this part of the treatment, I must refer the
reader to Mr. Cooper's Surgical. Dictioiwrii, and
limit myself to a brief enumeration of this class
of measures. The first and most important of

these is the insertion of setons in the tumour.
This practice was recommended by Dr. Quadui,
of Naples; and practised first in tills country by
Mr. Copland Hi'tchison, and with success.
According, however, to the experience of Mr.
James, Mr. Coopeu, and Rlr. Uunninu, tiiis
practice is liable to occasion dangerous hasmor-
riiage, sloughing of the tumour, and irritation and
inflammation of the trachea or larynx. JNIr. Ly-
FORD has, however, employed setons, success-
fully; whilst Hedenus states, that he has seen
tetanus occasioned by their introduction. It has
been recommended to cut off the supply of blood
to the gland by tying its arteries ; and the advice
has been followed by Buzard, Walther, Coates,
Brodie, and Earle. The cases thus treated by
Blizard, Coatfs, and Brodie, terminated unfa-
vourably ; whilst those by Walther and Earie,
succeeded. Lastly, he tumour has been alto-
gether removed by excii-ion. Dessaui.t first per-
formed this operation successfully; Gooch at-
tempted it in two cases, but failed; Dupuytren
and Kleik also failed; whilst Voget., Theden,
and Graeffe, performed it with success; and
Hedenus, of Dresden, succeeded in six cases in
which he resorted to this operation.

BiBLioG. and Refer. — Pliny, \\h. ii. cap. 37. — Celsus,
lib. vii. cap. \3.~ De',Hacn, Ratio Medendi, pars vii.

p. 285 Rus/i, 3Iedical and Physical Journ. vol. xvi,

p. 208. — Fodere, Traitc sur le Goitre et le Cretinisme,
8vo. Paris, An. 8. — Flajani, Collez. d' Osservazioni e
Refless. de Chirurg. t. ili. p. 270. Roma, \»,fi(\.—BailUe,

niorbid Anaton)', 8vo. p. 87 Larrey, Memoires de

Chirurg. Milit. t. i.p. \23.— Bally, in Diction. des Sciences
Wed. t. viii. — Wenzel, Ueb. den Cretinismus. Wien,
1802.— IVylic, in Hufeland'i Journ. 1809, 2d st. Febr.

p. 118 Maas, Diss, sistcns Gland. Thyroideoideam tarn

Sanara tam Morbosam. Wire. 1810, 8vo Pustiglione,

Mein. Patholog. Praciica sulla Natura di Gozzo. Flor.
181 1. — Alibeii, Nosologie Naturelle, t.i. p.464.fol. Paris,
1817- — Slrarib, in Naturwissenchaftlicher Aux. der AU-
gemeiner Scliweiz. Gesell. &c. voa Fr. Mcisner, 4to.

Bern, 1820 Coindet, Decouverte d'un Nouveau Remede

contre le Goitre, in Bibl. Univers. Jiiil. 1820, p. 190. ; et
Feb. 1821, p. 140. — Can-o, in Ibid. Mai, \»2\. — Brcra,
Saggio Clinico suit' lodio, &c. Pad. 1822. — Quadri, in
Medico-Chirurgical Society's Transact, vol. x. p. Ifi. —
Coates, in Ibid. vol. x. p 312. — A. C. Hutchison, in Ibid,
vol. xi. p. 235. — Roots, in Ibid. vol. xii. p. 310. — Kennedy,
in Lond. Medical Repos. vol. xvii. p. 177 — Hu7nboldl. in
Magcndie, Journ. de Physiol. Exper. t. iv. p. 109 — He-
rffnws.Tractat.de Gland. Thyroid. &c.;Lips. 1822.— Cosher,
Archives Gener. de Medecine, Juillet, 1823 — Gairdner,
On the EflFects of Iodine, &c. 8vo. Lond. 1824. _ Kolley,
Medico-Chirurgical Review, vol. vi. p. 229. — Tael, Journ.
Complement des Sciences Med. t. xxiii. Nov. 1825.^
Peschier, Biblioth. Univers. Oct. 1824, p. 146 — Manson,
Medical Researches on the Effects of Iodine in Broncho-
cele, &c. 8vo. 1825 Georgiani, De Praecipuis Thyro-

phraxiara Curandi Methodis, Svo. Pavia, 182-5, — Kriigel-
stein. Die Kunst d. Krankh. d. Schilddriise n. d. Kropf
zu Heilen, Sec. Gotha,8vo. }S2(J.— Earle, in Lond. Med.
and Phys. Journ. Sept. 1826. — Lawrence, Lectures by.

Medical Gazette, vol. vi. p. 719 J. Johnson, On Change

of Air, &c J. Bramley, in Edln. Med. and Surg. Journ.

vol. xliv. p. 448 Barker, in Med. Gaz. vol. xv. p. 230.

BULIMIA. See Appetite.
BULL J2. — Blains. Svn. ^\\iKTa.iva.i, Gr.
PhlyctencE, Ampullte, Auct. Lat. Bull<e,
Plenck. Ecp/i/j/sis, Good. Dartre Fhliicteiwide,
Alibert. Bulles, Ampoules, Fr. Blasen, Was-
serhlattern, Ger. Blebs, Eng.

Classif. 6. Class, 3. Order (Good). 4. Or-
rfer (VVillan). IV. Class, IV. Order
(Author).

1. Defin. An eruption of large vesicles contai?!-
itig a serous or sero-puriform fluid ; frequently
succeeded by yellowish or yellowish brown scabs,
and sometimes by ulcerations.

2. Plenck first separated the individual erup-
tions belonging to this order from the vesicular

27-2

eruptions, to wliicli they are intimately related,
and formed them into a distinct clas«. Wii.lan
afterwards adopted a nearly similar arrangement,
comprising under tiiis head erysipelas, but leaving
out lupia. JM. BiKTT has, however, with stricter
propriety, excludfd from it the former disease,
and introduced the latter. Adopting, therefore,
his classification, this order of eruptions embrace
pemphigus, pomiiholu.r, and riipia. These forms of
bullae "proceed from internal causes ; but various
irritants, applied externally, will al?o give rise to
a similar eruption. The influence of cantharides
and other rubefacients, of excessive heat or cold,
of fiiction, of poisons, &c., in occasioning vesi-
cations, is well known. In a pathological point
of view, both the bullis produced by internal
causes, and tiie vesications formed by external
causes, depend upon very nearly the same state
of the reie mucosum. This tissue is more or less
inflamed, or aftecied in such a way as to secrete a
greater quantity of serous fluid than can be exhaled
through the cuticle, which is thereby separated
from the vascular tissue, and, by the increase of
this fluid, elevated into blisters, or bullae, of va-
rious dimensions.

3. The eruptions of this class are both acute
and chronic. The parts afl!"ected are often pre-
ceded by more or less redness, and occasionally
by a very slight elevation. But, in many in-
stances, no such inflammatory appearances are
observed before the serous effusion beneath the
cuticle takes place. After an indefinite period,
varying from a few hours to four and twenty, a
small vesicle appears, and gradually enlarges, until
it reaches, generally within eight and forty hours, a
great size. The bulla; thus formed are at first
tense, and the fluid contained in them serous and
transparent ; but it sometimes becomes, especially
at a later stage, sero- purulent, and rarely sero-
sanguineous. After an uncertain time the bullae
pass from a tense to a flaccid state, the included
fluid, at the same time, assuming a very slightly
opaque and thickened condition. If they be
situated where the epidermis is very thin, or oc-
cur in very young infants, they often break before
this change in the fluid takes place. But where
they are more persistent, the humour becomes
thicker, and often forms scabs of a light yellowish
colour. The affected parts of the skin are after-
wards cither provided with a new cutii le, or are
affected with more or less severe ulceration. lUil-
la? may thus appear in any part of the surface, and
even in the scalp, and be more or less numerous,
or thickly scattered over the body. 1 have ob-
served them so extensive, as respects both number
and size, as to occasion death, obviously from the
constitutional disturbance and irritation resulting
from the loss of the cuticle over more than two-
thirds of the whole surface of the body.

4. 'Jhese eruptions are also either idiopathic or
symptomatic — most frequently the latter, 'I'hcy
niny also be infectious, or dependent upon the
air of an hospital. Thus i have seen them pre-
vail (chiefly in the form of pemphigus) at one
time, in C^ueen Charlotte's Lying-in Hospital, to
the extent of affecting nearly all the infants
born there during several months, notwithstand-
ing fumigation and whitewashing were resorted
to ; no other disease having occurred there dur-
ing that period. In a chronic state, ihry are
usually symiilomalic of irritation or other di'-or-

CACIIEXY.

der of the digestive organs, inore especially of the
alimentai-y canal ; of clironic bronchitis, and of
general cachexy, 'i'hey are sometimes observed
as an attendant upon small pox, and vei'y rarely
in the other exanthemata.

BiBLioG. AND VIefer. —Baleman, Synopsis of Cut. Dis-
eases, &c. 7tli ed. p. 193.; and Med. and Pliys. Jomn.

vol. xi. p. 230 Tilesiiis, in Mar.'cns's Parodoxicii, iS.-c.

Leips. 1802. B. ii. Heft. i. p. m.— Rm/er, Tr.iitc des Mal.i-
dies de la Peau, &c. t. i. p. 142. — Cazeitave, et Sc/iciltl,
Abrege Pratique des Maladies de la Peau, &c. Paris, 1S28,

p. 12.'!.

CACHEXY. SvN. Cachexia (from KaKos, ill or
bad, and e|is, a habit). A had Habit of Ijorfi/.
Classtf. Constitutes the 3d Class in IJr. Ci(/-
len's Nosology ; and the 4th Order in the
Class, Diseases of the Sanguineous Func-
tion, in Dr. Conrf'i' Arrangement. 1. Class,
V. Order (Autlior, see Preface).

1. Defin. Depravity of the coiistitiition, with-
out fever, affecting more or less the solids, the cir-
culating fluids, and the secretions.

2. i. Sybiptosis. — The chief characteristics of
this state are, want of vigour and vital cohesion of
the soft solids, with defective digestion and assimi-
lation, diminished animal warmth, universal lan-
guor, and deficient strength or activity. The skin
is usually pale, yellowish, or lurid ; and the white
of the eyes in some cases almost ti-ansparent. As
this state advances, the countenance becomes
pale, white, or bloated ; the skin loses its vital tint,
and changes either to a dirty white, or to a yellow
hue. The muscles are flaccid, and deprived of
their healthy elasticity ; the mind is inactive ; the
breathing dillicult upon exertion ; the feet and
ankles swollen ; the pulse slow and soft ; the eyelids
oedematous; the urine turbid; the alvine evacu-
ations irregular and offensive ; the sltep oppressed,
and all the vital manifestations are enfeebled and
languid. In females, more or less of these symptoms
are associated with suppressed, retained, morbid,
or irregular menstruation ; pains in the forehead,
back, loins, or limbs; palpitations ; and longings
for noxious or unwholesome articles of food, or
for what is" not food. (See Appetite — Morbid,
and CifLonosrs.)

3. This state of disease appears to be chiefly
the result of diminished vita! energy, produced
by various mental and physical causes; in con-
sequence of which state the food is not sufficiently
elaborated and assimilated, the circulating fluid
does not experience tlie requisite degree of change
resulting from nervous influence, and the action
of the viscera, and the secreting functions are im-
perfectly executed, whereby the whole mass of
blood is impoveiished or depraved, the manifest-
ation of the nervous and muscular systems aie
feebly performed, and, ultimately, the whole of
the structures more or less vitiated. (.See Ijlood
— Allerations of, in Disease.) (Cachectic nrahidies
are very frequently associated with, or preceded by,
obstruction, or other disease of tome important
viscus. If the pulse does not exceed 80 or 84,
particul.irly towards evening, we may conclude
that the lungs are sound ; and if the ])ulse be re-
gular, and the sKep uiidisturbeil, we may infer
that the heart and its capsule are not, at least,
seriously affeeted. The viscera most frequently
diseased are the liver, mesenteric and lymphatic
glands, the spleen, pancreas, kidneys, uterine or-
gans, stomach and bowels ; and the affection of
these is sometimes a cause of, at other times an

CACHEXY — Afiiican — Causes

'273

attendant on, or oven consecutive of, t!ie cadiectic
state ; ilie vital endowment of t!ie frame baing the
first ta experience the morbid change. It would
ap[)ear iliat ihe earliest manifestation of this ch'.ngo
lakes place in llie ganglial system; ti)e internal
viscera and circulatory organs, wliose functions
are actuated by tiiis system, becoming next dis-
ordered, generally in such a manner as to attract
the attention of the observer to the nature and
source of disturbance.

4. ii. The Treatment of cachexies chiefly con-
sists of light nutritious food, taken in such quan-
tity as the digestive organs can easily dispose of;
healthy air, or change of air, with gentle and re-
gular exercise, short of fatigue ; of tonics combined
with deobstruents and gentle aperients, in order
permanently to excite the languid powers of life,
and to promote ll:e functions of ihe secreting
organs; and of the use of chalybeate and deob-
struent mineral waters, with frictions with stimu-
lating liniments, and pleasant mental occupation.
The sulphate of quinine, or the pieparations of
cinchona, particularly its compound tincture, with
small doses of the bichloride of mercury ; the
various vegetable tonics, bitters and aromatics,
with the mineral acids, especially the chloric
acid ; the preparations of iron ; the chlorates of
potash, soda, and lime ; sarsaparilla, with guaia-
cum, &c. ; the balsamic and terebinthinate sub-
stances; camphor, and the essential oils, and the
preparations of iodine ; are most serviceable in ca-
chectic diseases, either exhibited singly, or coin-
bined vvith laxatives or purgatives so as to pro-
mote the secreting and excreting functions. As
the various disorders of this description are often
connected with obstructed function, or infarction,
of some important viscus, it will frequently be
requisite to exhibit at the same time, or in conjunc-
tion with some of the above remedies, small doses
of blue pill, or of the hydrargyrum cum creta ,
or to combine them wii;h rhubarb, aloes, or other
purgatives, and often to add to them aromatics or
warm gum resins. The object in these cases is
to promote a regular action of the viscera, by in-
creasing their vital energy ; and this is bc-tter at-
tained by adopting measures calculated to benefit
the general health, and to increase the action of
the stomach an 1 bowels, than by the occasional
use of active and debilitating catiiailics ; which,
however, operate more efficiently and much more
beneficially in those ca-es, when combined with
bitters and tonics, — a fact long since, insisted on
by HoFi'MANN, and otheis. (See also JMeiiCurial
Cachexy, Scrofula, and Venereal Cachexy.)

BiBLiOG. AN» Refer. — Boyiettis, Sepulchretum, 1. iii.
s. XX. obs, 1 — 14. — ly'edd, lie Cacliexia. Jen. 1715. —
Stiihl, Diss, rie Cachexia. Ualae, 1710. — Hi'Jfmann, De
Cachexia, Opera, t. iii. p. 318. — Nicolai, Diss. Sistens Ge-
nuinara Cacliexia; iiulolem. Jenas, t7G0. — I'ogel, Diss.
Sistens Coguitioiiem Morboriim. Goet. I7G3. — Wcdekind,
Ueher die Kachexie im AUgeineinen, &c. 8vo. Leips.
1700.

Cachexy, African. Syn. Cachexia AJ'ricana,
Negro Cachexy, Dirt-eating. MuL d'Estomac,
Fr.

Classif. I. Class, V. Order (Author, see
Preface.)
1. Defin. General cachexy , with vitiated func-
tions of the stomach and bowels, and a propensity
to eat chalk, clay, or other dirty and unwholesome
substances, generally affecting the aborigines of in-
tertropical countries, i)C.
Vol. I.

2. i. Deschiption. — This disease is a compli-
cation of cachexy with anajniia and pica, or de-
praved appetite (see Appetite — Depraved), at
least in its advanced stages. It is very comnmn
amongst the natives of Africa, and the slaves in the
West Indian colonies; and is attended with lo.ss
of appetite, continued pain of stomach, whiteness
of tongue, difKculiy of breathing upon the slightest
exertion, drowsiness, inactivity, and general de-
bility, despondency, with, fondness of solitude,
palene-s of the face, lips, and palms of the Irmds,
coldness, and often oedema of the extremities,
glassy state of the tunica adnata, weakness and
smallness of pulse, scanty, pale, or milky urine,
whitish or clay-coloured stools, with other signs of
depressed vital power and deficient assimilation.
Owing lo the depressed energies of the frame, and
particularly of the digestive organs, a vitiated state
of the juices of the stonmch, with morbid acidity
of the prima via, evidently prevails ; occasionnig
sensations which probably excite the patient to
have recourse to chalk, clay, or other absorbent
matters to relieve them, and which occasion what-
ever vitiation of appetite may be additionally ob-
served. This morbid condition appears, however,
not to be limited to the stomach, but to be ex-
tended along the alimentary canal : the mucous
surface of the bowels is in a state of morbid
irritation, giving rise to ofl^ensive evacuations ; the
lacteal and mesenteric glands become irritated and
obstructed, owing to the passage through tiiem of
unhealthy chyle and morbid secretions, and sub-
sequently incapable of conveying sufficient nou-
rishment into the circulation; the blood is thus
rendered poor, pale, and in all re-pects such as is
described in the article on the Blood (§ 34. et
seq.) ; and the liver, pancreas, spleen, lungs, and
heart, become pale, atrophie<l, and sometimes
softened, from being deprived of the requisite
nourishment, and supply of the circulating fluid.
And at last the patient sinks from depression of
the vital power and anaemia, presentmg the fol-
lowing appearances on examination: —

3. The stomach is often flabby, softened, appa-
rently distended, and pale. The liver is soraetinits
enlarged ; occasionally atrophied, hardened, and
generally very pale. The bile is usually watery,
pale, or straw-coloured : the gall-bladder has
contained biliary concretions in a few cases. The
mesenteric glands are always enlarged and hard-
ened. The mucous follicles of the intestines are
often morbidly developed. The heart is soft and
flabby ; the blood in its cavities and large veins
is watery and thin ; and sometimes fibrinous
concretions are found in these situations. Serous
efl'usions, to a greater or less extent, are also fre-
quently found in the thoracic and abdominal
cavities.

4. ii. Causes. — This affection is very nearly
allied to chlorosis: but whilst the latter affects
females, and most commonly about the period of
puberty, the former occurs in both sexes, and
sometimes at as early an age as six or seven years.
It is generally attributable to depressing or debili-
tating causes — mental or physical. The despon-
dency and grief occasioned by separation from the
place of nativity and friends, and by a state of
bondage, often dispose to it ; and thus it is not
infrequently accompanied with nostalgia. The lax
and weak habit of body, and the indolent dispo-
sition of the negro, seem also to favour the appear-

274

ance of the disease, particularly in those who have
been badly nurseJ and neglected in early life. The
chief exciting causes are, poor diet, hard labour,
harsh treatment, exposure to cold and moisture,
insufficient clothing, and venereal excesses early
indulged in. The causes of the disease, the
symptoms it presents in its proi<ress, and the ap-
pearances observed after death, are altogether
irrefragable evidence that it proceeds from great
depression of the vital energies, especially of the
digestive organs ; occasioning, in its more advanced
states, anjemia, imperfect nutrition, and vitiation
of the fluids and soft solids of the frame.

5, iii. The Ti'.eatment is in no respects diflPerent
from what has been recommended in general terms
in respect of Cachexia and Depraved Appetite
(see these articles). Warm clothing, and a digest-
ible nourishing diet, are indispensable to recovery ;
and to these should be added, regular but mode-
rate exercise ; bathing, followed by frictions of the
surface ; tonic, aromatic, and saline medicines ;
the use of the carbonates of the alkalies, combined
•with tonics and hot spices. Warm stimulating
laxatives, such as the compound tinctuies of
rhubarb or aloes, or the bitter aperient tincture
(F. 699.); the elixirs prescribed in the Appendix
(F. 103 — 106.); the preparations of iron, cin-
chona, and myrrh ; are severally of the greatest
benefit, especially in conjunction with warmth, a
residence in a warm dry situation, and sufficient
nourishment. Care also ought to be taken to
preclude any access to the substances for which
the morbid propensity is entertained.

BiBiioG. :tND Refer. — Davidson, New York. Med.
Repos. 1799, vol. ii. No. iii. art. 6. — Ckis)iolme, in Ibid.,

and Med. and I^hys. Journ. 1800, p. 614 Httnter, On

the Diseases of the Army in Jamaica ; and in Edinburgh
Medical Commentaries, vol. xiii. p. 194.

CiECUM. — Its Diseases. 1. This viscus is
not infrequently the seat of dangerous and fatal
diseases, without any other part of the digestive
tube being affected ; and it is evidently concerned
in the production of other disorders, in which it
has usually been considered as merely accident-
ally to participate. If we consider its anatomical
relation-; and fun'tions in man and the lower
animals, we shall be justified in viewing it as a
disiinct organ, performing offices modified in their
nature from those of the rest of the alimentary
tube. Notwitli-tiinding thi^ indiviiUiality, both its
functions and its diseases have not generally at-
tracted that degree of attention, nor received the
investigation, they evidently deserve; and, hither-
to, the latter have not even obtained a place in
practical or systematic works. Some years ago,
I took occasion to notice the impoilnice of the
offices and pi'.tiuilogic.al stales of this viscus, and
detaded some ( ases in which it was remarkably
diseased. Several facts illusiiating the practical
part of this subject have been recently accumu-
lated, and some have since been observed by my-
self. From these sources, I shall arrange all that is
known respecting the diseases of this organ, after
having premised a few remarks on its fuuclions.

2. The nseiiiblanc(! of the caecum to the sto-
mach in most of the graminivorous, and particu-
larly the ruminaiing animals, a.s well as its form
and situation thioughout all the higher classes of
the animal kingdom, arc circumstances showing
that it is an important viscus, and one in which
the last act of digestion is performed. Rl. Vi-

C^CUM — ITS Diseases.

ridet appears to have been the first who enter-
tained correct ideas of the actions of this viscus.
" Sed de inlestino cseco," he states, " quidquam
dicere prasstat, cum in quibusdam aninialibns sit
summe necessarium, nempe quibus et amplissi-
mum, forsanque vicem alterius ventriculi gerit ;
nam glandulis criissioribus donatur, quorum suc-
cus solutione heliotropii rubescit, et solutione
sublimati albescit, suisque salibus acidis et volati-
libus prajditum est." (De Prima Cocliotie, p. 270.)
This view has been recently confirmed by the
able researches of Tiedemann and Gmei.in,
professors at Heidelberg. The situation of this
organ, its capacity, its attachment to the parietes
of the abdomen, and the circumstance of its con-
tents being propelled in opposition to their gravity,
are proofs of their longer retention than those of
any other part of the digestive tube ; and confirm
the view that has been taken as to its being, in
some respects, a reservoir, wherein is poured that
portion of the materials remaining in the ilium,
in order to undergo the latter stages of digestion,
and the first of fsecation. Besides other proofs
of these functions, it may be stated, that it is very
abundantly supplied with large follicular glands,
which, according to the experiments of Tiede-
mann and Gmelin, secrete an acid, albuminous,
and solvent fluid, which mixes with, and promotes
the digestion of, those portions of aliments which
have withstood the actions of the stomach and
small intestines, or been insufficiently changed by
them. In order that this office may be the more
completely performed, the anatomical relations of
the caecum admit of the remora, for a longer or
shorter time, of the matters which pass into it ;
so that a last effort is here made to obtain the
remaining nourishment from the ingesta : and
thus it performs, if not the very last act of diges-
tion, at least the last important part of it. But it
also seems to fill an additional office, namely,
that of secreting, chiefly from its numerous fol-
licles, an unctuous or oily fluid for the protection
of the surface of the large bowels from the irri-
tating effect of the faecal matters passing along
them ; and it is probable that the constituents
both of this fluid, and of the other secretions
poured out from its surface, consist of elements that
recjuire to be eliminated from the blood ; so that,
in addition to its other functions, it is also a de-
purating organ.

3. The usual contents of the caBcum are
of the consistence of a soft hniiUie, or gruel,
of a brownish yellow colour, and here fiist ac-
quire their fjeculent odour ; which, according to
Ti idem ANN and G.melin, proceeds from the
volatile oily substance secreted by its follicles.
During the changes that are eflected by the
caifium on its contents, an acid and hydro-
sulphuretted hydrogen gas is disengaged. This
gas seems to be generated only in small quan-
tities during the healthy functions of the organ;
but when its vital energies are diminished, and
when, consequently, a greater remora than usual
of its contents takes jdace, air is disengaged
in much greater quantities, and sometimes to
the extent of injuring its healthy tone. Whilst
the caecum reacts energetically on the distend-
ing power, this flatus, along with a portion
of its contents, is thereby propelled along the
colon : but on many occasions, and under parti-
cular circumstances, considerable opposition about

CiECUM — Functional Disorder of.

275

the right flexure of this bowel is offered to their
tran'sit ; and iience, pain and uneasiness in tliis
part of tiie colon, as well as in tlie cascum, are
complained of; giving rise to tiie idea of the ex-
istence of eitlier hepatic or nephritic disease.

4. Under other circumstances of protracted
disorder of the digestive organs, as when acidity
is generated in the stomach and small intestines,
and the food imperfectly digested ; or when the
inn;esta are of a stimulating, irritating, or other-
wise unwholesome kind ; or when the secretions
of the liver, pancreas, and mucous surface of the
small intestines, are of a morbid or excoriating
nature, — then the accumulation and reniora of
these luatters in the caecum are productive of
disorder of its functions, of inflammation, and
even of change of its structure.

I. Disordered Functions of the Cecum.
Ci.ASSiF. I. Class, I. Order (Author).

5. i. Pathology. — A. When the vital ener-
gies are weakened, and the alimentary canal debi-
litated, the ccecum often betrays greater disorder
than any other part of the digestive system. Its
situation and functions will, from "hat has already
been stated, account for the frequency and im-
portance of its diseases. In some cases, the irri-
tation produced by morbid or accumulated matters
in it is slight, and readily productive of sufHcient
reaction of its muscular coats to propel them
along the colon. In other instances, the efforts
made to accomplish this end, owing to the ob-
structions occasioned by the lodgment of flatus
about the right flexure of the colon, or by irregular
spasmodic contractions of this bowel, are inef-
fectual, and give rise to colicky pains. If the
interruption is removed, disorder soon subsides;
but if it continue for any considerable time, the
more violent forrns of colic or ileus supervene.
When the internal surface of the caecum is in an
irritable state, di'^orders of this description are
readily produced by the accumulation, even to a
small extent, of the intestinal matters poured into
it from the ileum, especially vvhen they are of a
more than usually stimulating kind, or if the se-
cretions be morbid. In young, irritable, or nervous
persons, and in those who partake of much acid
or unripe fruit, or who neglect their bowels, par-
ticularly females who wear very close cinctures
around the upper part of the abdomen, diseases
affecting the alimentary canal, and, sympathetic-
all}', soine other parts of the frame, not infre-
quently thus originate in this viscus. Accumu-
lations, however, of alimentary and laecal matters
sometimes take place in it to a great extent,
without producing much disorder, untd the dis-
tension and irritation thereby oicasioned give rise
to disease of its internal surface, of its follicles, or
its parietes generally. Persons advanced in life,
of a phlegmatic temperament, or lax and torpid
habit of body ; those who take little exercise, or
whose occupations are sedentary ; and especially
at^ed females ; are very liable to be thus affet. ted.
During this state of infarction, the retained mat-
ters are more or less changed, partially decom-
posed, become acrid, excoriating, and a source of
irritation both to the mucous surface itself, and to
its follicles ; which are thereby obstructed, and
ultimately inflamed and ulcerated. In this way,
most of the morbid states about to be described
originate.

6. Several instances have been recorded by

the older writers, where the stones of fruit=,
biliary and intestinal concretions, and hardened
fa3cal matters lodged in the caecum, have occa-
sioned severe colic, and even fatal ileus. Some
cases of this kind are referred to in Dr. Monro's
instructive work on Morbid Anatomy, as having
occurred in his and his father's practice. In one
of these, a concretion upwards of seven inches in
circumference filled up this viscus. Fontanus
found an earthy concretion in it, as the only
morbid appearance after death from ileus ; and
Helm, nearly three hundred cherry stones in the
saiTie situation, and in the ileum before it opens
into the caecum, in a fatal case of this disease.
In some instances, accumulations of faecal mat-
ters with great distension occur, without much
suffering referrible immediately to the caecum
being experienced ; the organs affected second-
arily evincing the most marked disorder. This
was shown by the case detailed by M. Odier,
of Geneva, of the celebrated M. de Saussure, in
whom this viscus was very greatly dilated. When
very much distended, it is generally diseased in
other respects; its coats are more or less thick-
ened, inflamed, and ulcerated, or its follicles en-
larged. JNJoNRo, Nacquart, and others, have
adduced instances in which its engorgement and
enlargeiuent were accompanied with chronic in-
flammation and thickening. Mr. Wilmot re-
lates a case in which it was dilated (o the extent
of containing a gallon, filled with faecal matters
and perforated by a circular ulceration. When
the distension by accumulated matter is creat, it
may, from rising high in the abdomen, and press-
ing upon the nerves, vessels, and ducts in its
vicinity, occasion numbness, and oedema of the
right lower extremity, retraction of the testicle,
and derangement of the urinary secretion ; and
thus be mistaken for disease of the kidney. M.
Duces has detailed an instructive case of this
kind; and two similar instances have been ob-
served by me. In general, the seat of the tumour
arising from collections of juorbid matteis in the
cacum, and the disorders connected with it,
readily lead to the recognition of its nature, as in
the case recorded by Dr. Barlow. When, how-
ever, there is little or no tumour formed, and the
symptoms are of a chronic and less violent kind,
the cause of disorder may long exist in this
situation, and escape detection. In a case of a
young lady whom I atiended with Mr. Annesley,
this part was considered as the seat of disorder,
from its fulness and hardness upon an examin-
ation matle when the patient was semi-recumbent,
and the thigh slightly bent, and a treatment in ac-
cordance wiih this view strenuously in-isled upon.
She lidd been attended by several eminent phy-
sicians during the preceding three or four years,
and very different opinions entertained of the
nature of her ailments. After persistence in the
treatment about to be recommended, an evacu-
ation of hardened balls, containing indigestible
substances which she had chewed many months
previously, were evacuated, the fulness and hard-
ness in the right iliac region disappeared, and the
patient perfectly recovered. Two nearly similar
cases to this were detailed by me in a work re-
ferred to below.

7. Substances incapable of digestion, either
taken accidentally or from a depraved appetite,
also frequently lodge in the caecum, and remain
T 2

276

C^ilCL'AI — Functional Disorder of.

ia it for a very long period, soaietinies without
producing inucli disorder, at otiicr timfs occasion-
ing tiie most violent etfects. In oiher eases, in
addition to various morbid matters, large balls of
worms, both lurabrici and ascarides, collect in
this viscus, and occasion much local irritation, or
even inflammation of its inner surface, and eon-
' stitutional disturbance. Mr. Bt.ackadder has
detailed some inteiesting instances of this occur-
rence. He found, in a patient who had com-
plained of disorder of various organs, and of a
gnawing soreness in the right iliac region, ragged
ulceration of -the inner surface of the cajcuni,
vrhicii contained an immense number of worms.
The rest of the alimentary canal was sound.

8. B. When the cascum is much enlarged, or
otherwise diseased, it may also be displaced.
Cases are recorded by Salzmann and Annks-
XEY, in which its attachment to the internal iliac
muscle had yielded so far that it had passed over
to the left side ; and others, in which it had de-
scended very low into the middle of the pelvis,
and pressed upon the urinary bladder.

9. Not only may indigestible substances and
morbid concretions sometimes lodge in the
caecum, producing much local irritation and
general disturbance, but they may, when small,
sometimes pass into the vermiform appendage,
where they occasion, as will be shown in the
sequel, the most dangerous effects. It does not,
however, appear that the simple presence of any
of these substances in this process is always fol-
lowed by such results. Mr. Blackaddeii relates
a case in which he found a small concretion in
this part, and yet the patient had not complained
of any symptom leferrible to the right iliac
region. I have treatid, or been consulted re-
specting, four cases, in which foreign bodies and
concretions were found in the appendix after
death ; and in all, the symptoms were those of the
most violent peritonitis complicated with ileus,
and terminating in sphacelation of this process
itself. Two of thesel attended with Rlr. Painter,
of Crawford-street, by whom the inspections were
made ; and who ascertained that the substance
found in the appendix, in one case, consisted
chiefly of cholesterine.

10. ii. Symptoms. — The phenomena usually
occasioned by fffical matters collected in the cas-
cum, and by distension, enlargement, or irritation
of thi-i viscus, will necessarily vary with the na-
ture of the offending substances, the extent to
which they may have accumulated, and the age,
temperament, and habit of body of the patient.
The disorcK rs which result are, 1st, Local; 2d,
Symptomatic, and 3d, Consiiiutional. — a. The
Incul signs are more or less fulness, hardness, or
distention in the right iliac region : sometimes, on
examination carefully with the points of the
fingers, the abdominal muscles being relaxed, a
doughy hardness is felt. In other casts little or
no pain, even upon a minute cxainination, is com-
plaiijcd of; hut occasionally, especially if the
disorder be about inducing inflammation, both
tenderness and pain either exist more or less con-
stantly, or come on in paroxysms ; and the patient
generally reposes on the right side. When the
bowels are constipated, and interruption of the
passugf, of matters through the ca.'cum occurs,
the paroxysms of jjain are very acute, and some-
times attended by vomiting, and all the sym-

ptoms of the most ssvere colic, or even those of
ileus. In such cases, upon examination, signs
of obstruction either in the cajcum or in its
vicinity are detected, unless general peritonitis
may have come on ; and then the origin of dis-
ease is very generally referred to the cajcal region,
or the tenderness and pain are most acute in that
situation.

11. h. The sympUnnatic disorders, when this
viscus is much distended, either by fa;cal or
other matters, or by flatus, or by both, as is most
cominonly the case, are, nunibness of the right
thigh, oedema of the right foot and ankle ; some-
times retraction of the testicle, or frequent calls
to empty the bladder, and sometimes haeinor-
riioids ; uneasiness or pain in the right iliac region,
often extending to the hypochondrium ; various
dyspeptic symptoms, costive or irregular state of
the bowels ; occasionally diarrhoea, with scanty,
oflfensive, and mucous stools ; and, if irritation
be excited in the mucous surface and follicles of
the organ, the efforts made to evacuate the bowels
are attended by severe tormina, and even by
retching. I have seen several cases of varicose
veins of the leg, or indolent ulcers, and a case of
disease of the bones of the foot, the occurrence
of which was evidently connected with great
distension and accumulations in the caecum ; the
symptoms of this disorder, with more or less
tumefaction and hardness in the iliac region,
having been found on examination. The justness
of this view was fully shown by the success of the
treatment, which was based upon it.

12. c. As long as the states of disorder have
not advanced to inflainmation or ulceration, the
effects are often not very manifest upon the con-
stitution. The countenance and skin, however,
are pale and lax; the complexion is deficient of
clearness, and, with the suiface generally, often
covered with an oily or dirty moisture ; the per-
spiration is foetid, and the breath oflTensive ; the
soft solids lose iheir elasticity, and are slightly
emaciated , the lips are usually pale, the tonL;ae
white or loaded at its centre and base, sometimes
red at its point and edges; the pulse is weak,
soft, or small, frequently slow, but easily acceler-
ated ; and, at an advanced stage, the symptoms
more clearly manifest that the blood is imper-
fectly depurated, or that it is affected by the
absorption of a portion of the excrementitious
matters retained in the caecum. In addition to
these symptoms, general debility, and disinclina-
tion to any physical or mental exertion, are often
complained of. The above states of disorder
continue for a longer or shorter period ; when at
last the local irritation either produces increased
action of the muscular coat of the cajcum, and
ultimately the dislodgment of the offending mat-
ters, or gives rise to acute or chronic states of
inflammation, and various consecutive organic
changes. In some instances, the accumulation
in this viscus, and the spasm of the adjoining
parts, amount to complete obstruction of the
passage through the alimentary canal, even with-
out inflammation or any disorganisation of the
caecum itself having taken place; causing violent
colic and ileus, as in the cases already noticed
(§ 10.) ; the most marked symptoms during life
being referriblc to the superior portions of the
tube, and the lesions after death being most re-
markable in those jiarts, particularly about the

C^'.CUJM In! I.AMMA7I0N Ol— CauSES.

277

termination of the ilium, and the ilio-L':i ca!
valve.

13. iii. Theatment. — The inlcntions in tiiis
slate of ilijonier are very obvious ; namely, 1st,
to evacuate nioibid collections; and, 2d, to ])re-
vent their re-accumulation, by preserving a
regular tonic action of the viscus, and by strength-
ening the digestive organs generally. — a. The
evacuation of the accumulated or retained mat-
ters is to be attempted by means appropriate to
the circumstances of the case. If theie exist
iirittibility of stomach, or even any tendency to
it, or to febrile action ; or if there be any pain or
soieness in the iliac region ; full doses of calomel
should be first exhibited, the enemata about to be
sui:gested administered, and the liniments pre-
scribed in the Appendix (F. 296. 311.) assidu-
ously rubbed over the cajcal region, with the
view of exciting the healthy action of the viscus.
If, on the other hand, the stomach and bowels
be torpid, and the former can retain purgative
or cathartic medicines, they may be given, select-
ing those which are the least irritating in their
effects. I have seen inattention to this caution,
the most stimulating cathartics, having been ex-
hibitetl, productive of the worst consequences; a
state of disorder simply functional, or colic from
distension and obstruction of the cajcum, being
converted into either inflammation of the bowels
or dangerous ileus. When, therefore, an irritable
state ot the stomach supervenes in our atti-mptsto
remove obstructions of this viscus, we sljuuld
desist from the exhibition of puigalives, or even
of aperients by the mouth, excepting full doses of
calomel, or calomel combined with hyoscyamus
or opium, and moderate doses of nitrate of [lotash,
or caibunate of soda, or of both, which will
generally be retained, and will allay the sickness
and retchings. But we ought strenuously to j er-
sist in the administration of enemata — preferring
those which are oleaginous, saponaceous, and sol-
vent — and in the u?e of the liniments and frictions.
The enemata should be always large, and injected
by means of the valve-syringe now in use, so that
they may reach the seat of obstruction. In ob-
stinate cases, this object will lie faciliiated by
placing the patient upon his knees and elbows
during their administration, and elevating the
pelvis as much as possible above the rest of the
trunk. The practitioner should not be discou-
raged by the ineflectual adm.inistraiion of several
injtciions, but repeat them according to circum-
stances, employing at the same time frictions over
the abdomen «ith the liniments already advised.
If flatulent distention of the abdomen be present,
they will assist in removing it; but in such cases
the terebinthinate enemata ought to be preferred.
When we suspect the presence of woims, in ad-
dition to other morbid matters, aloes and the
alkaline solutions, assafoetida, camphor, lime-
water, &c. may be used in the injections. In
the slighter and more usual cases, the aperients in
common use, particularly castor oil, the com-
pound decoction of aloes, the combination of the
com])ountl infusions of senna and of gentian, or
the infusion of senna with decoction of cinchona,
or the several formula; of this desciiption con-
tained in the Appendix (F. 215. 266. 5(y2. 575.),
may be prescribed, as they may appear appro-
priate to the circumstances of the case.

14. b. Having apparently removed whatever

obstruction may have existed, — the cascal region
being soft and natural, und the actions of the
bowels free, — the object is next to prevent the
lecuirence of disorder, and to strengthen the
digestive oigans, by vegetable tonics and bitters
combined with aperients; by sulphate of quinine
with aloes ; by small doses of blue ])ill with the
alkaline carbonates and other deobstruents, and
given occasionally with the view of promoting
and correcting the secretions ; by the occasional
use of the liniments above referred to, or by
wearing a warm stimulating plaster (see F. 109.
115. 117.) over the right inferior regions of the
abdomen. In every case, attention should be
paid to the state of the digestive, assimilating, and
secreting functions ; regular evacuations of the
bowels promoted, by the occasional use of ene-
mata ; and the diet strictly attended to.

11. Inflammation of xitE C^cuMc Ci.assif.
III. Class, I. Order (^Author).

15. Although iiijicanmatioiii of tins viscus have
been generally oveilooked or confounded with
those affecting either the colon, the small intes-
tines, or the peritoneum, there are few diseases
more defined in their ehaiacter, or more distinctly
limited in the great proportion of the instances of
their occurrence, than they are. In respect of
its seat, inflammation may affect chiefly the mu-
cous surface, or the follicles, or all the coats of
the organ more or less : or it may attack the ver-
miform appendix only, or the cellular tissue
connecting the ctecum to tlie internal iliac muscle.
As to the character of the inflammatory action, it
may be sthenic and acute; or acute, asthenic,
and spreading, as in dysentery and fever : it may
also be more or less chronic. Cases of all these
stales of disease are to be found scattered through
the works of modem medical authors, and most
of them have come before me. The first case
which attracted my attentinn to the importance
of attending to the state of this viscus in various
abdominal diseases, occurred in 1816, in a hot
climate. The patient had, the usual symptoms cf
inflammatory dysentery, with violent pain, and
subsequently tumefaction in the ca?cal region,
TI.e disease had been neglected in its early
stages ; and it was only shortly before the sudden
subsidence of this tumour that I observed it.
Upon straining at stool, a sensation of something
having burst internally was felt; and very soon
afterwards above a pint of purulent matter, mixed
with a little blood, was discharged. Upon exa-
mination six hours aficr death, the caecum was
found ulcerated, discoloured, and nearly sphace-
lated, with an opening through the part attached
to the abdominal parietes leading to the nearly
empty sac of an abscess which had formed in the
cellular tissue connecting this viscus to the side ;
the mucous inembryne of the colon was inflamed
in parts, and excoriated.

16. i. The Causes of inflammations of the cae-
cum are chiefly the functional disorders ali-eady
described. A morbid slate of the abtlomiiial secre-
tions, and particularly an increased secretion of
vitiated acrid bile ; the irritation of foreign bodies,
indigestible substances, and of worms; a strangu--
lated hernia, or the piessure of an ill-constructed
truss ; the suppi'ession of the hemorrhoidal and
menstrual discharges ; and the presence of biliary
or intestinal concretions, hardened faeces, or the
stones of fruits, or iheir escape into the vermiform

T 3

278

C-iECUM — Inflammation of the Appendix op.

appendage. Tnflammatory irritation of the mu-
cous membrane and follLcles of llie viscus is not
infrequent after cliild-birtli, and as an attendant
upon soifie of the diseases which affect chiefly
the bowels of females at this period. In connec-
tion with the, accumulation and retention of mor-
bid matters, it very olten constitutes the earliest
patiiological state in dysentery and diarrhoea, and
consequently then arises from the same causes
that pfoduce those diseases,

' 17. ii. Symptoms. — A. Of injiammution nf the
rnncotis surface if the ctecum. These chiefly con-
sist of an irregular, mucous, offensive, and some-
times slightly bloody appearance of the stools,
with tenderness upon pressure or examination
of the caecal region. The evacuations are gene-
rally preceded by tormina or giiping pain, extend-
ing from this part upwards to the right side, and
down towards the pelvis, 'i he tongUL- is slightly
loaded or furred; and more or less i-ymptomatic
fever is present. This state of disorder is liable
.to lapse into a chronic (brm, and to continue for
a long period ; or it occurs primarily, from the
functional disorders already described, and some-
times fluctuates as to the degree of severity. In
the more sliyht or chronic states of inflammation
of this surface, the patient often complains of
little beyond irregularity of the bowels and co-
licky pains in the abdomen, with slight emacia-
tion, and loss of tiie healthy complexion; till, at
last, an acute attack of the disease supervenes,
from the extension of the inflammatoiy action to
the more exterior coats ; or the chronic organic
change has proceeded so far as to implicate ad-
joining parts, and to occasion a train of severe
symptoms. In this manner, the more dangerous
forms of dysentery not infiequently take place.
During the earlier states of inflammation of the
internal surface of the CEBcum, ulceration may
have commence'd, or the follicles become diseased,
and the coats successively perforated, until the
peritoneal covering is attacked ; when the inflam-
mation assumes more serious features, owing both
to its extension, and to the nature of the tissues
which are now invaded by it. The perforation
may, however, take place in that part of the pa-
rietes of the viscus where it is attached to the
iliac muscle ; and thus infiamniation be extended
to, and abscess form in, the cellular tissue exterior
to it, and break either externally, or into the cae-
cum, or both ; a sinuous communication being thus
formed between the cavity of the organ and the
surface of the body. In the manner now de-
scribed, the more acute states of inflammation of
the cfficum, and its connecting tissue, may arise ;
or these states may primarily aflect the different
structures composing its parietes, or may originate
in its vermiform appendage.

18. B. Acute hijltimmutioii of the coats of the
ccecum generally commences with violent pain in
the right iliac region, fre(|uently attended with a
burning sensation, and most exquisite tenderness,
jiarticularly when the serous coat of the viscus
is affected. It is accompanied with the most
severe tormina, extending from the above region
upwards to the right hypochondrium, across the
abdomen, down into the pelvis, and along the
thigh of thiu side. If the disease be attended
by distension of, or (xc,\\ collections in, the
ca;cuni, the testicle is retracted, and the thigh
either very painful or numb. While the pain

otcurs in paroxysms, and shoots in various direc-
tions throughout the abdominal cavity, it is con-
stant and fixed in the situation of the cascum.
The regions of the abdomen, although sometimes
distended and tense, bear examination, excepting
in the cfecal region and its immediate vicinity,
where the least pressure cannot be tolerated.
The pain is usually increased when the body is
erect; and the patient reclines on the right side,
with the trunk slightly bent, and the thighs
drawn upwards, so as to relax the parts in the
vicinity of the disease. The bowels are generally
torpid ; but vomiting is not complained of, unless
obstinate constipation exists, or drastic purga-
tives have been given early in the disease. I'he
|)ulse is usually quii'ker tlian natural ; but it is
occasionally not much affected ; and tlie temper-
ature of the surface is increased. In some cases,
the above constitute the chief symptoms ; but in
others much more disturbance ensues, particu-
larly if the disease advances, or is neglected in
its early stages, and tlie peritoneal surface of the
icEcum is aflected. Wlien such is the case, the
local symptoms increase in severity ; the abdo-
men becomes more generally tense and painful,
owing to the extension of the inflammation over
the peritoneal coveiing of tlse viscus and the ad-
joining parts ; and the symptoms of peritonitis,
often attended by obstinate vomiting, supervene,
with great frequency of pulse, and general fever.
If the appendix participate in the disease, the
symptoms are still more acute : general peritonitis
is very quickly produced ; adhesions are formed
lietween it and the adjoining peritoneal surface ;
and the appendix soon sphacelates : a fatal result
taking place, usually in a very short time. In
other cases the disease assumes a somewhat less
violent character, and terminates in suppuration,
owing to the cellular tissue connecting the coats
of the intestine to one another and to the ab-
dominal parietes being chiefly affected. When
this occurs, the issue is not so rapid as in the
former instances, but is sometimes prolonged for
a considerable period ; and, in some cases, re-
covery IS at last brought about. The foregoing
history applies more strictly to inflammation ori-
ginating in the caecum ; but when ii commences
in the appendix, or in the external connecting cel-
lular tissue, the symptoms are olten much inodified.
19. C. Infammation of the appendix caci ap-
pears to be attended from its commencement with
more acute symptoms than that of the cmcum
itself. In four cases of this description which I
have seen, this part was primarily and chiefly in-
flamed, owing to hard substances having escaped
into it, and had occasioned general peritonitis,
and gangrene of the appendix itself. In all of
these, obstruction of the bowels, with obstinate
retchings, was present at the time when I first
saw them ; and in the latter stages of the disease,
vomiting was attended by violent tormina, and
the discharge of matters evidently from the
small intestines, 'i'hus the symptoms of ileus
were superadded to those of jieritonitis. Ujwn
ilissection, the ca-cnm was found inflamed only
in its peritoneal surface, in three of the cases ; in
the fourth, inflammation was observed also in its
inner surface. In one, where the appendix con-
tained a small biliary concretion, its extremity
adhered to the surface of the Cfficum after passing
around a convolution of the ilium, which it had

CiECUM — Chronic Inflammation of.

279

evidently strangulated ; but at the time of the
inspection it was quite gangrenous on each side of
tile concretion. In another case, appearances of
strangulation were manifested in a less satisfactory
manner; the surrounding parts being so agglu-
tinated by albuminous exudations, that their re-
speciive relations were not obvious. It does not
appear, however, that inflammation originating in
the appendix always arises Irom substances having
escaped into it. JM. Louyer Villermay has
detailed two cases of a similar state and termina-
tion of disease to the above ; one occurring with-
out any apparent cause, the other seen.ingly from
the pressure of a bandage in hernia. In one,
publl^hed by JMr. Parkinson, ulceration and
perforation of the appendix had taken [)lace from
the lodgment of a small portion of indurated fa;ces
in it. A very interesting case, where violent ab-
dominal symptoms were occasioned by a large
liimbiicus, which had passed into the cascal ap-
pendage of a person otherwise diseased, is recorded
by JMr. Blackadder. JM. Thiery found this
part engorged with fscal matters, and inflamed,
in a fatal case of ileus ; tiie caecum being nar-
rowed, but not otherwise di-eased. Heister met
with the appendix inflamed and ulcerated after
death, with similar symptoms. Amvand detected
a small nail in this part after fatal ileus. Moreau
and Ki.oECKHOFF record instances of this disease
produced by strangulation of the ilium by the
ciEcal appendage. Mr. Wai.dron discovered a
small concretion in it after fatal peritonitis ; and
MoRGAGNi, Van Doeveren, Sandifort, and
several others, have detailed cases of both peri-
tonitis and ileus, in which this part had adhered to
adjoining parts; and, in some instances, a loop of
intestine had been enclosed by it, and strictured.
From the history of these, and other cases, which
have occurred to me and several of my medical
friends, it may be inferred, that inflammation
affecting primarily the caecal appendage is most
frequently brought on by hard substances having
escaped into it ; and that the inflammation rapidly
extends to the peritoneum ; giving rise to the ex-
udation of album.inous lymph, to adhesion of its
opposite surfaces, and of the appendix to adjoining
parts, and to gangrene of this process.

20. Very acute pain, tumefaction, and tender-
ness, are complained of upon the invasion of this
form of the disease, first in the right iliac region,
and subsequently more or less over the abdomen ;
witii excruciating tormina, obstinate constipation
of the bowels, a very frequent, small, or con-
tracted pulse, heat of skin, dry tongue, great
thirsty sumelimes with numbness of the right leg,
or pain shooting down the thigh, and retraction of
the testicle. Vomiting comes on sooner or later,
and is often, at one period or another, attended by
the discharge of matters from the small intestines
— at least in the cases which I have seen. The
patient at last becomes restless, his countenance
sunk, and a fatal termination takes place, gene-
rally from the third to the sixth day, preceded by
the symptoms ushering in dissolution from intes-
tinal peritonitis.

21. D. hiflammation of the ■peric<i:cal tissue is
occasionally met with. Several interesting cases
of it have been published by French writer-,
especially by Mil. Dupuvtren and Meniere.
Mr. Copeland has detailed a case where a urinary
calculus was extracted from an abscess which

opened externally, and communicated internally
with the cavity of the caecum. It is piobaljle
that tiie calculus, in passing along the ureter, had
produced inflammation, extending to the cellular
tissue exterior to the caecum, and terminating in
abscess, which had opened in both directions. In a
case contained in Dr. Johnson's Journal, a!id in an-
other in which I was consulted, witii Mr. Fekcusson,
abscess had formed in the cellular tissue, external
to the caecum, had also burst into this viscu', and
pointed externally : and a similar instance is re-*
corded by M. Di'play. In all these a sinuous com-
munication between the cavity of the intestine and
external surface was formed. Several of the cases
of inflammation of the caecum and connecting
tissue, detailed or referred to by M. Meniere,
terminated in suppuration, and opened either in-
ternally or in the right iliac fossa. In some of
those published by M. Dupuytren, the purulent
matter had infiltrated itself as high as the kidney,
and as low in the pelvis as to collect between the
rectum and bladder.

22. The precursory symptoins of this state of
disease belong to pathological changes in the
functions or coats of the ceecum itself, and are
often similar to those already described as in-
dicating acute or chronic inflammation of its
luucous surface and iollicles; the disease in such
cases mo-t probably arising from ulcerative per-
foration of the coats of the organ, or the extension
of inflammation from its mucous surface. The
patient frequently is first afl^ected with either
diarrhoea or constipation, or by both alternately,
with colicky pains shooting in various directions,
but generally radiating from the right iliac region j
and he complains of pain or tenderness on pres-
sure. To the above symptoms, others sooner or
later are added, especially tumefaction, and con-
stant pain in this part, and in the right iliac fossa,
with anorexia, nausea, fever, and an irregular
state of the bowels. As soon as suppuration com-
mences, the disease presents the local and con-
stitutional characters usually accompanying the
formation of matter, with more or less tumour,
which is generally situated deep in the iliac fossa.

23. Inflammation in this situation will, if re-
cognised early and treated judiciously, terminate
by resolution, in perhaps the majority of cases.
But suppuration is almost as common a termin-
ation as resolution ; and, when it takes place, the
abscess formed mo?t frequently opens internally.
In several instances, peritonitis has supervened,
either previously or subsequently to suppuration,
but more usually the latter. The abscess may
also open externally, as in the cases already re-
ferred to ; but seldom without it having also previ-
ously established a communication with the cavity
of the cfficum.

24. iii. Chronic Inflammation of ihe C-ecum
generally comes on either primarily, slowly, and
insidiously, or consecutively upon functional dis-
order'of the viscus ; and it may be long limited to
the internal surface and follicles of the intestines, as
noticed above (§ 17.). It more rarely remains alter
acute attacks. In the former mode of appearance,
it often advances imperceptibly, until serious or-
ganic changes have taken place in the coats of
the organ ; the general health, although more or
less affected, not being so far injured as to alarm
the patient. In its progress, it sometimes presents
occasional accessions of severity, and even assumes

T 4

280 CJrLCUM — Inflammation

a sub-acute form. In other cases, an acute atlack
is superinduced, which may terminate in peritonitis,
or in suppuration, or even in gangrene. Chronic
inflammation is the most common organic state of
disease by which ihe caecum is affected.

25. A. Causes. — Tliis form of inflammation of
the caecum is, I believe, most frequent in females,
probably owing to contingencies connected with
the uteiine functions and child-bearing, and to
their modes of dress. It often occurs among them
previously to menstruation, or soon after the cli-
macteric epoch. Neglected functional disorder of
the CEECuin ; the use of unripe or acerb fruits;
sedentary occupations, or want of exercise ; the
depressing passions ; previous disoider of the di-
gestive organs, particularly costiveness, and habi-
tually, or occasionally, deferring the earlier inti-
mations to evacuate the bowels; suppression of
accusiomed discharges, especially the heemor-
rhoidal, the menstrual, and lochia! ; the pressure of
an ill-constructed bandage for +iernia ; blows or
contusions on the caecal region; and ocrasiontdly
too violent exercise on foot or on horseback ; are
its most usual exciting causes.

26. B. Symptoms. — At first the general health
and strength are not much injured ; but the pa-
tient loses hi-; heakhy appearance and activity.
He complains of colicky pains occurring occa-
sionally, or even periodically, in the right iliac
region, shooting through the abdomen, and recur-
ring soon after a meal. The appetite is not
materially affected, and flatulence is the most
constant gastric symptom. 'I"he tongue is gene-
rally red at its point and edges, and loaded at its
root ; sickness and vomiting are not present ; the
pulse is ofien little affected, or it is quick and
small ; the patient lies on the tight side, with the
body bent and the thighs drawn up, and feels
pain or uneasiness in the iliac region on turning
to the left side, which is increased by continuing
the position. The alvine evacuations are irre-
gular and (offensive, being at one lime frequent, at
another retained, generally muco-foeculent, fluid,
preceded by colic or slight tormina, and affordint;
little r( lief. The abdomen, on examination, pre-
sents little remarkable, until we reach the caecal
region, where pressure occasions uneasiness, and
a deeply seated fulness and hardness are usually
detected, if much fulness or distension be pre-
sent, the urine is generally voided frequently, and
slight pain or numbness of the right thigh, with
oedema of the right ankle, is often felt. If the
disease go on to ulceration, blood will appear in
the stools, which will also be of a more or less
dark colour. Such are the usual symptoms, until
some on(: of the acute states of the disease super
venes, when their attendant phenomena will indi-
cate the change.

27. C. 'J'he chronic stale of the disease may give
rife to very great thickening of the paiietcs of the
cacum, either with or without dilatation of its
cavity, and ulcerations in its internal suiface.
Fai3i;icius IIiidams describes a case of this
kind as one of cancerous ulceration ; but it seems
rather to have been chronic inflammalion, with
thickening and ulceration. Dr. Bkiczeley has
detailed an interesting case very t;early of this
description, wherein these changes were very re-
markable. The j)ati( nt corn|)lained of cclic, c(,n-
slipalion, flalub nee, mucous bloody stooN, and of
a large tumour in the iliac region, whicli was

OF THE — Complications.

mistaken for aneurism of the iliac artery. On
inspection, post mortem., tlie coats of the ciccuin
were found above an inch in thickness, scinhous,
inflamed, ulcerated, perforated, and its cavity en-
larged. When the disease has gone on to thick-
ening, as indicated by the obscure hardness, and
tumour, uneasiness, &c., in the iliac region, parti-
cularly if it be attended with ulceration, as may be
inferred froiu the presence of small quantities of
blood or pus mixed in fluid, or but little consistent,
muco-focculent and offensive stools, amendment is
procured with great difficulty, under the jnost
favourable circumstances; but it should not be
despaired of, although it may be long in appear-
ing. I have met with severe cases, obviously of
this description, where medical treatment was per-
sisted in for many months, and one or two for some
years, yet ultimately the health was re-established.
In a case recorded by M. Emeuy, the caecum was
remarkably constricted, and the appendix filled
with fa3ces. The patient died of ileus.

28. iv. Complications. — Inflammations of the
caecum, particularly of its internal surface, and in
their sub-acute and chronic forms, with morbid
enlargement and fungous ulceration of its follicles,
are very frequently associated with dysentery and
fever, in both temperate and warm climates. In-
flammation of its external connecting tissue is
much less common in these complications. I
ascertained the fact of the intimate connection of
inflammations of the caecum, with difsetitery, in
1816, my attention having been first directed to
it by the case already alluded to (§ 15.). In-
deed, they generally constitute the original disease
in dysentery ; the irritative state of inflammation
of the mucous surface and follicles of this visciis,
together with the acrid secretions and other mat-
teis retained in it, producing an excoriating state
of tiie discharges, whereby the caecum itself is
first affected, and subsequently those parts of the
colon and rectum where they are the longest re-
tained ; an opposite morbid relation, however,
obtains in resj)ect of its complications with fevers,
particularly those of a typhoid natuie ; for, while
in dysentery it is frequently the primary affection,
in fevers it is commonly a consecutive lesion
arising from the morbid states of the secretions
and matters, either retained in or passing through
it, and from the disposition to change possessed
by the mucous tissues and follicles during these
diseases, particularly those of an asthenic cha-
racter. It should not, however, be overlooked,
that lesions of the ca;cum may also arise in the
course of dysentery, owing to similar slates of the
secretions and mucous surface of Ihe intestines as
arc present in fevers ; and that the ca^cai disease
will very generally escape tieteclioii dating life,
])articularly in fevers, unless the attention of the
jjiaciitioner is alive to its occurrence. In every
case, therefore, should the regioi: of this viscus be
attentively examined ; and, if symptoms indicating
an affection of it be present, the means of cure
should be directed accordingly.

29. V. Laci iiA'iiON, or rnptuve o( the ca:cum
occurs in rare cases, either in consequence of pie-
vious disease and infarction of its cavity, or of
external injury. Some instances of this occur-
rence are to be found in early volumes of the
Philosophical Transactions, and in the 'J'ransac-
tions of foreign medical societies. Solmmi niKc;,
in his notes to the translation of Dr. liAiLLiJi'8

C^ECUfll — Intlammatio

Morbid Anatomy, mentions a case wlieie'.n it was
produced by vomiting, which may liave arisen
Iroin accumulation of morbid mailers in the cajcum,
with obstruction of its canal, and ulceration of its
internal surface. Mv. Spkeh and Mr. Siilwakd re-
cord instances of its rupture from contusion, — an
event which is very likely to occur when an injury
is sustained over it during distension of its cavity,
from wiiatever cause. The consequence ot its
laceration generally is rapidly developed, and
speedily fatal, peritonitis. Introsusceptions of this
part, itself having passed into the colon, or
portions of bowel having passed into it, are not
infrequent, particularly in young subjects; but
they require no particular notice, farther than as a
cause of ileus, inflammation of intestines, &c.
Cau'iform, and other fungous excre-cences, may
occur in the caecum, as well as the other morbid
changes described in the article Digestive Canal.
30. vi. 'J'he Prognosis in disease of the cajcum is
very different in each of its forms. — a. When the
internal surface is chiefly afTected, recovei'y will
take phice in most of the cases, unless ulceration
has commenced ; and even then a favourable
issue will sometimes follow judicious medical
treatiTient and regimen, b. In the acute states of
inflammation affecting the more external coats of
the viscus, the prognosis is upon the whole un-
favourable, at least it should be stated as such to
the friends of the patient ; and in every case it
should be given with caution, c. If we suspect,
from the severity of the symptoms, or from the
rapid extension of inflammation from the cfecal
region over the abdomen, that the appendix is in-
Jiamed, it is still more unfavourable ; if, in addi-
tion to this circumstance, the retching be fre-
quent, and more particularly if the matters
ejected appear as having come from the small in-
testines, we may infer, not only that the caecum
or its appendage is most acutely inflamed, but
also that either its canal is obstructed, or some
adjoinmg part of the tube is str.ingulated ; — in
either case the prognosis is most unl'avourable.
The subsequent appearance of tb.e symptoms
usually indicating gangrene of the intestines
leaves no hope, and is soon followed by disso-
lution, d. When considerable tumour, seated in
the iliac fossa, and the signs of inflammation of
the pericecal tissues, are present (§ 22.), a favour-
able opinion of the issue may be entertained,
if active treatment have been employed early
in the disease, and the patient's constitution be
not in fault. But in very many such cases, the
general health has been much impaired previoui-ly
to this disease, and has even predisposed to the
attack. In such cases, as well as when evidence
of the formation of abscess is observed, a very un-
favourable, or at least a very cautious, prognosis
ought to be given, e. In the chronic states of
the disease any opinion should be oflered with
much reservation. If the disease have come on
slowly, continued long, and the stools present the
appearances indicating ulceration (§ 26.), an unfa-
vourable stale of disease exists ; thickening of the
coats of the viscus merely {§ 27.) is more fa-
vourable, but is not readily removed, f. The
cowplications of this disease (§ 28.), particularly
with typhoid fever, are attended by considerable
dang(;r. The association of it with dysentery is
productive of the worst forms of that disease,
as well as its complication with fever, of its most

; or THE — Theatment. 281

dangerous states ; and onuses the former to as-
sume a chronic and obstinate form. g. Lacera-
tion, or rupture of the coats of the caecum, is ge-
nerally fatal in its results.

31. vii. Treatment. — ^. Inflammation of the
internal surface of the caecum, and the chronic
states of the disease ($ 17. 24.), require the appli-
cation of a number of leeches either near the iliac
region, or on the inside of the right thii;li, and a
repetition of them according to the circumstances
of the case. In robust or plethoric persons, gene-
ral depletion may precede the local. After the
leeches are reinoved, fomentations and a succes-
sion of poultices will be founil serviceable; after
which, a full doseof calomel with James's powder,
and, a few hours subsequently, a mild aperient me-
dicine, should be exhibited, and an aperient action
promoted by the ailministration, and frequent re-
petition, of demulcent, oleaginous, or saponaceous
enemiita (§ 13.). Drastic purgatives are seldom
more efficacious than tho^e of a milder kind, but
are often attended with risk. I have generally
found the infusion o'f rhubarb, with tartrate of
potash, and the electuaries prescribed in the Ap-
pendix (F. 82. 89. 98.), most serviceable. In the
majority of esses, the above means will remo\e all
ailment. The treatment in other respects should
be the same as is recommended in chronic Diar-
rhana and in Dysentery. If functional disorder
remain after the more inflammatory sym] tcms
have subsided, a blister may be applied, or a de-
obstruent liniment {^ 13.) rubbed over the cajcal
region niglu and morning; or a rubefacient and
deobstruent plaster (^ 14.), worn for some months
in this situation.

32. B, In the more acute states of the disease,
general blood-letting, repeated according to the
circumstances of the case, or followed by local
depletions, and the same treatment subsequently
as described above (i 31.) must be early and de-
cidedly employed. If there be vomiting, or retch-
ings upon taking substances into the stomach, a
large dose of calomel, — generally from 10 to 20
grains given either alone or with one or two grains
of opium, — will allay this disorder. If the sym-
ptoms still continue, or if they be but slightly mi-
tigated, blood-letting, general and local, followed
by fomentations, poultices, and oleaginous enemata,
having been carried as far as maybe deemed pru-
dent, the turpentine embrocation (flannel cloths
wrung dry out of very hot water, and immediately
soaked with spirits of turpentine), should be ap-
plied over the abdomen, and retained theie as long
as it can be borne by the patient. If the tormina
be severe, or if peritonitis have supervened, this
embrocation is, after depletions liave been prac-
tised, the most efficacious means we possess. In
a case of this disease, which had become compli-
cated with peritonitis, in a member of the family
of a medical friend, this means gave almost in-
stant relief, after other measures had been car-
ried to the utmost limits, and the piiticnl soon
afierwards recovered. In another instance of ex-
treme danger similarly complicated, which very
recently occurred, the repetition of this treatment
removed all complaint, although resorted to in
despair of success from it.

33. C. J have stated that inf animation of the
appendix caci, particularly when occasioned by
hr.rd bodies having passed into it, often does not
extend to the caecum itself, or, at most, only to

282 CANCER — Pathology of.

its peritoneal coat, in common with the adjoining
portions of this surfjice ; but that tlie supervention,
the extension, and fatal termination of peritonitis
in such cases are most rapid and dangerous, the
appendix itself generally soon becoming gangren-
ous. It therefore behoves tlie practitioner to have
recourse to the most decided measures, when he
finds the symptoms of peritonitis originate in the
ca3cal region, and when retchings come on. Vas-
cular depletion, and all the remedies already no-
ticed, must be energetically and early employed ;
but premature attempts should not be made to
evacuate the bowels, otherwise their action will
be inverted, and decided symptoms of ileus will
be produced. Fomentations should follow the
leeches; and afterwards hot pouliices should fol-
low; which in iheir turn ought to give place to
the terebinthinate embrocation, if requisite. A
large dose of calomel and opium should, however,
be given after the first full blood-letting; this will
generally be retained, even in the worst cases ;
and it ouj;ht to be repeated according to circum-
stances, without fear of aflfecting the system by it,
— an effect which it is even very desirabk- to
produce. Little other medicine need be exhibited
by the mouth, excepting draughts w;th niirate of
potash, or carbonate of soda, or both, with agree-
able demulcents and emollients, if the stomach
will retain tliem. But the assiduous administration
of enemuta u>\iAt not be neglected. It is entirely
by their ai;ency in this stale of disease, that the
bowels are to be evacuated, when it is judged
prudent to fulfil this intention, which should sel-
dom be omitted as far as they are calculated to
accomplish it; more es|)ecialiy alter depletions
have been practised. The enemata prescribed in
the Appendix (F. 130 — 151.), as they may appear
suited to particular cases, may be employed.
Pain, tormina, nausea, or vomiting, having been
relieved, gentle cooling aperients, and in the
interval diaphoretic medicines, may be exhibited
by the mouth. Warm baths are seldom of much
use in this malady: but when they will not
interfere with the treatment prescribed, they may
be tried, particularly in the more advanced periods.
After the disease has been removed, and merely
functional disorder remains, the measures already
advised may be put in practice.

34. D. The treatment now described is also
applicable to the early stages of inflammation
affecting the periciLCul tissues. If suppuration
takes place, the treatment recommended for Abs-
cess must be resorted to ; taking care to support
the eneigies of life under it, particularly when
the constitution or general liealth is in fault. If
we suspect either the existence of iilceralion or
of thickeiiing of the coals of the vi'icus (■§ 27.),
the assiduous employment of the liniments no-
ticed above ; of gentle aperients and deobstruents,
particularly the infusion of rhubarb with soda or
potash ; of electuaries, with sulphur, bi-tartrate
of potash and soda, or the bi-borale of soda;
small doses of blue pill or hydr. cum creta,
with ipecacuanha, hyos(;yamus, and camphor ;
repealed blistering, and subsequently the deob-
struent plasters ; the frequent use of large olea-
ginous, saponaceous, and demulcent enemata,
wiih the treatment recommended in chronic
ihjsenlrnj ; are the measures most to be depended
upon ; vviih strict attention to diet, which should
be chiefly farinaceous, to the state of the digestive

organs generally, and to the secretions and
excretions.

35. E. The complicati<m of the disease with
dysentery requires, in addition to the measures
used for that disease, the application of leeches
near the ritiht iliac region, and the other external
measures already noticed, with rhubarb aperients,
combined with camphor, narcotics, and ipeca-
cuanha ; laxatives, with demulcents and anodynes ;
the frequent administration of oleaginous and
emollient enemata ; and the usual means of cor-
recting the secretions, and diluting and carrying
off the acrid and excoriating fluids, and leecal
matters in the intestinal canal. (See Dysentery
— its Treatment.) A similar tieatment to the
above is necessary when ihe disease occurs in the
progress of fever. Depletions, however, are gene-
rally not so well borne in this complication as in
the former, and should therefore be carried to a
less extent; but all the external remedies, and
the use of laxatives, particularly those imparling
a tonic effect to the intestinal mucous surface,
should be often employed. Camphor, with hy-
drarg. cum creta ami opium, or with ipecacuanha
and ihubarb, terebinthinate injections, or even a
terebinthinate draught in the woist cases, have
proved most serviceable in this state of complica-
tion, in my practice. During recovery, the occa-
sional use of the liniments and plasters above
referred to, attention to the secreting and digestive
functions, particularly to the state of tlu' bowels,
which should be occasionally assisted by emol-
lient and laxative injections ; and a regulated
diet, easy travelling, change of air and of scene;
are the chief measures requiring attention. (See
the treatment of Fever.)

BiBLiOG. AND liEFER — Fitbricius Hildanus, Cent. i.
ol)s. 6. — Amyand, in Piiilos. Trans. No. -143. — Cniitwell,
in Ibid. No. 440. — Heister, Wahrnehmungen, vol i.
n. iii. ; Nov. Act. Curios. Nat. vol. ii. ol)s. Q'i.—Moreau,
Journ. de Med. 1790, n. 4. — Salxmmin. Ohserv. Anatuin.

[i. 53 Nacquart, Joiirn. Gener. de Med. t. xxxi. p. 384.

— Ihim, Zwe}' Krankeng. &c. p. 24.— Tiedctiiann, et
(imtlin, Kech. Kxperiment. Physiol, et Cliimiqiies sur la

Uigcstion, &c. 8vo. Paris, 1826 Author, Appendix to

M. liicheraitd's Elements of Physiology, p. 591. 2d edit.
Lond. 1829. — Parhhmon, in Medico-Chirurg. Transact.

vol. iii. p. bl .—Cupelimd, in Ibid. vol. iii. p. 191 Odter,

in Ibid. vol. vii. p. 'i2l.— Johnson's Medico-Chirurg. Re-
view, vol. iv. p. 739 Bartow, in Ibid. vol. xii. p. 181. —

Monro, Morbid Anatomy, &c. 8vo. 2d edit, ]). 20. — Eincry,

in Revue Medic, t. iii. )). 273. 1825 Loitycr i'ilUrmay,

in Archives Gen. de Med. t. v. p. 246 — Dlackaddcr, Kdiii.

Med. and Snrg. Journ. vol.xxii. p. 19 H ilntol, I'rans.of

.Assoc, of Irisli Coll. of Physic, vol. ii. p. 12 Speer, Dnb-

lin Huspit. Reports, vol. iv. p. 349 Bcezeley, in I'hilad.

Med. and Physic. Journ. vol. vi. p. 350, — Klockkoff, in

Auserl, .Abhandl. fiir Pract. Acrzt. b. i. st. ii. p. 184

Ducos,\n Archives Gen de Med. t. xx. p.5Hl Meniere,

in Ibid; t. xvii. p. 188. .013 Duplay, in Journ. lUbdom.

t. ii. p. 'iO'i.—Sheioard anii Waldru7i, Midi. Med. Repjrter,
vol. ii. p. .50. 463. — Ahcrcrombic, On the Abdominal Vis-
cera, &c. p. 237 — Farral, in Edin. Med. and Surg. Journ.
vol. xxxvl. p. I.

CALCULI. See Concretions, Biliary
and Intestinal; also Uhinaky Calculi, and
Urine.

CANCER. Syn. Scirrhns, Carciuus, Schirro-
Cuncer, Carcinoma, Auct. Var. Cancer, Fr.
Das Krebsgeschwur, Ger. Scirro, Canchero,
Cancro, Ital.

Classif. 4. Class, Local Diseases; 6. Order,
Tumours (^Cnllen). 3. Class, Sanguineous
Diseases; 4. Order, Cachexies (^Good).
IV. Class, IV. Order (Author, see
J'reJ'ace.)
1. Deiin. A disease often arising from he-
reditary predisposition, in the middle or advanced

CANCER — Pathoi.ooy of — SciRnHOiis Stage.

283

periods of life ; commencing with a local hardness,
U'ltich subsequentlti soj tens in itscentre, infects the ad-
joining parts, and ultimately contaminates the frame.

2. Cancer consists of two slates or stiiges: the
Jirst, in wliicli it presents the appearances usually

denominated scirrhus ; the second, in which it
softens, ulcerates, &c., and degenerates into true
cancer, or carcinoma. I shall describe each of
these successively.

3. I. Sciiiuiious Stage. — Occult cancer. It
commences with a tumour, a limited local hard-
ness; is usuully single; is very rarely, at its
Commencen:t;iit, detected in different parts at
once; and is not surrounded by a cyst. Several
authors have stated the occurrence of a cyst ;
but Otto more accurately excludes it from tiiis
structure. It is of importance to attend to the
appearances of the disease at its commencement,
as serving to indicate its nature. It is distin-
guished, at this period, by hardness, coldness,
whiteness or paleness, insensibility, and defi-
ciency of red blood vessels; — a state indicating
the low grade of vital endowment of the part.

4. The scirrhous structure, when fully deve-
loped, consists of a firm, hard, rugged, incom-
pressible, and unequal mass, the limits of which
are not distinctly defined. Its colour is generally
of a light grey, and when cut into thin slices, it
is serni-traiisparent. Upon close insj ection, it is
found to consist of two distinct substances; — the
one hard, fibrous, and organised ; the other soft,
.and apparently inorganic. The former composes
the chief part of the diseased mass, and consists
of septa, which are opaque, of a paler colour
than the soft pait, unequal in their length,
breadth, and thickness, disposed in various di-
rections; sometimes forming a nearly solid mass;
in other instances, a number of colls or irregu-
lar cavities, which contain the soft part. This
latter is sometimes semi-transparent, of a bluish
colour, and of the consistence of softened glue;
at other times more opaque, softer, somewhat olea-
ginous, and like cream in colour and consistence.

5. The fibrous structure seems to be the cel-
lular, or pioper tissue of the part, in a stale of
induration and hypertrophy; assuming, in con-
sequence of its increased density and bulk, an
appearance similar to the fibrous or fibro-cartilagi-
nous structure ; whilst the softer portion, contained
in the meshes and cells of the former, appears
to be merely a morbid secretion poured out by
the vessels nourishing the organised fibrous tissue,
and is probably the exhalation of the part, either
secreted in a modified state, or accumulated and
changed by the disease of its containing struc-
ture. If this view be correct, the former, or
organised part, may be considered as chiefly re-
sulting from an altered state of nutrition in the
seat of disease ; whilst the latter, or inorganised
portion, may be viewed as proceeding from a
moibid secretion, — the diseased structure thus
being a product of a disordered state of both the
nutritive and secreting (unctions, most probably
in consequence of alteration of the vital influence
exerted by the ganglial nerves on the capillaries
of the part.

6. The proportion of each of those two sub-
stances, and the modes of their distribution, vary
very considerably in different scirrhous masses.
This diversity seems to be owing to the difl^erent
tissues in which they are developed, and to the

iTiodifications arising from temperament, local irri-
tation, and various concurrent circumstances to
which the patient may have been exposed. It
has been attempted by ]\lr. Abernethy to ar-
range these varieties of scirrhus into species, and
to designate them according to the natural struc-
tures which they most resemble. Thus he divides
them into Mammary, Fancrealic, Tuberculous,
&c. : but these diflerent states of structure glide
so insensibly into each other, and are so perfectly
similar as respects their origin and consequences,
that little practical advantage is derived from
thus distinguishing them.

7. In some scirrhous tumours, the fibrous part
of their structure is both most conspicuous and
abundant, and is condensed into a solid mass,
having the appearance of a centre or nucleus,
whence radiate numerous sepia in everv direction.
This is the most common appearance of the dis-
ease. In other instances, the tumour forms an
uniformly hard mass, of an irregular shape, and
of no very defined structure. In some cases, the
organised part approaches more nearly to the
cellular structure, its cells being filled with a
soft matter which may be pressed out. Occa-
sionally, cysts are formed within the tumour, of
various sizes, containing a reddi>h, reddish brown,
or a chocolate-coloured fluid. These cysts are
lined by a smooth membrane, from which a
fungous tumour sometimes sprouts out. In some
instances, portions of the scirrhous mass are con-
verted into a iiard substance resembling cartilage,
in which bony or calcareous depositions are oc-
casionally found. When the scirrhous structure
is formed in the substance of a gland, its limits
cannot generally be accurately determined, the
two structures apparently being inseparably con-
nected. In some cases, the scirrhous tumour con-
denses the cellular tissue surrounding it, and
hence it acquires a somewhat sacculated appear-
ance. (Wardhop.)

8. At the commencement of scirrhous disease,
the structure of the tissue or organ in which it is
seated preserves for some time its aspect and
colour, being changed merely in volume and
density : sometimes, however, its volume is but
little augmented, whilst its density is very much
increased. As the disease advances, the proper
tissue of the organ becomes more obscure, and
verges nearer to that already described.

9. M. Hecht, of Strasbourg, analysed a portion
of fully developed scirrhus of the mamma, and
found 72 grains composed ot 2 grains of albumen,
20 of gelatine, 20 of fibrine, 10 of a fluid fatty
matter, and 20 of water and loss. He likewise
analysed, by a similar process, 72 grains of scir-
rhous uterus, and found it to consist of 15 grains
of gelatine, 10 of fibrine, 10 of oily or fatty
matter, and 35 of water and loss. (Lobstein,
Anat. Path. t. i. p. 403.)

10. Scirrhous tumours do not always remain
in the state now described ; and the period durino-
which they thus continue is not determinate.
When once they commence, they seldom retro-
grade, and the part affected never is restored to
its healthy state. It is chiefly in this respect
that the early stages of scirrhus differ from sim-
ple induration proceeding from chronic inflamma-
tion. Scirrhus may remain nearly stationary
for several years, occasioning but little constitu-
tional disturbance; but generally an important

284 CANCER — Patiioloov o

cliange takes place in its structure, and tiie dis-
ease afterwiirds makes rapid projiress.

11. II. Carcinomatous, or Cancerous Stage.
— Open or ulcerated cancer. After a time,
portions of the scirrhous mass begin to soften,
and pass into a state of unhealthy suppuration
and ulceration, — unliealthy as respects the cha-
racters ami progress of lliese processes, and their
contaminating influtnee upon the whole frame.
Tlie soft or inorganic substance resolves itself into
a thin ichorous matter, very different from pus ;
and disorganisation commences, generally about
the centre of tlie mass, and extending towards that
part of it which is nearest either tiie surface of
the body or any of the natural openings. When
this process commences, it is in that state which
has been denominated Carcinoma, or Cancer.
When tills ciiange takes place, the diseased mass
seldom increases much in bulk, but is destrosed
by an ulcerative process. Tlie disease now makes
rapid progress, owing to the contamination of
the adjoining structures by the morbid uialter
secreted by the ulcerating part, a portion of
which matter is evidently absorbed, irritating the
lymphatic glands, and vitiating tiie whole frame.
In consequence of this infection, the powers of
life sink, the soft solids become cache\ied, and
the progress of the local affection accelerated.
At last the patient sinks from the contamination
of the circulatmg fluids, and the different textures
of the body ; the blood lieing diminished in quan-
tity, as well as otherwise altered.

12. When the skin covering a scirrhous tumour
ulcerates, a fungus of a cauliflower appeal ance,
and iiard gristly structure, sometimes proceeds
from the surface of the mass. In some cases, ul-
ceration destroys both the fungus and the primary
tumour. It has been observed by Sir E. Home,
that some cancerous sores have suddenly changed
from a painful and malignant character, to a more
healthy aspect at some part, and even have begun
to cicatrize, 'ihis apparent amendment is never
permanent, for, sooiicr or later, the ulcerative pro-
cess is renewed, and the disease pursues its usual
course. Dr. Parr (Diet. vol. i.) states, that he has
seen several cases thus terminate spontaneously ;
but the patients were all soon afterwards cut off
by internal disease ; probably consisting of the
internal developement, or metastasis of the malady,
casts of which occurrence arc not infrequent.
(See Jimrn. Hehdnm.t. i. p. 323. for a case wherein
internal cancer a])peared after the removal of the
external disease by compression.)

13. Cancerous tumours generally contaminate
the glands in the vicinity, particularly after ulcer-
ation has commenced. iiut these glands are
seldom primarily affected. Wr. W Annitop states,
in his excellent description of this disease, that he
has only met with two cases of primary affection
of the lympiiatic glands, besides these glands,
various other oigans and parts, sometimes far re-
iiiov(d from the seat (>( the primary disease, be-
coiTie sccondaiily affected. 1 his is most probably
occasioned by conliimination of the frame, from
absorption of the niorbid matter of the disease.
Sometimes the existence of cancer in distant or-
gans is not successive or secondary, but seemingly
coeval. In this case the cause must be looked
for in (he originally morbid slate of the system.
Inrleed, this stale always obtains, to a c( rtain ex-
tent ; the disease being strictly conslilulional even

K — Carcinomatous SxAor.

in its origin ; the consecutive contamination,
arising from the absorption of morbid matter from
ihe primary tumour, merely augmenting the ori-
ginal vice, and accelerating its noxious effects.

14. Scirrho-cancer most commonly originates
in glands wiiose functions have been interrupted,
or that have never pei formed the offices intended
for them ; or it affects parts which have been pre-
viously diseased, or have received at some period
an external injury. Thus it attacks the mammae,
the uterus, the ovaria, the testes, the thyroid
glands. It also very frequently commences in
the tegumental, and the digestive, and urino-
genital mucous surfaces ; more particularly in the
skin of the face ; in the mucous membrane of the
nose, lips, mouth, pharynx, and oesophagus ; in the
stomach, especially the pylorus and cardia ; in
the intestinal canal, the ilio-cjecal valve, lectum,
and anus, and in the urinary bladder. The vis-
cera which are seconduriUi affected, are com-
monly the lungs, bronchial glands, the liver, the
omentum, the mesentery, the serous membranes,
the spleen, tlie pancreas, the brain, the medulla of
the bones, and the skin. Several of these, particu-
larly the liver, pancreas, mesentery, brain, &c.
may also be primarily or coevally affected with
other parts. Scirrtius affectslhe skin in two forms ;

— the one is that of wart, the other that of tubercle

— the former being primary, the latter secondary.

15. III. Diagnosis.— It is of great importance
to be able to distinguish between this disease and
various others, for which it is liable to be niis-.
taken. For instance, the simple induration pro-
ceeding from chronic inflammation has, in several
instances which have come to my knowledge,
been mistaken for scirrhus. This mistake not in-
frequently occurs in respect of induration of the
neck of the uterus.

16. A. In simple induration, the part affected
is redder, more injected, retains more of its ori-
ginal structure, is less indurated, and less lobu-
lated, than scirihus. The parts also surrounding
the indurated portion are frec|uenl!y slightly infil-
trated with serum. Induration, the result of in-
flammatory action, admits of resolution, and entirely
disappears, sonietimes in consequence of a natural
flux or evacuation, of active exercise, llie return of
accustomed discharges, or pregnancy. Thus the
menstrual flux sonietimes dissipates inflam.matory
induration of the mamma;, or of the neck of the
uterus.

17. B. The Jihrous prodvcticn generally ap-
pears in the form of a rounded body, implanted,
but isolated, in the proper structure of the organ,
and adhering to it merely by means of laminated
tissue. Upon dividing the structure, it grates
under the scalpel ; and it sometimes presents
dilated vessels, which are never observed in
Scirrhous masses ; moreover, it occasions little or
no pain, and never passes into the cancerous
state.

18. C. Compared with tnherciilar or lardaceovs
])roductions, sciriho-cani'er offers remarkable dif-
ferences : — 1st, 'I his latter is never found isolated
in the cellular tissue, or in the parenchyma of
oigans, in the form of granulations, or of small
lounded tumours, as the tubercular formations
are; nor in largely diffused masses, as the lard-
aceous substance: 2d, It is never tnclose<l in a
cjsi : 3d, It doc-^ not gre;'.tly increase the volume
of the part it affects ; sometimes the part is even

CANCER — CANci:nou

diiiiinished, but much more dense : 4th, It is not
;;useei)tible of the same kind of soi'tening as the
tubercular and hii-diiceous productions ; but rather
of a peculiar rarefaction, pa-;sing into a peculiar
form of fungus, followed by the developement of
blood-vessels: 5lli, Its vital properties are ex-
cited, and its sensil)ility becomes exalted, as the
disease advances, — circumstances which are never
observed in connection with these productions.

19. D. Cancerous ulceration is characterised
by a jagged, thick, soft edge, which is turned
outwards. The surface of the ulcer is greyish, or
greyish brown, sometimes livid brown, elevated
into loose, fungous vegetations, discharging a
foetid, corroding sanies or ichor, and bleeding
slightly upon irritation. — a. Chronic injiammatorij
ulcers differ from the former in the absence of a
fuelid corroding ichor ; in the hardness of their
margin, which turns inwards; and in the reddish
and more healthy appearance of their bottoms,
which in cancer is colourless, or a livid brown,
hard, irregular, fungous, sometimes with cauliform
excrescences, and extremely offensive. — b. , Local
tutnours sometimes appear, particularly on the
tongue, originating in irritation, and exasperated
by the continuance of this cause. These usually
commence with a small pimple or wart, becoming
more and more hard and u'ritable as they in-
crease, until they assume a scirrhus-like indura-
tion. They seldom endanger the constitution,
yet appear sometimes to assume a malignant
character. (JNIr. Earle, in Tram, of Med. Chir.
Soc. vol. xii. art. 22.)

20. E. As soon as the carcinomatous change
takes place in the scirrhous mass, the disease in-
volves adjoining ])arts, anil tlie system generally.
The local suffering is more fully develo;:ed, and
the vital actions of the part are changed greatly
from the healthy course. The sensibility is mor-
bidly augmented in short paroxysms ; the pain
being violent, and what is usually called lan-
ci)iating or stinging during the exacerbations, but
olten slight, or almost altogether absent in the
intervals. If the surface be exposed, the pain is
burning, and the part is always sore. As the dis-
ease advances, and particularly as the ulceration
proceeds, the paroxysms of lancinating and burn-
ing pains increase in violence, and the remissions
become more impeifect, and of shorter durati(m.
The cancerous sanies is generally very fluid ; but
its api)earance varies with tlie treatment, the
situation of the disease, and with the diet of the
patient It is generally of a greyish white, or red-
dish grey; it slightly effervesces with sulphuric
acid, and turns syrup of violets to green,

21. F. The extension and contamination of the
system characterising cancerous ulceration appear
to be owing, 1st, to the corroding influence of the
secretion on the parts with which it is in contact ;
2d, to the absorption of a portion of the morbid
secretion by the lymphatic vessels : this is evinced
by the swelling and affection of the glands in the
vicinity of the primary disease. ISut the affection
of the glands may not be altojether owing to the
absorption of the morbid matter, but partly to the
irritation of the lymphatic vessels occasioned by
the disease of the part in which they originate :
and, 3d, to the absorbing function of the veins,
according to the researches of JMayer, ]\I.4gen-
DiE, TiEUEMANN, GiMEi.iN, &c. Tiicse different
sources of contamination teem more than sufficient

Cachexia — Causes of. 285

to account for the general cancerous cachexia
characterisino the advanced stages of the disease,

22. G. The characters of this cancerous
cachexia are, emaciation ; softness and flaccidity
of the soft solids; oedema of the extremities;
hectic fever ; a peculiar change of the com-
plexion and colour of the whole surface of the
body, which become of a pale leaden, or pale
straw colour, or waxy hue ; and general depra-
vation of the functions. This state of cachexia
increases with the progress of the disease, and aug-
ments at the same time the primary local change.
It is rapidly developed and increased when the
scirrhous mass ulcerates, when also carcinomatous
tumours frequently manifest themselves in various
paitsof the body. Ultimately the circulating fluid
IS deficient in quantity, and is poor and morbid ;
and the vital cohesion of the soft solids, and even
of the bones, is diminished.

23. IV. Causes. — A. Fredisiiosing. — Scirrhus,
like scrofula, is undoubtedly an hereditary malady.
Instances are numerous of several individuals in
the same family having been affected by it. It
is almost altogether confined to persons advanced
in life. Cases of the disease are very rare before
the age of thirty. Sir A. Coopeii met with it
only twice previously to this age. Mr. Wardrop
has seen one instance of it in the skin of a girl of
twelve years. Females, owing to the liability of
their appropriate organs to be attacked, are more
subject to it than males; especially those who
have not borne children, the disease appearing in
them upon the cessation of the catamenia. It
seems commonly to result from an original or
acquired diathesis, existing previously to the de-
velopement of morbid structure, and very often
connected with the lymphatic temperament.
MM. Breschet and Feurus found 23 instances
of this temperament prominently marked, out of
44 cases of the disease. Anxiety and distress of
mind, and all the depressing passions, are most
disposing causes, particularly to cancer of the
breast. An inactive state of the part for a con-
siderable time [ireviously yn poor, unwholesome
iliet ; laborious and exhausting occupations, and
an unhealthy locality ; also dispose to it.

24. B. It is generally excited by blows and ex-
ternal injuries; by repeated or continued irri-
tation; the abuse of spirituous liqnors ; and by
low and poor diet. It is not liable to be propa-
gated by contagion ; the experiments of MM.
Alibert, Biett, and Dupuythen, having shown
that the matter dischart^ed from a cancerous ulcer
cannot produce the disease in another person.
Although irritating agents of any description may
give occasion to its appearance, yet there must
have previously existed a cancerous diathesis, or
constitutional disposition, in which it almost always
orijiinates.

25. C. The proximate cause of this dreadful dis-
ease is extiemely obscure ; and opinions respecting
it have consequently been numerous. Sch.i.ffer
and Gamet consider it to be caused by a singular
depravation of the nervous fluid. Dr. Adams and
Dr. Baron impute it to the existence of an hy-
datiform body, which they call the h^datis car-
ciiumiatosa ; and Mr. Caumichael, to a body en-
joying an independent state of existence developed
in those parts of the frame, the vitality of which
is enfeebltd, and the organised niaiter of which be-
gins to be decomposed. Me supposes that, at first,

286 CANCER —

'•his constituent of cancer occupies but a minute
spot, consist* of a substance nearly similar to car-
tilage ; and that it afterwards extends itself in the
form of radiations, resembling ligaments formed
by thickened cellular tissue. These opinions,
which are not essentially different from each other,
have been completely refuted by Burns, Cleri,
and HiMLY. According to JM. Broissais, scir-
rho-cancer is the result of an intlamniatory or
sub-inHammatory state of the vessels (Examen des
Doctrines Med. t. i. prop. 93 — 95.) ; and the
opinions of MM. Begin, Brfsciiet, and Fkrrus
(Did. de Med. t. iv. p. 133.), differ but little from
that of jM. Bnot'ssAis. They impute the disease
to irritation of an inflammatory nature, occasion-
ing the secretion of a coagulable lymph that be-
comes condensed into a scirrhous substance, which
may remain stationary for a longer or shorter
period, but which sooner or later undergoes a
secondary inflammatory process, and experiences
softening and disorganisation, with various other
changes, as these processes proceed. 'J"o this
doctrine of the modern French pathologists it may
be objected, that scirrhus furni-hes no sign, local
or general, of inflammation, and yet it goes on
increasing ; and if it can increase rapidly without
inflammation, may it not also originate independ-
ently of this cause ? Where, therefore, neither the
local appearances, nor the u<nal consequences,
nor the constitutional symptoms, of inflammation
can be perceived, ought we to impute the disea'^e
to this state of vascular action? The inference is
obvious ; but it is only one of many arguments,
which, if they were not superfluous, might be ad-
duced against the doctrine.

26. According to M. Andral, cancer is not
a specific alteration, but a state of disease arising
from lesions of nutrition and secretion, which have
reached the period of their termination in ulcera-
tion; the ulcei'thus arising, constantly increasing
either in depth or extent of surface, without any dis-
position to cicatrisation. Thus, 1\]. Andral consi-
ders cancer in a generic acceptation, and comprises
under it the ulcerative process in various species
of disease of a constitutional origin and malignant
nature, which, although always considered as
closely allied, in their origin, nature, and ten-
dency, to scirrhus, have usually bi en viewed as
distinct maladies. This opinion is more in accord-
ance with the wide signification of the term cancer,
in the writings of French pathologists, hut is very
deficient in precision and apjjlicabrlity ; inasmuch
as it embraces the advanced states only of several
organic changes, which, in their earlier periods
especially, are very di>irnct fiom one another —
distinct in c.iu^e-;, origin, the structures they prin-
cipally attack, atid in their appearances and pro-
perties. 1 have, therefore, adopted the more
accurate views of Briiisli pathologists respecting
this disease, which 1 consider in relation to lis
predisposing and exciiing causes, to the states of
the system in which it occurs, to iis IochI rrppear-
ances, and constitutional effects, to the results of
treatment, and to the ultimate changes produced
in the blood, and in the various structures, as
essenliiiUt) depending ujion a weakened and other-
wise worliid niale of the si/stem f^enevully ; and
arising from drjiramtion of the i ital conditions nf
the part njf'fcled, whereby its nulriiion, nervous
semihililii, and secretinf;; fuiiclioii, heroine speciji-
callij changed, and all the Jiuids and solids ulli-
mately contaminated.

Treatment of.

27. V. Treatment. —• The conclusion now
drawn respecting the nature and morbid relations
of scirrho-cancer must render very apparent the
futility of various measures which have been em-
ployed to remove it. Some writers have too ex-
clusively viewed the disease as local ; and thus,
even in its advanced stages, resorted to most
dangerous and painful operations to extirpate an
evil, which, instead of being local, proceeds from
the morbid state of the system generally, and
which all depressing causes (the surgical opera-
tion itself being one) rapidly increase, disposing
not oidy to its extension in its primary seat, but
also to its appearance in new situations and more
vitiil organs. The means of cure, therefore, should
have especial reference to the state of the con-
stitution favouring its developement and progress ;
for, when the malady is advanced, local measures
can, at the best, only be palliative, and are there-
fore subsidiary to judiciously devised means em-
ployed internally, and assisted by suitable diet
and regimen.

28. Before I proceed to state the indications
which should guide the treatment of this disease,
and the medicines which seem best calculated to
fulfil them, as far as this is possible, 1 will take
a brief view of the means which have been recom-
mended or tried by preceding writers. The real
importance of this subject to the physician will be
the more obvious, when he reflects, that cancerous
diseases are often — indeed most legitimately on
all occasions — within his province, more parti-
cularly when they invade, as they frequently do,
internal orgirns ; and that the life of the patient
may be greatly prolonged, and his sufferings much
alleviated, by judicious medical treatment.

29. A, At tlie commencement of the scirrhons stage,
various means have been employed, and sometimes
with some advantage, according to the showing of
those who employed them. Coniiim has, upon the
whole, found the greatest number of supporters ;
and 1 think that, when it has been combined
with the alkaline tonic and stomachic pi'epara-
tions, it has been often of considerable benefit.
This seems to be nearly the opinion of several
writers, and amongst others, of GEs^'ER (Beohacht.

b. i. p. 213., iii. p. 242.), Giuard, Hufeland
(Journ. der Fruct. Heilk. h. ix. 3 St. p. 86.),
Hahnemann (in Ihid. b. ii. p. 473.), and Thile-
Nius (Med. vnd Cliir. Bemerk. p. 100.). Elec-
tricity and Galvanism have been employed by
Brisbane (Select Cases, &;c. p. 36.) and Wal-
tiier ( Ueber die Ther. hid. der Gulc. Oper. iji;c.

c. 12.) ; the chloride of barium, by Hi'eeland ;
antimoniaLs, by Rowley and Dowmann ; aconi-
tum, bv GriEDiNO ; drgiialis, hy Mayer (Bich-
ter's Chirtir. Biid. b. v. p. 531.) ; laur-el-water,
by Tiin.EMus ; mercury, paiticularlv the bichlo-
ride, by RiivsCH, Thilenius, and Harris; hy-
drochlorale of ammonia, by Justamond; bella-
donnrr, by Gataker ; and the niezereon, by Home
(Clin. Kiper. and ///.sf. p. 428.), with more or
less benefit, chiefly of a temporary kind in those
cases which were obviously scirr-hous, and with
permanent service in those which were only sup-
posed to be of this description.

30. B. In the more Jnllu developed and less
dovhtfid stales of the disease, as well as in its
earliest stage, a number of mcdrcines have been
reconnnended, and for a while have obtained .some
credit, which few of them have long retained.
The great majority, however, of them have been

brought forward ratlier as palliatives, and with
the view of keeping the disease in check, than as
possessing the power of curing it; yet some have
been exhibited with more sanguine expectations,
particularly arsenic, coniuni, hyoscyanius, and
belladonna. — a. That conium is productive of bene-
fit, when judiciously combined with other reme-
dies, is manifest, notwithstanding the contradic-
tory evidence respecting it. While we find
Stokhck {Lib. cle Cicut. Vind. 1761, 8vo.), Fo-
THERGiLL (Works, vol. ii. p. 47.), Hamilton,
Fhancke (-De Cancro. len. 1778.), Nicolson
(Med. Obs. and Enquir. vol. iv. n. 31.), Quaiun
(De CiC!if((, cl). 4,5.), Fearon, Bell (On Ulrers,
pt. ii. sect. 8.), Gruelmann (De Usu Ciiutic,
hfc. Goet. 1785.), Renard (Journ. de Med.
t. xxiii, p. 41].), ScH.EFFER, and several other
writers, in favour of it, we observe Siebold (Chir.
Tugeb, n. 74.), Lange, Hill (Erf. Med. Com-
ment, vol. i. p. 140.), Akenside (Trans, of Col. of
I'hvs. vol. i. n. 6.), OBEnTEVFFER (Hufeland's
Journ. b. ix. st. 3. p. 81.), Schneider (Chirurg.
Gcsch. h. iv. n. 19.), and Burns, expressing opi-
nions as to either its little efficacy, or its entire
want of effect. This discrepancy may be ac-
counted for upon the supposition of want of virtue
in the preparations p'-escribed ; the extract gene-
rally losing the virtues of the plant during the
modes of preparing it formerly in use : and I
find, upon referring to most of the authors now
quoted, and to others not referred to, that the ex-
tract and decoction were usually employed by
those who found it productive of no benefit ;
whilst the powdered leaves, the expressed juice
of the plant, or an infusion of it, had been pre-
ferred by those who have expressed themselves
in favour of it. I have prescribed the inspissated
juice and powdered leaves of this plant, in several
cases of internal scirrho- cancer, in combination
with the alkalies and tonics, and have always
found them much more beneficial when associated
with it.

31. b. Belladonna was first exhibited by Alberti
(De Bellad. taniftium Specif, in Cancro, S^'c. Halae,
1739.), who highly praised it in the occult stage
of the disea-e. it was alterw^rds recomniended
by Lambergen (Mailer's Disp. Pract. ii. n. 41.),
Bellot, Lentin (Beobacht. S)C. n. 2. and 3.),
Amoureux (Journ. de Med. t. xiii. p. 47.), Cam-
PERDON (Ibid. t. Iv. p. 342. 423—502.), Sul-
ZER (in Ibid. t. xxiv. p. 68.), and by Grandvil-
liers (Ibid. t. xvi. p. 449.) ; and declared of little
use by ZiMMERMANN and De Haen (Rat. Med.
pt. ii. p. 37.). I believe, however, that some
advantage will be procured from its internal
and external use, particularly as a palliative,
and when combined with medicines which are
calculated to support the energies of life, and
improve the secreting and digestive functions. A
similar opinion may be offered respectmg sti-amo-
Ilium and hyosaiamus.

32. c. There is, perhaps, no medicine which
has been so commonly prescribed in this malady
as arsenic. It foruis the base of the several secret
remedies, internal as well as external, employed
by empirics; and has been very generally used
by them as an escharotic, sometimes with very
injurious effects, from being absorbed largely into
the system. There can be no doubt, however,
of its beneficial influence, in many cases, when
cautiously prescribed, and judiciously combined

CANCER — Treatment of, 287

with other medicines ; but chiefly as a most ener-
getic tonic and excitant of the capillary vessels,
and powerful detergent in the ulcerative stage of
the disease. Justamond prescribed it both inter-
nally and externally, with opium and various
other medicines; Stark (Archiv.f. d. Geburtsh.
b. ii. p. 673.), Rush (I'.din. Med. Comment.
vol. xi. p. 312.), and Odhelius, state that they
have found it cure incipient cancer, when applied
in solution to the part; Collenbusch (in Hufe-
land's Journ. d. Pract. Arzn. (Sfc, b. iii. p. 103.),
(bund it beneficial when employed externally,
tonic extracts having bten given internally at
the same time: Fischer (in Richter's Chir,
Bibliog, b. viii. p. 76.), AIichaelis (in Ibid. h. v.
p. 132.), and Reusni.r, prescribed it in the form
of the ponder of Guy* (composed of arsenic,
sulphur, ranunculus sylvest., 6ic.), with marked
benefit; Salmade (Mem, de la Soc. d'Emulat.
t. i. p. 152.) cured a case with the ponder of
Rousselot, the twenty-fifth part of which, he
says, consists of arsenic; Balascon de Tarare
gave it with the expressed juice of the solanum,
and HoRNUNG with serpentary and soot. This
evidence, however, in its favour, is not without
powerful Opposition. Fabricius Hildanus (Ce«t.
vi. obs. 81.) says, that arsenic was introduced
into practice by a monk named Theodoric, in
the tenth or eleventh century (having •probably
been made acquainted with it in the East), and
details cases in which he considered it detiimental.
A similar opinion has been entertained of it by
Schneider, Thilemus (Med. und Chir. Bemerk.
p. 101.), Acrel, Murray (Med. Pr. Bibl. b. iii.
p. 485.), Adams, Oberteuffer (Stark's N. Ar-
chiv, b. iv. p. 673.), and Delius. IMr. Hill.
however, expresses a very favourable opinion as
to the effects of this mineral, and states that it
will retard the progress of the true scirrhous
tumour, in the great majority of eases, and often
prevent it from becoming cancer ( Erf. Med. and
Surg. Journ. vol. vi. p. 58.). 1 believe that,
when this medicine is cautiously employed, both
internally and externally, -in conjuncnon with
narcotics and alkalies, or with iodine, or otherwise
judiciously combined, Mr. Hill's opinion in its
favour is not much too highly coloured.

33. rf. The preparations of mercurij are always
injurious in this disease, when exhibrted in any
other manner than as an alterative, and, externallv,
as an astringent and stimulating wash. The bi-
chloride in minute doses internally, with the hy-
drochlurate of ammonia, or the compound sarsapa-
rilla decoction, or with the tinctures of cinchona,
yuaiacum, \c., is often of service, at least in re-
tarding the progress of its early stage ; and when
the disease has advanced to ulceration, the external
use ot the bichloride, with the hydrochlorate of am-
monia, lime vvater, &c. may occasionally be of some
service. Reidlin (Cur. Med. Milieu, n. 408.)
states, that the preparations of this mineral are
always injurious when productive of salivation,
or the accuracy of this opinion, there can be no
doubt. Prescribed, however, as now recom-
mended, it has received the approbation of Mose-
ley, Gooch, Gmelin (Method. Cancrum Sanandi,
Tub. 1756.), Hagen, Gataker, Chapi-is, BI'ch-
NER (De Med. Mercur. Usu in Caucro. Hal. 1755.),

* A secret remedy, recommended bv Richard Guy, in
a production, entitled Essmjs on Scirrhous Tumours and
Cancers, Svo. Lond. 1759.

288

CANCER — Tkf.atmint of.

Champem-e (Sat- le TialUm. dii Cancer. I'.ir.
an viii,), und by Sir A. Cooper {Lectures, in
Lancet, vol. iii. p. 190.)

34. e. The prejiarations of iron have beea lecom-
niendeil by JusTAMONuaiid De Mare ( Tnict. Med.
Chirurg. de Caacrn, l<;c. Vien. 8vo. 1767.), who
gave them variously combined, particularly with
liydrochlorate of ammonia, and in the state of
neutral salts. Mr. Carmichael strenuously ad-
vises the sub phosphate, combined with a little
pure fixed alkali. He prefers this preparation,
but occasionally also employs the carbi)nate, the
polassio-tartrate of iron, the phosphate and
oxyphosphate of the metal. If it occasion cos-
tiveness, he combines with it a little aloes; and
if it produce lieadach, fever, or full pulse, he
leaves it off, and gives four grains of camphor
every five hours. He prescribes it as follows;
directing exicrnally to ulcerated cancers, the
carbonates, phosphates, or arseniate of iron, made
into a thin paste witii water; and to occult can-
cer a lotion constantly applied, consisting of a
strong solution of some one of the sails of this
metal.

No. 85. li Sub-Fhnsph. Fcrrigr. xxx 9ij.; Potassae

vel. Soils Purae gr. iij v.; Extr. Aloes gr. iv. ; Pulv.

Glycyrrh. 9j. ; Albuiiiinis Ovi 4. s. ut fiant Pilulee xij.
Capiat binas, tertiii vel quarlis horis.

Besides these preparations, theyer?'( ammonio-chlo-
ridium i5 entitled to notice. It was consiilered
the best medicine that could be directed against
this disease by Dr. Denman {Observ. on the Cure
of Cancer, p. 77.).

35. f. The preparations of lead have also been
used, chiefly externally, when the disease has
advanced to ulceiation. Gesner (Beobach. b. v.
p. 141.) recommends the acetate in the form of
liniment with turpentine, and Schoenheyder
(.S'oc. Med. Hann. Coll. vol. i. n. 4.), advises the
continued application of lotions of this salt in a
decoction o( conium. It has also been used in
thin sheets constantly pressed upon the scirrhous
tumour. Of the various other remedies brought
forwards by authors at different periods, and stated
by them to have proved serviceable, I may briefly
notice the following: — Honsnus {Observ. 1. ix.
ob. 3.) prescribed internally, and externally, ml-
phur, with spirit of turpentine; Ruland {Cur.
Ampir. i, n. 1*2.), the balsamum auliihiiris ; and
various other writers, the oleum sulphuris (F.
21.). The sulphurels have al.-o been employed,
both internally and externally, either alone, or
with narcotics, and fometimes with benefit. Ga-
TAKI-.R {Ohser. on the Litem. Use of the Sotanum.
Lond. 1757.) used the solantim nigrum; and
Paulus yEoiN/i-. (1, iv. c. 25.), Okibasius (Synop.
1. vii. c. 13.), and Careue, the expressed juice
of the solanum dulcamara, externally; the
la>t-nained author exhibiting it internally at the
same time. Opium, as well as other narcotics,
is often necessary in order to alleviate the pa-
tient's sufl^erings, and with this view has chiefly
been employed. 1 believe, however, that, when
combined with suitable remedies, it is olherwise
productive of benefit. The volatile iim\f.ied al-
kalies have been exhibited by Barkkii (A'eic York
Med. liepos. vol. iv. n. 4.), AIautinet and 15ar-
hktie (Jouru. de Med. t. Ivi. p. 559.); anti-
moiiiuU, by Howi.ev and Tiieoen (liemerk. b. ii.
p. 08 ); haryles by Chawi'oud {Duncan's Med.
Comment, vol. xiv. p. 433.) ; cinchona, by IIom-
uuuo, ViEusstNS, and Plenk {Samml. von Beo-

liarht. i. n. 6.); the ex|)ressed juice of tne cheli-
doniuin and the sulphate of sine, by BEiiCiiEL-
MANN ; lime-water by Vogel {De Curat. Cancir,
per Aqnam Calcis Vivtt potam, tS'c. Goet. 1769.) ;
the orohanche Virginian 1, by Barton and Ben-
sell {Philad. Med. Journ.) ; an ointment with
the juice of the bardana and acetate of lead, by
Pehcv {Hufeland N. Annalen, i. p. 381.);
camphor, by several authors : the sedum acre, by
BucHoz and Quesnai; t^ie onopordum acanthium,
by Guelicke (De Onopordo Carcin. Aver. 6^c.
Fr. 1739.), Handel, Juncker, ^d Ross;
myrrh, by Nicolas {Hufeland N. Annalen.
i. p. 362.) ; fxed airs, by Beddoes, Percival,
{Essays, ii. p. 73.), Ingenhousz, and Peyriliie
{De Cancro, p. 75,); digitalis, by Richter
{Chirurg. Bibl. b. iv. p. 591.); the hydro-sul-
phurct of ammonia, by Burns; petroleum, by
Rammazzini and Pierce ; the rhododendron
chrysanthemum, by Pallas ; and aconitum, sur-
saparilla, guaiacum, the beccahunga, the phellan-
drium aquuticum, &;c. by various writers. All
these have been prescribed both internally and
externally, with little or no advantage, or with
very temporary benefit only.

36. g. Of the numerous external remedies re-
commended at various periods, the preparations
of arsenic and quicksilver ; charcoal and carrot
poultices; the mineral acids, particularly chlorine,
hydro-chloric, and chloric acids ; the chlorureis,
and many of the metallic salts; camphor, the bal-
sams, and the terebintliinate substances ; ammonia-
cum, galbanum, and myrrh ; and the greater pait
of the astringent, antiseptic, detergent, and sti-
mulating vegetable medicines, have obtained a
greater degree of reputation ; and, when some of
them are judiciously combined with one another,
and with narcotics, they are deserving of notice as
discutients in the early stage of the disease, and as
palliatives in its ulcerating state.

37. Frictions of the part were advised by Poi -
TEAu, and Young entertained sanguine expect-
ations of the result of pressure, — a practice which,
vei'y recently, has received the support of Reca-
MiER, and several French physicians. M. Joi-
BERT states, that he has found small local blood-
lettings, and the following pills, most serviceable
in the different stages of cancer. {Archives Gen.
vol. xvi. p. 282.)

No. 86. R Saponis Medic. 3 iv. ; Gum. Aramoniiui
3ij. ; Ext. Conii et Ext. Aconiti Panic. 3jss. ; Mas.'aj
Piliil. Kufi 3j. M. Coniunde bene simul, et divide in
Pilulas gr. V.

He directs two of these to be taken night and
morning, increasing the dose by an additional
one daily, until twelve, fifteen, or even twent} ,
are taken, morning and night. The rest of tliu
treatment consists in applying poultices of the
recent conium ; using deobstruent and solvent
beverages, a mild diet and regimen, and wearing
an i.ssue or seton in the arm or thigh. This plan
has likewise been advised by Dr. Lowassy, by
wiumi it was first practiced.

38. /(. Sir A. (^ooi-eu expresses himself very
strongly against low diet in ihisdi.sease, — a practice
which had been much insisted on by Mr. Pearson,
Dr. IjAmbk, and Hiifeland {Journal der Pract.
/l)Z)(e(7c. b.i. p. 289.). The opinion of Sir Astley
is certainly in accordance with accurate observ-
ation, and rational induction. This very eminent
surgeon slates, that he has seen most benefit
derived from Plum.mek's pill given at bed-time.

CANCER — Treatment.

289

and stomachic tonics in the day, consisting ciiiefly
of the bitter infus^ions, with ammonia, and the
carbonates of the alkalies. Some advantage was
also derived from a pill, consisting of half a grain
of stramonium, with two grains of camphor, given
twice or thrice a day.

39. Since the introduction of iodhie into prac-
tice, the preparations of it have been tried in the
different stages of cancer by several physicians.
l"he results of the trials which have been made of
this substance are certainly such as ought to war-
rant the use of it in the eai Iv states of the disease.
The cases recorded by Dr. Wagner (Rev. Med.
Juin, 1823), and by Wr. Hill, of (Chester, are
much in favour of it. I have been consulted in
two cases occurring in females between thirty and
forty, for what was considered, by the attending
practitioners, scirrhus mammiE, owing to the lan-
cinating and remitting pains, and the diseased
state of the nipple and axillary glands. They were
both put upon a course of iodine (F. 328, 329.) ;
with conium, and the solution of potash ; a light
nutritious diet, and strict attention to the state of
the uterine functions, were also observed. Perfect
recovery has taken place in both : but it appears
doubtful whether or not they were genuine cases
of scirrhus, notwithstanding the signs now al-
luded to were present. They had, however, with-
stood other means of care for a long time. The
treatment, in one of the cases, was chiefly con-
ducted by Mr. Faxon, according to the above
suggestions.

40. C. Conformably with the opinion stated
above (§ 26.). I conceive that the treatment of this
disease should be directed to the fulfilment of the
following intentions : — 1st, To supjiort the energies
of life, by exciting the digestive functions, and
the abdondnal secretions and excretions ; 2d, To
soothe the morbid sensibility of the part, and
promote the absorption of mo: bid depositions in
its tissues, by means of anodynes combined with
deobstruents and discutients ; and, 3d, To impart
vigour to the frame by suitable medicine, diet,
and regimen. The remedies which are calcu-
lated to fulfil the first indication, may be often
conjoined with those intended to accompiisii the
second and third ; and both internal and external
means may be simultaneously used, with those
views. The medicines already enumerated com-
prise neaily all that have been found of any ser-
vice in this distressing malady. But the advantage
to be derived from them will mainly depend upon
their combination and exhibition appropriately to
the circumstances of individual cases.

41. The preparations of iodine given in very
small and frequently repeated doses, with iron —
the iodide of iron — or with potass, and conium,
or opium, will be found amongst the best remedies
that can be used ; inasmuch as, when exhibited in
this manner, they are both tonic and deobstruent.
They may also be used externally in the form of
ointment; but one third of the propoition of
iodide of potassium to the ointment usually em-
ployed should be prescribed, and friction with it
ought to he of much longer continuance than
commonly directed. Either stramonium, conium,
opium, belladonna, hyoscyamns, or aconitum, may
be given in various forms in the intervals between
the exhibition of the iodine ; and be combined
with tonic infusions or decoctions, with the fixed
or volatile alkalies, or with camphor in doses of

Vol. I.

from two to six grains. They may also be tried
in conjunction with the preparations of arsenic, or
of iron, or llie chlorates or potash, soda, or lime,
and as external applications also, when the disease
has gone on to ulceration. In females, scirrho-
cancer is generally connected, at its commence-
ment, with disorder or the cessation of the men-
strual discharge. In such cases, the preparations
of iron with ammonia, or the fixed alkalies, and
aloes, are sometimes of service. I have observed
most advantage in these cases from frequent and
full doses of conium, in the form of powder, given
with the biborate of soda.

42. Tonic infusions, or decoctions, with liquor
animonije acetatis, or with the solution of potash,
or the carbonates of the alkalies, and extract of
conium, or the tincture of hyoscyamus ; the bi-
chloride of mercury in the compound tincture of
cinchona, or compound decoction of sarsaparilla ;
or small doses of blue pill, or hydrarg. cum creta,
with camphor, and either of the narcotic extracts;
the preparations of sulphur and the sulphurets;
the phosphates of iron, or this metal combined
with ammonia, and conium ; the sulphates of
quinine and zinc ; and the balsams and terebin-
thinates ; may severally be employed.

No. 87. R Decocti Cinchona; 3 j. ; Liq. Ammon. Acet.
5ij.; Liq. Amnion, ttl xx. ; Exti- Coiiii gr. vj. ; Tinct.
Capsici Annui|n|viij. M.'Fiat Haustus, ter die sumendus.

No. 88. I^ Potassii Sulphureti 3 J5S. ; Pulv. Fol. Bella-
doniise 9jss.; Saponis Castil. 3 j. ; Gum. Ammoniaci 3 j.;
Syrupi Simp. q. s. Simul contunde, et divide massam iu
Pilulas Ix. quarum capiat Ires ad qnatuor ter quotidid.

No. 89. R Infusi Antiiemidis 3jss.; Liq. Potassce
VI X.; I'inct. Hyoscyaini j ss. M. Fiat Haustus, ter die
capiendus.

No. 90. R Hydrarg. cum Creta pr. j. ; Caraphora rasa;
gr. iij.; Extr. Aconiti (vel Belladonnae, vel Stramonii)
gr. ss. ad gr. j.; Soda? Carbon, exsic. gr. viij.; Bals.
Peruviani q. s. ut fiaiit Pilula iij. mane nocteque sumeu-
dae.

No. 91. R Acidi Arseniosi gr. vj x.j Opii Puri gr. xij.

—XX.; Oxydi Zinci 5ss.; Butyr. Recent. 3j. ; Cer.ne
Flavje Liquet". 3 jss.; Longa triturat. misceantur exactiss.
et fiat Ungiientum pai ti alfecta; applicaniium. (Harless,
De Arstn. Usii in M,d. Norim. 1811.)

No. 92. R Extr. Coiiii mac, Balsami Periiv., aa 3 j. :
Plumbi Acet. 3j. ; Tinct. Belladonna; 111 xij.; Tinct
Opii Corap. (F. 729.) 3 j.; Ungueati Ceiaj 3 j. M. Fiat
Unguentum.

No 93. R Ferri Ammonio-chloridi 3 jss.; Extr. Conii,
3j.; Pulv. Capsici Annul 5ss.; Extr. Aconiti gr. iv.;
CainphoriE rasa; gr. xv. ; Extr. Aloes purif. 3j ; Syrup]
Simp. q. s. M. Contuniie bene simul, et diude in Pilulas
xlvii'. quarum capiat tres, ter, quaterve quotidie.

No. 94. R Herbas BeccabungtE contus. .3ij.; Pulv.
Capsici Annui 3 jss. : Aqua; Ferventis Oj. ; Maceraben^
et cola. Deiu adde Liq. colato Solut. .irsenici 5ij. (vel
Chlor. Calcis 3 jss.); Extr. Opii Aquos. 3j. U. Fiat
Lotio, pro parte affecfa.

No. 9.'). R Balsami Canad. 3jss. ; Oxydi Zinci 9 ij.
(vel Carb. Potassse exsic. 3 j.) ; Pulv. Folior : Conii 9 ij. ; ■
Pulv. Capsici 9jss. ; Pulv. Tragacantha; Comp. q. s. ut
fiat Massa Pilularis, qu.im divide in Pilulas xlviij. Capiat
tres, ter die; et augeatur dosis ad quatuor, quaterauo-
tidie. ^

43. D. Athough the malady obviously has »
constitutional origin, yet the propriety of extir-
pating the affected part, as soon as the true
scirrhous cliaractcr becomes manifest, may be
conceded. After this is accomplished, the consti-
tutional vice may be more successfully combated,
and the reappearance of the local disease more
probably prevented than at a later period. When,
however, the system exhibits any of the symptoms
of the cancerous cachexia, whether the adjoinini'-
glands be enlarged or not, nothing will be o-ained
by an operation ; but some advantage may stiil
accrue from judicious and energetic medical treat-
ment, particularly from tonics combined wiiii
anodynes, alteratives, and deobstrueals. Whilst
U

290

CATALEPSY — Pathology.

medical measures have often obtained the credit
they by no means deserved, from the circumstance
of local diseases mistaken for scirrhus having been
removed by them ; so I believe that surgical
operations have sometimes acquired reputation
from the same cause.

44. During the treatment of this malady at-
tention must be especially directed to the secre-
tions and evacuations. The bowels ougiit to be
kept freely open with deobstruent laxatives, com-
bined with tonics and vegetable bitters. The diet
should be nutritious, and easy of digestion. Pork,
in every state, ought to be avoided, as well as
other indigestible kinds of meat. Change of air,
and of scene, with agreeable amusements, serve
essentially in assisting the influence of a judici-
ously devised method of cure, and should, there-
fore, not be overlooked by the practitioner ; and
several of the tonic and deobstruent mineral
waters are of use, particularly those of Bath, Tun-
bridge, Buxton, Spa, Marienbad, &c.

BiBLioG. AND Refer. — Le Dran, Mem. de I'Acad.

Roy.deChiriirg. t.vii.p. 223 B.Peyrilke, On Cancerous

Diseases, translated from the Latin, witli Notes, &c.

Lond. 1777 M. Akenside, On Cancer, in Transac. of

Coll. of Physic. Lond. vol. i. p. 45 Johnson, Practical

Essay on Cancer. 8vo. Lond. 1810 Himly, in Hu/e/and's

Journ. der Prakt. Heilk. 18U9, par. xii. p. 126. — Uotne,
Observations on Cancer, &c. Lond. 1805. — Adams, On

Worljid Poisons, 2d edit. 1807 Howard, Pract. Obser-

vat. on Cancer, 8vo. Lond. 1811 Young, Cases of Can-
cer and Cancerous Tendency, vol. ii. Lond. 1816. — Rouzet,
Eecherches et Observations sur le C.mcer, 8vo. Paris,

1818 Baylc et Cayol, in Diet, des Sciences Med. t. iii.

p. bbh.— Wrnxcl, Ueber die Induration und das Geschwiir
an Indurirten Theilen, 8vo. Mainz. 1815. — Bauinann,
Ueber den Krebs, &c. 8vo. Leips. 1817. — Hill, in Edin.
Med. and Surg. Journ. No. Ixxxvii. p. 282. — If'afdrop,
in Introduction to Or. Baillie's Morbid Anatomy, vol. ii.
p. 36 — Scarpa, SuUo Scirro e sul Cancro Memorie, 4to.
1822. — Cruveilhier, Essai sur I'Anat. Patholog. t. i.
p. 127. — Veljieau, in Revue Medicate, t.'i. p. 217. 1825. —
La?nbe, On the Effects of a peculiar Regimen in Cancer-
ous Complaints. Lond. 1815.— Carmickael, On the Effects
of the Preparations of Iron upon Cancers, &c. 2d ed. 8vo.

Dub. 1809 Abernethy, Surgical Works, vol. ii. Lond.

1811 Rodman, On Cancer of the Breast, 8vo, Lond.

1815 C. Bell, On Carcinoma, in Trans, of Med-Chirurg.

Society, vol. xii. p. 21.'i. — A. Cooper, Lectures, in Lan-
cet, vol. ii. p. 5.59 — Breschet, et Ferriis, in Diet, de Med.
t. iv. p. 131. — Ullmann. in Encyclopad. Worterb. der

Med. Wissen. b. vi. p. 5.5!> Recamier, Sur le Traite-

ment du Cancer, &c. t. i. Paris, 1826 Begin, in Diet, de

Med. et Chirurg. Prat. t. iv. p. 42.5.

CARCINOiMA. See Cancer.
CARDIALGIA. See Indigestion.
CARDITIS. See Heart, hijiummation of, &c.

catalp:psy axd caialeptic" ecs-
tasy,

Ci.assif. 2. Class, Nervous Diseases ; 1.
Order, Comatose Affections (Cullen).
4. Class, Diseases of the Nervous Func-
tion ; 4. Order, Affecting the Sensoiial
Powers (Good). 11. Class, III. Ohdeu
* (Autlior, see Preface).

1. I. DtscniPTioN. — Catalepsy and Ecstasy,
although treated of by some writers as distinct
afTeclions, generailv present very nearly tlie same
pathological conditions, sis respects the presumed
stales of circulation in the brain, of vital energy,
and ol nervous influence ; manile-t similar moiiiid
relations and conijilicaiions, in their origin and
progress; are so far modified in their symptoms
as frequently to pass insen>^ibly into each other;
and ihereCon; require, accoidmg to such manifest-
ations, 11 liealmcnt in all respects the same. I'or
these reasons I shall consider thctn, in this article,
as varieties of the snuie sj)ecii's of disease ; and, if
nothing more be gained by thus connecting them,
repetition will be, at least, avoided.

i. Catalepsy — Trance (from KaTa\r)^ts,
the action of seizing, and that from kuto,-
Aap.§diw, I seize). Syn. KaTaA.7ji//i$, Greek.
Catalepsia, Cutalepsis, Cutoclius, Prehensio,
Coit^elatio, Auct. I. at. Cams Ecstusis, Cams
Cdlulepsia, Good. Entonia Catalepsis, Young.
Catalepsie, Fr. Die Slarrsucht, Katalepsis,
Oer. Catalepia, Ital. Trance.

2. Defin. — A sudden deprivation of sense, intel-
ligence, and voluntary motion, the patient retaining
the same position, during the paroxysm, in which he
was at the moment of attack, or in uliich he may he
placed during its continuance ; the pulse and re-
spiration being but little affected.

3. This disease is very rare ; so much so, that
its existence has been doubted by many writers,
who consider it to have been feigned. Its occa-
sional occurrence is, however, well ascertained.
1 have seen three cases of it in my own practice,
and been consulted by letter respecting a fourth.
I recollect, also, an undoubted example of it in
an hospital, the practice of which I attended when
a student. It presents no precise or undeviating
train of symptoms, but varies in many particulars ;
the phenomena noticed in the definition being
those most uniformly present. This varying cha-
racter of the disease, according to the description
given of it by authors, is owing to two circum-
stances;— 1st, to the modified state which it ac-
tually assumes, from the circumstances connected
with its origin ; and, 2dly, to certain of its phe-
nomena having been more particularly noticed by
some authors than by others, who have either
mentioned them incidentally, or entirely over-
looked them.

4. Symptoms. — This is an intermittent and
apyrexial disease, occurring in paroxysms of vari-
able duration ; and generally after very irregular
intervals. The seizure is occasionally announced
by premonitory symptoms, — by headach, mutabi-
lity of temper, yavi-ning, tinnitus aurium, vertigo,
palpitations, lassitude, pain or slight spasm of the
limbs or neck, confusion of mind, &c. ; but it is
commonly sudden, — the patient retaining the
same expression of the countenance, and posture
of the body, as at the moment of attack. The
eyes are fixed, are open or shut, the pupils usually
dilated, and imperfectly contractile from a strong
light ; and, from their unvarying expression, and
the unchanged attitude, the body has the appear-
ance of a statue. Any position, in which the head,
trunk, or limbs are placed, is retained without de-
viation ; the passive contractility of both the flexor
and extensor muscles being such as to admit of a
change as well as retention of the position during
the paroxysm.

5. After a very indefinite duration — sometimes
of only a few minutes, at others of several or even
many hours, but rarely of days — the patient is
reslored to consciousness. In a remarkable case,
however, detailed by Dr. Burrows, the fit lasted
miinydays. Restoration is usually instantaneous,
acrompariied with sighing, shuddering, or rigidity
of ])aits or the wliole of the body, and followed
by pain or confusion in the head, and a sense of
fatigue and lassitude. The patient, it is said, has
no recollection of what has passed during the fit:
and the same ideas, and, iiccording to some, even
the same sentences, which had been suspended by
the seizure, have l>een pursued, the moment of re-
covery. 1 n the cases, however, that occurred in my
practice, consciousness continued during the seizure'

CATALEPTIC ECSTASY — Pathology.

291

6. The countenance, during the paroxysm, is
sometimes little changed ; at other times, it is
paler than usual ; but it is more commonly
slightly suffused, and the pulsations of the caro-
tids more forcible than natural. The respiration
is variable, sometimes it is embarrassed ; the tem-
perature of the surface is also unequal ; being
generally depressed in the extremities, and in-
creased in the head, evincing an irregular distri-
bution of the circulation. The pulse is occa-
sionally very slow ; Sauvagf.s found it only 50 ;
but it is more commonly quick and small. The
senses are so entirely abolished, that the patient
may be pinched without feeling it ; and he cannot
hear the loudest noises. The state of the muscles
during the attack varies somewhat in different
cases. They are often slightly rigid, but not to the
extent of preventing the easy change of position of
the limbs ; and sometimes the position so perma-
nently retained is one which no person in health
could so long preserve. M. Geohget states, that
the muscles often present a degree of tetanic rigidity;
but this is only sometimes the case, particularly
when the disease is more nearly allied to Ecstasy.
In some cases, it would seem as if a partial state of
volition existed, of which the patient either had no
consciousness, or a very imperfect consciousness
at the time, and, consequently, no recollection of
the act subsequently, as in some states of sleep.

7. In the more complete seizures, sense, intel-
ligence, voluntary motion, and consciousness, are
entirely abolished ; but, in some instances, the
abolition is only partial ; the patient being con-
scious, but incapable of moving or speaking. This
imperfect form of the disease has very generally
received the appellation of catochus from nosolo-
gists ; and numerous instances of it are on record.
A very marked case, and nearly approaching to
fully formed catalepsy, is recorded in the Edin-
hurg Medical Commentaries, by Dr. Fitzpatrick;
and slighter grades of it have been met with as a
subordinate symptom of chronic nervous diseases,
particularly of the severe and obstinate forms of
hysteria. In a case, however, of well-marked cato-
chus, in a female, detailed by Dr. Lubbock, no
hysterical symptoms existed; and, instead of un-
usual susceptibility of the system having been
observed, in this and other cases which he h;id
met witli, more than common torpor was apparent.
M. Pftetin and others, who believe in animal
magnetism, conceive that sensation, instead of
being lost for the time, is concentrated towards
the epigastric region ; and that the intelligence, so
far from being altogether abolished, is exalied to a
degree to amount almost to prophecy. But these
opinions can only be applicable to ecstasy.

ii. Cataleptic Ecstasy. — Ecstasis, Ecstasy
(from iKra-air;, from £^i'o-tTjw). Svn. Exstuse,
Ft. Entziichnng, Bcgeisteriing, Ger. Estasi,
Ital. Ecstatic Trance.

8. Defin. Suspension nf consciousness of exter-
nal objects, and oj voluntary motion, arising Jtojn,
U7id attended tii), n high degree of mental excilemenl
and abstracted contemplation, tlie muscles continu-
ing more or less rigidly contracted, or only partially
relaxed.

9. Under the term ecstasy. Dr. Good has
describefl a variety of catalepsy, but little dif-
ferent from the usual appearance of that form of
seizure, instead of the particular modificaiion of
disease to which the name ecstasy has usually

been applied. This variety of cataleptic disorder
is generally induced by mental excitement and
sustained contemplation of some particular sub-
ject, most generally of religious topics, and of
those exciting the affections and passions. The
patient suddenly seems mentally struck, or carried
away from all external objects ; either standing or
sitting in a most excited and impassioned position,
with the eyes fixed and open ; and sometimes
uttering either the most enthusiastic and fervid
expressions, or the most earnest denunciations and
warnings, or the most absurd exclamations, with
the feeling or belief of their reality ; and total
abstraction from, or unconsciousness of, all sur-
rounding objects or persons.

10. This affection is variously modified. In
some cases it very nearly approaches to pure
catalepsy ; in others, to a sort of maniacal excite-
ment. Dr. CniSHOLM r.ecords an instance of this
latter state in a young female, in whom it alternated
with rnania ; and I was consulted by a practitioner
in the country respecting a most marked case oc-
curring in a religious young lady, where it was
evidently connected with, if not consisting of, an
exalted form of hysteria. During the attack, she
sung and composed long doggerel strains. ]\Iany
of the cases which have lately made so much
noise in this metroj)olis, under the idea of inspir-
ation with " unknown tongues," evidently belong
to this affection ; at least, such of them as have
not been feigned. The effects produced by the
practisers of animal magnetism, upon nervous
persons, sometimes appear allied to this affection.
Many of the Italian improvvisatori are possessed
of this faculty only whilst they are in a state of
ecstatic trance, similar to this disease. And few of
them enjoy good health, or consider their faculty
otherwise than a morbid one.

11. II. The Terminations or Cataleptic and
Ecstatic Seizures are generally either in health,
or in disease of the cerebral functions. They
may pass into mania, epilepsy, or confirmed in-
sanity. Dr. BuRROws's case, already alluded to,
was complicated with mania, following excited
and ungratified passions, and interruption of the
menses. Recovery, however, took place, and the
patient afterwards bore children. Dr. Gooch
met with a case which supervened on, and was
followed by, melancholia. J. Frank treated a
case of catalepsy, that terminated in mania, of
which the patient at last recovered ; and Beh-
rends details the history of a case complicated
with mania. Pinel records a ca.se of catalepsy
which terminated in apoplexy. Rostan states,
that he has observed a case in which ii flamma-
tion of the lungs was a.ssociated with it. In many
instances, these affections terminate, as they com-
mence, in most severe hysteria ; with which a
very large proportion of them are more or less
intimately allied. In one case, the subject of
which has been occa'-ion^illy under my care for
years, the disorder still recurs.

12. But little is known of their relation to
morbid states of the brain or viscera. Holier,
however, informs us, that he found the vessels of
the brain and cerebeliijin distended wiih black
blood, and slight extravasation in a case wl ich ter-
minated fatally. Lieutai'd and Ab Heers make
mention of fibiinous concretions for^i ed in the
longitudinal sinus, with disease of the lungs and
liver. According to the state of the countenance
U 2

292

CATALEPSY

temperature of the head, and action of the carotid
arteries, during the tit, it may be inferred that
active congestion, or an e(flax of blood, far beyond
what obtains in healtli, takes place to the brain, and
is instrumental in the production of the disease.

13. in. Diagnosis. — The practitioner must
not overlook the fact of all those affeciions being
frequently feigned, particularly by females, even
by those in good ciri'umstances, and when there
can be no end to serve by the imposture further
than to create interest in their behalf. Although
cataleptic and ecstatic seizures pass insensibly
into each other, and are in their nature obviously
very intimately related, yet their more extreme
and distinct forms are very different. In the
former affection, the patient resembles a statue, is
entirely deprived of voluntary motion, and is per-
fectly mute : in t!ie latter, the countenance is
animated and earnest ; the muscles are more or
less rigid ; the patient talks, exclaims, or eve i
sings with the utmost arlour; and the character
of the whole frame is that of the most; abstracted
and intense contemplative excitemeat ; conscious-
ness of all other subjects and ideas, except of
the particular subject by which the mind is ex-
cited, being abolished : but the consciousness is
often of a morbid or imaginative kind : the patient
conceiving, as in the instances adduced by Tissot,
that he has seen wonderful visions, and heard
singular revelations. Ecstasii may be confounded
with somnambaiism and reverie. The excited, and,
as it were, inspired appearance of the patient, in
the former affection, is sufficient to distinguish it
from the more passive character of the latter, in
both of which he resembles a peison half asleep,
or sleep-walking. The statue-like appearance and
muteness of the cataleptic are alone sufficient to
distinguish this disease from these latter affeciions.
(See § 4—6.)

14. Catalepsy may also be mistaken for as-
phyxia, syncope, apoplexy, and even for death
itself. The total suspension, however, of re-
spiration and circulation, the deep colour of the
lips and countenance, in asphyxia ; the flexi-
bility of the limbs, great paleness of the face, and
the scarcely perceptible performancij of the re-
spiratory and circulating functions, in syncope;
and the congestion of the head and face, the
stertorous breathing, relaxed and flexible limbs,
and the attendant paralysis, in apoplexy ; are suffi-
cient of themselves to distinguish them from any of
the modifications of the affection now under con-
sideration. It is possible, al^o, that a cataleptic
patient may be considered as being dead. Theie
are many instances on record, wliere persons in a
state of trance have narrowly escaped being buried
alivi' ; and there is even reason V) suppose that,
in countries where burial usually takes place
much sooner after dissolution than in this, such a
circumstance has actually occurred. JJut this
could nevei' have occurred, unless the respiration
and pulse had been suppressed, and the counte-
nance pale. The stethoscope may now possibly
prevent such an occurrence from taking place, by
detecting the feeble aciion of he heait, which can
never be altogether extinct in catalepsy. The .states
of the sphincters, and of the cornea, ;ind the tem-
perature of the trunk of the body, will further serve
to prevent so distressing a nii^take from ever oo
curring, even inde[)cndeiitly of due reservation of
'.he body from inhumation, till indubitable proofs

—Treatment.

of death show themselves. As to discovery of
feigned seizures of these affections, the general
characters of the case, and the practitioner's ovvn
acumen, must be the chief guides.

15. IV. Progmosis. — These affections do not
appear to be attended with much danger. The
fully formed cataleptic seizure is, however, a seri-
ous disease. The cases already adduced in illus-
tration of its termination are sufficient to indicate
this. Fatal cases are, however, noticed by Homer,
DoDONCEus, and the authors just quoted, Aetius,
De i.a Tour, Fahr, and Sauvages, state that
they have seen it disappear after copious epistaxis,
and return of the menses.

16. V. Causes of Cataleptic Seizures. — A.
The predisposing causes are, whatever diminishes
vital power, and increases the susceptibility of the
nervous system, particularly the depressing pas-
sions, violent and continued sorrow, great anxiety,
unrequited affection, intense and sustained mental
applications, religious contemplations, exhaustion
from repeated miscarriages or severe confinements,
and excessive venereal indulgences and manustu-
pration. The hysterical, hypochondriacal, and
inelancholic temperaments, are evidently most dis-
posed to these attacks. They occur at all ages,
from six or seven years till old age ; but they are
very rare before puberty ; and are much more
frequent in females than in males,

17. B. These affections are most commonly ex-
cited by some violent mental impression ; by certain
of the above predisposing causes, when acting in-
tensely, particularly religious enthusiasm ; great
mental application, and the passion of love ; frights,
terror, or uncommon dread; by startling noises
and frightful sights ; the irritation of worms in the
prima via ; suppression of the menses, of eruptions
and accustomed discharges; injuries of the head
(Stark); concealed inental emotions, and un-
gratified passions ; and disturbance of the uterine
functions. Renard (^Hujeland's Journ, die Pr.
Heilk. June 1815) relates a case which was oc-
casioned by disease of the ovaria, Sprengel
states, that these seizures are induced by onanism.
J. Frank remarks, " nunquam catalepsin in Ju-
dseis observavi, ac onaniaj vitium rarius inter cos,
quam alias apud gentes inveni." (Prax. Med.
Univ. Pr(£cip. v. ii. p. 487.) 1 believe that many
cases in females are chiefly exalted or more severe
states of hysterical affection ; and more or less
connected with disorder of the nerves and circu-
lation in the uterus and ovaria,

18. VI. Treatment. — When we consider that
evidence of determination, or of active congestion,
of blood ill the head, has generally been furnished
in these affections, the propriety ol vascular deple-
tion will not be disputed. If the signs of general
or local plethora be very manifest, and if the
disease have any relation to suppression of the
menses, cupping between the shoulders, the ap-
])lication of a number of leeches to the nape of
the neck and behind the ears, stimulating pedi-
luvia, and bleeding from the feet, should be em-
ployed. If the temperature of the head, and the
action of the carotids be increased, the affasion of
cold water on the head, or the use of cold or eva-
porating lotions in this ([uaiter, whilst the lower
extremities arc plunged in warm water, will be of
service. In addition to the.ic, purgatives should
be given by the mouth, and rej>eated ; a constant,
but moderate action, being thereby exerted upon

CATARRH.

293

the bowels; and nnlispasmodic or turpentine
enemata s-hoiild be administered from time lo
time. (Ste F.130. 135.150. 152.) Tlie aloelic
purgatives ( F. 450 — 455. 470. 518) are parti-
cularly eligible, when the afl'eclion is connected
with irreeukirity of the menstrual evacuation.
DiEDiEu advises active hydragogue cathaitics.

19. The above means are equally applicable
to the paroxysm, and the interval, or supprtssion
of accustomed evacuations, in cases characterised
by plethora, or local determination of blood. If
resorted to in the fit, they may lie cotijoined with
various antispasmodics, as valerian, musk, ether,
assafoetida, camphor, ammonia, iScc, and volatile
stimuli may be occasionally held to the nostrils,
when the face is pale, and signs of determination
of blood to the head are wanting.

20. The utmost attention should be directed,
■luring the intervals, to the state of the uterine
organs. If signs of congestion or of irritation are
detected in this quarter, cupping on the loins, the
application of leeches (o the groins and tops of the
thighs, and the internal use of the boracie acid, or
of the bihorate of soda, combined with refriiie-
rants and anodynes, shouKl be resorted to. The
frequent association of these complaints with hys-
teria indicates the projiriety of having recourse to
a nearly similar treatment to that recommended
in it, and to the same appropriation of medicinal
means. Behrends attaches considerable im-
portance to the state of the stomach and prima via
in cataleptic seizures. There can be no doubt of
the functions of these organs being often impeded
or disordered, and of tiie propriety of restoring
them to a healthy state. This can be done only
by a judicious combination of tonic and aperient,
or o( denbstruent medicines.

21. When these affections have arisen, as they
not infrequently do, from depressing or exhaust-
ing causes, the judicious combination of tonics
with gentle aperients and antispasmodics, will be of
much service. The shower-bath, salt-water bath-
ing, change of air, tonic and deobstruent mineriil
waters, regular exercise, early rising, and mental
amusement, will be most advantageous in such
cases. Several of the causes of the disease are
both of an exhausting nature, as respects the con-
stitutional energies, and of an exciting kind, in
regard of the cerebral organs, particularly some
of those which induce the ecstatic form of seizure
(§§ 8 — 10.). In these, it will be necessary to dimi-
nish the local determination to the brain, which
is generally present, by the means indicated above
(§ 18.), whdst we soothe the nervous system,
and restore the digestive functions and the ener-
gies of the frame. To accomplish these ends, we
must resort to a combination or alternation of
tonics with anodynes, antispasmodics, and ape-
rients ( F. 453. 672.), keeping at the same time the
head cool, the secretions and evacuations free, the
mind amused and disengaged, the feet warm, and
the blood as regularly distributed throughout the
body as possible.

22. When the disease is complicated with
mania, melancholia, or epilepsy, similar means to
those already stated may be employed, appro-
priately to Ihe state of vascular excitement and
vital powers, and to the symptom^ more imme-
diately connected with the l)rain and the uterine
oigans. In several cases of ihese complications,
full and frequent doses of calomel will be of ser-

vice, and, under careful supervision, it may be
judicious to exhibit, in conjunction with anodyne,
nervine, or antispasmodic remedies, the nnUler
preparations of mercury, until the mouth is slightly
aflected. In all cases where the above means
fail of producing the expected effect, and parti-
cularly in these complications, issues, or setons,
perpetual blisters, or the tartarised antimonial
ointment, or moxas, slionld be directed to the
nape of the neck, the oc<;i|)ut, or behind the ears,
and perseveringly continued. In most instances,
whether simple or complicated, after the aflection
of the mouth by mercurials or the long-con-
tinue<l use of setons, &;c., the more tonic and
restorative means advised above should be pre-
scribed. Amongst the various antispasmodic
medicines recommended by authors on these affec-
tions, I may notice the different antispasmodic
gums, by Stark {Klin. Instit. p. 172.) ; the ammo-
nio-sulphate of copper, by Theussink {Sannnl.
Auserl. Abh.fur Piact. Acrzte, b. xvii. p. 279.) ;
electricity, by Ledra and Sigaud la Fond {De
I'Elect. Mtd. p. 396.); the cautery to the occi-
put, by Blankard {Collect. Med. Phps. cent. v.
No. 18.); and cinchona combined with valerian.
The different preparations of iron, and various
antispasmodics, have been recommended by Dr.
Lubbock, and exhibited by him in a case where,
however, they appeared of little service, most ad-
vantage having been derived from travelling, pure
air, and agreeable mental occupations. (Edin.
Med. and Surg. Jovrn. vol. i. p. 61.) During
the whole course of treatment, the strictest re-
ference ought to be had to the nature of the
predisposing and exciting causes, the habits and
practices of the patient, and lo his diet, and phy-
sical and moral regimen.

BiBLioG. ANu Refer. — Schoih, De Catalepsi. Jense,

1671 F. Hoffmann, De Affectu Catalept. raris. Fraiicf.

1692 Bucrhaave, Apliorismi, &c. § KlZG.—DiorJs, Diss.

sur la Moit. subite et la Catiilepsie. Paris, 1718.— G.fr.
TVcclel, Diss, de Cataleiisi Aftect. raris. Jen. 1711. — Hoe-
der. Diss. Raro Aflfict. Caialepsi. Erf. \",2\. — Reynell,
in Philos. Trans. 'Ho. \'i1. — Delins, Diatribe de Cata-
lepsi. Ed. Secun. Erl. 1754.— L. £. Hirschel, Gedan-
ken von dcr Starrsucht oder Catalepsie. Berl. 17<'9. —
Home, Principia Medicinar, ed. Amst. 177S, p- 232. — Gun-
dramm, Disser. de Catalepsi. Helms. 177G — Schilling,
Diss. ^gr. ex Amore Caralep. factum exhibens. Geiss.

177G Baumer, De Differ. Extas. et Catalep. Gciss.

177G. — Sfl?/!'«g<-«, Nosol. Mtthod, t. ii. p. 418. — FiUpa-
triclc, Kdin. Med. Comment, vol.x. p. 242. — Tissot, Traitc,
des Nerfs et de leurs Malad. &C. ch. 21. — G. I.. Fabri,
Tract. Pathol, de Catalepsi. Halge, 17SG. — //. Go son.
Diss, de Catalepsi. Gtitt. 1797. — 0«(«4-, De Catalepsi.
Marb. 1799._C. A. Illinaer, De Catalepsi. Frai.cf. ISi'O.
— W. F. Vreysig, Handworterliuch der Medic. Kinder,
b. iv. abth. 2. p. 360. — I'eielin, Elect. Animale prouvee
par le Decouv. des Pheiiom. Physiq. et Rlor. de la Cata-
lepsie, &c. Paris, 1808 — A'. Sprengel, Handbuch der
Pathol, b. iii. p. 225. — Dvfuur, in Journ. de Med. t. Ixx.
p. 418. — Savery, in Jouni. de Med. Contin. Dec. 1811.
p.AVJ.—Gilibert, in Actes de la Societ. de Montp. Ann. xiii.
No. vi. — l'ya7i et Lenormand, in Revue Medicale, t. iii.

p. 52. 1825 Haiidtiuick. Diss, de Ecstasi. Rost. 1775 —

Eber, in Halleri Kiblioth. Med. p.sr. ii. p. 131. — Bang, in

Act. Reg. Societ. Med. Havn. vol. i. p. 101 ije//, Fietier-

Ichre, b. iv. p. h72.— Ztringer, Theatrum Vita^ Humana?,
p. 223. — Sauvages, Nosol. Meth. 1. iii. p. 442.. et 1. iv.
p. 397. — J. F)«w/i-, Praxeos. Med. Universa Pia-cepta,

t. ii. p. 475 Robert, in Journ. de Med. Contin. Dec. 1811,

p. 415. — Sarlnndiire, Histoire d'un Calaleptique, &c.
Paris, 1816. — i). A. G. Richter, Die Specielle Therapi.-,
^c. hd. viii. p. 465. — Bouillavd, in Dici. de Med. et Cl.ir.

Pratiques, t. v. p. 15 T. Goebel, De Catalepsi. Berl.

8vo. 1818 T/I07HS071, Ryan's Med. and Surg. Journ.

No. 160. p. 102.— Aiinali Universali, &c. Oct. 1830. ^

CATARRH. — Simple Catarrh. Syn. Ch-
turrhus (from Karappew, defluo). Gravedo,
Corysa, Bronchos, Catnrrheuma, Fluxio, llhen-
U 3

294

CATARRH.— Causes

ma, Capiplenium, Auct. Var, Catai-rhiis
s»np/er, Richter. Phlegmhijmenilis (Irom
(pKeyjxa, riiucus, nnd vfxev, a membrane),
Hililenbrimd. Calairlie, Rhiime, Fluxion, Fr.
Ein Fluss, Schntipjeii, Katiirrh. Ger. Catarro,
Reiana, lliil. A Uejiuxion, a Cold.

Classif. 1. CUiss, Fevers; Order, Fluxes

(Cullen). 3. Class, SsitiiJuineou'! Function ;

2. Order, InfliimmHtions (G'wd). II.

Class, I. OrtDEH {Author, see Preface.)

1. Dkfin. Sneezing, vmtery discharge from the
nostrils; lurhrijmose stale of the eyes; slight
gruvdtive headuch, chillness, evening fever, some-
times accompanied ivith sore throat, hoarseness, and
cough.

F'ath. Defin. Specific irritation of the mucous
surface of the nostrils, extending to the frontal
sinuses and eyes, in one direction ; to the posterior
nares, fauces, and throat, in another ; and occa-
sionally also to the pharynx, (Esophagus, glottis,
and trachea, thus terminating in catarrhal bron-
chitis.

2. Although the most common of all diseases,
there are few which are less understood, or h&ve
called forth a greater diversity of opinion, than
catarrh. This uncertainty is chiefly owing to its
varying characters, arising from the limitation or
extension of its seat, the temperament and habit
of body of tlie patient, the causes which occii-
sion it, and the severity of the attack. If the
affection be not extended much beyond the
Schneiderian membrane, it very generally receives
the name of coryza, or catarrhal coryza ; if it be
seated in the frontal sinuses, it is called gravedo,
or catarrhal cephalalgia ; if in both these situ-
ations, a cold in tlie head : if the fauces be its
principal seat, catarrlial cynanche, or catarrhal
sore throat ; if the glottis and pharynx, catarrhal
cough and hoarsene-ss ; if it advance to the trachea
and bronchi, catarrhal bronchitis ; and if the eyes
be primarily affected, catarrhal opiithalmia. It
may thus be limited to any one of those situ-
ations, or be extended to two, or more, or even all
of them, according to the predisposition of the
parts and of the person affected. It may even
proceed furtiier, as to the air-passages on the
one hand, or to the oesophagus and digestive
organs on the other, after having subsided in, or
disappeared from, its primary seat ; and it may
even l)e co-existent in several, or even all of these
situations.

3. If we consider the origin and phenomena
of catarrlial affections, we shall observe many
characters warranting an analogy between them
and rheumatism on the one side, and erysipelas
on the other. Catarrh is a disorder proper to
mucous membranes, and is not limited to the
parts of this tissue above specified. The same
causes which occasion it in them, will sometimes,
although much less freijuently, excite it in other
parts of this system, accordmg to morbid predis-
position of the organs. Rheumatism is an affec-
tion of the fibrous, sero-(ibrous, and aponeurotic
structures, and generally proceeds from the same
or very similar causes to those which produce
catarrh ; they are both also often present at the
same time, and in the same person, and the epi-
demic jirevalence of both is not uncommon.
Erysipelas is an affection of the skin, also often
depotiding upon similar causes to those which
produce catarrh and rheumatism, particularly

those connected with the states of the atmosphere ;
and all of them are benefited more or loss by a
nearly similar treatment. Neither of these dis-
eases is the same as true inflammation, although
presenting more or less of the inflammatory cha-
racters, but also some which are proper to each.
On this account, therefore, should they be viewed,
even when apjiroaching the nearest to inflamma-
tion, ;is essentially specific diseases; possessing,
however, certain symptoms in comtTion wiih one
another, and with inflammation ; the same causes
acting on a certain number of individuals, pro-
ducing catarrh in many, rheumatism in some,
erysipelas in a few, and true inflammation in
others, according to the diathesis, habit of body,
stale of the abdominal functions, previous dis-
oider, &;c. of the affected.

4, I. Causes. — ^. The predisposing causes of
catarrh are referrible chiefly to original con-
formation and diathesis, and to previous disorder,
particularly as respects the state of the digestive
and assimilating organs. It most frequently
affects persons of a phlegmatic temperament,
relaxed habit of body, and delicate constitution,
or who are weakened by any cause, particularly
be morbidly increased secretions and discharges ;
also those with long necks and narrow chests, or
who indulge in warm apartments and beds, who
rise late, and take little exercise in the opeii air.
It is very common among the inhabitants of cold,
moist and changeable climates, more particu-
larly during spring and autumn, and in variable
or wet seasons ; and in persons whose digestive
organs are deranged, the functions of the liver
torpid, and whose biliary organs and alimentary
canal are loaded by morbid or accumulated
secretions.

5- B. The exciting causes of catarrh are most
commonly cold and moisture, or other states of
the air, which either are or are not perceptible to
the senses, but which impede or check the insen-
sible cutaneous perspiration, and change the func-
tions of those parts of the mucous surfaces most
obnoxious to their first impression. That there is
something in the air, often producing catarrh,
beyond what is perceived by our senses, is shown
by the very general or even epidemic preva-
lence of the affection during states of the weather
and of the air, in which nothing peculiar can be
observed. Its great frequency, particularly in
certain localities and seasons, has induced some
authors, amongst whom Dr. Maccullocii is pre-
eminent, to impute it to a diluted or generally
diffused malaria pioceeding from the usual sources
of this active agent of disease.

6. Change of locality, whilst it will often re-
move a cold, will also frequently occasion it,
especially in some constitutions; and a current of
air, particularly if it come directly on the face,
is a very common cause. The occurrence of
catarrh on travelling and visiting places at a dis-
tance has been attributed to malaria; and this
may very possibly be the case in many instances.
Whenever I have gone any distance into Essex,
I have returned with catarrh. It is very com-
monly believed by unprofessional persons, that
the disease is infectious ; from the circumstance
of its commencing in one member of a family,
and attacking others successively. This spread
of the ailment, however, may be in a great
measure owing to the diffusion of the same

cause in tlie atmosphere, whether it be a much
diluted or weak local nialiiria, or a more widely
spreading epidemic influence. Still 1 believe
that there are some grounds for ihe popular
belief. Alihough these causes wdl explain much
of what is imputed to infection ; still, it may,
either of itself occasion the disease, or, when
superadded to them, induce an attack in tho-^e
whom the states of the air, without such aid, might
have spared. When catarrh is occasioned by
local or generally dilTiised influences, it may not
only thereby assume an infectious character, but
really possess it ; thus countenancing the opmion
of Dr. CuLLEN, that the epidemic prevalence of
the disea-e only is infecliou-; ; yet, still I ques-
tion if this liinititiou be just. There can be no
doubt, however, that when it arises from e(ji-
demic, malarial, or infectious sources, it is usually
febrile and severe, and very prone to extend
along the aii-passages onthe one hand, and to
the digestive mucous surface on the other, par-
ticularly the former; while catarrh arising from
the more common causes of told and moisture
merely, in any one of the many ways in which
these causes are applied to, and affect, either the
whole or parts only of the frame, is more commonly
seated in the cephalic mucous surfaces, assuming
the form of cold in the head, coryza, or sore throat,
and quickly subsiding. It should not be overlooked,
also, that sudden change from a low to a high tem-
perature, or from a very dry to a very moist air;
and even the being more than commonly over-
heated, without any very apparent chill, or ex-
posure to cold in any form subsequently ; will
often produce catarrh. This is especially the
case, if the exposure to warmth be sudden, after
an impression of cold of some continuance, as
the coming into an overheated apartment out of
a cold and moist atmosphere, — tiie instantaneous
transition from a raw air of about 32° to a dry-
air of upwards of 70°.

7. II. Symptoms. — Owing to the circum-
stances already alluded to (§ 2.), catarrh ma-
nifests itself in various forms ; but most com-
monly in the following manner : — A. Its slighter
states. At a period generally varying from a
day or two, to six or seven, but occasionally
after even a shorter or longer time, from ex-
posure to the cause, this affection commences
with a sense of chilliness or coldness, lassi-
tude, and heaviness of the head, followed by
dryness, fulness or stuffing of the nasal pas-
sages, frequent sneezing, a dull pain and sense
of weight in the forehead, and stiffness, or rather
uneasiness, in the eyes. To these is inore or less
quickly added a distillation of a watery fluid
from the nose and eyes, with slight redness and
tumefaction of the mucous surfaces of these
parts. Occasionally the above symptoms appear
nearly simultaneously. The defluxion is gene-
rally somewhat acrid and saline, producing slight
excoriation of the parts over which it passes.
These phenomena constitute the grnvedo of Cel-
sus, and the coryza or defluxion of various au-
thors. They may be the only ailment, and not
proceed further, or they may have others rapidly
superadded to them, depending upon greater con-
stitutional disturbance, and the extension of the
affection to a larger surface. In the former
case, the general lassitude and chilliness ushering
in the complaint are often so slight as to be over-

CATARRH — Progress and Terminations. 295

looked ; but, in the latter case, and in the severer
states of the disease about to be noticed, they are
commonly more marked from the commencement,
and amount even to slight shiverings, lollowed by
while tongue, acceleration of pulse, and inciease
of heat in the evening. The posterior nares
and fauces, as well as the nose and eyes, are af-
fected ; and the patient complains of a sense of
roughness, or soiene^s of tiie throat ; loss of the
sense of smell ; sometimes of duiness of hearing,
with soreness or pain extendmg along the Eusta-
chian tube to the ear, with slight redness of
the fauces and mouth, hoarseness, frequent tick-
ling cough and efforts to excrete a mucous
fluid abundantly secreted from the posterior
nares, fauces, pharynx, and trachea ; and some-
times with a loss or suppression of voice, from
slight oedematous fulness about the glottis. To
the foregoing are very commonly added pains re-
sembling those of rheumatism in various parts of
the body, particularly about the neck, head, and
limbs, loss of appetite, costive bowels, and slight
thirst.

8.' B. Its severe forms. — The above symptoms
constitute the usual form of simple catarrh, which
frequently subsides in from three, to seven or
eight days ; the fluid secreted becoming gradually
less copious, more opaque and coloured, and,
at last, thick, small in quantity, and yellowish
white, or yellowish green ; all disorder quickly
disappearing. But in very many other instances,
as the coryza and watering of the eyes subside,
straitness, oppression, and uneasiness in the chest,
supervene ; with fits of coughing, and all the sym-
ptoms described- under the catarrhal form of
Bronchitis. In other cases, the symptoii.s indi-
cate, from the beginning, a more severe affection,
and a more evident constitutional disturbance, ap-
proaching more nearly to a state of inflammatory
irritation of the mucous membrane of the cephalic
passages, than the preceding form. In this case,
the coryza and watering of the eyes are attended
by much soreness and heat of the eyes, nostrils,
fauces, and throat ; by frecfuent sneezing ; and by
the secretion of a very copious, watery, and
colourless fluid, excoriating the parts over which
it passes. The fauces are led ; the tonsils some-
what inflamed and enlarged ; and there is a
short, dry, tickling cough. The fever, which, in
the slighter state of di-ease, was scarcely noticed,
is much more evident in this, particularly towards
evening; and is ushered in by chills, or shiv^rings,
the chills often continuing throughout, and pre-
ceding the evening febiile exacerbations ; catar-
rhal fever usually thus assuming a remittent type.
The pains felt in tlifferent parts of the body, and
the general la-situde, cough, anorexia, sluggish-
ness of the bowels, and thirst, are also greater in
this, than in the preceding state of the affection.

9. Throughout the disorder, the patient is un-
usually susceptible of the impression of cold, even
although the skin be warmer than natural. He
is also inordinately disposed to experience an
accession of, or to contract a fresh cold, upon the
slightest exposure to its causes, or even to the
least depression of temperature. Owing to this
circumstance, catarrhs are often very much pro-
longed, and either assume a chronic form, or
induce chronic bronchitis, and other serious af-
fections of the air-passages and lungs.

10. C. Progress and terminations. — This form
U 4

296

CATARRH — Complications of.

of catarrli, either disappears, as in the slighter
states of the disorder, witii a diminislied and
thirkened secretion, less frequent and less seevre
fits of coughing, and subsidence of fever, in from
four, to seven or nine days ; or it affects, in a
much shorter peiiod, — sometimes almost] from
its commencement, — tiie pharynx, trachea, and
large bronchi, producing slight or severe bron-
chitis; or it terminate^ in this disease, or in pneu-
monia, or even in pjeuriti?. But most commonly,
under proper mnnii<:enu nt, it is attended merely
by a moderate catarrhal affection of the trachea
and bronchi ; with fits of coughing, increased
mucous expectoration, &c., constituting catarrhal
bronchits. It also sometimes extends down the
cesopiiagus, and affects slightly the stomach, in-
ducing numerous dyspeptic symptoms ; and, in
persons with an irritable state of the digestive
tube, occasionally passing off at last vvilli m ucous
or serious diarrhoea.

11. III. Prognosis. — In general, catarrh is a
very slight ailment, and attended with no danger
as respects itself. But, in aged persons, in those
disposed to pectoral diseases, particularly those
who may have tubercles already formed in the
lungs, who have had haemoptysis, or who are
asthmatic, or have experienced attacks of bron-
chitis, pneumonia, or pleuritis, catarrhal affec-
tions rerjuire strict attention, as they very often
quickly produce, or terminate in, these maladies.
In many persons, also, they are very prone to
become chronic, either in the form of a chronic
coryza, with continued irritation, and slight red-
ness of the posterior nares and fauces, and an
abundant niuco-puriform discharge; or in some
one of the states of chronic bronchitis. In the
aged, and in tho-e of a pidegmatic temperament,
or lax habit of body, catarrh often passes into a
chronicbronchial flux, when it has been neglected,
or renewed by incautious exposures during the
treatment. Children of a lymphatic and flaccid
habit of body are very liable to catarrh in the
form of coriiza ; and in them it very frequently
assumes a chronic form ; the thick muco-purulent
secretion filling up the nares, and, in infants, pre-
venting them from taking the breast, and render-
ing them irritable, each atten)pt at sucking
disordering the pulmonary and ceiebral circula-
tion in such a manner as even to occasion
convulsions. In children also, the coryzn, when
allowed to become chronic, sometimes degenerates
into iizxiia, with ulceration.

12. IV. CoMi'i.icATioNS. — Catarrh very com-
moidy usiiers in the febrile exanthemata, particu-
larly measles ; and even accompanies them through
their course, especially in the form of bronchitis.
It is al.-o very liable to appear during convales-
cence from them. Its connection with rheunia-
tisni has .ilready been noticed (§ 3.), both dis-
orders evidently spriiiging liom tlie same causes.
Continued fevers, as well as some epidemic visit-
ations of fever, are not infre(]uent!y complicated
with catarrhal affections. The association of
catarrh with biliary and gastric derangements is
very common, sometimes in consequence of the
dispo-ition to be affeeled by its causes during
biliary disturbance, and occasionally owing to
the cirtuiusiance of simultaneous disorder of the
digestive, cephalic, and resj)iratory mucous sur-
faces, haying arisen from the impression of the
same exciting causes. These complications liave

especially characterised the various occurrences
of epidemic catarrh, which have been observed.
(See art. Influenza.)

13. V. The Nature of Cat.ii'..ii is deserving
of some notice. IMany pathciogisls, particularly
those of the modern Parisian school, — the fol-
lowers of Laennec and BnoussAi-, — consider it
as ordinary inflammation of the cephalic mucous
membranes, or part of this tissue which it usually
affects. Other pathologists, more especially
RiciiTER and Hildenbuand, view it, with stricter
propriety, as an inflammation of a specific kind.
I believe, although it very often terminates in
true inflammation when it extends to the bronchial
tubes, that it chiefly consists of a specific irritation
of that portion of the mucous surface primarily
affected by it, nearly allied to inflammation, and
soon followed by, or accompanied with, great in-
crease of the secreting functions of the part ; or,
in other words, that it is not pure inflammation,
but an irritation of a specific or peculiar kind,
attended by slightly increased vascularity, afflux
of the circulating fluids, and augmented secretion.
Since the lime that Van IIelmont ridiculed, in
his Catarrlii Jjeliramenta, the opinions then en-
tertained respecting catarrh, intpiiries into its
nature have been more rational, although, up to
the present time, ideas have still continued very
vague as to the extent of surface affected by it,
many even of modern writers comprising under
catarrh, not only bronchitis, but even all affec-
tion of mucous surfaces, attended with a copious
serous or sero-mucous discharge.

14. One of the most interesting questions con-
nected with this subject, and one which has been
agitaterl by J. P. Frank and others, is, whether
the detiuxion is a consequence of the suppression
of the cutaneous perspiration, arising out of the
irritation which the secretion retained in the cir-
culation produces upon the cephalic and pulmonic
mucous surfaces ; or of the specific irritation and
morbid imp)cSsioii of those parts by the exciting
causes of the disease. The former opinion was
very generally received by the followers of the
humoral pathology ; and the latter by IIofFMANN,
and subsequently by Cullen, Pinel, and other
disciples of his school. Pinel considered the
febrile phenomena merely as symptomatic of the
inflamed mucous membrane, discarding the plau-
sible opinion advanced by Eotal, that whatever
of inflammation exists is caused by the acrimony
of the catai'rhal discharge, and that the local
ailment is consecutive of the constitutional dis-
turbance,— a doctrine which is in strict accord-
ance with the description of the disease given by
RicHTEn, and with the more usual succession of
its phenomena. In some cases, however, it is
very diflncull to determine the priority of the
geneial disturbance, the local ailment being
ccjually early. Upon the whole, 1 believe it is
not pi'oved that tiie constitutional affection is the
consequence of the local, although the former is
generally increased in propoition to the severity
of the latter ; nor docs it appear that the de-
fluxion is caused by the suppression of the cuta-
neous perspiration, even granting that suppression
is actually produced, — a position by no means
eslabhslieil. 1 would thence itjfer that the causes
of catarrh affect primarily the organic nerves
snpjilying the surface principally disordered, and,
llirough them, the system generally ; and that,

CATARRH — TitEATMENT.

owing to this change, the secreting functions and
circulating actions of tlie part primarily or spe-
cifically impressed, are altered, and the disease
fully developed ; its chief modifications arising out
of the degree to which the conslituiionisl actions
are disturbed, of the extent of surface affected,
and of the grade of irritation produced in the
capillaries of the part.

15. VI. Treatment. — The treatment varies
much according to the symptoms and periods of
the disease. Immediately upon the approach of
catarrh, before febrile exacerbation has appeared,
and whilst ailment is limiied to the cejdialic
mucous surfaces, very oppnsite means to those
required when fever is present, or wiien the afi'ec-
tion has extended to the trachea, and threatens to
produce bronchitis, are generally most serviceable.
Under tiie former circumstances, a judicious ex-
hibition of stimulants of any kind, but especially
stimulating diaphoretics, will either cut short the
disorder, or render it much shorter and more mild ;
whilst, in the hitter state, particularly when any
pectoral symptoms have appeared, considerable
risk will be incurred in some constitutions, al-
thougii either little or none in others, of inducing
inflammatory action by the same measures.

IG. Early in the disease, therefore, and while
a copious defluxion has not come on, the patient
may inhale thiough the nostrils the vapour of
warm water, or of any emollient and anodyne
decoction or infusion ; if the ailment is no more
than a coryza, or cold in the head, febrile action
not having appeared, he may take, upon going to
bed, an active stimulating draught, consisting
chiefly of ammonia, camphor, spirit, aether, ni-
trici, &c., with or without a narcotic. Either of
the following will be used with advantage as long
as febrile action, or any acute affection of the
bronchi, has not appeared; —

No. W. R Spirit. jEther. Nit.3j.— 3iij. ; Tinct. Cam-

phoris Comp. 3j 3ij.; Miicilag. Acaciae 3ij.; Spirit.

Anisi 3j- — 3ij.; Liq. Amnion. Acet. 3ij.; Mist. Cam-
ptiorae 5j.; Syrupi Tolutani 3j. M. Fiat Haustus, liora
somni sumendiis.

No. 97- R CaraphorcE rasje, gr. iij. — vj. ; Animon.
Sesqui-carbon gr. vj. — x. ; Pulv. Ipec ic. gr. j. ; Extr.
Hyoscyami gr. vj. ; Conserv. Ros. q. s.ut tiat Bolus, li.s.s.

17. The above draught will often ai rest the dis-
ease, when given sufficiently early. In some cases
I have directed the bolus to be taken with it,
either the hyoscyamus or the tinct. camph. co.
being omitteil. On the following morning, a sto-
machic aperient may be taken ; but nothing more
is necessary, not even diluents, as, at this period,
they will have little further effect than to increase
the defluxion. When the pulse becomes acceler-
ated, and somewhat fuller or harder than natural,
with other signs of febrile action ; or when the
throat is more or less affected, and particularly
if there be irritation about the glottis and trachea ;
a different practice is required. Diluents will
now be of service, particularly in conjunction
with emollients, diai)lioretics, &c. Any of the
medicines of this description in the Apjiendix
(F. 238.244.), or those denominated pectoral (F.
389. 426.), will be of service ; or the following may
be used. Richteu states, that the first of these has
generally been emplo}ed by him early in catanh.

No. J^8. B Calomel gr. j.; Extr. Hyoscyami gr. ij.;
Gum. Acaciae Pulv., Sacchari Albi, aa gr. xv. Misce et
fiat Pulvis. Dispens. tales quatuor. Sumat ager tertia
quaque hora unum.

No. 99. H Mucilag. Acaciae 3 j. ; Mist. Camphora; et
Uist. Amygdal. Dulc. aa B^s.; Liquor. Ammon. Acet.

297

3 iij. ; Tinct. Camphorae Co., Spir. /Ether. Nit., Sa 3 ss. ;
Syrupi Tolutani 3 ss. M. Fiat Haustus, quarts vel quinta
quaque liora capiendus.

18. Whenever we deetn it requisite to act
moderately on the bowels, either in the course or
at the decline of the complaint, a full dose of the
flour of sulphur, either with, or without cream of
tartar, will be found to act most beneficially, both
on the catarrh and on the abdominal functions.
When febrile action becomes inore fully developed,
or if the disease assumes an inflammatory character,
with headach, flushed countenance, or hard cough,
a suitable quantity, either of the litjuor antimon.
potassio-tartratis, or, of the vinum ipecacuanha;,
may be added to the above draught ; and either
of the following given at bed-time : —

No. 100. IV Piilv. Ipecacuanhae gr. ij.; Hydrarg.
Chloridi gr. iij. ; Pulv. Opii Puri gr. j.; Mucilag. Acaciae
q. s. ut fiant Pilula; ij.

No 101. R Pulv. Jacobi Veri gr. iij.— v.; Hydrarg.
Chloridi gr. iij.; Opii Pmi gr. j. (vel Extr. Hyoscyami
gr. V.) j Syrupi q. s. M. Fiant Pilula? ij.

19. When ailment begins to subside, or when
it seems likely to degenerate into a chronic state,
with more or less affection of the bronchi, the
treatment recommended in Catarrhal bronchitis,
or in the slighter chronic states of the di.-ease,
should be prescribed. (See Bronchitis, § 69.)
HuFELAND recommends a decoction of the un-
roasted coffee- berries, or the cardims henedicLus,
in those cases. Joerdens advises the oleum cam-
phoratum (F. 449.) on sugar ; Lentiv, the oleum
terebinthin2B rubbed on the loins ; and Kortum,
camphor, with hydrochlorate of ammonia. The
decoction of Iceland moss, with ipecacuanha, or
spiritus £ether. nit. and syrup of poppies, may
also be used, or either of the following : —

No. 102. R Zinci Oxydi gr. j. (vel .Sulphatis gr. ss.) ;
Pulv. Ipecacuan. gr. ss. ; Extract Hyoscvami (vel Cor.ii)
gr. iij.; Extr. Glycyrrh. gr. ij. Fiant Pilulae ij. tor qua-
terve in die sumendse.

No. 103. R l^xtr. Papaveris Albi gr. iij. ; Mucilng. .Aca.
ciaeoj.; Tinct Camphorae Comp. 3 ss. ; Spirit. Anisi 3 j.;
Decocti Althaefe et Aq. Sambuci aa Ji ss. ; Spirit, .father.
Nit. Til XX.; Syrupi Tolutani 3 j. M. Fiat Haustus, tor
quaterve quotidie capiendus.

20. W^hen catarrh is cpnnected with biliary
disorder, or with accumulated sordes in the prima
via, an ipecacuanha or antimonial emetic at the
commencement of the treatment will often he of
much service ; especially when followed by a
dose of calomel and an aperient draught, or sto-
machic purgative, in order to evacuate whatever
morbid secretions or faecal matters may have been
collected. If it be complicated with 7-/(ei(Wiua'.sm,
calomel, coinbined with antimony and opium,
and subsequently with camphor, ipecacuanha, and
opium, will be found of service ; biliary collections,
&c. being carried off by the exhibition, every day
or alternate days, of a stomachic purgative. If
catarrh be accompanied with symptoms of debi-
lity, or with those of a nervous character, forming
what some German pathologists have termed
nervous catarrh, the liquor ammoniac acetatis,
with larger do-es of camphor than under the pre-
ceding circumstances, or with the spirit, ammon.
atom, or tinct. ammon. comp., or the -spirit, aetheris
sulphur, comp., and any of the anodynes in coin-
mon use, are appropriate medicines. When the
disease becomes chronic, change of air is most
beneficial. During the tieatment, the patient
should avoid exposures to atmospheric vicissitudes,
and partake only of light bland diet, observing
the injunctions laid down for the management of

298

CELLULAR TISSUE— Alterations of.

convalescence from bronchitis. (See. Bronchitis
and Imluenza.)

BiBLioG. AND Refer. — Ci»/sms, De Medicina, iv. p. 2.
37"i.- Satnl, Comment, de C;itarrho. Lu)»d. 1.5h5, p. lUO.
— Schneider. De Catarihis, llbri vi. 4to. Witeb. 1660.—
Uoljink. De Catarrho Nariiim. Jen. 16'.lO; et De Catarrho
ad Nares, ad Fauces, et Pulmones. Jense, 1672 — Junckcr,
De Congestionibus, viilgo Calarrhis i-t Rbeumatismis.
HalcB, 1748. —Chandler, Treatise on the Disease called a

Cold, 8vo. Lond. 1761 Stoll, Rat. Medendi, t. iii. p. 39-,

t. iv. p. 223. — Wallic/i, De Frequent! Catanhoruin e
Primis Viis Origuie. Gdtt 1777. — I P. Frai.k, De Cu-
rand. Morbis, lib. v. pars i. p. 108 — Kelson, On the Nature
and ('ure of Colds 8vo. Lond. 1797.— Cw/toz, lirst Lines
of the Pract. of Med., vol. ii. p. 83. 4th ed.—Hanrtmanii,
De iEti'ilog. Calarrhi, Abo. \802.—Korlum.m Hujeland
uiid Himly. Journ. der Pract. Heilk. July, 1810, p. 48. —
Hufeland. N. Annalen, b. i. p. 173. — Leiitin. Beytrage,
ii. observ. 16. — Jaerdcns, Htijeland's, Journal d. Pr. Arzn.

b. vi. p. 429 Parr, Med. Diet. vol. i. p. Hid. — Bichlcr.

Thara|iie Specielle, b. ii. p. 84. — Hildenbnnid, Institu-
ticnes Praciico-Medicae, t. iii. p. ih'i.—Dnges, Sur I'Etat.
Cntarrhal. Rev. Med. t. iii. p. 210. \%2h.—Macculloch. On
the Production and Propagation of Malaria, and the Dis-
eases occasioned bv it. 8vo. Lond. 1827.
CELLULAR TISSUE— Irs Diseases. Syn.
Tela ceUuiosa, Corpus cribrosum, Tela mucosa,
Auct. Var. Tissii CeUulahe, Fr. Ti^su Mu-
queux, Bordeu. Corps Cribletix, Fouquet. Re-
ticular Membrane, W. Hunter. FiUanentous
Tissue. Cellulo-Jilamentnus Substance.

Alterations of the. Classif. Special
Pathology. — Morbid Structui-es.

1. A. The quantity of the cellular tissue varies
greatly in different constitutions, a large proportion
of the soft solids consisting of this structure, par-
ticularly in persons of a lax fibre and rounded
fleshy form. It is relatively more abundant in
the female than in the male ; in the young than
in the aged ; in the sanguine, phlegmatic, or
lymphatic temperaments, than in the melan-
cholic ; and in those who are fair, than in the dark
complexioned and swarthy. ltma.y he diminished,
in parts, from pressure; or throughout the body,
from disease, or inanition. Long-continued and
laborious exertions will also apparently lessen it ;
or at least diminish its bulk, by causing the ab-
sorption of the serous and fatty matters deposited
in its areolae or interstices. It is remarkably in-
creased by full and rich living, and by indolence;
but its bulk is then evidently, in a great measure,
owing to the general fulness of its minute vessels,
and to the greater proportion of fluid contained
in its interstices. Partial increase of this ti'-sue
is also observed, but chiefly in consequence of
disease. It forms, in such cases, the basis of va-
rious morbid growths, particularly encysted, scro-
fulous, sarcomatous, and scirrhous tumours.

2. B. The consistence of the cellular tissue also
varies greatly. In some persons it is unusually lax
and extensible ; in others, it is uncommonly f/e/jse
and tenacious. The sli<;hter changes of consistence
are the result of original conformation, and of
age. It is usually more lax in females than
males, in the phlegmatic and lymphatic temper-
aments than in the melancholic antl bilious; and
in very young persons, than in those of mature or
advanced age. The state of vital energy also in-
fluences its consistence; for as the jiowers of
life are reduced by disease, &c. its cohesion is
proportionately lessened, and it becomes more lax
and inelastic. Changes of con-istence occurring
in parts are chiefly the consequences of inflamma-
tory action. Continued pressure has the effect
of condensing it, and changing it from a nearly
semifluid state, into a fibrou.^, lamcllutcd, and firm
structure.

3. C. Inflammation of this tissue gives rise to the
most varied and important changes, according to
the vital energies of the frame, the state of con-
stitution, and habit of body, the nature of the
exciting causes, and the intensity of the disease.
In a previously healthy state of the system, and
when the exciting cause is not of a septic or poi-
sonous nature, the inflammation is usually of the
phlogistic or phlegmonous character, and its ex-
tension is limited f)y the formation of coagulable
lymph around the centre of the part inflamed ;
and which, becoming condensed with the cellular
tissue exterior to it, forms a cyst for the enclosure
of the purulent matter which is usually formed
within the part, when the inflammation has pro-
ceeded to a certain height. (See Abscess, § 5.)

4. When the inflammation arises from septic
or poisonous animal secretions, or from the more
common causes of irritation, or of local injury
acting on an unhealthy habit of body, or during
unwholesome or epidemic states of the air, it as-
sumes a spreading or diffusive character. The
disease, however, may be spreading, without being
primarily diffusive; for it sometimes commences in
a point or circumscribed spot, as in phlegmonous
inflammation ; and from the influence of certain
causes, hereafter to be noticed, coagulable lymph
is not formed so as to limit its extent, as in that
form of the disea^^e, and it consequently spreads
more or less rapidly ; the part soon losing its vitality,
and the secretion from the affected vessels infiltrat-
ing and contaminating the portions adjoining it,
until extensive destruction and sphacelation of
this tissue takes place. The inflammation may, on
the other hand, owing to nearly the same causes,
attack, almost coetaneously, a considerable extent
of structure, and terminate either in the same
way, or jn a manner nearly resembling it. Spread-
ing inflammation of the cellular tissue is generally
the consequence of external exciting causes, par-
ticularly punctures, abrasions, wounds, fractures,
&c. acting upon a predisposed system, and more
commonly gives rise to a foul serous or sanious
secretion, and terminates in sphacelation or gan-
grene; whilst diff\isire inflammation is more
usually produced by internal causes, or such as
affect the nervous or constitutional powers pre-
vious'y to the development of the disease in the
cellular tissue; the secretion which is formed in
the part approaching more nearly than that of
the foregoing to a puriform matter, and extending
in various directions in the course of this structure,
under the integuments, &c. which it but little
afiPects. The former is often connected with hos-
pital gangrene, or is nearly allied to it, as well as
to various forms of foul spreading ulceration ; the
tatter is frequently an attendant upon erysipelas,
without, however, constituting any of the states
of that disease; and upon the inncnlation of ani-
mal poisons, as in the dissection of bodies recently
dead of diseases in which the blood and soft solids
are more or less vitiated. (See Cellular Tissuf,
— Diffusive Injiammation of.)

5. Cellular tissue is also often the seat of
chronic inflammation, generally in circumscribed
])arts, giving rise to cold or chronic abscess (sec
AnsCESS, § 19.) ; or to certain tnanifestions of
scrofulous di.seasc. In this state of inflammatory
action, gelatinous or albuminous fluids are com-
monly effused into the interstices of a greater or
less extent of this tissue ; imparting to it a swollen

CELLULAR TISSUE — Diffuse Inflammation of.

299

or hardened appearance ; as in rheumatism, goul,
imperfecily cured erysipelas, pelagia, elephantiasis,
and probably that peculiar affection denominated
the induration of the cellular tissue of new-boin
infants. Otto comprises also phlef^masia doltns
under the class of lesions of this tissue, which
arises from chronic inflammation ; but we have
not sufficient evidMice of this ori^iin. Indeed,
facts, as far as tliey have been ascertained le-
garding it, very conclui^ively show, tliat other
structures besides this are affected at a very early
period of the progress of this disease.

6. I). i((/(7;r(ji/0Hs, or effusions of fluids from the
circuhiting vessels, frequently take place in this
tissue, and constitute the prominent phenomena of
various discafcs. Haitwrrliage sunietimes occurs
in it, either from external injuiies, or from internal
causes affectmg tlie vitality of tiie system and
the states of the capillaries and circulating fluids.
When it originates in the latter source, the effused
blood is usually infiltrated into the interstices of
the structure in circunifcribed spots, forming ec-
chymoses, and sugillations, as in scurvy and pur-
pura ha'morrhagica, &c. When the haemorrhage
is extensive, it is commonly owing to the rupture
of an aneuiismal vessel or varix. The infiltration
of strous fluids is very common, either in circum-
scribed parts (wdema), or more or less generally,
although in difl^erent di grees, in the greater part
or the whole of the body {anasarca). This preter-
natural increase of the sero~ity usually moistening
the cellular tissue is owing to various causes, ex-
plained in the article Dropsy ; and cliiefly to
increased exhalation, either from augmented de-
termination of the circulation, or deficient tone of
the exhalants, or botii, — to impeded absorption,
either from obstructed circulation in the vems or
inactivity of the absorbents, — and to oppletion of
the vascular system by the serous or watery parts
of the blood, Irom obstructed elimination by the
kidneys or by the respiratory and digestive mucous
surfaces, and by the skin. A general state of very
slight oedema, or an unusual fulness, softne-s, and
flaccidity of the cellular tissue, — a condition ob-
viously depending upon its laxity or deficient
cohesion, conjoined with the presence of a greater
proportion of watery fluid than in the healthy
state, — not infrequently also is observed, particu-
larly in phlegmatic and lyinphatic constitutions.
This has usually been termed leucophegmasia;
and although it may not amount to actual disea=e,
yet it undoubtedly forms the first stage of seveial
slowly formed maladies, and is usually attended
with that state of the frame described in the article
Cachexy. It is of importance to attend to the
chief pathological relations of this state of tiie
cellular tissue, as they furnish useful indications
respecting the nature and treatment of various
diseases with which it is often connected. It
commonly proceeds from an originally weak con-
formation, subsequently heightened by diminished
vital power of the system in general, and defective
cohesion of this tissue in particular.

7. 1 he urinary secretion sometimes escapes
into the cellular structure, which it violently in-
flames ; the part thus infiltrated being usually
affected by the spreading form of the disease, and
the constitution thereby suffering most severely,
as in other cases of this state of inflammation.
This tissue is sometimes also infiltrated by a'trijor7n

Jluids, constituting the emphysema or pneinnatusis

of authors. This species of infiltration arises eii her
from tiie escape of air into the cellular s\ibsiance,
owing to laci ration of some jjarl of the respiratoiy
mucous membrane ; or from a morbid secretion
by the vessels in certain advanced stages of dis-
ease, as in the last period of some forms of inflam-
mation. (See art. Emphysema.)

8. E. The cellular tis-ue is also very frequently
the seat of a great vaiiety of morbid growths, and
formations of a specific and malignant kind.
Amongst these, the most important are simple
serous cysts, hydatids, tubeicles, melanosis, eartiiy
and bony concretions, the vascular sarcoma of
Abernethy, &c. These adventitious productions
very often commence in some part or other of this
tissue, even when they are found in other struc-
tures ; the matrix, or medium of connection fur-
nished by it to other textures and organs, being
most fre(]uenlly their point of origin. Certain
parasitic animals, especially the larva? of the astrus,
Jilarite, and cysticerci, are also occasionally met

with in the cellular membrane. Changes of colour
are not unusual, most commonly in consequence
of biliary obstruction, giving rise to jaundice;
and of certain malignant fevers, when it is either
yellowish or yellowish green, and deficient in its
vital cohesion.

Cellular Tissue — Diffusive Inflammation

OF THE. — Classif. III. Class, I. Order

(Author).

9. Defin. — Severe constitutional disturbance,
either preceding or following intense pain and dif-
fuse sivelling of some part of the cellular tissue,
ivith rapid pulse and depressed vital power.

10. The parts of the cellular tissue chiefly af-
fected, according to IMr. Hunter and Dr. Craigie,
are those in which the adipose substance is most
abundant. In respect, however, of its seat and
nature, this important malady has been much
misunderstood, owing to the circumstance of its
most commonly occurring as a complication with
diseases of those structures, whose anatomical
connection with this tissue is extremely intimate.
Dr. Duncan, to whom \\6 are indebted for the
most comprehensive account of it which has
hitherto appeared, has erred in considering other
maladies, thus contingently related to it, as form-
ing varieties of it, rather than as being occasional
complications with it. It is true, that, while
diffusive inflammation of the cellular structure
arises primarily, constituting the only or principal
complaint, it is also associated (generally in a
secondary form, or in consequence of the exten-
sion of inflammation from immediately adjoining
tissues) with inflammations of absorbing vessels
and glands, with phlebitis, with inflammation of
the fascia;, and most commonly with erysipelas ;
tiiese generally proceeding from the same causes,
and from similar states of constitution and vital
energy of the patient, as occasion it ; and one or
other of these diseases often appearing simulta-
neously with it. But, when thus associated, it may
constitute either the least, or the most remarkable
part of the malady ; and, therefore, in such cases
at least, can only be viewed as a more or less im-
portant part of a complicated disease.

11. I. Causes. — ^4. The predisposing causes, as
far as they are ascertained, are epidemic states of
the atmosphere ; impure conditions of the air
originating in local sources, particularly the foul
air of crowded or imperfectly ventilated hospitals

300 CELLULAR TISSUE

and apartments ; morbid accumulations of bile in
the gall bladder and ducts, and of sordes, &c. in
the prima via ; lowered vital power, from whatever
cause ; the use of unwholesome food, a cachectic
habit of body, and deranged state of the digestive
functions, or of the secretions.

B. Tiie excilhig causes are chiefly local injuries
and sprains, especially punctures and abrasions ;
venaesecdon and the ligature of veins ; the inocula-
tion of various animal poisons, generally of a septic
tendency ; acrid substances, or vegetable or animal
matters in a state of disease or decomposition, ap-
plied to the cellular tissue; and even the simple
contact of morbid secretions and fluids, more es-
pecially those of erysipelas and of j)ueiperal ma-
ladies, with any part of the body. The numerous
instances which occurred a few years since in
Plymouth Dock, and described by Dr, Butteu
and Mr. Tripe, were chiefly referrible to epidemic
or endemic states of the air; were generally ex-
cited by local injury ; and were complicated with
erysipelas.

12. II. Symptoms. — A. Thelocal symptoms are
variously modified, according to the causes by
which the disease is produced. — a. In some cases
it proceeds with very severe lesion of the part to
which the cause is applied, as when the fluids and
secretions of a diseased animal come in contact
with the skin, and give rise to the disease called
" pustule matigne" by the French, or malignant
anthrax. In this case the morbid matter produces
a vesicle, from its effects on the rete mucosum,
followed by a tubercle, arising from the extension
of the inflammation to the true skin, whence it
penetrates to the subjacent cellular tissue. Its
progress then' is very rapid and alarniing. A con-
siderable swelling now extends to some distance,
presenting a peculiar cliaracter. The surface of
the skin is shining, and the swelling is elastic,
diffused, and resisting, with a throbbing pain and
sense of heat, followed by a feeling of torpor,
tightness, and weight of the part. This morbid
state extends in all directions; and, upon exami-
nation, excites a sensation between the softness of
cedema and the elasticity of emphysema, to which
the terms hoggy, or doughy, have been applied.
The central paits generally soon become entirely
deprived of life, and the mortification glides
below the skin, and destroys the cellular tissue
all around; the constitution being most seriously
affected. A nearly similar state of the part pri-
marily injured not infre(]uently follows the ap-
plication of various acrid matters, animal or
vegetable, directly to the cellular tissue itself.
Punctures, also, which penetrate as far as this
tissue, or mere abrasions of the cuticle, may also
occasion it ; the chief difference being in respect
of the extent to which the skin is aflected. In
some of such cases, particularly when punctures
are the cause, either with or witliout the appli-
catiim of morbid matter, the skin is very slightly
diseased, although the cellular tissue is exten-
sively destroyed ; whereas, in other instances, es-
pecially when the cuticle is abraided, or when
acrid matter is applied externally to the skin, this
structure is very manifestly inflamed at the same
time, and the malady presents the characters of
erysipcjus, complicated with this aflection of the
cellular meiTibrane.

13. h. When the disease arises from punctures,
mechanical injuries, chemical irritants, and some-

Inflammation of — Symptoms.

times from wounds received in dissection, the
constitutional disease is, as in the foregoing in-
stances (§ 12.), preceded by the local affection.
The mischief commences in the seat of injury,
and extends from thence to the trunk of the body,
and sometimes also in an opposite direction,
without leaving any interval apparently sound.
The progress of this variety differs greatly in dif-
ferent cases; being in some confined to the limb,
or part of the limb, to which the cause is applied,
and in others proceeding rapidly to the trunk, and
terminating fatally. In a few of the instances
following veniEsection, the puncture heals as usual,
and either remains permanently united, or opens
again, and gives vent to some purulent matter ;
but inore commonly union does not take place ;
the lips of the incision remaining slightly swollen,
red, and everted. Some ichorous or purilorm dis-
charge appears, and disease extends continuously
from the wound to the shoulder or breast.

14. c. In the most dangerous form of the ma-
lady, as that consequent upon the inoculation of
a virus or morbid matter, a vesicle or pustule
forms in the part to which the poison is api)lied,
with very remarkable constituiional disturbance,
followed by severe diffusive inflammation of some
part of the celhdar texture, generally on the
same side with that on which inoculation of the
disease took place, but at a distance from it, and
not continuously with the primary pustule. In
such cases, the manner in which the malady is
propagated from the local injury, — which is most
commonly in the fingers, — to the seat of the
diffusive inflammation, which is usually in some
part of the trunk, has not been satisfactorily
shown. It has been supposed to pass along the
absoibents, and, arriving at the axillary glands,
to excite inflammation in theirt, extending to the
surrounding cellular tissue ; others have thought
that the process takes place along the veins; but
the accuracy of either of those views has not been
deinonstraled by dissection, both these sets of
vessels having been found free from disease in
cases of this description. The history of this most
dangerous malady, and the nature of the cause
which excites it, render it more probable that the
morbid impression is made upon the organic nerves
of the part, and that the frame is soon generally
afltcted owing to the anatomical and functional
relations of this system of nerves ; the intimate
connection of which with the blood-vessels di>'-
posing the consecutive diffusive inflammation to
appear on the same side with that on which the
morbid impression was first made. The primary
pustule is usually of very little extent or severity,
often heals before the consecutive inflammation
takes place, and is evidently the local efl'ect of the
virus u|)on the capillaries of the part to which it
was applied. 15ut it is quite insuflitiient to account
for the rapid and violent constitutional disturbance
which follows, and which can only be explained
by referring it to the clinnge jiroduced by the
niorbid matter in the organic system of nerves pri-
marily, and consecutively in the vascular .system,
and in the blood itself.

15. The chief and not infrequent illustration
of this form of the disease is furnished us in the
cases which follow punctures received on open-
ing recent subjects. In the course of ten or
twelve houi-s from the lime of sustaining the in-
jury in the finger, or not until after five or seven

CELLULAR TISSUE — Inflammation of — Tkuminations.

301

days, the patient complains of rigors, remarkable
debility, and frequency of pulse, with sickness at
stomach, retching-s, &c. A pustule appears in
tlie part, but not always ; and generally no con-
nection can be traced between it, even when it is
formed, and the diffusive inHammation which
takes place durin:; the progress of tiie constitu-
tional affection. In some cases, a few led lines
may be traced, or swelling of the surrounding
part is observed ; but neither advances any dis-
tance, the parts above being pei feci ly sound. In
tiie course of the violent fever induced by the in-
oculation in the hand, the consecutive inHamm;i-
tion usually appears in the axilla, and extends
towards the sternum, along the neck, down to the
loins or haunch, or even to the thigh of the same
side. In some instances, it terminates at the
mesial line ; in others, it passes continuously to
the other side. It occasionally is translated from
one side or part to the other, by a kind of metas-
tasis, as in gout or erysipelas.

16. The inflammation of the cellular tissue of
the trunk, whether arising from a continuous ex

wounds from dis?ecting';recent subjects, and whea
preceding the disease of the cellular tissue of the
trunk. The fever sometimes commences insidi-
ously, but more frequently in a very evident or
tumultuous manner. The pulse soon becomes
very quick, sharp, broad, soft, or compres-
sible. The paiient lies in the supine posture,
with depressed shoulders, and without turning to
either side. Delirium is common, but it is gene-
rally intermittent ; and profound coma is rare.
The res|)iration always is quick, laborious, and
painful, partly owing to the inflammation of the
cellular tissue of the side of the thorax, and its
extension to the costal Jpleura. As the disease
advances, the peculiar cadaverous foetor emitted
by the patient, the yellowish or lurid hue of the
surface, the offensive and sjmetimes coloured
sweat, wh'ch, in rare instances, proves critical,
and the tendency to ulceration in the parts pressed
by the weight of the body, show that the blood,
the secretions, and the soft solids, are more or less
contaminated. Towards a fatal close, the raving
delirium is often accompanied with mutterino-^

tension of the disease from the arm, or part ori- i and starting of the tendons ; and alternated with

jmally affected, as in certain stales of the disease
(§§ 12, 13.), or in the course of the constitutional
commotion (§ 14.) excited by the inoculation of
a morbid virus, always possesses peculiar cha-
racteristics: it is diffuse or extensive, without the
smallest tendency to point; being flatly elevated
above the sound parts, usually by a raised or
defined margin. It is smooth and equal, without
central hardness, and with all the characters
already noticed (§ 12.). In general, no chords,
which can be supposed to be diseased lymphatics,
veins, or arteries, can be traced under the surface,
and the glands are either very slightly or not at all
enlarged. The diffused swelling commonly fur-
nishes an obscure sense of fluctuation ; but, fre-
quently, when punctures have been made into it,
little or no discharge has been procured.

17. The pain of the swollen part is most acute
in every instance, whether the swelling be in an
extremity, or extend along it to the trunk, or com-
mence in the trunk itself; and it is quite inde-
pendent of whatever affection of the skin may
accompany the malady. In some cases, the in-
teguments present not the least redness, although

stupor ; the breathing becoming panting, labori-
ous, or interrupted.

19. The Terminations of the disease vary
with the exciting cause, the state of the patient's
constitution, and the part primarily affected.
When its arises from mechanical causes, as after
venaesection, simple puncture, &c., it may termi-
nate with spreading suppiirution, which may or
may not be attended by sloughing of the cellular
structure : and this result may occur both in cases
which end fatally and in those that recover; a
partial regeneration of this tissue taking place in
some of the latter. In the milder cases, the in-
flammatory action changes its character, and
shows a tendency to stop ; the disease terminating
in phlegmonic suppuration and granulation. If
the cellular substance adjoining a serous mem-
brane become affected, tliis latter participates,
and the inflammation spreads rapidly over it,
generally producing an eflPjision of sanguineous
serum ; but sometimes, also, adhesion of the
opposite surfaces. Occasionally the adjoining
periosteum becomes diseased, and even the car-
tilages and bones denuded. A. fatal termination

the cellular tissue has extensively suppurated, or ; occurs either rapidly from the intensity of the
even sphacelated ; but the skin is commonly more j disease, or more slowly from some one of its

or less afl^ected, although in a secondary manner,
in consequence of the extension of disease from
the cellular tissue to it, and generally subse-
quently to the manifestation of acute pain. In
the advanced stages, the skin has often a reddish
or pink-coloured blush, and occasionally a mot-
tled or livid hue. In some cases, at a still further
advanced period, solitary vesicles form over the
diseased cellular tissue, and contain a serous, or
sero-sanguineous, or ichorous fluid. The tem-
perature of the part is sometimes much below
natural.

18. B. The febrile commolion, whether appear-
ing consecutively of the dift'ase inflammation,
directly produced in the part primarily injured,
or previously to the afl'ection of the trunk, is of a
typhoid or adynamic type, and is accompanied with
the most marked disorder of the nervous system,
with anxious collapsed countennnce, and fre-
• quency of pulse ; more particularly when excited
by the inoculation of a morbid matter, as by

sequelae: and usually takes place, in the first
instance, in from four to fourteen days ; in the
second, not till after two or more weeks, or even
longer ; but the common period is from the sixth
to the tenth day.

20. Ill, Appearances ON Dissection. — Dr.
Duncan has given a very minute and accurate
account of the successive changes that take place
in the diseased structure. As the malady often
attacks progressively various parts, it is some-
times found after death, in all its stages, in the
same subject. In the part last affected, which
is frequently the space between the last ribs and
the OS ilium, the cellular substance is merely
(edematous, with increased vascularity; the infil-
trated fluid being either limpid or tinged with
red, and readily flowing from the divided tissue.
In a more advanced stage, the efl^used matter is
less fluid, often higher coloured, but not yet puri-
form. The diseased structure is next found gorged
with a white semifluid matter, which greatly aug-

302

CELLULAR TISSUE — Inflammation of— Diagnosis.

irients its thickness, separating the panicles of fat
at a distance from each other, but does not flow
from tlie incision. In a subsequent stage, this
matter is opaque, whitish, or reddish, or greenish,
but is now so fluid that it flows from the incision.
It is still, however, contained in the cells of tiie
thsue ; and it is only in the last stage, and after
the texture of the part is entirely broken down,
that this puriform matter is met with in collec-
tions, mixed with portions^ of the sloughy tissue.
At this last stage the matter is not circumscribed
by any cyst, or defined cavity, but is gradually
lost in the adjoining cellular substance, without
any line of demarcation. (See art. Abscess,
§15.)

21. The cellular tissue itself is usually gray or
ash-coloured. It is detached extensively from
tlie textures it connects, or adheres to them and
the skin in sloughy shreds ; and long sinuous ca-
vities are found between the tendons or muscles.
The muscular structures adjoining are generally
more or less diseased, the inflammation extending
to their interfibrous cellular tissue ; which, how-
ever, does not appear to be alone affected, the
muscular fibres having their colour altered, and
b;-ing more easily torn than in health. As respects
the hl'jod-vessels, the number of visible red arteries
is increased, and the veins are enlarged, and tur-
gid with black blood. Mr. J. Hvntkr states that
he found, " in all violent inflammations of tlie
cellular membiane, whether spontaneous or the
consequence of accident, that the coats of the
larger veins passing through the inflamed pans
became also considerably inflamed ; and that their
inner surfaces take on the adhesive, suppurative,
and ulcerative inflammations ; for in such inflan.-
mations, I have found in many places of tiie veins
adhesion, in others matter, and in others ulcer-
ation." (Trans, rf Soc.for Improvement of Med,
Knowledge, 8vo. Lond. 1793, p. 18.)

_ 22. The liimphatic vessels have not been sufli-
ciently examined. The axillary glands have,
however, been observed somewhat enlarged, and
embedded in the diseased cellular tissue. Dr.
Duncan states, that, although a tender and
swelled axillary gland has been frequently men-
tioned as one of the fiist symptoms observed,
he has never found them so much changed as at
all to support the idea that their afl^ection was
the primary cause of the alteration of the sur-
rounding parts. The state of thc/asc!> has been
very generally overlooked in dissections of fatal
cases of this malady, as well, indeed, as that of
the blood-vtssels and lymphatics ; but the fascia;,
tendinous expansions, sheaths of tendons, &c., are
not always unchanged, although they appear not lo
have suffered in some instances. The sldu is often
severely aflfected, but not essentially or primarily,
in the idiopathic form of diflfuse inflairiniation of
the cellular texture.

23. J\^ Diagnosis and Complications. — a.
Difl'use inflamriialinn is readily rlistinguislievl from
phlegmonous inflanimatioii of the cellular tissi e,
by the circumscribed hardness c f the latter, Ity
the elevation of the lumour, and its pointing and
becoming soft in the centre; and especially by
the phlogistic character of the attendafit lever,
whicli will ;,lj.o indicate the nature of the diease,
W'iifcti i)ldet;tnonou9 inflammation is seated be-
ne ith lascia!. In the less severe cases of the
diffuse dibease, particularly when it is principally

seated in those parts to which the exciting cause
has been directly applied, and when it has been
judiciously treated in the early stages, a disposition
to pass into the phlegmonous state, by the forn)-
ation of coagulable lymph, and the limitation
thereby put to its extension, are very generally
observed. Indeed, this change of character con-
stitutes the favourable termination of the disease;
although it may also occur as a complication in
unfavourable or even fatal cases, especially when
veins or fasciae are also affected.

24. I). Diff'use inflammation of the cellular
tissue is often consequent upon erysipelas, or
complicated with it, particularly the erijstpelas
phlegmonodes ; the difference between them con-
sisting in the circumstance of this tissue being
primarily and mainly aflPected in the former ; and
consecutively of the inflammation of the skin, in
the latter.

25. c. hijiamed veins may be distinguished from
this disease, when they can be felt stretching like
chords in the direction of the swelling, and when
the pain and tenderness on pressure are chiefly
limited to the same line. There is usually, also,
little or no affection of the skin, even secondarily,
and the disea.se is generally more confined to a
limb ; fulness of the pectoral, cervical, and late-
ral muscles and surface being commonly wanting.
(See Veins — Infiammation of.) When the
tumefaction is very great, it is extremely difficult
to determine respecting the affection or non-affec-
tion of the veins : the consecutive inflammation of
these vessels, however, and its complication with
this disease is very common, as IMr. Hunteh has
so accurately stated, and more recent researches
have confirmed.

26. d. The diagnosis between this malady
and inflamed liimphatics is also extremely diffi-
cult, owing chiefly to the same cause, namely,
to the oedeina and congestion of the surrounding
and distant cellular tissue consequent upon the
obstiuetion of these vessels in the inflamed state.
The existence of superficial red streaks, not con-
nected with veins, running along an extremity
from the part where the exciting cause is sup-
po;jed to have been applied, and swelling of the
lymphatic glands to which they lead, are the
only proofs we usually possess of the lymphatics
being diseased ; and the absence of their appear-
ance is the chief evidence of their being un-
affected. But, as in cases of inflamed veins,
difl^use inflammation of the cellular substance very
generally follows inflaiimiation of the absorbents,
as satisfactorily shown by AiiiLUNExiiy, .James,
Duncan, and BiiFsciiEr. The difficulty of dia-
gnosis, however, in a great jtroportion of cases,
excepting at their commencement, must be evi-
denily owing to the very sufficient reason of their
co-existence.

27. e. The same circumstance also explains
the difficuliy sometimes found of distinguishing
the disease from iujiani motion of the I ai^cia ; for
in the majority of irisiances, the affection com-
men(;es in llie relluhir tissue, and extends to the
fascia, this latter structure being very rarely in-
flamed pii(!!arily, unless after it has experienced
some external injury. Even when the fascia is
))iimarily inflameil, it will not l)e possible, on some
occasions, to form an accurate diagnosis ; as dis-
ease commonly extends thence to the cellular tissue '
on each side of it. When the fascia is affected.

CELLULAR TISSUE — Inflammation of — Pathological Inferences.

303

either primarily or consecutively, contraction of
the limb is generally occasioned : but tliis is in-
sufficient evidence of inflammation of the fascia,
as inflammation anil distension of the ])arts en-
closed by it will produce this effect. Wlien the
disease commences in the cellular tissue, and
extends to that portion enclosed by fascia, or
to this structure itself, the skin is often unaltered
even in colour. In a most severe case, attended
by Rlr. Parker and myself, the whole leg and
thigh, to far above the hip, were affected, and
the limb contracted, and yet the skin was na-
tural. The inflammation may, however, origin-
ate in the skin, extend to the subjiicent cellular
tissue, thence to the fascia, and, ultimately, to
the cellular tissue beneath it ; forming an im-
portant variety of erysipelas, well described by
]\Ir. Copland IIdtchison, and constituting the
triple complication of diffuse inflammation of the
cellular substance with that of the skin on the
one side, and with that of the fascia on the other,
the first being most extensively and destructively
diseased. The local and constitutional suffering
in such cases chiefly arise from the pressure
made by the fascia upon the inflamed and tumid
cellular tissue underneath it.

28. y. Whilst it is important to distinguish be-
tween injxiry or injiammation of a nerve, and this
malady, it must not be overlooked that the one is
often associated with the other; priority of afiiec-
tion in respect of either being the chief object of
diagnosis. When, after a puncture or other local
cause, very acute pain is complained of, particu-
larly in the situation and the course of a nerve,
with severe or obstinate symptoms of great nervous
irritation, convulsions, &c. accompanying it, we
may conclude that the disorder has originated in
a nerve ; and, if to those symptoms are added the
diffuse, 'boggy swelling, &c. already described
(§ 12.), we may likewise infer that diffuse inflam-
mation has subsequently attacked the cellular
tissue.

29. 0-. I have met with some instances of dif-
fuse inflammation of the cellular tissue as a com-
plication and termination of several severe or
fatal states of diseai^e in the puerperal state, both
with and without affection of the skin ; but only
in the wards of a lying-in hospital. I'hey have
appeared in two forms : 1st, In the advanced
progress of asthenic inflammation of tiie uterus,
attended with an excoriating and foetid discharge,
which has first irritated the skin about the nates,
— the cellular tissue underneath becoming dif-
fusely inflamed to a >jreat extent, and de-
stroyed ; and 2d, After cases of inflammation of
the uierine veins, evidently in consequence of
the vitiation of the circulating fluid. Ir. Otto,
Dr, Duncan, and Dr. Craigie, refer phlegmasia
dolens to dtfl^use inflammation of the cellular
substance ; but, I think, on insufficient evidence.
If this tis-ue be really inflamed in that disease,
other structuies participate; and it certainly is
not the part first aftected. In the cases which I
have seen examined after death, — only three in
all, — the nerves and veins were the parts to
which the symptoms of disorder were first re-
ferred ; the veins being obstructed in all the
cases. (See Phlegmasia Dolens.)

30. /(. The cellular tissue of the side of the
neck and throat is sometimes dift'u-ely inflamed,
apparently from an extension of disease, in an-

gina maligna, and worst form of scarlet fever, the
patient sinking from it rapidly. I have, however,
met with one case of this description, where re-
covery ultimately took place. This disease also
rarely occurs near the anus, or about the buttock
and peiinacum, in the course of fevers, dysenteiy,
&c. But it is more disposed, on these occasions,
to limit itself, and to terminate in suppurating ab-
scesses. When it occurs in ased persons, from
the escape of urine into this tissue, it generally
extends rapidly and terminates fatally ; and a
nearly similar re-ult follows its appearance after
important surgical operations, as after lithotomy,
amputations, and the ligatures of veins and arte-
ries for aneurismal dilatations of them.

31. V. Pathological Inferences. — a. Con-
formably with recently accumulated facts con-
nected with diffusive inflammation of the cellular
tissue, it may be concluded that it presents various
morbid associations and grades of intensity, as well
as distinct rel.itions to the attendant constitutional
disturbance, according to the diversified causes
which occasion it : — 1st, That depressed vital
power, or a previously disordered state of the
chylopoietic viscera, or general cachexy, is often
requisite to its occurrence: — 2d, That abra-
sions, the irritation of acrid secretions or decom-
posed animal or vegetable matter, simple punc-
tures, injuries received during the dissection of
subjects in a slate of incipient decay, and the
contact of morbid fluids, most commonly produce
the disease primarily in the part in which the
injury is sustained, the mischief spreading con-
tinuously from thence ; although occasionally
appearing afierwaids in other parts, without any
continuous connection, when the circulation has
become contaminated by the primary affection :
3d, That, when originating and spreading as now
stated, sometimes the skin, at other times tlie
veins, occasionally the lymphatics, on some occa-
sions the tlieca or fasciae, and more rarely the
voluntary nerves, or any two or more of these,
participate more or less in the disease : 4lh, There
appear to be other causes, .which, acting in the
manner of specific poisons, produce comparatively
but little ettect on the part to winch they are
directly appHed ; but which aftect the system
universally, chiefly by depressing and otherwise
changing the orga.-ic, nervous, and circulating
functions, the alteration of the cellular tissue
appearing subsequently : 5th, I'hat the local
affection in this form of disease, which may
be denominated consecutive diffusive inflamma-
tion of the cellular tissue, is often of very small
extent compared with the severity of the consti-
tutional disturbance; and, very frequently, ap-
pearances of contaminaticm of the frame present
themselves before tiie cellular tissue is affected,
and even then the affection may be trifling, or
even not recognisable (see Poisons — Animal):
6th, Ihat the malady originating in the inocu-
lation of a poison or virus, paiticularly during the
examination of recently deail bodies, cannot be
ascribed to inflammation of veins, or of lymph-
atics, or of nerves, or of fasciae, or even of the
cellular tissue itself; and that, all hough this last
mo>t fiequently exhibits morbid appearances, yet
are these appearances obviously contingent upon
general disease of the frame, involving in a spe-
cial manner its various vital manifestations. (See
^ Author, in Land. Med, Repos. vol. xx. p. 24. 1823.)

304

CELLULAR TISSUE — Inflammation of — Treatment.

32. b. As respects the association of the local
tnid constitutional affection, all the cases of this
disease may be divided into two classes : —
1st, Those in which tiie constitutional disturl)-
ance is mainly owinjj to the primary local lesion,
or its extension, whetlierit be inflammation of the
cellular tissue alone, or of this ti-sue associated
with inflammation either of veins, lymphatics,
thecae, aponeuroses, or of the skin ; the relation
subsisting between the intensity of the primary
local aflfeciion, and the constitutional disorder,
being more or less apparent and co-ordinate
(§ 12, 13.): 2d, Those in wliich the local lesion
is obviously the least important change that has
been induced, either directly by the exciting
cause, or consecutively by the constitutional
affection ; and, even when it becomes the most
serious, is manifestly the result of' the constitu-
tional artection (^ 14.), and dispropoitioned to it.
Tiius the local and the geneial symjitoms are
presented to us in a different order in these two
forms of the disease. In the first, also, the febrile
action is more inflammatory than in the second,
but still partaking of the irritative character, as
has been very justly insisted upon by iMr. Tha-
VERS. In the second, it is more asthenic ; the
nervous system is much more disordered ; the
anxiety, distress, and mental and physical depres-
sion, are greater than in tiie first ; and all the
organic functions more gravely affected ; the
blood, the secretions, and soft solids, becoming
at last very evidently altered.* (See Blood,
$ 139. et se(/.)

33. VI. Pkognosis. — The danger of this dis-
ease is much less when it is accompanied with
inflammatory, than with adynamic or highly irri-
tative fever, and morbidly excited sensibility. In
general, the rapid extension of the disease from
the arm to tiie trunk ; great tumefaction of the
region of the pectoral muscles ; the first appear-
ance of the inflammation in this situation, or in
any part of the trunk, from causes which first
occasioned serious onstitutional disturbance ; re-
markable frequency of pulse following rigors,
with anxious collapsed countenance, ferrety eyes,
delirium, difficult respiration, depression of mind,
the accession of fresh rigors, extreme debility,
and stupor ; are all indications of great danger.
The nature of the cause, also, should influence
the prognosis. When it proceeds from the liga-
ture of a vein, venaesection, and particularly from
wounds in dissecting recent subjects, the danger
is great. There is, however, less risk when the
disease arises in the part to which the cause has
been applied, and when the skin becomes much
affected with a disposition of the inflammation to

* It may he statcJ at this place, tliat tlie disease wliicli
has been obierved to follow inoculation of an animal
poison during the examination of recent subjects is ob-
viously distinct from dilFiise indammatiou of tlie cellular
tissue, although this local afTection, or some modification
of it, often takes place in the advanced stage of that dis-
ease, which has accordingly been referred to in this
article as one of the chief causes of the lesion now under
consideration. The subject is, however, considered more
fully in the article on Poisons. In justice lo mys If, I
should state, that I published, in the Lcndnu Mrd/cal Jic-
positdry for July, 1823, p. 24—27., soim- reiuirks on the
nature of the malady infected iiy inoculation from recent
suhji.'cts, and the operation of animal poisons on the eco-
nomy ; and I request the favour of the reader who is
interested In these important subj'Cts to reler to these
remarks, and to the conclusions to which Mr. Travers has
come. 111 his work on Con»titutiouul Irritation, p. 413.
Lond. 1826.

limit itself, and form healthy pus, than when it
appears consecutively of a pustule merely in the
part inoculated, and of fever with extreme de-
pression.

33. VII. Treat.ment. — A. Prophylaxis, Pre-
cautions are absolutely requisite when punctures
are received in post mortem examinations, or
when the cuticle about the nails and hands
of the examiner is abraded. Some constitu-
tions are more liable to be inoculated in this
way than others, particularly persons who are
out of health at the time, or whose vital ener-
gies are depressed. Wearing gloves during a
morbid dissection may be of use in such circum-
stances. Dr. Duncan suggests the anointing of
the hands with camphorated oil, or with simple
axunge, befoie handling the viscera. Abrasions
about the fingers should be protected by adhesive
plaster. If, notwithstanding, punctures are re-
ceived, or if an abraded or punctured part come
in contact with any of the fluids or soft solids of
a recently dead body, with animal or vegetable
matter in a state of decomposition, with acrid or
morbid secretions, suction or perfect ablution of
the part ought instantly to be performed ; a
pledget of lint, wet with either a strong solution,
or the oil, of camphor (F. 449.), or with turpen-
tine, applied to it, and the application covered
so as to prevent its quick evaporation. On the
several occasions of the employment of these
means, in the persons both of myself and of my
medical friends, no disturbance has accrued from
these accidents. Two partial exceptions, how-
ever, have occurred, but in such a way as to
confirm the propriety of this practice, and illus-
trate the nalure of one form of the disease. The
punctures, in these two cases, were received when
examining the bodies of females who had, but a
few hours previously, died of malignant puerperal
fever; and the application was not resorted to
until after leaving the apartment where the in-
spection was made. In one of those cases, —
that of a pupil, — camphor was used ; in the
other, that of my friend, Mr. Churchill, —
ammonia was einployed, Boih these gentlemen
experienced, within twenty four hours afterwards,
C(msiderable general disturbance, with sickness at
the stomach, and nervous depreS'sion and debility.
All disorder, however, disappeared in a day or
two alter the exhibition of warm diaphoretics and
stimulants ; but in neither case was the least
irritation observed in the part punctured. The
morbid impres.sion was evidently made upon the
orgiinic nervous system, as evinced by disorder
of the functions more immediately dependent on
it; but was not so intense, relatively to the state
of predisposition, as to occasion further disease.
As to the use of ligatures, ike, I must refer tiic
reader to what I have stated respecting them in
the article on Aiiiniol Poisons.

35. H. Curatire treatment. — a. It will be evi-
dent, from the history of diffusive inflammation
of the cellular tissue, that /oa;/ meaos are chiefly
applicable to certain of its states and complica-
tions. When the primary local afl^ection is at-
tended by much pain, both cold and warm
applications have been recommended by different
writers. The choice, however, between them, may
be determined by the sensations of the patient:
but wiirm fomentations, unremittingly employed,
appear to me the safest, particularly when inflam.

CELLULAR TISSUE — Ik

mation is externally apparent. When the local
affection is limited chiefly to the part to which
the cause was applied, or its vicinity, the detrac-
tion of blood from it by leeches or scuiijicatio'us,
and incisiiiiis through the integuments, ought not
to be neglected. The latter of these two modes
of local evacuation, as first recoinnienJed by I\lr.
Copland Hutchison, is evidently the most, bene-
ficial, not merely by procuring a more decided
and rapid discharge, but also by giving an exter-
nal outlet to the matter wiiich othenvi^e would
infiltrate the cellular tissue, and extend the mis-
chief. Even in ca-es of great vital depression,
and when the cellular tissue is consecutively dis-
eased, incisions should not be neglected j they
being compatible equally with au energetic, tonic,
or stimulating treatment, as with its opposite : and
they are not the less necessary in the early stages
than at later periods, and when fluid is diffused
through the cellular structure. ^Vhen the part
affected is deeply seated, they should be deep
and large, so as (ully to reach it ; their number
being proportionately diminished. Eut the great
object is to make a free passage for whatever fluid
matter may have formed, or that will form sub-
sequently. This practice has received the appro-
bation of Dr. Duncan, and the best recent writers
on this disease ; and its propriety has satisractordy
been shown in those cases which have fallen under
my own observation.

34. A. The generul means of cure are usually
directed with the intention of subduing the local
affection, and more especially the state of high
nervous sensibility and vascular irritability which
exists, whether this state be consequent upon the
]>rimary lesion produced by the exciting cause,
or whether it be the immediate effect of that
cause, and the antecedent of any affection of the
cellular tissue, as in cases of inoculation by mor-
bid matters or animal poisons. But, although
this intention is generally kept in view, very
different, and even opposite, measures have been
recommended for fulfilling it. It is eviilent that
the same measures are not suitable to all states
and periods of the di^-ease; and possibly to this
cause may be imputed the great diversity of
means which have been advised, and the partial
success attributed to very opposite methods.
j\Iuch also is owing, more generally than has
been admitted, to the constitutional powers of
the patient. A number of practitioners and
writers advocate general blood-letting, and trust
chiefly to it for the fulfilment of the above in-
tentions, without advening to the fact, that the
morbid states forming the essential characters of
the disease are, in their severest and most deadly
forms, independent of sthenic action, and cannot
be either limited or subdued by venaeseetion,
although it may be required to a moderate extent;
particularly when the local affection arises pri-
marily and directly from the exciting cause, im-
plicates any of the parts which I have noticed as
being involved in its complicated forms, and is
chiefly antecedent of the grave constitutional dis-
turbance characterising the advanced stages of
disease. But even in such cases, the depletion
should be practised early, and confined chiefly
to young, plethoric, or robust persons ; the local
evacuation consequent upon free incisions being
sufficient in most cases. In other respects, the
treatment in this form of the disease may be
Vol. 1.

FtAMMATION OF TREATMENT. 305

similar to that recommended in inflammation of
the veins; for the principle acted upon by Mr.
John Hunter in respect of that malady, and
which is founded on accurate observation, is
equally applicable to this — namely, to imparl
energy to the system, so as to enable the vessels
to form coagulable lymph, by which the exten-
sion of the morbid action may be limited, and a
diffusive or spreading inflammation may be con-
verted into the phlegmonous state. This practice
is still more imperatively required in the other
form of the disease, or that in which the aflisction
of the cellular tissue is consecutive of a constitu-
tional disturbance, excited by a morbid virus or
animal poison.

35. The frequent inefficacy of depletions
and the antiphlogistic treatment, and even their
injurious efl^ects as shown by the rapid sinking
consequent upon them, are fully demonstrated by
the history, given by Dr. Butter, of the disease
which occurred in Plymouth Dock, and by the
cases after wounds in dissection recorded by va-
rious writers. The instances of recovery after
this practice cannot be brought as evidence of
its efficacy ; inasmuch as the srnallness of their
number ; the tonic treatment, which, in several of
them, followed vascular depletions ; and constiiu-
tional energy ; may be adduced to disprove it.
After studying the cases which have been pub-
lished by Dr. Duncan, Dr. Colles, Mr. Tra-
VERS, Dr. Dease, Dr. Butter, &c., and re-
fleeting on my own limited experience, I would
strenuously recommend the following measures,
in addition to those already advistd ; — As to the
question of blood-letting, that is already disposed
of; but I may further add respecting it, that,
however great the severity of the pain, or the
sensorial excitement; or however frequent, open,
sharp, or bounding the pulse; these symptoms
should be arguments against, rather than in
favour of venaeseetion. But if the pulse be not
remarkably frequent, or if it be firm and con-
stricted, then this operation ought to be per-
formed. Yet I should expect little or no advan-
tage from this practice, in those cases of the
disease which proceed from the inoculation of
putrid or morbid animal matters or poisons,
whatever the character of the pulse may be. It
is, however, seldom such as can warrant depletion
in these cases ; being generally of the former
description, and rarely of the latter. The object
which we should propose to accomplish, next to
that already stated, is to rouse and support the
energies of life, and thus to oppose to the exten-
sion of the disease an augmented vital resistance.
'I'his can be done only by a stimulating and tonic
treatment, and by the expulsion from the frame
of such impurities and morbid matters as may
tend to impede the natural functions, and depress
their energies. The means which we should
employ with these views, if judiciously selected,
will be more efficacious than any other for the
fulfilment of the intention proposed above (§ 34.).
The agents which I have found most successful
in attaining them, are large doses of camphor,
with opium, sometimes also with calomel, and
the occasional exhibition of spiiits of turpentine,
either alone or with castor oil, and of one of the
enemata(F. 148, 149.) contained in the Appendix.
The plan I have followed in several cases of this
disease, mostly of a more or less complicated

306

CELLULAR TISSUE— Induration or.

nature, which I have treated, has been to give
the following bolus, or the pills first prescribed ;
and a few hours afterwards the draught, which,
jn three or four hours, should be followed by an
enema (F. 151.):

No. 104. R Caraphoraj rasae gr. x — xv. ; Hydrarg,

Chloridigr. X xx.; OpiiPurigr.jss.-ij- ; Pulv. Capsici

gr. iv. ; Conserv. Rosar. q. s. ut tiat Bolus, statim sumen-
dus, et horas post tres quatuor repetendiis.

No. Ui5. R Camphora; rasa; gr. vij.— xij.; Ammon.
Sesqui-carbon. gr. xv. ; Hydrarg. Chloridi gr. xx.; Pulv.
Capsici Annui gr. viij. ; Opii Puri gr. iij. ; Mucilag. Aca-
ciae q. s. ut fiant Pilulae xij., quarum capiat duas omni
hora vel bihorio.

No. lOG. R Olei Terebinthina; 3 ss.— 3j. (vel etiam
Olei Ricini ? ss.) ; Olei Cajuputi nivj.; Lactis ReceBtis
3ij. >'iat Haustus.

36. If a free evacuation of the bowels be pro-
cured, the bolus and draught should not be
repeated more than once ; if the evacuation be
scanty, they may be given a third time, having
prolonged the period between the second and third
doses; in the intervals between which, as well as
subsequently, the following pills and draughts
may be taken : —

No. 107. R Camphorse rasffi gr, iij — v.; Ammon. Ses-
qui-carbon. gr.iv. ; Pulv. Capsici gr.j.; Mucilag. Acacise
q. s. M. Fiant Pilulae ij., secunda, tertia, vel quarta
qiiaque hora sumendae, cum Haustus sequente.

No. 108. R Mist. Camphorfe 3j.; Liq. Ammon. Acet.
3 jss. ; Spirit. iEther. Sulphuric! Comp. 3 j. ; Tinct. Cap-
sici Annui nix. ; Syrupi Aurantii 3 ss. M. Fiat Haustus, nften extending to the trunk, the parts being cold.

Comment, vol. ii. p. 430. 8vo. ed. 1775 ; and Trans, of Soc.

for Improvement of Med. Knowledge. Lond. 1793

Wilson and Wells, Ibid. vol. iii. pp. 3(i0. 3G7.— C. Smyth,
Med. Communications, &c. vol. ii. p. I'JO. Lond. 1790.
— Ciillcs, On Wounds received in Dissection, Dublin
Hosp. Reports, vol. iii. p. 200. ; et Ibid. vol. iv. p. 240. —
Iiease,\x\ Edin. Med. and Surg. Journ. July, 1826. — Wise-

man, in Ibid. July, 1825 ZJwncara, Trans, of Med. and

Chirurg. Soc.of Edin. vol. i. p. 470. — Herisse, in Journ. d*
Med.&c.t. xii.p 417. Paris, 1806.— //o?hc, Philos. Trans

for 1810, p. 7-5 James, On the Nature and Treatment o

Inflam. Sec. 8vo. Lond. 1821 A. C. Hutchison, Trans, o

Med. and Chirurg. Soc. vol. v. p. 280 Trovers, On Con

stitutional Irritation, 2d ed. 8vo. Lond. 1827; in Lond.
Med. and Phys. Journ. Feb. 1823, p. ^^(\ — Barlow, in
Ibid. Aug. 1823, p. Ml. — Rust's. Magazin fur die Ge-
sammte Heilk. b. xiv. p. 100. — Wanshorough, in Lond.
Med. Repos. May, 1823, p. Zh^.— Author, Ibid. vol. xx.
p. 24. — Shaw, in Med. and Phys. Journ. Ap. 1825, and
Feb. 1827. — Nelsoti, in Ibid. Aug. 1823. — Thomson, in
Ibid. Ap. \H2!i. — Forbes, in Ibid. July, \m6. — Earle, in
Ibid. Jan. 1827. — Butter, On Irritative Fever, &c. 8vo.
1825, — Craigie, Gen. and Path. Anatomy, 8vo. p. 34.

Cellular Tissue — Induration of. Syn.
QHdematie concrete, Billard. Scl^reme,
Chaussier. Squirrho-Sarque. Beaumes.
Skin-bound.

Classif. III. Class, I. Order (yJwt/ior).
Df.fin. a wax-like consistence of the skin
and sub-cutaneous cellular tissue, commencing in
the hands, face, and loiver extremities — the parts
most remote from the centre of the circulation ;

1.

cum Pil. supra pra?scriptis capiendus ; vel

No. 109. R Infusi Cinchona Sj-!; Liq- Ammon. Acet.
3 ij.; Spirit. Ammon. Arom. 3 ss. ; Tinct. Capsici HI xij.;
Olei Cajuputi 111 vj. M. Fiat Haustus, ut supra sumen-
dus.

37. In the slighter cases, less active means
will be found sufficient ; but when the disease
assumes a serious form, and particularly if the
constitutional symptoms manifest themselves be-
fore the affection of tlie cellular tissue has com-
menced or made any sensible progress, the above
or similarly active remedies must be energetically
prescribed.

38, During the course of the more adynamic
states of the malady, after alvine evacuations
have been procured, I have seen the best effects
from the liberal use of wine, and large doses of
bark with the aromatic spices. If the tongue and
mouth be parched, the pills or bolus, and the
turpentine draught, prescribed above, should pre-
cede the exhibition of the wine, bark, or sulphate
of quinine. The irritability of the stomach and
delirium, often accompanying the advanced stage
of the worst states of the disease, being more
readily allayed by powerful stimuli, as camphor,
capsicum, ammonia, ether, spirits of turpentine,
cajuput and other essential oils, cinchona, and
serpentaria, with the carbonates of the alkalies,
sulphate of quinine, wine, brisk bottled ale and
stout, very small doses of opium, brandy, &c.,
than by medicines of any other description, it will
be necessary to administer these, in forms of com-
bination suited to the circumstances of the case ;
chiefly with the view of rousing and supporting
the energies of life, changing the state of morbid
action, and thereby preventing the extension of
the local mi.schicf, and the tendency to contamin-
ation of the fluids and solids of the frame. The
regimen during the treatment should be in ac-
cordance with these intentions, and the patient
should be allowed what he may crave for; as de-
sire in such cases for articles of food, or for par-
ticular beverages, is the instinctive expression of
the wants of the economy.

Rini.ior.. AM) lirrER.— Morand, Hist, dp I'Acadi'mie
Roy. dc8 Scienc»s,Au. 17GG f. Hunter, Med. and Philos.

often pale, yellowish, or rose-coloured , frequently
mottled, or livid, with weak pulse and respiration,
terminating in congestion of the lungs and asphyry.

2. This affection was first described, in 1718,
by J. A. UzEMBEzius, physician to the hospital
at Ulm, and afterwards more fully investigated
by Doublet, Andry, Auvity, Hulme, Denman,
and Underwood, as well as by several contem-
porary writers. It is very prevalent and fatal in
some of the lying-in and foundling hospitals on
the Continent, but is comparatively rare in this
country, especially during recent times. Its na-
ture and seat have been much discussed by foreign
medical writers ; and even at present, various
points connected with its pathology are not fully
established. It is, however, evident that the dis-
ease assumes various forms, and exhibits different
morbid relations, which may be referred to the two
following varieties.

Var. i. (Edematous Hardening of the Cellular
Tissue ; Sclerime ccdemateux, Chaussier and
Duces.

3. In this form of the disea.se, the sub-cuta-
neous cellular tissue is infiltrated with a yellowish
coagulable albuminous serum ; the limbs of the
infant are more or less tumefied as well as hard,
are somewhat rigid, and the skin assumes a vio-
let tint, owing to the pulmonary congestion ac-
companying it ; with weak oppressed respiration,
and feeble irregular pulse. In some cases, it
commences with simple oedema, particularly
when it arises from exposure to cold. If the cold
have acted upon the greater part or whole of the
surface of the body, the affection is sometimes
more or less universal, but u.sually most remark-
able in the limbs. It rarely attacks the abdomen,
chest, and neck. The parts diseased are cold,
tumid, discoloured, insensible, hard, and receiving
and preserving the impression of the finger when
very firmly applied. During the progress of the
affection, the cry becomes very weak and peculiar ;
dyspnoea increases ; the thorax is dull on per-
cussion ; and the impulse of tiie heart and the
respiratory murmur are found weak on ausculta-

CELLULAR TISSUE —

tion. Death often follows in from four to eight
days, without any convulsion, but generally pre-
ceded by a lethargic somnolency ; and spasmodic
attacks resembling slight trismus, and opistliotonos
sometimes occur in the advanced stage. The in-
durated parts occasionally assume an erysipelatous
appearance, and, in rare instances, pass into sphace-
lation. In favourable cases, or after an early and
judicious treatment, tiie affection subsides; the
hardness, and afterwards the oedema, disappearing
in the course of two or three weeks. I\I. Gardien
states, that he observed suppuration of tiie affected
part to occur in one case only.

Vur. ii. Imiurtition affecting chiefly the Adipose
Tissue ; Scltreme coiicret, Chavssier, Duces;
Skin-boiuid , of English autiiors.

4. This variety generally depends upon the
sudden impression of severe cold ; is compara-
tively rare, and is chiefly met with in lyiug-iu
and foundling hospitals. The cheeks, limbs, fore-
arms, thighs, back, abdomen, chest, and jUeck,
successively, or two or more of tiiem simultane-
ously, assume a remarkable hardness, which
yields not to the pressure of the finger. The
temperature and sensibility of the surface are
mueli depressed; aDd with difficulty raised. The
skin is pale or yellowish, and wax-like ; sometimes
livid or mottled. Trismus and opisthotonos are
more common in this than in the preceding va-
riety. There is little or no tumefaction or cedenia ;
the skin being fixed and immoveable upon the
subjacent parls. In some instances, the extre-
mities and back are somewhat emaciated, dry,
and even rigid, particularly in the advanced
stage; and the cheeks and temples are collapsed.
At the commencement, the appetite and digestion
are often not much affected ; but during the pro-
gress, and towards the close of the disease, the
bovvels become more or less disordered. Dr. Den-
MAx and Dr. Underwood seldom met with it
but accompanied with some bowel complaint.
The infant soon becomes too feeble to draw the
breast ; it utters a peculiar moaning noise, or
feeble whining cry ; and has the appearance,
even early in the complaint, of dying; and, at
last, sinks, apparently asphyxied. In favourable
cases, the skin and extremities lose their hardness
and rigidity, and the infant recovers gradually,
if pulmonic inflammation does not come on, and
carry it off. Inflammation of the indurated parts
seldom or never appears in the course of this
variety.

5. I. Pathgi.ogy. — i\I. Gardien states, that he
has sometimes remarked a slight increase of heat
precede the insensibility, coldness, and hardness
of the parts affected ; but without any general
febrile symptoms. The only indications of dis-
order he has observed to usher in either variety,
are difficulty of respiration, and a peculiar feeble-
ness of the pulse and of the voice. Somnolency
or lethargy is very usual during the course of the
disease, and, as JM. Doublet observes, increases
towards a fatal termination. The aflfection, par-
ticularly the latter variety, is rarely congenital.
M. DupARCQUE has detailed two cases in which
the infant upon delivery was so hard and rigid as
to resemble a mummy, the vessels of the umbilical
chord being diseased.

6. A. Causes, — The different states of this
disease have been attributed to a syphilitic taint.
It is, however, most commonly owing to the

Induration of — Causes.

307

influence of cold upon new-born infants, and
generally occurs from the second to the four-
teenth day after birth. Imperfect or unwhole-
some nourishment, and the influence of a vitiated
atmosphere, particularly the air of crowded hos-
pitals, upon the imperfectly developed respiratory
functions, are, in my opinion, amongst its most
energetic causes. It is very apt to occur in pre-
maturely born infants, in those of a feeble con-
stitution, and who are deprived of the mother's
or nurse's milk. M. Palletta remarks, that out
of sixij'-five cases, forty were prematurely born.
M. Ratier states, that ils dependence upon at-
mospheric cold is shown by the greater number
of cases at the Hospice des Enfans-Trouies, when
winter sets in. But as a free ventilation, and dis-
sipation of the foul air of an hospital ward, are in
some measure prevented during cold weather, the
prevalence of the disease at this season may be
equally owing to this circumstance. JM. Billard
has shown that the number of cases in the warm
months is usually not much less than in the cold,
in the above-named hospital. Dr. Bigeschi, how-
ever, states a fact, in his report of the Lying-in
Hospital at Florence, which shows the great
influence of cold in causing this aflfection. He
observed the disease very prevalent during the
winter season, especially if rigorous ; and he con-
sequenily ordered the infant to be kept in the
mother's bed, as warm as possible ; and from that
time no case of it occurred. JM. Souville has met
with the disease frequently in the northern de-
partments of France, and also attributes it chiefly
to cold, the influence of which is likewise admitted
by Palletta. It sometimes, also, occurs in the
course of the bowel complaints incidental to in-
fants, particularly when improperly nourished ;
and it is frequently complicated with the jaundice
of this epoch. JM. Bili.ard states that, in seventy-
seven cases with cedematous induration, thirty
were jaundiced.

7. B. Appearances in fatal cases, — In the first
or most common variety, the cellular tissue is
found loaded by a thick albuminous serum, which
coagulates by heat, and which, according to JM.
Leger and JM. Billard, partly escapis upon
dividing it. Dr. Palletta, however, states that
upon division, it remains firm and concrete, the
infiltrated matter not escaping. In the second or
more rare foim of the affection, the cellular and
adipose tissues are hard, concrete, and frequently
of a deep yellow colour. The adipose tissue often
presents a number of small dark yellow grains
dispersed through it. The lymphatic glands, as
well as the mesenteric glands, are enlarged ; and
slight serous or sero-albuminous deposition into
the cellular tissue is observed throughout the
body, with sanguineous or sero-sanguineous infil-
tration of parts of it ; and eff"usion into the shut
cavities. The vessels of the brain are usually
congested. The cavities of the heart are loaded
with blood ; the foramen ovale is sometimes more
open than it should be ; the pericardium contains
some sanguineous serum ; the lungs are often
congested or hepatised ; and the larynx and
epiglottis cedematous. The liver is frequently
large and congested ; the gall-bladder and he-
patic ducts full of bile; and the gastro-intestinal
mucous surface more or less inflamed. The most
constant morbid appearances are the engorgement
of the venous system ; the dark or black state of
X 2

308 CELLULAR TISSUE — In

the blood ; the accumulation of a thick, deep-
coloured, viscid, or coaguliited fluid in the adipose
and cellular tissues, impartincr to them a condensed
or firm appearance ; and the congestion of the
thoracic viscera : but these latter are commonly
not otheiwise diseased.

8. C. Proximate Cause. — The first variety of this
aflfection may be considered as a form of oedema ;
the peculiarity resulting chiefly from the thick,
coagulable nature of the effused fluid, and the de-
ficient developement of animal heat in parts far
removed from the centre of the circulation ; in
consequence of which the adipose matter either
is secreted in a morbid state, or cannot be pre-
served in its natural semifluidity. The second or
more rare form of the affection is chiefly to be
attributed to this change of the adipose substance,
which, owing to defective vital manifestation in
the part, and the depressed grade of animal
warmth, assumes the condition which it usually
presents soon after death. M. Uenis supposes
that the disease is connected with the gastro-
intestinal irritation so frequently found upon dis-
section. Dr. HuLJiE, and, more recently, Dr.
Pali. ETTA, viewed it as consecutive of, and occa-
sioned by, the congestion of the lungs and the
difficulty of the pulmonary circulation ; whilst
M. Bahon, physician to the Parisian Hospital,
in which from two to three hundred cases occur
every year, considers that the internal congestion
takes place subsequently to the appearance of
the di'^ease. 1 believe that this is the more cor-
rect view ; for M. Billard found unusual con-
gestion or hepalisation of the lungs in less than
one half the cases he examined. There can be
no doubt, however, that as the affection of the
cellular tissue proceeds, and as the circulation in
this tissue and in the extremities is more and
more retarded, congestion of the internal viscera
comes on, but not always in the same organ ; the
encephalon, cavities of the heart, liver, and spleen,
also experiencing tliis change ; sometimes with
serous or sero-sanguineous efl^usion into the ad-
joining shut cavities. The frequent complication
of the disease willi jaundice would seem to indi-
cate that the biliary organs are moi-e or less
affected ; and such may be the case in respect
of their functions: but M. Billard found, in
ninety cases, twenty only of organic lesion of
the liver, the icteric appearance being evidently
dependent upon the morbid state of the serum
of the blood, and the deficient viial endowment
of the cutaneous capillaries. JM. Breschet had
found the foramen ovale more than coinmonly
open in many cases, and inferred that the aflfec-
tion was caused by this circumstance. M. Bil-
LAKD states, that his numerous examinations do
not countenance this inference, but admits that
tbey are often coincident changes. This writer,
who has paid much attention to the subject,
concludes, that general debility, congenital ple-
thora of the va-^cular system, congestion of venous
blood in tlie tissues, and unusual dryness of the
skin previous to the exfoliation of the ej)idermis,
are its chief predisposing causes ; and that vas-
cular plenitude, an engorged state of the cellular
atid adipose tissues, and the influence of external
agents interrupting cutaneous li-anspiration, are
its more immediate causes ; the coldness of the
extremities and affected parts resulting from the

duration of — Treatment.

slowness of the circulation and the depression of
the vital powers.

9. DiAONosis and Prognosis. — A. This af-
fection is obviously more or less intimately re-
lated to oedema on the one hand ; and, in some
instances, to erysipelas on the other: — to the
former, by the effusion of fluid in the cellular
iissue ; but difl'ering from it chiefly in the persist-
ent, firm, wax-like, and coagulated state of the
infiltrated past, and in the reddish yellow, livid,
or mottled appearance of the skin ; — to the latter,
by its frequently dark red or livid colour ; but
difl^ering still more widely from it, in the pi'incijial
aflfection of the cellular tissue, in the remarkable
coldness of the part, languor of the circulation,
and general absence of any change in the skin
itself. And it is distinguishable from both, by the
peculiar cry of the infant ; the weak, moaning,
and sibilant respiration, the dyspnoea, the feeble
irregular action of the heart ; the leipothymia and
lethargy, and the frequent complication with tris-
mus and tetanic spasm ; as well as with the peculiar
jaundice of infants. It may be also mistaken for
erythema nodosum ; but the knotted sensation upon
passing the fingers over the skin, furnished by this
affection, is sufficient, of itself, to distinguish it
from the smooth, cold, and diflfused hardness of
the present disease.

10. B. The Prognosis should be always re-
served or cautious. A large proportion of those
attacked die, particularly in hospitals, even under
the most judicious management; sometimes in
two, tiiree, or four days, in the most severe cases,
and in prematurely born children that have been
exposed, soon after birth, to cold. But, generally,
the disease does not terminate either way in less
than from six or eight days to twenty or thirty.
It may even be more prolonged ; and, when re-
covery is advancing, inflammation of the lungs or
digestive canal, or effusion on the brain, may occur,
and either cut oflT the patient, or put his life in the
utmost jeopardy.

11. II. Treatment. — The intentions of cui-e
will vary with the particular form of the disease.
In the first, ov cedematous vaiety, in which vas-
cular plethora is generally present, depletion is
often of service ; particularly if the circulation in
the extremities and affected part be at the same
time excited by means of frictions with warm sti-
mulating liniments. MM. Baron and Billard
prefer frict'ons to the use of the vapour bath, recom-
mended by MM. DuGKs, Peligot, and others. In
the second variety, in which there is less oedema,
and greater induration, and, according to several
recent writers, a coagulated state of both the adi-
pose substance and the fluid eflfused into the cel-
lular tissue, blood-letting may not be admissible.
MM. CiiAMDON, Pai.letta, and Gardien, how-
ever, consider that, in this variety also, depletion
sl.ould be practised, in order to relieve the cere-
bral congestion attending it ; and therefore re-
commend two small leeches to be applied behind
the ears. In this practice I have generally con-
curred, but have adopted it with much caution in
prematurely born or weakly infants ; directing,
also, for all the states of the disease, calomel or
iiydrarg. cum creta, witli soda, and small doses of
ammonia; the compound decoction of sarsaparilla
with liquor potassaj ; the warm bath, followed by
repeated frictions of the surface with stimulating

CHEST— External Ex

liniments ; and the nouvishmentof Nature intended
for the infant. Although a very common and
fatal disease in France, it is seldom observed in
this coimtry ; and even at the Infirmary for Chil-
dren, cases of it have very rarely presented them-
selves. I have not met with an instance of it in
tlie Queen's Lying-in Hospital.

12. After the above means have been perse-
vered in for a time, a few drops of spirits of tur-
pentine and sweet spirits of nitre may be given
occasioniilly in sugared dill-water ; and the infant
enveloped in very soft flannel or wash-leather,
which ought to be covered over with oiled silk, in
order to prevent the dissipation of the animal
heat. Dr. Palletta states that he treated, with
uncommon success, the very numerous cases that
occurred in the Lying-in Hospital at ftlilRn, with
half a grain of the kermes mitiernl ( F. 6.37.)
given three or four times a day, and warm bran
or warm flour applied to the parts affected. An-
DRY and Gardien advise the use of blisters; —
the former to the affected parts ; the latter to the
nape of the neck, with the view of preventing the
occurrence of cerebral conge?tion; — but I have
had no experience of their U'^e in this disease ;
and consider them less efficacious than frictions
with stimulating liniments, several formiilae for
which are given in the Appendix. During treat-
ment, a pure warm air, and the natural food of
the infant, furnished by a healthy nurse, will be
found extremely conducive to recovery.

BiBLioG. AND Refer Vzembezhis, in Ephem. Nat.

Curios, cap. ix. ob. 30. p. 62. 171S. — Doublet, in Joiirn. de
Med. Avr. 1785, p. 447. — Beaumes, Fondemens de la
Science Method, des Maladies, t. i. p. 31-1 — Underwood,
On the Diseases of Children. 8th edit. 8vo. p. 25G Gar-
dien, Traite Comp. d'Accouchemens et des Malad. des
Filles, des Fern, et des Enfans, t. iv. p. 91. Paris, 1826.

Pallctla, in .\rchives Gen. de Medecine, t. v. p. 105.,

et Ibid. t. ix. p. IIG.—Liger, in Ibid. t. vii. p. 16 Du-

parc(/ue,'tiouv. Bibliotheq. Med. Sept. 182S, p. 333. —

Jin/wr, Arcliives Gener. de Medecine, t. X'ii. p. 42

Bitlard, in Ibid. t. xiii. p. 204, et Traite des Maladies des
Enfans, &c. 8vo. Paris, 1828, p. 169 — Duges, Manuel
d'Obstetrique, &c. Paris, 1830, p. 437.

CEPHALrnS, See Brain, Inflammation of.
CHEST. Svx. Thorax, Fr. Der Brustkasten,

Ger. Tnrace, Ital. The Thorax.
Exterval Examination of, in the course of

Disease. — Classif. General Pathology

— Semeiologv.
1. Regions of the Chest. — It is necessary to
divide the chest into different regions, in order to
give precision to our diagnostic researches. This
is done by drawing horizontal and vertical lines
from certain conspicuous parts of the body. The
first horizontal or transverse line extends ante-
riorly from the humoral extremities of eacii cla-
vicle, across the junction of the clavicles with the
upper part of the sternum, posteriorly passing over
the last cervical vertebrffi ; the second, around
the middle of the chest, anteriorly passing over
the nipples, and posteriorly parsing between the
spine of the scapulae and their inferior margins;
the third pas^^es around the lowest part of the
chest, from the zyphoid cartilage, and over the
hypochondria. The first vertical line extends
from the upper to the lower extremity of the
sternum ; the second and third, from each acro-
mial extremity of the clavicles to the external
rami of the pnbes ; the fouttb and fifth, from
each posterior margin of the axilla; to the crests of
the ilia; the sixth and seventh, from the clavicular
transverse line along the posterior border of each

AMINATION of, in DtSEASE.

309

scapula, or a little exterior to it, to the middle
horizontal line ; and the eighth, along the spinous
processes of the dorsal and cervical vertehrae.
'i'o these lines may be added one drawn on each
side, from the last cervical vertehra, around the
lower pait of the neck, and sloping downwards to
the upper part of the sternum. I'hus the chest
will be divided into sixteen regions, viz. two
superior, or humoral regions ; four anterior, — the
subclavian and submammary ; four lateral, — the
axillary and subaxillary ; and six posterior, — the
scapular, subscapular, and interscapular.

2. The viscera lodged beneath each of the
difterent regions of the chest, and the nature of
its parietes, are too well known to require any
notice. I therefore proceed to point out the va-
rious methods which are employed to investigate
the diseases of the thoracic organs. These con-
sist of inspection, mensuration and manual ex-
amination, percussion, succussion, and auscul-
tation.

3. A. Inspection. — It is important for the
physician to take into consideration the form and
size of the chest, in estimating the causes, nature,
and tendencies of disease. Vigour of constitution
is generally incompatible with a small or ill
formed thorax ; this conformation not only dis-
posing to various affections of the viscera con-
tained in this cavity, but also aggravating their
severity. Every change from the due proportions
of the chest ought to be considered of importance.
This cavity is generally artificially modified in
its form in females. Its capacity is reduced in
a transverse direction, by the lateral compression
to which it is subjected ; and, owing to the same
cause, the superior abdominal viscera are pushed
upwards, and it is thereby further diminished in
a vertical direction. But the compression thus
exercised not only reduces the absolute capacity
of the chest, but it also prevents the elevation of
the ribs, and the descent of the diaphragm during
respiration, rendering each inspiration of small
amount, and insufficient for the developement
and wants of the frame. It moreover presses the
lower ribs downwards and inwards upon the more
important viscera contained in the abdomen ;
prevents the ascent of the contents of the caecum ;
and favours lateral curvature of the spine, which,
in its turn, tends remarkably to diminish the ca-
pacity of the chest.

4. During inspection of the thorax, there are
other circumstances, besides its form and size,
which should fix attention. 'The action of its
parietes, the equality of the motions of each side,
and their connection with the movements of the
abdomen, are of the utmost importance. In
pteuritis, the motions of the ribs of the aflTected
side are greatly impeded ; and if both sides be
afl^ected, the costal parietes are but little moved
during respiration, this function being chiefly per-
formed by the diaphr.igm and abdominal muscles.
On the other hand, when the diaphragm, or
either of its serous surfaces, are inflamed, or when
intense inflammation affects any of the superior
abdominal viscera, respiration is chiefly performed
by the costal parietes. In the first case the re-
spiration is said to be abdomimd, in the second
thnracic.

5. It is chiefly by actual inspection of the
chest that we can ascertain the existence of
oedema of its surface: the distance between the

X 3

310

CHEST — Deformities of the.

ribs, the prominence of the spaces between each,
the existence or non-existence of partial contrac-
tions, and bulgings or prominences of its walls,
— are all important facts in our diagnosis of dis-
eases seated in this cavity. Thus, in phthisis, when
the pulmonary tissue is tuberculated, shrunk,
or contracted, &c., a falling in of the ribs, par-
ticularly of the subclavian region of one or both
sides, is observed : whilst in asthma and em-
physema of the lungs, the ribs are full and ex-
panded. This slate, however, of the ribs may
exist only on one side; as in cases of pleurisy of
one side, terminating in effusion, in empyema,
and in pneumothorax, we often observe the af-
fected side expanded, and the intercostal spaces
prominent, whilst the other is natural. In other
instances of organic disease, one side may be un-
commonly contracted ; as after cures of old, or
chronic, or circumscribed pleurisy, in partial or
general destruction of one lung, and in lateral
curvature of the spine. In many of these, the
opposite or sound side is fully developed, owing to
a slight hypertrophy of the sound lung; in eases
of curvature, one side is always prominent in pro-
portion to the depression of the other. The pro-
minence of the sternum, and lateral depression of
the ribs, which is so common in children ; and
the falling in of the sternum, and prominence of
the ribs; are ascertained by inspection.

6. B. Manual examination and mensuration, —
It is of importance to ascertain the existence of
tenderness on pressure in various parts of the
chest, particularly when the patient complains of
pain, or difficult respiration. This can only be
done by manual examination. Extreme sensi-
bility of the external surface indicates either irri-
tation of the membranes of the spine, or rheuma-
tism affecting the parietes of the chest. When
pressure in the intercostal spaces is required to
develope the pain, disease is usually seated in the
pleura, or parts beneath it, or in the pericardium.
It is seldom, however, that we can occasion pain
by pressing between the ribs in cases of organic
disease of the substance of the lungs, or even of
the pulmonic pleura, unless this latter has formed
adhesions to the costal pleura. During manual
examination, attention should be paid to the ex-
istence, the kind, and the extent of moisture on
the surface of the chest ; to its temperature,
which is generally more or less increased in in-
flammations; and to the palpitations or impulse
of the heart. It is evident that the existence of
oedema or emphysema of the surface of the chest
is chiefly to be ascertained by manual examina-
tion of it.

7. Mensuration of the chest may be sometimes
required, in order to ascertain either the degree
of prominence of one side, or of the contraction
of the other. In both cases a piece of tape is
used ; the measurement being made from the
spinous processes of the vertebra; to the central
line of the sternum, and from the lop of the
shoulder to the lowest rib. The admeasurement
should be taken during a full inspiration and
expiration, and the progressive increase or de-
crease noted. It will often happen that no dif-
ference between either side exists during a stale
of tran(|uil respiration; and yet, upon forced re-
Kpiniiioii, the difference is very manifest.

H. Mr. AijiKNiiiiY pro|)os'j(l, many years ago,
— and the proposition has been recently revived on

the Continent, — to ascertain the capacity of the
lungs, by measuring the quantity of air they are
capable of containing, as an indication of the
extent of disease by which they are aflfected. The
recommendation was rational, and deserving of
greater attention in several affections of this organ
than it has received, particularly when the evi-
dence furnished by the measure is duly estimated
in conjunction with other signs. The method
simply consists of the patient taking as deep
an inspiration as he is able, and then expiring
through a tube, one end of which is passed under
a glass jar, containing, and inverted over, water.
The quantity of water displaced is the measure
of the capacity of the lungs. A person, lull grown
and in health, usually displaces from six to eight
pints. If the amount be much less than this, it
may be inferred that the lungs are obstructed by
disease of their substance, or by tumours, effu-
sions of fluid in the pleura, or other causes press-
ing upon them externally. Although muscular de-
bility, or spasm, may diminish the quantity of air
inspired, yet there can be no doubt that the method
is calculated to furnish very useful information.

9. Some years since, it was proposed by a
physician on the Continent, to test the capacity
and soundness of the lungs by causing the patient
to take as full an inspiration as possible, and to
count from one upwards, in a deliberate manner,
during the following expiration, and whilst ex-
piring as slowly as he can. The number that
will be reached, either during the expiration or
whilst the breath is retained, or before a new in-
spiration is entered upon, will be an index of the
soundness of this organ. Dr. Lyons, who has
more recently recommended a modification of
this method, advises that the period should be
noted by the seconds hand of a watch. He states
that a healthy individual will not continue count-
ing above thirty-five seconds; and that, in con-
firmed phthisis, the period never exceeds eight,
and seldom six seconds. I have practised this
method during the last five years, and have sel-
dom found a healthy person who could proceed
beyond thirty-five seconds, and scarcely one who
could go beyond forty ; but I have met several
cases of pulmonary consumption, where, up to a
very advanced stage of the disease, twelve, fifteen,
and, in one case, twenty seconds were reached;
and even in the last stage, eight or ten seconds
are not uncommon ; although the number men-
tioned by Dr. Lyons is much more fre(]uent.

Percussion, succussion, and ausciiltation of the
chest, are comprised in the articles Auscultation
and Percussion.

BiuLioG. AND ItEFER Aucnhrugfser, in Journ. de

Medcrine, t. xxxii. p. 84 Duttble, in Journ. Gener.

de Med. t. xxix. p. 241. — Lacnnec, De I'Aiiscultation
Mediate, I've. 2d edit. 8vo. t. i. Tar. lA'ir,. — Ahciwlhi/,
Physii>liigical Essays, part ii. p. I.i7. — Lynns, VaUw. Meil.
.loiiru. vol. xxviii. p. 45:). — Unpuylroi, Ariliives (ion.dc
M6d. t. xvi. p. .').56. — I'iorry, I'roccde Operatoire, &c.
dans rExploration des Organes, 8vo. Paris, 1831.

DEionMrriES or the Chest. .— Classif. I.
Class, III. Order (Aullior).

1. I. Latehai, Depression of the Chest. —
Depression of the lateral parietes of the chest had
escaped the attention of authors, although of very
frequent occurrence, until ]\]. DuruviREN wrote
a memoir on the subject {Repertoire Gen. d' Ana-
tomic, &;c, I. v. p. 1 10.). A few scattered remarks
on the subject may be found in the writings of
V'an Swieten, J. L. I'etit, Levacheu, and

CHEST — Defo

oilers, who have attributed it to rickets and other
affections, and iiave evidently been unacquainted
with its nature, causes, effects, and metliod of treat-
ment. Not a week passes without cnses of this
contraction being presented at the Infirmary for
Children ; and, although sometimes a congenital
deformity, it has appeared to me very frequently
to be greatly increased, if not altogether occa-
sioned, subsequently to birth, by the very common
practice among nurses of lifting the child by press-
ing the palms of the hand on the sides of the chest,
immediately under the armpits. This deformity
consists of a greater or less depression of both sides
of the thorax, with a proportionate protuberance
of the sternum and abdomen forwards, and of the
vertebral column backwards.

2. It is most commonly found in infants born of
debilitated, lymphatic, scrofulous, and rickety pa-
rents,— particularly tliose inhabiting low, cold, and
moist situations, or who live in small ill-ventilated
apartments, — and amongst children who are badly
clothed and nourished. In many cases the de-
formity does not consist of merely a level depres-
sion of the lateral parietes ; but the ribs are
actually bent inwards, the sternum and spine
forming a curve outwards. In some the lower or
upper parts of the sternum are the most promi-
nent. This extreme grade of depression is seldom
or ever met with at the moment of birth ; M. Uo-
PUYTREN thinks differently. My experience leads
me to state that it generally comes on gradually
after biith, owing to deficient inflation and deve-
lopement of the lungs, arising from the weakness
of the muscles of inspiration, and flexibility of the
ribs at the time of birth. In cases of this descrip-
tion, the vital energy of the lungs is insufficient
for their healthy actions, and the respiratory me-
chanism is unable to accomplish their full expan-
sion, or to sustain the continued pressiire of the
atmosphere, before which the soft and imperfectly
formed thoracic parietes gradually yield. The
manner in which nurses frequently lift infants, as
already stated, tends further to increase the mis-
chief, particularly in those who are originally
weak and ill-nourished. The effects of this co-
arctation of the thorax upon the functions, and
ultimately on the structure, of the lungs and
heart, soon become very evident. We usually
find the pulse quick, and the breathing oppressed ;
with a weak voice, occasional anxiety, and inca-
pability of speaking or reading for any time, or of
uttering many words without frequent pauses.
In the newly-born infant, there is a great difficulty
of suckling, from its inability to raise the ribs with
sufficient power to perform this process. It is
seized with suffocation when at the mother's
breast, which it often quits with fits of crying.
As it advances in age, the disorder of respiration
and circulation is still more remarkable, particu-
larly upon ascending acclivities. The pulse be-
comes quick, irregular, or intermittent ; and is
accelerated upon the slightest cause, whether phy-
sical or mental.

3. In children whose chest is thus compressed,
the tonsils generally, or rather constantly, become
tumid, — so much so, as frequently to increase the
disorder of the respiratory actions ; and all the
structures and organs of the body are impaired
both in function and in developenient, owing to
tlie derangement which the deprc'^sion occasions to
respiration and ciicuKition. In many cases which

RMITIES OF THE. 31 1

have coine before me, rapid emaciation, great de-
bility, defective assimilation and sanguifaction, an
atrophied and flaccid' state of the muscles, soften-
ing of the bones, frequently asthenic or chronic
bronchitis, and swelling of the glands, have fol-
lowed the deformity, and terminated the life of
the patient.

4. Organic lesions. — In these cases the appear-
ances observed on dissection are such as the ori-
ginal and consecutive ailments lead us to expect.
These consist in retarded developement of the
skeleton ; want of union between the bones com-
posing the cranium ; enlargement of the heads
of the long bones, sometimes with softening and
flexures of their bodies. Dentition is also re-
tarded ; and, if it have proceeded, the crowns of
the teeth are eroded. The voluntary muscles are
atrophied, soft, pale, and exhibiting a fish-like
structure. The lungs are compressed towards the
vertebral column, and present a corresponding
depression to that of the lateral parietes of the
chest, with the marks of the ribs indented in their
posterior and lateral surfaces. This organ is often
studded with tubercles of various sizes ; portions of
it are frequently inflamed or hepatised ; and, in
some cases, attended with bronchitis, the bronchi
are more or less loaded with mucus, or muco-
purulent matter. The substance of the heart is
commonly pale and flaccid ; and, in young in-
fants, the foramen ovale is sometimes widely open ;
and in older children but imperfectly closed. The
mucous follicles of the intestinal canal are often
tumefied, but rarely ulcerated, excepting when a
chronic diarrhoea has attended the latter stages of
the thoracic compression. The mesenteric glands
are also occasionally much enlarged.

5. II. Depression of the Sternum, with late-
ral prominence of the ribs. — This deformity is the
reverse of the former: the sternum is pressed in-
wards, either at its middle or lower part, or along
its whole extent ; the ribs are very much bent,
and prominent laterally ; the chest being broad,
but compressed anteriorly, the shoulders high,
and the spine either straight or but little altered
from its natural form. This change has also been
much overlooked by authors. INIr. Coulson, how-
ever, has lately noticed in it an instructive article
on deformities of the chest. It is by no means
uncommon both in young and grown-up subjects,
although not so frequent as the lateral depression.
In cases of depression of the sternum, the lungs
and heart are compressed anteriorly ; their func-
tions much altered, and ultimately their structures.
This deformity is very seldom congenital, being
the consequence of weakness, or of a scrofulous
or tubercular diathesis. I have met with two in-
stances of it out of six members of one family who
died of consumption soon after puberty. It is in
some cases antecedent of any apparent disease of
the lungs ; in otfjer instances, it is consecutive of
pulmonary disease ; and in others, of external
pressure and stooping occupations.

6. It is not uncommon to find females with
the chest of a cylindrical or oval form, instead of
being a truncated cone ; entirely in conseciuence of
the inordinate pressure to which its lower part has
been long subjected from tight lacing of the stays.
In some of these cases, the sternum, particularly
its lower part, is piesscd inwnrds. The effects,
however, of this habit, and of the deformities
which it occasions, have been alluded to in an-

X 4

312

CHICKEN-POX.

other part. (See Chest — Examination of the,
§3.)

1. III. Treatment.— ^^. The cure of the lateral
depression of the chest is by no means so hopeless
as it may appear, -particulaily if it be attempted
at an early period, and before serious organic mis-
chief has been pruduced. Invigorating medicines
and nourishing diet are requisite, particularly in
conjunction with various external and mechanical
means.

8. a. The external treatment which I have found
the most successful, consists of warm or tepid
salt water bathing in infants ; and in directing
tlie mother to make pressure very frequently
tlirougb Uie day upon the protuberant spine and
sternum, by placing one hand on the former, and
the other on the latter. But this pressure must
be so managed as to be made only at the moment
of expiration, and entirely suspended during the
moment of inspiration, so that no impediment may
be in the way of the free dilatation of the parietes
of the chest. The practitioner should take care
to instruct the mother in the manner of employ-
ing the pressure upon the sternum and spine,
with the view of throwing outwards the depressed
lateral walls of the chest. The more frequently
this pressure can be employed, the better ; and
its benefits will be considerably promoted by ap-
plying the following liniment, night and morn-
ing, along the spine, or even uport both the
sternum and spine. I have employed this and
similar liniments, in these situations, with the
gieatest advantage, in this and several other dis-
eases connected with debility, particularly in
young subjects.

No. 110. R I,inimenti Campliovae Comp., Linim. Sa-
ponis Comp., aa 3 j. ; Olei Tereljintliinae 3 vj. ; Beiizoini
Sij-; Stjracis Balsamijjss.; Olei Cajuputi, OleiLimonis,
aa 3 ss. M. et fiat Linimentum.

9. In public practice, I have visually substi-
tuted for the above, either equal parts of the com-
pound camphor and turpentine liniments; or
the=e, with the addition of the soap liniment, or
their equal quantities of olive oil and turpen-
tine, with a liltle soft soap. In conjunction
with these means, the artificial salt water baih,
with a very large proportion of salt, at a tem-
perature suited to the peculiarities of the case,
will be found extremely serviceable. As soon as
children affected by this depression of the walls
of the che>;t can be brought to employ the muscles
of the upper part of the body in a determinate
manner, this mode of treatment should also be
employed. Perhaps the best mode of overcoming
the depression, by developing muscular action and
power, is to cause the child to raise weights, by
mejins of ropes and pulleys plactrj at a consider-
able height o\er its head ; so that, by taking hold
of the lope with both hands raided above the
liead, and pulling it downwards, the muscles may
be brought into action, anil the parietes of the
chest thereby dilated, iiut modemte and duly
regelated exercise, particularly of the muscles of
the aim and trunk of the body, accompanied with
invigorating nitdieines and regimen, will be pro-
ductive of benefit.

10. h. Inlernal treatment should always be
conjoined with the means stated above. The
digestive functions generally retjuire regulation,
and tonic or permanent excitement. After having
evacuated nuirbid si cretions and faval accumu-
lations fiom the bowels, by means of the usual

purgatives, of which rhubarb, or senna combined
with a tonic bitter, is among the most suitable,
Brandish's alkaline solution, or the solution of
potash, or other preparations of this substance,
may be given, either in some gruel or mutton
broth, or in a tiniic infusion, or combined with the
preparations of iron. The following powders may
also be taken once, twice, or thiice daily : —

No. 111. R I'erri Sulphatis exsic. gr. ij. — vj.; Potasss

.^ulphatis gr. xij xx. ; Pulv. Ca>CHrillaB 3j. — 3 jss.

Misce bene, et divide in Chartulas xij. sequales, quarum
capiat unam bis terve quotidie.

No. 112. R Potassae Carbon, gr.j iv. ; Ferri Sesqiii-

oxidi gr. iij.; Pulv. Rhei gr. iv. — ix. ; Pulv. Cascarillae
(vel Calumba") pr. v — xij. Misce. Fiat Pulvis.

No. 113. R Ferri Potassio-Tartratis gr. iij. — xvj.;
Pulv. Caluraba; gr. vj — xij. ; Pulv. Zingib. gr. ij. M.
Fiat Pulvis.

11. Instead of these, the tincture of the am-
monio-chloride of iron ; mixtures containing sul-
phate of quinine ; or the tincture of iodine, in doses
of one to three dops, twice or thrice daily, may be
employed advantageously. In every other respect
the treatment is the same as that recommended
for Rickets. But whatever mode of cure be
adopted, change of air, or at least a wholesome
pure air, with regular exercise, is requisite to its
success. In this deformity, the various exercises
resorted to with the view of imparting strength and
agility to the frame, will be useful, if judiciously
directed.

12. B. The treatment of the other deformities of
the chest must be conducted very nearly on the
same principles ; the pres-ure, in cases where it
may be proper to have recourse to it, being made
in an opposite direction to that recommended
above, when the anterior parietes are depressed.
But this deformity is very seldom met with so
early in life a? to admit of any expectation of ad-
vantage fi om the use of pressure. The other means,
as Icng as the pathological states of the thoracic
viscera do not contra-indicate them, are tlie most
applicable.

BiBLiuG. AND Refer Dripuytren, in Repertoire Ge-
nerate d'Anatomie et Patliologie, tS;c. t. v. p. 128 — Cuiii.
son, in London Medical Gazette, vol. iv. p. G'J. ; and on
Deformities, &c. 8vo. Lond. 1S3.5.
CHICKEN-POX. SvN. Varicella, Crystalli, Va-
riola Spuria, Variola Lymphatica , Variola Vola-
tica, Auct. Var. Variola Pusilla, Ileberden.
Exanthema Varicella, Parr. Synochus Vari-
cella, You\ig. Emphlysis Varicella, Good. Verole
Volnnte, Fr. Die Undchten Kindipocken , Ger.
Ravaglione, Ital. Water-jags, Water-ppx.
Classif. 1. Class, 3. Order (Cullen). 3.
Class, 3. Order (Good). 111. Class,
III. Order (Author).

1. Dkitn. A71 eruption over the body, of semi-
transparent glabrous vesicles, ivith red 7nargins,
accompanying a slight attack of fever, seldom
passing into suppuration; hut, on the third day,
bursting at their tips, concreting into sinnll puck-
ered scabs, and leaving no cicatrices.

2. Under the name chicken-pox, or varicella,
have generally been comprised certain eruptions,
which closely agree in many features with each
other, and which in some respects resend)le small-
pox. Jt is from this latter circumstance that
they claim a very particular notice, as they are
generally of .so slight a nature as to require but
little medical treatment. They were formerly
very generally confounded with small-pox : but
the difference between them was remarked as
early as the beginning of the sixteenth century by
\'iDus Vioius and 1ncrassi.»\s. Sennert and

CHICKEN-POX — Descrii-tion "of.

313

RivERi, professors at Wurtemberg and INIontpel-
lier at the conimencenient of the seventeenth
century, and DitiiKnuiiOEK, state that the dis-
tinction was well known in Germany, France,
and Italy, to the vulgar, who had a separate ap-
pellation for this eruption. RIomoN was the first
in this country to mark the difference, and to de-
scribe this disease under the name " cliicken-piu,"
by wliicli it appears to have been commonly
known before lie wrote. Since then it has been
noticed by Fuller, and accurately defined as a
distinct disease by Heberden. He, however,
continued to designate it by the term varioLi
piisilla ; whilst his contemporaries, Vogel, Bur-
SEiuus, and Sauvages, also applied to it the
generic term variola, with the specific desig-
nation of vclatica, spuria, and lumphatica. But
as Dr. Bateman has remarked, this circumstance
cannot be considered evidence of their consider-
ing it as generically the same with smallpox.
The entirely distinct nature of chicken-pox was
very generally believed in, since Dr. Heberden
pointed out the difference between it and the
small-pox, until recently questioned by Dr. John
Thomson, by whom the opinion of the earlier
physicians, that they are merely varieties of the
same disease, has been revived. This learned
physician, and M. Berard, urge in favour of
this opinion the circumstance of variola and vari-
cella appearing from the same exciting causes,
whether those affected have been vaccinated or
not; and affirm, that persons exposed to the in-
fection of chicken-pox have caught small-pox,
and that the foimer appears only in those whose
constitutions have been modified by the influence
of either small-pox or cow-pox. On this subject
j\IJ\l. Schedel and Cazenave remark, that in
those epidemics which they have had opportu-
nities of noticing in Paris, the several eruptions
might be classed under three heads : 1st, Variola
properly so called ; 2dly, The malady termed vari-
loide, or variola modified ; 3dly, An eruption purely
vesicular, ofTering every appearance of varicella.
'J'he same cause, namely, variolous infection,
seemed to develope these several eruptions, which
were observed in the same quarters, in the same
streets, in the same houses. VV hen the disease
made its appearance among a numerous family,
some had small-pox, some modified small-pox,
and others chicken-pox. One circumstance was
striking to every one, namely, the mildness of the
disease in those persons who had been vacci-
nated, and in the majority of those who had al-
ready had variola.

3. These facts certainly favour the opinion of
Dr. Thomson ; but, as the above writers have
stated, many cogent arguments have been urged
against it, especially by Abercrombie, Bryce,
LuDERs, &CC.: — 1st, It is very difficult to deter-
mine, during a small-pox epidemic, whether the
occurrence of that disease among individuals
coming in contact with persons infected with
chicken-pox is rather the result of tliis communi-
cation, than of the variolous infection which at
tiiat moment developes the malady on all si<les :
2d, A'esicular varicella, properly so called, is not
transmitted by inoculation, and never produces
variola: 3d, Those persons who consider chicken-
pox as contagious, have confounded it with modi-
fied small-pox : 4th, Varicella appears in persons
who have not been vaccinated, and who have

never had tire variola, consequently, in such
cases, it cannot be regarded as a variola modified
by the prior existence, either of this disease or of
vaccination ; 5th, Vaccination practised shortly
after the disappearance of varicella pursues iis
course in the most regular manner, which never
happens when vaccination follows variola: 6th,
The progress of varicella is uniformly the same,
whether ii occurs before or. after vaccination, or
alter variola : 7th, Variola sometimes reigns
epidemically, without being accompanied by vari-
cella ; and, on the other hand, the latter may
become epidemic without being attended by the
former. In fact, the characters ol the eruption,
and the symptoms of varicella, differ essentially
from those of variola.

4. I. Description. — A. Of the eruption. Un-
der the name chicken-pox are included different
varieties of eruption, generally characterised by
very slight and brief antecedent fever, consisting of
vesicles or very imperfect pustules which maturate
and decline in three, four, or five days, occurring
chiefly during infancy and childhood, but also at
adult age, and occasionally prevailing epidemic-
ally. 'I'he generic term, chicken-pox, comprises
three species, or rather varieties, which have been
distinguished from each other for very many
years in dift'erent parts cf this country, by the
popular names of chicken-pox, swine-pox, and
hives. These VVillan and Bateman distin-
guished, according to the form of their vesicles,
into, 1st, Varicella Lentifcrmis ; 2d, V. Conifar-
mis ; and, 3d, V. Globularis. Dr. Good has adopted
these names and distinctions, but has added u

Jourth, the V, Coriimbosu, the clustering or con-
fluent chicken-pox; which, if considered at all as
a distinct variety, is not of frequent occurrence ;
but has occasionally been observed by Bateman,
King, and myself.

Var. i. Lenticular Chicken-pox, Varicella
Lentiformis ; V. Lymphatica, Plenck.

5. 'J his variety appears on the fiist day of erup-
tion, in the form of small red protuberances, of an
inegularly circular, or rather, tending to an oblong
figure, with a nearly flat and shining surface, in
the centre of which a transparent vesicle is very
soon formed. On the second day of the eruption
the vesicle is filled with a whitish lymph, and is
about the tenth of an inch in diameter. On the
third day the lymph is straw-coloured; and, on
the fouith, the vesicles which have not been
broken subside, and are puckered at their mar-
gins. Few of them are entire on the fifth day ;
but the orifices of several which have broken are
closed or adhere, so as to confine a little opaque
lymph within the puckered margins •, on the
sixth day, small brown scabs appear in place of
the vesicles; and become yellowish on the seventh
and eighth days, gradually drying from the cir-
cumference to the centre. On the ninth and
tenth days they fall off, and leave for a time red
marks on the skin, without depression. ' The dis-
ease may, however, be longer than now slated,
owing to fresh vesicles appearing during two or
three successive days, and going through the
same stages as the first. The eruption is usually
distinct, is general over the body, and comes out
fiist on the back and breast. The vesicles, even
when they suppurate, leave no cicatrices. The
pustules of small-pox break out first on the face,
neck, and breast, and always leave depressions.

314

Var, ii. Conoidal Chicken-pox, Varicella
Coniformis ; Varicella Verrucosa, Plenck ;
Variola Lymphatica, Sauvages ; Pemphigus
Variolodes, Frank ; Verolette, Fr. ; Bavaglio,
Ital.; Swi7ie-pox,

6. The vesicles of this variety arise suddenly,
have a somewhat hard and inflamed base, and
are on the first day acuminated, contaiaing a
transparent lymph. On the second day they
are a little more turgid, their bases more inflamed,
and the lymph in many of them is of a light
straw-colour. On the third day the vesicles are
shrivelled, and those which are broken have their
lymph concreted into slight gummy scabs. Such
of them as remain entire, and have their bases
much inflamed, contain, on this day, a whitish
puriform fluid ; every vesicle of this kind leaving,
after scabbing, a durable cicatrix. On the fourth
day, thin dark brown scabs are seen intermixed
with others, which are rounded, yellowish, and
semi-transparent. These scabs gradually dry,
separate, and fall off in four or five days,

7. A fresh eruption of vesicles usually takes
place on the second or third day, and has a simi-
lar course to the preceding ; the whole duration
of the eruptive stage being thus six days in this
variety of varicella. In some instances minute
red tubercles appear, and subside without forming
vesicles. The scales last formed are generally not
separated till the eleventh or twelfth day. In
some cases, when the febrile symptoms have been
severe, slight ulceration takes place in the vesicles
from which the scabs have fallen off, leaving de-
pressions or cicatrices, but only in parts subjected
to pressure.

Var, iii. Globular Chicken-pox, Varicella
Globularis ; Hives.

8. The vesicles of this variety are large and
globular, but their base is not quite circular.
'J'hey are surrounded by inflammation, and con-
tain a transparent lymph, which is slightly turbid,
and resembles milk whey, on the second day of
the eruption. On the third day tiiey subside,
become shrivelled as in the former varieties, and
appear yellowisii from the admixture of a small
quantity of puriform matter with the lymph ; some
of them remaining in the same state till the fol-
lowing morning ; but before the conclusion of the
fourth day, the cuticle separates, and thin dark
scabs cover the basis of the vesicles. The scabs
dry, and fall off in four or five days afterwards.

9. B. Of the constitutionul affection. — All
these varieties of chicken-pox may attack the
same individual at difl^eretit epochs, and offer the
same symptoms, whether before or after small-pox
or vaccination. They are frequently associated
with the epidemic prevalence of small-pox. They
appear principally in the early months of the
year, and tiie spring ; seize chiefly young persons,
and adults sometimes ; and eacii of them, with a
few exceptions, affects a person only once in their
lives. Varicella is preceded, for twenty-four or
forty-eight hours, by chills, depression, anorexia,
costiveness, and thirst, with heat of skin, flushed
countenance, accelerated pulse, tendency to per-
sijiration, and other febrile symptoms. Some-
times there is nausea, or even vomiting, with
pain at the epigastrium and tiirough the limbs.
In some cases, the fever is so very slight as
to be overlooked ; and, in infiinis, is often indi-
cated only by heat of skin and IVetfulness. The

CHICKEN-POX — Diagnosis.

eruption usually commences on the back and
breast ; appearing next on the face, neck, and
scalp; and lastly on the extremities. It is some-
times preceded, for a few hours, by a general
erythematous rash ; and the vesicles are usually
most abundant in the conoidal form ; they being
sometimes coherent, or seated close together, but
seldom confluent. When thus coherent or clus-
tering, they form the fourth variety of Dr. Good
(§ 4.). Owing to the itching which accompa-
nies them, children often break the vesicles by
scratching ; whence proceeds an increased in-
flammation, forming a yellowish pus, more or less
consistent. This happens particularly on the
face. The crusts which replace tliese pustules
remain much longer, and leave small cicatrices.
As the vesicles appear successively during two
or three days, we may perceive the eruption ex-
hibiting its several stages at the same period, in
the same individual.

10. II. Diagnosis. — The vesicle full of serum
on the top of tlie pock, on the first day of the
eruption, — the early abrasion of many of tlie
vesicles, — their irregular and oblong form, —
tlie shrivelled state of those that remain entire
on the third and fourth day, and the radiating
furrows of others which have had their ruptured
apices closed by a slight incrustation, — the gene-
ral appearance of the small scabs on the fifth day,
at which time the small-pox pustules are not at
the height of their suppuration, — sufficiently dis-
tinguish chicken-pox from small-pox. Dr. Willan
has pointed out the characteristic circumstance,
that variolous pustules are, on the first and se-
cond day, small, hard, globular, red, and painful ;
imparting the sensation, when the finger is passed
over them, similar to that which one might con-
ceive would be excited by the pressure of small
round seeds under the cuticle. In varicella,
almost every vesicle has, on the first day, a hard
inflamed margin ; but the sensation communicated
to the finger is like that from a round seed flattened
by pressure. As the pustules of small-pox, more-
over, become gradually developed, they contain
a white thick matter; the formation of which pre-
cedes suppuration, as shown by Dr. AsmsuRNEn.
When the globular vesicles or hives appear, as is
sometimes the case, intermixed with the lenticular
or conoidal eruption, they afford a ready distinc-
tion from the small -pox, to the pustules of which
they bear little resemblance.

11. It is not, however, so easy to distinguish
varicella from modified small-pox. The symptoms
precursory of the latter are usually intense, which
is never the case with the former. In modified
variola, the eruption is puslulent, and the pustules
are small, circular, and generally depressed in the
centre. After the scaly crusts drop off, tubercles
are frequently seen, which disappear but slowly.
In varicella, the vesicles, which are at first trans-
parent, contain a fluid which becomes sero-puru-
ient ; and they are never followed by tubercles,
as in modified variola. To this I must add, that
varicella is not infectious, whereas modified va-
riola may be transmitted by inoculation, and may
even, in some cases, occasion a very severe attack
of true small-pox.

12. III. The Treatment of varicella is very
simple : 'the patient should remain in bed, in a
temperate atmosphere ; ought to be placed on low
diet, and abstain from animal food for a few days ;

CHLOROSIS — Causes.

315

should have the bowels duly regulated, and par-
take freely of lukewarm diluents.

BiBLiOG. AND Refer — Vi'dus J'tdius, De Chrystallis.
— iTigrassias, De Tumor. Praet. Nat. 1. i. c. I. — Sennet:

tus, Med. Pract. 1. iv. cap. 12 Riverins, Prax. MeJ.

cap. ii. — Diemerbroeck, De Variolis et Morbis, cap. ii

iierton, Pyrotologia, )xc. p. 38. — Fuller, Exanthemato-
logia, p. 161. 1730. — Hcbcrden, in Trans, of the Coll. of
Pliys. vol. i. art. xvii. ; et Comment, de Morbis, cap. <M.—
Vopel, De Cognoscend. et Cur. Horn. Morb. § 128. 1772.
— Bursen'us, Inst. Med. t. ii. cap. n. § 30,5. — Saiivagcs,
class iii. gen. ii. sp. I — Wilson, On Eruptive Fevers,
4tli edit. p. 321 . — Rin^. Med, and Phys. Journ. vol. \iv.

p. 141 — Thomson, On Varioloid Diseases, 8vo Hayer,

Traite de Maladies de la Peau, 8vo. t. i. p. 340. — Cazcnave,
et Schedcl, Abrege Pratique de Mai. de la Peau, 8vo.
p. 61 — J. Green, On Diseases of the Skin, 8vo. Lond.
1834, p. 1 16 — G. Gregory,C}xlop. Pract. Med. vol . i. p.377.
CHLOROSIS. Der. and Svn. From
XAcop^s, paleness, yellowish green, Pallidiis
Morbus ; Fadus Virginum Color ; Pallor Vir-
ginum ; Morbus Virgineus ; Faedi Colores ; Ic-
terus uibus ; Icteritia alba ; Cachexia Virginum
vel Muliebrum ; Febris Amatoria ; Chlnrosmu,
&;c, Auct. Var. Chlorose ; Pales Couleurs, Fr.
Die Bleiclisucht, Ger. Green Sickness, Eng.
Classif. 2, Class. Nervous Diseases; 2.
Order, From Defect of Vital Energy
(^Cullen). 5. Class, Diseases of the Sexual
Function ; 2. Order, Affecting the Or-
gasm {Good). I. Class, II. Order
(Author, in Preface}.

1. Defin, — Pale yellowish green complexion,
languor, debility ; depraved appetite, with occa-
sional nausea or sickness, and disorder of the
sexual secretions ; generally occurriiig about pu-
berty, or soon afterwards.

2. Chlorosis has been very generally con-
sidered as a variety merely of amenorrhoea, par-
ticularly by Cullen', PiNEL, and Frank, although
they have classed it as a distinct disease. As to
its occurrence independently of retained or sup-
pressed menstruation, there can be no doubt,
although it is frequently connected with such
disorder. It is also similarly related to dyspepsia,
and to anffimia ; Dr. Young classing it with the
former disease. Sauvages includes, as a variety
of chlorosis, the cases of ancemia which occur in
infants and ciiildren, denominating them the
chlorosis infantum. Eut although several such
cases are met with in practice, they .'^eldom pre-
sent the yellowish green tinge of this disease, being
usually of a white or e-xsanguineous paleness, un-
less when complicated with jaundice, which is
but rarely remarked. They are entirely referrible,
in respect of their pathological relations and ter-
njinations, to anaemia (see Blood — Deficienci/ of) ;
and are sometimes, owing to the exhaustion at-
tendant upon their last stages, mistaken for hydro-
cephalus. Sydenham considered chlorosis as a
variety merely of hysteria, connected with a
cacochymia, — its frequent complication with that
disease being evidently the source of this fallacy ;
and lastly, Van Swieten viewed it as a form of
cachexy. These opinions serve to show the
propriety of considering it as a distinct disease,
but more or less intimately related to those com-
plaints, owing to the circumstance of their all
originating in a nearly similar state of vital energy,
particularly as manifested in the organic nervous
sy.stem ; specific differences between them con-
sisting in the particular viscus or part more es-
pecially affected, and in the grade and mode of
such affection,

3. Dr. Good divides chlorosis into two species,

' the atonic and entonic ; but this is an unnecessary
refinement, no phenomena which warrant such
a distinction presenting- themselves in practice.
Indeed, the entonic only consists of a state re-
latively of less deficiency of vital power than the
atonic, and is, in many cases, merely the first
stage of the disease ; particularly when it occurs
in tolerably strong females, and whilst the torpid
function has not as yet extended much further
than the sexual organs, in which it originated,
the digestive, assimilating, and vascular organs
not having sustained much disorder. Dr. Goocn
has likewise made mention of an acute chlorosis,
occurring chiefly in married women. But the
state of disease thus designated by this physician,
is simply that chronic disorder, often attended with
sliglit irritative fever, following large losses of blood,
which are not readily supplied by the digestive and
assimilating functions ; and is in all respects a state
of anremia. (See Blood, ^ 34, et seg.)

4, I. Causes. — A. Predisposing causes. Chlo-
rosis is most frequent in girls about the age of
puberty ; either previously to the appearance of
tiie menses, or when they are retained, or occur
irregularly, or with difficulty. But married wo-
men, particularly widows and those who have
not borne children, are not exempt. In them it is
generally connected with suppression of the menses.
It is even met with in males, although rarely, about
the period of puberty ; as remarked by Hamilton,
Blane, Desormeaux, Roche, and myself in two
or three cases. When observed in this sex, it is
apparently connected with protracted evolution
of the sexual organs ; and one or two of the
young females of the same family are sometimes
also afl"ected. The lymphatic and melancholic
temperaments; feeble and delicate constitutions;
residence in cold, moist, and miasmal localities
and climates ; insufficient, unwholesome, innu-
tritious, and watery vegetable food ; inattention
to the digestive functions, particularly liiose of
the bowels; the abuse of diluents, of acid weak
wines, or of spirituous liquors, early in life ; too
great indulgence in warm bathing ; prolonged
sleep ; tight lacing at an early age ; and whatever
debilitates and relaxes the system ; predispose to
this disease. The most frequent causes are seden-
tary occupations in crowded and ill-ventilated
manufactories and towns, especially those employ-
ments which require a stooping position, and are
prosecuted by females at a very early age, or
before the frame is developed.

5. B. Tiie more common exciting causes, are
longings after objects of desire ; depressing pas-
sions and affections, especially unrequited love,
or unfortunate or imprudent attachments ; long
entertained feelings of sadness or anxiety, particu-
larly when caused by removal from friends, and
the scenes of recent happiness and affection.
According to MiNI. Desormeaux and Roche,
privation of the physical gratification of love is a
very frequent cause. Retention, difficult and
imperfect occurrence of the menses, have very
generally been enumerated amongst its causes;
but the uterine disorder is rather a coincident
effect of the same pathological state that produces
chlorosis (§ 12.). Suppression of the menses,
excessive menstruation, and manustupration, are
sometimes concerned in its appearance ; the latter
acting chiefly by debilitating the frame generally,
by exhausting tiie energy of the sexual organs, and

316

CHLOROSIS — Diagnosis — Prognosis.

thaieby assisting the operation of other causes, par-
ticularly when the functions of the sloinacii and
bowels are torpid, or otherwise disordered. The
influence of constipation, and faicul collections in
the cfECum and colon', in occasioning the disease,
cannot be questioned, although somewhat exclu-
sively insisted upon by Dr. Hamilton; in oppo-
sition to the opinion of Dr. Cullen, who referred
it chiefly to an inactive state of the ovaria. It
seems, however, quite as evident that the torpor
of the digestive organs, especially of the lower
bowels, and the inactivity of the uterine organs,
depend upon the state of the organic system of
nerves, which supply not only those viscera, but
also those concerned in assimilation and circula-
tion, — all those functions presenting more or less
disorder in the course of tiie disease.

6. II. History and Symttoms. — Chlorosis
presents two stages; the incipient, and the fully
developed or confirmed. It also manifests various
morbid associations or complications. A. The
incipient stage commences insidiously, and almost
insensibly. The patient is at first languid, listless,
weak ; loses her complexion ; has no disposition to
amusement, if it require mental or physical exer-
tion ; is often without appetite, or craves for
particular, and sometimes unwholesome, kinds of
food ; the bowels are costive ; bodily exertion
soon occasions shortness of breath, and fatigue ;
the breath is offensive ; the tongue is white or
pasty ; sleep is disturbed or unrefreshing, and op-
pressive in the morning ; she often complains of
intermittent lieadach, pain of the left side, and
palpitations, which are induced by the slightest
cause ; the pulse is quick, weak, and small ;
and the catamenia are either retained, or are
scanty, and of a pale colour : all these symptoms
gradually increase, and the countenance becomes
more and more pale, and assumes a greenish
yellow tint.

7. J3. The fidl}i developed disease presents its
characteristic complexion — the pale greenish yel-
low of an etiolated plant. The lips, gums, and in-
sides of the cheeks, are pale ; the eyelids are livid,
sometimes CEdematous, particularly in the morn-
ing ; the conjunctivae are remarkably white ; the
soft solids flaccid ; the extremities cold ; and the
aukles oedematous. The tongue is usually pale,
soft, flabby, and indented at the edges by the
teeth ; sometimes it is smooth, glossy, and fissured.
The appetite is more and more capricious and
morbid ; sometimes with pica, or a desire for
pickles and acids; and nausea and vomiting, es-
pecially in the morning, and cardialgia or gastro-
dynia after meals, not infrequently occur. If
the menses have already appeared, they become
gradually more diflfieult, and scanty ; are attended
with syncope oi pain ; are of short continuance,
pale, or watery , recur at longer period-;, and at
lust di-appear. The patient is ollen sad ; enier-
lains depressing and sinister ideas ; prefers solitude,
and is capiicious. In the more advanced or
inveterate ca^es, the finger nails are brittle, dry,
and sjdit or break off; the hair is weak, falls out,
is lank, dry, and splits at its extremities. The
abdomen is often tense, distended, and slightly
painful. A constant pain is complained of under
the left breast, sometimes with a slight cough ;
the constipation alternates with diarrhoea ; some
degree of emaciation lakes place ; the cudema
extends, or assumes the form of an anasarca or

ascites ; various irregular states of hysteria occa-
sionally appear during the course of the disease ;
and some one or two symptoms become promi-
nent, occasionally deceiving both the patient and
medical attendant by their severity. Thus the
lieadach, pain of the side, palpitations, cough,
&c., occasionally lead to the apprehension of in-
flammatory states of the brain, or of the pleura,
of disease of the heart, or of phthisis.

8. C. Terminatinns and complications. — When
the disease becomes inveterate from neglect, in-
eflficient treatment, or the continued operation of
its causes, &c., it often assumes diversilied forms,
owing to morbid associations. The continued
disorder and debility of the digestive organs, and
the consequent insufficient supply of healthy
chyle to the blood, as well as the imperfect san-
guifaction of what is supplied to it, sooner or
later gives rise to anasmia, which, in its slighter
grades, owing to the causes hereafter to be noticed
{§ 12.), even accompanies the early stage of
chlorosis. In females who have been married,
or in those who, previously to the appearance of
the disease, had the uterine functions and dis-
charges regularly and fully established: hysteria,
in some one or more of its numerous states, is
commonly observed. Chlorosis is sometimes also
complicated with swellings of the glands, or with
chronic cutaneous eruptions, or with haemate-
mesis and malffina ; and occasionally terminates
in dropsy of either the thoracic or abdominal
cavities. ]\Iania and delirium rarely ensue in
the course of its advanced stages and inveterate
forms,

9. III. Diagnosis. — Chlorosis is most intimately
related in its symptoins, and the nature of the
changes which constitute it, to anaemia. Indeed,
the advanced stage of the former is often identical
with the latter ; the chief difl^erences consisting
in the pale, greenish, or greenish yellow tint of
the countenance, the torpor or disorder of the
uterine functions, and affection of the stomach in
chlorosis. It also often resembles other chronic
diseases, particularly those seated in the stomach,
and tuberculous affections; but not so closely as
to be mistaken for them. Neither the nervous
headacli, nor the hysterical pains, particularly
those complained of in the left side and under the
left breast, nor the palpitations of the heart, can
with due attention be confounded with inflamma-
tion or organic change in these situations : yet
have I seen these mistakes made, and nearly
fatal consequences ensue, — the practitioner having
been deceived by the frequency of the pulse in
such cases. In this, as well as in other diseases,
much advantage will accrue from recollecting
that tiie most acute pain is generally owing to a
patlioloi;ical state the reverse of inflammatory ;
iind that the most fre(iiient pulse is very far from
indicating a necessity (or blood-letting, which, if
practised in such cases, will increase the morbid
sensibility and the vascular irritability, even when
it does not hasten a fatal termination.

10. IV. Phognosis. — Cliloiosis is always
chronic ; is generally cured, particularly in its
sinipleform ; but sometimes also terminates fitally,
owing to the associated lesion of various functions
and organs. Recovery may be confidently ex-
pected, when it is incipient or uncomplicated, and
none of the internal viscera betray marked dis-
ease ; especially if it have not continued longer

CHLOROSIS — Pathology — Treatment. 317

than two or three months, and tlie menses have
not appeared. If it occur in married women,
sterility is often the consequence ; or, if cliildren
are borne, tliey are generally feeble and unhealthy.
Chlorosis should be viewed in a serious light, if
it have been of lonsf duration ; if the catamenia,
after having appeared, are gradually suppressed ;
more particularly if the signs of an2emia to a con-
siderable degree be present ; if emaciation be
rapid, with quick respiration and cough ; if the
oedema of the extremities extend ; if symptoms of
efTusion of serum into the cavities supervene ;
if hffimatemesis or malajna occur; and if it have
resisted, in its early stage, a judicious treatment.
In the advanced progress of the disease, espe-

of this system is insufficient for the purposes it is
destined to perform. We know that the evolution
of the sexual organs is owing to the state of vital
power ; and that, by a reciprocal influence, the
activity of those organs increases all the other
functions of the frame. Therefore, as we com-
monly observe this disease at the period of puberty,
and associated with imperfectly developed or per-
formed function of the sexual organs, we must
necessarily infer, that the defective energy of the
organic nervous system delays or arrests their
developement, and weakens their functions ; the
whole frame being thereby deprived of the stimu-
lus they impart to it. Consequently, if the causes
continue to operate, or if this system experience

cially when it is complicated, death sometimes no salutary or natural excitement, all the organic
takes place unexpectedly, but seldom without t functions languish more and more ; the chyle is

evidence of excessive depression of the organic
nervous influence, and of great deficiency of the
circulating fluid. (See Blood, §42. et seq.)

11. V. Pathology. — A. Morbid appearances.
The adipose substance is sometimes not much di-
minished ; but the rest of the soft solids is flaccid
and pale, from a deficiency of the red blood.
Effusion of serous fluid is commonly met with in
the large cavities, particularly those of the pleura,
pericardium, and peritoneum, and occasionally
also in the ventricles of the brain. The lungs
are frequently oedematous, or studded with tu-
bercles; the liver is often enlarged, and some-
times pale or tuberculated ; the stomach small,
pale, and contracted ; the mesenteric glands
slightly enlarged ; the ovaria and uterus, in some
instances, are impeifectly developed, or contain
small tumours ; the cavities of the heart are oc-
casionally somewhat enlarged, and their parietes
are generally flaccid and pale, or slightly atro-
phied ; the blood is commoidy pale, aqueous, and
deficient in coagula, — those which are found in
the large veins and auricles of the heart being
of a very light colour, and small. These are the
most common lesions ; but others are sometimes
noticed, both in the organs now mentioned, and
in difl^erent parts, as in the spleen, pancreas, gall-
bladder, kidneys, &c. In some cases but little
change beyond the exsanguineous state of the va-
rious structures are observed, as in those recorded

by LlEUTAUD.

12. B. Nature of the disease. — It has been
considered by many writers, and amongst others
by Wedel, Koute, Cullen, Desormeaux, and
Roche, that chlorosis is chiefly dependent upon
debility or torpor of the nervous influence deve-
loping and actuating the ovaria and uterus.
Hoffmann, Darwin, and Saunders connect it
more immediately with obstructed function of the
liver. Hamilton refers it chiefly to torpor of, with
accumulated sordes in, the digestive organs, par-
ticularly the lower bowels ; and Andral, to the
deficient and morbid state of the blood. If we
reflect upon the character of the associated phe-
nomena constituting the disease, in relation to
their causes, on the one hand, and to their conse-
quences and terminations on the other, we must
necessarily arrive at the inference, that all the
organic functions — those of digestion, assimila-
tion, sanguifaction, nutrition, and generation, —
are inadequately performed ; and, as tho organs
devoted to these oflices are intimately connected
one with the other, and actuated by the organic
nervous system, that consequently the vital energy

imperfectly prepared ; and sanguifaction and as-
similation are inadequately pertbrmed ; all the
phenomena of an advanced state of the disease
being the result.

13. VI. Treatment. — A. In its^irsf stage, this
affection is generally soon removed, 1st, by a due
attention to the causes, — particularly the mental
or moral causes, — and by removing or counter-
acting them as far as possible ; 2d, by eva-
cuating all morbid and accumulated sordes fiom
the alimentary mucous surfaces, and regulating-
the alvine secretions and excretions ; and, 3d, by
imparting vigour to the digestive and organic
functions, and exciting at the same time the torpid
or in-.perfect actions and secretions of the uterus.
It will generally be necessary to ascertain the
causes of the affection, or to direct the attention
or the friends of the patient, to their nature, ten-
dencies, and the best means of counteracting them.
The medical treatment may be commenced with
a moderate dose of calomel or blue pill, and a
few grains of powdered ginger, given at bed-time ;
and the following morning the secretioi.s should
be more fully promoted and evacuated by a dose
of castor oil, or of the compound decoction of
aloes. After the bowels have been freely eva-
cuated, the following pills, or F. 877. should be
taken^daily, either during or after dinner : —

No. 115. R Aloes Socot., Ferri Siilphatis, aa gr. ij. ;
Gum. Masticli. gr.j.; Pulv. Capsici gr. ij.; Syrupi Siiiii>.
vel Olei Caryopli. q. s. M. Fiant PiluIiE diia;.

During the use of these, it will generally be
requisite to promote the functions of the liver,
and excite the bowels, by the occasional repetition
of the calomel and ginger at bedtime, and the
purgative draught the following morning. Ir»
some cases, the operation of the medicine may be
very advantageously promoted by an enema. In
many instances, nothing beyond what is now re-
commended will be necessary ; but, in addition,
a course of chalybeate mineral waters may be
directed ; and, under every circumstance, exer-
cise in the open air, particularly on horseback,
change of air to the sea-coast, a light nutritious
diet, and warm clothing, especially of the lower
extremities, should be recommended. Flannel
drawers will be found of service in winter.

14. B, In its second stage, or in the more ob-
stinate cases, or when the affection is attended
with diflrcult or scanty menstruation, the tinct,
ferri ammonio-chloridi, or the tinctura guaiaci
composita, and the phosphate of iron or the io-
dide of iron, are preferable to the sulphate of
iron, — the compound aloetic decoction being the

318

CHOLERA — History and Symptoms.

most suitable aperient. When pains of the head,
or of the left side, or other symptoms of hysteria,
or palpitations, are complained of, these medicines
will be advantageously associated with camplior
and hyoscyamus. When the torpor of the uterine
system is evident, conium will, however, be pre-
ferable in such cases to hyoscyamus, and may be
given either with these medicines, or with any of
the ammoniated spirits. In a few obstinate cases
of the disease, 1 have prescribed, with marked ad-
vantage, small doses of the extract of nux vomica,
and the strychnine, as in Formulai 542. 565. and
907.

15. If the disease still persist, if the ankles
swell, or if dropsical symptoms come on, and the
menstrual evacuations continue suppressed, ad-
vantage will sometimes accrue from the iodide of
iron, and from rubbing the loins assiduously every
night with either of the liniments, F. 296. and
311., and acting gently on the bowels by means
of the following pills : —

No. 116. R Pilul. Aloes cum IMyrrha 3j.; Saponis
Castil. 3ss. ; Olei Crotonis Tiglii HI iij. Contunde bene
simul, et divide in Pilulas xxiv., quarum omni nocte
capiat unain, duas, vel tres.

16. In the course of practice, I have seen three
cases of the disease complicated with swelling of
the parotid and submaxillary glands. In order
to remove these tumours, I prescribed iodine in-
ternally, in small and frequent doses, giving also
at bed-time the aloes and myrrh pill. In these
instances, the menses gradually came on, and all
disorder vanished. I have on other occasions
observed a very marked emmenagogue, as well
as tonic effect, produced by the preparations of
iodine ; and from these effects, as well as from
their efficacy in the above cases, I consider them
calculated to prove of use in certain states of
obstinate chlorosis. On some occasions, par-
ticularly when chronic eruptions appear in the
course of the disease, sulphur will be fouml the
best aperient, and the following pills will be pro-
ductive of benefit ; but, in addition to those al-
ready particularised, several recipes will be found
in the Appendix suited to the different forms and
complications of this affection, as well as of other
derangements of the uterine functions.

No. 117. IV .Sodse Bi-boratis 3 ij. ; Sulphuris Pracip.
3 j. ; Mucilag. Acacia; q. s. Fiant Pilulfe xxiv., quarum
■capiat tres, ter quotidife. (See also F. 519.)

No. 1 18. R Sodse Bi-boratis 3 ij. ; Pulv. Capsici Annui
9 j.': Pilul. Aloes cum Myrrha 3j--, Olei Sabinae q. s.
M. riant Pilula? xxx., quarum capiat binas ter die.

No. 119. R Ferri Sesquioxidi 3j.; Sulphuris Depur.
3 j.; Myrrhse, Alfies Soc, Fellis Tauri Insp.,aa 3 ss. Con-
tunde bene simul, et divide in Pil. gr. iv., quarum sumat
binas vel tres, bis lerve in die.

17. Electricity and galvani.sm have been ad-
vised by IIenaud and Sigaud la Fond for this
disease: and the ammonio-sulphate of copper, by
BiANciii. The preparations of iron have very pro-
perly been directed, in conjunction with the alkalies
and myrrh, byWiLi-AN, with stimulants and bitters,
by Scii/EFFEn, with assafoetida, by Hirsciiel, and
with cinchona and rhubarb, by RANoii. Mar-
riage has been suggested as a remedy for chlorosis,
by Wedki,, Le 13lanc, Koute, and several
others. Cold bathing has been recommended by
JiRANDis, and condemned by Darwin ; and pur-
gatives have been chiefly depended upon by
Hamilton. The use of mineral waters is cer-
tHJnly of much service in chlorotic cases. Those
of Driburg, Pyrmont, Spa, Carlsbad, &c. on the

Continent, have been much praised by Brandis,
Marcard, and Kressio ; and the chalybeate
springs in this country, by most practitioners.
But equal advantage will sometimes accrue, in
the inveterate forms of the disease, from the sul-
phureous and saline waters, in addition to a ju-
dicious course of medicine; and from the Bath
and Buxton warm springs, used in the form of
baths. The warm hip-bath, some salt and a
little mustard having been added to the water, is
also beneficial. (See IMenstruation.)

BiBLioG. ANO Refer. — Hippocrates, De Morb. Mul.
sect. V. p. \25.—Ballonius, De Mofb. Mul. Opera, vol. iv.
pp. 6G. 129. — Le Blanc, Ergo Venus Amantium Ictero.

Paris, IGId i/()/5/!«nn, De Genuina Chlorosis Indole,

V. Opera, Supp. ii. part ii. p. 389. — Wedel. De Chlorosi
seu Foedis Virgiuium Coloribus. JenaB, 1681; et De Ve-
nere Medica et Morbosa, p. 2.3. — Kortc, De Pallore Vir-
ginum, Venerem indicante. Hal. 1759. — Ilanoe, in Acta
Keg. Soc. Med. Haun. vol. iv. p. 114. — Richter, die Spe-
cielle Therapie, &c. b. iii. p. 7.52. — Darwin, Zoonomia, vol.

iii. p. 157. 8vo. ed Brandis, Ueber die Wirkung der Eis-

eniinittel und, &c. p. 1 13 Sc/icejfir, in Hufeland's Journ.

der Pract. Arzueyk. b. vi. p. 267 Bianc/ii, in Brera, Com-
ment. Med. dec. i t. ii. n. 2. — Cullen, Works by Thom-
son, vol. ii. pp. 293. 384 Hamilton, Observ. on Purgative

Med. &c. ch. iv. — Gagnion, Sur la Pubertede la Femme,
et sur le Chlorosis. Paris, 1809. — Frank, Efemeridi Fisico-
Medici, 1805. — Horn, Archiv fiir Pract. Med. b. v. st. 1.

p. 90. — Desormeaux, Diction, de Med. t. v. p. 166

Roche, Diet, de Med. et Chir. Prat. t. v. p. 230.

CHOLERA. SvN. Cholera Morbus, Passio Cho-
lerica, Diarrhoea Cholericu, Auct. Lat. Cho-
l^ree, Cholerraggie,Trouise-galant, Fr. Die Gal-
lenruhr, Brechruhr, Ger. Diarrhwa Cholera,
Young. Bilious and Spasmodic Cholera,
Classif. 2. Class, Nervous Diseases; 3.
Order, Spasmodic Affections (Cjillen).
1. Class, Diseases of the Digestive Func-
tions; 1. Order, Affecting the Alimentary
Canal (^Good). II. Class, III. Order
(^Author, in Preface).

1. Defin. Griping pains, followed by vomiting
and purging, very rarely uith flatulent eructations
and dejections, and always with spasms of the
extremities, particularly the inferior, and anxiety.

2. I. History and Sybiptoms. — The term
Cholera 'has been in use since the time of Hip-
pocrates, who admitted two species of the dis-
ease,— one humid, the other dry, — xo^^'p" ^7P^>
XoXepoL ^vpO: According to Cflsus, it is derived
fiom x^^h and peco, signifying literally hile-fux.
Trallian, however, derives it from x^^"-^ ^nd
piiji, intestinal fux. Galen, adopting the dis-
tinction established by Hippocrates, attributed
the humid cholera to the presence of acrid hu-
mours generated by the corruption of the food ;
and the dry cholera, to an acrid flatus. With
very slight modifications, this doctrine was re-
ceived by Fernel, Baillou, Sydenham, F. Hoff-
mann, Bianchi, Sauvages, and Vogel, the dif-
ference chiefly consisting in the part they ascribed
to the bile, and to the state of this secretion, in the
production of the disease. Cullen directed atten-
tion, more accurately than his predecessors, to its
nervous and spasmodic characters. Pinkl was,
however, the first who made any considerable in-
novation on the opinion of the Ancients as to its
nature. He classed it as a species of the genus of
fevers, to which he applied the term of Meningo-
gaslric. M. Gfoffroy (^Dict. des Scien. Med.
t. V.) subsequently attributed to it an inflamma-
tory character ; and RllVl. Buoussais and Gravier
afterwards contended that it consists of inflamma-
tion of the mucous surface of the digestive tube
commencing with nervous symptoms.

CHOLERA — History and Symptom?.

319

3. This diversity of opinions will be fully ac-
counted for in the sequel ; but I may at present
remark, that they may be in many respects recon-
ciled, inasmuch as the particular form of disorder,
for which each exclusively contends, frequently
exists as a part of the morbid condition con^ti-
tuting the disease. After having paid considerable
attention to the literature of cholera, and had
much experience of all its forms — of two of them
in my own person — I consider that it admits of
division into the following distinct varieties: —
1st, The Cholera Biliosa, or bilious cholera ; 2d,
Cholera Flatulenta, flatulent cholera; 3d, Cholera
Spasmodica, the spasmodic cholera, or Mart de
Chien. As I believe the disease which has
appeared in recent times, and has received nu-
merous appellations, among which that of epide-
mic cholera has been most commonly used, to be
a different malady from the other forms of cho-
lera, 1 have treated of it in a distinct article.
(See Pestilence.)

i. Choleua Biliosa, Bilious Cholera; x°^^P°-
vypriyGr.; Cholera Humida, Lat. ; Choler-
ragie, Fr. ; Die Gallenruhr, Ger.

4. Defin. Copious and frequent vomiting and
piirgiiig, at Jirst of the alimentary andfiEcal mat-
ters, with a redundancy of bile, and spasms of the
legs and thighs.

5. Causes, States, ^c. — This is the most common
variety, and presents itself sporadically, endemi-
cally, and in an epidemic form. When it appears
sporadically, it is often slight, and of short duration ;
but it is also sometimes extremely severe, accord-
ing to the state of the patient, and nature of the
exciting causes. In this form, it is not infrequently
met with during summer and autumn, and but
very rarely in spring. It generally attacks persons
whose bowels and secreting viscera have either
been, for some time previously, in an inactive
state, or become loaded by an accumulation of
retained, and thereby altered secretions, particu-
larly bile; and arises from exposure to the sun's
rays, or to a high degree of temperature, and after-
wards to cold, or cold combined with moisture,
particularly when applied to the extremities ; from
sudden atmospheric vicissitudes, particularly cold
easterly or northerly winds after hot weather ; from
cold miasmal night air, and dews, after a warm
sun ; cold drinks when the body is overheated, and
the incautious use of ices ; from cold, indigestible,
or unripe fruits, particularly melons, cucumbers,
pine-apples, and poisonous or irritating ingesta of
any kind ; the excessive use of spirituous or malt
liquors, and ingui'gitation ; from large doses of
cathartic or emetic drugs (Henry, Diss, de Choi.
Morbo. Hal. 1740.); fright, particularly from
thunder (Phil, Trans. 1667.) ; and from whatever
occasions a sudden depression of the vital ener-
gies of the frame, and irruption of accumulated
bile into the duodenum.

6. The intimate relation existing between this
species of cholera, and the colica cibaria or sur-
feit, in respect of their causes, and several of their
symptoms, did not escape the notice of Syden-
ham. Dr. Good has also remarked the similarity.
But the distinctions are nevertheless sufficiently
marked, and more numerous than those writers
have assigned. The spasms of the extremities in
the latter; the retraction of the testes, the copi-
ous vomitings and alvine evacuations, with redun-
dancy of bile, particularly after the vomiting and

purging have continued for some time, and the
more acute character of the disease, are sufficient
to mark the wide difference between them.

7. In the endemic form, cholera is seldom
presented to tiie observation of practitioners in
northern countries. To certain districts in some
southerly climates, particularly between the tro-
pics, bilious cholera may be said, from the fre-
quency of its occurrence, to be strictly endemic,
although in a less marked degree than certain
forms of fever, or dysentery, or even hepatitis.
According to my own observation, and that of
several friends whose range of experience has
been great, bilious cholera is very prevalent in
situations which are subject to emanations from
decayed vegetable matter, or putrid matter of any
description ; particularly from swamps, moist
grounds, the banks of rivers, lakes, or canals, &c.,
and from foul drains or cesspools, during warm
seasons, or wide and rapid changes of tempera-
ture; or when the thermometer rises high during
the day, and sinks low towards the night and
morning.

8. Bilious cholera assumes the epidemic form,
sometimes in warm climates, and not infrequently
also in temperate countries. In the latter, this
form of the disease manifests itself only in the
months of July, August, and September, — the
number of cases increasing from June to Sep-
tember, when they are usually most numerous,
and diminishing rapidly in October. The epi-
demic bilious cholera is generally most remark-
able during very warm summers and autumns,
occurring after a very rainy winter and spring,
or after a succession of wet seasons ; and when
the days have been warm, bright and sunny, and
the nights comparatively cold or chilly, with
heavy dews. Owing to this state of season, the
atmosphere is humid, and loaded with the miasms
of decayed vegetable and animal matter; and,
owing to this cause, together with the high range
of temperature, the bile is secreted in greater
abundance than usual, and is more liable to be-
come acrid or otherwise altered (see Liver —
Disordered Function of the) ; and the cool nights,
particularly if the air be much loaded with ex-
halations set free from the soil by the rays of a
scorching sun, tend to check the cutaneous ex-
halations, and determine the chief current of
circulation and secretion to the abdominal viscera.
The use of fruit, which is usually abundant at
these seasons, also augments the frequency of
the disease, by promoting the operation of the
other causes. It increases the acidity of the
prima via, as contended for by Bertrand and
Linnaeus, renders the contents of the bowels, and
the secretions poured into them, of a more irri-
tating quality to the nerves of the stomach and
intestinal canal, and thereby often promotes the
irruption of acrid bile, which had been long pent
up in the gall-bladder and hepatic ducts, and
which is a great cause of irritation when it is
suddenly poured into the duodenum.

9. During states of temperature and of season
which favour the extrication of exhalations from
the soil, the epidemic visitations of this variety of
cholera are more severe. In many cases, occur-
ring at these periods, the disease can scarcely
be imputed to the state of the biliary secretion
merely, but rather to the internal congestions
occasioned by its exciting causes, giving rise to

320

C'lOLEPvA — DuR

spasmodic contractions of the alimentary canal,
to vomiting and purging, and to spasms of the
voluntary muscles, &c. ; the bile accumulated in
the gall-bladder and hepatic ducts being let loose
and thrown into the intesiines only subsequently
to the seizure, and owing to the vomitings and
purgings wliicii usher it in. In some cases, in-
deed, this irruption of bde is pravented from
taking place, until an advanced stage, by spasm
of the common duct, extended to it from the
duodenum, as more commonly occurs in the third
variety of the disorder. When the various causes
now referred to combme to produce the disease,
particularly in persons of a nervous and irritable
tersperament, and who have neglected, for a con-
siderable time before, the state of the bowels, and
secretions poured into them, it cannot be a matter
of surprise, that its siimptoms assume the severe
form described by Sydenham.

10. Symptoms. — Bilious cholera, in whatever
state it occurs, differs chiefly in its degree of se-
verity. It is chiefly characterised by anxiety,
and by painful and violent gripings, evidently
proceeding from spasmodic contractions of the
alimentary canal, taking the duodenum for their
point of departure, and occasioning the continued
or frequently repeated rejection of their contents
by vomiting and purging. Owing to the ana-
tomical connection of the great sympathetic or
ganglial system with the voluntary nerves and
other parts of the frame, the spasms extend to
the abdominal muscles, and muscles of the lower
extremities, — the testes being forcibly retracted to
the abdominal ring, — and are accompanied with
great pain. Tiie tongue is dry or clammy ; tiiirst
is very urgent, and the urine scanty and hi^h
coloured. The pulse is at fiist full and frequent ;
but, as the disease continues, it becomes smaller,
weaker, and more rapid. At more advanced
periods, the spasms sometimes txttnd to the arms
and hands. The symptoms often continue with
little variation for some hours ; but, when the
attack is severe, seldom witliout the patient's
strength being greatly reduced ; the countennnce
at last becoming anxious and collapsed ; the
breathing frequent, interrupted, and laborious,
and sometimes with singultus : the pulse feeble,
irregular, and intermittent; and the extremities
cold or clammy, with leipothymia or fainting.

11. Duration and Prognosis. — The cholera of
temperate climates is seldom fatal, unless when it
is more than usually ])revalent, after very rainy
and hot seasons. But, when neglected or im-
properly treated, especially at such times, a fatal
issue may occur, but very rarely in less time
than twenty-four hours. In milder cases, it may
extend to two or three days, and then terminate
either favo\irably or unfavourably, most com-
monly the former; the vomiting, purging, and
spasms subsiding, and entirely ceasing, tiie pulse
becoming slower and fuller, and the countenance
resuming its former expression. An unfavour
able issue is indicated by a continuance of the
purging and vomiting, particularly after sub-
stances are taken into the stomach, a hurried,
gasping respiration ; great frequency, feebleness,
irregularity, and intermissions of the puis'! ; col-
lapse and paleness of the countenance ; coldness
and pulselessness of the extremities, wilii anxiety,
and frequent fainlings, &c. In general, iiow-
ever, even when left to itself, the disease operates

\TION AND PaOGNOSIS.

its own cure in the course of some hours; or it
continues for one, two, or in milder cases for even
three days, and ceases by degrees; the morbid
secretions which excited the attack having been
evacuated, and the irritation they occasioned
having subsided. Although nature may accom-
plish this without aid, yet the assistance of art is
generally required to ensure its attainment. The
febrile symptoms attending the early stage of the
disease, unless in some instances of its epidemic
prevalence, are merely the consequence of the
pain, spasms, vomitings, and general commotion
of the nervous system, and usually subside im-
mediately these disorders are allayed.

ii. Cholera Fi.atulenta, Flatulent Cholera ;
XoKepa ^ripa, Gr. ; Ch. Sicca, Lat.

12. Defin. Vomiting and purging rare, some-
times retchings; gripings aud spasms of the ab-
dominal muscles, with great and oppressive Jlatu-
lence, temporally relieved by eructations, and
dejections of flatus.

13. This variety was formed by Hippocrates,
continued by Sydenham, and, after having been
discontinued by the majority of modern writers,
who, if they at all remarked it, considered it
rather as a form of colic than of cholera, was
again distinguished as a species of this latter dis-
ease by Dr. Good. It is very rarely met with in
practice ; and generally holds an intermediate
rank between flatulent colic and cholera, some-
times approaching more nearly to the former.
In none of the very few cases of this description
which have come before me (not exceeding two
or three), have I observed a natural secretion of
bile ; but, on the contrary, the liver has evinced
signs of gnat torpor, and the whole digestive
organs have been manifestly enfeebled, long pro-
tracted dyspepsia and hypochondriasis having
existed previous to the attacli.

14. This form of the disease is chiefly cha-
racterised by spasnis of the alimentary canal,
apparently excited by acrid, rancid, and indi-
gestible substances ; and by an irritating gas,
either secreted from the digestive mucous surface,
or generated from the decomposition of the im-
perfectly digested food. (See articles Colic and
Flatulency.) Tlie painful and flatulent griping
is accompanied with severe spasms of the abdo-
minal muscles, anxiety, occasional retchings,
flatulent irritations, and calls to stool, with slight
tenesmus, and very scanty, ofl^ensive, pale co-
loured, and watery evacuations, with flatus. Con-
siderable depression of the powers of life, acceler-
ation of pulse, pale, anxious countenance, cold-
ness of tiie extremities, ^nd sometimes alarming
sinking, supervene, when the disease has been
neglected.

15. Causes. — This rare form of cholera chiefly
appears in the debilitated, and those of a melan-
cholic temperament ; and is generally excited by a
surfeit, by cold drinks when the body is overheated,
by the use of cold or unripe fruits, particularly
melons, water-melons, cucumbers, unripe plums,
mushrooms, and animal poisons, especially the
rank parts of bacon, or tongues, sausages, &c.
wlien kept too long, or insufficiently cured ; also
by unhealthy or stale fish, and by cold or mois-
ture after having been exposed for some time
previously to a high range of temperature. The
author was very recently the subject of an attack
as described above, from having partaken of

CHOLERA

tongue kept too long sifter having been imperfectly
cured. In this case the aft\!Ction was mucli more
nearly allied to ehciiera than to colic ; and this
he is the better enabled to slate, from the circum-
stance of having been ti)e subject of the other
varieties of the former disease al difierent periods
of his life.

iii. Ciior.ERA SvAsyionJCA^Spasmodic Cholera;

Mort de Chien. Yr.— Sporadic and Endemic

Spasmodic Cholera.

16. Dtuv. Vomiting and purging of watery
matters, ivithout anij appearance of bile; spatnis
violent, and extending geueraltii through the frame ;
speedilq followed 61/ sinking of the powers of life.

1 7. This variety of cholera may be said to be en-
demic in some intertropical countries, particularly
in the eastern hemisphere, where it has occasion-
ally assumed, also, an epidemic form, neatly ap-
proaching the remarkably fatal pestilential cholera,
which appeared in Bengal in 1817, and which
has subsequently spread over all Asia, Europe,
and part of Atriea. (See Pestilence.) It has
been very imperfectly noticed by Boniius, Cur-
tis, Paisley, Sonnerat, and Girdlestone ;
but its nature and treatment were very imper-
fectly known, until Dr, Johnson described its
symptoms, and pointed out a more successful
method of cure than had previously been em-
ployed. Several of the cases of cholera, which
Sydenham has described as epidemic in 1669,
seem to have been of the variety now under con-
sideration.

18. Causes, Symptoms, &;c. — This form of cholera
proceeds from exposure to cold, or to a cold, raw,
and moist atmosphere, or to the night air loaded
with terrestrial emanations after the prevalence of
warm weather, or exposure to a hot sun ; or, in a
word, it: generally results from a more intense grade
of the same causes, particularly the exhalations
from the soil, that produce the bilious cholera. It
commonly commences with chilliness, sometimes
amounting to a rigor or shiver ; soon followed by
gripings, and frequent purging of a watery, slimy,
or sero-mucous matter, which is sometimes thrown
off with great force. To these succeed nausea and
retchings, with the ejection of a watery fluid ;
anxiety at the epigastrium ; spasms of a violent,
painful, and tonic character, attacking the muscles
of the abdomen, thighs, legs, thorax, and, lastly,
the arms au'l hands ; a small, quick, and con-
tracted pul-;e ,- great thirst, and immediate rejec-
tion of wha'ever is taken into the stomach. As the
disease proceeds, the pulse beeumes weaker and
smaller; the spasms more general; the purging
constant and painful, generally with tenesmus;
the vomitings are renewed upon tlie ingestion of
substances into the stomach : and the powers of
life rapidly fail. Uiiiing this time, the fluids
evacuated from the stomach and bnwels present
no appearance of bile, although occasionally bile
is seen in the ev;icualinns to a small extent. In
the course of a few hours, the features shrink, the
hands and feet become cold and clammy, the
exacerbations of the spasms force out a cold
clammy sweat on the face and breast ; the pulse
is extremely small and weak, or nearly disap-
pears ; — in a case which came before me in Africa,
in 1816, the pulse could scarcely be felt four
hours !rom the attack ; — the spasms as-ume more
of the clonic character; and the contents of tlie
stomach are now, in the more dangerous cases,

Vol. I.

— Spasmodic.

321

sometimes thrown off without any effort or
retching. Commonly, during all this time, fascal
matters, and the biliary secretions are retained,
apparently owing to the exteu-ion of the spasm
from the duodenum to the common biliary duct
and to spastic constrictions of parts ot the co-
lon ; the epigastrium and hypochondria being
sore, tense, and tumid. When the disease is
treated with decision, the vomitings cease ; free
evacuations, with a discharge of bile, take place;
and the patient soon recovers. But if neglected,
or improperly managed, the powers of life fail
very rapidly ; the eyes sink, and are surrounded
with a livid circle ; the countenance assumes a
remarkably anxious cast;, or is pule, wan, and
shrunk ; and the spasms extend to the very
fingers. The breathing now becomes extremely
laborious; the patient is restless; and at last is
carried off, sometimes in the space of ten or twelve
hours.

19. Such is the progress of spismodic cholera,
as it was observed by the wiiter in the years 1816
and 1817, in an intertropical climate, and as he
then experienced it in his own person. About
the same time, other ca-es of a milder form oc-
curred, and presented the characters described as
constituting the bilious variety of the disea-e,
with which the writer had also been formerly
attacked in this country, in the end of September,
181&, — a season of unusual vvarmtii, — when he
was attended by his friend Mr. Queade. There
can be no doubt that the first and thud varieties
of cholera chiefly differ in degree, and in the
circumstance of the latter arising, in most cases,
from the operation of causes of a more intense
grade than those which induce the former. But
as additioiial phenoniena are developed in the
latter variety, and other symptoms assume a dif-
ferent or modified character, and especially as a
distinct method of cure is requisite to its removal,
the propriety of distinguishing it as a separate
form of the disease is manifest.

20. II. Diagnosis. — This disease can be mis-
taken only for the pestilentTal cholera, or for
poisoning by acrid substances. The diagnosis
between this and the peslileniial m-nlady is fully
pointed out in that aiticle. It is often difficult
to distinijuish between the different varieties of
true cholera (the pestilential disease which has
been very geneially viewed as a form of cholera
being, in my opinion, very diffeient in all its
relations from this), and the disorder occasioned
by irritating poisons. Dr. Christisom, in his
very able work on Poisons (p. 93.), has assigned
the more rapid termination of poisoning, in fatal
cases, as a ground of distinction. But he sup-
poses that death from chidera occuw at a later
period than it usually does ; and hence this
source of diagnosis cannot be much re!ie<l upon.
Death from irritating poisons usually takes place
within thirty-six hours, and sometimes within
twelve hours; being seldom delayed beyond sixty
hours ; but the fatal issue in cholera is very rare,
he considers, in less than three days. I believe,
however, that, although death from the common
cholera of this climate is rare, it more frequently
occurs fiom twenty- four hours to eight and forty,
than at a later period. Greater dependence is to
be plaied upon the appearance of the matters
vomited, which are more frequently sanguinolent
after initating poisons than 111 cholera. But tiiQ

322

CHOLERA — Causes — Theatment.

chief diagnostic sign is the sense of heat, acridity,
or burning in the throat, descending in the cour-ie
of the oesophagus to the stomach, which is so much
complained uf in poisoning, and precedes the vo-
miting. In cholera, when a similar sensation is felt,
it is usually confined lo the region of the stomach,
and is con^eqiient upon the vomiting.

21. The diagnosis between cholera and other
diseases which reseml)le it the nearest is easy.
It is distinguished from colic, by the frequency of
the vomiting and purging, the spasms of the
muscles of the extremities, and the greater acce-
leration of pulse ; — from diurrhcea, by the vomit-
ing and the spasms ; and by the quickness of the
pulse in the latter stage of cholera; — from
dusenterii, by the tenesmus, bloody stools, ab-ence
of the spasms of the extremities, and of the vo-
miting ; or the occasional p-esence merely of this
last symptom in that disease ; — from ileus, by the
appearance of the matters vomited, and the ob-
struction of the bowels constituting that malady ;

— and frorn painter's colic by the absence, or
occasional occurrence only, of vomiting ; by
the constipation, the paralytic signs, &c. charac-
terising that disorder ; and by the history of the
case.

22. III. Causes and Pathological States.

— The remote causes have been already noticed
in connection with the symptoms and forms of
the disease they occasion. — A. As to the morbid
appearancef, they may be stated as generally
bemg very slight in rapidly fatal cases, and con-
sisting meiely of irritation of the mucous surface
of the duodenum, stomach, and small intestines;
but without any change of structure. If deatii
takes place at a more or less remote period, in-
jection of the capillaries, with congestion, some-
times with ecchymosis, and enlargement of the
mucous follicles, is observed more or less exten-
sively— either in streaks or patches — in the
inner surface of the digestive tube. In fatal cases
of the third variety of the disease, the liver has
been found congested, the gall-bladder and he-
patic ducts filled with dark coloured inspissated
bile, and the cornrnon duels sometimes constricted
or oi)Structed.

23. B. The pathological state constituting the
disease seems to consist of irritation of the mucous
suiface of the digestive tube, commencing in the
duodenum, and extendmg in each direction, — to
the stomach, small intestines, and along the com-
mon duct to the gall-bladder and liver, — with
increased action of the muscular coats of these
viscera, and determination of the circulating fluid
to tliem. I'his irritation or morbid excitement
owin'4 to the connection of the organic nerves
supplyiirg these ])aris, is propagated to the spinal
nerves, by which the muscles of the abdomen
and extremities are affected by painful and vio-
lent contractions; and it is chiefly owing to the
exiiaustion of the vital manifestations of the or-
ganic system of nerves, ami to the frequent and
profuse discharges, that a fatal issue takes [)lace :
the circulating organs, which are actuated by this
system, being, in consequence, incapable any
longer of performing their functions.

24. A question may arise as lo whether the
di-ease commences with the irritation of the mu-
cous surface of the duodenum and ailjoining por-
tions of the digestive iul>e, or with deteimination
of the circulation to the liver and adjoining vis-

cera, and an irruption of bile, which has become
more than usually irritating, owing to its retention
in the biliary apparatus, or to its formation from
redundant or noxious materials accumulated in
the circulating fluid (see Blood, $§119. and 120.),
during high ranges of temperature, and moist
miasmal states of the air. It is not very material
which of these phenomena is the first to occur:
probably either may precede the otiier : and
even, in some cases, that both may be nearly
coetaneous. It is, however, most likely that
the procession of morbid phenomena described
above (9 22.) obtains in the great majority of
cases.

25. C. The different states of cholera may ter-
minate differently from either of the ways already
noticed ($$10. 14. 18.) : it may pass into inflamma-
tion of the stomach or of the intestines, or of both ;
it may also lapse into dysentery, or into a regular
attack of gastric, bilious, remittent, or intermit-
tent ("ever. The supervention of some of these
diseases upon, or their association with, cholera,
has been long since noticed by MonxoN and
ToRTi ; and, more recently, by Jackson, J. P.
Frank, and Schmidtmann ; and must be familiar
to experienced practitioners, particularly in warm,
moist, or miasmal climates. In many such in-
stances, this mode of termination is to be imputed
to the nature of the exciting causes, the constitu-
tion of the patient, and sometimes also to the pre-
mature arrest of the evacuations by opium, and the
nejjlect, subsequently, of procuring the discharge
of morbid secretions by purgatives, &;c.

26. IV. Treatment. — Demulcents, diluents,
and weak broths or soups, have been very generally
given at the commencement of a choleric attack,
particularly of its first or common form, since
the time they were recommended by Sydenham.
In slight cases, and at its beginning merely, this
is as judicious treatment as can be adopted. But
in the more severe seizures, and particularly if a
delay of two or three hours has taken place in
applying for or procuring medical aid, much
moie decided means should be resorted to. In
such cases, it is no longer necessary lo promote
the evacuation of the offending matters, which
have gener.illy by this time been expelled. It is
preferable, therefore, in these, and, indeed, under
most circumstances — 1st, To allay the irritable
state of the stomach, the spasms, and other urgent
symptoms of the disease ; 2d, To remove, by
appropriate means, as blue pill, diluents, mucila-
ginous fluids, and deobstruent aperients and en-
emata, whatever morbid secretions may be re-
tained or re-accumulated ; 3d, To prevent the
occurrence of inflammation of the digestive mu-
cous surface, by sheathing the surface of the
bowels from the irritating action of the morbid
ami accumulated secretions during their dis-
cliarge; 4tli, To support the powers of life
when they appear to sink ; and, 5th, To re-
store and promote the functions of the various
emun<!tories.

27. A. Opium, generally in the form of pill, is
the medicine most to be de|)ended on for the ac-
complishment of the first intenlioii, es[)ecially in
mild cases of the first variety. From one to three
grains of it may be taken at once ; but, in more
severe attacks, and in the second and third varie-
ties, it is preferable at first to combine it with
from ten to twenty grains of calomel, which, in

CHOLERA — Treatment.

323

a larse dose, is one of the most quickly efficacious
means we possess of diminishing vascular irrita-
tion of the internal surhice of llie stomach and
small intestines. When a large dose of these
remedies has been given, a repetition may not
even be required ; but, in tiie severe states of tlie
disease, it will be neces>ary to repeat it once or
even twice, after an interval of from three to six
hours, or even longer, accordmg to the urgency
of the case. If the attack require the exhibition
of two or three sucli doses of calomel, little appre-
hension of its ati'ecting liie mouth siiould be enter-
tained, as such a state of disease admits not of the
retention of the whole of it ; and, when it is neces-
sary thus to repeat it, the bdiary organs will deiive
benefit from it. If the first doses of opium and ca-
lomel be not retained, tliey should be immediately
repeated. In pletlioric or robust subjects, when
the pulse is fully developed, and tlie spasms
severe, especially in the third variety of the dis-
order, a full or moderate bleeding may be directed ;
but it should be perforcned early, and restricted
to young or robust subjects. Tiiis practice was
employed by Dr. J. Johnson in India; and sub-
sequently adopted by numerous other practitioners,
as well as by myself. 1 sliould, however, state,
that I have prescribed it only for Europeans who
had recently arrived in a warm climate ; but
natives, or acclimated Europeans, require a dif-
ferent treatment (§J 30, 31, and 32.). In slighter
cases opium, if not loo early exhibited, will besufH-
cient to cure the disease ; and the instances must
be few, in which its use, in some form or other,
can be dispensed with. Its superiority to otiier
medicines in cholera has been admitted by Lix-
tuEVS (Morhi Naut. Lidi<E. Ups. 1768.), Tho-
MANN (^Aniiulen ad 1800.), Yovkg (On Ojnum,
6^c. p. 36.), QuARiN (^Aniinaduersiones Pract.
pp. 204 — 207.), and by most recent writers.
Reide (^View of Dis. of the Armu, p. 63.) advises
it to be given in copious ilraughts of tepid diluents :
Percival {Essays, vol. ii. p. 405.) in enemata;
and Sydenham {Opera, p. 177. ed. Lug. Bat.),
after diluents and demulcents had been freely
given, and the oftending matters removed.
When, however, vomiting and purging have
existed some time, more particularly in severe
cases, opium ought to be immediately exhibited ;
but in order to secure the effect of it, or of calomel
combined with it, the patient should now re-
frain from diluents, in order that the rejection of
the medicines may not be risked by them; and
should merely rinse his mouth frequently with
some cooling beverage, swallowing only minute
portions of it, at short intervals. Sydenham has
very justly reniaiked, — and the importance of
the observation has been acknowledged by Frank
and ScHMiDTMANN, — that when opium is given
too early, much disorder of the bowels and al)do-
minal organs, with more or less fever, continues
aflerwaids to be complained of; evidently owing
to the arre.5l of a salutary effort, and the letention
of morbid secretions, liut the second intention
of cure (§ 26.), and the combination of caloinel
Willi the opium, have for their objects to prevent
this result in cases where all the morbid secretions
may not have been expelled beloie the opium has
been administered,

28. It is not unusual to find, upon being called
to a case of the disease, that aperients had been
freely exhibited with the view of promoting the

evacuation of the offending secretions. But this
is a hazardous practice, and is often, as Syden-
ham has remarked respecting it, adding fuel to
the fire : its piopriety at a later period, when the
vomiting and spasms have disappeaied, will be
admitted.

29. If the spasms, pain at the epigastrium, and
internal heat, be severe, very waim fomentations,
or the hot bath at about 100"^ or 102°, are of
much service if ust;d early in the attack. But
neither these, nor blisters, nor sinapisms, are so
instantly and perlectly remedial as tiie turpentine
fomentation applied over the abii )men. (See art.
C.scuM, §32.) Several authors have recommend-
ed the use of cold or iced fluids, with the view of
allaying the heat complained of in the stomach.
They deserve notice chiefly from being recom-
mended by Aret/Eus (Curat. AciU. Morb. 1. ii.
ch.iv.), C-1CLIUS AiiREi.iANi's (p. 258.), Lienahd
(Ergo CholeiiE Morbo Erigidus Pottis. Paris,
1626.), Hoffmann (De Cholera, obs. v. Opp. iii,
p. 173.), Crr.GHORN (Diseases^of AE^norca, p. 222.),
Penada (Osservazioni, &;c., IVeigel Jcal. Bibi.
b. iv. St. 1. p. 134.), and Panzani (Beschr. der
Krank. von htrien, <5)C.). Bartholin us (De
Usii Nivis Med. p. 141.; advises the application
of ice over the epigastrium ; and Birnstiel, cold
vinegar to the same region. The nitric acid
drink has been much employed in India in cases
of cholera. A favourable account of it in this
disease was published by Sir J. AIacgrioor, in
Duncan's Annak tor 1802. And JMr. Hope has
recently recommended it conjoined with opium,
in the cholera of temperate climates.

30. When the seventy or duration of the more
urgent symptoms has occasioned feebleness of
puLe, with cold skin, and oilier symptoms of
exiiaustion, restorative means are requisite. Am-
monia, camphor, the aethers, brandy, Cayenne
pepper, the various aromalics and spices, are
now the most serviceable medicines, and should
be given frequently, and in moderate doses,
variously combined, and generally with small
quantities of opium. Although at an earlier
stage it was necessary to prescribe opium in a
large dose, yet at this period very small quan-
tities only ought to be given, particularly if exhi-
bited frequently. Any of the following will be
now of advantage : —

No. 120. B Aq. Anetlii 3j-; Magnes. Carbon. Dj.;
Spirit. Ammoii. .iroiii. Ill xxvj.; I'ulv. C'apsici gr. iij ;
Tnict. Oiiii Comp. (F. 729.) IRx.; Confect. Aroin. gr.
vij. M. Fiat Haustus, seciiiKiis horis capiendus.

No. f2l. B Aq. Meiith. Vuid. 3 x. ; Amiiicn. Sesqui.
carbon, gr. V. ; iMagnes. Caloinat. 3 ss. ; Tinct. Capsici
An. Illxij.; Spirit. IMinentK 3 j. ; Tinct. Opii Comp.
m xij. ; Olei Cinnam. m j. M. Fiat Haustus.

No. 122. R Infusi Caiyoph. 3 x. ; Magn. Calcin.3j.;
Tinit. Cardamom. Comp. 3 x.; Tinci. Opii Camphor.
(F. 7^8.) 5j. ; Syrupi Zingibens 3 j. M. Fiat Haustus.

31. In this stage of the disease, the application
of sinapisms or blisters to the epigastrium, as
directed by Celsus (1. iv. ch. xi.), Morflli
(Nuovo Giornale di Milaiio, 1792.), and Aaskow
(Acta Reg. Soc. Med. Uuun.\. p. 154.) ; of stimu-
lating and irritating frictions of the surface,
as advised by Aret-^us (Cur. Acut. Morli. 1. ii.
ch. iv.), C.«nus Aurelianos (p. 257.), and
Alexander 'I'ralles (I. v. ch. vi.), and of warm
analeptic and aiomatic epithems and embroca-
tions, as prescribed by jNIorton and Quarin
(Aiiiinud. Pract. p. 206.), may be resorted to.
in the third variety of cholera, — which differs

Y 2

324

CHOLERA —Treatment.

from the first chiefly as to severity and the more
prolonged obstruction to the How of bile in its
early stages, or throughout its course in fa'al
cases; — in.addiijon to the means already stated
(§ 30.), tli% external measures now mentioned
may' be emj)loyed ; but they are much less effica-
cious than the embrocation noticed above (^29.).
One of our principal objects in this state of the
dist-a'^'e is to procure a discharge of bile into the
intestines. Lar;je Hoses of calomel, with opium
and camphor, are the internal remedies most to
be depended upi)n for the attaining of this end.
But, if the energies of the frame begin to sink
before it be obtained, it will be necessary to have
recourse to diffusive stimulants in order to coun-
teract the depression : at this period the calomel
either may be left off, if a sutificient quanliiy has
been t^iken, or may be combined with full doses
of ammonia or camphor; the stimulants already
prescribed (§ 30.), or warm brandy and water,
being also given at short intervals, or in larger
quantities. The second variety requires the mea-
sures now stated, with the addition of purgative
and emollient enemata. If the flatulence be
urgent, F. 135. 150. will be productive of imme-
diate relii f.

32. 'i'he natives of warm climates, or Euro-
peans acclimated in them, require, from the be-
ginning, that the calomel should be combined as
now advised; and that aromatics, aati-^pasmodics,
and anodynes, be given early in the disease.
The large quantities of hot spices usually em-
ployerl by these classes of per-ons, as well as the
nature of the attack resulting from the constitu-
tion, natural and acquired, of those affected,
render it necessary to prescribe aromatics and
hot spices, especially Cayenne pepper, in large
proportions, in conjuiiclion with opium, camphor,
inc., and to have recourse to the external means
already noticed, almost from the coinmencemcnt
of the attack. Afterwards when urgent disorder
has subsided, calomel, or blue pill, with aroma-
tics, followed by warm stomachic aperients, and
by purgative and antispasmodic enemata, will be
required.

33. B. Having relieved the more urgent sym-
ptoms, whc-tlier of violent irritation or of conse-
quent exhaustion, and having allowed some time
to elapse in order that the viscera may recover
their functions, it will be necessary to promote
the discharge of the secretions which may have
accumul.ited during the calm which had been
procured, particularly when the inordinate action
is followed by complete torpor of the bowels. In
cases where calomel had been freely exhibited,
niihl stomachic aperients will be all that is ne-
cessary ; but they should be given with caution,
and at a time when there appears no risk of
exciting theciioleric attack, whnh may be readily
done by the too early exiiiljition of purgatives. It
will therefore, at first, be better to trust chiefly to
enemata; to prescribe the mildest aperients only,
and when they are absolutely required; and
to administer chiefly mueilagiiioiis fluids, &c. If
Calomel have not been previously given, a mo-
derate do-e, either of it or blue pill, at bed-time,
»vill be even now necessary ; and the latter may
V>e rejjcatud every t'lird night, an aperient draught,
or a (lose of castor oil, being taken on the morii-
mus follovvjni;, for some time siibse(|uently, until
the alvme functions assume a healthy stale. But

if the stomach still remain irritable, it will be
preferable to prescribe merely a blue pill, or the
liydr. cum creta, at bed-time, and emjiluy ene-
mata.

34. C. If, during the progress of disease, or when
the urgent symptoms have somewhat subsided,
the pulse continues frequent, sharp, or constricted,
with tenderness of the epigastrium, a furred
tongue, great thirst, nausea, and retchings upon
substances being swallowed, and general un-
easiness, we should conclude that inflammation
of the stomach and upper part of the intestinal
tube has come on. In this case, from twelve to
twenty-four leeches should be placed upon the
epigastrium, and afterwards a succession of warm
poultices, the last of which should be followed by
the terebinthinate fomentation already noticed.
In some cases, it will be necessary, from the seve-
rity of this consecutive disease, and the patient's
habit of body, to bleed from the arm, previously
to applying leeches. In cases where the foment-
ation is not employed, sinapisms or blisters may
be directed, but not until depletion has been
carried as far as may be considered either neces-
sary or judicious; and small doses either of
hydrarg. cum creta, with magnesia or carbon, of
soda, may be given every four or five hours ;
or of nitrate of potash, and almond emulsion, or
any other demulcent substance, with the frequent
use of enemata. The termination of cholera in
gastric, bilious, reniittenf, and intermittent fever,
or in dysentery, and the circumstances to which
I have imputed this occurrence (jS^ 18. 25.), ought
not to be overlooked, but should influence our
practice both at the commencement and during
the course of the attack. When it has passed
into these diseases, it must necessarily be treated
according to the new form it has assumed.

35. An attack of cholera soon occasions great
exhaustion; and sometimes so great sinking, that
even fatal syncope has occurred froin allowing
the patient to remain too long on the night-chair,
or suddenly to assume the erect posture. In
severe cases, the patient must be kept in a hori-
zontal position ; and besides the medical treat-
ment already prescribed in this state of the disease,
mild demulcent soups, beef tea, chicken broth,
jellies, and sago or arrow-root, with wine, may
be given him. In cases of this description, the
exhibition of aperients by the mouth must not be
ventured on during convalescence, at least not
for several days ; and even then with circumspec-
tion, and in conjunction with stimulants or tonics.
We must endeavour to regulate the secretions by
gentle alteratives, and to procure their discharge
by enemata. During convalescence from cholera,
strict attention should be paid to the state of the
digestive functions. The patient ouv;ht to abstain
from all irritating and indigestible kinds of food,
and heating liiiuors, and from overloading the
stomach. Change of air, gentle travelling, and
moderate exercise, are extremely conducive to
perfect recovery.

BiBLiot;. AND ilEKER. — Nippocfates, Epici. v. 114t.
11. W. — J'iilie, Krgo Clioloiac Morljocoiiveiiit Venaesectio.
Paris, l()'2t — Buntiiis, Med. Indor. cap. (!. — lialloniits,
Opira, vol. i. n. .'i.'j. bl. vol iii. ii. Gh —lieidlin, Lin. Med.

p. 'iii. tO'J.'j Mnrtiin, Pvri'tolonia, sive de Morb. Acut.

&c. pp. .V>— 40. i:i3. 4to. H.'JO. Geiipv. edit — Uianchi, Hist.
Hcpatica, p. \\7. — JIu(fmann, Oc. Cholera, Opp. vol. iii.
p. 174.— Tuiif, Therap. Special, ad Fehres Peiiol. Pfr-
nici()sa.s,&c. 1. iv. c. i. p. 250. 4to. I'^ranc. n^G.—JIcbeirien,
TraiLS. ol Colt.of Pliys. Lnnd. vol.ii. p. i'yi.—I'urttr, Kd.
Med. Kssays, vol. iii. p, a.')7. — iVo//, Hat. Med. part iii.

CHOLERIC FEVER OF INFANTS — Sympjoms. 325

p. 64— /-/■«(/, On the Dip. of Hot Climates, &c. p. 248. —
Cul/en, Works, ed. l>y Thomson, 1827, vol. i. p. 301., and

vol. ii. p. 476 Dick, in Medical Comment, vol. x. p. 12.

Jackson, On Febrile Diseases, vol. ii. p. 27. 8vo. Lond.

1820. —J. P. Frank, De Curand. Homin. Morb. lib. v.
part ii. p. 436. — Ilichlz-r, Die Specielle Therapie, b. iv.
p. l.'J7. — J. Johnson, Diseases of Intertrop. Climates, p.

270. 4tli ed Chisho/m, On Dis. of Trcjiical Countiies,

Ac. p. 85. Svo. Lond. 1822. — Sihmidtmann. Sinnma Ob-
servat. Med. vol. iii. p. 403. Ber. 1826 — Hope, in Ediii.
Wed. and Surg. Journ. vol. xxvi. p. 41.

CHOLERIC FEVER OF INFANTS.— C/io-
le.ra of Children, Cholera Infantum, Rush and
Dewees.

Classif. — III. Class, I. Order (Author).

1. Defin. — Vniniling and purging, uilh Jeter
generally of a remittent type, irregular spasmodic
convulsions, and rapid enuiciution, attacking in-
fants and children.

2. I. IIisTOKY, iScc. — This disease attacks
children duiing the summer and autumnal months,
and sometimes as early as April and*]\]ay. It
occurs at any period, from the age of two or/hree
weeks to that of several years. After this age,
the same causes which produce it occasion, ac-
cording to their combinations and the state of
predisposition of the patient, either fever of some
kind, or cholera, or inflammation of the stomach
and bowels.

3. A. Causes. — It is often independent of any [
disorder from dentition, as shown by the age at '
which it frequently occurs, and the seasons to
which it is almost entirely limited. That it is not
always caused by acid, acrid, or stale fruit, and
indige-tible substances, has been proved by ex-
amination of the history of numerous cases;!
although, doubtless, this cause, as well as den- j
tilion, will contribute to its occurrence. It is I
certainly not owing to worms, as far as my own j
observation may be depended upon ; besides, it is
often met with at an age anterior to that at which
worms form in the intestinal canal ; and, in fatal
cases, worms are not more frequently expelled
from the bowels than in many other di-^eases, as
remarked by Dr. Rush. But it is evidently
owing to the influence of high ranges of atmo- i
spheric temperature acting upon malarious locali- ^
ties, and upon close, low, thickly inhabited, and
imperfecily clean.sed and ventilated streets, closes, \
and lanes, assisted by the above causes, particu- '
larly by premature weaning, want of the mother's ;
milk, errors in diet and clothing, &c. That it
originates chiefly in an atmosphere loaded with
putrid or mephitic effluvia, is shown by its occur- '
rence amongst children thus circumstanced ; by its
frequency during the seasons already specified in
temperate climates, particularly in localities which ,
possess the materials or sources of such exhala-
tions ; bv the periods of its prevalence among
children in warm climates, and in America ; and
by its appearance at the same time with the cho-
lera of adults, and with remittent and intermittent
fevers. This origin is further shown by the cir-
cumstance of its being generally accompanied
with fever, frequently of a remiitent type. In
some very unhealthy climates within the tropics,
the children born of European parents seldom
reach two or three years without having an at-
tack ; and, in some places, scarcely one will
s'irvive this age, if allowed to remain in them, —
this disease cuiting them oft' before they reach a
year or two, and often when they are only two or
three weeks old. According to Dr. Dkwees, it is

one of the most fatal diseases of children in the
laroe towns of the United' States ; and it is cer-
tainly not an infrequent malady of the same class
of patients in this metrojiolis.

4. B. Si/mptoms. — The choleric fe^er of infants,
sometimes begins with diarrlioea ; •but.iiiore com-
monly with violent vomiting and purging, which
are soon followed by lever. The matters vomited
are usually yellowish or greenish yellow ; and the
dejections are slimy, watery, someiimes offensive,
with a scur or putrid odour, and tinged with '
blood. 'J"he natural faeces are generally retained,
although small lumps are occasionally passed.
In some cases, at an advanced stage, they consi-t
nearly altogether of water, or of substances re-
cently taken. The muscles are irregularly and
spasmodically convulsed or contracted ; the child

is much pained, is restless, anil throws the head
backwards and forwards, the lower limbs being
forcibly drawn upwards. Thirst is intense and
unquenchable, cold fluids being eagerly desired.
The pulse is smalt, quick, and feeble. Deter-
mination to the brain is soon sympatlietically
excited, as evinced by increased tempeiature of
the head, and a tendency to stupor. 1 he extre-
mities are commonly colder ihan usual ; and the
abdomen is hot. All the febrile symptoms are
exacerbated in the evening, and occasionally at-
len<led by delirium during the night. The eyes
are languid and hollow, are halt-closed during
sleep; the countenance soon becomes contracted
and collapsed, and the cutaneous surface in-
sensible. In the most acute cases, death may
occur in twenty-four hours; but the disease is
most frequently of considerable duration, present-
ing occasional remissions. Its violence is much
lessened by cool dry stales of the air, and increased
by a close moist atmosphere. In some cases the
vomitings soon abate, and it seems to pass into
dysentery, or chronic diarrhcEa, either with or
without tenesmus, tormina, and occasionally with
prolapsus ani. It often runs on several weeks
with temporary exacerbations and remissions ; oc-
casioning remarkable emaciation, and, lastly,
flutuleiit distention of the abdomen, and aphtliae
on the tongue, lips, &c.

5. C. The Prognosis will depend upon the
eflPect of the remedies employed, particularly on
the state of the discharges. If these become
more abundant, of a daiker colour, and more
bilious; and if the irritability of the stomach, the
cerebral disturbance, and the fever, subside ; we
may expect a favourable issue. On the contrary,
increase of restlessness, of the spasms or con-
vulsive movements, and of the cerebral symp-
toms, rapid emaciation, small thready pulse, cold
dampsurface, watery pink-coloured stools, constant
puking, and especially flatulent distention of the
abdomen, and the appearance of aphtha; about
the mouth, continued stupor, with the eyes half
open, and occasional convulsions, are very nnfa-
vourable signs. A favourable i.ssue should not
be expected wiih any confidence until healthy
bile appears in the stools, and the evacuations
assume a natural character.

6. D. In fatal cases, the digestive mucous
membrane is commonly found more or less in-
flamed, thickened, softened, its submucous surface
infiltrated, and rarely ulcerated or excoriated.
The mucous follicles, especially those of the small
and large intestines, are enlarged or ulcerated ;

Y 3

326

CHOLERIC FEVER OF INFANTS — Treatment.

^he mesenteric glanrls nre often enlarged; the
liver is sometimes darker, and generally much
larger, than natural ; the crall-bludder is occasion-
ally filled with bile ; and the spleen is maniiestly
congested. In a few instances, the intestines have
been found more remarkably inflamed, and ad-
herent by means of exudations ot lymph on their
peritoneal surfaces. In the more protiacted cases,
effusions of serum are found witiiin the cranium ;
but, in recent cases, the brain presents little or
no morbid appearances beyond slight congestion.

7. E. Its Niitiiie.'—'Vhe symptoms, and the
appearances after death, clearly show that this
disea'^e consists of inflammatory irritation, often
rapidly passing into inflammation of the greater
part of the mucous surface of the stomach, and of
the small and large intestines; frequently accom-
panied with depressed vital energy of the frame,
congestion of tlie liver, and a morbid state of the
abdominal secretion'^, and occasioning sympathe-
tic disorder either of the functions or of the sub-
stance of the brain and its membranes.

8. II. Treatment.. — At the commencement
of the disease, demulcents may be administered.
Dr. Rush recommends an ipecacuanha emetic;
but Dr. Deu'ees disapproves of emetics, — an opi-
nion which is agreeable to my experience. I
have usually first had recourse, in the slighter
cases, either to hydrarg. cum creta or caloinel, in
frequent doses, and combined with magnesia or
soda ; or to nitrate of potash with the carbonate
of soda, in demulcents; and to the application
of leeches on the epigastrium, whenever tender-
ness of this region could be detected. After a few
of these powders have been taken, a dose of calo-
mel, sometimes with a grain of James's powder,
has been given at bed-time, and castor oil the
following morning: at the same time, oleaginous
clysters have been administered, and, as the
symptoms abated, those of an emollient kind
employed. If the patient be not very young, a
few drops of tioct. opii, or a little syrup of pop-
pies, may generally be added to the injection. The
warm bath, or the semicupium, should never be
omitted in the treatment of this disease, the sur-
face being well rubbed with a coarse towel upon
coming out of the bath, and the child afterwards
placed in warm blankets. These means, if early
resorted to, will generally succeed in the less
severe cases occurring in temperate climates.
But, in the more intense states of the malady,
medicines given by tiie mouth will not be re-
tained; and such a dose of opium as will not be
rejected, may be injurious. In these, it will be
preferable to commence with the application of
leeches to the epigastrium ; and to endeavour to
procure more healthy evacuations and a dis-
charge of bile downwards, by repeated injections,
consisting of a solution of common salt (about
two or three tea-spoonfuls) in warm water, 'j he
fr. quency of the stools ought not to prevent the
administration of the injection ; which will gene-
rally relitve the vomiting and other symptoms as
soon as bilious or fa.'cal evacuations are procured, i

9. When the disease appears to be brought on '
by improper ingesta, the vomiting may be pro- j
moled by diluents. I$ut the objei^t should be to
quiet the stomach as soon as possible. For this
purpose Dr. Dewees recommends, for very young
children, as well as for those who are older, a tea-
fipoonlul of strong coflee, without sugar or milk, !

every fifteen minutes. Of this treatment I have
had no experience. In cases where the more
bulky medicines are not retained, the plan of
giving minute doses of calomel, adopted by Dr.
Dewees, may be followed. He directs a quarter
ot a grain of calomel, intimately mixed with half
a grain or a grain of sugar, to be placed dry,
every hour, upon the child's tongue, until the
stools become more copious, less frequent, and of
a dark green colour. When this change is ef-
fected, the powders are to be given less frequently.
After the bowels have been well evacuated, he
prescribes an injection in the evening, with a few
drops of laudanum, according to the age of the
child ; and if the disorder is not much abated,
he recommences with the calomel powders as
above, on the following morning, repeating the
injection at night. I have never trie 1 this prac-
tice, having tound the means recommended in
the preceding paragraph (§<3. ), with those about
to be noticed, generally successful.

10. In the more acute cases, especially when
fever is early developed, and much heat of the
abdomen or of the head is complained of, the dis-
ea-^e should he viewed as being entirely dependent
upon inflammation of the mucous surface of the
digestive tube, and affecting the brain sympa-
thetically. In these, leeches must be placed
upon the epigastrium, or behind the ears; if ap-
plied to the former situation, a succession of warm
poultices should follow them, a full dose of ca-
lomel, intimately mixed with a little sugar, be
exhibited, and, soon afterwards, an oleaginous
injection (olive oil or castor oil, or both, in gruel,
strained mutton broth, or any other demulcent
vehicle) thrown up. If these measures fail of
producing the advantage expected, the back,
loins, or insides of the thighs, should be rubbed,
twice or thrice daily with either of the liniments
F. 296. 300, 31 1., particularly upon coming out of
the warm-bath, or semicupium, which ought to be
employed once or twice daily, and rendered more
efficient by adding salt or mustard, or both, to it.
The application of blisters for two, three, or four
hours, and reapplication of them for an equally
short time in another place, may be subsequently
had recourse to, when the preceding measures do
not answer the purpose for which they were
directed. In the more severe cases, particularly
when the motions are bloody, a mucilaginous
draught, with castor oil and two or three diops of
laudanum, may be given ; and, if it be not re-
tained, an enema, consisting of the same ingie-
dients, m'ay be administered, or any of the ene-
mata contained in the Appendix suited to the
circumstances of the ca»e, and proportioned to
the age of the patient.

11. In the advanced stage of the disease, espe-
cially when it passes into a dysenteric state, and
when the exhaustion is great, and tlie stools are
offensive, small doses of the chlorate of lime, or
of potash, in an aromatic vvater, or in mucilaginous
draughts or injections, will be very serviceable.
In this chronic period, when the disorder lapses
into the form of diiirrhoia, proceeding from (diro-
nic inllamniation of the intestinal mucous surface,
the following powders may be given alternately
with the chlorates, or either before or after they
have been tried : —

No. 12.'?. IV Hydrarj;. cum Crpta gr. j. ; Magn. Cali-in.
gr. iij. ; Ouni. Acaciif tl Sa-.cli. Al'oi cia gr. v.; 'J'liitt.

Opii Comp. 1llj— ij. Fiat Piilvis.quovis inveliiculo ido-
neo sumiMidii'i, bis tcrve in die.

No. 124. R Sodie Carbon, gr. iv.; Pulv. Acacifesr. xij.;
Aquae Cinnam. 3 vj.; Syrupi Papaveris 3 ss. M. Fiat
Haustus.

12. It will often be of the utmost service, even
at tills advanced stage, to give a full dose of
calomel, and, if there still be fever, a grain of
James's powder, at bed-time j from half a drachm
t ) a drachm of the spirits of turpentine occasion-
ally, with an equal quantity of castor-oil, being
taken on the following morning in some aromatic
water, or in milk : or, from five to twenty-five
drops of the spirits may be prescribed three or
four times daily in any suitable vehicle. During
this period of the complaint, small quantities of
rhubarb, magnesia, and gingery lime-water with
milk, the preparations of calumba wiih soda,
those of catechu with chalk, the hydrarg. cum
creta with Dover's powder, the decoction of
pomegranate bark, or small doses of the sulphates
of iron and of potash, may severally be employed
according to circumstances. If pain be still
complained of, small doses of the compound tinc-
ture of opium, or of Dover's powder, or of syrup
of poppies, become absolutely necessary. In
this chronic state of the disease, the bi-borate
of soda given internally, either alone, or with an
equal quantity of bi-tartrate of potash, has proved
extremely useful in my practice at the Children's
Infirmary ; either of the liniments. No. 296. 300.
311., being rubbed daily over the abdomen, and
a flannel roller afterwards placed around it. In
this stage of disorder, Ur. Chapman recommends
the following : —

No. 12.7. B Ferri Sulphatis gr. ij. ; Acidi Sulphur. Dil.
gtt. X.; Sacchari Albi Sj.; Aq. Fontan. J j. IM. Capiat
5 j. ter quaterve qiioticiie.

13. The febrile nature of the disease, and its
evident connection with inflammation of the mu-
cous surface of the stomach and bowels, ought
not to be overlooked. In its early stage, there-
fore, cooling febrifuge medicine and beverages
may be allowed the child, in oider to assuage the
thirst. With this view the liquor amnion, acet.
with nitre, and spirit, aether, nit., may be given
with aq. fceuiculi, at short intervals ; and, in the
more advanced stage, when the irritability of the
stomach has subsided, small doses of the sulphate
of quinine, either in syrup or in compound infu-
sion of roses ; or the infusion of cinchona, with a
few drops of liquor potassee, or of the carbonate,
may be directed. When the stomach will retain
it, this infusion, with liquor ammon. acet., very
small quantities of nitrate of potash, and the spirit,
aether, nit., has proved beneficial.

14. Regimenal and Prophylactic Treatment. —
a. When the disease occurs, as is mo>t commonly
the case, in infants under a twelvemonth, the
diet should consist, at the commencement of the
attack, exclusively of the mother's milk ; or when
it has been recently weaned, a healthy wet-nurse
should V>e procured. If, however, the child will
not take the breast, small quantities of diluted
sweetened milk may be given, or thin rice or
barley-water, with some gum added to if. Be-
sides these, soda water, marsh-mallow tea, and
the water poured ofl' an infusion of toasted oatmeal,
or oat-cakes, may be also tried. In the latter
stages of the complaint, the usual farinaceous
aliments may be allowed. Dr. Rush attributes
much importance to the moderate use of salted
provisions at this period, and of port wine ; and I

CHOREA — Symptoms. 327

have had occasion to know that both of these arc
often extremely beneiicial when properly re-
stricted. I believe that the want of a sufiicient
quantity of salt in the food of children, in climates .
and states of the air requiring this condiment, is
often concerned in the causation of the dise.ise.
For no malady is change of air more necessary than
for this. The child should be removed from the
crowded town to the open country ; an elevated,
dry, but not bleak, situation being selected. Re-
moval to the sea-side is also very beneficial ; or,
when a more complete change cannot be enjoyed,
a close, low situation, may be exchanged, even loP
a time, for one that is more open and elevated.

15. b. The prophiilartic measures may be briefly
stated to consist of allowing the infant a healthy
breast of milk till it is a year old; of wearing
flannel next the skin, and keeping tlie lower ex-
tremities warm •, of regulating the diet, and avoid-
ing excess in fruit, and the use of unripe, over-ripe,
or stale fruit ; and of attendmg to the state of the
gums during the period of dentition.

BiBLMG. AND Reper. - TJmiA. Medical Inquiries aid
Observations, p. 131 . 2d ed. — Valenlhi, in Jourii. Gt'n. de
Medecine.vcd. xxlx. p. 459. — Dewees,0\\ the Pliysical .ind
Med. M inagementof Children, &c. Lund. ed. 8vo. p. 443.
182G — Parn'sh, On the Prophylactic Treatin"nt of Cho-
lera Infantum, Sec, North Amer. Med. and Phys. Journ.
July, IH26. — Billari/, Traite des IMaladies des Enfans
Nouveau-nes a la Mamelle, &c. 8vo. Paris, 1H28, p. 414.

CHOREA. SvN. Chorea Sancti Vili (from
Xop^a, a dance with singing); Saltns Vili,
Chorea Sli. Modesti, Choreonmnia, Baltiimus,
Orchestromania, Epilepsia Saltaloria, Auct.
Var. Choree. Fr. Der St. Veitslanz, Ger.
Classif. 2. Class, Nervous Diseases;

3. Order, Spasmodic Disorders (Cullen).

4. Class, Nervous Affections; 3. Order,
AflxiCting the Muscles (Good). II. Class,
III. Order (Author, see Preface).

1. Defix. — Tremulous, irregular, involuntary,
and ludicrous motions of the muscles of voluntary
motion, more marked on one side than the other,
without pain, occurring in both sexes, more fre-
quentlif in the female, and chiefly between eight
and fifteen xfears of age.

2. This disease was formerly called the Dance
of St. Guy by the French, and of St. Weit by
the Germans, from the circumstance of it being
so prevalent in Swabia, and other piirts of Ger-
many, during the fifteenth and sixteenth cen-
turies, that patients crowded to a chapel near
Ulm, dedicated to this saint, who had, by the aid
of the priests, obtained great celebrity in its cure.
It appears to have been known to the ancients ;
for the Scelotyrbe of Galen very nearly resembles
it. The earliest writers, since the revival of
letters, who noticed this affection, are, Plater,
IloRSTius, and Sexneut, under the name of
Chorea Sti. Viti. In 1560, Bairo, physician to
the Duke of Savoy, mentioned it under the name
of " Inilispositio Saltuosa Membrorum." But Sy-
denham was the first author who accurately
described it.

3. I. History, &c. — A. Symptoms. — The patho-
gnomonic characters of chorea consist in disordered
movements of p-.irts actuated by the voluntary order
of nerves ; the functions of volition and of muscu-
lar action being deranged analogously to the ma-
nifestations of the mind in mental alienation. The
disordered movements vaiy very considerably, in
respect of the number of parts affected, aoc* of
the intensity of the afl^ection : hence it ir,ay be

328

partial or general, slight or severe. It is more
frequently partial than general, and is ver}' often
contined lo the mui^clts of one side of tlie body.
'Ihe description by Sydenh^im has been copied
with little alteration by many authors; and,
althougli extremely accurate in respect of some
states of liie disease, it by no means embraces all
the varieties: tliat by Dr. Hamilton is, upon
the w hole, the best, particularly as respects its
fully developed form.

4. Tiiis affection is often preceded by more or
less marked disorder of the ori^anic functions:
the appetite is variable, the digestion imperfect,
the bowels costive, the abdomen tumid, and the
vivacity and physical activity diminished. To
tiiese are frequently added timidity, fretfulness,
desire of solitude, sighing, palpitations, concealed
mental aflection, &c. These symptoms of dis-
ordered health are followed by slight, irregular,
and involuntary twiichings of the muscles, par-
ticularly those of the face. These motions increase,
assunie tiie form of irregular clonic and continued
convulsions, and are often attended by increased
hardness, or tumefaction, of the lower regions of
the alidomen, and consti(iation. Owing to the
irregular convulsive motions of the lace, jaw,
head, and neck, of tiie trunk and extremities,
and from the circumstance of these motions
taking place at different times, the patient has a
jumping, starting, or palsied walk, and cannot
perform the usual occupations of the extremities
with the steadiness and regularity of health. The
characieiistic motions vaiy in degree ; but they
are always present during the continuance of
the disease, excepting while the patient is asleep,
when, in most instances, they altogether cease.

5. Different muscles are sometimes successively
aflPected ; but those fiist convulsed still continue
so untd the termination of the disease. When
the affection is fully formed, aiticulation is im-
peded, hut seldom completely suspended. De-
glutition is often ditficult ; the e\es lose their lu>tre
and expression; the countenance becomes pale,
languid, vacant, and, in the severest and most pro-
tracted cases, conveys the idea nf imbecility, or
even of fatuity. In the course of the disorder, the
muscles seem much more soft and flaccid ihan na-
tural,andemaciation lakesplace ; vertigo and luad-
ach are often complained of. Tiie pulse is a little
accelerated ; the bowels are always constipated,
and the urine is usually pale and copious. The
tongue and gums aie pale ; the former being occa-
sionally protruded, irregularly and spasmodically.
In some of the severest cases the mouth is va-
riously t\viste<l, and a drivelling of saliva takes
place from it: the ey<>s are disiorted, or rolhd in
various directions, and the sight is occasionally
defective. 1 he disposition and temper are un-
stable or irritable ; the mind is often liarassed by
various concealeil mental impressions and ideas ;
and the emotions or desires nve variously excited,
without any sufficient or apparent cause. In some
cases, deglutition is much impeded, and fluids are
forcibly thrown up from the pharynx in attempts
at swallowing them. Bmint and I'imnk state
that the urine and fa-ces are occasionally passed
involuntaiily during the height of an attack; but
this rarely oicurs in simple chorea. There is
seldom any pain complained of, and, although the
movements cease during sleep, yet the rest is
oiten disturbed.

CHOREA— History of, &c,

6. Such is the state of the fully formed dis-
ease ; but it presents endless varieties, sometimes
insensibly lapsing into hysteria, in other cases
appioachiiig to paralysis ; now scarcely to be dis-
tinguished Irom convulsions ; in one instance le-
sembling taraniulism, and in another being closely
allied to paialjsis tremens. In some cases, the
muscles of the face and neck are more affected
than those of other parts; whilst in others, those
either ot the upper or of the lower extremities, or
of one limb only, are most convulsed.

7. B. Duration, complicntinns, and terminations.

— a. The(/i/)«fa)« of thisafl\^ction under treatment
is various — irom two or three weeks to seveiul
months: the most common duration being lr(.m
one to two months. The shortest period of treat-
ment, in the cases which have occurred to me,
was eleven days. Relapses, are, however, not
infrequent. I have seen the affection to return
thrice in the same patient. — /). Chorea is very fre-
quently assoc/uterf with other disordeis : in females
vviih chlorosis, retention or suppression of the
menses, anaemia, hysteria; and, in males, with
rheumatism, with paralysis, disease of the head,
and dropsical effusions in the serous cavities.

— c. It also not infrequently teiininuies. in these,
and in convulsions, epilepsy, anajmia, dropsy,
palsy, hydrocephalus, and complete idiotcy. A
return, however, to health, is its most common
issue. In a case related by Dr. Elliotson, it
terminated in apoplexy ; and Dr. Brown refers
to three instances in his practice, where it termi-
nated in violent convulsions, with cerebral sym-
ptoms, coma, and death.

8. Its complication with rheumatism, rheumatic
pericarditis, and disease of the membranes of the
spine, was first demonstrated by the writer, in
a case, the post mortem inspection of which is
detailed in the fifteenih volume of the London
lAJedical Repository ; the connection having been
subsequently confirmed by Dr. I'richard and by
Dr. RoEbER, who have met with similar cases.
The association of chorea with hysteria is very
frequent about the period of puberty ; and when
the former occurs, after this term. Indeed, the
majority of cases exhibiting choreal symptoms at
or subsequently to the epoch of puberty in the
female, partake more or less of the hysterical
chaiacter — in many instances to the extent of
appearing as a modified form of hysteria, rather
than as chorea : and upon strict inquiry, some
irregularity is generally det( cted in the accession
or subsequent occurrences of the calamenia.
Females who are attacked by, or have been sub-
ject to, chorea anterior lo ilie period of puberty,
occasionally exjierience at this age retention or
|iost]jonenient of the catamenial discharge ; or,
if this secretion at all appears, it is scanty and at
irregular intervals. I^oih the chorea and disorder
of the caliimenia evidently depend upon a similar
condition of the vital manifestations of the oiganic
nervous system, and chylopoietic viscera. 'J he
following jjrocession of morbid phenoniena is not
unconimon : chorea with defective action of the
digestive, assimilating, and secreting functions,
and torpor of the liver ; at a subsequent teim,
protracted calamenia, or scanty and irregular ap-
pearance of the secretion, occasionally with va-
rious hysterical affections, seldom amounting to a
complete fit of the hysteria ; and, lastly, when the
catiimcnia become established, the hysterical af-

CHOREA

fection is sometimes more fully pronounced ; and, '
with the regular e^lablisiimenl of the uterine
functions, the chorea <iisappears. Dr. \\ iute
relates the ca^e of a lady, aged 42, who appears
to have been the subject of chorea of an irregular
or rather doubtful character, and liable to atiacks
of hysteria. In this case, which has been loo
readily admitted by Ur. Good as one of chorea,
the menstrual discharge is reported to have been
regular ; but it is probable that in this, as in many
other instances of diseases occurring in females, a
more strict inquiry would have detected some de-
rangement in tiie uterine functions.

9. C. The appearances J oiuid on dissection of
fatal cases are rather referable to the complications
than to the disea-e itself. In general, the body is
somewhat emaciated, and the muscles soft, flaccid,
and pale. The stomach, bowels, and associated
viscera, present only contingent lesions: they
are, however, often flaccid and pale, sometimes
with a slight effusion of seium in the peritoneal
cavity. In a few instances signs of irritation of
the uterus have been observed. Dr. Hawkins
found in a case he examined, besides increased
vascularity of the uterus, earthy concretions in
the pancreas, omentum, and mesentery, willi
tubercles in the lungs. In the fatal cases re-
corded by Dr. Pkiciiard, Dr. Roeseu, and
myself, adhesions of the opposite surface of the
pericardium, with efl^usion of serum in it, and
Slight effusion into the pleura, were observed. In
a case which occuired in my practice, the surface
of the heart vvas covered in parts with coagulable
lymph : its cavities were much enlarged, and their
walls thin, pale, and flabby, l■e^embling the mubcles
of white-fleshed animals. M. DtsPEnniEiiE met
with effusion of serum into the pericardium.
Soemmering states, that he delected the results
of inflammatory action in the membranes of the
brain ; and several authors have made mention of
small o^siflc deposits in the arachnoid of the dura
mater. Dr. Brown, in the only one of the three
cases which terminated wiih convulsions and
con)a, that he had the opportunity of examining,
found congestion of the vessels of the brain, witli
slight serous effusion between tlie membranes, and
in the ventricles, and a calcareous concretion of a
cubic form, and the size of half an inch, in each
side, in the medullary substance of the left hemi-
sphere,— the convulsive movements liaving been
chiefly on the left side of the body. Dr. Coxe
found the vessels of the brain congested, and
twelve oun<;es of serum in its ventricles : Dr.
VViLLAN, also, in two instances, obseived several
ounces of serum in the ventricles of the brain.
Dr. Patterson describes appearances of the
membranes, consisting of vascular congestion
with efl^usion of serum, and etates, that a patient
cured of the disease very soon died of hydroce-
phalus. JM. Serres found in one instance, a
fatty tumour resting on the tubercula quadrige-
niiiia; in another, appearances of increased vas-
cularity, with sanguineous effusion ; and in two
others inflammation of this part ot the biain. He
further states, that, in experinients on living ani-
mals, he remarked injury of these parts to produce
phenomena resembling chorea ; but he at the
same time admits that he has sometimes met with
cases of chorea, in which no diseased appearances
in the brain could be detected afier death. In a
case which occurred to me in 1819, complicated

Diagnosis and Prognosis. 329

or rather alternating with rheumatism, with me-
tastasis of this disease to the heart, and subse-
quently to the membranes of the spin.il chord, in-
flammatory appearances, with coagulable lymph,
and an eflTusion of tuibid serum, were found
through nearly the whole extent of these mem-
branes, the piuient having died in a state of uni-
versal ])aralysis. Changes in the spinal mem-
branes, similar to tho-e described by me, were ob-
served in the four very interesting cases detailed
by Dr. Priciiard: in these latter, also, more or
less congestion of the vessels, with effusion of
serum between the menibiams, and in the ven-
tricles of the brain, was remarked. Dr. Aliprandi
has also detailed a case, in which morbid appear-
a nces, similar to tho-^e de?ciibed by myself and Dr.
Priciiard, were found in the spinal canal.

10. II. Diagnosis and Prognosis. — a. This
disease, in its ordinary states, may be distinguished
from other affections of a similar kind by the per-
manency, the clonic, and the partly voluntary
nature of the movements, and their cessation
during sleep. In convulsions, the movements,
however irregular, and in other respects re-
sembling chorea, are not continued, are not even
partially under the influence of the will, and are
of the most violent or tonic kind. The di>ease to
which the name chorea was originally given ap-
proached nearer this latter description, but pre-
sented no uniform character, — various nervous
disorders, very diffeient from each other in many
of their essential symptoms, and pathological
states, as the nervous afi'ections resulting from the
bites of the tarantula or other insects, irregular
forms of hysteria, and convulsion, receiving this
appellation; and, even at piesent, many irre-
gular forms of convulsion, particularly those of
a clonic kind, are often conlounded with cliorea.
I'he only other disorder for which it may be mis-
taken is paralysis tremens, which occurs at a later
period of life than chorea, is generally moie li-
mited to a single limb or part of the body, the
movements being more of a tremulous than of a
spasmodic kind, and to a mtich less extent, and
not partaking of the starting, jumping, twitching,
and ludicrous character, possessed by those of
chorea.

11. b. The Prognosis in the simple or uncom-
plicated state of chorea is generally favourable.
15ut when it comes on after attacks of iheuma-
tism, or in conjunction with this disease ; if it
follow the disappearance of the acute or chronic
exanthemata and eruptions, or arises from injuries
of the head, or from manustupralion ; if it be as-
sociated with epileptic convulsions, or with more
or less complete paralysis of some linib or pait;
and if siyns of anremia, chlorosis, dropsical effu-
sion, affection of the functions of the brain, or
idiotcy, manifest themselves, an unfavourable, or
at least a cautious, ojiinion of the result should be
ofl'ered. It would seem that the diseiise is more
severe, or niore frequently complicattd in large
cities, or in some places, than in others, lor the
very difl^erent results of practice cannot other-
wise be well explained. Dr. Park states, tiiat
in about sixty cases, in which the treatment very
generally employed by other physicians was re-
sorted to, all recovered, and only two had relapses.
I have met wiih thiee or four fatal cases; Dr.
I'riciiard has recorded four; Dr. Bromn re-
fers to three in his piactice; and 1 have occa-

330

CHOREA— Causes— Nature of.

sion to Know tliat a similar issue is not rare in
cases occurring both in London and in Paris.

12. III. Causks. — A. PredisjMsing causes. —
Cliorea is much more frequent in the female than in
the male sex. Accordino; to the experience of He-
berden.Thilenius, J. Frank, Reeves, jManson,
Elliot^on, and mvself, three of the former to one
of the latter are affected by it. The most com-
mon period of life is from seven years to fifteen —
from second dentition to puberty ; but no age
is entirely exempt from it. M. Bouteille met
with it in a lady of 80, complicated with hemi-
plegia ; Dr. Powell and Dr. IMaton, in females
of 70 ; Dr. Crampton, in a female upwards
of 40. I have seen it in a man upwards of 50 ;
and cases sometimes occur as early as five or six
years. The nervous temperament, and great
sensibility of the nervous system ; hereditary dis-
position ; constitutional debility, from whatever
cause, either from original conformation, or from
bad or deficient nourishment in early infancy,
particularly an insufficient supply from the mother
or nurse's breast, or total deprivation of this
nutriment ; efFeininate education, and premature
exercise of the mental powers; precocious excite-

humour aflectiug the nerves. Sauvages, Cul-
len, and many others, ascribed it to general
debility, attended by unusual mobility of the
system ; and several writers, among whom I may
notice BouTEiLi.E, Clutterbuck, Serres, J,is-
franc, &c., to inflammatory action of some part
of the cerebro-spinal axis ; thus viewing it as in-
timately related to paralysis. Dr. Hamilton attri-
buted it to disordered functions of the bowels, af-
fecting the muscular actions sympathetically ; and
a very large number of writers, to debility, derang-
ing principally the nervous and muscular systems ;
the torpid states of the organic functions being a
related or associated manifestation of disorder.

15. A. The exact sent, as well as nature, of the
disease, can be inferred with accuracy only from
attentive observation of the causes in relation to
the states of the system at its commencement, of
the phenomena in its course, and of the struc-
tural changes existing in cases which have ter-
minated fatally. The writer was the first who
demonstrated, by post mortem research, inflam-
matory appearances of the membranes of the
spinal chord ; but he cannot on that account
infer that the disease is owing to that cause. In-

ment of the desires and affections ; debility of the i deed, in the case in which he observed it, the

digestive and assimilative viscera ; neglected state
of the bowels, leaUng to accumulations of de-
ranged secretions in the prima via ; torpiil function
of the liver, and other secreting and assimilating
organs ; cold and moist climates; confinement or
sedentary occupations in low, unhealthy, or
crowded places ; low or innu'ritious diet, espe-
cially vegetable food ; impure miasmal air ; want
of personal cleanliness; and the rickety, scrofu-
lous, and rheumatic diathesis, constitute the chief
predisposing causes of the disease.

13. B. Exciiiiig causes. — These are not often
readily ascertained. The mo^^t common are th.e
irritation of worms or of morbid matters accu-
mulated in the bowels (Stoll, Baldinger,
Wendt); and fright. Dr. Reeves and Rlr. Be-
DiNGFtELD State, that the great majority of cases
which they treated was attributed to fright ; and
a nearly similar statement is made by Stoll and
EcKER. Injuries affecting some parts of the nerv-
ous system especially, as (alls upon the head and
back (Geash, Frank) ; the improper employment
of lead, mercury, &c. (De Haen) ; suppressed
eruptions, discharges, Ike. (Tiiilenius, Darm'In,
and Wendt), particularly tinea capitis, iich,
herpes, perspiration of the feet, &c. ; metasiasis,
or extension of rheumatism to the membranes of
the spinal chord (Ploucquet, Copland, Pri-
charo, &c.) ; previous disease, especially the erup-
tive fevers, epilepsy, hysteria, and mental disorder
(Sallaba); second dentition; suppressed dis-
charges; anxiety, the dread of impending occur-
rences, concealed mental impressions and moral
emotions, and the influence of imagination ( Dar-
win, IIavoartii), pariiculaily morbidly exercised
imagination in connection with sexual desire ; fre-
quently excited jealousy and envy; masturbation,
and retained, oi diflficult, or sup])re-sed menstru-
ation, particularly if occasioned by this practice
(RiciiTER, &C.), and cold long endured, — are
all occasionally exciting causes of the disease.

14. IV. Nature OF THE DisEA-^E, — Opinions
as to the yiatholotiical state originating chorea have
been extremely various. Sydenham considered

affection of these membranes was recognised,
doling the life of the patient, as a contingent
lesion arising froin metastasis of the rheumatism
with which it was associated. M. Serres, having
found disease of the corpirra qitadrigemina in
four cases, considers these bodies as the seat of
chorea, and thinks the results of his experiments,
and of those of MM, Flourens and Rolando,
on the functions of this part of the brain, counte-
nance this opinion. Other pathologists, particu-
larly RIM. I3ouii.LAUD and Majendie, conceive
that it is seated in the cerebellum, because the
functions which they ascribe to this organ are
chiefly affected — the disease, in their opinion,
consisting of disorder of the actions of this part.
If we reflect that a number of disorders, more or
less resembling each other, have been considered
as chorea ; that these, as well as chorea itself, are
often complicated with, or run into, other aflfec-
tions of an organic or inflammatory kind; and
that it is never fatal excepting in consequence of
its consecutive and associated changes, especially
those afl^ecting the brain and spinal chord ; the
diversity of lesion observed afier death, and of
opinions derived from this source chiefly as to its
seat, will not appear surprising.

16. I think that chorea, in its simple stale,
occurs most commonly in persons whose vital
powers are depressed, the whole circle of vital
organs performing their functions imperfectly, and
thereby occasioning increased su'^ceptibility of the
nervous system. This state constitutes the aptitude
to be affected by the exciting causes of this disor-
der ; whether those acting directly upon ihe brain,
through the medium either of the mind itself or
of the senses, as terror, fright, mental impres-
sions, moral emotions, &c.; or those which in-
fluence indirectly the cerebro-spinal nervous
system, by irritating or otherwise disordering the
organic nerves, as worms, morbid matters in the
prima via. 1"he susceptibility of the frame having
been induced, either class of causes may occasion
the malady, — the former, by changing the condi-
tion of those parts about the base of the brain

i( as a sj)ccies of convul-ion, occasioned by u which direct or influence the functions of the spinal

CHOREA AND RELATED AFFECTIONS — History or,

331

chord, and, tliiougli it, of the voluiitnry muscles,
- — the latter, by disordering the functions of the
organic nervous system, and thereby atfeeting,
through ihe medium of the brandies communi-
cating with the ganglia placed on the roots of the
spinal nerves, the nerves of voluntary motion:
occasioning, by reflected sympathy, the irregular
muscular movements constituting the disease, in
the same manner that irritation of the visceral
nerves produces the automatic movements of the
foetus in utero* In such cases, the disorder of
the organic nerves may be extended, by means of
the sympathetic, to the spinal nerves either of one
side only, or of both, as well as to the nerves and
parts about the base of the brain, disease being
also subsequently induced in those parts of the
brain or spinal chord in which they originate.
According to this view will readily be explained
the frequent connection of chorea with hysteria
and uterine disorder, as the patient advances
through the period of puberty and adolescence, as
well as the disappearance of the disease alter the
development of the sexual organs, and the healthy
establi-hment of the uterine functions — events
intimately related with and necessary to, the due
manifestation of vital energy throughout the frame.

17. In other words, therefore, the proximate
cause of chorea, in its simple and true form,
seems to consist of debility, with some degree of
irritation of the organic or ganglial class of nerves,
extended more or less to those of volition, and oc-
casioning morbid susceptibility of the nervous sys-
tem, generally, with diminished power, increased
mobility and irregular action of the muscular
system, particularly of those muscles supplied
with the nerves principally aiTected. Whilst
this appears to be the pathological stale of the
majority of cases of chorea, yet instances not in-
frecjuently occur in which disorder evidently com-
mences in the spinal chord or its membranes,
disturbing the functions of the nerves issuing from
the affected part. In many cases the lesion of
the chord and of its membranes is occasioned by
irritation propagated to the roots of the voluntary
nerves ; but in those which are connected with
rheumatism, as well as in some otherwise related
and produced, the mischief evidently originates in
the membranes of the chord itself. When, bow-
ever, the disease commences in the organic nerv-
ous system, affecting the voluntary nerves only
secondarily, pain is not complained of upon ex-
amining the spinal column; but when it is seated
in the chord or its membranes, pain or uneasiness
is felt in this situation, and the disordered motions
are more or less limited to particular parts. When
the original cause of mischief is seated in the
biain, or when the cephalic organs become con-
secutively diseased, the affection partakes more of
the characters of true convulsion, either with or
without hysterical symptoms, but most commonly
with such phenomena.

18. V. Of nervous Disorders resembling
Chorea. — Whilst true chorea, according to the
application of the term in recent times, seems to
originate in the organic nerves, and to disturb the
functions not only of the voluntary nerves, as ex-

* Since this was pubti-hed in .September, 1S32, Dr-
Hall's paper on the reflex function of the spinal chord
appealed in the F/n/osuphical Transactions, it having
been read to the Royal Society in June, 1S33.

plained above, but also of those parts of the cerebro-
spinal axis in wliich they originate; the affections,
1 am about to notice, most commonly depend
upon a disordered state either of the mind, or of
some of the parts within the cranium, and are
often attended by more or less affection of the
generative and digestive organs. The disease
to which the name Chorea Sti. Vili was first
applied, very nearly resembled that produced by
the bite of the tarantiita, as it is described by
Baglivi and Sauvagts ; and, if the description of
the former disorder, furnished by Schenck, Para-
celsus, and Felix Plater, had not been con-
firmed by the more accurate observation of modern
practiiioneis, it might have been viewed as greatly
exaggerated, if not entirely feigned. — a. The
chorea of the writers of the sixteenth century
appears to have consisted of inoidinate muscular
exertions and movements in regulated measures,
proceeding t>om an irresistible mental impulse,
excited by the influence of music or imitation
on the mind. IIorstius states, that it some-
times recurred annually at the same period ; and
that the sound of music often increased it to a
state of phrensy, thiise affected continuingdancing
for an incredible long period, in a most excited
manner. It appears to have consisted cliiefly of
a sort of lascivious dance, kept up an uncommon
length of time until the impulse to excessive
muscular motion was subdued by exhaustion, and
has not inappropriately been called Morlnis Salta-
torius and Epilepsia Sultatoria by later wi iters.—
h. According to the account given by Baglivi and
Sauvages of the effects of the bite of the taran-
tula, the patient is seized, a few hours after the
injury, with difficulty of breathing, anxiety, and
sadness. The violent symptoms of the fiist d;iys
are succeeded by a peculiar melancholy, which
continues until, by darning or singing, it is at last
entirely removed. Persons thus affected frequent
churchyards and solitary places, lay themselves
out as if they were dead, evince the utmost de-
spair, howl and sigh, assume various indecent
attitudes, run about, or roll themselves on the
ground, and are either pleased with or dislike par-
ticular colours. Slionly after being stung, they
fall down, deprived of sense and motion, either
breathing with difficulty and sighing heavily,
or lying as if quite dead. Upon the sound of
music they begin to move their fingers, hands,
feet, and successively all the parts of the body,
sighing, dancing, and assuming a thousand fan-
tastic gestures. Ihey continue these motions for
several hours, until they are exhausted, and
covered by perspiration ; but they return again,
after some repose, to this violent exercise, which
is kept up for ten or twelve hours each day,
during four or five, but seldom so long as six days.
This afl'ection has received various names frcim
continental writers, amongst the chief of which
are tarantif,mus, tarantiilismvs, Choreomniiia, Me-
lancholia saltans, Chorea Sti. Joliannis, Chorea ift.
Valenlini, and Diemojwmunia.

19. According to the above account of both
affections — the original chorea ui the Germans,
and the taraiitismas of Sauvages — there appears
to be but little difference between the latter, at
its advanced or second stage, and the former. It
is very difficult to believe that the whole, or sit
least the gieattr part, of the phenomena in both
these affections was not feigned. It i«, however.

332

CHOREA AND RELATED AFFECTIONS —Treatment of.

admitted, that tlie poison of the tarantula spider
is most successfully counteracted by the exciting
influence of music on the mind, and the profu-e
perspirations produced by continued dancing. A
writer in the New Yo>-k Medical Repositoiy detAlh
an instance of a convulsive disorder occasioned
by the bile of a spider, and cured by music. Mr.
KiNUEii Wood has lecorded a case, which ori-
ginated in disoidered menstrual function, with
cerebral symptoms and painful affections of the
nerves of the tace, that resembled in every respect
the malady to which the German physicians gave
the name of chorea.

20. The dis irder, also, which has usually been
called the " Leaping Ague" in .Scotland, seems to
be very closely allied to the original chorea. It
is described very nearly as follows by a writer in
the Edinburgh Medical and Surgical Journal: —
Those afl^ected first complain of a pain lu the
head or lower part of the back, to which suc-
ceed convulsive fits, or fits of dancing, at certain
periods. Dating the paroxysm they distort their
bodies in various ways, and leap about in a sur-
prising manner. Soinetimes they run with great
velocity even in dangerous places, and when
confined, climb or leap from the floors of the cot-
tages to ilie rafters, or swing by, or vvhiil around,
one of them. I'hey olten dance or leap about
with greater agility, vigour, and exactness, than
they are capalde of exerting at other periods ;
the affectim apparently consisting chiefly of a
morbid and irresistible propensity to dance, tumble,
and run about in a fantastic manner. Cases of this
form of disorder have been detailed by Tulpius,

PliNADA, ReII,, BniiCKMANN, WeSTPHAL, (JlUCIi-

TON, FiiDAGNEL, Laurent, and others. In M.
Piedaonel's case there was a propensity to run
forwaids until the patient, a man, dropped down
exhausted. On examining the brain after death, tu-
bercles were found pre>sing on the anterior part of
the hemisphere. A similar instani:e occurred in
the father of a medical friend, and terminated in
paralysis. The subject of JM. Laurent's case was
propelled backwards with considerable velocity.

21. Dr. Watt has given ihe history of a dis-
order, which he has called chorea, or periodical jac-
titation, in a girl of ten years, that was preceded
by excruciating headach and vomiting. To this
affection of the head succeeded the propensity to
turn round in one direction on her feet with
great velocity like a spinning-top. 'i his propen-
sity subsided alter having continued above a
month, but was followed by an exasperated re-
turn of the headach, and loss of power over the
muscles of the neck. She was afterwards seized
by a diflerent kind of motion, occuring in fits,
which lasted daily, from two to thiee, to six or
seven hours ; this consisted in placing herself
across the bed, and rolling lapidly round on her
sides from one end of it to the other. When laid
in the shallow part of a river she rolled around,
although at tiie point of being drowned. 'Jhe
afl'usion of cold water did not slop the rotations,
which were about sixty in a minute. In a little
more than a month these movements were re-
placed by others of a different kind. She now
laid herself on her back, and drawing her head
aiid heels towaids each other, raised her trunk,
afterwards falling with some force on her back by
stiaightening her boily. '1 hese motions weie le-
pealei! ten or twelve limes in a minute, were con-

tinued for about five weeks, and were then fol-
lowed by the propensity of standing upon her
head. Having raised her feet perpendicularly
upwards, she fell down as if dead, but instantly
placed herself on her head as before, again fell,
and continued to repeat these movements for fif-
teen hours a day, and as rapidly as twelve or fif-
teen times a minute. The affection had resisted
emetics, cathartics, local depletion, blistering,
setons, 6cc., but disappeared after a spontaneous
diarihoea. Dr. Watt refers to two similar cases
which had come to his knowledge ; and another
instance has been adduced by the writer, under
the des gnalion of " Inquirer," of an instructive
article on the subject, in the third volume of the
EdinhurgJi, Medical Journal. Mr. Hunter has
also given the particulars of an instance of rotatory
affection resembling chorea, in the twenty-third
volume of the same work.

22. Dr. RoBEiiTsoN has described a peculiar
form of convulsion, in many respects like chorea,
which spread at one time (1800) as an epidemic
amongst a sect of religious enthusiasts in the states
of Tennessee and Kentucky, evidently from the
influence of imagination and irritation on morbidly
excited minds. The seizure was violent, and dis-
tinctly convulsive at the commencement, but it
usually passed from this state into one more
chrome, and more nearly approaching chorea.
Persons thus affected are desciibed by Dr. Robert-
son as being continually interrupted in their con-
versation by the irregular contractions of the
muscles, and as having no command over these
contractions by any effort of volition ; lying down
in Led does not prevent them, but they always
cease during sleep. Remissions and exacerbations
are Common, butoccur without regulaiity. During
the remission, a paioxysm is often excited by the
sight of an affected person, but more frequently
by shaking hands with him. The sensations of
the patient during the fit are said to be agreeable,
and are expressed by the enthusiastic by laughing,
shouting, dancing, &c., followed by fatigue, and
a sense of geneial sorenes^. The affection at latt
becomes slighter by degrees, and finally disap-
pears. Cases of similar nervous disorders, and
apparently intermediate between chorea and con-
vulsions, and often partaking of many of the
features of hysteria, as well as the affection called
Mullealio, have been detailed by Tulpius, Hohs-
tius, JMoruagni, WicHMANN, IVJagenuie, and
ollieis above referred to (J 20.). It is difficult to
believe, however, upon perusing the particulars of
the foregoing cases, that they are altogether the
actual plienomena of disease. It is very probable
that the morbid affection of mind — thedisuideied
state of the desires, or of the mental impiessions, —
exalts the derangement of the nervous sjsteni to
that singular pitch, of which these cases are rate
examples. (See arts. Convulsions, and II vs-

TEI'.IA.

23. \"I. TiiEAiMENT. — A. Conspectus of the
treatment. — Purgatives have been iecimniend(d
in chorea by Svoeniiam, Wiivtt, 11 a mu, ion,
CnEYNi-, and others. Svdenhaiv], however, did
not coniide the cure of this affection to them en-
tirely, (or he also directed occasional depletion,
with tonics, in the days inteivening between the
exhibition of the purgatives, and narcotics at Led-
tiiiie. ]''.niiiieniigogiies, particularly aloes, myrrh,
as.afatida, iullaboie, savine, castor, the melissa

CHOREA AND RELATED AFFECTIONS — Treatment of. 333

ofKcinalis, tinctura ammoniae composita, saffron,
bi-l)oiateof soda, &c. Iiave been vei-y properly pre-
scribed by RiCHTER, SciiMiDTMANN, 311(1 sevcral
otlier Germaa writers, particularly when the dis-
ease occurs about the period of puberty, and is con-
nected with hysteria, or dsorder of the menstrual
discharge. Antlielmintics are the chief medicines
advised by Hufki.and and Tiiilemus. Watt
and Sallaba viewed the disorder as po-sessing an
inflammatory character, and therefore directed for
it the antiphlogistic regimen. Tunics have found
supporters in Dover, Werlhoff, Maiion, Eck-
stein, Hildebrand, Ei.LiOTsoN, and many other
writers. But they do not agree in the iiind of
tonic wliioh should be emjiloyed : thus Hilde-
BR.VND prefers the sulphuric and mineral acids ;
Werlhoff and Maiion, the cinchona bark ; Grif-
fith prescribes the bark, with the bi-carbonate of
potash. Eckstein, Wendt, and Elliotson re-
commend the preparation of iron, in preference
to otiier tonics. The Jixed alkalies have been
noticed favourably by VVendelstatt ; and the
mineral springs at Ems by Brijckmann. Sir Geo.
Baker, Nagei, and RJichaei.is prescribed the
flowers of the cardamine pratensis ; the latter in
doses of a drachm every six hours. The leaves
of the Seville orange tree, in tiie form of powder,
decoction, or infusion, were much praised by
De IIaen, Westerhoef, Werlhoff, and En-
gelhard. Tiie arnica montana received the
cornmendalion of Theussink ; and the chenopo-
diiun amhroisioides, that of Plentk and of Ecker,.

24. Narcotics and sedutives have also been pre-
scribed in this affection. The inspissated juice of
the root of the belladonna was employed in doses
of one sixth of a grain, with apparent advantage,
by Stoll, Lentin, and Ketterling. Stoll,
liowever, directed at tiie same time friction with
a liniment compo-ed of the spiritus serpilli, es-
sentia caslorei, and camphor, to which 1 am in-
clined ciiietiy to attiibute the benefit derived.
]M. Allamand has likewise prescribed belladonna
with advantage. Stramonium was used by Sidren ;
digitalis hy Uwins and some others; and opium
by Swainston. The hydrocyanic acid has lately
received the commendation of JVIr. Stuart. He
employed it in two cases, after purgatives had
been exhibited in large doses, with decided ad-
vaniage. The cyanides of iron or of zinc are also
productive of benefit.

2.5. Antispasmodic remedies have been resorted
to by several physicians. Camphor has obtained
a well-deserved notice from Werlhoff, Wahon,
^VlLsoN, and others. The cupri ammonio-snlphns
has been prescribed by Dr. Walker, after alvine
evacuations, and found beneficial in cases where
bark and other tonics have failed. Willan,
Uwins, Delarive, and Theussink, have also
spoken of it favourably ; and Merk carried it so
far as to produce an emetic effect. Valerian lias
been recommended by Bouteille, Bernt, IMur-
RAY, Guersent, &c. After the bowels have
been evacuated, it is in many cases an excellent
remedy, eitiier given by the mouth, or adminis-
tered as an enema. The oxide of zinc has re-
ceived a very extensive trial in this affection from
Hart, Burseri, Thilenius, Sciiuaud, Wright,
Hufeland, and Kerst. Stoll, however, states
that no benefit is derived from it, altiiough
pushed to a great length. 1 have seen much more
arlvantage produced from the sulphate than from
the oxide of zinc. Although tlie oxide may bq

given without advantage, and irritate the stomach,
the addition of a full do<e (gr. ij.)of the cupriani-
monio-sulpiias in combination with the zinc will be
borne without inconvenience. This fact, which
was first noticed bj' Dr. Odier, of Geneva, in a
letter to Dr. Duncan, may be taken advantage of
in the treatment of cliorea ; for I am not aware
thai it lias as yet been acted upon in respect of
this disease, 'i'he nitrate of siUer has likewise
been fully employed, and certainly with benefit
if purgatives have been premised. Franck,
Uwins, and Crampton have found it successful
in extreme obstinate cases.

26. Arsenic, in the form of Fowler's solution,
has also been directed with advantaj^e in severe
cases of chorea, e-pecially after free alvine eva-
cuations have been procured, by Mr. Martin,
Dp. Salter, and Dr. Gregory. Iodine has been
given by Dr. Manson, Dr. Gibney, Dr. Peltz,
and myself; and when judiciously prescribed,
particularly when the disease appears about pu-
berty, and is connected with obstructed menstru-
ation, is often of great service. In cases of this
kind, a blister applied over the sacrum, as re-
commended by Dr. Chi-holm and Mr. Swan,
and found beneficial by them, has been produc-
tive of marked advantage in my practice. The
propriety of scarifqing deeply the gums, when the
affection occurs about the period of second denti-
tion, has been very properly insisted upon by
Dr. Gregory and Dr. iNIonro.

27. The cold bath has been much used by
M. DupuYiREN in chorea ; warm baths, containing
sulphuret of potass (4 3 to a bath), by Baude-
LOCQUE ; and sea bathing has been recommended by
HuFtLAND and Himly ; but the shower bath, or
the simple affusion of cold water on the head, whilst
the pitient is seated, is preferable at first, in my
opinion. If the shower bath be directed in cases
of females, the patient should stand, whilst re-
ceiving the bath, in a pan of warm water. Dr.
Ferrari prescribed with beneht a solution of
potassio-tartrale of antimony internally, and ice
along the vertebr d column, followed by immer-
sion daily in a cold bath, and by purgatives, bitter
tonics, and hyoscyamus. Setons, issues, and moias
in the neck, or over the vertebrae of the back,
have also been employect by several piactilioriers.
Dr. Alipuandi, however, relates a case where
is<ues and moxas proved of no service. Drs.
Physick and Young have made use of the black
snakeroot, the rimicifuga racemosa, and experi-
enced decided advantage from it. This substance
seems to act more rapiilly than others in the cure
of the disease, and without any sensible action on
the secretiui,' functions. It is given in doses of
from ten grains to a drachm. The animal oil of
Dippel has been found of service by Werlhoff ;
the cajupnt oil by Ramspek ; and the cod and
tusk-liver oil, and spirits of turpentine by the
author, who first prescribed them in this disease.
Electricity has been suggested by De Ha en,
Fothehgill, Sch;effer, &c. ; and galvanit^m by
several writers. Large doses of mush were directed
by Dr. JMaton and Ur. Powell, after free alvine
di^char^es had been procured.

28. Respecting the propriety of bload-lettin<'
in chorea, much coniradictoiy evidence has been
furnished. Svdenhaim prescribed it as a subsi-
diary remedy ; Dr. Cullen states that it was
sometimes useful, at other times injurious ; Dr.
Watt obtained, he informs us, decided advan-

334

CHOREA AND RELATED AFFECTIONS — Treat.ment of.

tage from the practice ; Dr. Armstrong found
it very liurtful ; and Dr. Clutterbuck trusted to
it almost entirely, repeating it several times after
intervals of a few days. M. Bouteille viewed
the disease as either congestive or inflammatory,
and commenced the treatment with blood-letting,
which he generally repeated, and with purgatives,
M. Serres, iiaving observed vascular turgescence
about the corpora r|Uiidiigemina in four fatal
cases, has recommended leeches, and counter-irri-
tants to be applied to the upper part of the spinal
column; and M. Lisfranc, also, has. directed
blood-letting and leeches to the nape of the neck.
Dr. Hunter and Dr. Harrower have depended
upon purgatives and the inunction of the tartar
emetia ointment on the scalp and along the spinal
column. Aromatic liniments to the spine were
directed by Chrestien; the turpentine and cam-
plior embrocation to the same situation, by the
author; and tartar emetic plasters by Dr. John-
son, who also advised a grain of the nitrate of
silver, with two grains of pilul. hydrarg. and five
of the extr. colocynth. comp. as a purgative. It
may further be added, that Ecker justly insists
upon the superiority of sulphur as a puigative in
this disease. The application of t/isfers to the spine
lias been recommended ; but, in two cases in which
1 have had recourse to this practice, I thought the
effect was injurious raiher than beneficial.

29. B. Treatment recummeiided bq the Author.
— A careful consideration of the nature of the
disease will readily suggest a rational treatment.
Thejirst indication is to remove morbid secretioiis
and iJBcal accumulations, the usual cause of irri-
tation of the organic nerves. 'TUa second, to sub-
due vascular irritation or erethysm of the vessels
of the spinal chord or brain, when the symptoms
indicate its existence. The third, to rouse the
energy of the organic nervous system, and the
vital actions of the assimilating and secreting or-
gans, and to impart energy to the frame. — a. A
judicious employment of purgative remedies, va-
ried according to the peculiarities of the case, and
the states of the patient's system, is indispensable
to the fulfilment of the first intention. When the
disease appears previously to approaching puberty,
it is not very material what kind of purgatives are
first prescribed : but it should be recollected, in
the treatment of this disease, perhaps, more than
in many others, that a judicious combination of
purgatives, with tonic, or stimulating, or antispas-
modic remedies, will more rapidly restore the
patient than confiding in purgatives merely.
Indeed, we are enabled, by such combinations,
partly to accomplish two indications of cure at the
same time ; and fre<|uently we secure a more
decided operation on the bowels and secreting
viscera by the combined means. It will very
generally be necessary to commence with the ex-
hdjjtion of a full dose of calomel, either alone or
wiih other purgatives, or followed l)y them five or
six hours afterwards ; but the doses of calomel
ought not to be frequently repeated in thisdi'^ease ;
nor, in my opinion, will it be, found serviceable lo
continue [iur;4atives long, without either exhibiting
ihem with a bitter tonic or antispasmodic remedy,
or with both, or alieiiiiiling them with llie.se re-
medies. When |)ur;4atives are thus prescribed,
they may be continued longer, not only without
producing any <lctriment, but geni.rally with de-
cided advantage. Cases will not infrequently
occur, in which little or no benefit can be re-

marked until they have been given almost un re-
mittingly for a long period — the evacuations
being at first nearly natural, but afterwards
betraying disorder, and proving that the repeated
exhibition of purgatives was requisite to unload
the biliary ducts and gall-bladder, and remove
faecal mailers retained m the cells of the colon.
For this purpose, I have generally preferred the
compound infusions of gentian and senna, in
equal proportions, with some antispasmodic and
a corrigent. This combination seldom acts fre-
quently, but usually copiously. The oil of tur-
pentine, either followed soon after its exhibiiion,
by some other purgative, if it does not act upon
the bowels, or combined with it, is extreniely
beneficial ; and, whenever the evacuations are
offensive, or of a morbid appearance, especially if
the case be complicated with worms, ought never
to be neglected. In such cases, a single dose of
calomel at bed-time, followed, in the morning,
with the turpentine, combined with castor oil (lu
the proportion of three parts of the former to two
of the latter), and floating on the surface of milk,
or some aromatic water, is most decided. In this
affection, especially, the medical attendant should
examine carefully the state of the evacuations,
and be guided, in a great measure, by their ap-
pearance, as to the repetition and selection of
purgative medicines. The benefit derived from
this class of remedies in chorea was sufficiently
demonstrated by Drs. Hamilton and Parr, and,
although questioned by several piactitioners of the
present day, cannot be denied. Instances of their
failure have been chiefly owing to the neglect of
combining them in the manner insisted upon
above, or of exhibiting tonics, stimulants, or anti-
spasmodics, in the intervals between their opera-
tion. The good eflTect of treatment, as well as the
operation of purgatives, will be much enhanced
by rubbing either of the liniments F. 296. 311. on
the loins or abdomen, once or twice daily, and by
allowing a light nutritious diet, chiefly of animal
food.

30. b. Contemporaneously with the fulfilment
of the^Vst indication, the second should receive
due attention. In many cases, the means u>ed to
accomplish the former will be sufficient to remove
existing irritation about the roots of the voluntary
nerves ; but when we have mai'ked evidence of
irritation of these parts, or of determination of
blood to any part of the cerebro-spitial axis or
investing membranes, either in the state of the
pulsation of the carotids, increased temperature
of the head, coldness of the extremities, tender-
ness or pain from the occiput along the spiuiil
column, particularly when pressing between the
vertebra; on each side of the spinous proce-ses,
the application of leeches behind the ears or along
the spine, and repeating them accoi'ding to cir-
cumstances, or cupping in that situation, will be
recjuisite, and not incompatible with the use of
tonic and antis[)asmodic medicines, in cases pre-
senting sym[)loms indicating the propriety of le-
soriing to them. Alter leeches, the cold affusion
on the head or on the spine, night and morning,
or the shower bath ; rubefacient liniments to the
hitter situation, the turpentine embrocation, or the
tartar emetic ointment or jihisler ; the warm sul-
phur-batli, or the sulphur fumigating biitli ; warm
woollen clothing on the lower extremities, and
attention to the mental emotions ; constitute iin-
poil:int parts of the treatment.

CHOREA AND RELATED AFFECTIONS — Treatment of.

335

31. An accurale idea of the remote causes of
the disease, as well as of their probable opeiation
and continued effect, should lead not only to their
removal as far as possible, but also to a treatment
modified accordingly. The mental impressions
and moral emotions are often more or less affected,
particularly in those irregular foims of disorder,
whicli have very generally been confounded wiih
chorea. This circumstance should not escape the
attention of the phy-.ician, as it points to the em-
ployment of moral management in aid of medical
measures. As the mental affection, when it ex-
ists, has generally an intimate relation to the
remote causes of the disease, the importance of
ascertaining the existence of the former, as well
as the nature of the latter, as a basis of an appro-
priate treatment, must be manifest.

32. c. Having removed accumulations of mor-
biil matters, and subdued irritation existing about
the origin of the voluntary nerves, or in pans of
the cerebro-spinal axis, or enveloping membranes,
and having excited the actions of tlie secreting
and assimilating organs by the means stated
above, the third intention of cure is to be now
entered upon in a more decided manner, by the
exhibition of tonics combined with antispasmodics,
and by due attention to the state of the bowels,
and functions of the secreting viscera and sur-
faces. The combination or alternation of bitter
tonics with aperients and antispasmodics will often
be necessary during this stage of the treatment ;
or an occasional do?e of a brisk purgative, or of
calomel, will be exhibited with advantage during
the employment of tonics. Even when the bowels
are so active as apparently to render this inter-
ference unnecessary, a dose of the pilula hy-
drargyri, given once or twice a week, either with
or without the pilula aloes cum myrrha, will he
found serviceable. As to the choice of tonics, no
immutable rule can be laid down. The state of
the pulse, and of the secreting organs, should
be the chief guide in the selection of them. At-
tention to the mode of combining them is also of
much importance. The carbonate, the sulphate,
and the iodide of iron, and the sulphate of zinc,
aie the most appropriate. Bark, in any form,
will be beneficial when judiciously prescribed.
'J'he following powder will be found serviceable,
and may be taken in some aromatic water ; the
doses of the ingredients being varied according
to the age of the patient, and tlie state of the
bowels : —

No. 126. R Pulv. Cinchonae gr. xij.; Pulv. Rhei
gr. viij. ; SoUae Carb. gr. x. ; Pulv. Capsicl Annul gr. ij.
iVIisce.

If the decoction be preferred, it will be found
most beneficial when given with liquor ammonias
acetatis, and spiritus ammoniaj aromaticus. The
sulphate of quinine is an excellent medicine, espe-
cially when the patient is old enough to take it in
the form of a pill, when it may be most advan-
tageously combined with aloes, as in F. 572 — 577.,
or with camphor, iron, and aloes, as follows. In
this state of combination a decided action will be
exerted on the bowels : —

No. 127. R Camphorae rasas, Ferri Sulphatis, Qiiinina;
Siilphatis, aa 3 j. ; Extr. Aloes Puril'. 3 ss. ; Extr. Gen-
tianae (vel Pilul.Galban. Conip.) 3j-; Syrupi Siinp.q. s.
M Fiant Pilula xxxvj., fjuarum capiat duas bis quo-
tidie.

33. In this stage of treatment much advantage
will often be obtained from valerian, combined
with other antispasmodics and tonics, or with the
alkalies (F. 269. 36y.); from the preparations of

iron, as recommended in the article on Chlorosis,
(§ 13.), or in F. 521.523.; and from the sulphate
of zinr (F. 582 — 587.), or the arsenical solution
(F. 364.). As chorea is sometimes complicated
with disease about the heart, or the roots of
the voluntary nerves, or the membranes of the
brain or spinal chord, or an inflammatory nature,
caie should be taken not to exhibit this last ac-
tive substance, or even the preparations of iron,
or of bark, until tiie symptoms of these complica-
tions have been removed by local depletions, cold
affusions, or the shower bath, and counter-irrita-
tion. A similar precaution is still more requisite
in respect of the employment of stri/chnine, or the
nux vomica (see F. 443. 541, 542. 565. 907.),
which J. have found of much service in the ad-
vanced cour-e of treatment of the simple form of
cliorea, or when it has been associated wUh rheu-
matism of the joints or extremities, with chlorosis,
hysteria, or amenorrhoea ; in which complicated
states of the disease 1 have likewise found the
ioduret of iron, the tincture of iodine, and iodide,
or ioduretted iodide of potassium, of great service
(F. 234. 722.). The formulas for the above me-
dicines given in the Appendix, or the following,
may be adopted : —

No. 128. R Olei Valerianae Ttf xij. ; tere cum Sacch.
Purificati 3 lijss. ; turn adde Int'us. Valerianae 3 vijss. ;
Liii. Potassse Arseniti> iri xv. ad xxx. Misce. Capiat Coch-
learia duo larga ter quotidie.

No. 129. R Pulv. Calumbae gr. x. ; Pulv. Valprianae
gr. ,\ij — 3j. ; Ferri Sesquioxidi gr. x. ; Pulv. Cinnani.
gr. vj. M. Fiat Pulvis, vel Electuarium nioUe cum Syrupi
Ziiig.b. q. s., bis terve quuitidie sumatur.

No. I'M. R Ferri Sesquioxidi 5 ss. ; Pulv. Bilart.
Potassae 3 vj. ; Confection SeiuiK, Syrupi Zmgiberis, aa
3jss. Misce. Fiat Electuarium, cujus capiat Cochleare
uimiri minimum mane nocteque.

No. 131. R Ferri Sesquioxidi ; Sulph. Praecip.aa 3 ij.;
Potassa; Bitart. Pulver. 5 v. ; ConCectioius Seiiiife et
Syrupi Zingiberisaa 3 jss. Misce. Fiat Electuarium. Su-
matur Cocii. unum minimum mane nuctequp.

Nil. 132. R Biboratis Sodae, Kitart. Potasss, aa in
Pulv. 5 iij. ; Sesquioxidi Ferri 5 ij. ; CoHl'ectionis Sennas
3 ij.'; Syrupi Zingiberis q. s. ut fiat Electuarium molle,
cujus Cochleare unum miiiiinura mane nocteque sumatur.

34. During the use of these medicines, the oint-
ment or plaster of the potassio-tartrate of antimony
may be applied !o the spine'; and when the tonics
are not combined with aperients, the former may
be exhibited in the course of the day, and the lat-
ter at bed-lime, as they may be required. '1 he
nitrate of silver may also be tried in doses of half
a grail), or a grain, combined with aloes, or the
aloes and myrrh pill.

35. C. The treatment of the complicated and
irregular states of this disease must necessarily be
modified according to the diversified foini it as-
sumes. The association of the disease with
rheumatism has been observed by me on several
occasions, and, in nearly all, there has been a
marked disposition of the rheumatic affection to
recede from the joints or extremities, and attack
the internal fibro-serous membranes, as those of
the cerebro-spinai axis and the pericardium.
This unfavourable result has generally been pro-
moted by a loo lowering treatment ; but pre-
vented by tonic and stimulating medicines, with
due atiention to the alvine evacuations. In case^^,
therefore, complicated with iheuniati-m, chloro.sis,
anfemia, or retention of the menses, ihe purgatives
selected should be of a warm and stomachic
kind, or combined with cordial and stimulatinLr
substances ; the compound tincture of guaiacum,
camphor, serpentaria, and similar medicines, beiii"
also employed. In these states of disease, the
internal use of the cod or tusk-liver oil will be

33G CLIMACTERIC DECAY — Symptoms.

found most beneficial. Having observed instance's
in which the suppression of the rheumatic affection
of the joints by the use of embrocations and lini-
ments was rapidly succeeded by the appearance
of internal disease, the application of such reme-
dies to the external seat of the rheumatic disorder
should not be resorted to.

36. In the irregular J'orms of chorea, particu-
larly those which present more or less of an hys-
teiic cliaracter, the functions of the uterus, and
the circulation of the brain or spinal ciiord, or
both, are often disordered. In these it will be
requisite not only to evacuate the bowels freely,
but also to alhiy uterine irritation, where it seems
to exist, by leeches a|)plie<i to the tops of the thighs,
or cuppmg over the sacrum, and to promote the
nionili.ly evacuation, when scanty or retained, by
purgatives and emmenagogues. In many cases
of this description, the application of a number of
leeches to the occiput, neck, and behind the ears,
the cold affusion on the head, or the shower bath,
with warm clothing on the lower part of the body,
and due regulation of the moral emotions, will
materially aid the treatment. The more the
attack assumes the chaiaciers of tonic convulsion,
the more requisite will it in general be to have
recourse to local depletions, especially if the affec-
tion occur after pubtrty, and be connected with
interrupted menstruation.

37. During convalescence, and even in the ad-
vanced course of treatment, change of air, agree-
able amusement, exercise in the open air, the use
of chalybeate or aperient mineral waters, and a
light nutritious diet, commencing with warm salt
water bathing during the treatment, and conclud-
ing with cold salt water bathing in advanced con-
valescence, followed by smart frictions of the
surface of the body upon coming out of the bath,
will materially piomole and confirm recovery, as
well as prevent a return of the disease.

BiDLiOG. AND Refer Willis, De Morliis Convulsivis,

rap. vii. p. 21 — Tulpins, I. i.cap. 16, 17 Ho;-s</ms, Epist.

M d. s, vii. ; Opera, 4 to. 2d vol. p. lit). — Si/denhnm , Oxii'Ta,

J). H;o iVcdel, De Chorea Sti. Viti. Jen*, 16K2.— _F,'&,

Plater, Observ. I. i. 130. — Ramspek, Diss. Biga Itemedior.
Pra?stanti^s. &c. Bas. 174.'>, p. 'Afi. — Schwartz, De Taran-
tisino et Chorea Sti. Viti, &c. Vieii. 1766 — h'otlicrgiU, in
Philos. Trans, for 1799, part i — iJe Haen, Rat. Med.
part i. p. Ml., part iii. cap. vi. \).'i'l\ .— Bur.'-erius, Institiit.

vol. iii. p. 242 Prnada, Saggio d'O.sservazioni. n. 9. —

Merit, Museum der Heilkunde, b. iv. p. 198 Sti.ll, Rat.

Med. pars iii. p. 40.5.. et pars i v.)). 469 JVendt, Nachriclit

von dem Krankeninstitut zii Ertang. 17^3 Baldinger,

N. Mag. b. ix. p. Ih.^ Eclcer, in Phwl's Kosog Fhilos.

t. ii. p."94. — Gen4A, Phil. Trans, vol liii. \lGi.—De Haen,
Kat. Med. par. iii. p 202. — Sidren, Dissert. Mirb. Casus,
Sp. &c. Upsal. \1H^.— Hallaba, De Morb. Variol. Posth.
Vien. nH<.). —Pluucvjuet, Obser. Med. Tubing. 1787.—

White, Edin. Med. ( omrnent. vol. iv. p. 326 Hart, in

Ibid. vol. i. p. 76 — Odier.xn Iliid. vol. iii. p. 191 Walker,

in Ibid. vol. x. p. 28S Artnslrortj;, in Ibid, vol, ix. p. 317.

— 'I'/tilenius, Medic, und Clilr. Bemerk. &c. p. ll.'i. — Werl-
h'ljf', Ob.s. de Feb. sect. ii. h i. — Sirninstan, Thoughts,
Phys. and Pract. \c. York, 17'.i6._ A'wAci/iwn, On Chorea
•Sti. Viti,8vo. Philad. ISO!) lla»iilti»i. On I'urgative Me-
dicines, ch. vi. — Plenck, De Morhis Infantuin. Vien. 1807.

llichter. Die Speciellc Therapie, li. vii. p. T'l — Ilufe-

land, in his Journ. der I'ract. Heilk. b. i. p. 1.52., et Jiiiie,
1811, p. 8'^. May. 1812, p. VI. — Hiltiehrand. in Ibid.
b. xxlv. St. i. p. 147. — Wend< Islalt. in Il)id. p. 149— Eck-
stein, in Horn's Archiv, &c. b. iii. p. 241. — lirUckni'tiin,
in Il)id. Jan. 1811, p. 9., et 1812, p. 168 ; et Journ. de Med.
t. Ixxiv. p. 1.36. — >>•>/>///, Mem. of Med. Soc. of Lon<l.
vol iii. Ap. n. U. — Lentin, Med. Bemerkung. &c. 18(10.
p. 1l\. — F.n'jelh<ird. Mus. der Heilk. b. iv.p. \m. — Wcsl.
jihal. Pathologia Dasmonlacn, p. I. — iyiehmn>in, Ideen
zur Diagnostili, b. i. pp. 131. \U.— Mahiiu, Joiirn. de
M6d. I. Iviii. p. .5.53. — Alliiniand, Jonr". <le Med.
Cont. t. xviii. p 2fi3. —Frank, Acta Instit. Clin. Vil-
Iien*. I. 111. p. .51.- 7'A,7/sjiH;f. ]{e(,b.ulit. <ler K. K.

J'',*','!''','-'^'-'"''-'"'''. '>■'■ "••'' Ketlnliui:. l)c Chorea Sti.

Vitl. Erf. 1803. - SchtcjSfer, Kliidcrkranidi. ii.Wi.—llcil,

Fieberlehre, b. iv. p. ^1G.— Martin, Trans, of Med "and
Chirurg. Soc. vol. iv. p. ih. — Kinder Wood, in Ibid.
t. vii. p. 237 — Wall, in Ibid. vol. v. p. I. — Salter, in
Ibid. vol. X. p. ilH. — G report/, Ibid, vol.xi. p.2y9. — Jf')7-
lan. Reports on the Diseases of London, p. 24.5. ; and Med.
and Phys. Joiirn. vol. vii.— Coxe, Med. and Phys. Journ.
vol. xiii.p. 40.5., and vol. xviii. p. 221. - Paterson, in Ibid,
vol. xiii. p. 119., vol. XV. p. 127., and vol xviii. p. 234.—
Peltx, Ibid. vol. lix. p. 4.54. —Kerst, De Zinco ejusque Usu
pra?Lipue in Chorea. Jen. 1812. — A/a/o», in Lond. Med.
Repos. vol. v. p. MH. — Bedingjield, Compend. of Med.
Practice, Lond. 1816. p. 52. — Copland, in Lond. Medical

Repository, &c. vol. w.p. 23 Prichard,m Ibid, vol. xxi.

p. 1 — Roeser, in Hufelarid's Journ. der Pract. Heilk.
Nov. 1828. — Serres, Lancet, vol. xiii. p. V6^.— Aliprandi.
in Giornale Analit. di Med. Milano, Guigno, 1828.— Fer-
rari, in Ibid. Novemb. \%29,. — Gibney, Med. Gazette,
vol. i.p. 54. — Armstrong, his Lectnreson Medicine. Lan-
cet, vol. viii. p. 70. — Clutlerbuck. Lectures on Med. Ibid,
vol. xii. p. ilX.— Piedagnel, in Majendie's Phvsiology,
translated by Millignn. 3d edit. p. lS^. — Laure7ii. in Ibid.

p. \d\.—Bouleille, TraUeAeUCuorHe.&c. Paris, 1810

Pov'cll, Tr.ms. of College of Phys. vol. v. p. 3.58. — Maton,
in Ibid. vol. v. p. 188 — Crampton, Trans, of the Assoc, of
Phys. of Dublin, vol. iv. p. \\\. — Griffith, Philad. Med.
Mus. 1806. — Reeves, in Edin. Med and Surg. Jonrn.
vol. viii. p. 314. —Hunter, in Ibid. vol. xxiii. \>. mi. —Jef-
freys, Ibid. p. 273. — Stuart, in Ibid. vol. xxviii. p. 271.—

Uirins, in Ibid. vol. viii. p. 408 Swan, in Ibid. vol. xxii.

p. 94. — Crichton, in Ibid. vol. xxxi. p. 300 Manson, Re-
searches on the ElTects of Iodine, &c. p. 230 Etliotson,

Trans, of Med. and Chirurg. Soc. vol. xiii. p. 2.52. ; and
Med. Gazette, vol. vii. p. 6.52. — C/iisholm, On Diseases of

Trop. Climates, 8vo. 1822, p. 97 Lisfrank, Archives

Gener. de Med. Sept. 1827 Harroieer, in Glasgow Med.

Journ. vol. ii. p. 212 Young, in the American Jonrn. of

Med. Sciences, vol. ix. p. 310. — Broivn, Medico-Chirurgi-

cal Review. &c. vol. xv. p. 326 Johnson, in Ibid, vol.xv.

p. 481 — Serres, Revue Medicate, 1827, t. iii. p. 518.

CLIMACTERIC DECAY,— C/(ma<mcD(>ase,
Classif. 3. Class. 4. Order (Good). I.
Cl.ass. V. Order (Author).

1. Defin. — General decline of the vital power's,
at the age of senescence, icithout unij evident cause.

2. The ancients believed that very impoitant
changes took place in the economy at certain
periods ; the first being the seventh year, and
the subsequent epochs answering to the numbers
resulting from the muhi[dication of three, seven,
and nine, into each other : as the twenty-first,
the foity-ninth, the sixty-third, and the eighty-
first years. The two last were called grand cli-
macterics, as the life of man was supposed to
have reached its allotted term. The doctrine of
climacteric periods has been traced to Pythago-
ras, who derived it from the Egyptians; and,
although its truth has been denied by many emi-
nent physicians, it has been believed in by others.
The changes which take place at these epochs
are of two opposite kinds ; that of renovation,
and that of decay. It is the latter of these which
will be here considered.

3. I. Symptoms. — This di.sease has been very
minutely described by Sir H. Halford. It
usually comes on insensibly. The patient fiist
complains of fatigue upon slight exertion ; his
appetite becomes impaired ; his nights are dis-
turbed or sleeple.'is, and his mornings unrefieshed.
The tongue is somewhat while ; the pulse a liiile
accelerated ; the face extenuated, occasionally
slightly bloated ; the body emaciated, and the
ankles and legs disposed to swell. 'The urine is
not deficient, but the bowels are sluggish, and
j)ains, with vertigo, are occasionally felt shooting
through his head and various parts of the body,
but are not possessed of the rheumatic character.
As the vital exhaustion proceeds, the stomach
lo,'<es all its powers ; the emaciation is greater;
the lower limhs are more oedenialous ; restlessness
through the day and sleeple-^sness through the
night, increase, and all the vital manifestations,

C LIMACTERIC DECAY — Causes — Treatment.

337

mental and physical, are gradually extinguished.
Such is the usual progress of the simple form of
the disease, or rather gradual decay of the vital
energies, — a decay which is not peculiar to, but
which may occur at any time intermediate be-
tween, the grand climacteric periods. I'his sim-
ple form of decay is, however, less frequently
observed than its complication with other aftec-
tions. Persons who, together with the anxieties,
griefs, and distresses of life, have been subject to
disease of some particular organ, as of the lungs,
liver, brain, heart, &c., who are of a gouty.

the affection, the digestive, secreting, and excreting
functions require to be assisted, by means of the
warm, bitter, and cordial aperients (f .86.214.266.
572.) ; and if internal congestions, or sub-inflam-
matorj' disorders, manifest themselves, evacuations
should not be practised without combining or alter-
nating them with restoratives and tonics. The best
aperients are, in such circumstances, rhubarb or
aloes combined with gentian, quinine, guaiacum,
or myrrh, or with tiie carbonates of the alkalies and
the balsams. But, on all occasions, even of acute
disease occurring at the climacteric epochs, it

rheumatic, or calculous diathesis, generally expe- : should be recollected that the vital energies soon

rience at these epochs an aggravation of such
diseases, which assume a more dangerous charac-
ter from the vital decay which is thus attendant
upon them. Indeed, in most cases, these acci-
dents, moral and physical, constitute the exciting
causes or occasions of the appearance of climac-
teric disease, as well as complicate and aggravate
its progress.

4. II. Causes. — This disease is more common
to men tiian women, probably owing to the more
tumultuous and exhausting life passed by them —
to their greater expo-ure, during the preceding
terms of existence, to the numerous causes of
mental and corporeal exhaustion incidental to the
states of modern society and civilisation. It is
not infrequently occasioned by the mental de-
pression arising out of pecuniary losses and disap-
pointments, and the death of old and attached
friends and relatives. Tiius, we sometimes ob-
serve it proceed rapidly to a fatal issue, or com-
bated with great difficulty, after the loss of the
partner of the principal part of the patient's exist-
ence. It may also be caused by a marriage con-
tracted late in life, or by unusual intemperance, or
some accidental shock or commotion of the frame.

5. As to its nature, climacteric decay is ob-
viously the concatenated phenomena arisino- from
that exhaustion of the vital energies which takes
place at a more or less advanced age, in conse-
quence of the cares, turmoils, and physical exer-
tions, attendant on the existing states of society,
particularly in the middle classes of life ; the
exhaustion manifesting itself especially in these
functions which are most intimately related to,
and concerned in, the perpetuation of the vital
endowment of the frame, and which are actuated
by the organic system of nerves. As this decay
of the vital energies — this breaking up of the con-
stitution, as it is commonly called — is necessarily
experienced by the whole frame, it is obvious,
that it may not only be hastened by whatever is
either mentally or corporeally injurious, as well
as by specific forms of disease, but that it will be
more or less remarkably evinced in those organs
which have especially suffered during attacks of
previous illness: hence the complicated states in
which senile decay is usually observed, and the
rapid progress and unfavourable issue of maladies
appearing about the climacteric periods.

6. III. TriEATMF.NT. — The simple form of this
disease requires tonic and cordial medicines, with
generous diet, a dry wholesome atmosphere, change
of air, the occasional use of the tonic and deob-
struent mineral waters ; agreeable occupations
and amusements ; and, above all, the consolations
arising out of the recollection of a well-spent life,
and confidence of the future. During the course of
treatment, particularly of the complicated states of

Vol. I.

feel the shock, not only of the malady, but also of
a too active or lowering treatment ; and that,
even when such practice is most required, we
should endeavour to support the powers of life by
means the best calculated to fulfil this object,
without increasing the morbid action, and to meet
the first indications of depression or exhaustion by
suitable cordials and tonics. The utmost atten-
tion should also be paid to the previous habits
and indulgences of the patient; and if the discon-
tinuance of them is likely to sink the constitu-
tional energies still lower, they ought not to be
relinquished. Various instances have occurred,
showing the ill efllscts of want of attention to the
above caution, during the course of my practice.

7. A sontleman had been for some years at-
tended by the writer. At the age of eighty-one
years, auring a severe winter, he suffered much
from bronchitis, accompanied with great sinking
of the vital energies. His habits were social, and
he lived highly. He recovered, however, by
means of warm diaphoretics, and tonic cordial
aperients, with a due regard to his accustomed
indulgences, and to the precept of Hoffmann,
" lie suhito muta assueta, (/uia assueludo est altera
natura." The following year he had a similar
attack, at his seat in the country. A nearly op-
posite treatment to that which was adopted by
the writer in his previous illness was directed by
his medical attendants on this occasion, and in a
few days he expired wlien seated on the night-
stool, (see Hoffmann's treatise " De Situ erecto
in Blorbis periculosis vahle noxio,") about half an
hour after the physician had left him, and given
a favourable opinion of the result to his friends.

8. General had served nearly all his life

in the East Indies, and was upwards of eighty,
but of a robust constitution. His ailments, when
he was seen by me, could not be referred to any
particular organ, and were attributed at the time
to senile decay : the liver performed its functions.
Nothing beyond the regulation and promotion of
the digestive and excreting functions was at-
tempted; and he was allowed a light and nuti'i-
tious diet, with change of air, the use of the Bath
water, Sec. Under this plan he improved greatly,
and was able to travel with ease from one part of
the country to the other, and, when in town, to
dine daily at the Oriental Club. The last occa-
sion but one on which I saw him, he came to my
house to inform me that his relatives were not
satisfied with the progress he had made, and had
repeatedly irrged him to change his physician.
I accordingly retii-ed ; but, a few days afterwards,
was requested to see him. He was then sinkino-
fast, evidently from the efl^ects of a lowering treat-
ment, and of profuse evacuations upon a decayed
frame. Speedy dissolution could not be averted;

338

CLIMATE — Physical Relations of.

I therefore declined all interference. He died not
many hours afterwards.

BiBLioG. AND Refer Coclronclii, De Annis Climac-

tericis Comment. 8vo. Bon. 1()2(). — Broidelius, Blonu-
ment. Fragilitatis Humana; mementauea; Anni Cliraac-
terici, 4to. Alst. 1G58. — P(i<m, Ergo ab Annis Climac.
tericis nil metuendum, 4to. Paris, 1657. — De Filisco,
De Fato Annisque Fatalibus tam Hominibus quam Reg-
nis, 4to. Franc. 166-1. — Salinasms, De Annis Climacte-
ricis et Antiq.Astrolog. Diatribe, 8vo.Leyd.1678. — Ziegra,
De Annis Ciiraact. Vit^-e Humana;, 4to. Viteb. 168'2. —
Hqffmann, Annor. Climact. Medica et Rationalis Expli-
catio, Operum vol. v. p. 89., et vol. vi. p. 10."). — Hilsc/icr,
De Vano iEtatis HumanEe Anni 63 Climact. magni vulg5
dieti Timore, 4to. Paris, 1743. — Gruni-i; De Annis
Climact. 4to. Jen£e, 170% — Ha/ford, in Trans, of the
College of Phys. of Lond. vol. iv. p. 316., and Essays and
Orations, Lond. 8vo. 1833. p. 1 — RenauMin, Hict. des
Sciences Medicales, t. v. p. .360.— Goorf, Study of Medicine,
edit, by Cooper, vol. iii. p. 226. 3d edit. — Pinel, in Archives
Gener. de Med. t. ii. p. 7 Foucart, in Ibid. t. v. p. 398.

CLIMATE. Syn. (Fjom nxi/xa, a region. —
Climat, Fr. Dus Clima, Ger. Ctima, Ital.
Classif. General Pathology — /Etiology
and Therapeutics.

1. Climate, in its rigorous acceptation, means
only a district placed between certain equatorial
and meridional circles ; but it possesses a much
wider signification in medicine, and is more com-
monly applied to the conditions of the soil, surface,
elevation, and position of a country in connection
with the general states of the atmosjiliere, influ-
encing the health of the human species, and of
the higher races of the animal kingdom : — ' L'en-
semble de toutes les circonstances naturelles et
physiques, au milieu desquelles nous vivons dans
chaque lieu." — Cabams.

2. I regret that my limits will not admit of
entering fully upon the consideration of the phy-
sical conditions which combine in forming the
climate of a country, and not only modify the
constitution of man, giving rise to a great part of
the most acute diseases to whicii he is liable, but
also assist in removing others of a dangerous
tendency. It is obvious, that a knowledge of the
elements out of which disease arises, and which
may be taken advantage of, and even artificially
combined, for its removal, must be of essential
advantage in the healing art. Indeed, the im-
portance of the suljject has been admitted since
the time of Hippocrates, whose treatise Trspi
aifiMv v^aToiv Koi -roitrnv will be read, even at the
present day, with the greatest advantage. I shall,
therefore, draw a mere sketch of the subject, and
indicate the sources whence more detailed inform-
ation may be obtained.

3. I. 'J'liE Physical Relations of Climate.
— The climate of a district or of a country essen-
tially depends, 1st, upon its position, in respect
of distance from the equator ; 2d, upon its ele-
vation above the level of the sea, and its proximity
to the shores of the ocean, or the beds of large
rivers, &c. ; 3rd, upon the geological and minera-
logical formations constituting liie basis of its soil ;
4th, upon the nature of the soil itself, its cultiva-
tion, and the vegetable productions by which it is
covered ; and .5th, upon the prevailing winds, or
currents of air. Under these heads are com-
prised a number of subordinate phenomena,
giving rise to important modifications in the
climate of a district. In the brief account about
to be given of tiie sul)ject, tiie temperature, and
liuniitiity of .a jjhicc will be first considered, and
afterwards those circumstances which relate more
immediately to the nature of its loculity.

4. A. Of the temperature and humidiiy of
climates and their effects. — The temperature of a
place influences not only the organisation, but
also the diseases, of the inhabitants ; and, as it
varies with the latitude, physical conditions of a
district, state of cultivation, &c., it is evident
that the physicians of the northern countries of
Europe have to treat different constitutions and,
states of disease, from those which come before
practitioners in more southerly regions. The
efl'ects of temperature upon the human frame
vary remarkably, owing to numerous concurrent
circumstances, and the extent, rapidity, and fre-
quency of its changes. The mean annual heat,
the extreme range of temperature, not only during
particular seasons, but also in each month ; the
usual mean of such month, and daily variation ;
have altogether a manifest influence upon the
human frame. Geographers have divided the
globe, in relation to its temperature, into arbitrary
divisions, well known as the torrid, the two tem-
perate, and the two frigid zones ; but the climate
of the countries placed within these divisions
are so greatly modified by other circumstances
than by distance from the equator, especially by
elevation above the level of the sea, by distance
from the ocean, want of cultivation, &c., that
many places within the temperate zones, and,
even in those parts of them which are the nearest
the meridian, experience, particularly at one
period of the year, remarkably low ranges of
temperature ; whilst others, much further removed
from the equator, are subjected, during summer
especially, to as great heat as places within the
tropics. In countries or districts near the ocean,
or large lakes and rivers, and particularly in islands
or places partially surrounded or indented by the
sea, the extremes of heat are moderated, but the
air is moist, and the changes of season are uncer-
tain and variable ; whilst in those situate far inland,
and removed from lakesor the beds of large rivers,
the range of atmospheric temperature is very
great, particularly in latitudes above 40° noith,
or in places considerably elevated above the
level of the sea ; and the air is remarkably dry.
Even in countries within the tropics remote
from the ocean, or having high ranges of moun-
tains placed between them and it, that may attract
and condense into clouds and rain the moisture
carried by the sea winds over the land, the dry-
ness of the atmosphere is very great, and, where
the currents of air have passed over extensive
tracts of arid country, is even extreme. This is
well shown by the Harmattan winds, which,
having blown over the diy countries of central
Africa, visit its western coast, and change the
extreme humidity of that part, during their con-
tinuance, to a state of remarkable dryness. In
the more inland districts, therefore, of large con-
tinents or islands, j)laced without the torrid zone,
the depression of the thermometer during their
winter months, and elevation of it in sunmier, are
greater than is indicated by their distance from
the equator, and the air is much drier than in
places otherwise circumstanced. In these latter,
particularly insular situations, &c., the climate is
more equable, but mucii more humid. In the
former tiie seasons are regular, the ciiange con-
stant and rapid ; in the latter they are variable,
irregular, their accession slow, and attended by
storms and hurricanes.

b. The intensity of tlie solar beams, and conse-
quently of light, in warm countries, is very influ-
ential in modifying not only the vegetable and
animal creation which inhabit them, but also
many of the physical phenomena which contribute
to the constitution of their climates. It would
seem as if the solar beams were decomposed by
tiie soil and its products, and, whilst furnishing
heat and light to objects upon the surface of the
earth, served to supply or to replace the loco-
motive electricity, which is constantly circulating
through, and actuating, not only the crust of the
globe, but also the vegetable and animal creations
which cover it ; passing thence, at lust, into the
atmosphere. Observation has clearly shown that
electrical phenomena are most energetic, and
of most frequent occurrence, in countries and
in seasons in which the solar influence is the
greatest ; and that, while dryness of the atmosphere
causes its accumulation in objects placed on the
surface of the globe,' a moist state of the air
favours its passage thence, and its excessive in-
crease in the clouds, giving rise to various me-
teorological phenomena. In a dry atmosphere,
particularly in inland districts, thunder and
lightning, — the more violent electrical changes
occurring in this fluid, — do not take place ; whilst
vegetables and animals, as well as other bodies,
placed on the earth's surface, are more than
usually charged with electricity ; whereas, in a
warm and moist atmosphere, especially in mari-
time or insular situations within the tropics, these
phenomena are very frequent, and the electricity
is rapidly carried of from the earth.

6. It is evident that the annual quantity of rain
in a particular district, is very intimately con-
nected with the nature of the climate ; depending as
it does upon the sources and amount of evapor-
ation, and the prevailing winds. In the middle
countries of Europe, the annual quantity of rain
usually ranges from 12 to 18 inches. In the
south-cast side of this island, and in the vicinity
of London, it commonly varies from 20 to 25
inches ; whilst it is nearly double this amount in
tlie western parts of Great Britain and Ireland;
the greatest quantity falling in July, when the
mean monthly temperature is highest, and the
smallest quantity in February and March. As we
advance towards the equator, tlie annual quantity
of rain increases, chiefly in maritime countries,
and parts in which ranges of high hills or moun-
tains skirt the sea-coast, and varies from 80 to 120
incites. Eut the number of dry days is increased,
particularly in districts situate inland ; the greatly
augmented quantity of rain falling at a^particular
season, and in a much shorter space of time than
in colder regions. In cold or temperate maritime
places, on the other hand, the rain descends in
slighter showers, and much more frequently, al-
though in much less quantity ; leaving fewer dry,
and occasioning more foggy and drizzling days,
than in warm or inland countries.

7. B. Besides the foregoing, there are other
circumstances which concur in form.ing the cli-
mate of a place. The chief of these are, the
nature of the localitii, the soil, the abundance and
exuberance cf lite vegetable creation, the state of
cultivation, the prevailing winds, &c. In the
consideration of the locality, elevation above tlie
level of the ocean, proximity to its shores, the
vicinity of large rivers or lakes, the condition of the

CLIMATE— Physical Relations of. 339

surface, its elevation into hills or mountains, or
depression into valleys or ravines, and the state
of vegetation and cultivation, arc the chief fea-
tures tiiat require notice. Places inland, which
are elevated high above the sea, or the banks of
large rivers or lakes, have their mean temper-
ature diminished, in proportion to the elevation,
much below those which, although equally far
removed from the equator, are situate near the
level of the ocean, or the bottoms of valleys;
and the inhabitants tlius breathing a drier, purer,
and cooler atmosphere than in these latter local-
ities, are more athletic, less subject to febrile
diseases of a malignant or severe character, and
reach more advanced ages. The influence of
elevation above the level of the sea, and other
circumstances of locality, upon the health of
man, is chiefly sliown in warm climates, and the
more southerly of temperate countries. In the
north of Italy, and in various districts in the
south of Europe situate on the sea-coast, near the
banks of lakes and rivers, and in low or narrow
valleys, where a deep, moist, and rich soil abounds
with organic substances in a state of decay, the
air is hiimid, loaded with effluvia; is much more
stagnant and dense; and, although the heat is
inoderated, as respects the extremes of its range,
much within the limits to which it advances in
elevated and inland parts, yet is it more oppres-
sive, the atmosphere frequently being sultry and
relaxing. Hence it is, that in these low situations
the human frame is imperfectly or weakly con-
stituted ; a small proportion of the children
born are reared ; visceral and glandular dis-
eases abound ; and the mean duration of human
existence is much shorter than in adjoining
districts, which are either more highly elevated,
or removed from the sources of contamination ;
and, from these districts, the diminution of
the population of the former, continually oc-
curring, is chiefly supplied. The East and West
Indies, and the coasts of South and North Ame-
rica, furnish numerous illustrations of the influ-
ence of locality upon the climate, and thereby
upon the constitution and health of the human
race. So very different is the climate of Vera
Cruz, and places in the vicinity, from other parts
in the same latitude, but situated some hundred
feet above the level of the sea, that the compara-
tively robust and healthy inhabitants of the latter
are more subject to the endemic fevers of the
former localities, when they visit them, than the
natives ; a continued residence having impaired
the susceptibility of the inhabitants of the former
places.

8. In the consideration of the soil, the geologi-
cal and mineral relations of the place can scarcely
be overlooked. In general, the older formations
of rocks, and those of a homogeneous and compact
nature, support a finer, a more deep, and more
absorbent soil than the sandstone rocks and
others, the debris cf which form a coarse and gra-
velly substratum, through which the rain per-
colates and flows off, it not being retained in the
surface to be evaporated, carrying with it into
the air a portion of decayed vegetable and animal
matter, as in the case of clayey, deep, absorbent
soils, that yield by evaporation nearly all the
rain wiiich falls upon them. AVhilst deep, rich,
and moist soils, particularly near the banks 'or
embouchures of rivers, on the shores of lakes, on
Z 2

340

the sea-coast, and near its level, or in low confined
valleys, or at the bases of mountains, especially
in countries within 40"^ of the equator, are very
productive of malaria ; dry, sandy, or gravelly
soils, somewhat elevated above or removed
from the mouths and banks of rivers, and cover-
ing level, gently undulating, or moderately
hilly places, are most salubrious. In northern
and temperate regions, maritime places are
equally healthy with inland districts, or even more
salubrious, unless the latter be considerably ele-
vated, possess a dry, well-cultivated soil, and be
without marsh lands in their vicinity. But in
warm chmates, and even in many temperate
countries, during warm seasons, places on or near
the sea-coast, are more productive of insalubrious
exhalations tlian inland districts, owing not merely
to their being more nearly on a level with the
sea, and subjected to a denser and more moist
atmosphere, but chiefly to the circumstance of
the soil in such localities being more deep, rich,
and absorbent : more liable to inundations from
heavy rains or swollen rivers, and from the sea
itself; more fertilised by the decay of vegetable
and animal bodies ; and hence, more productive
of the elements of unwholesome exhalations, when
their extrication is favoured by a hot sun, and
their retention and accumulation in the air are
promoted by its more constant and greater hu-
midity. Ravines, deep valleys, marsh grounds,
the banks of rivers liable to exposure after inun-
dations, the banks of lakes or canals similarly
circumstanced ; a soil profusely covered by suc-
culent plants and other vegetable productions,
and not reclaimed by cultivation, or but recently
cultivated ; grounds and soils exposed to the
action of the sun, after having been long covered
by an exuberant vegetation ; the cultivation of
rice, or other vegetable productions, which require
occasional inundations or profuse irrigation ; the
partial admission of sea water, or its percolation
through the natural embankments thrown up by
the waves in low swampy parts of a coast ; and
the accumulation of dead vegetable or animal
matter, of ordure, &c., in ditches, sewers, or
drains, &c. ; are the principal sources of those
vapours and gaseous emanations which, being
extricated by heal, and dissolved in the moisture
of the air, act unfavourably upon the human con-
stitution, and originate several of the most fatal
diseases to which it is liable.

9. C. Tiie cultivation of a country has also a
marked influence upon the state of its climate. A
district covered by a rank and exuberant vegeta-
tion — by extensive forests — is cold and moist, if
situate beyond the tropics, its temperature and
humidity being many degrees lower than that
which a state of high cultivation would produce.
A country similarly circumstanced within the
tropics is also cooler and more moist than if it
were cultivated ; but the air is remarkably close
and opj)ressive, and teems, as well as the soil,
with the lower grades of animal creation, to the
generation and nourishment of which its abundant
wild vegetation chiefly contributes. Whilst the
wooded and uncultivated districts of higlr lati-
tudes occasion coldness and humidity of the
atmosphere, abound in miasms from ■ decayed
vegetable matter, and produce the diseases usually
proceeding from tliese causes, especially intermit-
tenls, catarrhs, rheumatism, pulmonary afl'cctions,

CLIMATE — Physical Relations of.

&c., places covered by an exuberant vegetation
within the tropics, particularly those near the
sea-coast, and upon its level, abound with the
effluvia arising, not only from vegetable matter
constantly in a state of decay, but also from animal
exuviae, and the dead of myriads of insects and
reptiles which infest these localities, and occasion
malignant and remittent fevers, dysentery, and
diseases of the abdominal viscera.

10. Although cultivation renders a climate
warmer, drier, and more salutary, especially in
temperate countries, yet for many years after the
soil is cleared from its more bulky vegetable
productions, and when it is first exposed to the
action of the sun, especially in low latitudes, its
endemic diseases often become more severe than
even previously, and not infrequently assume an
epidemic or pestilential form. The medical his-
tory of the West India islands and adjoining coast
of America, as well as of the United States,
furnishes numerous proofs of this position. The
surface of the earth, previously in a great measure
protected from the action of the sun's rays by the
thick and exuberant vegetation that covered it,
and the temperature lowered by a freer evaporation
and transpiration from the leaves, yielded a less
noxious effluvium than when entirely exposed to
the sun's rays, and to the free action of air heated
many degrees higher by the exposure. In its
unreclaimed state, the noxious exhalations proceed
chiefly from the decayed vegetable matter cover-
ing the soil, a great portion of which seldom rises
above or extends beyond the higher foliage of
trees ; in its cleared state, the emanations are the
product of the earth itself, and result from its
richer constituents, and those elements of animal
and vegetable matter, with which a deep absorbent
soil abounds, particularly in warm countries.
The exhalations from the former source aie more
constantly and uniformly generated ; but, from
the latter, they are only occasionally formed, and
require a concurrence of circumstances, especially
a high range of temperature, a situation but little
elevated above the sea, the vicinity of the sea-
coast, and probably a certain degree of humidity
of the air, and peculiar state of its electricity, for
their generation.

11. -D. Prevuiliiig winds have much influence
upon a climate. .In Great Britain, and most
countries forming the north-west of Europe,
northerly and easterly winds are frequent during
March, April, and May, owing to the current
established to replace the warmer air, as it rises
from the surface of the Atlantic and more
southerly countries, now warmed by the sun as
it passes to the northward of the equator. These
winds are generally dry and cold, precipitating
the moisture in fogs, and occasioning catarrhal,
bronchial, pulmonary, and rheumatic affections,
and, under .certain circumstances, agues. Dur-
ing summer and autumn, southerly and westerly
winds are most prevalent, and the air is more
moist, owing to the temperature of the inland
countries of Eurojie being now greater than the
surface of the Atlantic, and to the air, loaded
with exhalations from the ocean, rushing to re-
j)lace the strata wliich are constantly rising from
the heated surface of these countries, and depo-
siting the moisture in the form of showers, &c.
as it jjasscs over the land ; the hills, mountains,
and places in their vicinity, which first attract the

CLIMATE — rny

clouds formed by the exhaled moisture, experienc-
ing the greatest fall of rain. During November and
December, northerly and easterly winds are again
frequent, and the fall of rain is mucli increased. As
the atmosphere receives or dissolves a portion of
tiiose fluid or gaseous substances with which it
comes in contact, it is obvious that currents of air
passing over the sources of the insalubrious exlia-
lations enumerated above (§ 8.), will be more
or less fraught with them. On the other iiand,
the air readily imparts a portion of those foreign
substances dissolved in it, when brought in con-
tact with bodies differently circumstanced. Hence
it follows tiiat prevailing winds, whether in [[nor-
thern, temperate, or warm countries, will have
considerable influence on tiie climate, particularly
in these last, for there the winds are generally
most regular and constant, especially at certain
seasons : places experiencing the sea breezes, and
the winds which have passed over a dry and well
cultivated country, being favourably circum-
stanced ; but those exposed to currents of air
from the sources of disease already referred to,
being not much more fortunately placed than
if they were' immediately surrounded by insa-
lubrious localities. In the case of towns, vil-
lages, or dwellings, tims situate, ill effects may be
partly guarded against by planting double or treble
rows of tall trees in such a manner as to intercept
the noxious exhalations in their passage from tlie
places in which they are generated. In this way
the ancients protected their villas and towns from
malaria ; and it has been shown in modern
times, that the foliage of trees attracts and ab-
sorbs tliese exhalations as they circulate through
it, particularly at the season when they are most
abundantly extricated from the soil.

12. Maritime places, in warm climates, and
the more southerly of temperate countries, whilst
they experience in the day-time, during the
greater part of the year, regular sea breezes arising
from the current of air replacing that which has
been rarefied by the heated surface of the earth,
are also subjected to land winds during the nights,
owing to the less rapid evaporation and greater
heat of the surface of the ocean at this time, the
rapid radiation of heat from the soil soon reducing
the temperature of its surface below that of the
ocean in the same latitude. These winds are
often fraught with effluvia, which, having been
exhaled during the heat of the day into the upper
regions of the atmosphere, are at night precipi-
tated to its lower stratum, and are very produc-
tive of disease in those exposed to tliem. The
currents of air that during the heat of tlie day
passed from the ocean more or less loaded with
moisture, return to it in the night, charged not
only with humidity, but also with terrestrial ema-
nations ; thus rendering places situate in the
vicinity of the sea, and nearly upon the same
level, more insalubiious than the elevated dis-
tricts inland. IVumerous places in the East and
West Indies, South America, and Africa, furnish
illustrations of this principle, as well as various
districts in North America, and in the south of
Europe, particularly those on the shores of the
Mediterranean.

13. General view of the subject. — From the
foregoing, therefore, it will be seen that the word
climate embraces not only the temperature of a
country, and the phenomena which depend upon

sicAL Relations of. 341

the distribution of heat, but all the modifications
of the atmosphere by which our organs are sen-
sibly afl^ected, particularly states of humidity,
variations of barometric pressure, changes of
electric tension, the admixture of gaseous emana-
tions or substances dissolved in the atmospheric
moisture, clearness and serenity, and tranquillity
as respects both horizontal and vertical currents.
All these exert a powerful influence, not only
upon the development and health of the vege-
table and animal structures, but also upon the
sensations, the intellectrial endowments, and the
moral emotions of mankind, in the different re-
gions and zones of the world. Comparatively
few of these atmospheric changes can be ascer-
tained otherwise than by a long series of attentive
observations ; and these have been made only at
a few parts of the earth's surface ; and hence, as
remarked by an able writer, though we know
with some precision the general circumstances
which modify the distribution of heat, we are still
imperfectly informed as to the influence of local
causes of deviation from the mean state that
would be attained if the surface of the earth were
perfectly regular, and its power of absorbing and
emitting heat and light were every where the
same. Europe and Asia are contrasted with each
other in respect of many of the circumstances
which affect their climate. In a general view,
Europe may be regarded as being almost a pen-
insula, broken, moreover, and intersected by
numerous arms of the ocean and inland seas.
Owing to the causes already alluded to (§ 11.),
the predominating winds are from the west, and
these, for the whole of the western portion of this
quarter of the globe, are sea winds softened by
passing over a mass of water, the temperature of
the surface of which, even in the month of Janu-
ary, under the mean parallels of 45 or 50 de-
grees, does not fall below 48° and 52° of Fahren-
heit. Europe has also the advantage of being
placed to the north of immense tracts of tropical
land, which, by its diurnal radiation, produces
eft'ects very different from an t'qual superficies of
ocean. INIasses of heated air are constantly
rising from the arid surface to the higher regions
of the atmosphere, and are impelled towards the
colder countries of the north. On the northern
side of this quarter, circumstances are unfavour-
able to the accumulation of extreme cold ; for a
very small portion of land is placed beyond the
polar circle, and the whole northern extremity is
separated from the polar ice by an open sea, the
temperature of which is very much higher than
that of a continental country in the same latitude.
The comparatively high temperature of the sea
on the north of Europe is chiefly to be ascribed
to the direction of the great oceanic valley which
separates Europe from America, and the exist-
ence of the gulf stream ; the intertropical Atlantic
waters flowing from the Gulf of Mexico into the
polar seas.

14. The circumstances which thus contribute
to render the climate of Europe mild, do not
exist in respect of Asia, or even of America.
Their northern boundaries extend to the winter
limit of the polar ice. The north winds, unob-
structed by any chain of mountains, blow with
unmitigated fury over icy plains extending north-
ward to the pole, and eastward to the point of
maximum cold, which, according to Humboldt
Z3

342 CLIMATE — Its

and others, seems to be situate near the meridian
of Behring's Straits. The refrigerating effects of
these winds are not counterbalanced by burning
deserts on the southern side of these continents ;
or, as respects Asia, by any great extent of land
placed below the equator ; consequently the
Asiatic countries situate in the temperate zone,
more especially, are not warmed by ascending
currents of heated air, such as those which arise
from the deserts of Africa, and are so beneficial
to Europe. The position of the great mountain
chains of Asia, and the elevation of the country,
also contribute to diminish the temperature, by
presenting a barrier to the warm winds from the
equatorial regions. Elevated plains and groups
of lofty mountains accumulate and preserve the
snow till late in the summer, and give rise to de-
scending currents of air, which cool the circum-
jacent countries. Asia, moreover, in the whole
extent of Europe, has no sea on its western side ;
consequently the west, or predominating winds,
are, for the greater part of this quarter, land
winds ; and their severity is increased by the
great enlargement of the land towards the north.
These circumstances occasion remarkable differ-
ences in the climates of Asia and the western
countries of Europe. The eastern part of the lat-
ter, however, nearly assimilates with the western
districts of the former; and, with the whole of it,
to the north of the 35th degree of latitude, has a
climate in which the temperatures of summer and
winter are widely different from the mean tem-
perature of the year. At Moscow (lat. 55° 45'),
where the mean temperature of the year is only
40° Fah., the mean temperature of the hottest
month is 70|° ; while at Paris (lat. 48° 50'), 7°
farther south, where the mean temperature of the
year amounts to 51°, that of the hottest month is
only about 65J''. In no part of the world, not
even in Italy or INIadeira, do finer grapes come to
maturity than at Astracan, on the borders of the
Caspian ; and yet at the same place, or even
still farther south, under the latitude of Avignon
and Rimini, the thermometer falls in winter to
18° and 22° below the freezing point. On the
western coast of France, in the latitude of 48°,
the mean temperature of the year is the same as
at Pekin, the latitude of which is only 40° ; v.hile
the temperature of the winter months is 14^°
higher in the former.

15. The mean temperature under the equator is
not precisely determined ; but Humboldt thinks it
does not exceed 80° of Fahrenheit. The greatest
summer heats are found in countries contiguous
to the tropics. On the lied Sea, for instance,
and in Arabia, the thermometer is often seen to
rise to 110° at mid-day, and to remain at 94°
during the night. A few degrees witliin the
tropics, the sun at midsummer continues for a
considerable time to pass daily very near the
zenith ; and the day, increasing with tlie latitude,
is longer than under the equator; so that the
amount of nocturnal radiation is diminished.
Among the local causes which contribute to give
an excessive temjieratnre to the Arabian peninsula
and the north of Africa, the sandy surface
almost deprived of vegetation, the constant dry-
ness of the air, the direction of the winds, and the
quantity of heat radiated from earthy |)articles
carried about in the atmosphere, arc tliC most
prominent.

Influence on Man.

16. II. Influence of Climate on the
Human Constitution. — From what has been
already adduced, the action of climate on the
human frame must be admitted to be extremely
complex ; the ultimate result arising chiefly from
the combined operation of heat, light, electricity,
atmospheric pressure, the various emanations
arising from the soil, and the productions, vege-
table and animal, constituting the food of man.
The human species is, in many respects, moral as
well as physical, moulded by the climate and soil
which he inhabits; and, by this pliabibty of his
functions, under the influence of atmospheric and
other vicissitudes, is the only animal that is truly
cosmopolite. In considering the influence of cli-
mate on jiian, it will be advantageous to view it,

Jirst, with reference to extensive communities and
races of the species ; secondly, as respects the na-
ture of the food which different climates provide
for the uses of man, and its co-operation with the
climate in modifying the human frame, and coun-
teracting the effects of rigorous seasons, and the
unfavourable influences to which it is exposed in
arctic and tropical regions; and, thirdly, ns re-
gards the changes produced in individual consti-
tutions after migrating from one climate to another.
Neither the limits nor the scope of this work will
permit me to consider these subjects in all their
relations ; I must, therefore, confine myself to
such topics as have an evident and important
bearing upon practical medicine — in respect
either of the causation and nature of disease, or of
rational methods of cure.

17. i. Climate in relation to the Vauieties
OF the Species and their prevailing Diseases.
— Although man is more readily assimilated with
particular climates than any other animal, yet
this faculty is not equally possessed by all the
varieties of the species and the natives of every
latitude. It is more particularly manifested by
the inhabitants of temperate climates; probably
owing to their greater vital energy, and to their
habitual exposure to alternate extremes of tem-
perature and of season. The natives of polar
regions on the one hand, and of tropical countries
on the other, possess it in a much less remarkable
degree ; and not only are they speedily cut off by
removal from the one climate to the other, but
they often suffer greatly from a residence in tem-
perate countries. It should not, however, be
overlooked, that man, like many of the individuals
below him in the scale of creation, often derives
advantage from a change of locality ; provided
that the change is not made to opposite cli-
mates, but to districts of equal or greater salu-
brity.

18. It has long been a matter of dispute
whether the differences, intellectual and physical,
presented by the various races of man, have arisen
from the continued, slow, and imperceptible oper-
ation of climate ; or have been originally impressed
upon the species. The evidence and arguments
connected with this subject fall not within my
province, l^ut it is of importance to the practical
physician to note what those p(!culiaritics are,
that characterise the difliarent races of man ; and
whether they be the result of climatorial influ-
ence or of original conformation, to consider them
in connection with the climates to which vre
find tiiem more particularly appropriated in our
survey of man in his distribution over the globe.

CLIMATE— Its

However cursory tliis survey may be, there are
certain facts of the utmost practical importance to
every one who entertains philosophic ideas in
medicine, which should not be overlooked j
namely, that the slow and continued operation of
a particular climate actually changes the human
frame in many respects to that state which its
indigenous inhabitants present ; and tiiat tiie con-
stitution, thus assimilated, is necessarily the best
suited to the external influences to which it is ex-
posed, and the food furnished by the soil of which
it is the native. There are, however, certain cha-
racteristics, especially those which distinguish the
-Ethiopian and IMongolian varieties, that a succes-
sion of ages has not been sufficient to impart to
different races which had tnigrated to the climates
they inhabit ; and which must, therefore, be im-
puted to original conformation.

19. A. The effects cf great cold, and of the pri-
vation of solar light, during nearly two thirds of
the year upon the human frame, are observable in
the stunted growth and the weak muscular power
of the Samoied, the Ostiaks, the Esquimaux, the
Greenlander, and the Laplander, compared with
the inhabitant of temperate climates. In the
arctic regions, the human body, like many of the
lower animals, and the productions of the vegetable
kingdom, rarely reaches that state of develop-
ment it jiresents in temperate countries : the fea-
tures and stature retain an appearance of boyhood
or youth, almost until marks of age appear ; the
complexion is greyish : the head flat, the face
broad, the eyes far apart, and the whole figure
squat and unattractive. Female pubescence,
however, according to the accounts given by Lin-
Nsus, Humboldt, Lyox, Parry, and Franklin,
as indicated by the accession of the catamenia, is
not delayed beyond the period usual in temperate
countries — most probably owing to the prema-
ture excitement of the generative organs in the
unrestrained intercourse of the sexes, that takes
place at an early age. To this cause, also, is to
be imputed the circumstance of their females
being less prolific than those of temperate climes ;
whilst, in these races, the instinctive feelings which
tend to the preservation of the individual and of
the species are sufficiently strong, the intellectual
endowments and moral sentiments are remarkably
torpid. The benumbing influence of cold, and of
the privation of solar light, is also manifested in
the functions of the nervous and sanguiferous sys-
tems. Diseases generally assume among tiiem an
asthenic form; feveW' being of a low type, and
sthenic inflammations of rare occurrence. As
long as the natives of arctic regions remain in
their own countries, they are exposed to but few
causes of disease besides cold, the scarcity of pro-
visions, occasional excessive repletion, and various
contagions. The soil being almost constantly
frozen, even during summer, at the depth of a
very few feet, deleterious emanations seldom or
, never issue from it ; but infectious maladies, when
once introduced, become extremely destructive,
and several of them often very prevalent, owing
to their low, small, and unventilated dwellings,
and their want of personal and domestic clean-
liness. \Yhen, however, they migrate to more
temperate and southerly regions, they are very
liable to febrile and sub-inflammatory diseases,
arising from increased temperature, the vicissi-
tudes of season, and other novel causes to which

Influence on Man. 343

they become exposed : whilst their maladies sel-
dom require, their constitutional powers can but
ill tolerate, a lowering treatment, or large san-
guineous depletions.

20. B. Although extreme and continued de-
pression of temperature produces the above efl^ects,
more moderate cold, particularly when alternating
with a temperate summer heat, promotes the de-
velopment of both the body and mind. Countries
situate between 45° and 63° of northern latitude
are inhabited by the most robust and enduring of
our species, in respect of both physical and in-
tellectual powers. It may be stated in general
of the northern temperate zone, that the inhabit-
ants of its more southerly countries have made
the earliest advances in civilisation, and that
those of its middle and more northerly climates
have carried the useful arts and sciences to the
highest perfection. VVitliin tlie range of this zone,
man presents the greatest diversity of tempera-
ment, of constitution, and mental endowment.
IMuscular frames, plethoric habits of body, and
the sanguine temperament, predominate among
the natives of the more northerly of temperate
climates, particularly as regards Europe and its
western countries. Afliections of the chest and
respiratory organs, inflammations, fevers compli-
cated with inflammations of the lungs or of the
brain, and rheumatism, are the most prevalent
diseases. Epidemics assume most frequently
amongst them a phlogistic character : and vas-
cular depletions are more required, and better
borne, in the treatment of their maladies. Cli-
mates which are the most variable, as to both
the commencement and the course of the dif-
ferent seasons, are, notwithstanding the many
disadvantages imputed to them, the most favour-
able to the advancement of the various bodily
and mental powers. The rapid and frequent
vicissitudes of weather preclude, as respects the
community generally, the regular adoption of
means to guard the body against their operation:
consequently the frame becomes habituated to
their operation, and thereby fortified against the
injurious impressions which would be otherwise
made by them. Tiiai countries thus circum-
stanced are benefited rather than injured by this
state of weather and season, is shown by the ro-
bust frames, the mental activity, and the longe-
vity of their inhabitants. The physical and moral
history of the British Isles, Denmark, Sweden,
and the more continental districts of western
Europe, demonstrate this fact. In the eastern
countries of this quarter of the globe, as well as
in central Asia and in North America, the seasons
being mucii more regular in their advent and in
their course, measures are more regularly and
uniformly adopted to moderate the extremes of
temperature and the vicissitudes of weather ; and
these have, in many instances, the effect of ener-
vating the frame, of promoting the extension or
prevalence of disease, and of tliereby diminishing
the mean duration of human life. Of this de-
scription is the use of excessively warm clothing
and of stoves, which overheat the air of the
apartments, without renewing it so rapidly as is
often requisite to the wants of the economy.
Hence, whilst the external atmosphere is cold
dry, and invigorating to the healthy frame in a
slate of activity, the air in-doors is close, warm,
and depressing ; the irequent alternation from
Z 4

344

CLIMATE — Its iNrLUENCE on Man.

the one to tlie other, or the constant residence in
the latter, being injurious even to those in health,
and causing diseases of the thoracic and abdo-
minal viscera.

21. While the natives of northerly inland coun-
tries suffer more especially from the extremes of
temperature and of season, and the circumstances
which arise out of them, they are less exposed to
emanations, arising chiefly from the decomposition
of vegetable and animal matter — to those ende-
mic sources of disease that produce so much suf-
fering and mortality in low or level districts, and
in more southerly climates, where the atmosphere
is moist and warm. The inhabitants of temperate
countries, considerably elevated above the level of
the sea, and of mountainous places, are generally
of a spare, firm, and muscular habit of body, and
strongly formed ; chiefly owing to their active
and industrious modes of life, and the pure and
light state of the air they breathe. The irritable,
sanguine, and nervous temperaments, and quick,
irritable, and generous dispositions, predominate
among them. Inflammatory, haemorrhagic, and
spasmodic diseases, particularly ha;moptysis, bron-
chitis, consumption, asthma, inflammations of
the lungs and pleura, rheumatism, and disorders
of the circulatory organs, are most common.
Their females are more virtuous and prolific, and
the mean duration of human life longer than
amongst the natives of lower districts and warmer
climates.

22, C. There are certain peculiarities in the na-
tives of temperate countries, particularly of Euro-
pean countries, that must strike the pathologist
as intimately connected with the nature and treat-
ment of their diseases. These are chiefly the
complexion of the skin, the large development of
the respiratory, biliary, nervous, and circulating
organs, compared with those of the natives of in-
tertropical countries. The skin of the dark races
is not only diflerent in colour, but is also con-
siderably modified in texture, so as to enable it to
perform a greater extent of function than the more
delicately formed skin of the white variety of the
species. The tiiick and dark rele mucosum of the
former is evidently more suited to the warm,
moist, and miasmal climates of the tropics, than
that with vvhicli the latter variety is provided.
The skin of the negro is a much more active organ
of depuration than that of tlie white. It not
merely exhales a larger proportion of aqueous
fluid and carbonic acid from the blood, but it also
elaborates a more unctuous sucretion, which, by
its abundance and sensible properties, evidently
possesses a very considerable influence in counter-
acting the heating effects of tlie sun's rays upon
the body, and in carrying ofl' the superabundant
caloric. Wliilst the active functions, aided by the
colour of the skin, thus tend to diminish the heat
of the body, and to prevent its excessive increase
by the temperature of the climate, those mate-
rials that rec|uirc removal from the blood are eli-
minated by this surface, wliich,in the negro espe-
cially, performs excreting functions very evidently
in aid of those of respiration and of biliary secre-
tion. In the white variety of the species, on
tlie other hand, the functions of the lungs
and liver are much more active than in the
darker races, clianges to a greater extent being
performed by respiration in the former than in
the latter, as I have proved by experiment. Tiic

liver is also larger, and its secretions more
copious in the European than in the negro or
JMongol.

23. In the inhabitants of northern climates,
and elevated or cold countries, the functions of
the lungs and kidneys are extremely prominent,
and those of the skin and liver much less so ;
eliminating or depurating actions on the blood
being performed chiefly by the former organs.
But, in the natives of intertropical climates, the
skin assumes, as shown above (§ 22.), a more ex-
tensive function, and, by its activity, compensates
for the diminished operation of the lungs, liver,
and kidneys, generally observed among them,
aided, no doubt, by the secretions from the in-
testinal mucous surface. In temperate countries,
the various emunctories of the frame present a
degree of activity in strict keeping with this ge-
neral connection of climate with the development
and activity of these functions. In the warmer
districts of temperate climates, and especially in
those which are subjected to a dense, moist, and
miasmal atmosphere, the changes produced by
respiration are diminished, and those effected by
the cutaneous and intestinal mucous surfaces are
increased. If the natives of such districts belong
to the white variety of the species, their cutaneous
surface not being constituted so as to enable it to
perform the compensating action for which the
skin of the darker races is destined, a different or-
gan performs this office, and the liver assumes an
increased action, combining and eliminating se-
veral of the efl'ete constituents or elements as
they accumulate in the circulation, and thereby
giving rise to an increased and modified biliary
secretion.

24. D. If we compare the organisation and
functions of the negro (and I may add of the
Mongol) with those of the European, the follow-
ing general results will appear, and, together with
what has been now advanced, will serve as the
source of very important pathological and thera-
peutical inductions: — The circulating organs,
the lungs, the liver, the middle and anterior lobes,
and convolutions of the brain, the muscles, and
the bones, excepting those of the head and face,
are very evidently smaller, and their functions
less prominent in the former than in the latter
variety ; whilst, on the other hand, the skin and
its functions are much more developed. With
the activity of function, conjoined with fre-
quent exposure to the action of numerous ex-
citants, the disposition to, Al occurrence of, dis-
order increase ; and, accordingly, diseases of the
lungs and circulating organs, of the liver, and of
the nervous system, predominate in the white
races of man ; and chronic affections of the skin,
and those acute maladies which chiefly attack
this surface and the intestinal mucous membrane,
in the dark varieties of the species. Amongst
the latter, fevers are not common ; and when they
occur, they are usually slight, terminate speedily,
seldom assume an inflammatory or continued
type, often pass off with critical discharges from
the skin or bowels, and not infrequently lapse
into a state of low or chronic dysentery. 'I'he
cxanthcmalous diseases generally assume in them
a severe and asthenic form, and raj)idly spread
by infection. Verminous disorders arc very
common iu them ; but aft'ectiuns of the brain and
its membranes, and of the teeth, arc extremely

CLIMATE — In relation to the Food of Man.

345

'"are ; the cranial contents seldom suffering ma-
terially in the course of febrile attacks. The
remarkable thickness of the bones of the head, in
nearly all tliese races, protect the membranes and
brain from tiie causes of disorder to which they
are liable ; and the continued exposure of the head
to the action of the sun and air, the absence of
mental culture, and their modes of life, by no
means dispose these parts to disease. Inflamma-
tions, particularly those of a sthenic character, are
very rare ; and, if vascular excitement attend the
early stage of these maladies, it soon exhausts
itself and passes into the opposite extreme. Dis-
orders, which consist chiefly of morbidly in-
creased discharges, from deficient tone of the
extreme vessels, and those of a spasmodic form,
are not uncommon.

25. E. The organisation of the dark races of man,
chiefly as respects the state of vascular action
and tone, the development of the viscera already
referred to (j22 — 24.), their food, modes of life,
excessive addiction to venereal indulgence, the
continued influence of a moist and miasmal at-
mosphere, and the characteristic features that
their diseases consequently assume, generally
preclude the employment of large vascular de-
pletions. During the progress of febrile and
exanthematous maladies, critical evacuations

in some measure independent of the nature of the
soil or climate in which he lives, is yet, in
several points of view, the creature of both.
Ills manifestations, both moral and physical,
are moulded by both influences, like the animals
which are below him in the scale of creation,
although generally in a much less degree.
It is the soil that furnishes him food, and the
air which he respires derives much of what is
noxious to his frame from that source. When-
ever, therefore, the natural history and diseases
of man come under consideration, they should
be viewed in relation to those productions of
the soil on which he subsists — with which, in
many respects, he may be considered as a
fellow product, but holding a superior station,
and by which are often caused many of his ail-
ments. As it is beyond the scope of this work to
enter fully into the very interesting consider-
ations which this subject involves, I can only
point to its more general connections ; and I do
this more with a view of directing the attention
of others to the subject, than of satisfying my
own wishes as to its discussion.

27. As the physical and intellectual powers of
man enable him to occupy the whole surface of the
globe, it follows that he cannot be restricted to any
particular kind of food — in other words, he must

from the skin and intestinal mucous surface fre- | be naturally omnivorous, as a consequence of his

quently occur, the latter of which are very apt
to assume a colliquative or chronic state, and, if
not judiciously controlled, to carry off the patient.
Hence the propriety of employing free evacu-
ations of the 2"'>'i>('' I'ioy with warm diaphoretics,
at the commencement of their diseases, and of
supporting the energies of life in the advanced
stages. The circumstances now referred to as
modifying the constitution and diseases of the
dark races of our species, should never be over-
looked when devising plans for treating them.
Nor should the fact be neglected, that worms,
especially lumbrici, in the intestinal canal, are
very frequently connected with the origin of
many maladies of remote but related organs.
Affections of the stomaeh, diarrhoea, colicky pains,
leucorrhoca, various spasmodic, and convulsive
disorders, chronic dysentery, &c., very often'arise
from this cause ; and no more than the cause itself,
will ever be permanently removed, in these
races, especially by evacuations alone, but by
combining them with stimulants, tonics, and an-
tiseptics. Although both the habits and modes of
living of the dark races, and the constitution of
their digestive organs, require the occasional use
of active purgatives, in order to remove the
saburra and coUuvies which so rapidly collect
on the intestinal mucous surface, yet those medi-
cines should generally be combined or alternated
with substances which exert a cordial and tonic
influence, as their vital energies soon sink under
frequent evacuations when deprived of an accus-
tomed or requisite stimulus. (See Art. Disease.)
26. ii. Of the Food of ]Man in Helation
TO Climate and the Constitution of the
VAniLTiES of the Spec:ies. — The intimate
relation which subsists between the food ,of
man, and the nature of the soil and climate
which he inhabits, and the combined operation
of both upon his constitution and the character
of his diseases, have seldom been considered in a
manner deserving of the subject. Man, although

ubiquity. If the wastes of Lapland, the shores
of the icy sea, the frozen coasts of Greenland,
and the deserts of Terra del Fuego, were destined
by nature for the habitations of man, then is he
not an herbivorous animal ; nor is even a mixed
diet necessary for his support. It would be im-
possible to procure vegetable productions where
the earth's surface is almost constantly either
frozen or covered with snow. The continual use
of animal food is as natural and wholesome to the
Esquimaux, as a mixed diet is to an Englishman.
The Ilussians who winter in Nova Zembla,
according to Dr. Aiken, imitate the SamoVeds,
and eat raw flesh and drink tjie blood of the rein-
deer, in order to preserve their health in these
arctic regions. The Greenlander devours, with
good appetite, the raw flesh of the whale, or the
half frozen and half putrid flesh of seals ; and
drinks the blood of these latter animals, or regales
on dry fish and whale-oil.

29. Within the tropics, man is subjected to
the continued operation of a high temperature,
which excites the nervous functions and vascular
action, notwithstanding the provision with which
nature has furnished his integuments, in order to
moderate the animal heat. This provision, as
we have seen, consists chiefly of the dark colour
of the rele miicostim, which speedily gives off the
superfluous heat of the body, and of the great
activity of the perspiratory functions (§ 22.). In-
tertropical countries, particularly such as are low
or swampy, while they abound with the produc-
tions of the vegetable kingdoms, and with nu-
merous swarms of insects and reptiles, maintain
very few of those gregarious animnls which serve
as food; and thus we perceive that their inha-
bitants, unless in elevated and cool situations, as
in Abyssinia, Mexico, &c., are obliged, by the
scarcity of these animals, to subsist on vegetable
productions, and to adopt a system of religion,
which, while it tends to prevent the entire de-
struction of the more useful species, is suflScient

346

CLIMATE — In relation to the Food op Mav.

to restrain their numbers within their appropriate
means of subsistence, and without encroaching
on or impairing the supply of food with which
the vegetable creation furnishes man. Hence, in
many places of intertropical Africa, the lower
animals, whose numbers are few, are occasionally
made sacred by the priests for a time ; and in
other places of this continent animal food is very
rarely enjoyed. In Hindostan, the natives are
almost debarred from the use of flesh meat ; and
the cow is made sacred, evidently to prevent the
destruction of a species, whose milk furnishes
man with one of the chief articles of diet.

29. But nature provides a more suitable ali-
ment to the inhabitants of those climates. The
date, the palm-tree, the cocoa-nut, the sago-tree
the plantain, the sugar-cane, and the banana ;
the yam, cassava, ground-pea, and other roots;
a great variety of refreshing fruits ; and, more
particularly, the very abundant production of
nutritious grains, especially the Indian corn and
rice, richly supply the natives of these climates
with wholesome food. The general and neces-
sary adoption of a vegetable diet within the tropics,
from the exuberance of the vegetiible creation
and the comparative scarcity of those gre-
garious animals chiefly destined for the use of
man in cold and temperate regions, is necessary
to the existence of the human species in the
higher ranges of temperature, and in the more
unhealthy districts in hot climates. The adoption
of animal diet exclusively, or of too large a
proportion of it, disposes the human frame, when
exposed to the influence of tropical heat, to those
diseases which arise from endemic causes, —
vii. the decay of vegetable and animal matters,
the exhalations of marshy and absorbent soils,
and otiier emanations accumulated in moist and
close situations ; and to those which affect the
alimentary canal and other abdominal viscera.
Various epidemic diseases also often produce their
greatest havoc, and assume pestilential characters,
amongst those who, to the predisposition occa-
sioned by a high range of temperature, have
superadded that arising from a too full animal
diet. It appears to be a salutary law of nature,
that, in those cliinates, where animal food would
b« detrimental to the human race, there the ani-
mals usually destined for the purpose are few in
number, and stunted in growth. The localities,
indeed, which are the most destructive to man, are
also the most inimical to these animals, which, if
they were cliosen as the chief article of food, would
both dispose to disease and increase its fatality.
Thus it appears that tlie distribution of the
classes of animals over the surface of the globe is
so apportioned, and certain of their orders and
genera so restricted to parl'cular latitudes and
climes, as to be subservient to the wants of man,
without becoming hurtful, or endangering his ex-
istence in countries in many respects unfavour-
able to his bodily and mental development.

30. While the vegetable diet, which the hottest
and most unhealthy climates furnish, is the
least liable to excite the nervous system, or
to overload the circulating and secreting oryans,
or to irritate and inflame the excreting viscera,
it serves to promote endurance, and, with the
hot spices which grow spontaneously in the same
localities, to counteract the contaminating changes
produced in the body by the vegeto-animal

effluvia to which it is frequently exposed. In
both Indies, and in intertropical Africa, the in-
habitants of low and moist situations live almost
exclusively on rice and maize ; with these they
consume, as a condiment, a very large quantity
of the hottest spices, the stimulating and tonic
qualities of which preserve them from the effects
of the diminished temperature and terrestrial
emanations, during, and after, the rainy seasons
and monsoons, and in some measure from in-
testinal worms and other parasitic animals. To
these spices even the feathered creation, and
the lower animals, occasionally resort, especially
during the unhealthy seasons. Were the inha-
bitants to live chiefly on animal food, and use the
strong fermented liquors made in colder climates,
the nervous and vascular systems would be inor-
dinately excited, irritability being thereby soon
exhausted, and they would be as much disposed
to, and affected by disease, as unseasoned Euro-
peans who, partly owing to these causes, so soon
become its victims, after having removed to
low, moist, and hot situations between the tropics.
Nature adapts her productions in every climate,
to the necessities of man ; and appropriates
them to his real, but not his imagined, wants, —
to his state of constitution, as modified by the
operation of soil, air, and temperature ; and no-
where is this provision more manifest than in
warm countries. There, if the causes of disease
be most energetic, as they most indisputably are,
she has chiefly resli-icted them to those which
proceed directly from the soil and the climate,
while she has confined those arising from the
nature and the abuse of food within narrow
limits ; as there man is destined, by the circum-
stances already alluded to, to live chiefly on a
vegetable diet, and is liable only to occasional
deficiency of its supply. But even the inflictions
which nature thus imposes on the inhabitants of
these climates are accompanied by abundant
means of preventing their invasion, or arresting
their progress. The most unhealthy situations
not only abound with suitable means of sub-
sistence, but also present spontaneously the most
efKcacious prophylactic and curative agents for
the diseases that are endemic in them. Thus
rice, the banana, the plantain, the juice of the
cocoa-nut and of the palm, the oil of the palm-
nut, &c., are the most wholesome articles of food
in the districts wherein they are most abundant
The low grounds on which these are produced
abound with deleterious miasms; and the stag-
nant water, which there often serves for the ne-
cessities of life, contains the ova of insects and
animalcula). While the former occasion agues
and remittents, the latter gives rise to diseases of
the digestive canal, and to the generation of
worms; and both causes combine to produce
fevers, diarrhoea, dysentery, cholera, visceral ob-
struction, &c. In the above localities grow the
diflNurent species of the capsicum, — the principal
condiments employed by the natives; and these
are also the chief prophylactics and remedies for
their constitutions against the diseases now alluded
to. By the side of the ])alms and the cocoa-nut
grow the different species of the tamarind and the
croton, which arc, respectively, the mildest and
most cooling aperient, and the most active
cathartic. Thus nature provides an antidote to
tho bane which is imposed on the inhabitants of

CLIMATE — Effects of
unhealthy warm climates, and, by adopting the
indications she presents, they are enabled to exist
without suffering much more from disease than the
natives of temperate countries, orhavingthe allotted
span of human existence much abridged. It is in no
small measure owing to his persisting in the diet,
beverages, clothing, and modes of living, suited to
a cold or temperate climate, and to which he had
become accustomed, that the European is liable
to disease when lie has removed to a hot country.
When travelling in the most unhealthy parts of
intertropical Africa, in 1817, I met with an Eng-
lishman, who had lived there between thirty and
forty years, and was then in the enjoyment of
health. The circumstance was singular ; and, in
answer to my inquiries as to his habits, he in-
formed me, that soon after his removal to that
pestilential climate his health had continued to
suffer, when, after trying various methods without
benefit, he had pursued as closely as possible the
modes of life of the natives, adopting both their
diet and beverages, and from that time he had
experienced no serious illness.

31. In countries approaching the poles, where
the continued low temperature, and the want of
solar light during two thirds of the year, tend to
diminish nervous and vascular energy and tone,
and to lower the whole circle of vital actions,
nature has furnished man with those articles of
food which are the best calculated to nourish,
to stimulate, and impart vitality to the frame, and
thus to enable it to bear up against the rigour of
the seasons, and the injurious influence of the
climate. Without such food, the inhabitants of
arctic regions would fall a prey to diseases of
debility, and the higher latitudes would soon be-
come entirely depopulated. In these, as well as
in northerly and elevated parts of temperate
countries, nature spontaneously provides man with
those substances which are the most energetic,
both as preventives and as remedies of those
diseases which arise from the influence of climate.
The various species of pine abound in the coldest
regions, and furnish, in numerous forms, the
most efficacious internal and external medicines,
and even the most wholesome beverages in these
maladies. Hasmorrhagic diseases, low fevers,
asthenic inflammations, scorbutic and cachectic
affections, the extreme effects of cold upon the
extremities, &c., are most successfully prevented
or treated by the judicious use of terebinthinate
preparations. This observation is also applicable
to the arnica montana, and other alpine plants.
32. The temperate zone, whilst it furnishes in

its wide range the greatest diversity of climate

in some localities that of the tropics, in others that
of arctic regions — provides man with the greatest
abundance of animal and vegetable food : thus
enabling him to combine both, or to adopt more
or less of either, according to the nature of the
seasons, of the climate, and the particular circum-
stances in which he may be placed. Nature is
always provident : she takes suflicient care that
each particular district or country shall have within
itself, or be capable of producing by requisite
labour, those articles of food which are most
appropriate to the climate, and thereby the most
wholesome to its inhabitants. When commerce
or manufactures iiicre;ise the population of a dis-
trict beyond the means of sustenance derivable
from the soil, and lower animals, in the vicinity, i

Change op, on Man. 347

the food which is obtained from a similar climate
is generally the most wholesome. \'arious dis-
orders originate from the introduction, from re-
mote countries, of unsuitable articles of luxury
into diet ; and not a few arise from the improper
mode of preparing food, which would otherwise
be wholesome. Thus, the hot spices and the high-
seasoned dishes, which, during the tropical rains
would be beneficial to the natives of those cli-
mates, who live chiefly on vegetable diet, fre-
quently are productive of disease amongst those
who partake too freely of animal food, or the high-
feeding inhabitants of commercial cities. The
adoption, also, of highly seasoned dishes, with an
undue quantity of flesh meat, — undue, because
exceeding the wants of the economy, and the cir-
cumstances of the climate, — and the use of spi-
rituous and fermented liquors, are fertile sources
of disease, particularly fevers, and affections of
the abdominal viscera, among Europeans residing
in warm places or during warm seasons.

33. From these and other considerations tlie
following corollaries may be drawn : — That the
climate of a country should, in a great measure
guide man in his selection of food; those produc-
tions which are most abundant around him beinn-
most appropriate to tiie circumstances in which
he is placed : and that the nature of his food thus
conspires with the climate to modify his constitu-
tion, whilst it serves to counteract the rigours of
season, and the unwholesome influences to which
he is constantly exposed in very hot as well as in
very cold countries.

34. iii. Of the Effects pnoDucED on the
Human Constitution by Change from one
Climate to another of a very different or
opposite Description. — By referring to what
has been already advanced respecting the phy-
sical relations of climate, and the circumstances
more immediately connected with cold and warm
countries respectively, and by connecting these
with the peculiarities characterising the races of
man inhabiting both, we shall readily perceive that
a most important revolution will take place in the
animal frame from the change, in whichever di-
rection it may be made; and that such revolution
will be great in proportion to the suddenness and
greatness of the change; it being in either case
attended with more or less febrile commotion or
other diseased action.

35. 1st. Of cliange from a cold or temperate to a
ivarm climate. — A. Keeping in view the followino-
characteristics of a cold and temperate climate —
viz. its low temperature, the alternations of sea-
son, the pureness of the atmosphere, the more
nutritious, invigorating, and stimulating nature of
the food, and the effects of warm clothing — and
connecting these with the vascular plethora, the
active functions of the brain, lungs, liver, and
kidneys of its inhabitants, the disturbances which
will result when they are subjected to a continued
high range of temperature, and to an atmosphere
loaded with moisture, and frecjuently with vegeto-
animal effluvia, may be anticipated. It is now
fully ascertained that the effects of a high range
of temperature, and of moist miasmal air, on the
European constitution, are a diminution of the
changes effected by respiration on the blood, an
increase of the secreting and excreting functions
of the liver and skin, and a decrease of the urin-
ary excretion. When, therefore, the plethoric

348

CLIMATE — Effects of Chakge of, on Man.

European migrates to an intertropical country,
the functions of the lungs and the pulmonary
exhalation become diminished ; the requisite
changes are not effected on the blood, notwith-
standing the excitement of the nervous and vas-
cular systems by the increased temperature ; and
the already active and developed liver is irritated,
and has its functions augmented by the increase
of those elements in the blood, that the lungs and
skin cannot remove from it. Hence proceed fe-
brile attacks, particularly when excited by their
appropriate causes ; inordinate activity, with a re-
lative frequency of the diseases of the liver; the
secretion of acrid bile; and the disorders espe-
cially affecting the alimentary canal and excret-
ing organs. The general adoption of too rich and
nourishing food and beverages by those who re-
move from cold to hot climates, tends greatly to
increase these evils, as already explained (§ 30.);
and the influence of high temperature and of a
vertical sun upon the European head is produc-
tive of disease both of it and of the liver. To these
effects, the mental cultivation and activity of
Europeans somewhat predispose them ; whilst
their heads are not so well guarded from external
influences by the constitution of its integuments and
hair, and the tliickness of the cranial bones, as those
of the negro and iMongol varieties of our species.

36. The obvious indications resulting from
these facts are, that natives of cold countries
migrating to warm climates siiould, particularly
if the change has been made abruptly, live
abstemiously, and promote the functions of
those organs which perform the most essential
part in excreting effete or injurious elements
from the circulation. The head should be
kept cool, and protected from the> rays of the
sun ; the surface of the trunk and lower extre-
mities ought to be preserved in a freely per-
spirable state, so as to take off the load of
circulation, and derive from the excited liver.
In order to promote the secreting and depu-
rating functions generally, active exercise, short
of fatigue, should be taken, without exposure
to the causes of disease, particularly those which
are endemic. As the maladies which most fre-
quently supervene on change from a cold to a
warm climate proceed neither from the increased
temperature alone, nor from greater moisture of
the air, but from these conjoined with malaria,
and not infrequently also witii wide ranges of
temperature during the twenty-four hours, espe-
cially in high and inland localities — with hot
days, and cold, raw, and dewy nights, and with
a too full and exciting diet and regimen, causing
fevers, dysentery, and diseases of the biliary organs
— care ought to be taken to avoid those causes, as
well as wliatever may tend to assist their oper-
ation on the frame, and to protect the system
against the sudden daily changes by warm cloth-
ing at night, &c.

37. B. I'lie consideration of the effects produced
by migratian duiirii^ <i state of diseuse, from a
cold to a warm and moist climate, is of the utmost
importance. Keeping in mind its influence upon
the healthy frame — chiefly in exciting the func-
tions of the skin and liver, and diminishing those
of the lungs — we are led to prescribe it in the
treatriieut of various diseases. Jn htrmopliisis, this
change is obviously beneficial, especially or a
warm and moist atmosphere, by this mode of

operation, lessens the activity of the pulmonic
circulation and the disposition to sanguineous
exudation from the surfaces of the bronchi.
Bronchitis and tubercular phthisis are also often
benefited, and the progress of the latter much
delayed, by this state of atmosphere, espe-
cially when adopted early. Chronic rheumatism
is sometimes cured by this change, seemingly
owing to its influence in promoting the biliary and
cutaneous functions. Dropsies, particularly ayia-
sarca and hydrothorax, have been, in a few in-
stances, removed by a change to a warm climate;
but whilst a moist state of the air is most service-
able in pulmonary and hiemorrhagic diseases, dry
warmth seems more beneficial in dropsies, dys-
peptic affections, and hypochondriasis, evidently
from its effects in augmenting the insensible per-
spiration and the pulmonary exhalation, and im-
parting tone to the capillary circulation. Besides
these, gout, in its early stages, dysmeiwrrhoea, and
scrojula in nearly all its forms, are benefited by
a change to a warm, or even a mild and dry,
atmosphere.

38. 2d. Of migration from a'warm to a cold or tern-
perate climate. — This subject should be viewed in
relation, first, to the change as it affects the dark
races of man ; and, secondly, as it respects those
belonging to the Caucasian variety, who have
either been born or acclimated in warm countries.
— A. If change from a cold to a warm cli-
mate is productive of disease and great mortality
in the white constitution, the migration of the dark
races to a cold or temperate country is not less
fatal to them ; and whilst the change produces,
in the former case, fevers, diseases of the biliary
organs, and of the alimentary canal, it occasions,
in the latter, tubercular phthisis, and other tuber-
cular affections, with diseases of the bronchi, &c.
When the dark races, particularly the negro, and
those of the IMongol variety who are natives of
intertropical and low countries, migrate to places
subjected to a low range of temperature during a
great part of the year, the depressing influence of
cold upon the nervous system and vital actions
of the lungs and skin gives rise not only to tuber-
cular formations, but also to increased secretion
from the internal mucous surfaces, and tiicy are, in
the great majority of cases, cut oft', in a few months
or years, by diseases of the lungs, kidneys, and
bowels. Those, however, who change the climate
progressively, or who are born in countries of an
intermediate temperature, and who are provided
with warm clothing, and animal or nutritious diet,
suffer much less than those who migrate in a more
direct manner, even although possessed of these
latter advantages. The native African who re-
moves immediately to Europe seldom lives over
two winters in it ; whilst the negro, who has been
brought to the West Indies, and subsequently to
the southern states of North America, previously
to his arrival in mor;; northern countries, and
enjoys necessary food and clotiiing, will often not
suffer materially from the change.

39. ]i. 'i'hose who have been born of European
parents, or been seasoned in warm climates, not
infrequently suffer after removal to temperate or
cold countries. Even, although the change may
have become necessary from ciironic affections of
the liver or bowels, yet may it for a while aggra-
vate or render more acute hepatic disorder, or
superadd to it disease of the lungs ; and many

CLIMATE — As a Therapeutical Agent.

349

■who have experienced only functional disorders
of the stomach or liver, or who acquired merely
a tendency to them during their lesidence within
the tropics, have been attacked by active disease
soon after their return to Europe. Others, also,
who have suffered more seriously, have had their
complaints aggravated after a short residence in
England, although they were benefited during
their voyage home. This result of change to a
colder climate proceeds nut, however, altogether
from the temperature or the state of the seasons,
but in a great measure from the imprudence of
the patient. Frequently, however, a colder at-
mosphere is prejudicial for a time, by constricting
the vessels on the external surface, and determin-
ing an increased flow of blood to the large internal
viscera, and thereby occasioning congeslion and
obstruction of those organs which have been
weakened by previous disease or the influence
of climate. Another frequent consequence of
change from a warm to a cold country is a
diminution of all tiie secretions, particularly
those of the skin and liver ; originating vascular
plethora and visceral engorgement. In this state
of the vascular system, if the cutaneous or pul-
monary surface be subjected to cold, particularly
cold combined with moisture, after the circula-
tion has been determined to these parts by hot
rooms and crowded assemblies, or if reaction
rapidly follow the impression of cold, the great
mass of blood is thrown upon the internal vis-
cera, which, if not relieved by a free secretion,
become the seat either of congestion or of in-
flammation. Hence it is that hepatitis or dy-
sentery, so frequently follows changes from a
high to a low temperature. The remarkable
liability to diseases of the respiratory organs, ob-
served in those who have returned to Europe
after a long residence in warm countries, is evi-
dently owing, in many instances, to pre-existing
disorder of the liver, which has extended thence
to the lungs, owing either to the increased action
of this latter organ upon removal to a colder
climate, or to imprudent exposures to cold, or to
breathing a very warm and close air immediately
upon coming out of a cold and dry atmosphere.

40. In order to counteract these effects of
change, warm clothing, particularly of the lower
extremities, wilii the use of flannel next the
skin, should be adopted; and exposures to cold
and moisture, and the night air be avoided. The
diet ought to be light, and of moderate quantity;
the strong wines imported into this country ab-
stained from ; and, above all, the functions of
the bowels and abdominal viscera carefully
watched, and promoted whenever they seem to
flag. It may be of importance to know the most
suitable period of the year to arrive in tJiis coun-
try, after the frame has become assimilated, by a
long residence, to a warm climate. If an in-
valid return in uinter, the sudden transition
from a warm to a cold country may be detri-
mental ; if early in the spring, he is liable to feel
the effects of a variable season for some time.
The least objectionable period extends from IMay
to September ; and if the cold of the winter
months be found too severe in the more easterly
counties, or in the metropolis, the climate of
Devonshire or of Bath may be tried with as great
advantage as that of most of the southern parts
of continental Europe. Old residents in a warm

climate will experience much advantage from re-
siding some time in the more southerly parts of
Europe, before passing to England or other
countries of the north, more particularly if they
use a course of the warm mineral waters of X'ichi,
Carlsbad, or Ems, in their way.

41. The children born of white parents resi-
dent in the more unhealthy countries witiiin the
tropics, very generally die at an early age if they
be' not removed to a colder climate. '1 hey com-
monly sink from the choteric form of fever de-
scribed in a separate article as incidental to
infants; or from diarrhoea, dysentery, or diseases
of tiie abdominal secreting viscera, often assum-
ing a remittent foim. When, therefore, either of
these appears in this class of patients, removal to
a temperate climate should be advised when it
can be effected ; taking care to guard them, by
warm clothing, &c., from vicissitudes of temper-
ature for a considerable time after the change,
and attending to the first indication of pulmonary
or tubercular disease, or disorder of the liver and
bowels.

42. III. Of the particular Localities which

ARE BENEFICIAL IN DiSEASE, OR OF ClIMATE

AS A Therapeutical Agent. — In this part of
the subject, I shall consider, fint, the different
parts of Great Britain which may be suitable
places of residence for invalids ; secondly, those in
the south of Europe and the Mediterranean; and,
thirdly, those in the Atlantic and West Indies.

43. i. Climate of certain places in England. —
The chief difficulty in this country is to find a
mild and sheltered climate for invalids from pul-
monary disease ; and it is almost exclusively to
the south and south-west parts of the island, in
the immediate vicinity of the sea, that we must
direct our inquiries. The general use of coal
fires in all the large towns in Great Britain,
owing to the quantity of sulphur this mineral
contains, and of sulphuric acid fumes and
fuliginous matter generated, renders the air more
irritating to the lungs, and increases the risk
of a winter residence in these places, to all
those who suffer from, or are even liable to,
diseases of the respiratory organs. This, together
with other considerations- — especially the results
of observation — renders it imperative on the me-
dical attendant to recommend removal to a more
salubrious locality. The mild situations I shall
notice are in the south, the south-west, and the
west of the island.

44. A, The south coast is much milder and
more moist than the east and inland parts of the
island, during the months of November, Decem-
ber, .January, February, and j\Iaich ; but from
April till October the temperature of the latter
is greater. On this part of the coast, Underclijf,
in the Isle of Wight, Hastings, and Brighton,
have been recommended as winter residences
for invalids, a. Undercliff is the most sheltered
and mild of these places in winter, and its air
softer and more humid in summer than either.

b. Hastings is sheltered, during the winter and
spring months, from the north and nortii-east
winds ; and, of the various places on this part
of the coast, ranks next to Undercliff' as a resi-
dence for invalids with pulmonary affections.

c. Brighton is more exposed than the foregoing
to the north and north-east winds, and its air is
drier, and hence more bracing. It is therefore

350

CLIMATE — As a Therapeutical Agent.

more suitable than they to the nervous, the sim-
ply debiUtated and relaxed, to the dyspeptic, to
those aft'ected with chronic bronchitis and asthma,
attended by greatly increased secretion. Dr.
Clark very properly suggests that invalids, who
select the south coast as their winter residence,
should pass the autumn at Brighton, and the
winter at Hastings ; the climate of the former
being mild to the end of December.

45. B. Tiie soiith-icest coast of the island is
very mild in several situations during the winter,
and has, therefore, been very generally recom-
mended in diseases of the respiratory organs.
Sir J. Clahk estimates the temperature of its
more sheltered localities as being 5° higher than
that of London, during the winter months ; and the
temperature of the south coast as only 2° higher.
But I conceive that there are, at least, 6° and 3°,
respectively, of difference between these and
London and its vicinity. Besides, it is not only
the range of temperature that should be con-
sidered, but its greater equality and less rapid
vicissitudes, and the increased humidity, and
more soothing influence of the air. — a. The places
on the coast of Devonshire most in repute as
residences for the consumptive, are Torquay,
Dawlish, Sidmouth, Eimonth, and Salcomhe. Of
these, Torquaif is the best; and, according to the
reports of Sir .T. Clark, Dr. Foote, and of my
friend Dr. W. Hutchinson, who has resided in
it, superior to all other places in our island in
pulmonary cases.

46. h. Penzance is the principal place in Corn-
wall recommended for invalids. Its peninsular
situation, and south-west position, give it a re-
markably soft, humid, and mild atmosphere ; and
the equality of its temperature, not only through-
out the year, but also during the day and night,
renders its climate in many respects superior to
that of most places in the south of Europe, and
brintrs it next to Madeira. The quantity of rain
that falls annually at Penzance is nearly double
that which falls in London ; the number of rainy
days is much greater; and the temperature of
the air at night at least 7° higher during the
winter months. This mildness, equality, and
humidity of climate is, however, somewhat im-
paired by its exposed situation, and its liability to
high winds.

47. Both the Land's End and the coast of
Devonshire, owing to the predominating charac-
ter of softness, humidity, and equality of climate,
exert, along with a soothing, an evidently relax-
ing efTcct. Hence this coast is best suited to the
irritable and inflammatory states of disoiders of
the respiratory or;^nns, and such as are charac-
terised by irritation, but little expectoration, and
dryness of skin. Li cases attended with a copious
expectoration, great relaxation of the mucous
surfaces and soft solids, and in nervous debili-
tated persons, this climate will prove injurious.
Even in those cases where it is evidently indi-
cated, and actually proves of service, removal
will be necessary to a somewhat drier air during
the summer; and this should not be deferred
longer than .Tune, or undertaken before April or
]\Iay ; the patient generally deriving mucii be-
nefit by returning the succeeding winter. The
observations now made n])on the climate of the
Bouth-wcsl coast apply to tliat of Jeisey and
Guernsey, to whicii islands invalids sometimes

repair, and occasionally with advantage. South-
west winds generally prevail in them during
autumn and winter, and cold north-east winds
often continue long in the spring. The summer
climate of these isles is excellent. Of the two,
that of Jersey is preferable.

48. C. The West of England. — The mean
temperature of this part of the island is a little
lower than the southern coast, but in March and
April it rises somewhat above it. Bath and
Bristol are about 3° warmer than London during
the months of November and December ; but
this difference is reduced more than one half
during January, February, and March. In this
part of the country the vale of Bristol is the
most sheltered and mildest. The climate during
the winter is rendered more mild by the vicinity
of the ocean, whilst the groups of surrounding
mountains attract the clouds and diminish the fall
of rain below the current to which its western posi-
tion would otherwise subject it. Bristol Hot-wells,
and the lower parts of Clifton, are the most shel-
tered spots, and the best suited to consumptive
patients ; whilst other invalids will find most ad-
vantage in the more elevated situations which
the latter presents. In general, the climate of
this place is perhaps the mildest and driest in the
west of England ; and, therefore, one of the best
winter residences for invalids. It is drier and
more bracing than that of the south-west coast,
and therefore not so well suited to consumptive
cases, and to those affected by irritative action in
the respiratory passages and bronchi. For these,
the more soft and humid air of Torquay and
Penzance is preferable ; but, with the return of
summer, the consumptive invalid will relinquish
the latter for the former with benefit. Clifton
and Bath are certainly preferable places of resi-
dence to the south-west coast, in cases of pro-
tracted dyspepsia, gout, and scrofula, particularly
the last occurring in young persons, and relaxed
habits. In these affections, the waters of Bristol
liot-icell will, with regular exercise on horseback
or on foot, prove extremely beneficial.

49. The more inland districts of this part of
England furnish various places which are salutary
to invalids during the summer. Malvern, and
the surrounding country, with the Malvern
watei's, are very serviceable in scrofulous and dys-
peptic cases ; and, for the consumptive and other
invalids, various places in Wales, as Abergavenny,
Aberystwith, Tenby, Barmouth, ilkc.,will be visited
during the season with advantage. Vv'here a course
of goat's whey may be considered of advantage, a
summer residence in Wales will be preferred.
There are various other places which, besides their
mineral waters, furnish excellent summer resi-
dences for the invalid. Buxton, Matlock, Lea-
mington, Cheltenham, Tunbridge Wells, &c.,
independently of the use of their respective mine-
ral waters, prove excellent places of residence for
those who arc debilitated or exhausted, whose
mucous surfaces arc relaxed, or whose digestive,
secreting, and assimilating functions are imper-
fectly performed, and any of the abdominal vis-
cera congested or obstructed. In these latter
circumstances of disease, especially, the appro-
priate use of the waters of those places, assisted
by regular horseback or walking exercise, by
suitable medical trciilment, and by mental re-
laxation and amusement, will often prove of

CLIMATE — As a Therapeutical Agent,

351

great service. In prescribing the mineral waters
of any of those places, due reference shouhl be
had to the nature of the climate ; and, on the
other iiand, when directing change of climate,
some attention should be paid to the waters
which the place may afford; as the appropriate
use of the one, whilst the patient is experiencing
the influence of the other, will materially pro-
mote the end in view.

50. In a very great proportion of cases, where
the state of the patient admits of change of lo-
cality, much advantage will accrue from passing
the autumn on tlie south coast of the island, as
at Brighton, Hastings, or Undercliff, after having
passed the summer at the foregoing watering-places.
In general, when the digestive and generative or-
gans are disordered, frequent change of air, and
travelling by easy and short journeys, with gentle
exercise, particularly on horseback, agreeable
amusement, and regular habits, will prove of
marked advantage, and greatly aid medical treat-
ment,

51. ii. Of the climate of certain parts in
France. — .1. The West and South-west of France
furnishes several places, the climate of which
possesses the softness and humidity which are
requisite in pulmonary diseases. I'lie mean
annual temperature of the south-west of France is
stated by Sir J. Ci.ark to be 4° higher than
that of the south-west of England; and the
climate of both generally agree or disagree with
the same diseases. — a. That of the south coast
of Britany is mild during the winter, and tem-
perate in summer, the mean temperature of this
province being about 56^°. Its climate is soft
and relaxing; and it is hence suited to dry bron-
chial irritations, to haemoptysis, and tubercular
cases. Laennf.c found it very favourable to
consumptive patients, and states that the propor-
tion of such in this part of France is very small.
In scaly eruptions on the skin, dysmenorrhcea,
and in irritable habits of body, this climate will
be often of service.

52. b. Pan, situated at the base of the Py-
renees, from the account of it given by Dr. Clark
and Dr. Playfair, appears to be the best place
in the south-west of France for invalids ; and yet,
in no respects is it superior to the south-west of
England in consumptive cases. Its air is still
and mild in winter and spring; the chief advan-
tage it oilers being the great mildness of its
spring. Dr. Clark gives the following com-
parison : — its mean annual temperature is 4^°
higher than that of London, and about 3° higher
than that of Penzance ; it is about 5^ lower than
that of IMarseilles, Nice, and Rome; and 10°
lower than that of Aladeira. In winter, it is 2°
warmer than London, 3° colder than Penzance,
6° colder than Nice and Rome, and 18° colder
than IMadeiia. But in the spring, Pau is 6°
warmer than London, and 5° warmer than Pen-
zance ; only 2J° colder than Marseilles and Rome,
and 7° colder than jNIadeira. The range of tem-
perature between the warmest and coldest months
at Pau is 32° ; this at London, and likewise at
Rome, is 26° ; at Penzance it is only 18°, and at
JNIadeira 14°. The daily range of temperature at
Pau is 7^° ; at Penzance it is 6J° ; at Nice, 8^°,
and at Rome, 11°. Pau is drier and warmer
than the south part of England in the spring, and
northerly winds are less injurious. One of its

chief advantages is its vicinity to the watering-
places among the higher Pyrenees, which are
often beneficial places of summer residence to
those who have passed the winter and spring at
Pau.

53. B. The South-east of France. — The
climate of the tract of country extending alouo-
the shores of the Mediterranean, from Narbonne
and Montpellier to the Var, is warmer and drier,
but more exciting than that of the south-west. It
is subject to sudden vicissitudes of temperature
and to cold winds, especially the north-west, or
Mistral. It is decidedly prejudicial to consump-
tive patients, especially when the disease has
made some progress, and to irritative afFuctions
of the stomach, trachea, or larynx ; and is ser-
viceable chiefly in diseases of debility and relax-
ation unattended by inflammatory or ha?morrhagic
action.

54. Sir J. Clark ranks the principal places on
the coast of Provence in the following order, as
residences for invalids: — Hj'eres, Toulon, iNIar-
seilles, Montpellier, Aix, Nismes, Avignon. — a.
Hyires possesses the mildest climate on this part
of the coast, being sheltered from the north winds
by a range of hills ; and its inhabitants being
comparatively exempt from pulmonary affections,
b. At Marseilles the climate is dry, variable, and
subject to cold irritating winds. It is therefore
injurious to consumptive patients; and is one
of the places in France where pulmonary dis-
eases are most prevalent. Invalids requiring a
dry air, and capable of bearing cold winds, may
be benefited by residing here for some time. c.
Montpellier has obtained a reputation for salu-
brity to which it has no claims. According to
MM. FouRNiER and Murat, more than a third
of the deaths that occur in the hospital of this
city are from pulmonary consumption. The pre-
valence in this part of the country of northerly
winds during winter and spring, both accounts for
the frequency of pulmonary diseases and points
out its unfitness as a residence for patients thus
affected, d. Aix is still more exposed than Mont-
pellier to the INIistral and north winds, and pul-
monary cumplaints are very prevalent among its
inhabitants,

55. C. Nice, although situate on the same
line of coast as Provence, enjoys a much milder
climate than any part of that province. It is
protected by a lofty range of mountains from
the north winds ; and the daily range of temper-
ature is there less than at almost any part of the
south of Europe. During winter the weather is
settled, and the atmosphere clear, tlie thermome-
ter seldom sinking to the freezing point, excepting
at night. At this season, however, as well as in
the spring, cold dry winds are not infrequent;
and the climate is, upon the whole, dry and ex-
citing. Hence it is not favourable to pulmonary
consumption, — the very disease for which it was
formerly very improperly recommended. Itis like-
wise unfavourable to irritable or inflammatory
states of the larynx, trachea, and bronchi, attended
with scanty expectoration, or haemoptysis. But
chronic bronchitis, bronchorrhoea, and humoral
asthma, are generally very much benefited by
the climate of Nice. It is also serviceable in all
cases of debility, torpor, and relaxation of the
mucous surfaces; in chronic rheumatism, gout,
external scrofula, dyspepsia, and hypochondriasis.

352

56. iii. Of the Climate of Italij and Mediterra-
nean.— A. Genoa is not favourably noticed by Dr.
Clark as a residence for invalids ; but Dr. John-
son, on the authority of Dr. IMojon, speaks of it in
more favourable terms. It is best suited to those
affected by chronic bronchitis, and dyspeptic and
gouty complaints; and to persons of relaxed and
phlegmatic habits of body. Pisa, Rome, and
Naples are the other places in Italy most fre-
quented by invalids. The climate of Pisa nearly
resembles that of Rome, the latter being somewhat
warmer and drier in wiater. Dr. Clark considers
the climate of Rome as one of the best in Italy for
consumption, unattended by haemoptysis. For
those, however, who cannot take exercise in the
open air, and must confine themselves to shel-
tered situations, the Lung Arno, in Pisa, is the
best place of residence to be found in Italy.
The climate of Naples is considered by this
writer, as well as by M. Lasnyer, more exciting
than that of the two foregoing places; and it is
more subject to high winds. The diseases which
a residence in either of these three cities will
benefit, are those above enumerated. ^ Persons
who remain in Italy during the summer, will find
Lucca, Sienna, and the vicinity of Naples, the
coolest situations.

57. I>. There are various other places on the
shores and islands of the Mediterranean, the^cli-
mates of which are suitable to invalids ; but we
possess little or no accurate information respect-
ing them. Malaga in the south of Spain, Cagli-
ari in Sardinia, and some parts on the coast of
Sicily, afford a mild winter climate, but the diffi-
culty of reaching them, and of obtaining in them
many necessary comforts and conveniences, almost
precludes invalids from the northern parts of Eu-
rope from visiting them. Malta is not open to
these objections; but, according to Dr. Hennen,
the quantity of dust raised from its arid soil, and
suspended in the air, during dry weather, renders
it an unsuitable climate for consumptive pa-
tients. A considerable number, also, of the in-
liabitants die of pulmonary diseases. In his
work on the medical topography of the islands of
the Mediterranean, Dr. Hennen states a fact,
which is perfectly in accordance with my observ-
ation in warm climates, although doubted by Dr.
Clark, viz. that those of the Ionian Islands,
which are decidedly most malarious and remark-
able for remittents, have had fewest pulmonarii
affections amongst the British troops. In respect
of the health of the troops stationed in these
islands, tiiis writer states, that, from an average
of seven years, phthisis has borne a proportion to
other complaints of 1 to ]98|^ only. At Malta,
on an average of eight years, consumption has
occurred in the proportion to other maladies of
1 to 93^. Including all pulmonic complaints
whatever, the proportion to others, as regards the
Ionian Isles, has been 1 to 20| ; and, as respects
IMalta, I to 14. 'J'aking into calculation the
whole Mediterranean islands, the proportion of
pulmonic, to otiier diseases, has been 1 to 174 ''^
the liritish army.

58. iv. Climate of the Nortliern Atlantic. —
Umkr this head the climates of Lisbon, Cadiz,
Madeira, tiic Canaries, the Azores, liermndas, and
the Bahamas, may be arranged ; all of which have
been recommended to persons re(iuiring a soft
and etiuablt climate, during the winter and spring.

CLIMATE — As a Therapeutical Agent.

59. A. Madeira is, of all these places, indis-
putably the best, as respects both the climate, and
the comforts and conveniences within the reach
of the invalid. The frequency and excellency,
also, of the means of conveyance to and from the
island are no small recommendations. From the
minute account furnished of the climate of this
island, by Drs. Gourlav, IIeineken, and Ren--
TON, after a long residence in it, and from the
effects I have observed in several persons who
have resorted to it as a winter's residence, it may
be justly concluded, that it is superior to any
part of the south of Europe for consumptive
cases. Its central ridge of mountains gives it, in .
summer, a cool land wind ; and the north trade
winds, at this season, render it temperate, and
salubrious. During winter and spring, Funchal,
and parts near the sea-shore, are the best places
of residence; and during summer the more ele-
vated situations in the interior are cool and
agreeable. The mean annual temperature of
Madeira is about 6° higher than the south-east
of France and Italy ; and the heat throughout
the year is much more equably distributed.
The winter of the former is 12° warmer than
that of the latter, and the summer 5° cooler. At
Madeira the extreme annual range is only 14°,
whilst it is double this amount at Fisa, Home, and
Naples. In respect also of the progression and
steadiness of its temperature, it excels those
places. Rain falls at Jladeira on 73 days of the
year, and at Rome on 117 days, and chiefly
during the autumn in the former. Tiie air is
also more soft than at Rome.

60. B. The Canaries possess the next best
climate to Madeira. The mean annual tempera-
ture, however, of Santa Cruz, the capital, of the
former, is 71°; whilst that of Funchal, the
capital of the latter, is only 65°, • Tiie summer
temperature of Santa Cruz is 7° warmer than
that of Funchal, and the winter temperature 5°
warmer. Hence the mean annual range of tem-
perature is greater in the Canaries than in Madeira;
which possesses, in other respects, advantages suf-
ficient to recommend it in preference to the former
in pulmonary diseases. .. ,. j

61. C. The ]Vestern Islands, or Azotes, enjoy
a climate nearly approaching to thafof Ma-
deira. They are, however, more subject to high
raw winds, particularly those from the north and
north-west, which are often very cold and harsh ;
and the temperature of winter is lower, and that
of summer higher than in JNIadeira. The air is
also more humid. From a very short visit I made
toi\ladeira and the Azores, — to the former in the
spring, and to the latter in winter, — I should
conclude the Azores to be much inferior to Ma-
deira as a residence for invalids, chiefly, because
of the absence, of many necessary comforts .and
conveniences, of their stormy winters, and tlie in-
frequency and ineligibility of the opportunities
of transport between them and tiiis country. The
climate of the liermndas and Bahamas presents no
advantages sufllcient to obtain for Ihenj a prefer-
ence to those already noticed. Tiiey are liable
to storms, and to harsh northerly winds in winter,
from the American coast, whilst their summers are ■
very hot.

62. V. Climate of the West Indies.— The mean
annual temperature of the West Indies, at thel(?vel
of tlic sea, is 19°, 8if, and 81° ; and during the

CLIMATE — As a TiieuapEuticaL Agent.

353

^¥inte^ monthfS, iii some places, about 3'^, ami in
others only '2° lower. The extreme annual range
is 20°, and the mean daily range about 6°. This
continued high temperature exhausts tlie energies
of invalids ; and the clearness of the skies, and
great power of the sun, prevent suitable exercise
in the open air. A visit to the West Indies of a few
months' duration, made either to some of the most
healthy islands, or passed chiefly aboard sliip, will,
however, prove of service in several ciironic aflec-
tions, particularly those referred to above (§ 37.),
excepting consumjjtion in its more advanced
stages. Persons much disposed to this disease,
cither hereditarily or by the conformation of the
chest, &c., or who are threatened by its early
stages, will find a removal to the West Indies one
of the prophylactic measures most to be depended
upon. When residing some time in an extremely
malarious place within the tropics, I observed that
the most healthy persons in it were those who
were constitutionally disposed to pulmonary dis-
ease. But I believe, that the observation often
made, is perfectly correct, that removal to an in-
tertropical country, when phthisis is far advanced,
will only accelerate its progress. It may also be
stated, that severe and protracted catarrhs are
very common upon entering between the tropics.
In gout, chronic rheumatism, scrofula, and cal-
culous affections, a residence in the West Indies
is often productive of advantage.

G3. vi. Of residence on the sea shore and
' voi/iiging. — There are certain topics connected
with change of climate often discussed during the
course of practice, viz. whether are inland situa-
tions, or places on the sea-shore, whose climates
are physically alike, most serviceable in pul-
monary diseases? and whether or not sea-voyages
possess any advantage over a land residence in
these complaints. — a. In respect of the first ques-
tion, it may be stated, that places on the sea-shore
are generally more humid than those inland,
and ottener, on this account, preferable in the
dry and the hemorrhagic pulmonary aflections ;
whilst a situation somewhat inland, or not re-
moved above a few miles from the coast, seems
somewhat more serviceable in those cases of con-
sumption which are otherwise characterised. But
the question has not been satisfactorily determined,
and, indeed, is not easy of solution.

64. b. With reference to the second question,
it may be stated more confidently, that sea-
voyaging, in a suitable climate, is preferable to
land residence in the early stages of phtliisis, and
particularly when it is attended by haemoptysis.
This advantage is evidently to be attributed
to the influence of the ship's motion on the
sanguineous and nervous systems. 'J'his opinion
was argued for by Dr. GnLconv, in his excellent
thesis, De Morbis Call Mutatione Medendis,
and has been generally admitted. Cruising in a
warm or even temperate latitude, particularly in
the Atlantic, is preferable to voyaging, because
of its' longer duration. Whilst the sun is north
of the equator the climate between the 30th and
50th degree of latitude ; and while the sun is
south of the equator, that from the 20ih to the
35th or 40lh degree of north latitude, will be found
the most salutary. During winter, voyages be-
tween JNIadeira and the SVest Indies; and, in
summer, between iNIadeira and this country, in
the vessels constantly trading bctwceu England
. Vor. I.

and the West Indies, and which generally touch
at JNIadeira, might be undertaken with advantage.
These vessels furnish tolerable accommodations,
which may be easily improved or adapted to the
state of the invalid.

65. A. When the winter has been passed in any
of the warmer situations noticed above, attention
ought to be paid to the time of returning to
this country. This should not be earlier than
the first, or later than the last week in June.
If the invalid have passed the winter in the
south of France or in Italy, these places may
be left early in May, and he may travel cau-
tiously through Switzerland, avoiding exposure
to the evening and morning air. During the
journey, warm clothing should be resorted to
as soon as the temperature falls so low as to be-
come sensibly cold ; and a free circulition in
the skin and extremities ought to be carefully
preserved.

66. B. With respect to the diseases which are
benefited by change of climate, it is unnecessary
to add any thing at this place, as the climates
which seein most serviceable are noticed when
discussing the treatment of those diseases in
which most advantage is derived from removal to
particular climates. The affections for which this
treatment may be employed, are scro/'u/n, tubercu-
lar disease of ihe lungs, hantorrliagej'rom the liuigs,
S)C,, chronic bronchitis, asthma, hooping-cough,
chronic rheumatism, dyspeptic and hypochondriacal
ajfections, urinary calculi, and various fac/iec(ic and
hydropic affections. (See the treatment of these
complaints in their respective articles.)

BiBUOG. AND Refer — Hippocrates, Tli^i Ai^tuv, iSa.-
Tuv, T4!T«y, Vander Linden's edit. 8vo. vol. i. p. 327.—

Cruder, De Zonis et Climatibus, 4to. Witteb. IfifiO.

Wfrter, De Morbis Climatuni, 4to. Duisbiirgi, 17U4. —
Burgar, De Melhodo Medendi pro Cliniat. Diversitate
varie institueiula, 4to. Lugd. Batav. 17^4. — Hartmann,
Diss, de Climate, ejusquo Notitia Medico admod. neces-
■saria, 4to. Regio, 1729. — F. Hoffmann, De Medendi
Metliodo varia pro Climatis Diversitate. Halae, 1734 ; et

ill part i. vol. ii. Supp. ejusdein opeiiiin. Gen. ed. 1753

Krliger, De Diversitate Corporum Morb. et Curationum
secundum Regiones Euroiia;, 4to. Halie, 1744. — G.G.
liichter, De liisolatioiie, 0|)usc. t.'i. Goet. 1747. — i>e
liuchner, De Difteientiis Naturarum resipectu Cliniatum,
4to. Halne, 1746 — A'. A. Lorry, Sur I'Usage des Alimen.«,
iVc. vol. ii. Paris, 1757 ; Journal de Physique, vol. i. p. 430.

Paris, 1773 ; et Itnd. vol. iii. p. 243. Paris, 1774 A. Wilson,

Observat. relative to the Influence of Climate on Vcget.
and Animal Bodies. Lond. 1780. — J. J. Plenck, Broma-
tologia, s. Doct. de Esculentis et Potulentis, &c. Vindob.
1784. — J. /.. Schurer, De .\tniosphcra Electrica. Argent.
17S(). — Darluc, Hist. Naturclle de la Provence. Avign.
1782, t. i. p. 15 — Schneider, De Elficacia Ventorum,
Dnisb. 1790. — J. C. Kbermaier, De Lucis in Cnr|i. Hum.
Vivum cfficai'ia. Gut. 1797. — 1'.. Horn, De Lucis in Corp.

Hum. ^'iv. prater Visum effic. Goet. 1797 Cabanis,

Rap|;orts du Physique et Moral de I'Homme. Paris, 1802,

p. ioi) GourUty, On the Climate and Dis. of Madeira,

&c. 181). — Miiraf, Topograph. Med. de la Ville du Mont-
jielier, 8vo. 1810, p. 119.— C. K. IVeiss, Diss. Climatol.
Medica liiitia sistens. Lips. 1813. — L. Cerutli, Collect, de
Tellurisin Organism. Hum. Actioiie. Lijis. 1814. — J. En-
nemoser, De Montium influxu in Valefudinum Homin.
Vita; Genus et Morbos. Ber. 1816. — J. Knirsch, Synopsis

de Climat. Jled. Vind. 1815 Sigaud, Travaux de la Soc.

de MCd. de Marseille, ISlti, p. 14. — J. Copland, The Med.
Topography of the West Coast of Africa, in Quarterly
Joiirn. of Foreign Med. vol. ii. p. l.'; Appendix to Ri-
chcrand's Physiology, p. 582. G27. ; and in Gr/Jflt/i'sTr^ns.
of Cnuier's Regne Animal, vol. i. p. 130. — liny, in Diet.

dcs .Scien. Med. t. v. p. 33U Forbes, On the Climate of

Penzance and the Land's End, 8vo. 1821. — Ho/land, On
the Duration and Distribution of Rain, Sec. hvo. Lyme
IS28. — Xairmann, Allg. Semiotik. Ber. 1826, p. 125. et
scq. — Hennen, Sketches of the Med. Topography of the
Mediterranean, &c. 8vo. Lond. 1830, p. 221 . — A.de Huin-
buldt, Amiales de Chimie et de Physique, t. xiv. p. 22. ; et
Fragmcns de Geologie et de Climatologie Asiatlques,
2 torn. Paris, 1S3I, t. ii. ; Foreign Quarterly Rev. July,
lti7~. — V/iis/iolm, On the Climate of Bristol aul Clifton,
A a

354

COLD — General Effects of.

in Edin.'Med. and Surg. Journ. vol. xiii. p. 2(55., and vol.
xvii. |). 164. — B. Gaspard, Journ. de Physiol, t. vii. \>. 227.
— Foddre, Hist. Nat. Mcdicale, &t-. aux'Alpes Maritimcs,
&c. Strasb. 1823 — Rustan, Diet, de Medecine, t. v. p. SGI.
— Heineken, On the C'limate and IMed. Topog. of Madeira,
Med. Repos. by Copland, vol. xxii. 1S24-, p.rl. — J. John-
son, Influence of Tropical Climates on Europ. Const'itut.
Svo. 4th edit. 1827 ; and Change of Air, or tlie Pursuit of
Health, through France, Switzerland, and Italy, &'C.
Svo. 1831, p. 235. et scq. — Anneslcy, Researches on the
Dis. of India and Tropical Countries, &c. 4to. 1828 and

1829, vol. i. p. 6()1., and vol. ii. p. 6 Lasnyer, Sur des

Climats d'ltalie, Sic. dans les Aff. de Poitrine, S:c. in

Nouv.'Biblioth. Med. Juil. 1829. T. LVnri, The Influence

of Climate in Chronic Diseases of the Chest and Digejtive
Organs, &c. Svo. 2d ed. 1830.— Author, On the Climate
of Great Britain, &c., in J. M'Cullock's Statistics of Great
Britain, &c. vol. i. Lond. 1838.

COLD — (Cl.\ssif. Pathology. jEtiology and
Therapeutics.)

1. Cold is merely a relative term, e.vpressing
a sensation produced by the abstraction of heat Ijy
any substance of a lower temperature than tiiat
of the body or part which feels ; con.sequently this
sensation is not always occasioned by the same
degree of temperature. Nature has recourse to
various means for abstracting animal heat from
the body, under circumstances requiring it ; and
for preventing the dissipation of it, under other
circumstances; and the instincts and reason of
the animal creation are often evinced in further-
ing tliese objects. The dark skin of certain
varieties of our species, and the thin hairy cover-
ing of many of the lower animals inhabiting hot
countries; the fair well-clothed skins, and the
thick coverings of wool or fur witli wliich those
of cold climates are provided ; and the con-
stmction of the dwellings, &c. in different and
opposite climates ; are all provisions intended to
accelerate, under certain circumstances, and to
delay, under others, the dissipation of animal
heat.

2. The functions of the living economy can
be performed witiiin a certain range of temper-
ature only, for any considerable time. Above or
Lelow this range, they will more or less rapidly
cease, according to the extent to which the
change may be carried in either direction, and
the rapidity with which it is effected. Whilst
the abstraction of iieat is produced more rapidly
than it is supplied, either in a part or in the
whole body, depression of the vitality takes place
co-ordinately with the rapidity of the loss of tem-
perature ; but, on the other hand, when the
abstraction of heat is altogether prevented by
living in a medium of equal or greater temper-
ature, excessive vascular e.Kcitement, lapidly
exhausting the sensible and irritable properties
of the tissues, and thereby terminating human
existence, is the consecjucnce. The heat of the
human body seldom varies, in health, above
100° or below 96'^ of Fahienheit's thermometer;
and although man may live in a lower temper-
ature than the 7.ero of this scale, when suitably
fed and clothed, owing to the activity of the
respiratory and heating functions, yet, in conse-
(juence of the nature of tliese functions, he cannot
exist for any considerable time in it mean range of
temperature above that of his own body. In no
part of the globe is the mean annual range of at-
mosplieric heat within twelve degrees so great as
that of the living frame.

3. i. Pnvsiot.ociCAL AND Patiiologicai, Ef-
fects OF Coi.n. — A. A general i iew of its
effects. In considering, therefore, the effects
of cold upon the body, due icfereiicc should |

be had to the state of the respiratory and heat-
ing functions, which are essentially vital, and ac-
tive in proportion to the greatness of the consti-
tutional powers. The abstraction of caloric, or
cold, when carried far, first depresses, and after-
wards annihilatesy the vital actions of a part, by
depriving it of that principle which is necessary
to preserve the various tissues composing it in a
suitable state for reciprocity of action, and which
observation shows to be necessary to the healthy
performance of the sensiferous and circulating
functions especially. When heat is abstracted
to a greater extent than it is supplied, sensibility
is diminished or numbed ; and circulation, as
respects both rapidity and size of the current in
the vessels, is lessened. This effect may be pro-
duced in a part or extremity to the extent of anni-
hilating these functions in it, whilst in the internal
viscera they either remain entire, or are but little
changed. 'When this is the case, the part aifected
will permanently lose its vitality, if these functions
be not soon restored by frictions, and a very gra-
dual admission of heat. A part thus aftiscted by
cold is said to be fiost-bit, — an accident to which
the more exposed parts of the body are liable in
very depressed states of temperature. Even
friction only may occasion too quick a change of
temperature, if it be not made with some sub-
stance, as snow, which may prevent the too sud-
den increase of heat, and the risk of immoderate
reaction. When the vital energies are weak, a
less degree of cold will depress them than when
they are energetic ; and, upon its removal, vas-
cular reaction will be less apparent, or even not
at all supervene. If cold be not great, or too
long applied, relatively to the vital energies, in-
creased action, as evinced by a glowing sensation,
follows its impression. When, on the other hand,
it is excessive, either in degree or continuance,
the depression of vital power, especially the mani-
festations of this power in the nervous and circu-
lating organs, is co-ordinate, the living animal
sinking into a state of torpidity from which it is with
great ditKculty roused. Thus cold, momentarily
or briefly applied, when the constitutional powers
are not very much iuipaired, proves, if not ex-
cessive, an excellent invigorating or tonic agent,
owing to the reaction v.'hich follows ; but when
acting energetically, or for too long a time rela-
tively to the state of those powers, it will produce
one of two eflects, according to the circumstances
attending it, or following its application : either
it will depress the vital actions beyond the power
of recovery, the .system sinking into a comatose
state, or struggling between this state and partial
or irregular reaction ; or it will be followed by
increased or even uncontrollable vascular action,
soon exhausting the vital manifestations of the
vessels and the irritability of the frame, or of the
part principally expo,5cd, and occasioning disso-
lution of the blood. While the continued action
of that degree of cold, which may be endured for
a short time, very often produces the former re-
sult; the momentary exposure to excessive cold,
or the injudicious application of heat in an inap-
propriate or too rapid a inannei', alter the more
moderate but prolonged action of this agent, is
usually followed by the latter. Inflammations
are not infriiquenlly induced in this manner in
the organs to which cold has been directly ap-
j)lied, as in the case of inflammation of the lungs
coming on after passing into a warm apartment

COLD — Its Particulau Effects.

355

immediately from a cold atmosphere. In other
cases, the impression of cold when prolonged,
although moderate, may, by diminishing vital
action in the parts on which it acts, so determine
and increase it in distant or even opposite parts
or surfaces, as to give rise to inordinate secretion
or vascular action in tlie latter. Such being the
more general efl'ects of cold upon the system, it
will be advantageous to examine its mode of oper-
ation more closely, in order that we may be ena-
bled to form accurate ideas as to its influence in
the causation and removal of disease.

4. B. Particular effects of cald. — a. The
primary effects of the abstraction of heat from a
part, to the extent of producing a decided sens-
ation of cold, appear to be excited upon the
Jiervous siistem, whose sensibility and vital mani-
festations it lowers, and, when excessive, entirely
annihilates. These effects are obvious in both
the organic and voluntary classes of nerves ; and
are at first attended by an alteration of their sensi-
bility of a slightly painful kind, often followed by
loss of their functions. Thus, cold will occasionally
give rise to local paralysis. When an intensely cold
substance is applied to a living tissue, the rapid
abstraction and passage of its caloiic through the
living surface intervening between them, cause
similar eftects to those following the rapid commu-
nication of caloric by a heated body, and thereby
momentarily excite the nerves and vital turgescence
of the intervening parts. Thus, intense cold will
produce vesication, inflammation, &c. of the skin.

5. /'. The action of cold, when slowly or mo-
derately applied, in diminishing vital turgescence,
the bulk of the tissues, and the activity of tiie cir-
culation, seems coeval with the effects produced
by it on the nerves. By this action the small
arteries, veins, and secerning pores are constricted;
and the communicating canals between the ex-
treme arteries and radicles of the veins are ren-
dered smaller and less pervious. Hence, when
cold is t pplied to the surfaces of the body, the
circulation there and in the vicinity is diminished,
and tlie blood is driven thence, and accumulates
in the large veins of the internal viscera. Owing
partly to this operation, and partly to the sedative
effects of cold upon the nervous system, the whole
circulation becomes weakened, and congestion of
the large vessels and internal erectile tissues
takes place. If the impression of cold is only for
a short period, the vital energy not being at the
time materially deficient, the heart and large ves-
sels are enabled to react upon the load that op-
presses them, and an increase of the circulating
functions ensues. But when the impression of
cold continues, circulation becomes less and less
active, with at first slight or inefficient efl'orts at
recovery, and at last ceases entirely.

6. c. Muscular parts are very sensibly aflfected
by cold, in consequence of its effects upon the
nerves supplying them, and of the diminution
of the circulation in them. Nervous energy,
therefore, being depressed, and the circulation
weak and insufficient, muscular contractions also
become weak and tremulous ; and the muscles
subsequently stiff, or altogether rigid, frequently
with cramps or spasms intervening between these
states. A share of these extreme effects is,
doubtless, owing to the vascular congestion pro-
duced on the cerebro-spinal axis, and on the
origin of the nerves supplying the muscles. The

cramps often occurring after plunging into cold
water, or while swimming, are illustrations of the
effect on the muscular system of moderate cold
suddenly applied to the surface, and of its action
thereon, through the medium of the nervous and
vascular systems. After the power to make
muscular exertion ceases, in consequence of the
continuance or increase of cold, remarkable
stiffness and rigidity of the voluntary muscles
supervene, sometimes extending to the respir-
atory muscles, and producing asphyxy. In
many cases, where cold acts intensely or suddenly
upon the surface of the body, rigidity takes place
with remarkable celerity, as stated by Quintus
CuuTius, and MM. I'ahat, jMautin', and
Beaupue, to have occurred in the expedition of
Alexandeh, and the retreat of Napoleon from
Moscow. Trismus and tetanus have followed,
in some cases, a moderate decrease of temperature,
and difficult articulation is not an uncommou
efl^ect of this cause.

7. d. The influence of cold upon the respir-
atory and calorific functions is very manifest.
When atmospheric cold is moderate, and suf-
ficient exercise is taken in it, and the cutaneous
surface and extremities are sufficiently clothed,
then respiration is energetic, the changes pro-
duced on the blood are complete, and animal
heat is freely generated, and is sufficient to sup-
ply the continued loss of it from the surface of
the lungs. But when cold depresses the nervous
power, owing either to its excess, or to the circum-
stance of its acting simultaneously upon both the
cutaneous and pulmonary surfaces, or to the cir-
culation being unaided by muscular exertion, then
respiration becomes laborious, quick, and painful ;
and the production of animal heat is insufficient to
preserve the fluids and soft solids in a suitable state
for reciprocal action, rigidity, followed by congela-
tion, first of the extremities, and subsequently of
more central parts, taking place. As long as the
nervous energy and the circulation are unimpaired,
animal heat is freely developed ; but it becomes
co-ordinately depressed with the failure of these,
and returns in a proportionate degree with their
restoration. When cold has acted for a con-
siderable time upon the frame, animal heat is
either restored with difficulty, or it continues to
vacillate and sink with the nervous and circu-
lating functions until death supervenes. It js
chiefly during the period which elapses between
the exposure to cold, and restoration from its
efl^ects, that diseased action commences, or is
developed. Too long continuance in a cold
bath, wet clothes, and numerous other means of
refrigerating the body, will produce a loss of
temperature that may never be recovered. Dr.
CuRRiE found that a man with a temperature of
98°, three hours after cold bathing and exposure
to a north wind, had not recovered his natural
heat, although warm stimuli, frictions, &c. had
been employed. During such states of pro-
tracted restoration, various morbid states are apt
to originate and to give rise to a train of diseased
actions, varying in almost every case with the
constitution, temperament, predisposition, and
habit of body of the individual. Even after re-
action has taken place, some particular organ or
part may suffer especially, owing to these predis-
posing circumstances; and inflammation, with
effusion, disorganisalion, &c. may be the result
A ti 2

356 COLD— Pathologicai, Effects of

8. e. The eftects of cold upon the brain and the
organs of sense and vvlunlarii motion, are similar to
those already described. Hearing, sight, touch,
&c. become imperfect, the functions of mind im-
paired, and insensibility, somnolency, delirium,
and convulsions supervene. The somnolency, and
indifference to the consequences of indulging it,
when long exposed to cold, have been well known
since the accounts given of the cases of Dr. So-
I.ANDER and Sir J. Banks, in Terra del Fuego,
of Maupektil's in Tornea, and of Captain
.Parry's associates in the north-west expedition.
But the fullest description of its effects upon
the senses and cerebro- spinal centres is given by
Beaupre. The same degree of cold, according
to the state of the system, and the extent to which
the surface is protected, will cause either delirium
of a quiet comatose kind, or raving madness, or
convulsions, passing into tetanic rigidity. Great
insensibility and somnolency will also often steal
upon their victim, without any other mental dis-
turbance ; and occasionally they will be preceded
by tremors, delirium, and convulsions.

9. f. Cold produces very decided effects upon
secreting organs and surfaces. When it acts
directly upon either of these structures, it dimi-
nishes or entirely suspends their functions, owing
Loth to its sedative action on the nerves and
circulation, and to its constricting influence upon
the canals and pores of the part, it thereby lessen-
ing vascular turgescence and vital manifestation.
Cold air or cold fluids acting upon the external
surface interrupt the functions of the skin, par-
ticularly if the cold be combined with moisture.
A similar effect is produced upon the pulmonary
mucous surface, only if the cold be intense, and
if it be at the same time humid. As long as the
cutaneous surface is protected, and the vital
energy of the frame is unsubdued, t!ie exhalation
of vapour from the lungs, and the other changes
in the blood that take place in this organ, are not
materially interrupted until the temperature of the
air falls much lower than can be endured by the
external surface. When, however, the air is
very humid as well as cold, the aqueous exhala-
tion from this organ also is much lessened. I'he
remarkable tolerance of cold by the lungs
during exercise and a protected state of the
external surface, is evidently owing, 1st, to the
circumstance of the quantity of air received at
each inspiration being a part only of the whole
air contained by them ; and, '2d, to the changes
in the capacity of the circulating and respired
fluids for caloric, by which the respiratory
actions arc attended. Whilst the nervous and
circulating functions are unimpaired by cold,
diminution of the cutaneous and pulmonary
exhalations is compensated for, and injurious
plethoia of the vascular system prevcnle(l, by a
])roportionate increase of the secretion3 from the
kidneys and intestinal mucous surface. Owing
to this activity of the internal secretions, and
centralisation of vital energy, the appetite is
also increased — sometimes rendered even raven-
ous— digestion is accelerated, and the stomach
enabled to dispose of substances which would
otherwise be rejected from it. When cold acts
upon the frame tor some time, and is great rela-
tively to the condition of the; digestive organs or
vital |)C)\vcT, a nearly paralytic state of the nerves

1 the alimentary cuiiul njay ensue, giving rise to

interrupted secretion, to flatulent dilation of large
portions of it, either with or without spastic con-
striction of other parts, and to painful and anxious
suppression of all its functions.

10. C. 0/ the effects of cold in vurions states of
the system. — a. It has already been stated that
the injurious effects of cold are great in proportion
to the depression of vital power at the time of
its action. When the surface of the body is
warm, or even overheated, but not perspiring,
when vascular action is energetic, or the nervous
power excited, cold is well and safely borne ; but
when the body is perspiring freely, and at the
same time exhausted, or the depressing mental
passions are in operation, it produces a much
more intense and rapid effect, not only by ob-
structing the cutaneous perspiration, but also by
occasioning either interruption of the internal
secretions, followed by febrile action, or a mor-
bidly increased flow of some one or more of these
secretions, according to the state of the body at
the time. The experiments, however, of Fordyce,
Blag DEN', and Dobson, and the practice of the
Russians, show that the free perspiration pro-
duced by heated air and the vapour bath, as
long as the excitement of the nervous and vascu-
lar systems occasioned by these continues, may
be checked with impunity, and even give rise to a
salutary reaction.

11. b. Exposure to cold and wet, in cases of
shipwreck, &c., particularly in winter, is produc-
tive of bad efi'ects, great in proportion to the
rapidity with which evaporation of the moisture
from the surface of the body takes place. As
the temperature of the sea, in winter, is always
higher than that of the air, and is not lowered,
as that of the air is, by evaporation from the
wet clothes of the person thus exposed, so lias
it been observed on numerous occasions, and
particularly in the instance recorded by Dr.
CunuiK, that persons who have remained almost
wholly immersed in sea-water have always lived
longer than those who were exposed to the re-
frigerating action either of the wind only, or of
the wind assisted by evaporation from the wet
surface and clothes. Protracted immeision, also,
is not so injurious in salt as in fresh water.
This is chiefly owing to the higher temperatuic
of the former than of the latter, and partly, per-
haps, to the stimulating effects of the salts dis-
solved in sea-water on the skin. In cases of
shipwreck it is not unusual to find, that those
who had taken spirituous liquors to excess during
the period of their peril are the first to fall vic-
tims to the eflects of cold. This, most probably,
is owing to the exhaustion consequent upon the
excitement produced by spirits; to the fluxion
and centralisation of vital power in the parts on
which the stimulus directly acts; and chiefly to
the circumstance that such excesses co-operate
with cold in producing congestion of the vessels
within the cranium, and apoplectic lethargy.

12. c. During states of morbidly excited vas-
cular action, unattended by free excretion, or a
jierspiratory state of the skin, the external or
internal application of cold is beneficial, by
lowering the nervous and vascular excitement to
that state vviiich is requisite to a due i)erforniance
of the secreting atid excreting functions. But in
order that this eft'ect should be obtained, itvvill ge-
nerally be neccssiiry to continue the iipplication of

COLD — Patiiolocical Effects of.

357

cold for some time, or frequently to repeat it aftei | and even opposite effects, according to its in-
short intervals, as reaction usually follows a brief , tensity and duration. It has already been
use of it ; but as soon as the disposition of the ' shown, that, during the integrity of vital power,
morbidly increased action to recur no longer is i a brief or moderate impression of cold is an in-
evinced, a prolonged application of cold may be direct stimulant, and an excellent tonic remedy ;

injurious by depressing the vital energy so low,
that recovery either of the part on which it
directly acted, or of the system generally, may
be a matter of difficulty. In many of such cases,
rigors will follow the too protracted or intense
operation of this agent, and be the means of
bringing about reaction, which, however, ma}'
assume irregular or excessive states, or produce a
new or modified train of symptoms.

13. d. During the exhaustion following mus-
cular exertion in hot weather, and while the
surface is freely perspiring, cold in any way is
most intensely and rapidly injurious, particularly
when it is applied to the stomach. The inges-
tion of a large quantity of a cold fluid in this
state has been speedily followed by death. This
extreme effect has not been satisfactorily ex-
plained. That inflammation may be so quickly
induced cannot be admitted. It seems more
probable that the sudden impression of the cold
fluid upon the nerves of the stomach, together
with the rapid distension of the organ, paralyses
the system of nerves which supplies the digestive
organs, and which is evidently that part of ani-
mal organisation on which the vital manifestations
throughout the frame more immediately depend.
Even when cold, owing either to the less bulk
of the cooling body, or to the state of the stomach
and system at the time, is not quickly or intensely
injurious, still it may be productive of injury by
favouring the developement of inflammatory ac-
tion in the stomach or liver, or by interrupting
the secreting actions of these and adjoining vis-
cera.

14. D. Changes observed in cases of death by
cold. — QuELMALz fouud thc vessels of the brain
turgid with blood, and the large veins and arte-
ries filled by polypous concretions; and he refers
the sopor preceding death to congestion of blood
in the cerebral vessels, and effusion of serum in
the ventricles of the brain. Eosen also observed
thc vessels witliin the cranium engorged with
blood. Cappei, states that he found the blood
and fluids accumulated chiefly in the pectoral
and abdominal viscera. Dr. Kellie detected,
in two cases examined by him, the same appear-
ances as were remarked by Quei.jiat.z, IIosen,
and Capi'el ; and noticed, in addition, a blood-
less state of the scalp, engorgement of the sinuses,
integrity of the substance of the brain, remarkable
redness of the small intestines from turgescence
of the blood-vessels, and absence of tympanitic
distension.

15. E, Of cold, or inidtte abstraction of animal
heat, as a cause of disease. — Cold is either a pre-
disposing or an exciting cause of a very great
number of diseases, particularly among the poor,
and during the winter and spring seasons, as
J. P. Frank and Sir G. Blank have demon-
strated. The injurious effects of this agent on
infants and children are great in proportion to
the earliness of the age at which they are ex-
posed to it. I believe that more than one half of
the deaths, and two thirds of the diseases, that
occur among the children of the poor, are more
or less caused by it. Cold will produce modified

whilst a very intense or prolonged action of this
agent is a direct depriment of thc vital energies,
even although the rapid abstraction of much cold
may inflame and disorganise the parts through
which it is caused to pass. Ilencc it must be ob-
vious that cold will be either a predisposing or an
exciting cause of disease, according to the intensity,
duration, and manner of its operation, to the con-
stitution of the person on which it acts, and to the
other causes and influences which cooperate with
it. The same circumstances will also explain the
great diversity of its effects, and its operation in
determining the characters and complications of
numerous maladies, even after tiieir career has
commenced.

16. After what has been advanced respecting
the physiological and pathological action of cold,
I need not add any further observations on the
manner in which it operates in the causation of
particular diseases. It will be sufficient to enu-
merate those which it most frequently produces,
either by its unaided operation, or in conjunction
with a pre-existing disposition or disorder, and with
other morbid influences. Fevers, inflammations
of the individual viscera; dropsies of the shut
cavities and anasarca ; catarrhal and bronchitic
affections; hemorrhages; diarrhoea, dysentery,
and diabetes ; rheumatism and gout ; apoplexy
and paralysis ; tetanus, and other spasmodic
and convulsive maladies ; the obstruction of
secreting and excreting functions — of the bile,
of the urine, of the catamenia, and of the in-
testinal excretions ; scrofulous, scorbutic, and
chlorotic complaints, hardening of the cellular
tissue and oedema, chilblains, and congestions
and obstructions of glandular and secreting parts,
are among the most common consequences of this
agent. Fevers occasioned by cold alone are
generally ephemeral, or of short duration, when
no particular organ or function is already in
fault; and the reaction — generally ushered in
by rigors — is of a salutary tendency when kept
within due bounds : but cold favours directly
and indirectly the spread of typhoid infection ;
and its action on the frame during the progress
of all continued and exanthematous fevers is very
often injurious, unless judiciously regulated and
employed, and is productive of many of the dan-
gerous complications which frequently arise in
their course, as well as of the local affections
that appear during or after convalescence from
them. Such is more remarkably the case in re-
spect of the exanthematous fevers. Dropsical
and hremorrhagic effusions, although obviously
depending, in many cases, on pre-existing organic
change, yet often, even in these instances, have
been <letermined by this agent. The greater
prevalence also of dropsies, particularly after the
exanthemata, in cold thr.n in warm climates ;
and the paucity of pulmonary, hemorrhagic, and
diabetic complaints in hot countries, ought not to
be overlooked. The frequency of dysenteric,
tetanic, and spasmodic affections in warm cli-
mates is no argument against their production by
cold, inasmuch as they there arise chiefly from a
relatively great depression of temperature. Thc
Aa 3

358

COLD — Prevention and Treatment op its ill Effects,

influence of cold in occasioning apoplexy and
paralysis, particularly in aged persons, has been
Zong admitted and satisfactorily proved by Wep-
FER, Zacutus, Cullen, Fothergill, Marcard,
Penada, Waltiier, Thilenius, Weber, and
others ; and scrofula is almost entirely a disease
of cold and moist countries.

17. F. Circumstances often favuuring or de-
termining the injurious action of cold. — a. IVeak-
ness of constitution favours the injurious action
of cold upon the frame. Infants, convalescents
from disease, and aged persons, are more inju-
riously affected by cold than those in whom the
nervous, circulating, and respiratory functions are
fully developed and unexhausted, and who are
thereby enabled to generate vital heat to supply
the loss of it going forward on all the exposed
surfaces, b. Exhatistioji by excesses is one of the
most common predisposing states to the injurious
operation of cold. The violent or fatal effects
of a cold bath at a moment of exhaustion by
muscular labour have been well known, at least
since the time of Alexander the Great, who
nearly perished from this imprudence. The
exhaustion consequent upon venereal excesses
renders the system remarkably sensible of de-
pressions of temperature, as well as disposes it, in
an uncommon degree, to the ill effects usually
resulting therefrom. The same remark applies
to the depression consequent upon the excitement
of spirituous liquors. The habitual indulgence in
warm apartments, and sleeping in close chambers,
with too great a quantity of clothes on the bed,
are very injurious, especially to females, c. The
internal determination of the fnids, a.ccom'pany'mg
certain diseases, as chronic bronchitis and diar-
rhoea, chronic inflammations of the viscera, ca-
chectic affections, &c., and even that attendant
upon a full meal, or the occasional or repeated
indulgence in exciting beverages, or the operation
of cathartic medicines, favour the injurious opera-
tion of cold upon the frame, particularly in deli-
cate constitutions.

18. ii. Treatment of the ill Effects of Cold.
— A. Means of prevention and counteraction, a.
Vascular and mental excitement, and physical and
moral courage, are among the most powerful aids
to the resistance of cold. To these should be added,
when within reach, warm woollen or fur clothing;
exercise ; warm diluents, as tea, coffee, chocolate ;
gently stimulating cordials and tonics, and warm
nutritious diet, AH vinous and spirituous excitants
are injurious when used against intense or pro-
longed cold, as they occasion internal fluxion
and exhaustion. If resorted to at all, they
should only be taken in small proportions, and
in large quantities of hot diUienls. This opinion
is founded on repented observation, and agrees
with thai advanced by Dr. Ci.endinnixg, who
has paid much attt^ntion to this subject. Ac-
cording to the experience and practice of northern
nations, and of those in warm countries who use
either no clothing, or but little, the anointing
of the cutaneous surface with oleaginous sub-
stances tends greatly to retard the refrigeration of
the body.

19. b. When cold has produced incipient ill
effects in the frame, indicated by horrijjilation,
trembling, rigors, iScc, a warm bed ; coffee or
other hot diluents; stimulating diaphoretics, es|)e-
<;ially large doses of the spiritus a;theris nitrici (from

3 j. to 3 iij. for a dose), either alone, or with the ni-
trate of potash and camphor ; the repeated exhibi-
tion of ammonia, camphor, and opium — the last
in small quantities ; the warm or vapour bath, fol- .
lowed by friction of the surface ; warm spices and
cordials, are among the most certain means of re-
storation. It should be kept in recollection, that
the sooner we succeed in counteracting the di-
rectly sedative effects of cold, the less violent will
be the consequent reaction, and the less injury will
ultimately result to the economy. As soon as
reaction begins to appear, the treatment should
be modified ; and the means used to determine
to the skin should be of a less stimulating kind ;
as the preparations of antimony and ipecacuanha j
nitre, with camphor, and either of these substances;
Dover's or James's powders, &c. &c. Whenever
cold has caused shiverings or rigors, with pains in
the head, back, and limbs, free reaction not having
yet supervened, we may be satisfied that this state
of system is associated with interrupted secretion
and excretion ; and that a quick restoration of these
functions should be attempted. Therefore, if there
be no symptom to forbid it, an emetic, followed
by warm diluents, and the warm bath, and these
by a cathartic medicine, should be prescribed, in
order to restore a salutary reaction, and the sup-
pressed secreting and excreting functions. In
cases presenting the extreme effects of either very
intense or prolonged cold, the means of restoration
should be very gentle at first, and very gradually
increased, as the chief danger to be feared pro-
ceeds from excessive reaction — excessive as re-
spects the depressed state of vital power upon
which it supervenes — and the rapidit}' with which
inordinate action exhausts the remaining irritability
and vitality of the frame. The means found most
successful in restoring a frost-bit limb, viz. a very
gradual increase of temperature and cautious ad-
mission of stimuli, are required in such circum-
stances.

20. B. The injurious effects from cold fuids
taken into the stomach, when the body is perspir-
ing and exhausted, require instant aid. These
effects somewhat resemble those proceeding from
an injury sustained upon the epigastric region ;
and consist of quick, laborious, or gasping respir-
ation, remarkable weakness and irregularity of
the pulse, great collapse and pallor of the coun-
tenance and surface, rapid loss of the animal
heat, vertigo, with dimness of vision, loss of hear-
ing, &c., and general torpor, followed by coma
and deatii — the one rapidly succeeding the other.
In such cases, warm diluents, with ammonia, cam-
phor, and opium ; cordial diaphoretics, frictions
of the limbs and surface generally with stimu-
lating embrocations ; hot fomentations, sinapisms,
and cataplasms of Cayenne pepper to the epigas-
trium, and especially animal warmth apjdied to
the surface, particularly the anterior surface of
the trunk, are the chief means of recovery. The
remedy much employed in foreign countries in
cases of external injury on tiie epigastrium is ob-
viously approjiriale in such cases, viz. the appli-
cation to this region of one of the lower animals
the instant that it is killed and opened, and before
it is skinned, or has lost any of its warmth.

21. iii. Of jiiu remedial Operation of Cold.
— Itdoes not come within the scope of this work
to enter fully into the therapeutical ap])lication of
cold ; but I will very succinctly notice the subject

COLD — TiiEnAPEUTiCAL Operation or.

359

at this place. A. As respects the effect we wish
to procure from it, cold is employee!, 1st, ia a
slight degree, or for a sliort period, in order to
produce its indirectly tonic influence ; 2d, in a
greater amount relatively to the state of the
system, to procure its directly sedative operation,
without inducing in any considerable degree its
consecutive or indirect effect; and, 3d, to obtain
its astringent or constrictive influence on circu-
lating canals and vessels. JB. As to tiie mode of
using it in order to produce either of these effects,
much importance ought to be attached. It may
be directed, 1st, to a part or the whole of tiie
external surface. — a. by sponging with, or the
employment of a douche, or the affusion of a
continuous stream of, cold water locally, or using
a cooling lotion ; /;. by aftusing over all the body
some cold or tepid fluid, or by sponging the sur-
face generally with it ; c. by immersion in a cold
or tepid bath : 2d, to the internal surfaces — a. by
respiring a cool or even cold air ; b. by the inges-
tion of cold liquids ; and, c, by the injection of cold
or tepid fluids into excreting canals or passages,

22. It is obvious, from what has been ad-
vanced, that the mode of using cold will determine
its therapeutic effects, not absolutely however, but
only relatively to the state of the system at the
time, and the nature and stage of the complaint in
which it is prescribed. Thus, cold air, the cold
affusion, shower bath, douche, and plunge bath,
will produce either an astringent, or a tonic, or a
sedative operation, according to the length of
time either of them is employed without remis-
sion ; a brief or momentary use of either, whether
directed to a part only, or to the whole, of the
surface, being followed by its indirect or tonic
action ; and a prolonged use, by a more or less
permanent sedative effect. In the treatment of
diseases of debility, or states of depression, we re-
quire the former operation, and, suiting the mode
of applying the remedy to the nature of the
aftection, resort to it momentarily, and repeat it
frequently. In maladies attended with excite-
ment, interrupted secretion, &c., we desire the
latter effect, and prolong the application till we
are satisfied as to the extent to which we have
obtained it. In congestion and haBmorrhages we
wish to obtain the astringent or constrictive
operation of cold, and therefore resort to it in a
sudden or impulsive manner, as in affusion,
douche, or aspersion ; and as this particular effect
of cold appears to be connected, and to com-
mence, with its sedative action, and to terminate
with, or to be overcome by, the consecutive re-
action, according as it may supervene, so are we
guided in determining the degree and duration of
the cold to be employed, in order to astringe con-
gested or bleeding parts. In the appropriation of
each of the 7nodes of using this remedy, by which
very opposite effects are thus to be obtained, the
practitioner is guided by considerations arising
out of its operation upon the various systems and
organs of the body, by its effects directly exerted
on the seat of its application, and by its sympa-
thetic action upon parts remote from thence, and
upon internal viscera. It is, tlierefore, obvious
that mucii advantage in practice will accrue from
our entertaining correct ideas as to its action upon
internal organs, when applied to a part or the
whole of the external surface, I have already
stated, that cold — whether cold air or cold water

' — constricts the whole cutaneous surface, and de-
termines the flow of blood into the large trunks
from the smaller canals and vessels (§ 5,); and
that when directed for a short time, moderate re-
action is usually brought about by this internal
determination of the circulating fluid, and conse-
quent excitation of the centres of nervous and
circulating functions. This mode of operation
must never be overlooked when employing cold as
a remedy. The only question connected with it is,
whether this constriction of the vessels near the ex-
ternal surface is limited to it, or extends sympa-
tlietically to internal parts. It is obvious, that, when
the circulating fluid is propelled from one part, it
must be determined to some other; but, whether
does it accumulate in the large vessels, or retire
both to them and to other surfaces 1 Pathological
facts clearly show that the latter is most commonly
the case. Giannini has, however, argued that
the fluids are not driven upon the centre, but that
constriction also takes place in internal viscera.
That such an effect arises from the sudden
and momentary shock produced by cold on the
surface, and contributes to bring about the
consecutive increased action, may be admitted,
especially if it be employed locally, or in the
vicinity of a congested or relaxed part ; but when
its action is of any considerable duration, or is
directed to an extensive surface, the internal vis-
cera must necessarily experience a proportionate
increase of the circulating fluid. Thus, the brief
affusion of a stream of cold water on the head, in
cases of congestion of the encephalon, will tend
to constrict the congested vessels, and remove
the morbid condition, whilst a more general or
prolonged application of cold will actually pro-
duce the very state, which this local use of it, in
a sudden and momentary manner, is so efficient
in removing,

23. In many cases, as in the excitement of
fevers and acute inflammations, when the skin is
hot and dry, we employ either local or general
cold, with the simple view of abstracting a portion
of the increased heat, which, owing to inordinate
vascular action, and to the interruption of the
perspiring and cooling function, becomes a morbid
stimulus, and thus perpetuates the cause that ori-
ginates it. It is obvious that cold, when judi-
ciously employed in such cases, will even favour
transpiration, and will lower excitement to that
state which is compatible with a return of the
secreting functions ; but so much pathological
knowledge and experienced discrimination are
required to the advantageous or even safe em-
ployment of it, that no surprise can exist as to
the disuse into which the practice has fallen.
When the stage of excitement of continued and
exantliematous fevers has been either imperfectly
developed, or is about subsiding into collapse j
when internal viscera are weakened and con-
gested, and the skin is about regaining its inter-
rupted function, the employment of cold in any
way is attended by great risk, more especially
when applied to the surface generally.

24. The good effects of cold applied to the
head, in those diseases accompanied with an ex-
cited circulation in it; have induced various au-
thors to recommend a similar practice in acute
inflammations of the thoracic and abdominal
viscera. There can be no doubt that the strictly
local application of cold, as near as possible to

A a 4

360

COLIC — Its Pathology.

the organ affected, can be attended with no dan-
ger, particularly when the inflammation is acute,
and chiefly attacks serous surfaces ; and it may be
in some instances productive of benefit ; but we
are still in want of faithfully observed facts to
illustrate the effects of this treatment in a satis-
factory manner. In hemorrhagic affections, a
judicious use of cold is often of great service — as
the cold affusion or aspersion, the shower-bath,
and cold sponging, in epistaxis and hemoptysis;
iced fluids taken into the stomach in hajmate-
mesis; enemata, and injections per vaginam, of
cold liquids, in hemorrhage from the bowels,
xnenorrhagia, and flooding after delivery. Dr.
Drake, of New York, has recently recommended
very cold air to be respired in inflammations of
the respiratory organs ; but, from the admitted
influence of cold air in increasing the activity of
the respiratory functions, and, consequently, the
phlogistic disposition of the circulation, it appears
to me a practice of doubtful efficacy.

BiBLioo. AND RcPER i. Pathological Opcratio>i of

Cold, Sgc Q. Curfiiis, De Gestis Alexand. Mag. 1. vii.

cap. r>. — Boyle, History of Cold, 4to. Lond. 16'^3 — Wctlcl,
De Frigore iMorhit'ero. Jena^, 1()95. — K/oec/;/iof, Do l'"ri-
gidis Nervorum Systematis inimicis. Lugd. Bat. 17o6. —
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expcdit, Ike, in Haltcri Disp. Med. vol. vi. 17J8.. — Cappcl,
Observ. Anat. dec. i. p. 2. — Gmelin, Voy. en Siberie, t. i.
p. 381. — Gladbach, De Morbisa Vestitu insiifficientc, &c.
Franc. 1762. — Rosen, Anat. p. 142. — Lconhard, De Frig.
Atmosi>li. ERbct. in Corpus Huraanum. Lips. 1771. —
Hallcr. I'tiysiol. l.xii. \ 12. — Cullcn, De Frigoreetejusque
Vi ct Ellectibus in Corpus Humanum. Edin. 1780. — Curiic,
in Edin. Med. Comment, vol. xviii. n. 37. p. 237. — Hc-
herden, in Philos. Trans. 17!F) and 1796. — Piso, Do Med.
Brazil. 1. i. — Parat ct Martin, Actes de la Soc. de Sante
de Lyon, t. i. p. 300. — Hush, Med. Inquiries, No. !). — V.
Htimboldl, Vcrsuche iiber die Gereizte Nerven-imd Mus-
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Journ. der Med. Literatur. b. x. st. 1. p. ,01. — Roxicrc, Sur
la veritable Mode d'Action du Froid, Xc. Journ. Gon. de
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un Apergu sur la Canifiagne de Russie. Svo. Paris, 1817.
Translated, with additions, by .7. Clciidinning, Svo. Lond.
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Cold as a Cause of Disease, &c., Lond. Med. and Physical
Journ. for June, July, and Sept. 1832.

ii. Therapeutical Action of Cold. — Bartholinus, De Usu
Nivis Medico, cap. 1.^. ^ 31. — De Porraa, Animadver-
siones de Nivis in Potu Usu, Svo. Ifi2i. — fallisneri, Del'
Uso c dell' Al)u.so delle Bevande e Bagnature Calde o
Fredde, 4to. Modena, 1725. — F. Hnff'niann, De I'otus
frigidi Salubritate. Halac, 1729. — liichfer, De Salutari
Frigoris in Mcdioina Usu. Goct. IHV. — Bluhme, Morbo-
rum Curationcs per Frigus. Goct. MIS. — I.innaus, in
Amccnitat. Acad. vol. vii. No. 13ii. — Frank, Interp. Clinic,
vol. i. p. 4.37. el seq. — Klclt, De Epithematum frigidorum
Vi atque Usu,&c. Erl. 1794. — Born, De Cal. et Frig. Usu
Med. Itost. 1804. — Ilnfcland, Bibliothek der Pract.
Heilk. xii. b. iii. st. p. 3. — IVeber, Horn's Archiv. fiir
Pract. Mod. b.vi. p. 237. — ./. Carrie, Med. Reports on tlie
Eirects of Water, Cold and Warm, as a Remedy in Fever.
Svo. Livcrp. 1797. .— iJra/iT, On the Respiration' of Cold
Air in Pulmonary Diseases, A mcr. Journ. of Med. Sciences,
vol. ii. (). 229. — ./. Copland, On the AiTusion of Cold
Water in the 'J'reatmont of Di.scases, and of its Mode of
Oi)eratiun, in Lond. Medical Gazette, vol. x. p. 39. and 78.

COLIC. — Di:it. AND SvN. from kZXov, Colon.
KmXdiov aXynfJia,, (jr. Colicii, Passio Colica,
Dolor Colicus, EnteralL^ia, Colicodi/tiin, Tor-
miiia, Auct. Var. CoUijue, Fr. Das Banchgrim-
vien, die Kntik. Germ. Dolnri Colici, Ital.
Belly- Ach, Eng.

Classif. 1. C/f/M, Nervous Diseases;
3. Order, Spasmodic Affections {CuUen).
L Vlas!;, Diseases of Digestion; 1. Order,
Affecting tiie Alimentary Canal (^Good).
I. (Ji.ARS, I. OitDKii (Author, in Preface).
L Di i-iN. Severe ^ripiii^ pains in the lioivels,
with co.flirenes.i, and often with voniiling.

2. Colic was formerly cou.sidlrcd as seated

chiefly, if not entirely, in the colon; but many
writers of the last three centuries have applied the
term to acute pains of the bowels, attended by
costiveness, and unaccompanied by fever, arising
either from a primary aft'ection of them, or from
disease of some other viscus in their immediate
vicinity, with which they are connected, and
often sympathetically affected, through the me-
dium of the ganglial nerves.

3. The first mention made of the disease, by the
denomination Colicus Dolor, is to be found in
Cf.lsus and Pliny; and, according to SLNNEnr
and Tronchin, the same name was used by
Themison and PniLON, physicians of the Au-
gustine age, when, ns Sprengfl justly supposes,
colic must, from ti)e manners of that period, have
been a common complaint. But, although the
term colic appears not to have been in use, it
cannot be supposed that such affections were
before unknown. It is more probable that they
were included under the general appellation
of abdominal pains, in use from the time of
Hippocrates. The greater number of modern
writers have divided the disease into certain
species of varieties, according to the presumed
nature of its exciting causes and pathological
states. Sauvages presents us, accordingly, with
no less than 22 varieties. Dr. Cvllen arranges
the idiopathic states of the colic into, Lst, The
Spasmodic, either with stercoraceous vomiting, or
with inflammation superadded ; 2d, The Colic of
PoitoH ; 3d, Colic from continued constipation ;
4th, From acrid matters in the bowels ; 5ih, Fron>
retention of the meconium ; 6th, From stricture of
the bowels ; and, 7th, From the obstruclion occa-
sioned by calculous formations. Dr. Good
adopts a nearly similar division to the foregoing,
preserving the 1st, 2d, 3d, and 6th varieties; and
substituting for the others. Colic from Surfeit, and
Colic from the generation of Flatulence — C. Ci-
fcar/a and C. Flatulenta. ]\I. Pa riset gives the fol-
lowing varieties : — the flatulent ; the stercoraceous ;
the bilious; the inflammatory ; the ha^norrhoidal ;
the menstrual ; the spasmodic ; the metastatic ;
from calculous and other hard bodies ; the ver-
minous ; from organic changes in the bowels ;
and from lead. ]\f. Ciiomel divides the disease
into nearly the same varieties, and adds to them
that arising from acerb or acid fruits, and fer-
mented li([uors, or Colique Ve^^ilale. The only
additional arrangement of the forms of colic,
wiiicli deserves being noticed, has been given by
Scumidtmann, as follows: — A. Inflammatory
colic ; B. Sanguineous or plethoric colic ; C.
From substances passing through or lodged in
the bowels ; D. From the metiistasis or repres-
sion of other diseases ; E. Flatulent colic ; and
F. Nervous colic. Each of these comprises
several varieties, according to tiie exciting and
proximate causes.

4. Colic, according to the extended accept-
ation of the word, arises from so many causes,
and presents so many morbid relations, that a
satisfactory arrangement of its different states is
by no means an easy matter. 1 shall, however,
attempt to group into distinct species those forms
of the disease which resend)le each other most
nearly, or which aiise from intimately related
causes, noticing the peculiarities or modifications
presented by the principal varieties. Those
forms of colic which chiefly, or more imme-
diately, depend upon a morbid stale of the

COLIC — Its Pathology
first under

361

intestinal canal will come first under consi
deration ; and next, those which are symptomatic
of, or complicated with, other diseases. In
treating of the former, those states which are
the most simple, and apparently consist of func-
tional disturbance of the bowels, will be first
noticed, and subsequently those which proceed
from more complicated or organic causes. As I
agree with BunsERt, Cullen, Goon, Anr.n-
cROMBiE, Monro, and others, that ileus is often
either an aggravated state, or advanced stage, of
colic, or a consequence of organic or other causes
aflecting the calibre or canal of some part of the
small or large intestines, I shall treat of it at this
place, and after the more simple or less dangerous
forms of colic have been discussed.

5. I. Colic chiefly and primarily from

FUNCTIONAL DISORDERS OF THE BoWELS.

i. Simple Colic. Svn. Colica Convulsira,

Bonet ; C. Spasmodica, Iloflmann ; C. Fla-

tuleiiiu. Good, &:c. ; C. Nerveiise, Chomel ;

C. Nervosa, et C. Spasmodica, Schmidtmann.

Classif. I. Class, I. Order (Author).

Defin. Acute pain in the bowels, with occasional

partial remissions, Jiatulent distension, or spasmodic

cojitractions, or both at the same time, relieved by

pressure and the expulsion of Jiatus.

6. There appear to be three morbid conditions
of the intestinal canal, which more or less exist in
the simplest as well as in the most severe and
complicated forms of colic, and which evidently
depend upon depressed vital power of the digestive
canal:' 1st, Morbidly increased sensibility and
irritability of some part or the whole of the
bowels ; 2d, Irregular distension and spasmodic
constriction of different parts of their canal ;
and, 3d, More or less copious generation of
flatus in their tract, occasioning great distension
and irregular reaction of the muscular tunics —
the second morbid condition adduced. Accord-
ing as either of these states predominates above
the others, the attack assumes a nervous, a
spasmodic, or a flatulent character ; and it has thus
acquired these specific appellations from different
autliors.

7. A. The nervous form of the complaint occurs
most commonly in females, and in persons of a
nervous and irritable temperament, passing a
sedentary or indolent life, and of a costive habit
of body ; sometimes without any evident cause,
but often after inattention to the state of the
bowels, exposure to cold, or some mental emotion
or excitement. The attack is usually sudden, and
the pain is felt in one or more places in the
abdomen, but sliifts its place frequently, and is
exacerbated at irreguhr intervals. The face is
pale and anxious ; the abdomen is irregularly
contracted, and pressure of it often affoids slight
relief. During the severity of the pains, a cold
perspiration is forced out on the surface, and
leipothymia, or sinking, is frequently complained
of. The bowels are constipated, and borborygmi
arc constant. The duration of the attack is usu-
ally short — from one to several hours; and it
generally terminates favourably ; but repeated
returns of the affection are very common, upon
errors of diet, and from mental inquietvide.

8. B. The more /^n(!(/e)(t form of colic presents
greater distension of the abdomen, the expulsion
of flatus giving ease. The distension and pain
are often traced along the course of the colon

and are most complained of in the situation of
the sigmoid flexure and cascum. The quantity
of flatus generated is often very great, and it
evidently proceeds chiefly from irritation of the
mucous surface of the bowels, giving rise to the
separation of a gaseous fluid from the blood by
the vessels of this surface ; the matters retained
in the prima via being insufficient to furnish, by
their decomposition, — granting that they undergo
this change, — so great a quantity of flatus as is ge-
nerally voided. Owing to the irritation produced
by the flatus, the bowels are inordinately dis-
tended in one part, and irregularly constricted in
another ; the part which was contracted, losing
its tone, and becoming, after a time, greatly dis-
tended, and the distended portion experiencing, at
intervals, irregular spasmodic constrictions. Thus
the retained flatus is propelled from one part to
the other, occasioning griping, shifting pains, and
rumbling noises, or borborygmi, of the abdomen.
The bowels are always constipated ; and when
evacuations are procured, they chiefly consist of
hard lumps, and are accompanied with the escape
of much flatus ; the secreting functions of the
bowels being evidently impeded. This modifica-
tion of the complaint, as well as the preceding, is
frequent in hysterical females, and persons of in-
dolent habits, living much on vegetable diet,
whose intestinal and biliary secretions are scanty,
acrid, or otherwise vitiated ; and their digestive
functions weakened by indulgences.

9. C. The more spasmodic form of colic is in
many cases merely a somewhat aggravated state
of the preceding ; the extremely painful spasmo-
dic constriction predominating above the flatu-
lent distension, and extending more or less to tlie
abdominal muscles, giving rise to severe and
irregular contractions, often with retraction, of
the abdominal parietes. Whilst the two pre-
ceding varieties are very seldom attended by
sickness or vomiting, unless in the severest states,
this variety is frequently accompanied with this
symptom ; and, in its worst forms, vomiting upon
taking substances into the s'tomach, is very gene-
ral. Constipation is also very obstinate; inju-
dicious attempts at relieving it often increasing
the vomiting, and converting simple colic into
either enteritis or simple ileus. This form of
colic often attacks those of spare habits of body,
of the hypochondriacal and bilious tempera-
ments, who live chiefly on coarse vegetable
food, and are addicted to fermented or spirituous
liquors.

10. ii. Colic from the injurious Nature
or Quantitu of the Ingesta. — C. Acci-
dentalis, Willis and Cullen ; C. Vegttale,
Chomel; C. Cifcin/u, Good.

Defin. Severe twisting, griping pains in the
abdomen, witfi vomiting, and rigid contractions of
the abdominal parietes, folloived, in some cases, by
griping alvine evacuations, mid looseness.

1 1. ^4. This species of colic presents various mo-
difications, according to the nature of the offend-
ing cause ; and it has been accordingly differently
described and named. Its states vary greatly in
severity, according to the nature of the ingesta
occasioning it, wliethcr those of a solid or fluid
kind. It may be here remarked, that the
colic of Poitou, or colica Pictonnm (which name
has been very generally conibunded with colica
pictorum, or painters" colic), and the form of the

362 COLIC, BILIOUS

disease endemic in some other countries, although
in many respects the same as lead or painters'
colic, are evidently partly occasioned by the
crude wines, new spirits, and the acerb and acid
nature of the liquors in common use, as well as
by lead, which is sometimes dissolved in them.
(See Lead Colic, § 26.) Citesius, Piso, Car-
dan, Sennurt, VVepfer, and many recent au-
thors, have imputed the endemic of Poitou,
Madrid, and other places, entirely to the nature of
the ingesta, into many of which mineral sub-
stances could in no way enter. The evidence
furnisiied by their writings, and in the treatises of
Grashuis and TnoNCiiiN, and my own expe-
rience, favour the opinion that acid and acerb
liquors are often concerned in the production of
colic, without the aid of lead ; to which, however,
the most severe cases, and those accompanied
with paralysis, are attributable, as shown by Sir G.
Bakek. Dr. Bateiuan doubts the power of
these ingesta, independently of their impregna-
tioti with lead, to produce the disease. His opi-
nion is, nevertheless, opposed by the fact, that
a large proportion of the cases of colic which
occur in districts where acid and spirituous liquors
are much used, is not attended by the paralytic
and other symptoms characteristic of lead colic,
and that many of them run on to dysentery.
AVhether or not the colic stated by K;empfee to
prevail in Japan, owing to the use of fermented
beverages prepared from rice, depended on the
presence of lead, cannot be ascertained. I had
means of knowing that the colic so prevalent
among the natives of Africa is clearly owing to
the excessive use, particularly when over-heated,
fatigued, or covered by perspiration, of the acid
beverages prepared from the juice of the palm and
other trees, and in the making of which no sort
of metal utensil, or of glazed pottery, is at all em-
ployed. LiNN-T-us imputes the prevalence of the
complaint among the Laplanders to the use of
stagnant water, containing small worms, &c. In
various parts of the north of Europe, where
butter-milk whey, and vegetable infusions, are
fermented into very acid liquors, and used for com-
mon drink, most severe attacks of colic follow their
ingestion in a cold state, particularly when the
body is perspiring. Dr. Chisholm attributed
tlie prevalence of colic in Devonshire to tlie
abuse of cider in summer and autumn, by the
labourers, when busily engaged in the hay and
corn harvest — the cold acerb cider inducing a
spasmodic state of the bowels in persons over-
heated by laborious exertion.

12. B, Various articlosof food will occasionally
disagree from some peculiar idiosyncracy, the
articles themselves not being injurious. Such is
sometimes tlie case, when a person, who has been
living sparingly, indulges in a too full meal, or
partakes of a substance to which the stomacii, the
functions of which are perhaps weak, is unac-
customed. Pork, cooked very soon after being
killed, particularly if used as an article of diet in
warm climates, is very apt to produce attacks of
colic, followed by griping evacuations from the
bowels. A similar effect often is induced by
blown or tainted meat, mildewed wheat or rye,
and by cold, acerb, indigestible, or unwholesome
fruits, as cucuml)i;r, melon, ^c. The injudi-
cious use of cold griping purgatives, as senna,
&c., will often, if not properly combined witii

— History, &c. of.

other medicines, occasion this state of colic in
hypochondrial, bilious, or phlegmatic habits.

13. Most severe effects often follow the in-
gestion of poisonous fish, muscles, lobsters, mush-
rooms, &c., and of the minute fungi sometimes
formed on smoked meat and sausages, or on
cheese. But the colic which is produced in these
cases is the least dangerous part of the mischief;
the affection of the nervous and vascular systems
being often of still greater importance. Instead,
therefore, of considering the effects of these sub-
stances as varieties of colic, as Dr. Good has
done, I have viewed the disorder of the stomach
and bowels as a part only of the circle of morbid
actions they occasion, and have therefore treated
of them in the article poisons.

14. The presence of arsenic in wines, or the
fumes of this metal ; preparations of antimony,
copper, or zinc ; and the accidental solution of
these, or conversion of them into a salt by sub-
stances about to be received into the stomacii ; are
often productive of disorder, of which colic is one
of the most prominent features, generally attended
by vomiting, and sometimes followed by loose-
ness, 01' by tenesmus and dysenteric symptoms.
Lead colic is very often occasioned by the in-
gestion of the metal in some state or other by the
mouth, and should therefore be treated of at this
place, but the peculiarities of this variety require
for it a separate consideration. Many substances
occasion, when taken in hurtful quantities, effects
of which colic is among the most prominent; but
which, as they present certain diversities, are
described in a separate article. (See Poisons.)

15. C. Infants, especially from birth to the
termination of teething, and occasionally older
children, are very liable to this form of colic. The
state of the mother's milk, arising from the want
of health, or manner of living, the irritation
connected with dentition, too early feeding, too
much or inappropriate food, acidity of the prima
via, resulting therefrom, and want of attention
to the bowels, are the most common causes of
this complaint among infants. In children it is
often produced by acerb or unripe fruit, and
by cold. In very young subjects it is charac-
terised by more or less flatulence, screaming,
tossing of the arms, and forcible drawing up of the
lower extremities upon the abdomen, with vomiting,
costive bowels, and greenish, offensive, and acid
evacuations ; followed by looseness ; or free
evacuations attended by tormina.

16. iii. Colic from a morbid State of the
Secretions poured into the Biuvels, and
Retention of the Excretions, — Colica Atra-
liiliaris, Meyserey ; C. Bitiosu, Hoffmann;
C. Stercorea, Ettmuller, Sauvages, and Cul-
len ; C. Pitaitosa, Sennert, Kernel, &c. ;
C. Stercorale, et C. Bilieuse, Pariset ; C.
Constipata, Good; C. Biiiosa, et C. Ster-
coracen, Schmidtmann ; Hepatic Ileus, Mus-
grave ; Colica Madridensis, et C. Ilispaniensis,
Auct. Var. Dry Belly-Ach.

Deein. Severe griping pain, with porraccoits or
hilious vomitings, constipation, or scanty evacuu'
tions, and often loith hiccup, tension of the ab-
domen, and restlessness, the motions procured
presenting various morbid appearances.

17. This species of colic has been diflfercntly de-
scribed and named us above, according to the
views entertained respecting its nature. We

COLIC, BILIOUS

have seen that the Jirst variety of the disease
consists of various morbid states, chiefly charac-
terised by deficient function and altered sensibility
of the bowels, &c. ; and that the aecond variety
is principally occasioned by the nature and quan-
tity of the ingosta. The variety which I next
have to consider comprises certain forms of dis-
order arising mainly from the morbid condition
of the secretions and faecal matters contained in
the bowels, but aided by other causes ; and it may
be divided into, — a. The colic of infants, caused
by retained meconium ; — b. Colic arising from
accumulated f£eca! matters in the bowels ; and, —
c. From the irritation of morbid secretions poured
into the intestines from the liver, &c.

18. ^. The colic which is owing to the reten-
tion of the meconium {C. Meconiaiis, Sauvages
and Good), in new-born infants, is chiefly met
with in those who have either not been sufficiently
early put to the mother's breast ; or who have
been suckled by a nurse, or brought up by
hand. The milk which is first secreted, pos-
sesses purgative qualities, intended by Nature to
promote the expulsion of the secretions, which
had accumulated in the prima via during the lat-
ter period of foetal life ; and when the infant en-
joys not this requisite kind both of nourishment
and medicine, the meconium is retained, becomes
viscid, acid, and irritating to the bowels, occa-
sioning costiveness, distension, screaming, drawing
up of the lower extremities, sickness, &c.

19. B. It is evident that the retention in the
caecum and cells of the colon, of those excre-
mentitious matters which require to be thrown
off from the bowels, will be productive of more
or less disorder. Such retention usually occurs
very early, and in advanced life ; in those who
pass an indolent existence, or are engaged in
sedentary occupations ; in persons whose bowels
are torpid from debility or exhausted sensi-
bility ; in females who are pregnant, or who
are of an advanced age ; and in men who have
old herniaB. It is often preceded by indigestion,
cardialgia, constipation of the bowels, and ful-
ness about the cajcum, the sigmoid flexure, and
occasionally the whole course of the colon. In
many cases, large accumulations in the C jxum
or Colon (see these articles), maybe detected by
manual examination. Sickness and vomiting, how-
ever, seldom come on until abdominal griping pain
has been for some time complained of, and the
stomach has been irritated by acrid purgatives.
Later in the complaint, the abdomen becomes
tense, tumid, and painful on pressure; the pulse
accelerated ; and the tongue, which was from
the commencement loaded at the root, more foul
or furred. This form of the disease is very apt to
terminate in dysentery, enteritis, or ileus.

20. C. The form of colic which occurs, and
even prevails, in some of the West India islands,
has often been confounded with lead colic, from
the supposition that the new rum drunk in these
islands contains lead in solution. Rlr. Quier,
Dr. Chisholm, and Dr. Tiiojison, who resided
long in the West Indies, state that this disease is
not BO common as formerly in these islands, owing
to the improvement in morals, and the use Of
warmer clothing; and that nothing is more erro-
neous than attributing it to the poison of lead.
These physicians refer it to the intemperate use of
spirits, and to alternations of heat and cold.

— HisTonY, &c. OF. 363

Mr. QuiEn and Dr. Musgrave, who have given
a very detailed account of this complaint as they
observed it in Jamaica and Antigua, where
it is of frequent occurrence, state positively
that lead is not concerned in its production.
From the history they have given of this endemic
colic of the West Indies ; and from the descrip-
tions of the colic, which is perhaps the most
common disease in INIadrid and several provinces
of Spain, furnished by MM. Pascal and JMak-
QVAND, who treated many hundred cases of it in
the French army that occupied Spain during the
peninsular war, and in 1824 — all which ac-
counts are now before me; I conclude that the
colic of Spain and that of the West Indies depend
upon the same causes — evidently of an endemic
kind ; are characterised by similar symptoms ; run
the same course, evince similar lesions, and are
cured by the same treatment. Indeed, I have sel-
dom met descriptions of any disease so much alike
as those furnished by Dr. Musgrave and by M.
Marquand, who himself had the complaint, the
causes and treatment of which he has so ably in-
vestigated. After examining the causes to which
writers, particularly Hoffmann and Thiery, and
others copying them, have imputed this afl^ection,
viz. to lead and metallic substances dissolved by
acid wines, &c., M. Marquand states those
to which the natives attribute it; namely, the
use of vegetable acids and unripe indigestible
fruits ; large draughts of wine and water, and of
much milk ; and insufficient clothing on the trunk
of the body and abdominal regions. But these
causes, he remarks, are in operation in many places
of Spain and Portugal where colic is rare, and there-
fore some endemic cause not yet discovered must
be in operation. IM. Larrey imputes it to at-
mospheric vicissitudes and acid beverages, and
designates it " Colique bilieiise vheumatismule ;"
iMM. Aulagnier, Lidron, and Jacob, who have
had extensive experience of this disease in Spain,
concur with M. JMarquand in denying the in-
fluence of lead in producing it ; and think that its
causes are not yet fully ascertained. The nega-
tive information furnished by these writers, the
character of the symptoms, and particulaily the
appearance of the evacuations, would lead me to
infer that, in both the colic of Spain and the colic
of the West Indies, endemic causes, — especially
those which proceed from the soil, and produce
intermittent and remittent fevers, — impede the
functions of the liver and intestinal surface, and
occasion an accumulation in the hepatic ducts^
gall-bladder, and prima via, of acrid or otherwise
morbid secretions, which, owing to their irritation,
or to concurrent or determining causes, give rise to
a series of painful and diseased actions, and im-
perfect or abortive attempts at their evacuation.
The symptoms referrible to the liver — its con-
gestion — the signs of irritation about the duo-
denum, the vitiated dark appearance of the stools,
and the relief obtained from free alvine evacua-
tions, are proofs of this position.

21. Symptoms. — The patient generally experi-
ences premonitory symptoms before the accession
of the attack. These consist of dull and pressing
pains in the whole course of the colon, but parti-
cularly in its arch ; loss of appetite ; irritability
of temper ; and difficulty in evacuating the bowels,
which, however, are not costive. The patient
has often several evacuations in the course of the

364

COLIC FROM LEAD — History, &c. of.

day, but in small quantity, and with much
flatus ; and he experiences less distress in bed
than when he is up. The tongue is moist, and
loaded only at the root ; and there is much thirst.
These symptoms usually continue two or three
day^: about the third, the patient has no longer
any desire to. go to stool, and evacuates no more
flatus ; but the pain becomes more severe, and
more fixed and constant at the epigastrium, with
a twisting pain at the umbiUcus : the counte-
nance is pale, and expressive of pain and anxiety ;
the pulse is slow, small, regular, and constricted,
but not febrile ; the skin is dry, but not hot ;
and the urine is scanty, but not otherwise unna-
tural. 1 he patient often sits with his arms
crossed over, and pressed upon, the abdomen,
and the trunk bent forwards. If he be in bed,
the thighs are pressed up upon the belly. Along
with these symptoms, and generally soon after
the accession of constipation, porraceous or bilious
Vomitings come on, commonly in small quan-
tities, mixed with glairy matters, or those last
taken into the stomach, and accompanied with
hiccup. There is no sleep, but a continued
restlessness : the pain is now nearly constant,
and most severe, particularly about the epigas-
trium and umbilicus, and is not ameliorated by
any position. As the malady proceeds, the thirst
increases ; and the fluids taken generally aggra-
vate the hiccup, and are soon thrown ofl^. The
eyes are sometimes slightly yellow, and the whole
surface rather sallow. The patient is distressed
by the continued severity of the pain, the hiccup,
and the want of sleep ; wandering and delirium
come on, sometimes with deafness, epileptic
convulsions, and rarely with fa-culent vomiting ;
these latter symptoms generally portending a
fatal result.

22. This disease, left to itself, Usually runs its
course in eight or ten days, and rarely extends
beyond the fifteenth. Pain or uneasiness in the
right hyponchondrium is often felt some time
before the attack, and occasionally not until
the advanced progress of it. In some cases, the
pain and vomiting cease, upon the free spon-
taneous excretion of flatus, with dark, hard
motions : but occasionally they return after a
short time, and black atrabilious matter is thrown
off the stomach. The discharge from the bowels
is generally very morbid, ofl^ensive, and of a
dark, blackish, or deep green colour. In other
cases, where the patient has been neglected or
improperly treated, chronic debility, with maras-
mus, and, more rarely, paralysis, supervenes, and
usually terminates fatally. The abdomen is sel-
dom much retracted, excepting about the umbili-
cus ; but, at the last or fatal stage of the disease,
it is much distended. The bowels usually resist
the action of the most powerful purgatives at its
advanced period, and injections are thrown up or
retaineil with difficulty.

23. Prognosis. — a. A favourable issue is in-
dicated by free evacuations, followed by amelior-
ation of the abdominal jiain and vomiting, by
the circumstance of the pulse remaining below
100 beats in the minute, and the non-superven-
tion or subsidence of hicoip. h. An inij'avoiir-
alde result is preceded by more or less tender-
ness, tension, and tumefaction of the abdomen ;
by a pidse ahovc 100 ; by obstinate constipation,
and immediate return of the injections; by the

severity and continuance of singultus ; by dryness
of the tongue, and increased restlessness and
tossing.

24. Dissection has thrown little light on the
nature of the disease. M. Mauquand, whose
experience was extensive, considers that what-
ever change of structure is observed, is merely
a contingent circumstance, or accidental com-
plication. M. Pascal states, as the result of
the examinations he made of six fatal cases,
that little or no lesion was observed in any
part of the alimentary canal, excepting slight
redness of the mucous surface of the duodenum :
the gall-bladder was loaded with thick bile; but
the other viscera were natural. He further states,
that he found the sympathetic ganglia injected.
A perusal, however, of his description of the ap-
pearances presented by them, impresses me with
the belief that what he considered to be unusual
vascularity, was not more than they always present
in the healthy state.

25. iv. Colic from the Poison nf Lead. — Syn.
Colica Saturnina, C. Pictorum, C. Pictonum,
Auct. Var. C. Rhachialgia (j5a;^(aXyia,
6'/)uig-,4c/i), Astruc, Good ; C.du Poitou, C.
de Plomh, C. Metallique, Rachialgie Metal-
liqne, Auct. Gall. Bleicolik, Trocken Colick,
Germ. Devonshire Colic, Painters' Colic,
Lead Colic, S<;c.

Defix. Dull remitting pain, becoming constatit
and violent, extending to the hack and vpper and
lower extremities ; vomiting, obstinate constipation,
often followed by paralysis.

26. I have already noticed the fact of this
disease being often confounded both with the
form of colic produced by acid and acerb in-
gesta (§ 11.), and with that depending upon a
morbid state of the secretions poured into the
intestinal canal (§ 20.). Lead colic chiefly
attacks house-painters and plumbers, workers in
the different preparations of lead, glaziers of
earthenware, miners, ornamentnl and water-
painters, gilders, and rarely chemists and print-
ers. It is very probable that the colic so pre-
valent in Devonshire, Poitou, and, according to
TnoNCHiN and Wanstroostwyck, in Haarlem
and Amsterdam, arises in some instances from a
portion of lead contained in acid beverages, and
possibly from the water used for domestic pur-
poses; but that the endemic colic of the West
Indies and Spain is occasioned by lead, as many
suppose, has been disproved, as we have seen, by
the more accurate observations of modern en-
quirers, especially directed to this point. Lead
colic arises not only from the introduction of the
mineral into the system along with the ingesta,
but also from its oxides being allowed to remain
in contact with the surface of the body ; as in the
case of workers in lead, as shown by Lentin,
IJitAMBiLi.A, Sir Ci. Baker, and Dr. IIi;vnolds;
and from the volatilised fumes of lead floating
in the air, in recently painted apartments, as
observed by Pehcivai,, Hencrel, Gardanne,
]?AnELi,Y, and Goon. It is extremely probable
that lead produces a more injurious action upon
some constitutions than upon others ; and that
Us oxides and sub-salts are more injurious
than its acetate. The most (juickly, and some-
times the most powerfully, injurious operation
of lead is when its oxide is mixed principally
with turpentincj for the puiposes of house-

COLIC FROM LEAD ^ History, &c. OF.

365

painting. Tiiis spirit carries along with it,
(.luring its volatilisation, a portion of the oxide,
and thus poisons the respired air, thereby affect-
ing the respiratory nerves and even the blood
itself. Soon after Sir G. Bakeu's investigation
of the effects of lead, and of the substances which
either contained, or might by possibility contain
it, was made public, every thing which came in
contact with lead in any form was viewed with
suspicion. Dr. Peucival first demonstrated the
folly of these apprehensions; and although the
water which supplies a million and a half of per-
sons in this metropolis passes through leaden
pipes, and is long retained in leaden cisterns, which
are often allowed to become foul, yet, I believe,
that no case of lead colic occurs from this cause,
excepting in those who are affected by lead in a
different and manifest manner. Dr. Batemax
never met with a case in London which could
not be traced to this source ; and I certainly
never did, notwithstanding the readiness witli
which the effects of lead are produced in some
persons. Although lead is thus the efficient cause
of the complaint, it is not always the only cause.
Thus, the acid beverages or spirits in which the
food is taken may determine its effects ; or an
attack may be induced, in a person imbued with
tlie lead poison, by improper ingesta, spirituous
liquors, exposure to cold, and by sulphureous
waters, or sulphuretted medicines, and cold grip-
ing purgatives. Cases have been recorded by
Dr. Wall and Sir G. Baker, where the external
medical use of the preparations of lead occasioned
the disease, but such are of rare occurrence.

27. Symptoms. — Lead colic usually com-
mences with obscure pain of the abdomen, which
becomes, at first, at intervals, so severe, that the
patient screams, tosses himself about, and vainly
seeks a posture that will lessen his sufferings.
Some- lie for a while on the abdomen, and others
press upon or rub this part with the hand. The
pain is generally greatest at the pit of the sto-
mach, and as the disease proceeds, extends to the
back, upwards to the arms, and downwards to
the loins, thighs, and legs. A twisting pain is
also generally felt about the navel, which is at
first drawn inwards ; and cutting pains shoot at
times with great violence to both hypocliondria
and iliac fossaj, and through the abdominal mus-
cles. The voluntary muscles often become so
sore that they cannot bear the slightest pressure ;
and the pain frequently alternates between the
stomach and bowels and the external muscles.
Sickness and constipation are early symptoms, —
the matter thrown off the stomach consisting of a
slimy fluid, either with or without acrid deranged
bile, which is continually being secreted, accu-
mulates, irritates, and is evacuated. To these are
generally added bitter eructations, hiccup, severe
lieadach, pains of the wrists, hands, ancles,
soles of the feet, &c.-, and frequently of the
shoulders and neck. These symptoms are aggra-
vated during the night, depriving the patient of a
moment's repose. The pulse is not, at first,
affected — sometimes in no measure throughout
the disease ; in many cases it is below the usual
standard, and in others quicker and weaker, more
rarely fuller or stronger. The tongue is pale,
moist, and soft, without erection of the papillre.
'I'he skin is commonly soft and moist ; it is rarely
hot. Tiie urine is various, but more frequently

copious than otherwise. Costlveness continues
as the disease advances ; sometimes a gripino-
disposition to stool occurs ; and if any faeces are
passed, they are scybalous and hard, resembling-
sheep's dung, and are mixed with a dirty watery
fluid containing a dark slime, and occasionafly a
little blood. M. Merat analysed the matters eva-
cuated, but could not detect any lead in them.
The abdomen is insensible to pressure ; in some
instances rigid and knotted ; but in the latter,
stage often distended and slightly painful, chiefly
from the distension of the bowels, and affection
of the muscles. In the cases which have occurred
in my practice, distension of the abdomen was as
frequent as retraction, owing evidently to inflation
and f3?cal engorgement of the colon, the course
of which could be distinctly traced under the
abdominal parietes. j\I. Andral has also met
with a similar state of this cavity. In some
cases I have remarked considerable retraction
around the umbilicus, while all the rest of the
abdomen in the course of the colon was greatly
distended. Dr. MoNno states that the sphincters
of the bladder and rectum are sometimes so con-
tracted that the urine and fseces cannot be voided.
I have observed this chiefly as respects the sphinc-
ter ani — a clyster pipe being with difficulty
introduced. If the complaint be not soon ameli-
orated, the pains of the back, loins, and limbs
become more violent, and are attended by ex-
treme weakness, tremulousness, and even partial
or complete paralysis, particularly of the extensor
muscles. In some cases, dyspnoea, palpitations,
and a short dry cough, are complained of, seem-
ingly owing to the pressure of the inflated colon
upon the diaphragm ; and occasionally epilepsy,
coma, or even apoplexy, supervenes.

28. Duration, Complications, and Prog7ios!s. —
A. The duration of the attack varies from two or
three to twenty-five days. M. Ranque found
that, out of 147 cases, 129 recovered between the
second and the thirteenth day of treatment, and
the remainder before the twenty-sixth day. But
relapses, or rather returns, of the complaint are
most common. I have met with instances of a
ninth and tenth attack ; and more numerous
seizures have occurred in the practice of others.
In more unfavourable cases, the disease continues
for weeks, or even months, with occasional in-
termissions ; but such may be viewed as a suc-
cession of attacks, and occur chiefly in drunken
workers in lead — addiction to spirits aggravating
and reproducing the affects of lead on the system.

29. B. This disease is sometimes complicated
with epilepsy ; more frequently with palsy, in
which it often terminates ; and rarely with in-
flammation of some one of the abdominal viscera,
and with mania or delirium.

30. C. The prognosis is favourable when the
symptoms are mild, or are ameliorated by treat-
ment ; but it should be given with caution and
reservation when the attack is very severe, is
attended by hiccup, by obstinate and continued
vomiting, by tremulousness, and by distension of
the abdomen. It should be unfavourable, if
complications (§ 29.) appear in its course ; or if
deafness, blindness, ffecal vomiting, and symp-
toms of ileus supervene.

31. Appearances ohserved on dissection.

Lead colic is most commonly fatal from the
complications that occur in its course. In its

366 COLTC AND ILEUS

simple state it selJom terminates in death. The
examinations made by Senac, Astruc, and
BoRDiEu, furnish nothing satisfactory. Stoli.
observed the gall-bhidder loaded with dark bile;
Sir G. Baker describes the bowels as being per-
fectly natural throughout, and the muscles pale
and wasted. De Haen states, that he found
contractions of the colon and caecum in all the
cases he opened. j\l. Merat examined seven
cases, which he says presented the same appear-
ances as those described by De Haen ; whilst
M. Andral details six cases, in all of which no
such contractions were observed, nor any otiier
morbid change of the alimentary canal. J\I.
Louis, also, found no alteration in the bowels.
Most of those who die of this disease are carried
off in epileptic convulsions, or have had paralytic
symptoms. The state of the cerebro-spinal axis
is hence deserving of examination. M. Andhal,
however, states, tluit he detected no lesion of the
brain, nor of the spinal chord, nor of the volun-
tary nerves. A case I had an opportunity of
examining confirms the observations of Sir G.
Baker and Andual.*

32. II. Colic arising most frequently
froaM Change of Structure or relative
Position of the Bowels. — Classif. IV.
Class, I. Order (Attthor).

i. Colic from Mechanical Obstruction of the

Canal of the Bowel. — Syn, C. Calculosa

et C. Scirrliosa, Bonet, Chomel, Lamotte ;

C. Constricta, Good.

Defin. Costive, Jiatulent state of the bowels,

attended by passing colicky pains, relieved bii

liquid, difficult motions, and often accompanied by

a sensation of constriction ; tumour or difficulty in

a particular part of the abdomen.

33. Considerable mechanical difficulty is often
experienced for some time before a severe attack
of colic or ileus takes place. A patient, whom I
have long attended for slight colic pains, and
irregular state of the bowels, without full or
satisfactory evacuations, states, that a sensation
of soreness in tlie situation of tiie arch, and of
difficult passage to the left flexure of the colon,
with painful distension about the cEeeum and
right side, are often felt shortly before an evacu-
ation. Dr. Monro remarks that stricture of the
bowels in its early stage occasions costiveness,
alternating with diarrhoea and colic pains. If
the obstruction be low in the bowels, solid faeces
are eitiier not passed, or they are of small quan-

■ Pathology of.

• Mr. BvAM and myself recently examined the body of
a painter, wlio died at the age of 78. He had been a very
strong man, and in constant employment all his life up to
a few days before his death. He died of haemateinesis,
from disease of a branch of the coronary artery of the
stomach. The substance of tlie heart was soft and flabljy.
Tlie small and larj^e intOftincs were sound ; the liver was
studded with collections of a pultaceous semifluid matter,
of a greyish white colour, contained in very thin cysts,
from the size of a hazel nut to a walnut, the portions of
liver surrounding them being softened, and of a dark red
colour. The top of the anterior mediastinum, and spaiu'
behind the top of the sternum, contained an immense
mass, nearly the size of the close<l hand, of enlarged glands,
of a cheesy consistence and ai)i)earance ; and a similar
change of the absorbent glands existed behind the arch of
the aorta, the superior cava, &c., extending in the form of
a long cushion down the vertebra into the abdomen. 'I'he
small arch of the stomach, the pylorus, and commence-
ment of the duodenum, were remarkably thickened, from
the dep<i.'iilion of adventitious matter, the thickened nia.ss
nearly ajiproaching the characters of scirrhus. The coats
of the arteries of the stomach were diseased, and contained
atlicromat'jus matter.

tity and slender calibre. These strictures are
most commonly met with in the colon ; and their
situation, in some cases, may be inferred from
tlie sensations of the patient, and the symptoms
observed in examining the abdomen : they are
fully described in the article on Morbid Structures
of the Digestive Canal. (See also arts. Cecum,
and Intestines.) When colic is owing to the
presence of concretions, stones of fruit, &c. in
the bowels, distinct hardness, or even tumour, is
sometimes felt ; but, in many instances, no such
change can be detected, although the patient
generally refers to some part of the abdomen as
presenting a fixed pain, or obstacle to the func-
tions of the intestines. (See art. Concretions —
Intestinal.) In all cases of colic pains arising
from the above pathological slates, great disten-
sion and tenderness of the abdomen often speedily
come on, partly owing to inordinate dilatation of
that portion of the canal above the obstruction.
Sickness also at stomach, and vomitings, generally
precede or follow these symptoms, with restless-
ness and distress ; and the complaint soon assumes
all the characters of ileus, unless the retained
matters pass the obstacle, or the obstructing body
itself be propelled downwards and evacuated, as
is often the case in respect of biliary and other
concretions. When colic proceeds from incipient
mechanical obstacles in the intestinal canal, the
symptoms are less violent ; but they are of fre-
quent recurrence, until the obstruction is removed,
or they increase so as to produce inflammation of
the bowels or ileus.

34. ii. Colic, ivith comjilete Obstruction of the
Bowels, and Stercoraceous Vomiting, Ileus,
Volvulus — Syn. Elheo; (from ilkeai, I con-
stringe), Hipp. EiXlov (from elxiai, volvo, I
roll about — hence, volvulus), Aretaaus.
Xaiiiota^'Ci; (from p^opJJi, a chord, and aTrrai,
I kill), Galen, Morbus tenuis Intestini, Cel-
sus. Acutum Tormentum, Ccel. Aurel.
Iliaca Passio, Iliacus Morbus, Chordapsus,
Miserere, Dolor Ileus Spasmodicus, Auct.
Var. Volvulus, Baillou, Ileus Verus, Syden-
ham. Ileus Spasmodicus, Sauvages. Colica
Ileus, Good. Passion Iliaque, Fr. Darm-
gicht, Germ. Volvolo-passione, Iliaca, Ital.
Iliac Passion, Eng.

Defin. Violent griping pain, obstinate con-
stipation, with retraction, of the navel, and
spas7ns of the abdominal muscles, tension, tender-
ness and disteiision of the abdomen ullimaleli/
supervening, and generally with stercoraceous
V07mtings.

35. Galen, and after him Van Swiften,
viewed ileus as merely a form of inflammation
of the bowels. Others, particularly Sauvages,
Barihez, Cullen, Pinel, and Ai.iiiert, as-
cribed to it chiefly a nervous or spasmodic cha-
racter. Many writers of the lust century have
divided it into idiopathic and symptomatic ;
whilst M. Kaice Dei.ormk, and otiiers, have
disputed its idiopathic nature, and particularly
its nervous origin, and have considered it, as
it doubtless most frequently is, a consequence
of nieclianicul obstruction, inflammation, or some
pre-existing disease. There can, however, be no
doubt, although many of the cases observed may
have been merely severe instances of colic, in
which the proper sym])tom3 of ileus had not
come on, that it sonietimcs occurs as a simply

COLIC AND ILEUS

and idiopathic disease, as Bartiiez, IMaxwell,
and Dr. Abercrombie have demonstrated ; and
that dissections of fatal cases somelimes present no
morbid change sufficient to explain the symptoms
or to account for the result. In the cases re-
corded by Bahthez and JMaxweli., fa-'Culent
vomiting, and the discharge by the mouth of
matter thrown into the colon, are described to
have occurred, and yet recovery took place. In
many instances, perhaps the majority, ileus su-
pervenes on one or other of the forms of colic
already described ; or, in other words, certain
pathological states commence with symptoms,
which, in the tout ensemble, constitute some one
of tiie forms of colic described, and terminate in
fully developed ileus. Such terminations are most
common in the second, third, and fourth varieties
of colic. But, in rare instances, ileus comes on
suddenly, with the most violent abdominal pain
and vomiting, tlie patient tossing about in the
utmost agony, tiie other symptoms of the disease
rapidly appearing, and most frei.[uently terminating
fatally.*

36. A. Histflry. — Ileus is either preceded by
constipation and colicky pains, or it is a more in-
tense form of colic from the commencement, the
symptoms differing only in degree. Early in the
disease, constipation ; twisting and violent pain
about the umbilicus, sometimes not aggravated
by, but even alleviated by pressure ; constant
retchings ; absence of fever, and a pulse not ex-
ceeding, or even below, the natural standard, are
the usual signs. If relief be not sooa procured,
tlie abdomen enlarges, and becomes tense, tender,
and tympanitic ; the countenance is anxious and
collapsed ; fajculent matters are ejected by the
mouth ; the pulse becomes frequent, small, and
constricted, the thirst urgent ; and violent tor-
mina, with ineftectual attempts at evacuation of
the bowels, hiccup ; failure of the mental energies
and vital powers, with cold, clammy, and partial
sweats, cold extremities, cold, sunk features,
leipothymia, and sinkings, supervene. In many
cases, inflammatory symptoms appear early in the
course of the malady, and pass rapidly into those
indicating the commencement of gangrene. The
state of the tongue is different in different cases
and stages of the complaint. It is occasionally
not materially changed. Often the disease is re-
ferrible at its commencement to no particular
region of the abdomen ; but as frequently the
patient refers his sufferings to a particular part, —
sometimes to the ileo-cacal region, occasionally to

* Professor ■, of Berlin, during his visit to London,

was attacked theday after diningwitli a party of scientific
men, when he sat witli his back to a large fire. I was
called to him, and found him in the utmost agony, with
a pulse of natural frequency ; his abdomen tense, tympa-
nitic, and subsequently tender to the touch. What he
vomited at first consisted of half digested substances ; sub-
sequently it was mixed with matters which had apparently
come from the upper part of the small intestines. Calomel
and opium were administered, and oleaginous enemata
repeatedly thrown up. A flexible liougie was introduced
its whole length, and large glystcrs were injected without
difficulty ; but the latter were' returned soon after without
any effect. The abdomen increased in size ; mental dis-
tress and debility became extreme ; the matters rejected
by tlio mouth were more obviously feculent ; hiccup and
leipothymia appeared, and he died in two days. An ex-
amination was not permitted. The characters of the
attack suggested the idea of a paralysed state of tlie bowels,
with inverted action of their upper portion, gradually ex-
tending downwards. The origin of tlie sufferings was not
referred to any particular part of the abdomen, nor had
any obstruction been previously complained of.

HiSTonv, &c. or. oG7

the situation of The sigmoitl flexure of the colon ;
in some cases, in the course of the right or trans-
verse colon ; in others, above or about the umbili-
cus, or low in the iliac and pubic regions. In all
such cases, we may suspect mechanical obstruc-
tion arising from some one or other of the follow-
ing causes, which have been repeatedly discovered
on dissection ; —

37. B. Changes observed in fatal cases, — 1. Great
distension, as if from paralysis of the muscular
coat of a large portion of the small intestines,
without inflammation or any other change. 2.
Dilatation, with a chord-like contraction, in either
the small intestines, or in the large ; more fre-
quently the latter. 3. Dilatation, with inflamma-
tion, lividity, and exudation of lymph on the
serous surface. 4. This latter stale, conjoined
with gangrene, and either with or without exud-
ation, occurring in the small or large intestines ;
more frequently in the former. .5. These changes
combined with contractions, — occasionally only
one, often more, the intervening parts being di-
lated,— in some part of the bowels. 6. Unna-
tural convolutions, twists, loops, or knots, in
some part of the small intestines. 7. A^arious
convolutions, or duplicatures, or twistings in the
large bowel, with an appearance of elongation
owing to relaxation or paralysis of the longitu-
dinal bands of muscular fibres. 8. These latter,
conjoined with recent or old cellular adhesions of
the opposing serous surfaces of the duplicated
portions. 9. One or more introsusceptions ; the
introsuscepted portion being either in a down-
ward or upward direction, sometimes uninflanied,
as in infants and children ; frequently inflamed,
adherent by lymph, or gangrenous, particularly in
adults ; and occurring in any part of the intestinal
tube. 10. Old adhesions of one part of the small
or large intestines to another, or to the parietes
of the abdomen, or to the omentum, or some other
viscus, without obstruction of the canal. 11.
Similar adhesions occurring in reduced or old
hernitC, or in hernire for which an operation had
been performed and the bowel returned. 12.
Filamentous or cellular bands confining or en-
circling a portion of intestine, sometimes after
reduction of hernia, occasionally in a large and
irreducible hernia, and even where no hernia had
existed (Garthshore, JMoreau, Moscati, Wal-
THER, Abercrombie, myself, and others). 13.
Adhesions of the appendix of the caicum to some
part, after passing over or around, and strangu-
lating a portion of intestine. (See art. C^xum.)

14. Strangulation of a portion of one side of the
intestine in the femoral arch, without producing
any tumour, and without obliterating, or even
sensibly diminishing the canal of the bowel.*

15. ^'arious states and forms of internal strangu-
lation, often produced by old adhesions formed
between opposing portions of the serous surface,
more commonly low in, or about the middle of the
abdomen, — by portions of omentum, — by rents
in the omentum through which a portion of intes-
tine had passed, and by various atlhesions, ob-
structions, and changes in the position of parts of
the bowels. 16. Strangulation in the mesentery,
owing to partial adhesions (Swammeruam). 17.
Various states of contraction in the small and

* This occurred in a female servant of the author, who
was^seized with ileus, without any antecedent disorder.

368

COLIC AND ILEUS — HiSTony, &c. of.

large intestines from organic changes in their
coats, more particularly about the cajcum, sig-
moid flexure of the colon and rectum, as scirrhus,
fungus, soft cancer, &c. (De Haen, IIiian,
Hodges, Tiiomann, Howship, Annesley, Aber-
CROMBiE, TiiAVERS, &c.) 18. Internal polypous
or malignant excrescences, or external diverticula
(Portal, CLoyuET, Copland Hutchison, &c.).

19. Obstructions of the canal of some part by
biliary and intestinal concretions, stones of fruit,
bones, indurated fneces, and balls of worms.

20. The pressure of encysted or other tumours,
abscesses, ikc. in the pancreas, kidneys, omentum,
uterus, ovaria*, or between these latter and the
rectum. 21. And lastly, The circumstance of ileus
being produced by hernia;, both of the more com-
mon kinds, and of those that are uncommon, as
hernia of the ischiatic notch, diaphragmatic hernia,
&c., should not be overlooked. Of these, and even
of other internal changes productive of ileus, nu-
merous instances are to be found in the works to
which I have referred at the end of this article, at
the places pointed out. (See also arts. Cir.cvM,
Colon, Constipation, Digestive Canal, Intes-
tines, &c.)

38. C. Of Volvulus, or Ileus arising from intus-
susception.— a. The invagination of one or more
portions of intestine is not infrequently met with
in post mortem examinations ; and on some occa-
sions its existence may be known during the life
of the patient. The^ number of intus-suscepted
portions may vary from one to ten ; the greater
number being most frequently met with in chil-
dren, amongst whom invagination is also most
common. In this class of patients it is frequently
unconnected with any marks of inflammation ;
and, from the healthy appearance of the part thus
affected, and the facility with which the invagi-
nated portion is replaced, it seems probable that
intus-susception has taken place, either very shortly
before, or at the period of death. In the majority
of instances it is un accidental consequence of pre-
existing disease, most frequently of the intestinal
canal, arising from an irregular action of the
muscular tunics, occasioned by irritation of the
mucous surface. Thus worms have been found
in or near the invaginated part : and in adults it
is generally observed in connection with inflam-
matory action of some one of the intestinal sur-
faces ; and as a consequence of dysentery and
chronic diarrhoea, particularly the dysentery of
warm climates ; a considerable number of the
dissections which Mr. Annesley made in this
disease in the East Indies presenting one or more
invaginations, commonly in the small intestines.
I have also not infrequently found it in fatal cases
of inflammation of the brain, or its membranes, in
children. Although generally a fatal occurrence,
intus-susception is not necessarily such. I be-
lieve that it sometimes occurs in infants, without
being produced or followed by inflammation ;
gives rise to symjjtoms of ileus, or merely to slight
colic ; and, either with or without the aid of mcdi-

» A la<ly, to wliom I was called, had inflammation of
the utcrua, and an abscess formed between the upper part
of the vagina mid rectum, i)ressing upon the latter so as
to prevent the evacuation of the bowels and injection of
j^lystern. Colic, followed by ilcns, took place. During an
attempt to throw up an enema, by passing a male catheter
up the rectum, the al)sco»s burst into the rectum, and a
large quantity of pure pus, followed by copious facuUiit
motion*, came away, when all the lUuiyerous symptoms
ttisappearcd,

cine, sometimes is restored to its natural position.
In adults, however, even when it occurs without
pre-existing inflammation, it almost always causes
the most acute inflammatory action, often termin-
ating in the accretion of parts, or in gangrene,
chiefly owing to the strangulation of the invagi-
nated part. IMany cases, however, terminate
fatally before sphacelation takes place ; whilst
in others, gangrene occurs during life, and the
invaginated part passes oft' by stool ; union of tlie
opposing extremities of intestine formed by the
separation of the dead invaginated part, and the
ultimate recovery of the patient sometimes being
the result.

39. One of the most common causes of inva-
gination of the intestines is the inappropriate use
of drastic purgatives. In all the cases of inva-
gination observed after death from dysentery,
that I have perused, purgatives had been unspar-
ingly and unnecessarily exhibited. M. .T. Clo-
QUET has published a case, wherein a female died
of enteritis consequent upon invagination of
about fourteen inches of the ileum, occasioned by
a polypous excrescence arising from the mucous
surface, and which, having been pushed onwards
by the peristaltic action of the intestine, had
dragged the part to which it was attached along
with it. Costiveness is often a prelude to this
change, hardened faeces, &c., producing local
irritation. Intus-susceptions are most frequently
downwards, and but rarely upwards. Dr. jNIonro
thinks that an inverted action of the bowels is
requisite to the production of the latter. They
are most common at the termination of the ileum
in the cascum. The quantity of intestine that
passes within the other varies from one to thirty
inches, or even more. In an infant, to the examin-
ation of which I accompanied Mr. Alcock, nearly
the latter extent, including the ileum, ca2cum, and
ascending colon, was invaginated. In some rare
instances, the ileum, caecum, ascending and trans-
verse colon, pass into the sigmoid flexure, or even
as low as the rectum ; or the caecum and colon only
(WnATELY, Monro, Sic). I have met with two
or three such cases in infants and children. In
rarer instances, a portion of the colon and ileum
has passed out at the anus.

40. D. Diugtwsis. — Is it possible to distinguish
volvulus or ileus owing to intus-susception, fiom
colic or ileus arising from other pathological
states ? I think that symptoms may present
themselves, which will, in some instances, lead
the observing practitioner to infer the existence
of invagination. The sudden invasion of the
symptoms of severe colic or ileus after a violent
straining at stool ; and, subsequently, the constant
desire to go to stool, attempts at evacuation being
accompanied with violent tormina and tenesmus,
and either unattended by evacuation, or followed
by the discharge of a little bloody mucus, and
these by symptoms of enteiilis; are amongst tlie
most constant concomitants of invagination. In
some instances, also, the sudden occurrence of an
elongated tunniur, in addition to these symptoms,
and before abdominal distension comes on, will
further guide the o[)inion ; particularly if the in-
vagination be extensive, and seated in the ca?cum
or course of the colon. Much will, however,
depend upon the precision and tact with which
an examination of the abdomen is made. In all
such cases, the rectum should be examined by

COLIC — Sympathetic and Complicated Forms of. 369

inflammation of the uterus (C. Uterina, Auct.
var.) ; — and e. from haemorrhoiils (C. Hamor-

the finger ; and the extent lo which enemata may
be thrown up observed as an additional means of
information; for whenever the intus-susception is
in the colon, as mucii fluid cannot be tlnown up
as in health. Hiccup and a small irregular pulse
characterise the advanced disease, and indicate
the existence of inflammatory action in the in-
vaginated bowel. When a portion of intestine
is discharged by stool (as is rarely the case, the
patient even recovering and enjoying health after-
wards), there can be no doubt of the nature of
the malady. Dr. Monuo mentions an instance
of double intus-susception, or intus-susception of
the invaginated part, communicated to himby jNIr.
A. Burns. I once met with such an occurrence
in a child a few months old.

41. HI. Of the Sympathetic and Compli-
cated Forms of Colic ; or, Cone owing to
MORBID States of associated Viscera. — Colic,
in one or other of the forms already described,
but most commonly in its first or simple state
{§ 5. etseq.), is not infrequently caused by some
other disease. Many of the authors of the last two
centuries, and several contemporary Continental
writers, have treated of colic when thus originat-
ing or associated as essential forms of the com-
plaint. Although obviously only a symptom, or,
at most, a part, of an important and often exten-
sive disease, it is not the less deserving of notice
when thus associated. It cannot be a matter of
surprise, when we consider the relations subsisting
between the difl^erent abdominal viscera, by means
of the ganglial system of nerves distributed to
them and influencing their functions, that disease
of one of these will often change the sensibility
and functions of the alimentary canal, with which
it is more or less intimately connected in respect
both of organisation and function. As it is use-
ful to be aware of the various morbid associations
of colic, I shall notice such as are most commonly
met with in practice, with reference to the author-
ities who have considered them as distinct forms
of the disease.

42. A. Sennert, Kindler, Walter, Dethard-
iN'o, Boxz, TissoT, Sauvaoes, and Sciimidtmanx,
liave noticed an iiiJiammaUiry colic ; which, how-
ever, in no respect differs from inflammation of
the bowels either in an acute, sub-acute, or
chronic form. Colic often rapidly passes into
enteritis, and occasionally into dysentery ; and
chiefly from this circumstance, together with the
more phlogistic nature of the attack, and the
abdominal tenderness, Cullen and Goon also
have distinguished a variety of the disease by the
term inflammatory. In maay cases, also, of
chronic, sub-acute, or septic peritonitis, the mus-
cular tunics of the intestines are paralysed, and
their canal distended by flatus ; the coliclcy
symptoms predominating over and masking tlie
inflammatory action. Hence chronic peritonitis
has been often confounded with colic, as I demon-
strated in a memoir on that disease, published
many years ago : but, in such cases, the colic is
merely a symptom.

43. B. HoFF.MANN and Schmidtmann have
distinguished a species of colic by the term
plethorica nr sniiguinea, comprising under it the
varieties arising — a. from pregnancy ; — b. from
difficult or suppressed menstruation (the Colica
Menstrualis of various- writers) — c. from sup-
pression of the lochia; — d~. kom congestion or

Iwidtitis of Aluerti, Hom-mann, jS'ezel, RANois,
and Rave). That colic is often associated with
these afl'ections, or is occasioned by them, there
can be no doubt ; but it is unnecessary to dignify
these varied states of disorder by arranging ti)em
as distinct forms of this disease. It is sufficient
to notice them, so as to inform the inexperitnced
practitioner as to their occasional occurrence, and
the importance of attending to the connection in
practice ; more particularly as they require a
modified treatment for their removal.

44. C. Colic also frequently is an attendant
upon acute, sub-acute, and chronic diseases of
the liver, gall-bladder, and ducts; and, more es-
pecially, upon the pa:!sage of gall-stones through
the common duct. In such cases, the colic is not
infrequently associated with jaundice. This con-
nection of the complaint has been fully illus-
trated by Baillou,Vocel,Lieutaud,Prochaska,
Soemmerring, Wandeler, Witting, Conradi,
&c. and should not be overlooked. (See art.
Concretions — Biliary.) In such cases, the
fixed pain in the right epigastrium and hypo-
chondrium, extending to the back, and right
shoulder-blade or shoulder, in addition to the
abdominal colicky pains, vomiting, and costive-
ness, with or without jaundice, will assist the
diagnosis. Some authors have likewise noticed
the connection between colic and disease of the
pancreas. That the latter will sometimes occasion
the former cannot be doubted : but the difficulty
of ascertaining the connection during lite is great ;
more particularly as functional disorder of the
duodenum, so generally present in almost all
cases of colic, is readily mistaken for disease of
the pancreas. (See arts. DuodenuxM and Pan-
creas.)

45. D. The occasional dependence of colicky
afl^ectionsupon inflammation or other morbid states
of the kidney, and upon the irritation of calculi
in this organ, its pelvis, or ureter, has been long
known. Such complications have occurred to
every practitioner, and have been particularly no-
ticed by HoRSTivs, jMartius, Piso, Freytag,
and Cruchet : they are most frequently met
with in gouty and dyspeptic subjects, and persons
advanced in life.

46. E. — a. The frequent and obvious connection
of colicky affections with worms, particularly in
children and young persons, requires no further
remark than that, although the former is merely
a symptom of the latter, both obviously originate
in debility of the digestive functions. — b. The
occurrence of colic in the gouty and rheumatic
diathesis, during the more erratic and irregular
forms of these aflTections, and after the disappear-
ance or retrocession of them from an external
part, has been so often observed, that many
systematic writers have particularised a Colica
Arthritica (Hoffmann, IMusorave, Stole, Bang,
Brandis, Reich, Schmidtmann, &c.), and a
C. Rheumatica (Haller, Stole, Eyerel, Len-
TiN, IvANoii, Thorn, &c.). — c. The frequent
ap[)earance, also, of this affection in hysterical
females, or associated with liysleria, is well known,
and chiefly deserving of notice as respects the
treatment : the intimate connection of both
disorders with morbid sensibility of the organic
nerves, and increased mobility of muscular parts

B b

370

COLIC AND ILEUS — Eem ARKS on their Pathology.

influenced by them, and the not infrequent de-
pendence of them both on congestion of the
uterine organs, are too obvious to require illus-
tration.— d. Flatulent colic is often consequent
upon, and complicated witii, asthma and bron-
chorrluva ; owing to the impeded function of
respiration in these diseases, and the discharge
of gaseous fluids from the blood by the diges-
tive mucous surface ; and, when it occurs in
such cases, it aggravates the original com-
plaint.— e. The only other complication of colic,
which may be mentioned, is its occurrence with,
or even after the disappearance of, eruptive com-
plaints, and in connection with scortmlic and
chronic affections of the skin. This association
has been noticed by Haller, Sigaud i.a Fond,
ScHMiDTMANN, and others ; and has been termed
by some writers, CoUca Metastatica. It is pro-
bable that, in such cases, a sub-acute or chronic
inflammation of some part of the intestines takes
place consecutively of the primary aftection, the
colic being merely a symptom of the inflammatory
state. But we should recollect that, in all affec-
tions of the skin, the digestive mucous surface
is more or less irritated or otherwise affected,
and the allied functions disordered ; and that an
increase of such disorders may both change the
state of the cutaneous eruption, and give rise to
severe colic.

47. IV. General Remarks onthePathology
OF Colic and Ileus. — A. The remote caiises of
colic. Many of these have been particularised
when describing the different forms of the dis-
ease ; a few only require to be enumerated. The
more common of these are cold applied to the
abdomen, loins, or feet; exposing the back to the
strong heat of a fire ; acrid, cold, indigestible
esculents; cold fluids taken when the body is over-
heated ; solid bodies accidentally or otiierwise
taken, that admit not of change or solution by the
juices in the prima via ; irritating or poisonous sub-
stances, and the injudicious use of acrid or drastic
purgatives, particularly hellebore, scammony,and
colocynth : the violent passions and emotions of
the mind, as te/ror, anger, &c. (See § 12. elcet.)

48. B. Remarks as to diagnosis and prognosis.
—An important point connected with the nature
of the disease, and one which Dr. Aisercrombie
appears to have fully made out, is the fact of its
sometimes being fatal with no other morbid ap-
pearance than great and uniform distension of
the bowels. — a. There can be no doubt that this
state will of itself — without any inflammatory
action — give rise to tenderness and tension of the
abdomen, and thus simulate inflammation, with
which, however, it is very often accompanied ;
and into which sudden distension of the bowels
is very apt to terminate. — b. Although iletis is
generally the result of obstruction of the canal of
the bowels, it is not necessarily so: for in fatal
cases of both Madrid and lead colic, as well as in
several of ileus itself, recorded by Dr. Aheu-
CROMBiE and other authors already referred to, no
obstruction was found on dissection. 'J'iic cases
recorded by BAmiiEZ and Maxwell also show
the propriety of not losing sight of this fact in the
treatment of the disease. — c. Sudden cessation of
pain, and sinking of the vital energies, are not
necessarily evidence of the accession of gangrene ;
for they have occurred in fatal cases of colic and
ileus, where no inflammatory action and no gan-

grene were detected ; and, in some few instances,
recovery has followed ; and, on the other hand,
as Dr. Abercrombie has remarked, extensive
gangrene has been observed in cases where
the pain was violent to the last. These facts
confirm an opinion which I had given many
years since, that the symptoms often referred
to internal gangrene do not prove its accession,
but the exhaustion of vital power, and of the
sensibility of the organic nervous system ; and
that a great proportion of the inslar^ces of sphace-
lation found upon dissection did not exist pre-
vious to dissolution, but accompanied or followed
the fatal issue. — d. The pulse is often a most fal-
lacious guide in every form of colic and ileus ;
fatal cases sometimes occur, in which the pulse,
till within a few hours of dissolution, does not
rise above the natural frequency ; and in some
cases in which there is no inflammatory action,
the pulse is frequent throughout. — e. Although
fa;culent evacuations are amongst the most fa-
vourable indications in the disease, they are
not to be implicitly relied upon ; for, when the
disease is in the small intestines, much faeculent
matter may have accumulated in the caecum
and colon, which may be brought away by in-
jections without the affected part being benefited.
The subsidence of the more urgent symptoms aftec
the discharge of faeculent motions is the only sure
ground of a favourable prognosis. — /. Though
the organic changes I have enumerated (§ 37.),
often produce colic or ileus, they do not necessa-
rily do so; for gradual exhaustion of the organic
functions, and of life itself, without colic, may
be the result. They may also exist for a long
time, without sensibly interrupting the functions
of the bowels, until some concurrent-or determin-
ing cause occurs, and suddenly developes the
disease in its worst forms. — g. The existence of
spasm in some part of the intestines, so much in-
sisted upon by writers as the cause of various
states of simple, INIadrid, and lead colic, as well
as of volvulus, is evidently of less frequent occur-
rence than is supposed. Although I would by no
means disallow its existence, and cannot admit,
with Dr. Abercrombie, that the cord-like con-
striction of a portion of intestines frequently
observed is its natural state, as in the case of the
urinary bladder, yet it must be admitted that
several symptoms, which have usually been re-
ferred to spasm, are actually owing to flatulent
dilatation. Spasmodic constriction, however,
evidently exists ; for, independently of the occa-
sional detection, alter death, of a more constricted
slate of a part of a bowel than can be considered
natural, we cannot explain various phenomena
connected with colic and volvulus without its
aid. Besides, its existence is supported by
analogical evidence ; for it is a principle in the
human economy, that all membranous, and, «
fortiori, all muscular, canals contract spasmodi-
cally or inordinately u[)on irritation of their inter-
nal surfaces. — //. In lead colic, the last or more
dangerous symptoms, whether of the complete
form of ileus or not, are certainly more unequivo-
cally attended with inordinate distension, parti-
cularly of the colon, than with constriction, even
although the spliinrler ani may be at the time
s])asmodically contracted. — /. From the foregoing
facts, the reader may infer that the diagnosis be-
tween colic and inflammation cannot be stated with

COLIC — Treatment of its Simpie States

precision, as there is no one symptom that can be
relied upon, — for inflammation witli its conse-

371

quences may exist, and yet the abdomen may not
be painful on pressure. But it is from the man-
ner of their association, and, still more, upon
numerous minute circumstances, — some not ad-
mitting of satisfuctory description, others of only
casual occurrence, — and upon the age, employ-
ment, constitution, and habits of the patient, as
well as from the operation of remedies, tiuit we
are to form our inferences both as to the diagno-
sis, and as to the result.

49. V. Treatment of the different Species
AND Vahieties of Colic. — i. Or the Colic
depending chiefly on functional Disordlr.
As soon as a practitioner sees a patient in colic,
his hrst object is to ascertain whether or not
there be strangulated or incarcerated hernia, or
either tension, tumefaction, or retraction, of the
abdomen, or circumscribed tumour or hardness
in any part of it, or in its immediate vicinity. By
the knowledge thus acquired, as well as by the
information he may derive as to tiie cause and
history of the complaint, he will be much assisted
in devising an appropriate mode of cure.

50.^4. Treatment of tlie simple forms of colic
(j 5.). — We have seen that these states of colic
chiefly depend upon debility, or deficient vital
energy of the alimentary canal, giving rise to
altered sensibility of the organic nerves supplying
it, to imperfect or irregular action of its muscular
coat, and to interrupted or morbid secretion from
its mucous surface and associated viscera. These
states of disorder are to be removed, 1st, by
anodynes combined with stimulants and cordials,
which will generally calm the more urgent
symptoms ; 2d, by purgatives and enemata
directed so as to excite the secretions, and
evacuate retained excretions ; and, 3d, by gentle
tonics and cordials, in order to remove debility
and promote the digestive actions ; all the causes
litcely to reproduce the disease being carefully
avoided.

51. a. Such stimulants as are most antispas-
modic, and carminative in their action, judiciously
combined with anodynes, and assisted in their
operation by frictions of the abdomen with suit-
able sedative liniments, or by fomentations, may
be first employed. Formula; "l78. 187. 211. ;J77.
835. in the Appendix, or the following, will gene-
rally remove the painful symptoms: —

No. 133. R Aq. Mentha; Virid. 5x. ; Spirit. Pimento
(vel Sp. Anisi) .ij. ; Tinct. llyoscyami 3 ss. ; Conl'ect.
Opii gr. X. i\l. Fiat Haustus statim sumendns. Or,

No. 134. R Aq. Pimentie 3 x. ;Tinct. CamphoiEe Comp.
.3js5. ; Spirit. Myristic£B, Spir. Carui, aa 3 ss. ; Confect.
Aromat. gr. x. Fiat Haustus statim capiendus, et jjro re
nata repetendus.

No. 135. ti Camphorae rasas 3 j.; tere cum Ol. Amygdal.
.5 ss., et adde Ol. Lini 3 j- ; Tinct. Opii 3 ij. ; 01. Roris-
marini 3 ss. M. Fiat Linimentum, cum quo illiiiatur
abdomen assidue urgente flatu aut dolore.

If the simple colic evince nervotis or hysterical
characters, the preparations of valerian, the spirit,
amnion, foetid., &:c. may be given or added to the
above. If these afford not immediate relief, it will
be more judicious to have recourse to laxative,
oleaginous, and antispasmodic enemata, than to
pe-rsist in their exhibition. Any of the formula
in the Appendix suitable to the circumstances of
the case may be directed ; or the warm balsams,
assafcetida, the terebiiithinates, the oil or extract
of rue, and infusion of valerian, may be employed

in this manner, along with the oleum olivEe, or
oleum lini, or any demulcent decoction. When
the complaint assumes ihejiatulent form, the warm
spices, or their oils, triturated with magnesia or
sugar, may be prescribed, or added to the above
formulae.

52. b. Having relieved the more urgent symp-
toms in this way, — an indication the more requi-
site in the spasiuodic slate (^ 9.) of simple colic,
and often requiring a freer use of the narcotics
and antispasmodics than is specified above, — it
will be necessary to act upon the bowels by pur-
gatives given by the mouth. In most cases, a
full dose of calomel, or of blue pill, is least likely
to offend the stomach, whilst it is the most bene-
ficial in its operation upon the suspended secre-
tions ; it will be advantageously followed in a few
hours by a dose of castor oil, with a few drops of
tinct. opii. or tinct. hyoscyami ; or by the decoc-
tum aloes comp. with the carbonate of soda, the
tinct. of hyoscyamus and compound tincture of
cardamoms, either of which may be repeated, if
necessary, and its operation promoted by the ene-
mata already particularised.

53. c. Having evacuated the bowels, the next
object is to restore the energy of the digestive or-
gans, and to promote the abdominal secretions.
This may be done by a course of mineral waters,
as the Harrogate, the Tunbridge, the Bath, the
chalybeate Cheltenham waters, or the artificial
waters of Pyrmont, Carlsbad, Ems, &:c., and by
a judicious combination of gentle tonics with lax-
atives and the alkaline carbonates, according to
the peculiarities of the case; the blue pill, or
Plummer's pill, with soap, being also occasionally
given at bed-time. Sydenham recommended the
Peruvian balsam, to restore the digestive functions,
and prevent a return of the disorder ; and cer-
tainly there are few substances better suited for
the purpose than it, when judiciously exhibited,
or combined with other medicines.

54. If we find the foregoing means fail of af-
fording very marked relief, we should suspect
either some degree of latent inflammatory action
or a disposition of the complaint to pass into this
state ; and unfortunately inflammation of the
bowels may proceed to a dangerous extent, with-
out either the state of the skin, or of the pulse —
without any febrile symptom — indicating its ex-
istence. This topic should not be overlooked by
the young practitioner. Morgagni, Riverius,
SiMsoN, De Haen, Burseri, Schmidtmann, and
Abercrombie, have demonstrated — and my ex-
perience has frequently confirmed their observa-
tions— not only that enteritis will often assume,
during the greater part of its progress, all the
symptoms of simple colic, but that the complaint
may run its course, until the sudden cessation of
the painful symptoms, without any evident cause,
furnishes the first evidence both of pre-existing
inflammation and of incipient gangrene. On this
and other accounts, therefore, we should endea-
vour, in all the states of this ^■ariety of colic, to
ascertain the existence or non-existence of in-
flammatory action, or even vascular erethysm in
some part of the alimentary canal. If this dis-
oider exist, the tongue will general be red at its
point or sides, and furred or loaded in the middle ;
the urine will be small in quantity, or hi«h-
coloured; cardialgia will sometimes be com-
plained of; and if tenderness on pressure be felt,

B b 2

372

COLIC — Treatment of Bilious, &c.

it will either be independent of any marked dis-
tension of the abdomen, or it vvill be attended
•with tension and fulness, anxiety, a dark or dusky
appearance about the eyes and mouth, and with
thirst. Under these circumstances especially,
and in the more severe attacks, particularly in
the spasmodic, occurring in persons previously in
health, blocd-letting should not be omitted ; and
even in doubtful cases, blood may be taken
either from the arm, or from the abdomen by
cupping or leeches, followed by fomentations
and poultices, — if there be tumefaction, by the
warm turpentine fomentation and injection.
Heating carminatives and antispasmodics will be
injurious in all such cases, whether vomiting be
present or not ; and too active endeavours to
procure alvine evacuations by means of purga-
tives given by the mouth may increase the dis-
order. I have derived more advantage in these
cases from small and repeated doses of the car-
bonate of soda, or the biborate of soda, with nitre,
in camphor mixture or some aromatic water —
from the use of enemata and gentle frictions of
the surface of the abdomen with a rubefacient
liniment (F. 311. 313.) — than from purgatives.
In a few cases I have given the hydrocyanic acid,
either in full doses of the oleum ricini, or in the
oleum amygdal. dulcis. When judiciously pre-
scribed, tliis powerful sedative has a most benefi-
cial effect in restoring the digestive functions after
the attack is removed. The iiydrargyrum cum
creta, or the blue pill, with taraxacum, hyoscya-
mus, or extract of hop, may also be given after
the action of the bowels is restored.

55. B. Treatment of colic from injurious in-
gesta, 6\c. (§ 10,) — a. The state of disorder
proceeding from cold acid beverages will gene-
rally be soon removed by antacids, combined
with narcotics, as ammonia, soda, magnesia, &c.
given with opium, or hyoscyamus, and with cor-
dials or carminatives (F. 179.347, 348.); enemata
and frictions of the abdomen, as already recom-
mended ($ 51.) may he also employed, according
to the circumstances of the case. — h. When the
aflPection is occasioned by cold, acerb, or indiges-
tible fruit or food, it will generally be necessary
to commence the treatment by an active warm
emetic ; and afterwards cordials, cardiacs, and
enemata (§ 51, 52.), rnay be prescribed. — c. If
the complaint be produced by fish, Cayenne
pepper is an almost unfaihng antidote. — d. If it
be occasioned by smoked or tainted meat, or
other esculents that have disagreed with the di-
gestive organs, emetics, and afterwards cordials,
warm aromatics, and stimulating clysters, with
frictions of the abdomen, are among the most
successful means. — e. Colic sometimes is a conse-
quence of indigestion, and of acidity or sordesin the
digestive tube, often occasioned by too much or
indigestible food ; it then rc(|uires a combination
of antacids witii aperients or purgatives, as the
compound decoction of aloes, or the compound
infusions of gentian and senna, with soda and am-
monia. After the urgent symptoms are removed,
the digestive functions should he strengthened and
promoted by gentle tonics and deobstrucnt laxa-
tives (F. 214. 218. 3G2. 872.). KicnTEn recom-
niends for this purpose er|ual parts of assafa'.tida
and the_yb/ laiiri (;(j>/»'ss«(?t/«, especially in the form
of the couiplaiiit procc.'eding from acidity.

56, The culic if infants has been stated to

proceed chiefly from acidity of the prima via oc-
casioned by the quality or quantity of the ingesta
(§ 15.). The carbonates of the alkalies, mag-
nesia, and the preparations of chalk or lime, with
carminatives and cordials, are therefore required.
(See F. 616 633.). A combination of magnesia
with the oxide of zinc is prescribed by RrcHXER.
Magnesia, soda, or ammonia, in the aqua foeni-
culi dulcis or aq. anisi, and ai'terwards a dose of
fresh castor oil; the semicupium, and, if it be re-
quisite, an emollient or oleaginous enema, to which
a little extractum rutae, oleum anisi, or linctura as-
safoetidffi, has been added, will generally remove
all disorder. If, however, these do not soon give
relief, the enema sho\ild be repeated, and the
abdomen rubbed with an antispasmodic lini-
ment (§ 51, R 135.). If the complaint occur
about the period of dentition, the gums ought
to be examined, and scarified, if any fulness
or redness be remarked in them. If these
means fail, those recommended in the section
on voh-ulus {§ 77. et seq.) must be put in
practice.

57. C Treatment of colic from morliid secretion,
(Sj"c. — a. The colic occurring in 7tew-born infants,
from retention of the meconium, is generally soon
removed by a dose of castor oil ; and, if it fail,
by an oleagmous clyster, or by one containing a
tea-spoonful of honev and another of common
salt, assisted by the semicupium, and the means
stated above (§56.). — b. CoVic (rom accumula-
tion offucal matters (§ 19.), or from constipation
of the bowels, obviously requires purgatives
and oleaginous or saponaceous injections. Stoll
prescribed emetics in this form of the complaint,
and was followed in the practice by Sims and
HosACK ; RivEiiius gave rhubarb and the tur-
pentines ; and B.\glivi and Sydenham advised
cathartics and anodynes in oleaginous emulsions.
The preparations of sulphur, in doses sufficient
to act on the bowels, have been praised by
AonicoLA and Rave ; and frictions and bandages
of the abdomen have been recommended by
many eminent writers. In this form of the
disease, more advantages will be obtained from
the repeated exhibition of medicines of a simply
relaxing operation (see F. 82. 96. 430.), assisted
by large oleaginous and saponaceous injections
in the manner recommended by Dr. Maxwell
(see § 77.), than by cathartics, which may irri-
tate or inflame the upper parts of the digestive
canal, before they can reach or affect the parts
where obstruction exists. Spirits of turpentine,
with olive or castor oil, when perfectly difl'used
and suspended in a suitable vehicle, are ex-
tremely efficacious in this state of disorder. An
ounce of the spirits, with two or three of either
of these oils, in about sixteen or twenty-four
ounces of a mucilaginous decoction, should be
slowly but steadily thrown up by means of the
enema apparatus, the pipe of which may be pro-
vided with a guard, to prevent the regurgitation
of the fluid. In order to facilitate the passage
of this enema along the colon, tiie patient may
be placed in bed, with the pelvis considerably
elevated, and friction of the abdomen may be
employed during and after the injection of it.
If there be no nausea, the following may be
taken, and repeated in six or eight hours, if it be
requisite : —
No. J3G. R Potassx Uitart. in pulv. 5jss — 5ij. ; Mag-

nesiEB Calcinata; 3 ss, ; Confect. Sennaj et Syrupi Zin-
giberisaa 3 ij.; Olei Anisi 111 iij. M. Fiat Electuarium.

If nausea be complaineJ of, a full dose of ca-
lomel only may be exhibited ; and, after a few
hours, the above electuary given, and the injec-
tion repeated ; or the treatment recommended in
the article Constipation may be adopted. If
tenderness and tension of the abdomen, with
hard, constricted, oppressed, or quick pulse, be
present, inflammation should be suspected, par-
ticularly if vomiting also exist. In this case
blood-letting must be practised, and the disease
treated in ail respects as stated in the articles on
Ii)Jiammation o/' f/ie Intestines and Peritoneum.

58. D. The West Indian and Madrid colics
(§ 20.). — a Dr. RIusGRAvE, whose experience
of West India colic has been extensive, recom-
mends ten or fifteen grains of calomel to be
exhibited immediately, and afterwards five grains
combined with a cathartic, lie likewise advises
a dose of a purgative mixture to be given in the
intervals, if tlie stomach will retain it. The in-
tentions this physician proposes are to evacuate
the bowels, and to affect the system with mer-
cury. As soon as the mouth becomes affected,
the calomel should be omitted, and alvine dis-
charges promoted. When the spasmodic action
of the bowels is severe, and signs of vascular
excitement appear, blood-letting ought to be prac-
tised ; this evacuation tending both to relax the
bowels, and to promote the absorption of the calo-
mel. In addition to these means, the warm bath,
and terebiuthinate enemata, should be employed.

59. b. The Madrid colic (§ 20.).— M. Mar-
QUAND states that an emetic given at the very
commencement of the attack is sometimes of use,
by evacuating retained bile ; but that it may be
prejudicial, particularly if exiiibited in an ad-
vanced period of the complaint. He recom-
mends as the safest and most successful practice,
1st, to calm existing irritation by opiates; and
2d, to restore alvine evacuations. He prescribes
a grain of opium every three hours till relief is
obtained, which is usually the case after the
third or fourth dose. He afterwards exhibits
purgatives, and promotes their operation by glys-
ters, which generally bring away copious black-
ish and offensive stools. The Spanish physicians
have commonly recourse to the oleum ricini as a
purgative in this complaint, but M. Marquand
prefers scammony and jalap, as being, in his judg-
ment, more certain and quick in their operation.
This treatment is the same as that long since
recommended by I\Ir. Quier, in the dry belly-
ache of the West Indies.

60. E, Treatment of lead cgUc (§ 25.). — In
this variety of the complaint, as well as in those
forms which have received the denomination of
Madrid, West Indian, or hepatic colic, the
hepatic ducts and gall-bladder are obviously ob-
structed or loaded by morbid bile ; the irritation
caused by v/hich most probably occasions spasm
of the common duct, duodenum, and parts in
the vicinity in the early stages of the disease.
Very different, and even opposite, modes of
treatment have been recommended in lead colic.
— a. Blood-letting has been directed by Calmette,
AsTRUc, CiiRisTisoN, and Gregory; whilst
other writers, as Duboise and Dufresne, have
considered it either unnecessary or injurious. I
have prescribed it in some cases with manifest

COLIC FROM LEAD — Treatment of, 373

advantage, the state ofvascular action evidently
mdicating the propriety of resorting to it ; but, iu
others that I have seen, it obviously would have
been injurious. When the face is flushed, the
skin hot, and the pulse full or accelerated, it is
both safe and requisite. — /'. The use of opium
has the support of the ablest writers on the dis-
ease— of CJrashuis, Riedlin, Stoi.l, Schlegel,
Reynolds, Baker, Adair, Eyeuel, Warren,
Wolff, De Haen, and Gendron ; but they
are not agreed as to the period of exhibiting it.
Sir G. Baker commenced with purgatives, whilst
De IIaen, Darivin, Warren, and Bateman
began with opium, and gave purgatives after-
wards. Dr. Pemberton advised a combination
of both — of laudanum with castor oil. It ap-
pears to me preferable to combine the first dose
or two of opium with calomel, as recommended
by Burger, particularly if the functions of the
liver be obviously affected, as they often are, and
if the stomach be irritable, as it generally is in
the advanced state of the disease. But the dose
of calomel should be large (from 10 to 20 grains),
and not repeated oftener than once or twice.
This combination will frequently of itself open
the bowels ; but whether it does so or not, pur-
gatives ought to be exhibited, and their operation
promoted.

61. c. As to the propriety of having recourse
to this class of medicines, there is no difference
of opinion, however much sentiments may vary
as to the choice which should be made of them.
Grashuis, MosELY, f isciiER, Fuiese and Odieh
jirefer the oleum ricini. Burger advises it to be
given with manna; Eyerel, after blood-letting,
with emollients and opium ; andTissoT in clysters.
Several writers prefer the combination of anti-
spasmodics and sedatives with purgatives, on the
supposition, that the obstruction of the bowels
attendant on the disease arises from spasm in
some part of them. But, as Dr. Ciilyne and
Dr. Abercrombie have justly contended, it is
quite as much ov.'ing to distension, from a para-
lytic state of the muscular coat,, that the obstruc-
tion occurs, as to spasmodic constriction. Ac-
cording to this view, little benefit can result, as
respects the operation of cathartics, from com-
bining them with antispasmodic anodynes, unless
with such as may stimulate the intestinal canal ;
and, in fact, such seems to be the result of ob-
servation. Some writers, conceiving that lead
colic may arise from the presence of the acetate
or the oxide of lead in the prima via, have recom-
mended the sulphate of magnesia with the view
of forming an insoluble sulphate of lead. The
experiments and views of Orfila, Good, and
Dr. Paris, seem to favour the employment of
this sulphate as well as the sulphate of alumina,
exhibited with an excess of acid, or in the com-
pound infusion of roses ; and certainly unequivo-
cal benefit results from the practice. But whether
that benefit arises from reducing the lead to an
insoluble salt, or from the operation of the sul-
phates in exciting the action of the partially
paralysed muscular coat of the bowels, and
thereby enabling them to expel retained matters
of a morbid or noxious description, cannot readily
be determined. We have no evidence of the
existence of lead in the prima via to an extent
that admits of detection, nor has the formation of
a sulphate of lead been demonstrated. I am
Bb3

S74

COLIC FROM LEAD — Treatment OF.

therefore inclined to adopt the other mode of I efficacious. The sw/p/iate 0/ sine was recommended
explaining the operation of these salts. I have • ^ ^'
found the croton oil an excellent purgative in this
disease, particularly when it is added to either
castor oil or the oil of ttiypentine, or to both. I
have in one or two cases caused the croton oil to
be rubbed over the abdomen in this species of
colic, with the hopes that it might act upon the
bowels ; but I did not obtain this effect. The
quick irritation of the skin, however, that it
produced, evidently proved salutary. Sulphuy
and its preparations, as well as sulphureous
waters have been prescribed by Luzuriaga in
the Madrid colic, in which they are obviously
beneficial ; and subsequent writers, particularly
Garnett and Hahnemann, proceeding on the
erroneous opinion that the Madrid colic is iden-
tical with lead colic, have recommended them
also in the latter : but, as Orfi la has expressly
stated, they are most dangerous remedies in true
lead colic. A case demonstrative of this fact oc-
curred in my practice many years ago, and was
published in the London Medical Repository for
October 1822. The deleterious effects are there
ascribed to the absorption of sulphur, which was
taken by the patient, contrary to my advice, in
order to counteract the habitually costive state
of his bowels.

62. d. The sulphate of aluynina has been
given by some modern physicians, with the view
already stated (§61.) ; but with many its exhi-
bition has been altogether empirical. Grashuis,
QuARrN, Adair, Fischer, Schlegel, Lindt,
Percival, RIichaelis, Gebel, and Sommer
favour the use of it, either alone or with muci-
laginous and narcotic medicines. I believe that
its efficacy is much enhanced by giving it with
camphor, opium, and demulcents. Sciimidt-
MANN details a case, in which the exhibition of
two or three doses of alum produced a most
copious operation on the bowels, after the most
active purgatives had been given by the mouth,
and per annm without any effect. When re-
siding on the Continent in 1818 and 1819, I
saw many cases treated by this substance, given
in doses of from a scruple to two drachms in
gum-water, or with camphor and opium. M.
Kapei.er, in his hospital, into which many cases
of the disease are admitted, employed scarcely
any other medicine than alum dissolved in mu-
cilaginous decoctions, assisting its action by
oleaginous clysters. The worst cases, — those
with paralysis, loss of sight and healing, violent
cephalalgia, tremors of the muscles and limbs,
&c. were restored in a much shorter time by
this tiian by any other treatment, and with
much less disposition to relapse, or to pass into a
paralytic state. I have employed alum with
uniform success -n several cases, and combined
it with camphor, fJayenne pepper, and occasion-
ally with opium ; and have always found tliat,
when given in sufficient quantity, — from two to
four or five drachms in the twenty-four iiours,
and assisted by oleaginous clysters, — it will open
the bowels more certainly than any other medi-
cine. M. Genhrin has recently given alum in
fifty-eight cases of this disease, all of which re-
covered in from three to five days. He has also
found that a drachm, or a drachm and a half, of
sulphuric acid in the twenty-four hours, taken in

by Dr. ]Mosely, seemingly from considering its
operation analogous to that of alum ; and the
sulphate of copper was mentioned by HAnnisoN.
63. e. Mercury has been very generally pre-
scribed in this complaint, particularly by Clark,
Hunter, Warren, Biss, Burger, Ci. utter-
buck, and others ; but with very different views.
Some have given it simply as a cliologogue pur-
gative ; and others with the intention of pre-
venting the accession of paralytic symptoms ;
although it is by no means obvious how it can
have this latter effect, since these symptoms sel-
dom originate in structural change in any part of
the cerebro-spinal axis, when they occur during
or after lead colic. Those who have prescribed
the preparations of mercury with this latter
view, as Clark, Warren, and Biss, have
pushed it to the production of salivation ; but,
although 1 admit that salivation will speedily
alleviate the abdominal symptoms, yet I am of
opinion that it will rather favour than prevent
the accession of paralysis, the more especially
as I have observed this affection to follow, not-
withstanding the salivation which had been pro-
duced with the hopes of preventing it.

64. f. Besides the foregoing means, various
others have been recommended by writers on the
disease. Dr. Roberts has detailed two cases
in which the nitrate of silver was internally ex-
hibited with apparent benefit. Tobacco in variiius
forms has also been prescribed. Bartholi-
Nus was the first to employ this plant in the
treatment of colic, by directing its smoke to be
thrown up the rectum — one of the safest and most
beneficial modes of using tobacco internally. Dr.
Graves has derived much benefit from com-
presses moistened with a strong decoction of it,
applied over the abdomen ; and from croton oil
internally, assisted by clysters. Emetics have
been recommended by some writers ; but they
are required only after lead has been taken in
poisonous doses, or at the commencement of the
attack, when the biliary organs are loaded by
vitiated bile. They, however form a principal
part of the treatment usually adopted in the
Parisian hospitals. Cold and ivarm baths have
both been mentioned by writers as being some-
times of service ; but I consider the former at-
tended by some risk, and the latter seldom
required, although occasionally palliating the
more painful symptoms. The propriety of having
recourse to external irritation in this disease has
been admitted by many of the writers already
referred to, and blisters and various other means
of a similar kind have been adopted. In several
cases I iiave, however, found more advantage
from one of the liniments above recommended ;
or, if an irritating effect was desired in a short
time, I have obtained it from either increasing
the more irritating ingredients contained in these
liniments, or applying a cloth moistened with
one of them close to the abdomen. The hot
turpentine fomentation, or a few drops of croton
oil rubbed on the surface of the belly, will have
a similar effect; but the former of these, accom-
panied with suitable internal medicine, is the
most rapidly efficacious.

G5. g. The great number of cases of this dis-
ease admitted into the hospitals " La Chnrite"

three or four pints of water, is equally prompt and at Paris, and " Hotel Dieu " at Orleans, naturally

attracts attention to the plans of cure wliich are
there adopted ; but at neither of them is the treat-
ment so simple or so quickly beneficial as that
adopted by M. Kapeler, and already stated.
At La Charite the treatment consists chiefly of
emetics, purgatives, sudorifics, and opiates ; and
at several of the French hospitals large local
depletions are also employed. But the whole
plan of cure is generally complex and distressing
to the patient. ^I. IIanque, of the " Hotel-Dieii"
at Orleans, states, that of about 150 cases he
treated, he did not lose one. He commences with
the semicupium ; and afterwards applies on tiie
abdomen and loins a large plaster, consisting
chiefly of diachylon, conium plaster, campiior,
and the potassio-tartrate of antimony. This
is allowed to remain until pustules come out,
and the pained parts are rubbed with a liniment,
the active ingredient in which is the extract of
belladonna dissolved in sulphuric ether. He next
administers, once or twice daily, an enema with
four ounces of olive or almond oil, and twenty
drops of the aetherial tincture of belladoima in
tlie linseed decoction ; and prescribes, when tiie
sufferings are severe, small doses of the same tinc-
ture to be taken at the same time in a demulcent
mixture. This treatment is persisted in for three
or four days ; and if considerable relief has not
been obtained at the end of this time, castor oil
is given in small and repeated doses, the anodyne
liniment is assiduously employed, and the plaster
on the loins and abdomen is renewed, with an in-
creased quantity of camphor and potassio-tartrate
of antimony. Although this plan of cure appears
to be very successful, yet relapses are very fre-
quent after it.

66. h. The treatment adopted by the Author in
lead colic is directed with the views, 1st, of re-
lieving the sufferings of the patient; 2d, of eva-
cuating the retained secretions, which are always
remarkably morbid, and apparently the cause of
the phenomena constituting liie fully developed
disease ; and, 3d, of imparting energy to the
weakened nerves, and parts that they supply.
In fulfilling these intentions, the practitioner is
often placed in a practical dilemma, from the cir-
cumstance of the medicine, which is most to be
depended upon in relieving some of the most
urgent symptoms, and enabling the liver to throw
off the load of morbid secretions which oppress
it, having the effect, in some constitutions espe-
cially, of increasing the exhaustion of nervous
power, and the tremors and paralysis attendant
on the worst forms of the complaint. Calomel,
in a large dose, either alone or vvith opium, has an
excellent effect in allaying the distressing irrita-
bility of stomach, and carrying the biliary and
other morbid secretions downwards : but if it be
repeated in such quantity oftener than once, or
if free evacuations be not procured soon after
its administration, it is apt to aflfect the mouth,
and to prolong the period of convalescence. I
have therefore endeavoured to procure from it a
soothing effect on the stomach, along with its
chologogue operation, guarding against its se-
condary action on the system ; and have pre-
scribed from ten to twenty grains in a bolus, with
about ten grains of rri/»;)/ior, and sometimes with
two of opium. This will generally allay the
retchings, and enable the stomach to retain the
medicine next to be given. About three or four

COLIC FROM LEAD — Treatment of. 37^^

hours after the above has been taken, a draut^ht,
consisting of half an ounce each of castor o// and
oil of turpeniiiie, with one or two drops of croton
oil, on the surface of aqua piraentae, is admin-
istered, and its operation on the bowels promoted
by a clyster composed of about four ounces of olive
oil, or two of castor oil, one of turpentine, half an
ounce of sulphate of magnesia, and from ten to
twenty ounces of the decoction of linseed, or of
marshmallows. This enema should be steadily
thrown up by the improved apparatus. Whilst
this treatment is proceeding, a liniment may be
assiduously rubbed on the abdomen, and on the
limbs, if much pain be felt in them; or a piece
of flannel, charged with one of these liniments
(F. 297. 307., &c.), may be closely applied over
the belly. If these means procure evacuations,
recovery will soon follow; but if the draught
be thrown oft" the stomach, or the injection be
returned without effect, they should nevertheless
be repeated. If the abdomen be much distended,
and painful on pressure, the hot turpentine fo-
mentation ought to be applied, as long as the
patient can endure it, instead of the liniment.
These measures will seldom fail of procurino- most
copious evacuations, which should be promoted
by sulphate of magnesia and spiritus eether.
sulph. comp. in the compound infusion of roses;
and by oleaginous clysters with camphor or assa-
fcetida, and oil of linseed. After two or three
doses of sulphate of magnesia have been given,
the following draught may be exhibited, and re-
peated frequently ; the action of the bowels beino-
promoted by the enema.

No. 137. R C'amphorae rasa; gr. iij — vj.; tere cum Mu-
cilag. Acacias 3ss,et Aq. Pimentae 3j. ; Sulph. Alumina
pulver. 3ss.; Spirit. Anisi 3 j. ; Syrupi Croci 3 ss. Misce.
Fiat Haustus, quarta vel quinta quaque hora sumendus,
prius agitata phiala.

No. 138. R. Terebintli.Venet. vel Comraun. 3vj 3j.;

Tinct. AssafcetidK 3 ss. (vel Ol. Anisi 5 j.); Olei 01iv»
.5 iij. ; tere cum Vitel. Ovi, et adde Decocti Malvae 3 xvj.,
in quo prius soluta erat Sulphatis Magnesiae 5 ss. — 3 j., et
fiat Enema.

67. i. The treatment of convalescence from lead
colic is of much importance, particularly when at-
tended with tremors, epilepsy, severe cephalalgia,
or paralysis. At first the alum and camphor
should be given for two or three days ; and the
action of the bowels promoted by oleaginous ene-
mata; the loins and abdomen being rubbed nio-jit
and morning, with one ef the liniments already
recommended. As there is a great tendency of
the disease to return, particularly when the pa-
tient follows the occupation which occasioned it,
the strictest attention should always be paid to the
state of the bowels, and the sulphates of magnesia
and alumina, with cojnpound infusion of roses,
and some aromatic spirit, be taken frequently ;
and, upon the first indication of obstruction, re-
course should be had to oleaginous clysters.

68. k. In order to remove the sequelte of the
disease, particularly the paralysis, the patient
should be allowed a generous diet, with exercise
in the open air ; and strychnine, or the extract of
nux vomica, with the aloes and myrrh pill, or F.
541. 565. may betaken twice or thrice daily. The
palsy arising from the poison of lead is much
benefited by this active medicine, as well as by
frictions with stimulating substances, by electricity,
and the use of splints along the fore-arm and hand
as recommended by Dr. Pejibeuton. The Bath
waters are very serviceable in promoting perfect

Bb4

376

COLIC AND ILEUS — Treatment of.

recovery, and preventing a relapse : with these i
views, the balsams, particularly the Canadian and
Peruvian, may also be taken, with the sulphates
of alumina and quinine, or with tonic extracts,
camphor, &c.; and, under every circumstance, the
digestive organs should be strengthened and the
action of the bowels promoted by tonics combined
with aperients and antispasmodics. I have ob-
tained marked advantage from strychnine thus
combined, as well as from several of the gum
resins, as ammoniacum, myrrh, assafoetida, and
galbanum, particularly when, besides the reduced
nervous and muscular power, the digestive func-
tions still continue to suffer. (For the prophii-
lactic treatment of this disease, see the article
AnTs AND Employments^ § 17 — 30.)

69. ii. Treatment of Colic caused chiefly
BY Change of Structure or Position'. — A. Of
colic from constriction of the hoicels. This state
of disease will not be benefited by purgatives or
carminatives ; but a judicious choice and com-
bination of aperients will often be of service.
In all cases of this description, due examination
jier anum should be instituted ; and as stricture
frequently occurs at the upper part of the rectum
and lower part of the sigmoid flexure of the
colon, a very long flexible bougie should be care-
fully introduced, as recommended by Dr. Willan.
When we have reason to suspect the existence of
stricture in any part of the colon, the use of
mucilaginous, saponaceous, or oleaginous enemata
should be long persisted in ; but the patient
ought to be very careful not to employ any oil
that is not perfectly sweet. At the same time,
the action of the bowels may be promoted by
an electuary composed of equal parts of the bi-
tartrate of potash and bi-borate of soda, with
confection of senna and common treacle, or either
the inspissated juice of the sambucus, or simple
syrup. I have seen advantage derived from
a plaster, consisting of the emplastrum picis
comp., the emplast. ammoniaci cum hydrargyro,
and either the extract, belladonnae or the extr.
conii, kept long applied over the abdomen.
When the stricture appears to be low in the colon,
and yet beyond the reach of a bougie, suppositories,
with either of these extracts and the lead plaster,
will be productive of some relief; and when
it can be reached by a bougie, the occasional
introduction of one will often permanently remedy
the disease.

70. Most of the cases of this complaint that I
have seen, have occurred in persons who had long
been in the habit of having recourse to purgatives,
consisting chiefly of calomel and colocynth, or
the compound extract of the latter — substances
which have a remarkable effect in irritating the
internal surface of the colon and rectum, and
constricting their muscular tunics. It is obvious
that a frerjueiit repetition of these medicines,
unless their effects be counteracted by emollient
clysters, will at last give rise to inflammatory
thickening of the panetes of the bowel, and con-
striction of its canal. In most of these cases,
also, there exists inflammatory action of the in-
ternal surface of the constricted pait, and of its
vicinity. Hence the advantage usually derived
from a cooling regimen, a spare or farinaceous diet,
and cQolirig gentle laxatives, assisted by soothing
und demulcent clysters, as the following : —

Ko. 139, IV Scmln. Foenicul. dulc, Scmin. Anisia a

contus. 5 ss. ; Fol. Malvae et Flor. Anthem, aa 3 vj. ;

AquEE Ojss. Coque ad Oj. ; dein cxprime et adde liq.

expressoOlei Olivae, vet. Ol. Lini, 5iij.; Potassae Tartar.

et Bi-boratis Sodje aa 3j. — 5ij. Misce et fiat Enema,

pro re nata injiciendum.

No. 1411. R Extr. llyoscyami 3ij.; Camphora rasae

gr. vj. — X. ; Sodae Sesqui.carbon. vel Bi-boratis 3 jss. —

3 ijss. PotassK Nitratis 3 ss. ; tere cum Mucilag. Acaciae

3vj., et adde Decocti Papaveris 5 x. — xx. Misce et fiat

Enema.

No. 141. R Extr. Belladonnas gr. iij.— vj. ; tere curn

Decocti Cydonise (vel Decocti Althaae, vel Dec. Hordei

C(imp.) S xij. — xvj. ; et adde Potassae Carbon. 3j. ;

Potassai Nitratis 3 j. Misce pro Enemate.

71. B. Treatment of Ileus. — The importance

of ascertaining, previously to the adoption of a

plan of treatment in this state of the disease, the

existence of hernia, has been already noticed ;

but the young practitioner should be aware that
hernia may exist without the patient being aware
of it ; and the real state of the case may be mis-
taken, owing to the absence of any tumour, so
very small a portion of the side of the bowel
being strangulated as not even to obstruct its
canal. I have twice or thrice — once in one of
my servants — met with such cases, in consult-
ation with eminent surgeons, where the exact
state of parts was inferred, and a successful
treatment pursued. There are certain forms of
the disease which may be briefly characteiised,
as they require a very different treatment: —
1st, Great distension of the abdomen, with dif-
fuse, but not acute, tenderness ; obstinate costive-
ness ; retchings, particularly when substances
are taken into the stomach ; anxiety, and general
uneasiness : 2d, The above symptoms, with fixed
and severe pain, and great tenderness, felt in a
defined part of the abdomen, often about the re-
gion of the Cfficum : 3d, Violent attacks of tor-
mina, occurring in paroxysms, like the strong im-
pulse downwards from the action of a drastic
purge," — the action proceeding to a certain point
— there stopping, and becoming inverted, — fol-
lowed by vomiting, which soon becomes feculent
(Abercuoimeie) : and, 4th, Where the symptoms
of the third state are accompanied with tenesmus,
and the discharge of a small quantity of bloody
water or mucus, sometiines with indistinct or elon-
gated tumour, and the other signs already described
(§ 40.) as indicating invagination of the bowels.

72. In the frst of these the bowels are evi-
dently distended and inactive; — in the second,
they are probably in a similar state, owing to ob-
struction, stricture, or strangulation, with inflam-
mation, most frequently in the vicinity of the
crecum and its appendix; — in the third, there
are more evident signs of stricture or strangula-
tion ; but this may also be an advanced stage of
the second ; — and in ihefowth, the symptoms are
more strictly referrible to invagination ; although
this may also exist in the third of these states.

73. a. It is evident that the frst of these
states will very frequently be much benefited by
purf!;(itires, particulaily by a large dose of calo-
mel (from 10 to 20 grains), which will, either
alone orwith camphor and liyoscyamus, allay the
morbid action of the stomach, and move the
bowels, particularly if it be assisted by the hot
turpentine fomentation or epithem (§ 54.), and by
enemata (^ 57. 66.70.). In ca.ses where a full dose
of calomel only has been given, a dose of castor
oil, with ten or fifteen drops of laudanum, may fol-
low it in one or two hours ; and an injection with
three times the quantity of the same medicines
may afterwards be thrown up. In some instances

COLIC AND ILEUS — Treatment or.

377

equal quantities of castor oil and turpentine may i
be given soon after the calomel. After the irrita-
bility of the stomach has subsided, the action of
the bowels may be promoted by small doses, I
frequently repeated, of the purified extract oj
aloes, with hyoscyamus, and a small quantity of
extract of gentian, which will promote its action.
Gai.lesky states that he has found recently ex-
pressed linseed oil, in the dose of a large spoon-
ful, with a few drops of the oil of aniseed, given
every hour or two hours, extremely beneficial.
If the first dose of calomel neither opens the
bowels nor allays tiie action of the stomach, it
may be combined with from one and a half to
three grains of pure opium, 'i'his will, in most
instances, settle the stomach and open the bowels,
particularly if it be soon followed by the fomenta-
tion and enema already advised.

74. b. The tendency of colic to lapse into a
latent or obscure state of inflammation has already
been noticed (§ 54.) ; and this tendency is the
greater, the more nearly the disease approaches
to ileus from its commencement. As colic in
every form is more especially an aflPection of the
muscular coats of the bowel, and as inflamma-
tion, when it supervenes, as it so frequently does,
upon colic, seems to attack this part especially,
and to terminate then more rapidly in gangrene
than when it originates in either the mucous or
peritoneal coats, so it becomes necessary to iiave
a prompt recourse to blood-letting, particularly
when rigors have occurred, and the pulse is op-
pressed or constricted, and the habit of body
plethoric or muscular. In such cases, blood-
letting should be full and decided, and, if neces-
sary repeated ; but it ought not to be trusted to
alone, or even mainly ; for if carried too far, or
employed too largely, or even at all in some cases
and states of constitution, or too late in the disease,
it may hasten a fatal termination. It is beneficial
chiefly in the second and third states of the malady,
especially when resorted to early, and followed by
local depletion, by calomel and opium, the warm
turpentine fomentation on the abdomen, and sub-
sequently by clysters (F. 144. 146, 147.). I be-
lieve, however, that in many cases, particularly
those commencing as flatulent colic, blood-letting
carried to the utmost extent will not of itself pre-
vent either gangrene from taking place, or faecu-
lent vomiting from coming on. For in these, and
in the frst state above specified, the muscular and
other coats seem to lose their vitality, without
almost any other mark of pre-existing inflamma-
tion, that I could observe in some cases on dis-
section, than change of colour. And yet, when
duly employed, particularly early in the other
states of the disease, blood-letting will often give
decided and immediate relief, and be quickly fol-
lowed by free evacuations and speedy recovery.

75. c. Opiates and other anodynes are most
important remedies in nearly all the states of the
disease, but especially in the second and third
particularised. The propriety of premising ge-
neral or local blood-letting, or both, when it is
clearly indicated, and the advantages of com-
bining opium or hyoscyamus, at first with a large
dose of calomel, or camphor, or both, have been
adverted to. These remedies will often of them-
selves produce free evacuations ; but in the states
of ileus now mentioned, purgatives given by the
mouth, unless of the mildest kind, or combined

as above (§52.), and exhibited subsequently to the
above remedies, are seldom of service. Appropriate
enemata, however, should not be omitted.

76. d. The tobacco injection is one of the most
generally adopted remedies in this disease, and
one which has received the warm sanction of Dr.
Abercrombie. This able physician recommends
it with judicious caution, and directs at first only
fifteen grains of the tobacco to be infused for ten
minutes in six ounces of boiling water; the (quan-
tity to be increased to twenty grains, and repeated
alter an hour, if no eflPect be produced. 1 believe
that, when thus employed, early in the disease,
and in persons previously of sound vital power,
this will often be of service, or at least not detri-
mental. But I have seen several cases wherein
this powerful substance, even when no more than
half a drachm had been infused for fifteen minutes
in a pint of water, produced the most distressing
effects ; and in one case, where it was given in
opposition to my opinion, which was in favour of
a terebinthinate injection, death followed its ad-
ministration before three minutes had expired, —
evidently from its sedative operation in an ad-
vanced state of disease. I have seen many cases
in which it had been administered, and, unless
under the circumstances in which I have stated
it to be admissible, or when stimuli are given at
the same time by the mouth, I believe that it
favours a fatal termination, by exhausting the
vital power of the alimentary canal, and dispos-
ing inflammatory action to terminate in gangrene.
The introduction of tobacco smoke into the large
bowels appears a much safer and more efficacious
practice, and to be appropriate to a greater number
of the many morbid states of which ileus is an effect.

77. e. Various other kinds of injection have
been recommended ; and some of them are more
deserving of confidence in the treatment of ileus
than almost any other remedy. I have already
mentioned several (§66. 70.), and referred toothers
in the Appendix (F. 140, 141. 150.), on which very
considerable reliance may be placed. Dr. RI ax-
well has found large injections of u'nrm linseed oil
— from two to four pints — steadily and slowly
thrown up, regurgitation- being prevented by
pressing the guard of the pipe against the anus,
remarkably successful, after fajculent vomiting
had come on, and the usual means had failed.
He recommends, in such cases, the patient to be
placed on the right side, with the pelvis elevated
above the rest of the body, the premature return
of the injection being prevented by firmly press-
ing a ball of linen against the anus. He directs
this clyster to be repeated every three or four
hours, until relief is obtained ; and, when much ex-
haustion is present, with the addition of laudanum.
This physician and Dr. Wood likewise advise, in
cases where the existence of intus-susception is
suspected, the injlation of the ivtestines by air, and
adduces cases in which it was followed by copious
evacuations ; but it seems doubtful whether or not
invagination existed in any of them. This practice,
first recommended by Hippocrates, afterwards
insisted on by Alexander of Tralles, Zacutus
LusiTANus, and Riverius, and mentioned by
Sagar, and some other systematic writers, is cer-
tainly deserving of trial where we have reason to
suspect invagination or internal strangulation.
In most cases, however, inflation with tobacco
smoke appears preferable] but, as Quahin re-

378

marks, it should be frequently repeated, and its
effects carefully watched. Although the infu-
sion of tobacco has been chosen for injection by

ViOAT, FoWLEn, CaMPET, CoNRADf, HuFELAND,

and Adercrombie, yet I agree with SynENHAM,
De Haen, Sagar, Quarin, and many others, in
considering the smoke superior to the infusion ;
the former being adopted by some merely on ac-
count of the greater facility of conveying it into
the bowels, and without reference to the very
different operation of these two modes of employ-
ing this powerful medicine. But in cases where
inflation by air or tobacco smoke is adopted, purg-
ative injections should speedily follow, as di-
rected by Hippocrates, if evacuations have not
taken place ; for the smoke may even pass out by
the mouth, and yet copious motions may not
otherwise be procured. Besides these means,
yeast has been administered as an injection in
warm small beer, with the intention of evolving
its fixed air in the bowels, and thereby extricat-
ing any unnatural convolution or slight invagin-
ation that may have been formed. Sulphuric
tether has likewise been thrown into the large
bowels, with the expectation that its fumes would
operate in a similar manner. Anlinwiiuil icine,
and the powder or infusion of ipecacuanha have
been prescribed in enemata, with the view of re-
laxing spasm, in cases where it is presumed to be
the chief cause of obstruction ; whilst the infusion
of poppies and of chamomile flowers, various ano-
dyne, saponaceous, laxative, and oleaginous in-
jections (§ 57. 66.), have also been directed with
the views already stated.

78./. Baths, (Sfc. — Tepid or ivarm baths are
sometimes useful adjuvants in the early stages of
the disease, and are generally recommended.
Cold fluids taken into the stomach, and thrown
into the large bowels, in considerable quantities,
and cold epithems constantly applied on the abdo-
men, have been prescribed by Bureau*, Maret,
Range, Steidele, Darwin, Conradi, Bai.d-
iNGER, Smith, and Abercrombie. The dashing
of cold water over the lower extremities and ab-
domen of the patient, whilst he is kept in a stand-
ing posture, has likewise been directed by several
physicians ; but this practice, although occasion-
allv of service, seems less successful than the
judicious application of cold to the surface of the
abdomen itself. When this cavity is distended,
tense, painful on pressure, particularly in a cir-
cumscribed portion, with increased temperature
of its surface, the cold douche, or the applica-
tion of cloths moistened with vinegar and water,
will often prove of advantage. Dr. linANOis, of
Copenhagen, states that he has employed iced
drinks, and cloths wetted with iced water to the
abdomen, in ten cases with success ; and that in
some instances the practice requires to be perse-
vered in for a long time, and assisted by anti-
spasmodic and laxative enemata, and by opiates
with stimulants and tonics taken internally.

79. f;. Wiien signs of d(ipiession of the vital
energy manifest tiiemselves in the advanced stage
of the disease, stimulants are required, and, if judi-
ciously selected and combined, their exhibition

• Mr. nuREAU rprommemls the use, and gives a plate
(IcBcriiitivH, of asimpic liyclraulir apparatus for injections,
tilt i-aiiii' ill all rispccts ;'^^ inir lately intro(lii(:(^d into tliis
country from Tranci-, imilfr tlio nanio of clysmaduct, but
■which Is Buit«d only to the injection of water.

COLIC AND ILEUS — Treatment OF.

will sometimes be rapidly followed by amendment.
Wherever the lowering measures already noticed
are followed by increase of the symptoms, particu-
larly vomiting and restlessness, or by sinking of the
nervous power or of animal heat on the surface of
the trunk, antispasmodic stimulants and tonics
should be conjoined, according to circumstances,
with certain of the measures described above.
Purgative tinctures are sometimes of service in
this state, particularly the tinctures of aloes, with
liquor potassaj, and tinct. hyoscyami ; and the
compound tincture of senna, with tinct. ammon.
comp. and spirit, anisi, in large or often repeated
doses. Notwithstanding constant or even feculent
vomiting in this stage, advantage will sometimes
be derived from a full dose of unrectijied oil of
turpentine (from 3 ^y . — x.), taken on the surface
of aqua pimentae, to which either spirit, anisi,
tinct. cardamom. CO., or tinct. capsici, has been
added. I have seen the vomiting cease, and the
distension of the abdomen rapidly subside, im-
mediately after this draught, whicli should be
repeated if the former has been thrown off. A
full dose of common oil of turpentine, taken by
the mouth, has a singular effect in constricting,
and, as it were, drawing the small intestines close
to the root of the mesentery ; so tiiat, in cases
where I have given it, and in which hernia had
chanced to exist, tiie hernial sac has become
quite empty soon after its exhibition. May not
the advantage obtained by it occasionally arise
from the disentanglement of a constricted or im-
prisoned portion of intestine by this mode of
operation, as well as from its influence in restor-
ing the action of the paralysed and dilated coats
of the bowel in other cases? In manystat.es of
inflammatory action, particularly those attended
with exhausted tone of the capillaries and de-
pressed vital power, it is one of the most active
means we possess of preventing gangrene or
eflfusion, and of restoring the natural action of
the vessels.

80. h. In some cases, after depletions have
been carried far, or in nervous and irritable
habits, the inverted action of the stomach and
upper part of tiie alimentary canal appears to
continue in consequence of the vital exliaustion
and irritability of parts ; but if these states were
put a stop to for a while, and the powers of life
supported, the natural action of the bowels — re-
specting the immediate restoration of which the
patient is often injuriously harassed — would ge-
nerally at last return. Under such circumstances,
pills consisting of the trisnitrate of bismuth, camphor,
and opium, frequently repeated ; or of the fust of
these, and extract of hop, or of henbane, or the
hiidrocyanic acid, in tiie recent oleum amygdal.
dulcis, or oleum oliva;, in moderate but rather
frequent doses, and occasionally with an aro-
matic spirit or distilled water ; will often prove
of service, particularly when aided by the external
means about to be recommended. When thus
exhibited, the hydrocyanic acid has a restorative
effect ; and it is still further beneficial when
associated with suitable stimulants, as camphor,
a;ther, &c. In a few instances I have inferred
from tiie situation of the pain, and other symp-
toms, that the disorder originated in the duodenum
or jcjuiiuni ; and in these especially, tlie trisnitrate
of bismuth and the hydrocyanic acid have been of
considerable benefit. The compound tincture of

COLIC AND ILEUS. — Treatment of, from Intus-susception.

379

guaiacum, with paregoric elixir, in full doses, : of chamomile flowers and the potassio-tartate of

and given in milk, or in the recent oil of almonds
or of olives, or in linseed oil, has also occasionally
proved of advantage. The acetate of morphia is
sometimes of service in allaying the distress,
anxiety, and irritability of the stomach and dia-
phragm ; but it should be prescribed in an aromatic
spirit, and in a dose which will secure its anodyne
effect without sinking the vital energies. I have
used the following with marked advantage, repeat-
ing the dose every two hours until an eftect
was produced : —

No. 142. R Acetatis Morphiae gr. iv. ; Spirit. Myris-
ticee et .Spiric Pimenta; aa 3j. ; Spirit. Camphoraj et
Tinct. Benzoini Comp. aa 3 ss. Solve. Capiat 3 j. ad 3 ij.
in Saccharo vel Syrupo vel Oleis supra inemoratis.

81. i. The ingestion of crude mercury, or of
globules of lead, to the extent of one or two
pounds, has been recommended in ileus by seve-
ral authors, particularly in that state of the malady
which presents the symptoms indicating invagi-
nation of a portion of intestine. Sydenham,

SCHENCK, BeLLOSTE, PaRE, PaNZANI, HoFF-
MANN, SaGAR, QuARIN, NeVINSON, DaHWIN,

Abercro.mbie, and many others, have noticed
this practice ; some of them, as Sydenham and
Ql'arin, in doubtful terms — others more favour-
ably. M. Roll AND has detailed the history of a
case, wherein, other means having failed, he
gave about 10 ounces of crude mercury, wiiich,
after a short time, occasioned a sensation of cliange
in the position of some part witliin the abdomen,
instantly follovi'ed by relief. Similar instances have
been recorded by Dr. Uwins and Dr. Belluci. I
have never tried this metal ; but, many years ago, I
saw a patient — a female between twenty and thirty,
— relieved from all the characteristic symptoms of
this state of the disease by the ingestion of about
two pounds of common shot, which has also been
recommended in volvulus, by many of the best
medical writers of the three last centuries, and
by some of them in preference to quicksilver.
Large blood-lettings, the tepid bath, and various
other means (§ 54. 77.), should generally precede
the ingestion of lead or quicksilver.

82. k. Various external means besides those
already noticed, have been recommended in ileus.
Sagar* state', that he was cured of volvulus, by
having the abdomen, at the commencement of the
attack, kneaded like dough, with oiled hands, — a
plan instituted evidently with the view of disen-
tangling a displaced portion of bowel. Aret/Eus,
and Paul of j-Egina, directed cupping on the ab-
domen. Cei.sus advises dry cupping on both the
loins and abdomen; but little advantage can be
expected from this latter measure, unless it be
performed by one capacious vessel, as is, I be-
lieve, occasionally done in some northern con-
tinental countries, Quarin states, that in an
extreme case, all other means having failed, and
the pulse being small and irregular, the extre-
mities cold, the countenance sunk, with hiccup,
&c., he had recourse to dry cupping using for the
purpose porcelain bowls. Relief soon followed,
and the bowels were copiously evacuated, their
action having been assisted by enemata of infusion

soda.

83. /. Dr. Abercrombie expresses himself in
favour of large blisters on the abdomen ; but
much more certain and immediate relief — often
within ten minutes after its application — is derived
from the hot spirit of turpentine fomentation
placed over the whole abdomen. Where there
is little or no tenderness of this cavity, I have,
however, preferred inunction of its surface with
one of the liniments above directed (§ 51.),
keeping subsequently a cold turpentine epitliem
applied. Forbes, Wilmer, and Baldinger also
advocate the use of blisters on the abdomen ;
but Meier prefers placing them on the insides of
the thighs. The recommendation of Sydenham,
to keep a young dog constantly applied to the
abdomen, will appear to many a singular remedy ;
but the views witli which he prescribes it are by
no means devoid of reason.

84. m. Numerous writers antecedent to the
time of Quarin, and subsequently, have recom-
mended an incision to be made through the
parietes of the abdomen, and the internally stran-
gulated, or the invaginated, portion of bowel
extricated through it. Nuck has recorded a
case where this operation was performed with
success. Van Swieten objects to it, tiie uncer-
tainty of the existence of volvulus or internal
strangulation. But in several cases of invao-i-
nation which I have seen, and in a great many I
have perused — almost all those, the history of
which has been fully detailed — the symptoms
described (§ 40.) as characterising this state
were present, particularly the tormina, followed
by desire of evacuation, and tenesmus, with the dis-
charge of a little bloody mucus or water ; the
oblong tumour, in a part of the abdomen, ad-
mitting of being recognised at some period of the
disease; have been superadded to the otlier symo-
toms of ileus, and pointed out its precise nature.
In two cases I felt inclined to have had the
operation performed ; and, indeed, suggested it.
The diagnosis was found correct on examination
after death. A case is given by Dr. Fuscmus, in
Hufeland's Journal for February, 1825, almost
identical with one of these, and characterised
by the above diagnostic symptoms, in which he
resorted to this operation over the place to which
the patient referred the sensation of obstruction,
and where an obscure oblong tumour, in the situ-
ation of the ascending colon, was detected. An
invagination of the colon v/as removed, and the
patient perfectly recovered. The reader need
not be informed tiiat ileus very commonly proceeds
from strangulated hernia, and sometimes persists
from adhesions, &c., after the displaced bowel has
been returned. The propriety of having an early
recourse to the operation after we fail in returning
the protruded intestine is here very obvious.

85. n. During, and subsequent to, convalescence
from ileus, the patient should wear flannel next
tlie skin, and promote the functions of the sto-
mach and bowels by vegetable bitters combined
with gentle aperients, and the catbonates of
the alkalies. The bulky and flatulent vegetables

,, „,. „ ,. . L ,_ , , , , ■ ought to be avoided, and the extremities and sur-

' Ulira C)•^s^^ mcidi in huncmorbum (volvulum) ego : \ c c .^ i i ii ■ i n

Hungarus Sartor accitus me restituit intra trcs horas | "ace of the abdomen and loms kept equally warm.

methodo sequent! : impositum me supinum prato. in-
unctisve oleo olivaruni manibus suis depsabat prout pis-
tores pastara panis subtiliter incipiens successive semper
fortius totum abdomen meum." (p, 320.)

The utmost attention should be paid to diet ; all
indigestible substances, and acid or acerb beve-
rages being carefully avoided.

COLIC — Treatment of its Sympathetic States.

380

86. ill. Treatment of Symptomatic or
Complicated Colic. — A. The means of cure
in most cases of this description should be di-
rected to the diseased viscus, by which the func-
tions of the alimentary canal are . affected. — a.
Those colicky symptoms which are produced by
irritation, or the passage of gall-stones, through
the common bile-duct, and by the obstruction
occasioned by concretions in the intestines, wdl
generally be relieved by Tiearly the same treat-
ment as that recommended in this article ; but
whatever difference should exist, is detailed in
the article on Concretions. — b. The colic which
is symptomatic of woi'ms in the intestines requires,
if the attack be severe, the internal and external
means already recommended to allay the urgent
symptoms; but after this is accomplished, the
remedies resorted to for the cure of verminous
disorders should be employed. (See art. Worms.)

87. B. The occurrence of colic from uffections
of the kidneiis, particularly from calculi in their
pelvis or ureters, should not be overlooked by the
practitioner ; nor should he forget that it is some-
times consequent upon aneurism of the abdominal
aorta, and of tumours formed in the mesentery,
or in the omentum. — a. In the first of these
pathological states, much relief will be afforded by
the alkaline carbonates, with opiates, or sedatives,
and followed by oleaginous purgatives and enemata,
in addition to whatever depletory or other measures
the circumstances of the case will point out. The
use of liniments with camphor, soap, and opium,
rubbed on the abdomen and loins, will also give
much relief. — b. In colic depending upon the
latter organic changes, little beyond palliating the
urgent symptoms by the remedies now mentioned,
can be expected.

88. C. Flatulent colic, generally of a pro-
longed description, and often not easily removed,
at least in a permanent manner, sometimes occurs
in the course of asthma a.nd bronchorrha:a, owing
appirently to the interrupted functions of the
mucous surface of the lungs ; the evolution of
gaseous fluids, from the blood being impeded on
this surface, but supervening vicariously on that of
the alimentary canal. In such cases, after the
bowels have been freely evacuated, carminatives
combined with ipecacuanha and hyoscyamus; the
infut-ion of valerian, with hydrocyanic acid, and
spirit, anisi ; powders of magnesia, trisnitrate of
bismuth or oxide of zinc, and ipecacuanha; sul-
phate of zinc, with myrrh, camphor, and opium or
liyoscyamus; and camphor mixture, with extract
of belliidonna, spiritus aitheris sulphur, coinp. and
spirit. mentluB ; are among the means which will
afford the greatest relief.

89. 1). There are few more common compli-
cations than hi/steria and colic ; but the treatment
varies not materially from that now stated. — a.
In such cases, the functions of the uterus rciiuircs
strict attention ; for morbid sensibility, and even
vascular excitement, both of this viscus and of
the ovaria, are often present. The treatment too
commonly ado[)ted in this state of complication,
although it rnay give immediate but temporary
relief, not unfre(|uently perpetuates the patholo-
gical stale, of which both liysteria and colic are
merely symptoms. Instead of employing medi-
cines which excite both the digestive mucous
surface and the generative organs, in these cases,
coolinij and soothing remedies are much more ap

propriate to them, such as those above enumerated
(§ 87.) ; local depletions, nitrate of potash, car-
bonate of soda, extract of hop, cooling aperients,
vegetable tonics, exercise in the open air, &c. —
b. When the complaint is symptomatic of diffi-
cult menstruation (§ 43.), general or local blood-
letting may be resorted to in the plethoric sub-
ject : but in the weak or hysteiical, camphor,
ammonia, soda, &c. with hyoscyamus ; or the
acetate of morphia or laudanum given in some
aromatic spirit, the compound tincture of guaia-
cum in linseed tea, the preparations of rue and
of juniper, and the treatment detailed in the
article on the Disorders of INIenstruation, will
generally give speedy relief. — c. Colicky pains
sometimes occur during pregnancii ; in such
cases, cooling aperients, with antispasmodics and
opiates or other anodynes, and preceded by
sanguineous depletion, if congestion or plethora
exist, will remove all disorder. — d. Severe at-
tacks of colic are not uncommon upon suppres-
sion of the menses or of the lochia. If a tendency
to inflammatory action manifests itself, and espe-
cially if the patient be plethoric or robust,
general or local depletion should be practised ;
a dose of a mixture composed of a decoction
of the radix rubiae, tincture and syrup of saffron,
and as much biborate of soda as it will dissolve,
should be given every two hours ; the volatile
liniment with camphor and opium ought to be
rubbed on the abdomen ; and afterwards, a
fomentation with the decoction of poppy-heads,
&c. applied to the same situation. Schmidt-
MANN advises a cataplasm, consisting of marsh-
mallows, henbane, bruised linseed, and pojipy-
heads, to be placed warm on the abdomen ; and
the steam of hot water to be conveyed to the
pudenda. — e. If colic proceed from congestion or
infammatory irritation of the uterus or ovaria,
local depletions; diaphoretics, and refrigerants,
combined with sedatives ; aperients, with cooling
emollient enemata, and low diet, are the most
appropriate remedies.

90. £. Colicky complaints are not infre-
quently referrible to congestion and irregular
Vascular actio)i in the liver, pancreas, or spleen ;
or, if not arising from such disorders, are asso-
ciated with them, owing to deficient energy of
the organic nervous system ; and, consequently,
to imperfect performance of the abdominal func-
tions generally. — a. In cases of this kind, local
depletions, followed by purgatives, exerting a
chologogue and deobstruent action, external
irritation, and subsequently, by vegetable tonics,
laxatives, regular exercise, and a course of the
Leamington, Harrogate, Buxton, or Chelten-
ham, mineral waters, or the artificial waters
of Carlsbad, Sjia, Ems, &c., according to the
circumstances of the case, will generally re-
move all disorder. Impeded circulation through
the portal system is more or less concerned in
the causation of colic pains in these cases ; the
return of blood through the mesenteric and
haunorrhoidal veins deranging the contractile
actions of the intestines, and giving rise, in many
cases, })articularly those in which this patholo-
gical state obtains, to the additional association
of haemorrhoidal affections, which, if neglected,
may terminate in anal fistula;. — b. It is not un-
common to find a severe attack of colic usher
in hccmorrhoidal discharges : the impeded circu-

COLIC — Treatment of
lation through the portal vessels, and the conse-
quent fits of colic, being both relieve<l by the
consecutive haemorrhage from the lia;morrlioi(lal
veins and mucous surface of the rectum. In
almost all such cases, in addition to the conges-
tion and associated disorder of the assistant
chylopoietic viscera, there are more or less
vascular plethora, impeded secretion generally,
and deficient energy of the organic nervous
system, — a complicated state of disorder evi-
dently requiring local depletions from the region
of the liver, or, as Continental practitioners very
reasonably prefer, from the vicinity of the anus,
with the remedies above stated, and assisted by
regular exercise, gentle tonics, aperients, and a
regulated diet and regimen. From this it will
not appear singular tliat very dangerous attacks
of colic, or even of ileus, will sometimes occur
after the operation for hemorrhoids or anal
fistula;, or other morbid states of the rectum,
when performed, as they sometimes are, without
previous medical treatment of a kind appro-
priate to the state of internal disease. — c. The
complication of colic with either acute or chronic
jaundice is evidently referrible, either to the
passage of gallstones (§ 86.), or to the patholo-
gical state of the liver now noticed, or to inilamma-
torv action in the duodenum or biliary ducts, or,
lastly, to congestion of bile in the hepatic ducts, or
in the gall-bladder. ^Vhen symptoms of local
plethora or congestion can be detected, cupping,
and the rest of tlie treatment now directed, will be
serviceable. (See Jaundice — Treat ineiit of .)

91. F. When tiie colic arises from atonic,
misplaced, or erratic gout, large doses of the
carbonates of the alkalies, or magnesia, with cam-
phor or ammonia, are required, followed by blood-
letting:, if the pulse, habit of body, and strength of
the patient admit of it; by calomel, with cam-
phor and hyoscyamus, or opium, at bed-time ; by
active cathartics, conjoined with stimulants and
restoratives, as long as the alvine evacuations
indicate the propriety of their exhibition ; by
purgative and antispasmodic injections, and by
rubefacients and sinapisms to the lower extre-
mities. After morbid secretions and retained
fx'ces are evacuated, colchicum may then be
given with ammonia, or with camphor and mag-
nesia. But arlhvitic colic occurs most frequently
in aged persons, or in those with exhausteil con-
stitutions, in whom, instead of evacuations, be-
yond the expulsion of morbid secretions, active
stimulants, — as large doses of camphor and am-
monia, or of guaiacum and ammonia, — with
warm spices, Cayenne pepper, and sometimes
combined with opium or aeonitum, and assisted by
sinapisms, are indispensably requisite.

92. G. If colic supervene on the disappear-
ance or suppression of rheuinatism from the joints
or aponeuroses, or on the repulsion ol chranic erup-
tions, local depletions, followed by camphorated
liniments and fomentations ; warm turpentine
epitliems applied on the abdomen ; calomel, with
antimonlal preparations, or with ipecacuanha and
opium ; warm vapour and fumigating baths ; the
carbonates of the alkalies, sulphur, the compound
decoction of sarsaparilla, or the decoction of dul-
camara ; blisters, plasters, or ointments, with the
polassic-tartrate of antimony, saponaceous and
oleaginous enemata ; and sinapisms to the extre-
mities or parts primarily afl'ected ; constitute the

ITS Sympathetic States. 381

chief means of cure. The frequency, and, in two
of the forms of the disease especially, the danger,
of the complaint now discussed, have induced me
to be more circumstantial in the account of its patho-
logy and treatment tiian may appear requisite to
many : but I am convinced tliat the experienced
practitioner will not be of the number ; but will find
cause to regret, with myself, upon reviewing his
knowledge, that his information on the subject is
not greater than his means of observation have yet
afforded him, or my labours can possibly assist
him in obtaining.

BlBLIOC. AND KEFtn. — yi(. COMMON Fo RMS OF CoLIO

Pliny, Hist. Nat. 1. xxvi. cap. i. — Cchus, Ue Medi-
ciiia, 1. iv. sect. 13,' 14. — Alexander TrallUmus, I. iii.
ch. 44. — Baillou, Consult, vol. i. p. •'). — Schcnck, 1. iii.
pp. 173. \Ti. and 274. — Willis, Opera Omnia, de Anim.
Brut., par. ii. cap. 1-5. p. 202. — Bonet, Sepnlchretum,
&c. 1. iii. sect. xiv. bbser. 1. 5.; et Mercurius Com-

pitalitius, p. 115. et scq lUvcrius, Observ. cent. i. ob.

12, 13. m. &c. ; cent. ii. ob. 12. 38, &e. ; cent. iii. ob. 22.

48 Roifink, De Dolore Colico. Jena?, \WM.—Albcrii, De

C'olica Ha'morrlioidali. Hals, 1718. Hoffmann, De Intes-
tinoruniDoloribus, Opera, vol. ii. p. 294.; et Consult. cent. ii.
n 10. — Huxham, in Philos. Trans. No. 422. — Harris, De
Morb. Inf. p. 31. — KiEinpfcr, Araoen. Exot. p. 588. —
Juncker, De Morbis Colicam consequentibus, 4to. Hala;,
1749. — Agricola, Comment, in Poppium, De Sulphure,

p. 416. 4f)2 Sauvagcs, Kosologie Metiiodique, &c. t. ii.

p. b\0.— Stall, Katio Med. par. ii. p. 13,5. 138., par. iii. p. 05.
— Rosen, De Dolor. .Spastico- flatulent is Prim. Viar. 8vo.
Lond. 1771. — Burserii Institut. Med. Pract. vol. iv. ed.
Lips. p. 358. et seq. — Bung, in Act. Reg. Soc. Med.Havn.
vol.i. p.2S5. itseq.,et\o\.\\\. p. 11 5, et 141. elseq.—Ranoe,

in Ibid. p. 349., et vol. iv. p. 113 Kdnig, De Kerned. In-

digenis Tode, Biblioth. i. 3. 148.' — Tuurnai/, Ergo Co-
lico Dolori Opium, 4to. Nanceii, 1784 Baiidry. Sur la

Colique Nervo-gastrique. Paris, 1805. — Eberle, De Co-
lica Infantum. Aiq. 1784. —Barker, in N. Y. Med. Re-
pository, vol. v. No. iii. art. 3 Conradi, in Hvjeland's

Journ. der Pract Arzneyk. vi. b. p. 414. — Eave, in Ibid.
vii. b. p. 108. — Fronim, De Oleo Ricini, ejusque in variis
Col. Spec, effectu prsstant., 4to 1800. — Michaelis, in Lo-
drr's Journ. fur die Chirurg. iii.b. p. 033. — Tliomann, An-

nalenadl800, p. 271 Odier, in Journ. de Med. t. xlix.

p. .337. — Hosach, in Lond. Med.Repository,vol.xviii.p.77.
— Clionicl, Diet, de Mtdecine, vol. v. p. 448. — Schmidt-
mann, Summa Observat. Medicar. vol. iv. p. 373. et seq.

B. West Indian and Madrid Colic. — Hernandez,
Trattato del Dolor Colico, 4to. Madriti, 17.50. — Hunter,
On Diseases of Jamaica, &c. — Lind. On the Diseases of
Hot Climates, p. 254. — Luz?triaga, Dissertacion Medica

sobre el Colico de Madrid. Mad. 1790 Chisholm, On the

Diseases of Hot Climates, &c. 8vo. Lond. 1822. p. 92. —
Larrey, Mem. de Chirnrg. Milit. t.iii. — Aulagnier, Re-
cherches sur la Colique de Madrid. Paris, 1811. — Libron,
in Collect, des Theses souten. a I'EcoIede Med. de Paris.
1809, No. 82. —Jacob, Ibid, 1815' No. 86— 7"/iO?Hio«,.Edin.
Med. and Surg. Journ. Nov. 1818, p. 014. — Musgrave, in
Lond. Med. Repository, by Copland, Nov. 1825. — Pascal
in Journ. des ProgrOs des Scien. Med. t. ii. p. 240 — Mar-
qiiand, in Journ. Complement des Scien. Med. t. xxiii.
p. 97. — Quicr, Account of the Bilious Colic, or Dry
Belly-ache, 8vo. London, 1778. (extremely valuable).

C. Lead Colic. — Reidlin, Lin. Med. 1095, p. 102

Calmettc Riverius Renovatus, vol. i. Lyon. 1704. — I'an
Swietcn, Comment, vol. iii. p. 347. — Tronchin, De Colica

Pictonum, 8vo. Genevse, 17.'37 Grashtiis, De Colica

Pictonum. Amst. 17.55. — i)c //orn, De Colica Pictonum
Hagfe, 174-5. — Jl'arrcn, in Med. Transac. of Col. of Phys.

of Lond. vol. ii. No. 7 Eyerel, Sylloge.obs. iv Asiruc,

in Haller, CoWcct. Diss. Pract. vol. iii. No. Si.—Stoll, Rat.
Med. ii. p. 270., iv. p. 75., vi. p. 333., vii. p. 307. cl seq. —
G. Baker, Medical Tracts republished by his Son, 8vo.
1818, p. 1. and 420. — D?ibois, An Colicis figulis Venie-
sectio ? (neq.) Paris, 1757. — Di'fresne, Ergo non Colicis
figulis Venasscctio. Paris, 1777. ■ — Harrison, On the Cure
of the Dry Belly- Ache. Lond. nUCj.— Adair, in Edin.
Med. Comment, vol. x. p. 233. ; et Mem. of Med. Soc. of
Lond. vol. ii. p. 230. — Merat, Sur la Colique Metallique.
Paris, 1804. — Lentin, Beytriige. p. 330. ; et Memorab.&c.
p. 113, ; et in Blumenbach, Med. Biblioth. ii. p. 149. —

Hahnemann in Ibid. iii. b. p. .54-0 Ranquc, in Journ. des

Progr^s des Scienc. Med. t. ii. p. 242 If'olffl in Fonnay,

Ephemer. von Berlin, i. b. 2 st. p. 83. — (i«rt»v'«, Aiiimad.

versiones, p. 187 Lindi, Do Aluminis Virtute Medica.

Cot. 1784. — Hardy, of the Colic of Poitou and Devon-
shire, Svo. Lond. l~'i9.—Uar/iett, m Mem. of Med. Soc. of
Lond. vol. V. p. 123. — Percival, in Edin. Med. Comment,
vol.ii. p. 239. — Aleock. The Endemic Colic of Devonshire,
not caused by a Solution of Lead in the Cyder ; with Re-
marks on Dr. Bakcr'n Essay. Plymouth, \7W.— Fischer,

382

COLON-

Bemerkungen iiber London, Src. p. 173 — Burger, in Horn's.
N. Archiv. ii. b. p. 342. — Gemlron, in Recueil Periodique
de la See. de Sante a Paris, i<o. 5., et t.ii..p. 3SS.—C/i('i/7ie,
in Edin. Med. and Surg. Journ. vol. iv. p. 3\4.—Soni>ner,
in Hvfc'land's Journ. der Pract. Arzneyk. vii. b. p. 83.— r
Micluwlis, in Ibid. xii. 4 st. p. 31. — Gebel, in Hufeland's
Journ. der Heilk. i.b. p. 195., et xvii. b. 3st. p. lOS. —
JBateman, Art. Colic, in Rea's CycXoy^Aia.—Bobcrls, in
Transac. of Lend. Coll. of Phys. vol. v. p. 45. — Pct«-
bcrlon. On the Abdom. Viscera, Sec. 'p. \bd. — Andral,
Clinique Medicale, t. iv. Paris, \»27. — Farisei, in Diet,
des Sciences Med. t. vi. p. 'd.—OrJila, Toxicologie Gene-
rate, i. p. (,37. — Friese, in Archiv. der Pract. Heilk. iur
Schlesien, iv. b. 1st. n. 6. — Amlral, in Revue Med. t. li.
1824, p. 203. — A'flj3f/f;-, Archives Gener. de Medecine,
t. xviii. p.310.— Graves, Dublin Hospital Reports, vol. iv.
p. io.— Gregory, Practice of Phys. 3d edit. p. 5ii.—C/tris-
tison. On Poisons, p. i^Z— J. Copland, in Lond. Med. and
Surg. Journ. vol. i. p. 147. ; and in Lond. Med. Repository,
vol. xviii. p. 322. — Fournier, in Journ. Hebdomad, de
Med. t. vii. Paris, \^'iO. — Gendrm, Transact. Medicales,
Jan. \%i-i.— Uwins, Med. and Phys. Journ., v. xxx. p. 441.
ii. Ileus AND VoLVuHJs. — Hippocrates, IJi^i vouirm, iu..
Opera, p. 491 . ; Tlip rccdav. Op. p. o2. — ScribovUus Largus,
De Compos. Med. ch. 2S.—Aret(Fus,Curat.Acut.\.i\.c.b. —
Paidus JEgineta,\.in.c.ii.—Bartholimis, Epist.iii.p.284. ;
Historia. Anatom. cent. v. hist. 23. ; et De Usu Nivis Me-
dico, p. 145 Sydenham, Opera, p. 267. — Zacuius I.usi-

tanus, Pract. Admirab. 1. ii. obser. 29. — Bone/, Sepul-
chretum, 1. iii. sect. 14.obs. 7. 24.,etl.iv. sect, i.ob.23 —

Morgasni, Epist. xxxiv. No. 11, 12. 18 J'icat, Delect.

Observat. Pract. App. p. 31 — Hoffmann, De Passione
lliaca, Opera, Supp. ii. n. 2. — Sagar, Systema Mor-
borum, ..*i:c. p. 321. Vien. 1757. — Quarin, De Cur. Feb.
et Inflam. p. 384. Vien. 1781. — Monro, primus, Observ.
en Intus-susceptio, in Edin. Med. and Phys. Essays,
vol. ii. art. 27. ; Ibid. vol. iii. p. 387. — Simson, in
Ibid. vol. V. par. ii. p. 664. — De Haen, Rat. Med. par. i.
p. 113., par. viii.c.5.,par. ix.c. 5.,andpar. xi.c. 3 — Monro,
tertius. Morbid Anat. of the Gullet, Stomach, and Intes-
tines, 8vo. 2d. edit. p. 59 — Whately, in Philos. Transac.
vol. Ixxvi. — Foirler, Med. Reports of Tobacco, Lond.
l7Hy). —Bartliez, Observat. sur les Coliques Uiaques essen-
tiellement Nerveuses, in Mem. dela Societe Mtd. d'Emu-
lation, t. iii. p. 401. — Daririn, Zoonomia, vol. ii. p. -533 —
Liulivig, De Cau.sis Obstruct. Alvinae, p. 32. — Howship, in
Med. and Surg. Journ. vol. viii. p. 1^9. — Hvfeland, in Journ.
der Pract. Arzneyk. ii. b. p. 309. ; et in journ. der Pract.
Heilk. Nov. 1809, p. m.—Scha-ffer, in Ibid. Dec. 1810.

p. 30 Conradi, in Hufcland's Journ. der Pract. Arz-

xieyk. vi. b. p. 495. — Forbes, \a Edin. Med. Comment.
vol. ix. p. 266. — Scott, in Ibid. vol. v. p. 183. — Nevi".son,
On Crude Mercury in Obstructions of the Bowels, Lond.

1788 Baillie, Series of Engravings, fasc. iv. tab. i —

Sims, Observations on Epidemic Disorders, &c. p. 27 —
Gadolla, De Voniita Intestiuor. sive Volvulo. Vien. 1771.

— Hartinann,De Ileo Cognoscendo et Curand. 17K0 —
Galleshy, V'om Miserere, etc. p. 70. — Salgues, in Journ. de
Medecine, t. xxxvi. p. 515 — Wolff, in Hufeland's Journ.
der Pract. Ileilk. xvii. b. p. 189. — Btireau, in Mem. of
Med.Soc. of Lond. vol.ii. p. 227. — Baldinger, N. Magaziii,
viii. b. p. 77. — I'ogel, Methode den Ileus, &c. Coder's
journ. fiir Ghirurg. i. b. p. 541 — -Monfatcon, in Diet, des
Sciences Med. t. xxiii. p. 541. — Raigc Drlorme. in Diet, de

Medecine, vol. xxi. p. 402 Richter, Die Specielle The-

rapie, iv. b. p. 171 — 226 Rayer, Archives G^ner. de

Med. t. v. p. 68. — Lebidois, Ibid. t. xiii. p. 230 Louis,

Ibid. t. xiv. p. 185. — Regnaidt, Journ. Univers. des Scien.
Med. t. iv. — Morlier, Journ. Complement des Scienc.
Med. t. iii. — Paget, Journ..Gtner.de Med. t. xi — Dance,
Sur les Invaginations des Intestine, in Repert. Gtner.
d'.'Vnatom. ct Patholog &c. t. i. p. 441 — S7nilli, in Edin.
Med and Surg. Journ. vol. ix. p. 287. — Maxwell, in Ibid,
vol. xxi. p. 72. — Rolland, Archives Gener. de Medecine,
t. v. p. 220. — Fusdiius, in Ibid. t. ix. p. 116. — M. Bnet,
in Ibid. p. 230. — Belliici, In Ibid. t. xviii. p. 296 — Bli-
xard, in Trans, of Med.-Chirurg. Soc. vol.i. No. 14

— Bavd, in Journ. Gen. de Mi5d. t.xxiv. p. 20. — Brandis,
in Nouv. Journ.de Med.t.v.p.89. — JVillan, Miscellaneous
Works, hy Smilh, Lond. 1820, p. 285 — Abercroinbie, On
Diseases of the .Abdominal Viscera, &c. Edin. 1828, p. 104.

— Bcilby, Alison, SjC, in Ed. Med. and Surg. Journ.

vol.xliv. p. 280. el seq Wood, in Bost. Med. and Surg.

Journ. 1835,

Those who wish to be acquainted more fully with the
opinions of the writers of the fifteenth, sixteenth, and
seventeenth centuries, as to liens and Colic, will find them
detailed atconsiderable length in Hone r's Volyallhes, &c.
fol.vol. i. p. 500. et stq. ; in his Merciiriiis, fol. p. 115.; and
in M ANCv.i's Bibliotheca Medico I'raclica, fol. vol.i. p. 575.
Although I have not availed myself of these collections
in any way, owing to my circumscribed limits, and desire
to give more precise information of a later date, and more
in accordance with my experience, than that which they
furnish, yet will they he found to contain much of wha"t
has been considiTcd of much more modern date, and,
"when ulftcd from the refuse, of no mean value.

Torpid States of, &c.

The Bibliography of these diseases in Ploccquet's
3/fd. Digesta, is brought down to the commencement of
this century ; but many of the references are inaccurate :
that by Young is very scanty, and not select. The list
appended to the art. Ile^is, in the great French Dictionary,
is entirely a catalogue of Theses on the subject, of no
value; instead of consisting, as it ought, of references to
the experience of the best practical writers.

COLON.— SvN. Ka;Xo]/, Der Grimmdarm, Ger.
The Large Bowel.

1. The colon is very often the seat of disease,
the rest of the alimentary canal being but lightly
affected. In some complaints, as constipation,
colic, and dysentery, it is the part principally
disordered: and in others, as indigestion, diar-
rhcea, ileus, perito)iitis, &c., it participates in the
disease with the rest of the digestive organs. The
investigation, therefore, of these maladies neces-
sarily includes the consideration of the chief mor-
bid states of this viscus. But there are other
derangements which require a brief notice at this
place, and which do not belong to these diseases,
or to those changes of structure that are common
to it and the rest of the alimentary canal, and are
considered in the article on the Pathology of the
Digestive Canal.

L 'J'onpoR OR Atony of the Colon, and its
Consequences. — Classif. — L Class, I,
Order (Author).

2. Deiin. General debility, with indigestion ;
slow or irregular state oj' the bowels; distension,
borborvgmi, or stridulous noises, in the course of
the colon ; frequently pain or nneasiness, sometimes
with tumours in some part of this viscus.

3. i. Its Pathology. — Atony and distension
of the colon may be variously associated with
other disorders. They obtain more or less in all
cases of constipation and colic which depend not
upon inflammation, or upon diminution or con-
striction of the canal of the intestines ; and they
are also often complicated with torpor of the liver,
and deficient secretion from the internal surface
of the colon. Distension is usually occasioned
by flatus or fsecal matters: and it may produce
little or no inconvenience, beyond constipation,
until it reaches a great extent ; but it frequently
gives rise to flatulent and stercoruceons colic, and
even to ileus. The gases found in the colon are
azote, carbonic acid gas, and carburetted hydro-
gen, in varying proportions ; and when tliey ac-
cumulate largely, they always produce borborygmi
or an unpleasant or painful sense of distension,
and constipation or colic. A. Flatulent disten-
sion of the colon (see Flatulence) is commonly
dependent upon want of vital tone of the diges-
tive organs generally, and of this viscus particu-
larly. In irritation or inflammation of the bowels,
flatus is also generated in great quantity ; but it is
usually expelled quickly, especially when they
are unobstructed, owing to reaction of their mus-
cular coats. INIuch doubt exists as to the source
whence this flatus proceeds. The circumstance
of its rapid reproduction after its evacuation,
when tiie bowels contain no substances which
could give ris-e to it, and various physiological
considerations, lead me to infer that it is in great
measure exhaled from the digestive mucous sur-
face ; the gases consisting chiefly of those which
pass into, or arc formed by, the blood ; and which,
in health, are afterwards given out from it, on the
mucous surface of the lungs. Persons who often
expel the flatus from the lower bowels, where it
evidently is destined to perform useful purposei

COLON — ToHPOR OF.

383

in the economy, are most subject to an atonic
state of the colon, and to a continued as well as
an increased generation of the intestinal gases :
and, when circumstances prevent the accustomed
frequency of their discharge, are most liable to
experience the effects of their accumulation.
Atonic distension of the colon by flatus is also
a common attendant upon congestion of some one
or more of the abdominal viscera, and even upon
general vascular plethora, particularly when it
oppresses the circulating energies. It also often
accompanies hysieria : and, owing to the increased
sensibility of the organic nerves, as well as to the
morbid irritability and irregular action of the mus-
cular fibres of the bowels, gives rise to various
painful sensations in their course, and to anoma-
lous states of disorder.

4. B. When an atonic andjialulent s^ate of the
colon is associated witii morbid irritability of the
muscular coat, painful sensations in some part of the
course of this viscus are frequently complained of,
particularly by females ; are by them often referred
toils left arch and descending portion; and are
attended by loud croaking or stridulous noises,
especially upon full respiration and mental emo-
tion. The bowels are usually constipated, and
attempts at evacuation are accompanied vvith
slight tenesmus, the stools being discoloured, hard,
slimy, or in lumps. The abdomen is tumid ;
and tenderness, often shifting its place, and varying
in degree or duration, is sometimes felt. The
whole digestive organs necessarily participate in
this state of disorder, and perform their functions
imperfectly. The nervous system of organic life
acquires increased sensibility ; the cerebro-spinal
system becomes morbidly susceptible of im-
pressions, particularly in females ; the counte-
nance is pale, slightly discoloured, and often
covered by an oily moisture ; the tongue is loaded,
flabby, sometimes large, presenting fissures on its
surface, and the impressions of the teeth on its
edges ; the pulse is weak and soft ; and a sense
of distension and oppression follows a full meal,
'i'his state of disorder is very frequent in young
females, who take not sufficient exercise ; and,
when neglected, is often the forerunner of more
serious ailments, both of the bowels and of the
generative organs.

5. C. Deficient vital energy of the colon also
gives rise to relaxation or irregular action of its
coats, to constipation, and to collections of fascal
matteis, generally with more or less fiatulence.
Fcpcal accunuilations to a great amount is most
commonly met with in aged females, or persons
far advanced in life, who have injured tlie tone
of the bowel by the frequent use of cathartics,
and have passed a sedentary and luxurious exist-
ence. They also occur, but to a much less ex-
tent, in children and young persons, especially
females from the ninth to the eighteenth year of
age, and even upwards. Sometimes they occa-
sion large tumours, particularly in the cajcum
and sigmoid flexure, but occasionally also in the
transverse arch and other paits of the colon.
When distension proceeds from retained faecal
matters, in additions to the local signs observed on
careful examination and percussion of the abdo-
men in the course of this bowel, numerous symp-
tomatic ailments are complained of. These vary
but little from those described above (§4.), and
in the article treating of accumulations in the

C/EcuM (§11.)' The countenance and skin are
generally foul, unhealthy, and devoid of anima-^
tion ; the perspiration is thick, clammy, foetid,
and oleaginous ; the breath very offensive ; the
tongue loaded or furred ; the lips and gums are
pale ; muscular energy is much diminished ; the
appetite imperfect or capricious ; digestion diffi-
cult; headach or vertigo is often present; the
abdomen is tumid, doughy, and inelastic ; the
urine is loaded ; the bowels are either constipated
or irregular, or, if daily evacuations take place,
the motions are slimy, very dark, or otherwise dis-
coloured, scanty, and offensive; and the pulse
soft, weak, often slow, but afterwards accelerated.
In many cases, pains in the loins, abdomen, and
limbs are complained of, with mental inactivity,
general lassitude, oedema of the lower extremities,
flabby inelastic state of the soft solids, leipo-
thymia, or fainting, upon quickly assuming the
erect posture, and occasional fits of sinking, espe-
cially in females.

6. Although torpor of the colon is most fre-
quently followed by fajcal accumulations and
distension, yet these are neither constant nor ne-
cessary results of this state, at least to any very
manifest extent ; for sordes and faecal collections
may be very injurious to the mucous surface,
without proving so froin their bulk or mechanical
effects only. Indeed they are often noxious from
their acrimony, without occasioning remarkable
distension, or any degree of obstruction, par-
ticularly when the vital energies are depressed.
Their presence, therefore, should be inferred
rather from various remote symptoms than from
those which are rcferrible to the colon itself.
But whenever disorder of remote organs leads us
to suspect torpor of this bowel, the practitioner
should make an accurate examination of all the
abdominal regions, commencing with that of the
cagcum, following the course of the colon be-
tween the ilium and right ribs, below the epi-
gastrium and under both hypochondria, to the
left side and iliac fossa, and to the hypogastrium.
If a sensation of doughy fulness be felt by the
examiner, in any part of its course, the internal
surface of the bowel is probaTily lined with sordes
and accumulated secretions which its vital energy
has not been sufficient to throw off. If hardness
be felt, with more or less tumour, faacal col-
lections are most likely formed. liut the evi-
dence furnished by this examination should not
satisfy us : we should inquire after the symptoms
stated above, particularly the foul or clammy
tongue, foetor of the breath, unnatural state of the
countenance, and cutaneous surface, and the of-
fensive and morbid evacuations usually attendant
upon this ailment. A belief is too generally
entertained, that faecal matters and sordes will
not accumulate in the colon, unless the patient
has been constipated. But they may collect in
its cells, the more central part of tiie canal allow-
ing daily evacuations ; and they may even remain
there for a considerable period, producing much
irritation, and even a relaxed state of the bowels ;
thereby misleading the judgment of the prac-
titioner as to the pathological state constituting
the disorder. How, therefore, is he to form an
accurate opinion ? By a careful examination of
the abdomen in the course of the colon, of the
urine, of the stools, and of all the organic and
animal functions, and by ascertaining the presence

384

COLON — ToRPon OP.

or absence of the symptoms enumerated above ( § 4,
5.). In many cases, when the morbid collections
have become acrimonious, an irritative diarrhoea
continues for some time, or recurs at intervals,
before the morbid matters are fully thrown off,
owing to spasmodic constrictions of parts of
the bowel. On these occasions, the stools are
watery or fluid, and are apparently composed of
discoloured faeces, broken down and mixed in a
liquid ; at other times they are darkgreen, muddy,
putrid, &c. ; very frequently they are slimy, con-
taining lumps of hardened faeces, very offensive,
and of a dark green or brownish black hue ; and
their evacuation is preceded by griping, tenesmus,
or a scalding sensation of the anus.

7. D. Imperfect action of the colon is evidently
dependent chiefly upon deficient vital energy of the
frame, owing either to original conformation, or
to various causes of exhaustion, acting chiefly on
the digestive canal and associated viscera, with
more or less torpor of the biliary functions.
When allowed to continue, it perpetuates and
augments the morbid condition in which itself
originated ; drawing other organs within the
sphere of disease, particularly those of mental
manifestation, and of generative function, in the
female. In young persons it often occasions, oris
complicated ivith, curvatures of the spine, chorea,
chlorosis, retention or suppression of the menses,
nervous tremors and convulsions, &c., and when
the distension of the colon is great, dyspncEa or
shortness of breathing, palpitations of the heart,
6cc. ; these aftections appearing oftener, peihaps,
along with it, as associated effects of depressed
vital power, than as consequences of this particu-
lar lesion of function.

8. E. The more remote causes of torpor and
distension of the colon are, confinement in close
and crowded a])artments during the greater part
of the day, and sleeping in chambers similarly
circumstanced ; constrained and sedentary posi-
tions, in which the abdominal muscles remain
nearly inactive ; premature and excessive cul-
tivation of the mental, to the neglect of the phy-
sical powers, — the discipline of modern board-
ing schools; the inappropriate combination and
use of purgative medicines ; indolent and luxu-
rious habits ; occupations which prevent bodily
activity ; and particularly those performed by the
assistance of machinery, and in hotfoul air, stagnant
in crowded manufactories; pre-existing debility
of the stomach and digestive canal, or of the
frame generally ; paraplegia, or hemiplegia ; dis-
ease of the spinal column, its membranes, or
chord ; neglect of the first intimation to alvine
evacuations ; venereal excesses ; the disgusting
habit of expelling the flatus from the bowels ; and
whatever weakens, either directly or indirectly,
the vital manifestations of the alimentary canal, or
disorders the general health.

9. Local and constilutional effects produced hij
torpor of the colon. — A. Owing to the course and
connections of the colon, to the remote causes
above enumerated, and to the depression of di-
gestive and vital energy they occasion, the matters
discharged into this bowel from the small intes-
tines, and the secretions from its own internal sur-
face, are liable to be retained for a long time.
Fa;cal accumulations and obstructions have been
now shown necessarily to follow such retention. It
may be next requisite to point out certain of the

most important and frequent consequences of
these states: — a. One of the most immediate is
the retention of the mucous secretion within the
follicular glands, as well as in the ducts leading
from them; causing distension, and subsequently
inflammation and ulceration of them. — b. The
retention of fzecal matter in the colon is often
followed by absorption of much that otherwise
would have been excremenlitious, both into the
general curient of the circulation, and, at first, at
least, into the blood which flows into the portal
veins, where it often excites and irritates the liver,
and either is partially removed by this viscus,
giving rise to increased or vitiated biliary secre-
tion, or contaminates the whole circulating and
secreted fluids. — c. The bile also may, particu-
larly in warm countries, and in persons in whom
it is habitually secreted in excessive quantity, be
rapidly conveyed along the small intestines with
the chyme, and yet be retained too long in the
caecum and colon, whence it may be absorbed,
with a portion of excrementitious matters, into
the circulation, and give a lurid or unhealthy
aspect to the countenance, and occasion various
constitutional ailments, characterised chiefly by
lassitude, debility, irregular action of the bowels,
loaded urine, and a foul tongue. — d. Fsecal ac-
cumulations, when allowed to remain too long in
the colon, and thereby to give rise to gaseous and
noxious formations, not only impede many of its
functions, but also favour changes in the vascular
action and structure of its coats, particularly of its
mucous, sub-mucous, and muscular tunics. — the
first and second becoming irritated, inflamed, or
even ulcerated ; the third over distended, and
thereby deprived of its power of salutary reaction.
— e. Among the most common consequences, also,
of torpor and fa;cal infarction of the colon, are
ha;morrhage from it and the rectum, and hse-
morrhoidal tumours, arising immediately from the
foregoing changes, and from interrupted circula-
tion through the hemorrhoidal veins.

10. B. The effects of over-distension of
the colon upon the other abdominal viscera,
owing to the extensive connections subsisting
between them and this bowel, may be readily
inferred. — a. The distended caecum and sigmoid
flexure of the colon press injuriously upon the
femoral nerves and blood-vessels, the ureters, and
the internal iliac veins; producing numbness,
cramps, pains, and, owing to the impeded return
of blood, more or less oedema, of the lower ex-
tremities. The ascending atid descending por-
tions of the colon press upon the kidneys and
adjoining vessels, occasioning disorder of the
urinary secretion, with a sense of weight, or dull
acliing pain in the loins. Distension of the right
and left flexures, and transverse arch, deranges
the functions of the biliary organs, the duodenum,
stomach, and spleen. — b. If the colon be dis-
tended to the utmost, not only are all these
consecutive disorders much increased, but the
descent of the diaphragm is also much impeded,
and the actions of the heart and lungs materially
afl'ected ; occasioning palpitations, intermissions,
and irregularity of the pulse, dyspnoea, and a
short and rapid respiration. Owing to this effect
upon the circulating and respiratory organs, the
return of the blood from the head is retarded;
various nervous ailments, and headach, are occa-
sioned ; and determination of blood to, and con-

COLON — Tont'on of— Treatment.

385

geslions and effusions of serum on the brain
and its membranes, supervene as the more remote
effects. — c. F;ccal or flatulent accumulations in
the colon affect, in a very evident manner, the
functions of the small intestines and stomach, or
increase disorder in these viscera, when it pre-
viously exists, — a circumstance of frequent oc-
currence, the function of digestion being ei|ually
impeded with that of defecation, and owing- to
the same primary patholog^ical state, namely,
imperfect manifestation of vital power through-
out the organic nervous system. ]Ience the in-
digestion, the acrid and flatulent eructations, and
the imperfect chylifaction and nutrition, so fre-
quently associated with torpid function of the
large bowels. — d. In children and young per-
sons, the mucous sordes, morbid secretions, and
excrementitious matters, that collect as a conse-
quence of this state, become not only a nidus for
worms — remarkably favouring their generation ;
but also a cause of irritation to the mucous sur-
face, to the absorbing vessels, and to the mesen-
teric glands, owing to their partial absorption,
either alone, or with whatever chyle may be formed.
That diseases of the intestinal mucous surface,
and that obstruction and enlargement of these
glands, with the consequent marasmus, &c., often
arise from the morbid impression and irritation
caused by these retained excretions, an extensive
experience in the diseases of children has fully
convinced me; and that dysentery and diarrhcea,
among this class of patients, as well as in adults,
frequently proceed from this cause, more espe-
cially in warm and unhealtliy climates, will be
acknowledged by every experienced practitioner.
— e. Even many of the diseases that aftect the
skin, and chronic ulcers of the lower extremities,
arise from the absorption from the large bowels
of excrementitious matters, that irritate and in-
flame, in the course of their elimination from the
blood by the cutaneous function, the delicate
vascular tissue subjacent to the cuticle. This is
particularly the case in warm countries and sea-
sons, in which the quantity of these matters
always passing out of the circulation by the skin is
much greater than is usually supposed. What-
ever opinion may be formed as to the origin of
such affections, there can be no doubt that the
treatment based upon this doctrine is the most
successful in removing them. — /'. Among other
consequences of fa;cal accumulations in the colon,
elongations and displacements of this bowel may
be ranked ; and when these changes take place,
they increase the disorder which occasioned them.
It has often been remarked, particularly by Es-
QuiROT., HixzE, and others, that displacement of
the colon is one of the most common morbid ap-
pearances found in the bodies of hypochondriacal
and melancholic persons. Torpor or atony of this
viscus favouring fsecal accumulations in it, is an
important characteristic of these affections, and is
manifestly connected with the causation of dis-
placement of the large bowel. (See art. Hypo-
chondriasis, &:c.)

11. ii. Treatment. — The indications of cure
in cases of torpid function of the colon, consist —
1st, of evacuating whatever fascal or acrimonious
matters may have collected in it ; and, 2d, of
restoring the energy of the digestive organs, and
directing such regimen as may prevent a return of
this disorder, — A, Many practitioners, deceived
Vol. I.

by the reports of the patient, or misled by the
appearances of the stools procured by the first
purgatives prescribed, stop far short of the point
to which these medicines should be carried. It
is not sutticient to order two or three doses of
purgatives, or even of active cathartics ; but they
ou^ht to be repeated, or continued so as to
secure their full effect, and be combined with
such other medicines as will promote their opera-
tion without weakening the parts which they
stimulate, and will prevent the patient from being
debilitated by them. In all affections of the
colon, purgatives that procure full, bulky, and
not frequent or watery evacuations, should be
selected. The preparations of aloes (F. 181.
454.), those of senna combined with gentian
(F. 266. 430.), castor oil, rhubarb and mag-
nesia, precipitated sulphur (F. 45. 82. 96.), the
compound jalap powder, &c. (F. 635, 636.652.),
operate in this manner ; and, particularly when
we wish to promote the secretions from the in-
testinal surface, may be exhibited after a dose of
calomel or blue pill taken at bed-time ; or the
compound extract of colocynth, or the aloes and
myrrh pill, or jalap, may be combined with one
of these mercurial preparations, and the extract
of hyoscyamus, (see F. 462. 471.881.). When
it is necessary to continue the exhibition of
purgatives, they should be either alternated with
tonics, or combined with vegetable bitters, which
will both promote their action, and increase
the strength of the patient, (see F. 562. 572.).
When the motions are morbid, great advantage
will be derived from resorting to the use of clys-
mata, as recommended in the article Coi.ic
(^57.66.77.). If faical collections to a great
extent have form.ed, they are indispensable
remedies; and if symptoms of obstruction, or of
irritation, or chronic inflammation, are manifest,
they should be assisted by the external means
there advised (§ 66. 83.). Under every circum-
stance, the exhibition of purgatives by the mouth,
and of enemata, should be persisted in until the
stools assume a natural appearance. (See also
the Treatment of diseases of the Ca:cum, and of
Constipation).

12. In cases where retained matters in the
colon have occasioned irritation, such clysters as
will promote the full evacuation of its contents,
and at the same time allay irritation, ought to be
resorted to from time to time. These will relax
irregular constrictions of the bowel, promote the
operation of purgatives given by the mouth, dis-
solve hardened faeces, and loosen the adhesion of
tenacious secretions lodged in its cells. In cases
of this description, the soap injection, with, or
without, the addition of castor or olive oil, the
compound decoction of barley with common salt,
or the potassio-tartrate of soda ; the infusion of
linseed, with the biborate, or the carbonate of soda
and assafoelida ; the decoction of marsh-mallows,
with the infusion of camomile-flowers and linseed
oil ; and the turpentines, triturated with white of
egg or mucilage ; will have a most beneficial
effect, particularly when assisted by appropriate
laxatives taken by the mouth. When the irri-
tation of the bowel appears to be accompanied
by spasmodic constriction, the aperients should
be combined with either camphor, ammonia, ipe-
cacuanha, hyo-cyamus, the compound galbanum
pill, &c. (F. 463. 890.), according to existing cir-
C c

386

COLON — Unnatural Positions of.

cumstances, la cases of this kind, much debility
is often present, and the functions of the stomach
require the aid of light nutritious food and gentle
tonics ; the purgatives being exhibited either at
bed-time, or early in the morning, so as not to
disorder the functions of the stomach. Such
eccoprotic or alterative laxatives as are slow in
their operation (F. 503. 892.) should be taken at
night, and purgatives or cathartics that are quick
in tlieir action early in the morning, so that they
may not interfere either with necessary food or
with requisite avocations,

13. When tlie faecal accumulations cannot be
removed by the above means, others of a more
powerful nature, as the elaterium or croton oil,
assisted by colocynth or terebinthinate injections ;
and the purgatives advised in the more obstinate
cases of colic and constipation, assisted by shocks
of electricity and galvanism passed through the
abdomen ; should be resorted to. When the
bowels are acted upon with great difficulty, the
stools being very black and offensive, we may
generally infer that not only is the colon torpid, but
the follicles are loaded or obstructed, and their
secretion morbid. In these cases, galvanism, as
shown in an instructive case by Mr. Clarkson,
promises to be of much service. In several in-
stances, when the pulse has been weak, and the skin
cool, I have added the extract of nux vomica to the
purgative, with much advantage, and combined a
portion of this active substance with the liniment
(F. 306.) which has been rubbed on the abdomen.

14. B. In order to prevent the re-accumula-
tion of morbid matters in the colon, and give tone
to the digestive organs generally, the patient
should daily attend to the first intimations of eva-
cuation, and promote the functions of digestion
and defaecation, by resorting, whenever they
flag, to aperients or laxatives, combined with
tonics. Blue pill, with the aloes or myrrh pill,
or F. 470., may be occasionally taken at night,
and the tonic and aperient medicine (F. 266.)
the following morning. The diet and regimen
should be carefully regulated, and exercise be
taken in the open air, either on foot or horseback.
After health has been in a great measure re-
stored, chalybeate mineral waters, and the arti-
ficial waters of Ems and Pyrmont, will be pro-
ductive of much benefit; but frequently it will
be more advantageous to commence with the
Harrogate or Leamington waters, or with the ar-
tificial waters of Seidschutz, Eger, or Carlsbad,
and have recourse subsequently to the chalybeales
of Cheltenham or Tunbridge. In many cases,
the warm or tepid salt water douche over the
abdomen, sea-baihing, frictions of the surface of
the body, and of the belly especially, ni^ht and
morning, with either a hard towel or brush, will
prove of much service.

15. II. Unnatuual Positions of the Colon,
&c. — This viscus is not infrequently found mis-
placed, and forming singular flexures, in those
who have suffered from constipation, fajcal re-
tention, dysentery, hypochondriasis, or melan-
cholia. But there are no constant symptoms by
which such changes can be inferred with much
certainty during the life of the patient. M. Es-
nuinoL found, out of 168 dissections of melancho-
lic patients, the colon displaced in 33. 'J'his
chan^'C hud previously been remarked by JNJoii-
CAGM (VJc .Set/, et Cans. Morb. epist. iv. art. 16.

et seq.), Haller (Elem. Physiol. 1. xxiv. sec. 13.
et seq.), Soemmerrtno (De Corp. Hum. Fabrica,
t. iv. p. 313.), and Wells, but unconnected
with mental disorder. In many cases, the bowel
is not only displaced, but is also elongated, with-
out being divided, as in its natural state, into cells
by partial partitions, and the tonic action of its
longitudinal bands. These changes seem to be
favoured by relaxation of the mesocolon, and by
complete atony of those bands. An elongated
and displaced state of the colon is common in
cases of old hernia ; and in these is often con-
nected with a stretched appearance of the mesen-
tery, but without any organic change of the
coats of the bowel : but sometimes the unnatural
flexure or duplicature is adherent at its opposite
sides, forming a large loop ; particularly when it
has been consecutive of acute or inflammatory
dysentery. Displacement may take place in any
part of the bowel, but it is most common in the
transverse arch and sigmoid flexure ; the former
part hanging down towards the pubis, generally
in an unadhering, but occasionally in an adher-
ing, loop ; and the latter part crossing over to
the right side of the abdomen, or passing behind
the pubis. Duplicatures of the colon may also
form at the right or left parts of its arch ; the op-
posite peritoneal surfaces being more frequently,
in such cases, adherent to a considerable extent
by coagulable lymph. Several plates are given
by Rlr. Annesley, illustrative of this change ;
wliich is not infrequently observed in fatal cases of
chronic dysentery, particularly in warm climates.
That these unnatural flexures are also often caused
by fffical collections, and by obstructions to the
fjEcal discharges situated either in the rectum or
in tiie sigmoid flexure of the colon, appears very
probable ; but they may also arise from a na-
turally elongated formation of the bowel. That,
when once produced, they favour such collections,
with their consequences, particularly severe dys-
peptic and hypochondriacal ailments, dysentery,
severe colic, or even ileus, and great distension or
inflammation of the colon or small intestines, can-
not be doubted ; but that they will occasion in-
sanity or melancholy, as Esquirol and Hinze
suppose, seems not to be made out. Dr. Yelloly
states, that Mr. Lawrence and Mr. Dalrywple,
who have examined many bodies of insane per-
sons, have very seldom observed in them any devi-
ation from the natural course of the colon,

16. As we have no certain or even probable
means of ascertaining the existence of Uiese
changes during life, it is unnecessary to offer any
remarks on their treatment. But this is a matter
of but little importance, as the disorders which
they produce are in all respects the same as those
already noticed ; and even if their nature were
recognise<l, they can be remedied or alleviated
only by the means described above, particularly
by laxative and solvent enemata ; and by what-
ever will, whether taken by the mouth, orinjected
per anum, preserve a fluid state of the stools, or
reduce them to a softened condition, and promote
the healthy secretions and regular functions of
the large bowels, and of tlie digestive organs in
general. (See F.82.98. 144.)— See art. Digest-
ive Canal, for the organic lesions of the colon ;
and arts. DiAitRiicEA, Dvsenteuv, and Intes-
tines, for its other diseases.)
BiuLiuc. AND l\.)ii'ER. — Sever inus. De Uccond. Absc.

COMA AND LETHARGY.

Nat 1. iv. cap. 35. '.Greatly distended, Ssc) — Adolphi, De
liitcstino Colo, mult. ISIorbor. "Nido, &c. Lipsia.-, 1718.—
Vater, De Situ Natur. et. Pra?ternaturali Iiitcst. Coli.

Witeb. 1737. Fisc/icr, De Morbis Inlest. Coli, &c. Erf.

1728 — Hamberger, Observat. Clinic. Jens, 17.''4, p. lU.
(Great distension.) — S/ocrck, Annus Med. t. i. p. I2a, et
t ii p. 268 (Flatulent and ftecal distension, and laceration
of the longitudinal bands.) — Leusingk, De Morbis a Situ
Intestin. Crassor. pendentibus. Goet. 1756. — fan Iloijen,
De Intest. Crassis, multorum Morb. Causa et Scde. Lugd.
Bat. 175J, 8vo.— White, Cases in Surgery, p. U.— Hamil-
ton, On the Utility of Purgative Medicines, »tli ed. Svo.
ISai — Abernethii, On the Constitutional Origin ot Local
Diseases, Svo. —Roth, Patholog. Intest. Coli. Erlang.
1802.— Wells, in Transac. of Society for promoting Med.
and Chirurg. Knowledge, vol. iii. p. 158. — Esquiiul, ni
Diction, des Sciences Med. t. x.vxii. p. 172. ; et Journ.
Gener. de Med. Fran, et Etrang. Mai et Juin, 1818. —
Geoghegan, Transac. of the College of Physicians of Dub-
lin, vol. i. p. 194. {Great distension of the colon.) — Stoker,
in Ibid. vol. ii. p. fi. {Rupture from distension, without
ulceration.) — Hinze, Archives Gener. de Med. t. ni. ,
p. 125. {Displacement of colon.) — Yelloly, in Edin. Med.
and Surg. Journ. vol xvi. p 476. [Displacement of colon.) 1
— Clarkson, in Ibid. p. 475. — Annesley, Researches on the
Diseases of India, &c. vol. ii. p. 50. et seq.
COMA. — Syn. and Deriv. K%a, Profound
Sleep (from Km, I lie down). Cams, Sau-
vages, Good. Cataphora, J. Frank. Lethar-
gic, Assoupissement, Fr. die Schlafsucht,
Schlaffieber , Ger. Sopore, Somnolenza, Ital.
CL.4SSIF. 2. Class, Nervous Diseases ; and
1. Order of this Class {Cullen). 4. Class,
4. Order {Cwcd). IV. Class, III. Order
{Author, in Preface).

1. Defin. Preternatural sleep, with physical
torpitude, and siippression nf the mental powers.

2. I. Varieties and Symptoms. — There are
various modifications of coma, each of which have
received different appellations, as Lethargus, Cata-
j)hora, Agrypnia, Cants, &c. ; these names being
also used generically by some authors, but more
frequently specifically, as I shall apply them on this
occasion. They are all most commonly symptom-
atic of pre-existing disease ; but they are also
occasionally primary affections. I shall, there-
fore, after describing very succinctly each variety
of coma, and its more constunt symptoms, notice
it first as a primary affection, and next as an im-
portant phenomenon in other acute diseases, par-
ticularly of their severe forms or advanced stages :
afterwards the different pathological states causing
this affection, the signs which distinguish them,
and, lastly, the means best adapted to relieve them,
will be briefly stated.

3. i. Coma Vigil — Agrypnia, KSif/.a ay^uirvSih;
(Hippocrates), Tvphomania, Sopor cum Agryp-
nia—is characterised by a constant disposition to
sleep, without falling into quiet, sound, or natural
sleep ; by low muttering deUrium, or uncon-
nected talk ; unnatural action of the hands and
fingers, sometimes also of the feet ; pale sunk
countenance; a natural or but slightly increased
temperature of the head ; by the patient opening
the eyes and staring about upon the slightest dis-
turbance, or starting up as if frightened by strange
sights, and again attempting to lie down ; and
sometimes by difficulty of speech and of swallow-
ing liquids.

4. ii. Lethargy — Lethargus* (from KhQ>],

' * ^ have conformably with the received acceptation of
Iptharev in this country, made it the slightest form of
"soDoro^e coma ; although the ancients, our countryman
WiLi IS who has written ably on this affection, the greater
number of writers of the sixteenth and seventeenth cen-
turies and many modern German authors, have defined
it nearly as follows : — " Profound sopor, or preternatural
sleep with fever and delirium ;" thus applying the term
to the more profound state of febrile coma.

387

Lethe, et af-yoi;, celer), Vetermis, Lat. — is chw
racterised by slight but constant somnolency, or
mental and corporeal torpor, evidently depending
upon a morbid condition of the brain ; when
addressed, the patient answers forgetfully, and
afterwards sinks into the same stale as before. This
is a slighter grade of the following varieties, and
may pass into them.

5. iii. Coma SoMNOLENTUM — Cotaphorci — is
characterised by sopor or profound sleep, without
the power of wakening spontaneously ; the patient,
when roused, slowly opening the eyelids, and
answering either rationally, forgetfully, or inco-
herently, but iminediately afterwards falling into
the same state of profound sopor ; and frequently
by relaxation of the muscles of the lower jaw, it
thereby differing from apoplexy and carus.

6. iv. Co7na profundum — Carus, Kapof-— is
characterised by its "more or less sudden invasion ;
by the profound sopor, the eyes being shut as in
a deep sleep, and the patient being generally de-
prived of motion and sensation. Sometimes,
however, upon being called to loudly, he opens
his eyes, but immediately shuts them, without
answering any question ; and occasionally when
pinched he draws away the part, indicating re-
maining sensibility ; the breathing is undisturbed
or irregular, sometimes laboured, but without
stertor : there is seldom much febrile heat, and
the evacuations are passed without consciousness.

7. A. Review of the chief symptoms. — a. The
pulse varies greatly in each of the above states of
coma. It is generally slow, full, and soft; but
it is also often small and quick in coma vigil, or
in any of the varieties, when accompanying the
last stages of fever ; and small, hard, and some-
times inegular, in the coma attendant upon in-
flammatory action of the brain or its membranes.
It is also frequently unequal, intermittent, and
generally slow, but sometimes also quick, in the
coma produced by injury of the brain, and by
hemorrhage or effusion of fluid within it. — b. The
respiration is often natural, as in coma vigd ;
sometimes accompanied by sighs, or laboured, as
in coma profundum ; frequently slow, and very
seldom stertorous, unless in the coma of apo-
plexy.— c. The pupils of the eyes are generally
more or less dilated, and sluggish in their mo-
tions, or altogether insensible to light ; but they
are sometimes, in the most unfavourable cases,
much contracted, or one contracted and the other
dilated. — d. The countenance is usually tumid,
and without expression ; sometimes pale or
bloated, or red or injected ; the eyes are pro-
minent or suffused ; and the head somewhat warmer
than natural, or of the healthy temperature, the beat
of the carotids being full or strong : in the coma
consequent upon fever, and in coma vigil, the
features are commonly pale, sunk, and cool ; the
action of the carotids being weak and soft in
some cases, and hard and oppressed in others. —
e. The mental powers are commonly suppressed ;
but upon being momentarily excited, they some-
times appear more or less disordered, particularly
in any of the states of coma supervening upon
fever, or inflammation of the brain or its mem-
branes ; low delirium and febrile heat then being
also present. — f. The surface of the body is often
natural, sometimes cold or clammy ; but when
the affection is caused by fever or inflammation,
the temperature may be somewhat elevated,
C c 2

388

COMA AND LETHARGY —

and the skia dry.— ^^ The extremities are fre-
quently natural at first, but they are also often
cold or clammy, or become so. — h. The posi-
tion is commonly supine, without attempts at
motion, in profound coma ; and, in tiie worst
cases, the patient slips down in bed. — i. The
tongue is natural, or merely much loaded, in some
instances ; but in coma symptomatic of inflamma-
tion or fever, it is usually furred, dry, and brown,
hard, and constricted. — k. The alvine excretions
are either retained, or passed without consciousness.

8. B. Duration and termination. — a. Any one
of the forms of coma may be sudden in its attack,
and terminate speedily in death ; or it may come
on gradually, and be of short duration, sense
and voluntary motion as slowly returning. 'J'he
seizure may be repeated frequently, or it may be
periodic, particularly when attendant upon epi-
lepsy, or remittent fever of a bad form. When
its accession is slow, it often commences with
drowsiness or headach, — b. Its duration is very
various; the lethargic and slighter varieties being
occasionally of long continuance — sometimes
lasting many weeks, and spontaneously passing
off. The more profound slates of coma frequently
end fatally in a few hours, and seldom continue
longer than a few days. I however attended a
case of profound coma with Mr. BusiiEt.i., that
continued several weeks, and yet terminated in
recovery. — c. It may terminate in eitlier recovery
or death, or in some other disease with which it is
more or less closely related, — as apoplexy, para-
lysis, insanity, or melancholia, epilepsy, and epi-
leptic or other forms of convulsions, with which it
occasionally alternates ; and in inflammation of
the brain or its membranes,

9. C Diagnostic remarks. — The states or
grades of disease described above may pass one
into the other, or into some other malady, whether
they appear primarily or consecutively. They
are often very nearly allied to, or rather are less
degrees of apoplexy; and apparently consist of
a somewhat similar condition of the organic
nervous power and vascular action within the
brain, to that which obtains in a great propor-
tion of the attacks of that disease (§ 62. et seq.),
particularly those which do not immediately de-
pend upon haemorrhage. — a. Tiie close resem-
blance of many cases of coma vigil to ecstaci), and
of the other states of coma to catalepsy, not only as
to the grouping of the sensible phenomena which
respectively constitute them, but also as to their
presumed proximate causes, indicate that cata-
lepsy and cataleptic ecstasy are merely unusual
modifications of the state of cerebral disease now
under consideration. — b. The absence of stertor
constitutes the chief difference between the most
profound state of coma, carus, and apoplexy. — c.
The fulness and strength of the pulse, par-
ticularly in the carotids, and the natural or strong
state of the respiration, are sufficient to distinguish
eoma from syncope, in which latter the action of
the heart is greatly diminished i)rimaiily, the func-
tions of the brain failing consecutively. — d. Coma
diffc-rs from asphyxy in the circumstance of the
respiratory functions being first suppressed, and
subsequently the action of the heart in tiie latter ;
the consec(uent coma arising from congestion of
venous blood in the brain, ])roduced by the
abolished respiration, ami obstru(;ted circulation
through thy lungs and cavities of the heart.

iDioPAtHic — Symptomatic.

10. II. Op Primary or Idiopathic Coma. —
Either of the varieties described above may occur
as a primary affection arising from states of the
organic nervous power and circulation within the
brain, which will be noticed in the sequel {§ 13.),
and which are commonly produced by the fol-
lowing agents: — Causes. — The continued or
intense action of cold upon the nervous system
and circulation ; the influence of narcotics, par-
ticularly in some constitutions; indulgence in
spirituous or intoxicating liquors, either carried
too far or continued too long ; venereal excesses ;
insolation ; fatigue or prolonged watching ; the
influence of particular odours, condiments, or
kinds of food in some temperaments ; inanition
or exhaustion of vital power, by whatever cause,
especially in the aged of the male sex ; immode-
rate evacuations or discharges ; mephitic or car-
bonaceous fumes or gases ; sadness, anxiety,
fright, terror, anger, and other violent mental
affections ; the inappropriate use of either warm

■ or cold baths ; the exhaustion of vital or nervous
power by excessive or long-continued pain ; con-
cussions and injuries of tlie brain ; erratic, atonic,
or relrocedent gout ; pregnancy or child-bearing ;
and suppression of the menses or lochia ; are the
causes which produce, in a primary form, any of
the states of coma described above.

11. III. Symptomatic Coma. — Either of the
varieties of coma may supervene in tlie advanced
course, move rarely on the invasion, of inter-
mittent, remittent, or continued fevers, particu-
larly typhus ; of inflamitiations of the brain and
its membranes ; and of insanity and melancholia.
Simple determinations of blood to, or congestion
of, the encephalon, will frequently be sufficient to
induce the slighter states of coma ; whilst its more
severe or profound conditions are common con-
sequences of effusions of blood or serum, and of
numerous organic changes occurring within the
head. (See Brain — Organic Lesions of its Mem-
branes and Substance, § 21 — 84.). It is one of the
most important symptoms that appear in the course
of erysipelas of the face or head, and of exanthe-
matous fevers ; it may likewise supervene, par-
ticularly coma vigil, in the advanced stages of
several acute maladies evincing exhaustion of
the vital energy of the brain anil nervous system,
and in those in which the circulating fluid and
secretions become vitiated or contaminated. 'The
coma, which is usually consecutive of epileptic or
convulsive attacks, consists of the slighter varieties
denominated lethargic and somnolent, formino- a
part or conseijuence of these diseases. Coma is
sometimes, also, a symptom of severe hysteiia,
particularly in plethoric persons with interrupted
catamenial discharge; and, in rare instances, of
worms, but by no means so frequently as stated
by some writers. The occasional occurrence of
any of the varieties of coma from suppression or
retention of urine, from metastasis ot gout and
riicumatism, from the suppression of accustomed
(lijcharges, and more rarely from the retrocession
of cru])tions, and the drying up of old ulcers,
should not be overlooked, particularly as such
morbid relations require a peculiar and appro-
priate treatment.

12. IV. 'i'he Prognosis in most cases of coma
is unfavourable ; for, although many will recover
— even the great majority — the slighter cases
will often present sudden cliunges, A much more

COMA AND LETHARGY— rATHOLooY oi. 389

favourable opinion may be entertained of coma
■when it is produced by narcotics and spirituous
liquors, than when it comes on in the course of
febrile or malignant diseases, particularly after
the absorption of morbid matters into tlie blood.
Tile occurrence of epistaxls, of swellings of the
parotids ; the accession of the catumenia, or the
lia?morihoids ; a fiECuIent diarrhoea ; copious
general perspiration ; abundant discharge of urine
depositing a sediment ; erysipelas, eruptions, boils,
gout, or rheumatism, appearing in external parts,
])articulavly the lower extremities; and the re-
turn of sound natural sleep during a state of
coma vigil, or typhomania; are very favintrable —
indeed, critical symptoms. 'J'he persistence of
the affection ; scanty secretion or retention of
111 ine ; subsultus ; spastic contractions of one or
more limbs; loss of speech, and total insensibi-
lity; distortion of the eyes; vomiting or retching;
a previous breaking up of the constitution ; pre-
existing cachexy, and old-age ; bleeding from the
ear, when it has been caused by external injury,
as in concussion ; constant supine posture, and
slipping low down in the bed ; coldness of the
head, with sunk countenance, and cold clammy
surface ; loss of the faculty of deglutition, or re-
turn, of matters put in the mouth; are very w/t-
favouraMe signs.

13. \ . Pathology. — A. Primary and symp-
tomatic coma may be resolved into the following
fiatholog'ical states, either of which may exist
singly, or in conjunction with one another : — 1st,
Exhaustion of the organic nervous influence sup-
plying the brain, or torpor or suppression of it,
inducing a state which may be called paralytic —
a paralysis of all the cerebral functions : this
condition is produced chiefly by directly or indi-
rectly sedative causes, and by whatever depresses
or exhausts the vital energy generally, or the
nervous power in particular: it may be attended
by ana,>mia of the brain ; and then the coma will
be preceded by, or accompanied with, convul-
sions, or alternate with them; but it is more
frequently productive of some one of the states
about to be noticed, especially congestion, and
occasionally effusion within the head: it may go
on to dissolution, or it may be followed by re-
action and active congestion or acute inflamma-
tion ; the comatose states sometimes observed
at the invasion of dangerous forms of fever, and
of certain apoplectic seizures, and the coma of
the earl}' stage of concussion of the brain, being
of this description. — 2d, Congestion of the capil-
laries, veins, or sinuses of the brain, is, perhaps,
the most common morbid condition that obtains
in coma, as respects the vascular system : but this
state can scarcely arise, unless the organic nervous
influence with which these vessels are supplied
has been exhausted or depressed, excepting in
those cases where the congestion proceeds from
obstructed return of blood by the sinuses, or by
the large veins coming from the head : in many
cases, therefore, the existence of this slate pre-
supposes that first described, at least to some ex-
tent ; and whether thus originating, or proceeding
from impeded or obstructed return of blood, will
equally occasion pressure of the organic nervous
and cerebral tissues, and suppression of their
functions: congestion of the blood-vessels within
the head may, moreover, be associated with some
Other morbid states, as with contamination of the

circulating fluid ; as in the coma that occurs in the
advanced stage of typhus, and when morbid se-
cretions are absorbed into the blood. — 3d, Active
determination of blood to the head will seldom
occasion more than lethargy or coma vigil, —
states which are frequently produced in this way in
the advanced stages of various acute diseases, and
sometimes by the use of anodynes, which, in some
constitutions, disorder the nervous functions and
excite the cerebral circulation. — 4th, Inflammation
of the brain or membranes, owing to the tume-
faction consequent on it, &c., will often be ac-
companied with coma; and still more frequently
terminate in it, — as shown in the article on that
disease : and, as we have seen that coma will thus
proceed from very different or even opposite
states of organic nervous power, and of vascular
action, it becomes a matter of the utmost practi-
cal importance to distinguish them with accuracy :
but not only may those pathological conditions
exist in different cases, they may obtain at differ-
ent stages of the same case : thus the coma of
concussion, in which the first of those conditions
exists, may successively pass into congestion and
inflammatory action, forming the three stages
which Mr. Abernethy has very accurately
pointed out in concussion of the brain; coma,
accompanied with very different symptoms, and
modified in degree, being present throughout. —
5tli, The circulating fluid itself may be more or
less changed ; it either being of a darker colour,
and in a less decarbonised state, than in health ; or
having entirely lost the power of coagulating,
or presenting a coagulum of a weak or dissolved
texture. (See Blood, § 94.) In addition to
this state of the circulating fluid, congestion of
the cerebral vessels and increased action of the
heart may exist, as in the advanced stages of
malignant, exanthematous, and febrile diseases;
these associated lesions may be also preceded by,
or coexistent with, depressed vital or organic
nervous energy of the encephalon. — 6tli, Effusion
of blood or serous fluid within the brain will
give rise to profound coma, generally as a conse-
quence of either the first, second, third, or fourth
preceding states, occurring either primarily, or in
the advanced progress of febrile diseases.

14. B. It must be evident, that a successful
treatment of coma, under the numerous circum-
stances and diversified forms in which it presents
itself in practice, must be based upon a recogni-
tion of the pathological states that occasion it.
But how are these states to be ascertained 1 The
difficulty even of an approximation to this know-
ledge is doubtless great ; but the practical results,
to which the information leads, are of the utmost
importance, as respects both the issue, and the
reputation of the physician. I shall therefore
offer a few remarks, with the view of facilitating
the investigation of this subject, and placing our
intentions of cure upon a rational basis. — a. In
the Jirst of the above pathological states, the
pulse is weak, soft, unequal, or intermitting; the
pulsation of the carotids is smaller, weaker, and
softer than natural ; the breathing is soft, slow,
or laboured, but without stertor ; the limbs and
muscles are relaxed, and deprived of sensibility ;
the surface is pale, cool, moist or clammy, par-
ticularly the extremities; the head is cool, or at
least not above, frequently below, the natural
temperature ; the countenance is pale Qr sunk ;
Cc 3

390

COMA AND LETHARGY — Treatment OF.

the eyes open, without suffusion, and the pupils
dilated ; the tongue is soft, flabby, and broad,
unless in the last stages of fever, when it is covered
by a brown or dark fur ; and the skin is dry or
harsh. The feebleness and intermissions of the
pulse, the depression of animal heat, and the loss
of sensibility and voluntary motion, are generally in
proportion to the exhaustion of vital power in the
brain, and therefore important guides in the treat-
ment of coma. — b. The second pathological con-
dition, or that of congestion, will vary in different
cases, or even in different stages of the same case,
from the depressed state of vascular action and
animal heat, described above, to that now to be
noticed. The pulse is oppressed, or full, slow,
irregular, occasionally nearly natural, — in the
carotids somewhat fuller, stronger, or more labour-
ing, than in health, or in other parts where it can
be felt ; the respiration is either natural or slow,
laborious or irregular ; the countenance is slightly
tumid, bloated, or livid ; the eyes are somewhat
suffused and prominent, the pupils dilated and in-
sensible ; the temperature of the head is occa-
sionally natural, but more frequently slightly
increased, and the face and scalp moist ; the ap-
pearance of the tongue, as in the foregoing state,
varies according as the coma is a primary or con-
secutive state of disease ; the evacuations are
either retained or passed insensibly ; and sensi-
bility, voluntary motion, and mental manifest-
ation, are abolished in proportion to the extent of
depression of the organic nervous influence of the
brain, and of vascular congestion. This state
may supervene on the former with more or less
rapidity, and terminate either in a return to
healthy action, or in the third a.nd fourth states
referred to. — c. The third and fourth patho-
logical states are different grades of vascular
action, often arising out of the preceding : that
consisting of active congestion or increased deter-
mination of blood through the cerebral vessels
may present nearly the same symptoms as those
characterising congestion, but in a much slighter
degree ; sensation and voluntary motion not being
quite abolished ; the coma being in its slighter
grades, — as lethargy and coma vigil, very rarely
coma somnalentum. The pulse and respiration
may not be materially affected, or it may be
merely accelerated ; the temperature, even of the
head, may also be natural, or but slightly in-
creased, that of the extremities being depressed ;
the countenance may not be materially changed ;
in some cases it may be even sunk or depressed ;
but the carotids generally beat more fully and
strongly than in health ; and the mental mani-
festations are not merely more or less suppressed,
but sometimes also disordered. The state of in-
flammatory action, and its consequences, give rise
to phenomena of greater intensity than those now
noticed, and which have been very fully de-
scribed in another place. (See Uhain, $ 180.) —
d. The fflh state which I iiave referred to, as
obtaining in some cases of coma, seldom occurs
alone, but is associated witii one or two of the
preceding, particularly ihefrst, second, or even
the third conditions. It is characterised chiefly
by a lurid, foul, diity, or cachectic appearance of
the surface; a sunk or sallow countenance; a
frequent, soft, small, or broad and open pulse : by
low delirium or typhomania ; starting of the ten-
dons, and picking of the bed-clotlies ; preceding

and associated febrile, exanthematous, or malig-
nant diseases ; and by foetor of the secretions and
excretions. In some cases, when this state has
come on rapidly, the tongue is merely broad,
flabby, marked by the teeth at the edges, and
covered by a creamy sordes ; but in the last
stage of acute diseases, it is deeply furred, or
coated with a thick mucous sordes of a dark
brown colour, often extending to the gums, and
even to the lips. — e. The si.rt/i and last state,
that of effusion, may be consequent upon any of
the preceding, and be caused by one or more of
them. If the effusion be sanguineous, the attack
is often sudden ; the respiration is generally ster-
torous, irregular, iScc. ; and signs of local para-
lysis may often be detected. (See Apoplexy.)
If serum be effused, the coma is as profound as
that caused by sanguineous effusion ; but slower
in its accession, and less frequently attended by
stertorous breathing, and local paralysis ; it is also
more commonly preceded by signs of inflammation,
active determination, or congestioiiof blood, within
the head. (See Dropsy of the Encephalon.)

15. VI. Treatment. — The foregoing patho-
logical states will often insensibly lapse into one
another, as in concussion and inflammation of the
brain, giving rise to distinct stages of these dis-
eases, and requiring a different treatment for each i
and, according as they may thus vary, so will
their symptoms be modified ; the principal pheno-
mena connected with the cerebral functions,' the
pulse, the respiration, the animal temperature,
the state of the head and carotids, &c. being the
practitioner's guides in the direction and com-
bination of his means of cure. These means
will now require no further notice than a
bare enumeration, as they are more fully dis-
cussed in the articles on the diseases in which
coma, in one or other of its forms, most commonly
presents itself.

16. A. The first pathological state (§ 13, 14. a.)
requires stimulants and counter-irritants ; but these
remedies must be exhibited with much caution ;
as an excessive or inappropriate use of them
might produce, even in the slighter cases of cere-
bral exhaustion, determination of blood to the
head, and convert congestion into inflammation, —
consequences which will frequently supervene, at
least in a slight degree, as in concussion, not-
withstanding the utmost care to avoid them.
The preparations of ammonia, musk, and cam-
phor, internally and externally employed ;
enemata, containing the same medicines, or the
infusion of valerian, castor, assafoetida, or the le-
rebintiiinates ; win& and cordials, given frequently
and in small quantity ; irritating or vesicating
embrocations, cataplasms, sinapisms (Celsus,
Aret/eus, Paulus yEgineta), to the head,
and plasters, as well as moxas, and the cautery
(Zacutus Lusitanus, Ilnomus, and Seveiunus)
applied to various parts, or even to the head it-
self; blisters to the nape of the neck, behind the
ears, or to tiie head (Boxet, Lanzani, Syden-
ham); volatile substances held to the nostrils or
applied to the temples ; errhines (C-i:mus Aure-
lianus, &c.) ; urtication (Aret^eus Selti) ;
galvanism and electricity (Hufeeano, Sec); the
aftusion of warm, tepid, or, in some, cold water
on the head ; active and stimulating emetics
(UiviERE, lliGAL, &c.) ; purgatives combined
with stimulants, antispasmodics, and tonics ;

COMA AND LETHARGY— Treatment of. 391

cathartic clysters, conjoined with similar sub-
stances ; the use of coffee and green tea, particu-
larly when this state of disease has followed the
ingestion of sedative or narcotic poisons, and
after the stomach has been evacuated by emetics
and the stomach pump, and washed out by the
injection of warm water ; are severally of use in
this state of coma, and may be resorted to in
various combinations, according to the circum-
stances and severity of the case. All these mea-
sures are, however, not equally applicable to
every case where this pathological state may be
presumed to exist ; but the judgment and expe-
rience of the practitioner can alone enable him to
employ them in an appropriate manner ; the
shades of difference in particular cases requiring
certain means, or peculiar combinations of them,
scarcely admitting of description, at least within
the limits to which I am necessarily confined.

17. B.Thesecojfrf pathological state (§ 13, 14.6.),
when closely verging, as it occasionally does, upon
the first, will require several of the means enu-
merated with respect to it ; whilst, when fully
formed, and approaching that of active determin-
ation or congestion, but few of them are appli-
cable. Much, however, will manifestly depend
upon the habits, and the constitution of the pa-
tient ; upon the nature and duration of the disease
of wiiich coma is an advanced phenomenon ; and
upon the state of the pulse, the temperature of
tlie head, and the character of the countenance.
The ^'rst state is injured by blood-letting in any
form, it being even not an infrequent consequence
of inanition, or even of anaemia of the brain ; but
this second state will generally be benefited by
depletion, and in proportion to its approxima-
tion to the third and fourth states described
above (§ 13, 14. r.). The question chiefly is
as to what extent it may be carried, and the
manner in which it may be performed. In the
majority of cases, local depletions by cupping
between the shoulders and nape of the neck, or
by leeches applied behind the ears or on the neck
and occiput; by simple scarifications by a lancet
in the last-named situation, in some cases; in
others, bleeding from the feet .whilst they are
placed in warm water, and cold or tepid water
is being poured in a stream upon the head ; and
in certain instances the application of a number
of leeches on the inside of the tops of the thighs,
or about the anus ; are the preferable modes of
having recourse to depletion in this state of disease :
but the extent to which the evacuation should be
carried must entirely depend upon the symptoms
and circumstances of the case, and the effects
produced by it. In addition to this important
means, purgatives ought to be given by the
mouth, and their action increased by cathartic
clysters, in which either assafcetida, valerian,
camphor, the terebinthinates, or other antispas-
modics and stimulants, may be also exhibited.
Counter-irritants and derivatives should be ap-
plied, but at a distance from the head; and,
while a frequent operation of the bowels is pro-
cured, the functions of the skin and kidneys
should be promoted by diaphoretics and diuretics,
the extremities being kept warm, the head cool,
its hair cut off, and the shoulders highly ele-
vated. In many instances of this state, even
local depletion should be cautiously employed ;
and in these, as well as in others, much advantage

will often accrue from having recourse to resto-
rative means. It is in this pathological condition
of coma, and in those about to be noticed, that
oil of turpentine, in large doses, so as to act freely
on the bowels, has proved so beneficial in my
practice. This state very generally obtains in
coma from narcotics and spirituous liquors ; and
is then, especially, very remarkably benefited by
the cold affusion on the head, and the prepara-
tions of ammonia.

18. C. Thethird a.nd fourth states (§ 13, 14, c.)
require nearly the same treatment as the second,
but carried much further ; general and local de-
pletion, cold affusion on the head, or the applica-
tion of ice, or evaporating lotions ; the most
active cathartics, clysters, and derivants or coun-
ter-irritants, and the other measures, as fully
pointed out in the article on Injiummation of the
Brain (§ 174.). When these states have gone
on to effusion either of blood or of serum, — the
siith pathological condition adduced, — the
treatment recommended in Apoplexy and in
Dropsy of the Encephalon (see these articles)
should be employed.

19. D. The Jifth pathological state obviously
requires stimulants, tonics, and antiseptics, par-
ticularly camphor, in considerable doses ; the
chlorides of sodium, potassium, &c. ; wine, with
cordials, spices, &c. ; bark, with camphor ; purga-
tives conjoined with stimulants, so as to excite
the eliminating or depuratory functions ; cathar-
tic, tonic, and antiseptic clysters ; calomel,
combined with camphor and ammonia, or musk;
the turpentines given by the mouth, and in ene-
mata, with capsicum and aromatics; external
derivation and counter-irritation ; the various
balsams, with the chlorides, &c. ; quinine, with
the aromatic sulphuric acid ; the preparations of
cinchona or cascarilla with soda, or with the hy-
drochloric acid, or hydrochloric aether ; Cayenne
pepper internally, as well as externally in
camphorated embrocations, &c. When coma
is consequent upon the retrocession of gout ,
rheumatism, erysipelas, or cutaneous eruptions,
the propriety of having recourse to sinapisms,
rubefacient pediluvia, and other derivatives, in
addition to such other means as the symptoms of
the case may suggest, must be obvious. If it
follow suppressed discharges, we should endea-
vour to restore these, or produce one supplemental
of them. (See the treatment of the diseases of
which coma is most frequently an important
symptom.)

BiBLioG. AND Refer. — Hippocrates, IIej/ vovrtuv, iii.

Opp. p. 488 Galen, Lib. de Comate, cap. ii.' t. vii. p. 195.

— Celsus, 1. iii. cap. 20. — Aretceus, Cur. Acut. 1. i.'c. 2. — .

I'aulus JEglneta, 1. iii. cap. 9. et 10 Oribasius, Synop.

1. viii. c. i. — Avicenna, Canon. 1. iii. fen. i. tract, iii. c. 7.

&c Zacutus Lvsitanus, Pr. Hist. 1. vii. obs. 4. (The

actual cautery belmul the ears.) — Rhodius, 1. i. obs. 3fi.
(The cautery to the neck.) — Severinus, De Efficac. Med.

p. 21S. — I}iillomus, Consult. 1. i. 45., 1. iii. 32 Willis,

De Anim. Brut. Path. cap. 3, 4, 5 — Biverius, Prax. Med.
t. i. cap. i. — Sydcnhani, Opera, p. 281. — Bonet, Sepul.

chretum, 1. i. sect. iii. obs. 5. 13. 18 Eiscn, De Comate

Somnalento. Basil, 1674. — Heinz, De Affectibus Soporosis.

Argent. I(i77. — Morgagni, Epist. v. art. 13. 23. 29—36.

Bellini, De Morbis Capitis, p. 455. — Hoffmann. De Af-
fect. .Soporosis, obs. 5. Opp. iii. p. 216. — Boerhaave, De
MorlMs Nervorum, p. 640 — Cartheuser, De Typhomania.

Francf 1750 Kriiger, De Somno, Morborum Matre et

Fillo. Helms. 1754.— //a/to", Observat. Med. Pract. Goct.

1750. — Saiivages, v. iii. class, vi xxix. 7. — Bang, in

Acta Reg. Soc. Med. llafn. vol. iii. p. 127. f'ogel, Beo-

bachtungcn, No. 9. — Hinze, in Stark's Arctiiv. b. vi.

p. 178. — Behrends, in Uiijeland's Journ. der Pr. Heilk.

b. .\i. 2 St. p. 1. ; Ibid. b. xx. 4th St. p. 5. {Galvanism re-

C c 4

392

CONCRETIONS, BILIARY-

•Pathology or.

commenced in.)-^Iiigal, in Mem. de Toulouse, 1788. —
Portal, Cours d'Anatomie Med. t. i. p. 21 . [An instance of
coma from narrowing of the carotid arteries.)' — Selti, in'
BrugnateUi, Bibliotheca Fisica, v. ii. — Brewster, Ediii.
Philos. Trans, for 1817. {Idiopath. coma from coitgestiuij.)

— Cooke, Treatise on Nervous Diseases, v. i. p. .S72.
(Idiopath. lethargy.)— J. Frank, Praxeos Med. Univ. prae-
cepta, par. ii. vol.i. sect. i. p. 357. — /?('A«,',in Encyclopiid.
Worterbucii der Med. Wissenscliaften, b. viii. p. 107...—
{Boriet's Thesaurus Med. Scrip, t. i. p. 715., and iiis Mer,
curius, &c. ]). 61tj. ; also Mangel's Bibliotheca Med. Script.,
art. Carus, and Ploucquct's iNIedicina Digesta, art. Co7iia,
maybe consulted by the curious; but little information of
importance will be obtained.}

CONCRETIONS, Biliary. — Svn-. CaU
culi or hapitii Oystici ; Calculi Fellei; C.
Biliares;'C. BUiarii ; Chqlelhhi ; Hepatalgia
Calculosa ; Var. Auct. Concrementa Bitiuria,
Soemnj'errlng'. Chtriotithus, Good. Calcuts
Biliares, ¥r.>Difi, Galleiistein, Ger. Gall-stones,
Gl'assif. i.- C/ttss, Cceliaca ; 2. Order,
■ ■ Splanchnica, Gen. iii. (Good). I. Class,

,. I-l.- Order (Author).
I.'Defin. Concretions formed in the bile-pas-
sages, and occasioning in many instarfces more or
less disturbance, with paroxysms of pain commonly
referred to the right epigastrium and hypochon-
drittmt reaching to the back, t\r., with increased,
suffering whilst passing into the alimentary canal,
and often giving rise to sickness or vomiting, to
jaundice, and severe attacks of colic.

2. Biliary concretions were first noticed by
Benevenius, Fali.opius, Vesalius, Kent.mann,
and Fernelius, who were nearly contemporaries.
They were afterwards more accurately described
by Glisson, Hoffman, INIorgagni, Bianchi,
Boerhaave, Van Swieten, and particularly by
Haller ; and the more recent researches of

HebERDEN, SOEMMERRING, ThOMSON, ThENARD,

BosTOCK, Merat, and Chevreul, have greatly
advanced our knowledge of their nature and
pathological relations. Notwithstanding the fre-
quency of these concretions, and the very serious
symptoms they occasion, but little attention has
been paid to them by practical writers since the
appearance of Soeji.aierring's Treatise ; and they
have been nearly overlooked by the majority of
systematic writers. Haller remarks (what every
pathologist will acknowledge), that they are in-
finitely more frequently found in post mortem
researches than calculi of the urinary passages ;
and Heberden agrees with him in admitting
that, while urinary calculi are much more com-
mon in the male, biliary concretions are most
frequent in the female sex — probably in the
proportion of one in the former, to four or five in
the latter.

3. I. JJrscnii'TioN. — Biliary concretions vary
remarkably as to form, size, number, and colour,
as well as composition. — a. They may exist in any
number — from one to a thousand, or even more.
MoRGAGM, Walter, and ]?aillie, have found
the latter number; and Soejmmerring, with
many of the authors referred to at the end of the
article, have observed from fifty to several hun-
dreds, and even upwards, either in the gall-blad-
der, or in the ramifications of the hepatic ducts.
When thus numerous, they are usually very
small — the sizi; of pin-heads, or but little larger

— of a dark brown, green, or greenish yellow
colour, sometimes almost filling the gall-bladder,
and occasionally sliglitly agglutinatetl by thick
bile. IMore frefjucnlly, however, a small num-
ber, or two, tliree, or four are delected, and very

■often only one. When only two or three are
found, they sometimes are jointed into each other,
or have their opposite surfaces smooth or flat. In
rare instances they seem divided by a septum. —
h. •-When one, two, or three only exist, they are
u^sually large, but they seldom reach the size of a
hen's egg, or are much larger tlian a walnut.
Dr. Saunders, however, has found one of the
bulk and figure of the gall-bladder, which it
filled. They are not infrequently as large as a
pigeon's egg, or as a hazel nut; and are often
found from that size downwards. — c. Thtir colour
varies through every shade of black, green, brown,
yellow, white, &c., that of the surface often dif-
fering from the centres and certain of their layers.
They are often beautifully mottled or marbled ;
sometimes white and shining like spermaceti ; at
other times dull, like wax ; occasionally lamel-
lated ; often crystallised or striated, either with
or without distinct centres, which are frequently
different in colour and composition from the por-
tions crystallised or collected around them. They
are also more or less opaque, or slightly translu-
cent.— (/. Theiryarm varies from a round, oval, or
oblong — when they are solitary — to a cone, a
cube, pentagon, polygon, &c., when more nu-
merous. They are usually smooth, sometimes
polished, particularly the surfaces that have been
in contact with each other; more rarely rough
or glabrous, and occasionally they appear as
broken into fragments. — e. Their consistence also
varies from what is barely sufficient to preserve
their form, to that which does not yield to the
pressure of the finger, and is divided by a knife
witii difficulty. — /. Their specific gravity is much
more frequently below, than above, that of water ;
consequently, they are commonly found swim-
ming on the surface of water when the evacu-
ations are mixed with it.

4. Situation and Composition. — Biliary con-
cretions have been found in every part of the
biliary passages: — 1st, In the radicles of the
hepatic ducts; 2d, In the hepatic duct, and its
ramifications ; 3d, In the cystic duct ; 4lh, In
the gall-bladder; and, 5th, In the common duct.
They have been likewise found in every part of
the intestines, in their passage out of the body ;
and, in rare instances, in the stomach, whence
they have been observed to have been ejected
by vomiting. These concretions are often
the result of obstruction to the course of the
bile ; and are then generally found to consist
of an admixture of inspissated bile with mu-
cus. But more frecjuently they are a conse-
quence of an alteration of this fluid from its
healthy constitution, as respects either the pre-
sence of elements foreign to it, or the super-
abundance of those which are the least soluble,
and which are precipitated during the retention
or accumulation of bile in tlie ducts and gall-
bladder ; the latter being most commonly the
case. Of this description are the concretions
formed of a crystallisable fatty matter described
by Poui.letier de la Salle and Fgurcrov,
under the name of adipocire, afterwards by Mar-
CET, BosiocK, he, and named cholalerine by
CiiiiVREUL. Some biliary caL-uli consist almost
entirely of this substance. Others are formed of
mucus and the thit-kened yellow matter, or the
resin, of bile ; and many are composed of clioles-
terine, the yellow matter, and the resin. Instances

CONCRETIONS, BILIARY — Symptoms.

393

of concretions, different from these in composition,
have been noticed by JMarcet, Orfila, and.
Caventou ; but they are very rare. The greater
part of these that consist of chole§terine have
inspissated bile for nuclei, which, having passed
along the hepatic ducts into the gall-bFadder,
form tlie centres around which the cholesterine
crystallises. All these are soluble in warm
alcohol, which deposits the solution in brilliant
crystallised plates when cold ; also in spirit of
turpentine, and in the ajthers, or in an admixture
of turpentine and aether, leaving more or less of
a residuum, according to the quantity of mucous
or animal matter they contain. They also form
a soapy solution in the caustic alkalies, melt at a
high temperature, are inflammable, and insoluble
in water.

5. The formation of biliary concretions in the
radicles of the bile-ducts has been disputed ; but
I\I. Chuveilhier has given a very fine illustra-
tion of this rare occurrence in his excellent pa-
thological work. ^Vhen found in tiiis situation,
they generally consist of very small grains, of
variable size and form, and of a dark green co-
lour, disseminated through the healthy structure
of the liver, and are formed chiefly of inspissated
bile. Biliary concretions are most commonly
found in the gall-bladder, and are usually the
consequence of the remora or accumulation of
bile ; the absorption that takes place of its watery
parts during its retention probably occasioning
the precipitation or concretion of such of its more
solid ingredients as it can no longer hold in so-
lution or in suspension. Soemmerring, how-
ever, supposes that they form very rapidly, with-
out any absorption or inspissation of the retained
secretion ; and this is probably more frequently
the case, particularly in respect of those consist-
ing chiefly of cholesterine, and when irritation of
the internal surface of the gall-bladder produces
a morbid secretion, which may combine with tlie
less soluble ingredients of bile, or dispose them to
crystallise, particularly when they are secreted in
larger quantity than natural, owing to a defect
of the assimilating functions, and consequent ac-
cumulations of the elements of a morbid biliary
secretion in the blood.

6, II. Symptoms. — Calculi in the gall-blad-
der seldom give rise to any marked or definite
symptom unless they are very large, obstruct
the outlet of tiiis receptacle, or excite inflamma-
tion of its mucous surface. Every experienced
practitioner must have met with cases in which
these concretions have been evacuated, and others
also in which the gall-bladder has been found,
after death, filled with them, without any ailment
referrible to this organ having been complained
of. The symptoms, therefore, usually stated to
proceed from concretions in the gall-bladder
should be viewed with limitations, inasmuch as
they are not necessarily consequent upon their
actual presence in it, and as they may proceed
from some other pathological states. But, whilst
we should view these symptoms with caution, we
ought not to reject them ; for although concre-
tions may form, and even pass into the alimentary
canal, without creating much disturbance, or
giving rise to any symptom distinctive of the ex-
isting derangement, yet not infrequently their
presence, particularly their passage from the gall-
bladder into the intestines, occasions such a train

of morbid phenomena, as will often enable the
observing practitioner to form a correct diagnosis.

7. A. Of calculi in the gall-btadiler. — Pa--
tients with biliary calculi often complain of a
sense of weight and oppression at the epigastrium,
and right hypochondrium, with cardialgia and
various . dyspeptic symptoms, especially after a
qieal, with constipation or slight irregularity of
the. bowels, an occasioi>al deficiency of bde in
the evacuations, and sallow or yellowish tint of
the countenance and skin. In some cases a dull
pain in the epigastrium, with a tympanitic ful-
ness, is felt (Strack); and in lean persons, a dis-
tinct tumour below, the anterior, margin of the right
ribs may occasionally be detected, particularly
when signs of obstructed excretion of bile have
previously existed, indicating its^accu'niulation in
the gall-bladder. These may be all the syrnp-
toms, and often so slight as' not. particularly to
interest the patient; they may, even.vyhen most
evident, continue a longer or shorter time, until,
at last, the pain and uneasiness increase, — espe-
cially when the patient turns, or lies upon the left
side, uses exertion, rises quickly to the erect pos-
ture, takes a full inspiration, or soon after a meal,
— and extend to the right hypochondrium, to the
back or right shoulder-blade, sometimes to the
right breast, shoulder, arm, and side of the neck,
and even throughout the abdomen, particularly to
the right flank and hip.

8. B. The symptoms indicating the passage of
coficretions into the intestines may not differ
materially from the above, excepting in their se-
verity and duration ; and they often have little
relation to the size of the calculus. When the
concretions still remain in the gall-bladder, they
occasion either little or no disturbance, or such as
has been novv' described, in a more or less con-
tinued form. But when they are passing along
the ducts, the symptoms are often very sudden
in their invasion, of much greater intensity, of
shorter duration, and generally recur in paroxysms.
The pain is then frequently very acute, is attended
by nausea, flatulence, or vomiting, by a bitter
taste in the mouth, acid or bitter eructations,
irregularity of bowels, colic, or distension of the
abdomen, &c., and is followed by either a com-
plete jaundice, or a slight yellow tint about the
eyes or lips, the cheeks being clear. This discolour-
ation commonly passes oft' soon after the paroxysms
of suffiering, which often come on about two hours
after a full meal, and it either recuis along with,
or follows closely upon, them ; but it is not, nor,
indeed, are any of the symptoms enumerated,
constantly observed, as Coe, J. P. Frank, and
others, have demonstrated, and as every expe-
rienced practitioner must have remarked, even
when large concretions have found their way
into the bowels. The pulse is generally unaf-
fected, and there is no fever, unless in the more
violent seizures, or after their frequent recurrence
or long duration ; when, in addition to these
symptoms, loss of flesh and strength, a furred,
loaded, dark yellowish tongue, great restlessness,
anxiety, and tenderness at the epigastrium, and
right hypochondrium, are observed. The inter-
vals between the attacks are extremely variable.
Sometimes the paroxyms are periodic ; and are
evidently owing on these, as well as on other
occasions, either to some change in the position of
the concretions, or their passage into the intestines,

394 CONCRETIONS, BILIARY — Symptoms,

or to inflammation produced by them in the gall-
bladder and ducts. In many instances they are
most ex'cruciating ; the patient is bent double,
rolls about in great agony and anxiety, or presses
upon the epigastrium, and complains of an acute
or lacerating pain in the region of the ducts and
duodenum, cither with leipothyma or syncope ;
or with retching, distension of the abdomen,
and severe colic. Females- — who are most sub-
ject to these seizures — sometimes experience
more suffeiing from them, than from parturition ;
and even in them the pulse may not be afiected.
The bowels are more fiequently constipated than
relaxed, and the motions are often devoid of bile,
although dian'hcea be present. The most acute
attacks may terminate as suddenly as they com-
menced, the patient soon recovering his strength
and functions, unless more calculi remain to be
passed. Tiiey are usually of short duration —
not exceeding a few hours ; but they become
longer after their repetition, sometimes at least
continuing several days, with partial remissions.
Occasionally they are preceded by a sensation of
something unusual, or alive, in the region of the
stomach, or in various parts of the abdomen ; and
attended by dryness or slight pain of the throat ;
by thirst ; inability to straighten the trunk, or to
keep it erect ; by scanty, orange, or high-coloured
urine, and slight strangury.

9. C. The ufj'ections (iiid lesions sometimes ca7ised
hy biliary concretions attach to themselves m.uch
interest. In some cases, violent convulsive mo-
tions come on, from the pain and irritation they
occasion, either with or without vertigo, headach,
and cerebral congestion. Mental depression,
obstinate dyspepsia, hypochondriasis, and melan-
cholia ; also flatulent and colicky states of the
bowels, constipation, and diarrhoea ; are not only
frequent attendants upon, but also consequences
of, biliary concretions. 'J'he less common dis-
orde)"s they occasion are, dyspnoea, syncope, slow
remittent states of fever, ha-morrhoids, suppres-
sion of the catamenia, and apoplexy (15ue-
SEEi). The effects produced by them upon the
gall-bladder and ducts are often most important;
inflammation, thickening of their coats, ulcer-
ation, great dilatation of the ducts, adhesion of
them, or of the gall-bladder, to the duodenum,
or of the latter to the stomach, liver, or colon,
or even to the ])arietes of the abdomen, witii
ulceration, and passage of the calculus into any of
these parts of the digestive canal, or through an ex-
ternal opening at the rightepigastrium, having been
observed by several eminent authoriiies. Coi.om-
Bus states, that, upon the examination of the body
of the celebrated Ignatius LoYOtA, abiliaiy cal-
culus was found to have ulcerated its way through
the gall-bladder, into the trunk of the vena jjorta.
CiiEsici.DEN mentions a case in which two large
calculi made their way, by inflammation and ul-
ceration, tlirough the abdominal parietes ; and
.similar instances are recorded by Hoffmann and
CiiELL, in one of which about eighty small cal-
culi passed out through a sinuous ulceration
below tlie right ribs. 'I'oi.ir states a case in
which a biliary concretion of the size of a pigeon's
egg was discharged from an ulceration at the
umbilicus ; and BuF.TiNrn saw thirty-eight calculi
discharged in Xhc. same situation. S( iiuiuo men-
tions an instance of two such concretions having
been taken from an abscess in the anterior ab-

dominal parietes, opened by Fabeicius j and
cases have been recorded by Block, Hallee,
WiNCKEL, Dixon, Caixoway, and Baffos,
of tumours having formed below the cartilages
of the right false ribs, followed by inflamma-
tion, ulceration, and the discharge of biliary
calculi of various sizes. Soemmeeeing states,
that he has a preparation of a gall-bladder filled
with concretions, and having an ulcer at its fun-
dus, through which one of them had escaped. J.
P. Feank found, in the body of a woman who
died during the puerperal state, the gall-bladder
ruptured, and containing calculi, to which he
attributes the rupture ; and he met with another
case in which the calculi had occasioned abscess
and rupture of this viscus. Mr. Beayne has de-
tailed an interesting case, in which adhesion of the
gall-bladder to the duodenum had occurred, and
in the centre of this adhesion an ulceration into
the intestine had taken place, through which a very
large calculus had passed, and been discharged
by stool, a considerable period before the death of
the patient ; and similar instances are alluded to
by Dr. Saundees, as having been observed by
Dr. CfiESTON and Mr. Cline. It is not impro-
bable, that in some of the instances on record, in
which biliary concretions have been voided by
vomiting, adhesions of the gall-bladder to the
stomach had taken place, and the concretion had
made its way by ulceration at the place of ad-
hesion into this viscus, from whence it had been
ejected. A reference to the cases recorded by
ScnuEiG, Oetesch, and Biondi, in which biliary
concretions had been evacuated from the stonuich,
will show that this is not an unreasonable inference.
10. Besides the usual appearances produced
by inflammatory action in the coats of the gall-
bladder, viz. adhesion to adjoining parts, thick-
ening, ulceration, &c., they have been found
almost or altogether destroyed by suppurative
ulceration. In a case detailed by Dr. Scott,
they were half an inch in thickness ; and Hal-
lee observed them destroyed by suppuration and
ulceration — the calculus that had caused the in-
flammation lying in the midst of a disorganised
and puriform matter. Obturation of the ducts
has been often found on dissection, the gall-
bladder being at the same time enormously dis-
tended by accumulated bile. In many cases, the
ducts have been found very much dilated after
the passage of large calculi through them. Such
cases have been recorded by Walteb, Dieteich,
RicinEE, Thomas, Ceaigie, &c. Heisteu
found the common duct dilated so as to admit his
little finger. Morcacni states, that he has ob-
served the same ducts so wide that its diameter
was nearly two fingers' breadth; and Soemmee-
eing has preserved, in his museum, several spe-
cimens of great dilatation of this canal. Huysch
and Blumenbacii have found biliary concretions
in the substance of the liver; and others that had
perfori'.ted the cystic duct, and caused ulcerations
of both the liver and duodenum. Waltee ob-
served the ramifications of the hepatic duct,
throughout nearly all the liver, enormously dilated,
and filled witii bile and some thousand small cal-
culi ; and CiiuvEiLiiiEn and myself have met
with very great distension of all the ramifications
of this duct, with thickening of its coats, and con-
cretions mixed with viscid bile throughout their
canals. It is obvious that concretions, either ia

CONCRETIONS, BILIARY — Causes, &c.

395

the hepatic ducts or in the gall-bladder, will
sometimes give rise to very serious disease of the
liver itselt. A torpid state of this viscus, so fre-
quently observed in connection with their form-
ation, is rather their cause than their efl'ect. Hence
obstruction of the liver, and its consequences,
particularly dropsy in some one of the shut cavi-
ties, or the cellular tissue, are of more frequent
occurrence than inflammation of this organ; but,
nevertheless, both acute hepatitis and abscess of
the liver have been sometimes met with, owing to
biliary concretions.

11. D. When biliary concretions, particularly
those of a large size, have passed into the intes-
tinal canal , tliey often give rise to very severe
and even dangerous symptoms. Cases have been
referred to in the article C.'ecum, in which I had
seen fatal results, consequent upon the pas-
sage of biliary calculi into the appendix of the
CKCum, they having produced inflammation, ul-
ceration, or gangrene of this process, and, con-
secutively, fatal peritonitis : and, in the case
recorded by Civadieh, where a biliary concretion
had escaped by an ulceration in the right groin,
it is very probable that it had passed out through
the caecum, by inducing inflammation and ulcer-
ation of this part. The more common conse-
quences, however, are, thirst, constipation of the
bowels, colicky pains, sometimes tenderness on
pressure referred to a particular part of the ab-
domen, followed by tenesmus, alvine evacuations,
and the passage of the calculus. When it is
very large, the symptoms will be the same as
enumerated with reference to Intestinal Concre-
tions, or it will produce severe colic or ileus.
Instances of fatal results, sometimes occurring
very rapidly, from biliary calculi, have been ad-
duced by several of the authors already named,
as well as by Bianchi and Riciiter ; those of a
slower progress have presented, with various
organic lesions and dropsical eft'usions into the
large cavities, — consequences) which have some-
times not appeared until a remote period from the
voiding of concretions.

12. III. Causes. — Biliary concretions occur
much more frequently in the female than in the
male sex, and during the decline of life, than at
an early age. They are very rarely met with
much before the prime of life, and still more rarely
in children. Their generation is favoured by the
phlegmatic, bilious, and melancholic tempera-
ments ; by the violent or depressing passions —
particularly anger, sadness, anxiety, &c. ; the
use of spirits ; by sedentary occupations, rich
and full living ; protracted sleep ; by sitting with
the body bent forwards after meals (Hoffmann,
Van Swieten, Coe) ; by chronic dyspepsia and
costiveness ; and by imperfect assimilation and
corpulency. Torpid or disordered function of the
liver and gall-bladder ; inaction of the latter and
of its ducts ; and a vitiated secretion of the bile
itself; are obviously connected with the produc-
tion of these concretions. Several writers have
supposed that they arise from a putrescent state
of the bile retained in the gall-bladder ; but, as
GoLDwnz and SoEMMEnniNo have shown, this
change, even granting it to occur, would rather
prevent than favour their production. Various
writers, as Leake, suppose that they are formed
from the inspissation of the bile in the gall-
bladder, from absorption of its watery parts : but

this cannot be the only or even a principal cause,
as we often find this secretion remarkably thick-
ened from long retention in this receptacle,
without such formations. The absorption can,
therefore, only favour the occurrence of other
changes in the bile, to which certain peculiarities
in its composition strongly dispose it. The very
small concretions which occur in the ramifications
of the hepatic duct generally consist of inspis-
sated bile and mucus ; and these, as they pass
into the trunk of this duct, or are carried into the
gall-bladder, may become the nuclei around
which tlie superabundant cholesterine in the bile
collected in the gall-bladder or in the ducts may
ciystallise ; the increased quantity of this fatty
matter in the bile being the chief pathological
condition connected with their formation. As
far as my own observation has extended, these
concretions have occurred in persons whose assi-
milating functions have been imperfect. That
the liver performs an assimilating as well as a
secreting office, has been shown by me in another
work (see Appendix to Richekand's Fhi/iiologij,
p. 580.) ; and when, either fiom torpid function of
this organ, or from imperfect action of the other
assimilating viscera, the chyle is not perfectly
animalised, fatty matter abounds in the circu-
lation, and is modified into cholesterine during its
excretion by the liver — that portion of it which
the watery parts of the bile cannot preserve in
solution, crystallising into biliary concretions upon
the occurrence of the circumstances favouring
this change. The fact, that these concretions are
most commonly met with in fat persons, in whom
assimilation is defective, and at that period of life
wheii it begins to flag, — imperfect assimilation
causing the superabundance of fatty matter in
the circulation, and its consequent deposition in
the adipose tissue — seems a strong proof in favour
of this opinion, which is further confirmed by the
circumstance of my having observed the serum
whitish or milky on two occasions on which blood
was taken from persons with biliary calculi, — an
appearance now demonstrated to arise from the
superabundance of fatty matter in the serum
(see Blood, § 104.). I need' not occupy my limits
with the various speculations, or opinions, enter-
tained by authors respecting the remote as well
as pathological causes of bihary concretions, par-
ticularly as the most of them have been found to
be erroneous. Those who are curious respecting
them, will find almost all of any consequence
that has been adduced on the subject, in the
references at the end of the article, and particu-
larly in the works of Coe and Soejimerring,

13. IV. The Diagnosis and Prognosis can
only be inferred from the entire history and con-
tingent circumstances of the case ; as there are
no symptoms, which, from their constant pre-
sence, or relation to certain pathological con-
ditions, will of themselves enable the practitioner
to form a correct judgment as to the precise
nature or result of the disease : and yet the ex-
perienced and observing will very generally draw
tolerably correct conclusions as to both, from
reasoning on the procession, relation, or grouping,
of the symptoms present: and, although the dis-
ease is not frequently fatal, he will often have
reason to be cautious in hazarding an opinion as
to the ultimate or remote result ; especially as
the same morbid condition of the system that

396

CONCRETIONS, BILIARY — Treatment.

gives rise to these concretions, often occasions
other dangerous maladies, even although the
concretions themselves do not produce any fatal
lesion, or even serious disorder.

14. V. Tkeatment. — The measures required
in cases where the concretions are presumed to
be in the gall-bladder, are somewhat different
from those, which their passage along the ducts
usually demands : — 1st. \Vhen the symptoms
lead us to suspect the presence of concretions in
the gall-bladder, the medicines recommended by
SoEJiMERRiNG may be prescribed in various states
of combmation. These consist of the carbonates
of the fixed aliialies, the hydro-chlorate of am-
monia, the acetate of potass, the spiritus rctheris
nitrici, the liquor potassffi, Castile soap, the ex-
tracts or decoctions of taraxacum, of herba sa-
ponaria, the fumaria, &c. It is obvious that de-
obstruent aperients, and the above medicines, will
often have much influence in improving the
biliary secretion, and promoting its discharge into
the duodenum, particularly when the patient
takes regular exercise in the open air, and saline
mineral waters. The remedy of Duiiande, con-
sisting of three parts •^f the spiritus <etheris sul-
phur, comp., or the sulphuric aether, and two of
rectified spirits of turpentine, given in doses of
half a drachm to a drachm, has been much em-
ployed on the Continent ; and, although it gene-
rally occasions unpleasant eructations, and some-
times increases the sickness, it has received the
commendations of SoEMiMERRiNG and IIichter,
who advise it to be given after the exhibition of
emollient, resolvent, and aperient remedies ; and
to be followed, particularly in cases where the
passage of the concretions along the ducts is
suspected, by the repeated use of gentle laxatives.
I have prescribed the remedy of Durande in
somewhat larger doses, and combined with it the
tinct. of hyoscyamus ; and certainly with marked
benefit. Numerous French and German writers
speak favourably of this medicine, while otliers
fear its effects in cases where inflammatory action
may exist. But my experience has proved that
it will not aggravate such action, and far less give
rise to it.

15. The deobstnient medicines that are most
to be depended upon in this state of disease, are,
the extract or decoction of taraxacunr in large
doses, with the alkalies (F. 77. 391.), the car-
bonates, the acetates, or the biborates of the
alkalies ; or with soap, amnioniacum, blue pill,
small doses of vini antimonii potassio-tartratis, and
the aithers (F. 397.503— 510. 837.). After these
have been exhibited for some time, Uurande's
remedy may be taken on the surface of any fluid,
or mixed in the yolk of an egg. Active purga-
tives or cathartics arc upon the whole less bene-
ficial than a frccjucnt repetition of luxalives, or of
such purgatives as are gentle and emollient in
their operation ; and even these, when exhibited
early, are generally less successful than when
deferred to a more advanced stage of the treat-
ment. The oleum ricini, in doses of about one or
two drachms, triturated with mucilage, or with
the yolk of an egg, and repeated every five or six
liours until it operates, manna, the oleum oliv;c,
the acetate of potass, &.c., and warm milk whey,
are the most appropriate laxatives. In many in-
stances, a full dose of calomel, or five grains of
blue pill, may precede their exhibition, as either

of these often proves beneficial,— especially when
combined with a full dose of hyoscyamus, and
about a grain of camphor, — and without any risk of
those unpleasant effects imputed to it, or rather
dreaded from it, by various Continental writers.
The operation of laxatives should be promoted by
the exhibition of oleaginous, saponaceous, and
emollient clysters. As to the use of emetics, op-
posite opinions have been advanced. Hoffmann,
Durande, and Frank very justly express them-
selves decidedly against them ; and, indeed, Beh-
tin declares that he has met with cases, in which
they caused rupture of the gall-bladder, its duct
being obstructed by a calculus.

16. 2d. Those cases in which the symptoms
indicate the passage of concretions into the
bowels (§ 8.) require, in addition to the means
above enumerated, warm anodyne fomentations ;
the belladonna plaster placed over the right
hypochondrium ; the exhibition either of this
narcotic internally, or of the acetate of morphine,
opium, or hyoscyamus ; the remedy of Durande,
or the combination of it with one or other
of the medicines now mentioned. In some
cases, an anodyne. and discutient liniment (F.
297. 313.) may be placed over a warm poul-
tice, and applied to the chief seat of pain.
Local or general depiction is seldom of much
service either in this or the preceding state
of tlie disease, unless the existence of vascular
plethora, or of tenderness of the hypochondrium
and epigastrium, the state of the pulse, or habit
of body, indicate it, when it should not be omitted.
If tumour and tenderness of these regions, with
other marks of inflammation of the gall-bladder
and ducts, manifest themselves, general and local
hlood-letting, followed by poultices and foment-
ations, are requisite. In such cases, as well as in
the more violent paroxysms of the malady, the
treatment recommended by Bricheteau — of the
success of which, in some very obstinate and in-
structive cases, he has adduced very striking
proofs — may be put in practice. This consists of
the application of a bladder, containing pieces of
ice, over the seat of pain ; of repeating it, as soon
as the ice is dissolved, until relief is obtained ; and
of administering subsequently mild laxatives and
clysters until the bowels are freely evacuated.
IMi-.RAT had previously advised the injection of
cold enemata ; and Durande, of those which are
tepid; but the cases adduced by Bricheteau
seem conclusive of the superior efficacy of the
means he has recommended. Petit has contended
for the propriety of making an early opening into
such tumours at their more prominent part, with
the view of evacuating the calculi, or the accu-
mulated bile, which the gall-bladder cannot expel,
owing to occlusion of its duct. But the incerti-
tude of adhesions having been formed between its
fundus and the abdominal parietes, and of success
even although they have actually taken place,
must prevent every physician from directing the
performance of this operation. In the majority of
cases, the tumour will point outwardly, and either
open spontaneously, or ariive at that stage which
will warrant the artificial 0])ening of it if the
adhesion have formed. Even in three such
cases, MoROAGNi found only one which healed
up favourably ; the other two long remaining
in the state of fistulous ulcerations. — " Ergo
non, nisi in adhesione vesicula; felleae ad integu-

CONCRETIONS

menta abdominalia, tentenda exulceratio est, vel
apertura artificiosa." (Soemmerring.)

17. 3(1. When the previous ailments and the
existing symptoms indicate that the concretions
have passed into the bowels, tiie use of gentle
laxatives, as advised above, or the treatment di-
rected with respect to Intestinal Concretions, and
Colic, is strictly appropriate. In some instances,

'when the calculi are large, they will give rise to
much suffering referred to thecajcuni, the sigmoid
flexure of the colon, and to the rectum ; occa-
sioning, in this last situation, constipation, colic,
and urgent tenesmus. In these cases, the rectum
should be carefully examined, and meclianical as
well as medical means used to facilitate the passage
of the concretion,

18. 4th. After the patient has been relieved,
and, indeed, during the continuance of the treat-
ment, the evacuations should be carefully exa-
mined, and mixed with water, with the view of
detecting the concretions, — this being of much
importance as respects not merely the diagnosis,
but also the treatment. If we have reason, either
from their presence in the motions, or from the
disappearance of ailment, to presume that they
have been evacuated, remedies ought to be pre-
scribed with the view of improving the digestive,
assimilating, and biliary function?. The use of
taraxacum with soda, &c. (F,76. 392. ) ; of gentle
and deobstruent aperients ; of vegetable bitters,
with the alkaline preparations, and laxatives ;
regular exercise ; light digestible food, and ripe
fruits ; a moderate use of lean but fresh meat ;
the strict avoidance of fatty substances and of
spirituous liquors, of mental disquietude, and of
all the exciting cause* (i 12.) ; should be enjoined,
and the patient recommended change of air, the
Cheltenham or Leamington mineral waters, and
the artificial waters of Seidlitz, Scheidchutz, Eg :r,
Pyrmont, Spa, and Carlsbad, according as they
may be respectively appropriate to the circum-
stances of particular cases.

BiBLmo. AND Refer. — Fcrnelius, Patholog. lib. vi.
c.i|). 5 — 10. — Benivenius, De Abditis Morb. Causis, c. 94.

— Kentmann, apiul Gesner, De Omni Rer. Fossil. Ge-
nere ; et apud Sc/iciik, Observ. Anatom. 1. iii. sect. 2.
obs. 30. 36. — I'esaiius, Examen Observat. FalJopiaiiarum,

p. 124 Columbtis, De Re Anatoin. 1 xv. p. 491. — Sc/iu.

>ig, Litholngia, p. 968. — E. Staid, De Calcul. Gciicratioiie.
Hake, 1C99. — Morgagni, De .Sed. et Caus. Morb. epist. i.
art. 45—49. cp. il. art. 77. 7^ 413. — Bianchi, Historia

Hepatis, t. i. p. 475 Ruysch, Dilucidatio Valvul. cap. iv.

obs. '24, ; et Observ. Anatoin. obs. 87. fig. 69. — Glisson,

Anatom. Hepatis, cap. 8 Vaier, De Calculi in Vcsic.

Fellea General. 4to. Witteb. 1722. — Hoffmann, Medicina
Ration. Syst. et Museum, S:c. p. 95. ct96. ; etEphem. Nat.
Curios, dec. ii — Boerhaave, Praelcct. ad Institut. Path.

\ 790 Van Stvit'tcn, Commentaria, &c. § 950. — Oricsch,

Diarium, p. 283. — Cheselden, Anatomy, p. 166. — Snbnticr,

De Variis Calcul. Biliar. Spec. &c. Monsp. 8vo. 1758

F. L. Hochstctter, De Cholelithis Humanis, 4to. Tubing.
1763. — Simson, Medical Essays and Observat. vol. i. ]>. 315.

— Coe, Treatise on Biliary Concretions, &c. 8vo. Lond.
17u7. {An i7isiructive tvor!,-^. — Gmcliu, De Choleiithis
Hum. Tubing. 1763. — Pftit, Mem. de I'Acad. Roy. de
Cbirurg. t. i. — J. Maclurg, Experiments on Hum.
Bile. Lond. 1772. — Stall, Rat. Med. in Nosol. Pract.

Vindob. Vicn. 1777, vol. i. p. 213 J. G. Walter, Observat.

Anatom. Berol. fol. 1775, p. 46. — M. E. Bloch, Meeiicin.
Bemerkung. Svo. Berlin, 1774, p. 27. — Haller, Elem.
Physiol, vol. vi. p. 564. {A valuable cullcction of cases);
also, Opusculorum Patholog. t. iii. p. 324. — G. I'rochaska,
Adnot. Aqadem. fasc. ii. sect. 1. Pragffi, \~iS3.—Dura7i(1c,
Nouv. Mem. de I'Acad. de Dijon, 1782, p. 199. — //. F.
jDrlius, De Cholelithis Observat. et Experim. Erl. 4to.
1782. — G. S. Dietrich, Observ. qtiaeilam de Calculis in
Corp. Hum. inventis. Hala?, 17SS, Svo. — S. Golc/wix,
Neue Versuche viber der Path, dcr Galle. Bamb. Svo.
17S9. — J. Leake, On Dis. cf the Viscera. Lond. 1792,

p. 257 A. G. Bic/t/er, Medicin. und Chirurg. Bcmerk.

Erst. B, Goet, Wi,—}S._Sand>fort, Mm, Anat. Acad,

—INTESTINAL.

397

Lugd. Bat. Leida?, fol. Vl<^^.— W.Saunders, On the Liver,
&c. 4th ed. p. 244. — Meckel, in Mem. de Berlin, vol. x. et
vol. xi. p. 92. — A. M. Wadaberg, De Cholelithis per Absces-

sum Ruptuin egredienlibus, &c. Upsal. 17S8, 4to Four-

croy, in Annalcsde Chimie, &c. Paris, 1793, t. xvi. et xvii.

— Soemmerring, DeConcrement. Biliar. Humani Corporis,
Trajecti ad Mccn. Svo. 1795. — Baillie, Morbid Anatomy,
5th ed. p. 251. — Thenard, Mem. de la Soc. d'Arcucil, t. i.
p. 64. — Merat, in Mem. de la Societ. Med. d'Eniulation,
t. vi. p. 404. — Brunii, De Calculs Biliares, 4to. Paris, 1803.

— //. Biondi, in Giornale di Med. vol. i. p. 382 Blumen-

baeh, Medicin. Bibliothek, b. i. p. 121. — Heberden, m
Transac. of Col. of Phys. Lond. vol. ii. p. 137. — Blagden,
in Ibid. vol. iv. p. 181 — J. P. Frank, De Curand. Horn!
Morbis, \c. 1. vi. De Retenf. p. iii. p. SlB. — Bie/l et Ca-
det de Gdssicourt, in Diet, des Sciences Med. t. iii. p. 400.

^Crnigie, in Edin. Med. and Surg. Journ. No. 81 Scott

in Ibid. No. 83. p. 297 Brai/ne, in Medico-Chir. Trans!

vol. xii. p. 255. (Two interesting eases of large catcidi.)

T/iomas, in Ibid. vol. vi. p. 98. — ll'inckel, in Hufeland's
Journ. der Pr. Heilk. b. viii. ; and Dixon, Lond. Mod.
Repos. April, 1824, p. 291. ; and Callaway, in Lancet^
vol. xii. p. 296. ; and Boflos, in Archives Gener. de Mcde-
cine, t. xix. p. 459. {Cases of external tumour and fistulous
opening, discharging, at the right epigasiriiim, biliary
calculi with bile.) — Bricheteau, in Mem. de la Societe

Med. d'EmuIation. t. ix. Paris, 1826, p. 194. Orfila

Ann. de Chimie, t. Ixxxiv. p. 3i. — Caventou, Journ'
Pharm. t. iii. p. 369. ; et De Chimie Medicale, t. iii. p. 572.

— Cruveilhier, Anat. Path, du Corps Hum. 1. xii. Paris'

CONCRETIONS — Intestinal. Sv.v. — Al-
vine Concretions ; Alvine Calculi, Monro. Cal-
culous Concretions, Andral. Intestinal Calculi;
Enterulithus, Good.

Classif. — I. Class, 1 1. Order (Author, in
Preface.)

1. Defin. Substances accreted into solid masses
in some part of the alimentary canal, chiefly owino-
to imperfect action of the digestive functions and
nature of the ingesta, and gluing rise to dangerous
states of disease.

2. I. Calculous Concretions occasionally
form in various parts of the human alimentary
canal ; and, although generally the result of
weak digestive functions, hence, a consequence
of disease, they are, in some cases, the chief
cause of extreme suffering and danger. They
are most commonly found in some part of the
intestines, particularly the caicuni and hr^e
bowels ; but they are sometimes also found in
the stomach, and there reach a very large size.
BoNETUs, in his Sepnlcrelum-Anatomiciim, relates
two cases, in each of which a stone as large as a
lien's egg, and weighing four ounces, was found
in the stomach ; and a third case, in which this
vi.scus contained nine calculi weighing together
three ounces and a half.

3. i. Origin and Composition. — Intestinal
concretions are of several kinds, varying ex-
tremely in their nature and origin. In very
rare instances they have assumed the appear-
ance of hezoars, as in the case recorded by
iMM. Champion and Bracconnqt, who ascer-
tained their nature by chemical analysis. In
some cases, they consist chiefly of earthy deposits,
in obscurely crystallised layers, around a distinct
nucleus ; in others, they are formed principally
from those parts of the ingesta which are inca-
pable of change during the digestive processes.
The concretions which Dr. Goon names intes-
tinal calculi, and which consist chiefly of earthy
deposits, are found in the human intestines, as-
well as in the alimentary canal of the larger
ruminating animals. They are generally formed'
in concentric layers, and are often radiated,
.sometimes very obscurely, from nuclei, which
are either gall-stones, or some hard foreign body.
They are more or less porous, either spheroidal

CONCRETIONS, INTESTINAL — Number, Causes, &c.

398

or oblong, and vary from the size of a pea to that
of a hen's egg ; and sometimes reaching a much
larger size.

4. With respect to their origin, they may be
divided into three varieties: — 1st. Those which
have arisen from nuclei formed either ia the
alimentary canal, or in the biliary apparatus, such
as gall-stones, inspissated mucus, &c., around
which certain saline and animal particles have
attached themselves during their abode in the
intestines. 2d. Those having nuclei consisting of
foreicm bodies, such as fruit-stones, seeds, or the
husks of seeds, fragments of bones, &c., around
which the alimentary particles have collected and
crystallised, so that without the presence of the
nucleus the calculus would not have been formed:
and, 3d. Tiiose which are formed entirely in the
alimentary canal, and which are generally more
or less homogeneous, and present no distinct
nuclei.

5. The concretions of the first class have
their nuclei or central part composed chiefly of
cholesterine, the yellow colouring matter and
the resin of tlie bile, surrounded by layers of a
mixture of the phosphate of lime, and of the
ammoniaco-magnesian phosphate, with animal
matter. Haller supposed that the saline consti-
tuents of these, and, indeed, all the other calculi,
were furnished by the pancreatic juice ; and that
the resinous parts were derived from the bile.
That such are the chief, although not the only,
sources of these constituents respectively, will
not, I think, be disputed.

6. Those belonging to the second class are
nearly similar as respects their outer layers ;
their central parts varying according to the nature
of the substance or substances forming their
nuclei. This kind of intestinal calculi are not
iafrefjuent in those parts of Scotland where tiie
inhabitants live chiefly upon oaten bread ; the
beard and fibres of the husks of the oat resisting
digestion, and collecting together, so as to form
concretions or nuclei, around which saline matter,
wiih accessions of tiiese fibres, collect. The
external layers of the calculus formed from this
source are generally solid, compact, soft to the
touch, and composed of saline matter ; in other
instances, the outer layer has a velvety appear-
ance, and consists of very fine fibres, closely
united. Dr. Marcet found these concretions to
consist of compact layers of fibrous substances
and of phosphates. The following is his analysis:
— In 100 parts, 25'20 were animal matter ; 3-90,
resin; G'lG. ammoniaco-magnesian phosphate;
45'34, phosphate of lime ; and 20-30, vegetable
fibres. The vegetable fibres were cemented to-
gether by deposits of eartliy matter, and the ani-
mal matter.

7. Some of those concretions very nearly ap-
j)roacli liiose of the lliird class, and present no
distinct nucleus, being meiely an agglutinated
mass of vegetable fibres with inspissated mucus
and earthy phosphates, sometimes containing other
foreign ingredients or accidental ingesta.

8. Other concretions are formed in the intes-
tines of persons wlio have taken large ((uantitifH
of magnesia or ciialk, with tiie view of jjreserving
an open state of the bowels, or of corre< ting
acidiiy in the Rtomnch. The concretions, in these
case*), consist of those eartliy bodies cemented
togetlier by thick mucus. These concretions arc,

in some instances, merely agglomerated masses ;
in others, they are indistinctly disposed in layers ;
they seldom have any proper nucleus, and belong
rather to this third class, than to any of the fore-
going. To this division are also to be referred
those concretions which are formed of fa;cal mat-
ters with earthy phosphates, and inspissated secre-
tions sometimes hardened to the consistence of
calculi.

9. Number, Size, Colour, &c. — There are
seldom more than two concretions in the intes-
tinal canal, but a greater number is occasionally
found. BoNET met with nine in the stomach,
Lanzoni with ten, and Bilguer with thirty
in this viscus. The first Monro detected by
the touch twelve concretions in the colon of a
boy who was much emaciated ; and various
authors make mention of as great, as well as of a
lower, number. The colour of the smaller con-
cretions nearly resembles that of iron ochre :
the larger concretions are generally externally
of a coffee colour, sometimes approaching to
purple ; and occasionally they have a whitish
surface. The different layers often present a
slight difference in the deepness of shade. They
are sometimes so hard as to admit of an imperfect
polish. Some of the calculi have been found
extremely large. The first Monro met with
them five, six, seven, and even eight inches in
circumference ; and the second Monro removed
from tlie colon of a woman one which weighed
four pounds. The larger calculi are generally
more irregular in figure than the smaller. This
may be owing to the additions made to their
surface during the time they remain fixed within
a certain portion of the canal. Where more
than one are found, they often indent each other,
or form, as it were, parts of one long concretion ;
as in the instance of the very large one, which
weighed upwards of twelve ounces, and consisted
of three parts, recorded by Mr. Torbet (Edin.
Sled, and Surg. Joiirn. vol. xxiv. p. 87.).

10. ii. The Causes of these concretions are,
sedentary occupations, inactivity, and indolence ;
a slow, weak, and torpid state of all the digestive
functions ; deficient vital energy of the assimi-
lating organs (§ 4, 5, 6.) ; a long, free, and injudi-
cious use of magnesia, prepared chalk, and other
calcareous earths, for the purpose of correcting
acidity of the stomach (§ 7.), &c. ; portions of the
husk and beard of the oat, from living upon oaten
bread, &c.; swallowing incautiously fragments of
bones, stones of fruit, or seeds ; and an habitual
neglect of the stale of the bowels.

11. iii. Their Local Effects. — When these
concretions reach a large size, they interrupt the
functions of the intestinal canal, preventing the
passage of the fjeces, and occasion dilatation of the
bowel above the place in which they are lodged,
followed by inflammation, ileus, &c. In more
favourable cases, they expand the intestines sur-
rounding them into a sac, which in process of
time acquires considerable thickness. Dr. Monro,
in his very able chapter on alvine calculi,
describes three cases in which the ca;cum was
extended into the form of a sac, the muscular
fibres of which were hypertrophied, and the
mucous membrane thickened and corrugated.
This sac communicated with the commencement
of the colon by a circular opening, which, in one
case, was nearly an inch, in another scarcely

CONCRETIONS, INTESTINAL — Symptoms — Treatment.

above a quarter of an inch, in diameter. A
similar sacculated extension has been likewise
noticed by this pathologist at the extremity of
the ilium, near the caecum.

12. Owing to the irritation occasioned by these
concretions, the intestine is often found con-
stricted around and immediately below them, as
demonstrated by Schenk and jMonuo. Adhesion
of the concretions to the inner coat of the viscus
is a much rarer occurrence. Cases, however,
have been observed by Horstius and the first
INIoNno, where such adhesions existed. Ulcer-
ation of the parts in which they are lodged,
owing to the irritation occasioned by them, is
amongst the most common of the local efl'ects to
vviiich they give rise. In some cases, the inflam-
mation induced by them in the internal surface of
the bowel extends to the external tunics, until it
reaches the peritoneal surface, where coagulable
lymph is thrown out, and the convolutions in its
vicinity are agglutinated into one mass, or adhe-
sions to adjoining parts take place.

13. iv. The Symptoms which alvine concre-
tions occasion vary extremely, according to their
nature, and the size they have attained. Some-
times it seems wonderful, considering their great
bulk, that the intestinal canal is not completely
obstructed by them. In some cases they have
remained for years, with evident symptoms of
their existence. In more fortunate instances,
they have been ejected with the contents of the
stomacli after severe retching and vomiting ;
or have passed by stool, after severe dysenteric
symptoms and tenesmus. In almost every
instance, the digestive powers are very much
impaired, and the patient becomes, after a time,
greatly debilitated and emaciated. The pulse,
at first, is but little affected ; but the patient
complains much of pain and tension in different
parts of the intestines, and is subject to occasional
attacks of nausea, vomiting, tormina, or purging.
The pain in the bowels is usually referred to one
part, and is much more severe at one time than
at another, particularly after taking acids, or food
difficult of digestion. Constipation of several
days' duration is often complained of, and yet the
patient has a constant inclination to go to stool :
at other times, or in other cases, there are fre-
quent watery and scanty evacuations of a viscid
ropy mucus or blood, which sometimes give a
short relief.

14. When the concretion is of a large size,
and the patient is somewhat emaciated, a very
hard, painful, globular tumour may be felt in
the abdomen, most frequently in the course of
the large bowels, upon placing him on his back,
and relaxing the abdominal muscles. It can
seldom be made to change its place within the
intestine, but often appears to do so in conse-
quence of the change of place of the portion of
the intestine containing it, particularly when it is
lodged in the small intestines, or in the arch of
the colon. Some patients are under the neces-
sity of abstaining from solid food, and others
reject the greater part of their food. When the
concretion has existed for some time, the bowels
are generally so much obstructed that laxatives
or clysters are necessary to procure a passage.
Dr. Moxno states, that when it changes its
place, and passes down into the sigmoid flexure
of the colon, or into the rectum, it creates excru-

399

ciating torture in the region of the pelvis and
fundament, and the bowels become obstinately
constipated, and much distended, from the passage
being interrupted.

15. When alvine concretions lodge low in
the rectum, they occasion much pain when the
patient is sitting, and upon going to stool. When
this is the case, an examination per aunm is
requisite, which will lead to their extraction by the
forceps. In a case in which the second MoNno
was consulted by IMr. Goonsin, the patient passed,
in the course of two or three weeks, nine concre-
tions in this way, some of which were as large as
a hen's egg. This patient had laboured for many
weeks under very acute pain in the region of the
stomach.

16. When tlie concretions are small, they
frec|uently pass away with the fajcal matter,
without occasioning any evident disturbance; the
patients, generally, having complained of nothing
further than long pre-existing dyspepsia and
constifjation — the chief causes of their forma-
tion. In other cases, especially when tliey reach
a large size, most distressing and urgent symptoms
are produced by them ; commencing with those
already enumerated (§ 13, 14.), and terminat-
ing with violent colicky pains, obstinate con-
stipation, pain at the top of the sacrum and
loins, or in the hypogastrium, sickness, retchings,
and, at last, complete ileus, or all the pheno-
mena of acute enteritis, or peritonitis. Even the
smallest concretions occasionally give rise to
fatal consequences. Two cases have occurred
to me, wherein the most acute peritonitis, followed
by the effusion of coagulable lymph, with adhe-
sions, and terminating in sphacelus of the vermi-
cular appendix of the cascum, was occasioned
by these concretions having passed into this part.
A similar case is recorded by Kuysch (Muesum,
142.).

17. v. Treatment. — We are often vvithout
any satisfactory proof afforded us, during the life
of the patient, of the existence of these concretions
in the intestinal canal, the symptoms they occa-
sion being the same with those proceeding from
various other causes. Their existence is, there-
fore, often merely a matter of conjecture, to
which the deficient energy of the digestive action,
the means resorted to by the patient to palliate
dyspeptic symptoms, and his accustomed diet,
frequently lead ; and we seldom can form any
correct diagnosis, unless they are so large as to
occasion tumours in the course of the bowels, or
are lodged low in the rectum. When their exist-
ence is proved by their discharge, we may consider
the mischief, in a great measure, if not entirely
removed ; unless, indeed, the symptoms continue,
when we may infer one of two causes, namely,
the presence of more concretions, or the existence
of inflammatory action induced by them in a por-
tion of the intestines, or of intus-susception.

18. When the symptoms seem to pioceed
from the injudicious use of calcareous or mag-
nesian absorbents, these must be entirely avoided.
Aperients of a different nature should be em-
ployed, particularly the supersulphale of potash,
or the sulphate of soda or of magnesia, with the
addition of dilute sulphuric acid. In order to
relieve the more urgent symptoms, copious injec-
tions of an oleaginous, emollient, and purgative
kind, should be thrown up. And, in order that

400

CONCRETIONS, INTESTINAL — Origin of Fatty.

these may more fully answer the intention, they
ought to be administered whilst the patient rests
upon his knees and elbows, with the pelvis ele-
vated above the shoulders. If vomiting be pre-
sent, care should be taken not to increase this
symptom by the administration of medicines by
the mouth. For, by frequently exciting the
inverted action of the stomach, this action will
extend to the alimentary canal, and terminate in
fatal ileus. It is preferable to solicit the action
of the bowels by emollient, anodyne, and ape-
rient enemata, and by frictions with oleaginous
substances, or fomentations on the abdomen.
When we suspect the concretion is owing to the
nature of the food, this cause must be avoided.
When the concretions are seated low in the rec-
tum, their extraction by the forceps must be tried.
Those arising from the use of oat-bread being, ge-
nerally, partly composed of the earthy phosphates ;
and, considering the solubility of these salts, INlr.
ToREET and Dr. Duncan conceive that an im-
pression might be made on them by a course of
mineral acids taken by the mouth, or injected by
the anus.

19. Tlie second Wonro recommends, in cases
where the concretion is evident to the touch,
forming a distinct and fixed tumour in the bowels,
and where the symptoms are urgent, all other
means liaving failed, to attempt its extraction by
an incision through the abdominal parietes into
the intestine ; and in this recommendation Mr.
ToREET and Dr. Duncan agree. But, before
resorting to this last means. Dr. INIonuo advises
the following very judicious plan, which I ex-
tract from the very excellent materials which
his son has laid before the profession: — " 1st,
Let the patient (a female) take every day a
quarter of an ounce (1) of Castile soap, in pills,
and of castor oil. 2d, Once or twice a week, let
her take a purgative composed of sal glauberi,
2j., sugar half an ounce, and the same of salad
oil, and whey tbss., orlbj. 3d. Three times a
week let her get a clyster of a quart of water, in
which an ounce of linseed and half an ounce of
Castile soap have been infused for two hours.
4th, Let her foment the belly, and take the above
clyster, when she suffers much pain. Let her
diet consist of loaf-bread, milk, whey, broth, soft
eggs, butter, a bit of light-dressed meat ; and if slie
take porridge, let her melt a good deal of butter in
it." (p. 50.) Such was the advice of a most ex-
perienced physician in this description of disease ;
and it proved successful in the case for which it was
directed. (See also the Treatment of Colic and
li.EUs, and of Constipation.)

20. IL Fatty and IIkterogeneous Concre-
TiONS. — A. Concrete substances, differing very
materially from those already described, are some-
times formed in the alimentary canal, particularly
in the large intestines. These arc usually tlerived
from two principal sources ; viz., a morbid stale of
the secretions poured into the intestinal tube, or
secreted from their internal surface ; and altera-
tions of the usual state of the fa.'cal matters, during
their retention in the ca;cum and large bowels.
'J'o lliese, a third may be added, — the ingestion of
substances into the stomach, which are incapable
of undergoing any material change during tiieir
passag(! through the canal, excepting their agglu-
tination into (inn balls.

21. li. Vvncrcl'w)is oi an oletiginoHs nature, or

varying from an oleaginous to an adipocirovs or
even waxy character, are sometimes voided by
persons who sufl'er from a torjiid stale of the
bowels, and deficient digestive function. These
concretions are often mistaken for gall-stones,
but are readily distinguished from them by the
following characters : — They are generally of a
globular form, varying in size from that of a small
pea to the bulk of a large grape, are of a cream-
colour, slightly translucent, and of sufficient con-
sistence to preserve their form and be cut with a
knife, like soft wax.

22. These unctuous concretions cannot in
general be traced to any oleaginous material in-
troduced into the stomach ; yet there is some-
times evidence furnished of their origin in oleagi-
nous or fatty substances which have not under-
gone the requisite changes in the prima via, but
have been merely slightly changed by the acid
existing in the stomach, and by the secretions
poured into the alimentary canal, so as to assume
the appearances now described. It is possible,
however, that they may be occasionally formed
by intestinal secretion, or by a chemical change
effected on parts of the recrement of the food,
after having passed into tiie cacum and colon.
Fat, either in the concrete form now described,
or in a state of fluidity and purity resembling oil,
has been occasionally, although rarely, voided
from the bowels, independently of having been
taken by the mouth; although more frequently
proceeding from the latter source ; as instances
observed in the course of practice at the institu-
tion for children have proved. Cases of this
description have been recorded by Dr. W. Scott
(Ed, Med. Comment, vol. iv. p. 334.). Dr.
iJABiNGTON and Dr. Elliotson (Philos. Trans.
1813, art. xxi.), Dr. Kuntzmanz, of Berlin
(Journ. der Pract.Heilkunde, July, 1821), Diet-
rick, and several others.

23. Sir Everard Home endeavours toaccount
for the production of these adipocirous and fatty
concretions, by contending that it is the office of
the large intestines, particularly of the colon, to
convert a considerable portion of the matters
poured into them into fat, by combining them
with the bile ; and the fat thus formed in the
large intestines is taken up and conveyed into the
circulation, to be deposited in various parts of the
body, to supply tlie wants of the economy. But
the production of fat in the intestines seems to
be only the result of a diseased action, inasmuch
as it is voided from ihem, in any of its states, only
during disease — during visceral complaints, and
colicky or dysenteric affections — and is never
observed to be passed from, nor is found within,
these viscera, when they are in their healthy con-
dition. It appears from the history of the cases
on record, as well as from those recently ob-
serveil by Dr. Ei.i.ioison and Mr. Li.oyd, to be
especially connected with disease of the assimi-
lating viscera, and consequently with imperfect
assimilation ; a jiortion of the chyle, instead of
being ciianged to healthy blood, assuming an
oleaginous state, as not infrequently observed in
the serum. The fatty matter tiius accumulated
in the blood, will, in several states of disease, be
eliminated from it by excreting organs — particu-
larly by the mucous surfa(!e of the bowels, and
by tiie liver and kidneys — instead of being depo-
sited in the ttdiposc tissue for ultenor purposes, ami

CONGESTION OF BLOOD — Its Nature. &c. 401

thereby pivportionately disor-

will assume eitlier a concrete or fluid form,
owing to modifications of its state as orlginully
secreted, or to the action of other matters upon
it during its retention in the bowels or urinary
bladder.

24. A singular case has been recorded by Dr.
Kennedv (Medico-Chirurgical Jouriuil fur Sept.
1017.), of an intestinal concretion, which was
found, upon its analysis by Dr. Ure, to be similar
in its composition to ambergrise.

25. C. Intestinal concretions have been found to
consist entirely of those matters which have been
swallowed fiom either a depraved appetite, or
bad habit ; thus, concretions causing violent
symptoms, have been produced by the habit
of chewing the ends of threads used in sew-
ing, and which have formed a firm felt with the
mucus of the intestines and some faecal matters.
I was lately consulted in the case of a young
lady who had been long under treatment for
obscure abdominal disease, respecting the na-
ture of which no two of the several eminent
practitioners who had been in attendance agreed.
The existence of accumulated matters in the
caecum and colon seemed evident to me, upon
examination, and from the character of the consti-
tutional and other symptoms. Purgatives and
injections weie long persisted in ; at last several
concretions — (about twelve) — from the size of
a filbert, to that of a walnut, were evacuated.
Upon examination, they presented a substance
resembling pasteboard, with a fajcal smell, of
a brown colour, and containing earthy parti-
cles. On being broken down and macerated,
they were found to consist chiefly of coarse
paper reduced to a pulpy state, but containing
fragments not materially altered. The portions
of pulpy paper were agglutinated with mucus,
portions of faeces, and a little phosphate of lime.
After some time, the patient confessed that she
had occasionally been in the habit, about the age
of thirteen and fourteen, of chewing, and some-
times swallowing, portions of the grey paper, with
which she curled her hair. After the evacuation
of these concretions, all the symptoms disap-
peared, and she rapidly recovered. A few years
ago, I attended, with Mr. Annesley, a similar
case to the foregoing, but in a younger lady. She
recovered perfectly by the use of purgatives and
clysters.

BiBLiOG. ANn Refer. — A. v. Hallei; Elementa' Phy-
siologise Corporis Humani, t. vii. p. 176. — Jf'all/ier, l3e
Concremcntis terrestribus in variis Partibus Corporis
Humani repertis, fol. 1775. — S. Fitxgrraht, in Kdiii. Med.

Comment, vol. viii. p. 329 Sir E. Home, m Philos.

Trans. 1813, art. "il. — Marcet, On the Chemical His-
tory and Medical Treatment of Calculous Disorders, 1817.
— M. Lousier, Memoire sur les Concretions qui seforment

dans le Cjorps de 1' Homme. Paris, 1825 J. Porta et

Julia-Fonlenelle, in Archives Gen. de Medecine, t. xii.
p. 433. — P. Denis, in Ibid. t. xvii. p. 111. — Torbet and
Duncan, in Edin. Med. and Surg. Journ. vol. xxiv. p. 84.
and 90. — G. Aiidral, Anatomic Pathologique, &c. t. ii.
Paris, 1829— y/. Monro, S;c., The Morbid .Anatomy
of the Gullet, Stomach, and Intestines, 2d edit. Edin.
1830. (Contains the most complete account of Intestinal
Calculi with which I am acquainted.)

CONGESTION OF BLOOD. Classie. Ge-
nehal Pathology : and I. Class, IV. Or-
der (Author, in Preface).
1. Defin. Bejicient vital tone or power, chiejiii
of the capiUary vessels and veins, occasioning accu-
viulation of blood in them, and a languid or more
or less retarded circulation, tiie funclivns of the
Vol. I.

organ or part being
dered,

2. I. Nature and Relations of Congestion.
— It has been stated in other places (see arts.
Blood, Disease,) that moibid states of the vas-
cular system, and of tlie fluid circulating through
it, must be imputed, in a large proportion of cases,
to changes induced primarily in the organic
nervous system, which is, anatomically, most
intimately connected, not only with the circulating
system, but also with the organs essentially vital ;
this connection subsisting by ramifications pro-
ceeding to them both directly and obviously either
from the great central ganglion, or from appro-
priate subordinate ganglia, as well as indirectly
and less apparently through the medium of the
blood-vessels, on which the organic uervous
system is everywhere profusely distributed, the
one accompanying the other throughout the
frame. Thus intimately interwoven, they expe-
rience reciprocative changes, and generate a com-
mon influence. The vital organs, as well as
their subordinate parts, in the more perfect ani-
mals, being supplied by both these systems, —
the most rudimental type and essential requisites
of organisation, — and actuated by their common
influence, are thereby enabled to perform their
destined functions ; the superadded or peculiar
organisation of each organ being the instrument,
which, thus actuated, performs specific offices in
the economy.

3. It results from this, — 1st, That we are not
justified in considering changes in the states of
vascular action, or in the relation subsisting be-
tween the vessels and the quantity or quality of
the fluids circulating in them, apart from the
condition of the organic nervous system, which
is thus intimately connected, by structure and
function, both with them and with all vital
organs ; 2d, That changes in the vascular system
are very often induced by impressions made
primarily upon the organic nervous system ;
whilst, on the other hand, a morbid state of the
former, particularly in respect of its circulating
contents, will most seriously affect the latter ;
and 3d, That upon tracing the procession of mor-
bid phenomena, the first impression made by the
exciting cause, and earliest change from the
healthy state, will be found in the functions of
this .system of nerves, in perhaps the larger pro-
portion of cases ; vascular action, &c., and the
secreting and assimilating functions being very
soon afterwards disordered. The truth of these
propositions will become more manifest after
having surveyed the causes which induce con-
gestion, the phenomena which accompany it
either as coincidences or consequences, and the
results to which it leads ; and we shall be more
fully convinced of the propriety of viewing it as
very much more frequently a link merely in the
chain of morbid action, than as a primary or even
an early change.

4. Congestion has been divided by many mo-
dern pathologists into active and passive, they un-
derstanding by the former that state of vascular
action which coincides with active determination
of blood, according to the meaning I have attached
to itin another article. (See Blood, § 25.) It
may be defined to be a vital excitement with
somewhat of expansion of the vessels, and the cir-
culatioa of a larger quantity of blood through

402

CONGESTION OF BLOOD— Its Causes, &c.

them, without any obvious tendency to form new
productions, or to occasion disorganisation, unless
inflammation, or some other morbid condition,
supervene, which is very often the case. Prom this
state — active congestion (see Blood, § 26.) —
in which the vital action of the vessels is above
their healthy standard, there is every intermediate
grade, lapsing insensibly into extreme passive
congestion, in which there is deficient or depressed
vital power, tlie current of the circulation through
the weakened vessels being remarkably languid
and retarded. In this state, the venous and arte-
rial capillaries, having lost the principal part of
their tone or vital tension, re-act imperfectly upon
the mass of blood injected into them by the heart's
action, and become distended and congested. This
state, tlien, existing in any degree, down to that
wliicli is barely compatible with the continuance of
the life of the part, constitutes congestion ; it being
thus considered as a state of sub-action, and not of
super-action, as determination of blood undoubt-
edly is.

5. i. In respect of the modes of accession by
which congestion presents itself, much diversity
exists. It may occur suddenly, after intense
causes ; slowly, after slight influences or other
disease; and almost insensibly, after active deter-
minations of blood and inflammatory action. It
may be almost the primary lesion, the impression
made by the exciting cause upon the organic
nerves being the only previous change ; or it
may be one of the most remote, and only ante-
cedent of, or immediately consequent upon, dis-
solution. It is generally the result of directly or
indirectly depressing causes ; and assumes every
grade according to the intensity of their operation
relatively to the organic nervous or vital energies
of the frame on which they act.

6. ii. The textures most liable to undergo con-
gestion are such as, owing to their conformation,
particularly the laxity of their vital and physical
cohesion, admit of the distension of their vessels.
Cellular parts, and organs in which the cellular
structure predominates, as the parenchyma of
various internal organs, particularly the brain, the
lungs, the liver, spleen, and kidneys ; the mucous
membranes, especially those of the bronchi and
digestive canal, and the uterus and ovaria ; are
most liable to experience this state of tlieir blood-
vessels. Besides these, however, other and less
yielding structures, as the serous and fibrous
membranes, tlie skin, the muscles, &c., may be
congested to a certain extent, particularly after
exhaustion of the vital energies of the frame, and
diminution of the vital cohesion of these structures,
eillicr by causes which depress the organic ner-
vous power, or by noxious agents contaminating
the blood, or by over excitement of the vascular
system of the congested part, or of the whole
frame. In one or other of these three ways, con-
gestion supervenes when it is observed at the
commencement in the course, or towards the close
of febrile and constitutional maladies ; the same
causes, and operating In a similar manner, also
occasioning congestion of tliose viscera which are
most liable to it by conformation.

7. ill. 2'lie causes of congestion are, therefore,
1st, Those which act by primarily depressing the
organic nervous influence ; such as advanced age ;
tiie continued or prolonged Impression of cold,
mental anxiety, and all the depressing passions

and moral emotions ; prolonged sleep, mental and
physical inactivity; miasm.al, contagious, or
infectious emanations ; various vegetable, animal,
and gaseous poisons ; and the rapid loss of the
natural electrical tension of the frame: 2d, Those
which mechanically impede the return or circu-
lation of the blood itself, or which change its
quantity and quality, either locally or generally ;
as excessive heat ; general plethora, produced
either by too full living, or by the suppression of
the natural or accustomed discharges, interrupted
circulation through the heart, the lungs, liver,
&c.; a long retained posture by debilitated per-
sons ; the use of unnecessary ligatures and tight
lacing; Improper and unwholesome food; con-
tamination of the blood by the absorption or in-
troduction into it of noxious mineral, vegetable,
and animal substances, or gaseous fluids ; and
changes taking place in its constitution, from the
interrupted secretion and elimination of hurtful
matters from it (see Blood, § 1 15. etseq.) — these
latter causes aflfecting the vital manifestation of
the vessels and nervous systems ; 3d, Those causes
which exhaust the Irritability or vital tone of the
vessels, by previously exciting them above their
natural state of action ; as local determinations of
blood, general vascular excitement ; fatigue from
violent or continued exertion; pre-existing fever,
inflammation, or other diseases. Thus it will be
seen that congestion arises from changes induced
(a) in the state of organic nervous power, and
externally to the vessels ; (b) in the blood itself,
and acting internally on the vessels and struc-
tures ; (c) in the coats of the vessels them-
selves ; and (d) in two or more of these simul-
taneously.

8. iv. The symptoms indicating the existence of
congestion are sometimes very apparent, at other
times very obscure. When it is present in a
marked degree and in vital organs, the disturb-
ance of function is usually so great as to indi-
cate Its existence; but even then the kind of
disturbance may be very nearly the same as pro-
ceeds from morbid states, which we shall here-
after find congestion not infrequently occasions,
viz. sanguineous or serous effusion ; as in the
cases of intense congestion of the encephalon.
Upon the whole, however, it gives rise to partial
loss, or entire abolition, of tlie functions of the
affected part. Thus, congestion of the brain,
when moderate, will occasion a slight state of
lethargy, or vertigo, &c.; where more severe,
epilepsy, coma, or apoplexy. Congestion of the
liver is attended by more or less complete arrest
of tlie biliary secretion, with tumefaction of the
organ, &c. ; and congestion of the bronchial sur-
face and lungs, with dyspnoea, asthma, &c. Fe-
brile plienomena seldom accompany congestion,
unless it arise in the course, or towards the close,
of febrile diseases, or be excited by infectious or
miasmal emanations, or is about to pass into aa
Inflammatory or hsemorrhagic state. When it
occurs in large secreting viscera or surfaces, the
function of secretion Is either impeded, vitiated, or
altogether suspended ; a return or increase of
the secreting action either restoring the healthy
state of circulation, or converting it into active
determination, or even into inflammation. When
congestion affects several parts, or two or more
important viscera, as on the invasion or towards
the close of malignant fevers, or when the circu-

CONGESTION OF BLOOD — Appearances, &c.

403

liting fluid and soft solids become contaminated,
the functions of the economy are very gravely
d.sturbed, and some of them almost annihilated :
in such cases, the morbid impression made by the
existing causes upon the organic nervous system,
disorders the various functions it actuates, and
even puts a stop to some of them ; the derange-
ment of function being often a coeval and co-
ordinate effect with the congestion. Hence the
arrest or diminution of function becomes one of
the most common indications of the extent of
congestion, even although it may not be the actual
consequence of this state of the vessels.

9. V. The appearances presented by congested
parts after death vary extremely with their struc-
ture, and the degree and duration of the congestion.
In addition to more or less engorgement of the
small vessels and veins, there are generally found
a darker colour of the contained fluid than in the
natural state, considerable tumefaction, and di-
minished cohesion of the aflected structure, and
alteration of its colour. The change of colour
may be of various grades of deepness, to a brown-
ish or greenish black, as frequently observed in
the liver and spleen ; and the loss of vital cohe-
sion may be very remarkable, as in the same vis-
cera, tumefaction being then very considerable.
These appearances are often accompanied with
effusion of a serous, aqueous, or sanguineous
fluid from the congested surfaces ; and sometimes
with ecchymoses of a deep colour in or beneath the
mucous tissues, and occasionally in serous mem-
branes and parenchymatous parts.

10. vi. The general conseqtiences and terminations
of congestion are deserving strict attention, as to
this state are to be imputed several of those more
grave and dangerous changes presented to us in
the advanced stages of numerous diseases. 1st,
Congestion termmates in the restoration of the
healthy circulation. This is most frequently the
case in respect of secreting parts, as the mucous
and villous surfaces and glandular organs ; the
return of their secreting functions aiding most ma-
terially the restorative process, by diminishing the
fulness of the vessels, and soliciting an accelerated
circulation through them. Hence, although a
restoration of the circulation, to some extent at
least, is often antecedent of the return of the
secreting function, yet we frequently succeed in
restoring the former by exciting the latter; the
stimulus thus imparted extending itself to the
weakened and congested vessels. Parts which
have once suffered congestion in a very marked
degree, very often retain a disposition to expe-
rience it again upon exposure to its causes; this
disposition, however, diminishing with the lapse
of time, if judicious means of strengthening the
organ be adopted. 2d, Congestion may pass into
active determination, or into inlianimation of
various grades of intensity. This may arise from

' vicinity of the congested organ, or in the areolae
of its cellular tissue. We often observe this ter-
mination in the diflPerent internal viscera, and
cavities in which they are situated. It evidently
depends jpon the rarefaction of structure occa-
sioned by distension of the parietes, and loss of
tone of the congested vessels, most probably as-
sisted by weakened vital cohesion of the tissues,
and diminished crasis of the blood ; these con-
ditions either accompanying or following the
congested state, which very frequently is par-
tially, or altogether removed by the consequent
effusion. 4th, Hfemorrhage may supervene, either
from the surface, or into the substance of the
congested organ or part ; owing either to a con-
stitutional disposition to haemorrhage, arising
from original conformation, the vessels readily
yielding from distension or accidental impulse ;
or to the existence in a more or less intense de-
gree of the same changes which produce aqueous
effusion, particularly weakened cohesion of the
tissues, and, consequently, of the delicate canals
conveying the blood through them, and a morbid
state of the blood itself. 5th, Congestion of the
minute capillary canals, either frequently re-
curring, or continuing long, seems to give rise to
various morbid or adventitious structures, par-
ticularly when it takes place in persons of a
scrofulous diathesis, or affected by any other
constitutional taint. In such cases there is a
marked indisposition, both of the part to return
to a healthy state, and of the adventitious struc-
ture to be absorbed. 6th, Retardation of the cir-
culation in congested vessels may be so complete
as to occasion even loss of vitality and gangrene
of the part. We observe this in the congestion
arising from extreme cold, from the exhaustioa
consequent on intense excitement. Sec.

11. vii. Congestion, and its consequences in re-
spect of particular structures, are of great import-
ance, and are therefore considered among the
principal changes to which vital organs are sub-
ject. Although the local relations of congestion
fall under their appropriate heads, it may be
remarked, in general terms, that congestion may
occur in any structure or organ during life, with-
out evincing upon dissection unequivocal proofs
of having ever existed ; and that it may appa-
rently continue till dissolution, without being very
manifest upon examination afterwards. Such is
especially the case in respect of congestion of
mucous and serous surfaces, the vessels of which
empty themselves soon after death, when the pro-
pelling power no longer acts upon them and dis-
tends their relaxed parietes, in consequence either
of the passage of more or less of their contents
into the adjoining veins, or of the escape, through
the extreme canals and pores of these structures,
of the more aqueous or serous parts of the blood
they contained, or of both these changes con-

changes induced in the state of the blood itself joined. From this it will be manifest that many

relatively to that of the vessels; or from the
re-action of the vessels upon the distending fluid,
and the augmented impulse following the tempo-
rary retardation of the circulating current ; or
from the use of irritating and inappropriate stimu-
lants in order to remove the congestion ; or from

cases of recent or not very intense congestion,
wherein we have reason to infer that the small
vessels have not altogether lost their vital tone,
particularly of membranous parts, will present
upon dissection chiefly fulness of the veins, pro-
ceeding from these parts, with the eff"usion of

i nordinate excitation of the secreting functions, i more or less of a serous, aqueous, or sanguineous
when we endeavour in this way to remove opple- i Huid in their vicinity. On the other hand, con-
tion of the vessels. 3d, Congestion frequently , gestion of internal organs may not have been de-
occasions serous or aqueous effusions in the ' tected at all during life, or it may have occurred

D d 2

404

CONGESTION OF BLOOD— Treatment.

but shortly before, or at the time of death, and
yet be very evident upon inspection afterwards.
This is not infrequently observed in respect of
parenchymatous organs and mucous and villous
surfaces. When congestion, however, occurs in
the large viscera, as the brain, lungs, liver, and
spleen, and continues up to the time of dissolu-
tion, it is generally very manifest in them upon
dissection. In many diseases, particularly those
in which the blood becomes affected previously
to, or continues fluid after, death, and in those
which terminate by asphyxy, congestion of de-
pending parts is a very common post mortem
occurrence, and one which should be carefully
distinguished from the congestion that has existed
during life.

12. II. Of the Treatment of Congestions. —
i. It is necessary always to keep in view the fact,
that congestion is a consecutive lesion, arising
generally from causes which depress the vital
manifestation of the organic system of nerves
supplying the blood-vessels ; and that, although
it is very frequently associated with general ple-
thora, and necessarily implies the existence of
local plethora (see Blood, § 23.), yet, on ac-
count of this depression of nervous power, general
depletion, unless to a small amount, is seldom of
much service in the treatment of congestion, un-
less it be conjoined with the use of stimulants,
derivatives, and excitants of the secreting func-
tions.— a. But local depletions, particularly when
directed in such a manner as to operate some
degree of revulsion from the congested part,
sometimes carried to a considerable extent, or
repeated as circumstances require, are among the
most requisite means of cure. — b. When the
powers of life are much reduced, even local de-
pletions should be employed with caution, and
never without having recourse, at the same time,
or previously, to suitable excitants and external
derivatives. Of these classes of remedies, the
most preferable are such as tend to equalise the
circulation throughout the viscera, and determine
it to the periphery of the frame. Diaphoretics ;
the imrw or vapour bath; warm poultices and
fomentations ; rubefacient embrocations, epithems or
poultices, especially those with Cayenne pepper,
mustard, horseradish, &c. ; blisters, and warm and
rubefacient pedJ/((r(a; are calculated to accom-
plish these purposes. — c. Much advantage will
also accrue from attempting to restore by emetics,
purgatives, or other remedies, the secretions
of the mucous surfaces, and the functions of
the congested organ; as the restoration of these
functions, which are generally impeded or alto-
gether arrested, will unload the vessels, and acce-
lerate the retarded circulation in them. But it
should be kept in mind, that the medicines that
operate in tiiis manner are generally local and
specific excitants ; and hence that they, as well as
the stimulants usually given internally, should be
exhibited with caution, and preferably at the
same time that local depletion, with derivation to
the surface of the body and lower extremities, are
being employed. Without attention to these pre-
cautions, we may convert, particularly in plethoric
persons, simple congestion into active determin-
ation of blood, or into inflammation. — d. 'J'lie dij-
Jusible stimulants that are generally most service-
able in removing congestions are, camphor, the
p.cparalions of ammonia, the a;lhers, weak infu-

sions of arnica or serpentaria, warm diluents with
saline medicines or the nitro-hydrochloric acids,
the liquor ammoniaj acetatis, small doses of ipe-
cacuanha, with camphor and opium, &c., and
several of the gum-resins and essential oils. — e.
In many cases of congestion of vital organs, it
will be requisite, in addition to the foregoing
measures, to direct internal revulsaiit agents to
remote viscera. Thus, in congestion of the head
or lungs, we shall derive advantage from exciting
the action of the lower bowels by irritating ca-
thartics and injections; and, having prescribed
depletions and external derivation, from a judicious
employment of active diuretics. — /. In all cases,
it will be necessary to promote the natui-al secre-
tions and excretions ; inasmuch as we thereby
keep up a regular distribution of the circulating
fluids, and eliminate from them such hurtful sub-
stances as might irritate the vessels and induce
consecutive disease, if they were allowed to accu-
mulate.— g. In many instances, benefit will accrue
from the affusion or aspersion of cold or tepid
water over tl'.e part enclosing the congested or-
gan, especially when the state of the pulse, and
the seat of congestion, lead us to dread the super-
vention of haemorihage, as in congestion of the
brain or of the lungs. — h. Besides the external
means already alluded to, various others may be
employed near the seat of congestion ; as moias,
the acfual cautery, dry cupping, stimulating or
rubefacient liniments, dry friction, the warm and
tepid affusion or douche, the nitro-hydrochloric acid
lotion, chlorine or fumigating baths, electiicity
or galvanism ; but these are most appropriate to
the more chronic states of congestion. There are
other remedies besides the few now adduced,which
are suitable to particular states and seats of con-
gestion, and which fall under difl'erent heads.

13. ii. Having removed the congestion, it will
be necessary to employ means to prevent its recur-
rence, for the part once thus affected long retains a
morbid disposition. This object can be obtained
only by a careful avoidance of the exciting causes
— by preserving a free state of the secretions and
excretions — by promoting the digestive functions,
and invigorating the system by moderate exercise
in the open air, either on foot or horseback — by
the use of mineral waters, particularly those which
combine a tonic with an aperient and deobstruent
operation, as the waters of Cheltenham, Harrogate,
Scarborough, Leamington, Seidschutz, Carlsbad,
Bath, Marienbad, Vichy, and Eger — by warm
clothing, and by guarding against general vascu-
lar plethora.

BiuLioG. AND Refer Stall/, Tie Motu Tonico Vitali,

imieque pendente Motu Sanguinis particulari, &c. Jena;,
Ifiye. — /frtg/N'f, Opp. p. 350.— Juncker, Dissert, de Con-
gestionibus. Halw, 1748. — Iscvflminn, De Coiigestioiium
Mechanismo. Erl. 1749. — A. E. Bi<chner,'V>c Congest.
Natura, Causis, et Kffectibus. Ilala', 1749 — \i'co/<i/,l')e
Congestionibus. Jena? 17()1. — tVctzlar, De Congestioni-
bus. Lugd. Bat. 1779. — Cappcl, De Sanguinis Congest.
Helm. 179G. — (iu/tlhnf;cn, De Thcoria Congest, quatenus
Praxi inscrvit. Ilalae, 1781. — Murcard, Von I5;idern.
p. 397. — I.etit/ii. IJeytrage, Sec. p. 229 tt srtf. — Bloch,
Medicin. 15cmevkungen, p. .W. — Brandts, Versiich (Iber
die Lel)enskralt, p. 12i.'. — llartlicx, in IMcm. de la Soc
Med. d'Emulatioii, t. ii. p. 1. — IhtpJ'ciinarlnrr, Ucbcr die
Gehirnwassersuclit. p. 1'21. — llnin, lieitrHge zur Med.
Klinik. b. ii. \>. ii'A.\}i. — Autcnricth, I'liysiologie \ 383.
5i)9.— !ifil, Ucberdie Lebenskraft, v. Arcli. v. fur I'by-
siologic, b. i. st. 1. p. V29.-^(liii')i.sr/, in Ilufc/and'.i Journ.
der Pract. Heilkunde, b. xiii. st. 4. p. 128 — Sa/xhirgi'r,
Med. Chir. Zeitung, 1801, b. iv. p. '2bl. — Aliler, in Med.
and Pliys. Journ. vol. xxi. p. 29(i. — Pring, Principles of
Pathology. Lond. 1823, p. 443. —£. Sarlovi, in Cyclop,
of I'r.ict. Med. vol. i. p. 405.

CONSTIPATION

CONSTIPATION. — Svn. Constipatio vel Ohs- ,
tipatio Alvi ; Alv^ts tarda, dura, adstricta,
Vai". Auct. Tarda Alvi Dejectio, Vogel. Ohs-
tipatio AU?iita, Young. Stypsis (from a-rvipcD,
1 conatringe) Ploucquet. Coprostusis, Good.
Hartleibigheit, Germ. Constipalion, Paresse du
Ventre, Vr. Costipasioiie, Ital. Bound Belly,
Costiveness, Obstipation, Fcecal Retention, Al-
vine Obstruction.

Classif. — 4. Class, Local Diseases ; 5. Or-
der, Obstructions {CuUen). 1. Class,
Digestive Diseases; I. Order, Affecting
the Alimentary Canal (Good). I. Class,
I. Order (Aiiihor}.

1. Defix. Prolonged retention of the feeces ;
or slow, imperfect, or difficult eracuation of them.

2. Dr. GuoD has made Coprostasis, or Cos-
tiveness, a genus, and divided it into C, Co7i-
stipata, and C. Obstipata ; the chief difference
being, that the evacuation is voluminous in the
foimer, and scybalous or slender in the latter.
This division is nearly tiie same as that previously
adopted by Dr. Bateman, viz. into Costiveness
and Constipation. I believe, however, that any
distinction between them is quite unnecessary ;
inasmuch as either the one or the other, even
according to tiie import these writers attach to
them respectively, may arise from exactly the
same pathological conditions ; and that it will be
better to employ these terms in their usual ac-
ceptation, and to make constipation an inter-
mediate grade between costiveness and obstipa-
tion ; or, if any other difference than that of
degree be imputed to them, to consider obstipa-
tion as a modification merely of the others, by
attaching to it the idea of difficult and imperfect
voidance of the fa:ces, as well as of prolonged
retention of them — which latter alone vvill apply
to costiveness and constipation, according to the
degree of obstinacy by which the retention may
be characterised.

3. The slighter grade, or costiveness, can
scarcely be considered as a disease in some con-
stitutions, as it is often attended by a good state
of health in other respects, and seldom, continues
so long as to occasion any appreciable disturb-
ance. But, when neglected, it gives rise to those
collections in, and morbid conditions of, the
colon, which have been described in that article,
and favours the occurrence of other maladies.
Although cases are frequently occurring in which
little disorder results from constipation, except
from the means used to remove it, yet very
serious or even fatal effects not infrequently
accrue from it. I shall, therefore, adopt the
opinion 'of Cullen, and consider the retention
of the faeces beyond twenty-four hours, without
the desire of evacuation, as an approach to a
morbid state, and therefore requiring medical aid.

4. Duration, S)C. — The annals of medicine
abound willi cases in which the faeces had been
retained for an almost incredible time, with-
out any serious or severe symptom supervening.
The occurrence of constipation for several days,
or even weeks, is not rare, particularly in some
constitutions, and in weak or delicate females,
who take little nourishment, and as little exer-
cise ; and, excepting lisllessness with debility,
little disorder is complained of. It is not un-
common to meet with cases, especially in this
sex, where extremely little food is taken, and

— Its Pathologv. 405

where the faecal evacuntions are not more fre-
quent than once a week, or once a fortnight or
three weeks ; eliminations of effoete matters from
the blood taking place chiefly by means of the
skin, the surface of the lungs and kidneys, and
generally in an insensible manner. But cases
also more rarely occur, where the retention is
much longer, even without any other symptom
than great flatulent and fa>cal distension, par-
ticularly of the colon, until, suddenly, symptoms
of colic, ileus, or inflammation, come on, and
soon terminate the life of the patient, or put it in
extreme jeopardy. Instances have been adduced
by RiioDius, Pan aroi.us, Salmuth, Devilliers,
Blankard, Erhard, jNIossman, &c., of consti-
pation continuing for five, six, or seven weeks,
and even for as many months, without any faecal
evacuation. Dr. Baillie published a case which
continued for fifteen weeks ; and Joerdens met
with cases of fourteen, fifteen, and twenty-one
weeks. Instances of constipation continuing three,
four, five, seven, eight, and nine months, have
been detailed respectively by Trioex, Chaptal,
Smetii's, Staniland, Pom ma, Cramptox, and
V^alentin. In many of those very prolonged cases,
the appetite was very deficient ; but in that ad-
duced by Mr. Staniland, which continued for
seven months, the appetite continued good until
inflammation, which rapidly terminated life, came
on. This person, a young female, never had
more than one evacuation every two months,
during a period of five years ; all which time she
appeared otherwise in good health. Indeed, in
some instances of less duration than those now
alluded to, the appetite has been much greater
than in health. I have met with several cases of
habitual constipation, in which the patient had a
ravenous appetite, and yet did not pass a fascal
evacuation oftener than once every four, six,
eight, or ten days; but in almost every such
instance, either the breath has been loaded with
an offensive vapour, or the perspiration has been
abundant and disagreeable, or the urine copious
and much loaded, — evidently proving that the
disorder was connected with a rapid absorption
from the alimentary canal, and augmented evacu-
ation by the other excreting surfaces, or by the
kidneys". The inordinate excretion that takes
place by this latter emunctory, and the con-
stipation, and ravenous appetite accompanying it,
in diabete-, further shows that a very large pro-
portion — sometimes [nearly all — of the ingesta
vvill sometimes be so far digested as to admit of
their absorption, their subsequent discharge
taking place almost exclusively by the skin,
lungs, and kidneys ; a proportionate diminu-
tion of the excreting functions of the bowels,
and consequently of faecal matters in them, being
the result ; that portion, however, which does
collect, being retained until it excites them to
action, either by the bulk or by the irritating
properties it may have acquired, when also it
may be the cause of a morbid or perverted action.
The above circumstance shows (what, indeed,
physiological research has proved), that, in
healthy persons, the principal part of the fascal
discharges consists of secreted matters, and but a
small portion of them of such parts of the food
as have escaped the changes produced by di-
gestion ; and it proves the accuracy of the opinion
entertained by Cullex, at least as respects a
Dd3

406

CONSTIPATION — Causes of.

large number of such cases, viz. that costiveness
arises, in great measure, from the absorption of
the more fluid parts of the contents of the bowels,
whether consisting of the digestive aliments, or
of the exhaled or secreted fluids poured into
them.

5. I. Causes. — i. Remote causes. Habitual
costiveness is most common in persons of the
melancholic temperament, of a thin and robust
habit of body, and of a rigid constitution of fibre ;
and is often connected with great activity of the
absorbent function. The most prolonged cases
of constipation usually occur in thin delicate
females, and is obviously owing to an asthenic
condition of the organic functions, particularly
those more intimately connected with the ali-
mentary canal. Meckel states, that cretins are
very generally constipated, partly owing to their
inactive existence. It is very often caused by
the use of indigestible food, as heavy, or imper-
fectly leavened, or adulterated bread, new cheese,
nuts, cucumber, &c. ; by stimulant and astringent
aliments and beverages ; by the use of narcotics ;
by smoking or taking snuflf; travelling in carriages
or on ship-board ; by sedentary occupations ; too
long indulgence in sleep, and too warm beds;
inattention to the first intimation to alvine evacu-
ation ; venereal excesses; prolonged lactation;
excessive perspirations, or increased exhalation
and secretion from other surfaces and parts than
the intestinal canal ; mental or physical exertions
too long continued ; advanced age ; pregnancy ;
and the various mechanical and organic causes
about to be noticed (§ 9. et seq.).

6. ii. The im7nediate causes, or pathological
states giving rise to the retention and imperfect
excretion of the faeces, appear to be the follow-
ing : — 1st, Impaired or torpid functions of the
duodenum and small intestine. (See Duodenum.)
In this form of disorder, more or less obvious
symptoms of indigestion are usually complained
of from two to four hours after a meal, and it is
often attended by a slow pulse, slight sallow-
ness of the countenance and skin, with disten-
tion or uneasiness about the right hypochondrium,
and, in some cases, with a dull pain in this situ-
ation, and unnatural heat of the palms of the hand
and soles of the feet. The tongue is foul at the
root, while the sides and point are red ; the urine
high-coloured, or depositing much sediment, and
the pulse sometimes slower than natural ; but
occasionally quicker a few hours after a meal.
2d, Torpid Junction of the large bowels, affect-
ing either the cacum, colon, or rectum, in a more
or less special manner. In this form of disorder,
constipation is usually more prolonged tlian in
the foregoing, and the sense of distension or
uneasiness is referred to tlie situation of these
viscera. There is also much flatulence, and all
the symptoms more particularly noticed in tlie
article on Torpor of the Colon.

7. Constipation may thus arise from an inactive
state of any part of the alimentary canal, but it
most frequently and immediately depends upon
torpor of the portion devoted to the function of
ficcation ; and, although a part only of the di-
gestive tube may be chiefly affected, yet disorder
is seldom limited to it, — the fun(;tioiis of tlie ad-
joining portions, and, in many cases, of the whole
canal, l)eing impaired. It may bo useful, also,
to endeavour to estimate in what this disordered

function may consist, and whence it proceeds ;
and although nothing beyond conjecture will
often be advanced, yet will our opinions very
often be well founded, particularly after repeated
observation, and the attempt will therefore be-
come advantageous in practice. Impaired func-
tion, then, of any part, or even of the whole, of
the intestinal canal, producing either habitual
costiveness, or the occurrence of prolonged con-
stipation, may be owing to one or more of the
following states : — a. To a diminished secretion,
or modified condition of the biliary and pancreatic
fluids; — b. To lessened exhalation from the mu-
cous coat of the intestines, and to impaired secre-
tion from the follicular glands of this membrane ;
— c. To a rapid absorption from the internal sur-
face of the bowels ; — d. To relaxation, or torpor
of the muscular coats of the intestines giving rise
to distension, followed by imperfect or irregular
re-action on the distending power, and consequent
fascal and flatulent accumulations, particularly in
the large bowels; — e. To rigidity of the longi-
tudinal bands of the colon, forming this viscus
into cells, and diminishing the calibre of the
central canal, from each side of which the cells
diverge, — thereby occasioning that state of con-
stipation or obstipation, which is characterised by
scybalous stools, and a diflScult and imperfect
evacuation of them ; — /'. To the production and
accumulation of flatus in the intestinal tube,
which, by the distension and inaction of the coats
it occasions, as well as by its mechanical effects
in obstructing the passage of the faeces, and im-
pacting them into masses, often proves no mean
obstacle to the regular process of faecation ; —
g. To the accumulation of mucous sordes on the
surface of the intestines, or the lodgment of
hardened fa;ces in the caecum, cells of the colon,
or rectum ; and, lastly. To a varied combination
of two or move of the above states of function.
All these may be resolved into, or referred to, one
morbid condition, viz. impaired organic nervous
power, or diminished vital manifestation of the
digestive canal, expressed in one or more of the
above modes, or occasioning these pathological
conditions.

8. The above may constitute primary or idio-
pathic con^iipaiion, or intestinal indigestion; or,
in other words, functional impairment of the de-
fecating process. But constipation is as fre-
quently consecutive of lesions, either (n) of the
structure of the coats of the bowels themselves,
and affecting the calibre of their canal ; (h) or of
adjoining parts, causing obstruction, compression,
or displacement of them ; (c) and it is also very
often sympathetic of other diseases, which derive
from them some portion of the vital action requi-
site to the regular performance of their functions.
The last of these requires no further notice, as it
resolves itself into the pathological states above
enumerated ; but it is very important that the
practitioner should be enabled to recall to his
recollection the various changes which not infre-
quently do occur, and give rise to the same state
of disorder as the functional derangements above
stated ; as, upon a recognition of their presence or
of their absence, the prognosis and treatment
will very materially depend. The enumeration
of these will also comprise all that has been found
upon the dissection of such cases as have ter-
minated fatally, fuller details respecting them

CONSTIPATION — Consequences and Terminations or.

407

being given in other articles, particularly in that
upon the Organic Lesions of the Digestive
Canal.

9. A. Lesions, chiejiy of structure, affecting the
bowels and retarding the deftecating processes, — a.
Extreme dilatation of one or all of the large
bowels, soinetimes independently of much faecal
accumulation ; but most commonly accompa-
nied with large collections of hardened faces
and gases (Stcerck, Buendel, Callisen, Abeii-
cROMBiE, Staniland, and many others). Incases
of this description, the caicum and colon have
frequently been observed from twenty to thirty
inches in circumference. b. Scybala, hard
bodies, particularly biliary or intestinal concre-
tions, the stones of fruit, &c., in various parts of
the intestines, especially in the caecum or before
its valve, the sigmoid flexure of the colon, and in
the rectum just above the sphincter, and press-
ing upon it and the prostate. Instances of pro-
longed constipation have occurred in my practice
from the obstruction occasioned by large balls of
lumbrici and ascarides. A singular case of this
description was noticed by me in the London
Medical Repository (^vol. xvii. p. 243.), and similar
effects have been mentioned by Lieutaud,
Brera, Renauldin, and Bremser. c. Of in-
flammation of an insidious character, and sub-
acute or chronic form, affecting chiefly the mus-
cular or peritoneal coats of some part of tlie
bowels, particularly of the small intestines ; and
eitiier altogether arresting the peristaltic and
tonic movements of that part, or greatly diminish-
ing their activity, d. Contractions of various
parts of tlie intestinal tube, but most frequently
of the rectum, next of the colon, and least
frequently of the caecum and small intestines :
these may be small in extent, allhougb great in
degree ; or they may be the reverse. The nar-
rowed part may be affected by spasm, or by
thickening of one or more of its coats ; this latter
change being either so limited as to have the
form of a ring (Home, Baillie) ; or extended
much wider, and seated in a large portion of the
bowel, or in more than one part. It may, more-
over, be ulcerated, callous, cartilaginous, scir-
rhous, or even carcinomatous, &c., and it is
always attended by great distention of, and faecal
accumulations in, the part above it (AIqrgagni,
Lorry, Stole, Baillie, Portal, Howship,
Calvert, Annesley, &c.). e. Hajmorrhoidal
tumours, either in a state of inflammation or irri-
tation, and fissures, &c. of the anus, will often
occasion constipation : the latter, by rendering
the sphincter of the anus irritable and spasmodi-
cally contracted, so as to oppose the expulsion of
the faeces retained in the bowel ; the former, by
producing the same effect upon the sphincter, as
well as by presenting a mechanical obstacle when
seated internally, /'. Constriction, or contrac-
tion, of a portion of intestine by adhesions or by
cicatrisation (Theden). g. Polypoiis, fungous,
or flesliy excrescences growing from the inner
surface of the caecum, colon, or rectum ; polypi
of t!ie sigmoid flexure of the colon passing down
into thje rectum (Portal, Meckel, &c.) ; sar-
comatous tumours, and scirrhous and carcino-
matous productions in the rectum or colon, are
irremediable causes of obstruction when they
reach a certain extent, and occasion great, and
sometimes enormous distention of the parts im-

mediately above them, with fajcal accumula-
tions *, &c.

10. B. Constipation is also not infrequently
the consequence of diseases seated exteriorly to the
coats of the intestines, and compressing or dis-
placing them, and of which the following are the
most remarkable: — a. Tubal or extra-uterine
fcetation, pregnancy, hernia, &c. h. Pressure
on the rectum, arising from luxation or fracture of
the OS coccygis (Ephem. Nat. Curios, dec. iii. ann.
V. and vi. ob. 241.). c. The pressure of tumours
in the uterus or ovaria ; prolapsed or retroverted
uterus (Hunter, Wedel, Schultz, Marsinna,
and myself), d. Various tumours seated be-
tween the uterus, vagina, and rectum (Bader,
BoNET, Burggrave) ; abscess in the same situ-
ation (Ephem. Nat. Curios, dec. i. ann. iii. ob.
167., and myself) ; and too large a pessus in the
vagina (Bavauu). e. Abscess between the blad-
der and rectum (Conradi, Leske, &c.), and
enlargement or otiier disease of the prostate
(Ford, myself, and others). /. The pressure
of enlarged sacral glands (Cruickshanks), of an
enlarged ovarium descending in the pelvis (Mo-
eller, Odier, Sec), and of various kinds of
tumours — sarcomatous, steatomatous, fibrous,
and cartilaginous — developed in the omentum,
within the pelvis, &c. (Lauth, Reidlin, Schjef-

FER, OsiANDER, HuFELAND, &C.).

11. C. Obstinate constipation may also de-
pend upon, or at least be connected with, in-
jury or disease of the spine. In delicate females,
it is not uncommon to find ffecal retentions pro-
ceeding from this cause. In many of such cases,
much pain is felt when the spine is examined,
indicating the presence of inflammatory irritation
of the envelopes of tlie chord, or scrofulous dis-
ease of the bodies of the vertebrae. In cases of
this description, tlie functions of the intestinal
canal are iinpeded, or otherwise disordered, by
the morbid influence exerted by the spinal
nerves upon the organic nervous system, through
the medium of their communications with this
system.

12.11. The Consequences and Terminations
of constipation require the iitraost attention, as
respects both the prevention of such of them as
are unfavourable, and the recognition of their
early approach. Among the most common re-
mote consequences of fajcal retention, are cuta-
neous eruptions, headachs, vertigo, various

* The following case is not only extraordinary but in-
structive:— M. G , a medical olticer in the French

service, was always costive from birth. He ate largely,
but seldom passed a stool oftcner than once in one or two
months; and his abdomen assumed a large size. At the
age of 42, his constipation was usually prolonged to three
or four months. In 1S06, after medicines had been taken
to procure a stool, which had not been passed for upwards
of four months, abundant evacuations contmued for nine
days, and contained tlie stones of raisins taken a twelve-
month before : but the constipation returned. In ISOy, the
enlarged abdomen became painful, vomiting supervened,
and he died at the age of 54, having seldom, through life,
passed more than four, five, or six stools in the ye;ir. On
opening the abdomen, a fibrous partition obstructed
the rectum about an inch from the anus. Immediately
above this partition, the rectum was so enormously
dilated as to fill all the pelvis, and nearly all the abdomen.
The enormous cloaca contained thirty Kilogrammes of
brownish black and very oftensive pultacoons fteces. Its
inner surface presented gangrenous andulcerated patches.
The lower part of the colon was enlarged to the size of
the stomach ; which, with thesmall intestines, liver, &c.,
appeared diminished in volume and capacity by the pres-
sure of the distended rectum. (Renauldin, iii Did. des
Scien. Med. t. vi. p. 257.) , ,

Dd4

408

CONSTIPATION ■

dyspeptic symptoms, chlorosis, liysteria, and
chorea. ' The strainings at stool is liable to pro-
duce apoplexy and hernia in .aged, and hsemop-
tysis in young persons. When constipation is
-neglected or improperly treated, the most serious
effects are produced immediate^^^ upon the bowels
themselves ; hccmorrhoids,- severe colic, passing
into ileus or enteritis, being not infrequent results.
These very serious consequences of constipation
may, however, proceed as much from the use of
too powerful 'drastic or acrid remedies, to procure
evacuations, as from the fa;cal retention. I have
repeatedly seen dangerous effects follow a large,
or even a moderate dose of castor oil, which had
become rancid or acrid by exposure to the air, or
by long keeping. When the constipation has
continued long, the most distended portions of
the bowels, either by flatus or accumulated
fjEces, sometimes pass rapidly and insidiously
into an inflamed state, which, if not speedily
subdued, soon terminate in sphacelation, or in a
kind of sphacelating ulceration. In all cases,
therefore, of obstinate, and even of early con-
stipation, the state of the abdomen — particularly
in respect of tension, tumefaction, hardness,
definite or indefinite tumour, tenderness, heat
and dryness of skin, and pain on pressure, &c. —
should be carefully examined by touch, and
mediate percussion ; and if any of these symptoms
be present, the accession or early progress of in-
flammation, and other unfavourable consequences
now noticed, should be dreaded or even inferred.
If, to these be added nausea and vomiting, heat
of skin, high-coloured urine; an erect, wliite, or
loaded appearance of the papillae of the tongue ;
hard, constricted, or oppressed pulse, even al-
though it may be slower than natural ; and
more especially if pain, tension, &c. be present,
with hiccup ; inflammatory action of a serious or
unfavourable kind is obviously present, or even
far advanced, and calls for the most decided
means. (See arts. Colic, and Intestines — In-
Jiammation of.) Nor should we overlook the
fact, that constipation is a very common symptom
of enteritis, which may actually exist without
occasioning mucli febrile disturbance, or affect-
ing the pulse ; great care is therefore necessary at
the outset, in distinguisliing simple constipation
from the constipation which proceeds from the
slow and insidious occurrence of inflammation of
the intestines, — a diagnosis, which only a care-
ful examination of the abdomen, and enquiry as
to the above symptoms, can furnish.

13. III. The PuofiNosis in constipation is
very favourable in slight cases, and in those of
short duration, particularly wlien unattended by
nausea or vomiting, or by pain, tenderness, and
tumefaction of the abdomen, or by any febrile
symptoms : it should be given with great caution
when these symptoms are present, as tiiey indi-
cate ihe accession of inllammatory action : and
it ought to be unfavoitruble, when tiie obstruction
is prolonged, notwithstanding the judicious em-
ployment of remedies, or when any of the symp-
toms indicating the accession of the unfavourable
terminations noticed above make their appear-
ance; for these states of disease arc more dan-
gerous when they supervene on obstinate or pro-
longed constipation, than wiien they occur in a
simple and idiopatliic form. Wiien fa?cal reten-
tions apparently proceed from any of the organic

Prognosis — Teeatment.

changes enumerated above (§ 9, 10.), the prog-
nosis will necessarily depend upon the nature,
seat, and extent of these lesions, as far as they
can be ascertained ; as, for example, when it is
owing to enlargement of the prostate, contractions
of the rectum and colon, tumours in the pelvis, &c.,
an opinion of the result, although generally un-
favourable, will vary according to numerous
concurrent circumstances, particularly as respects
a permanent recovery, or an immediate or remote
occurrence of a fatal issue.

14. IV. TnEATMENT. — The mcans of cure
in every case of constipation are directed with
the intention, 1st, Of procuring ftecal evacuations
by as gentle and unirritating means as may be
adequate to the purpose; and, 2dly, After having
fully accomplished this end, of preventing a
recurrence of a torpid condition of the bowels
and digestive organs generally.

15. i. The removal of existing constipation. —
A. The slighter and more common cases of consti-
pation are most benefited by the use of such
means as are generally employed to promote the
secretions poured into the intestinal canal, and to
excite its peristaltic action. About three or four
grains of blue pill, either with or without a little
Castile soap and extract of taraxacum, taken at
bed-time, once or twice a week ; and a draught
consisting of equal quantities of the compound
infusions of gentian and senna, with a little neutral
salt, &c. (see F. 205. 266.) ; or of the compound
decoction of aloes , on alternate mornings, will
generally be all that is required. Besides these,
any of the stomachic and aperient medicines pre-
scribed in the Appendix may be adopted (see
F. 215. 252. 558. 574.); the patient having
recourse to the shower bath, or cold plunge bath,
in the morning, and resorting regularly to the
water closet after breakfast.

16. a. In the slight, as well as in habitual and
frequently recurring constipation, it will be useful
to ascertain, as accurately as possible, the par-
ticular viscera in fault, and what function is de-
ficient (§ 6. e£ seg.). When we suspect that the
duodenum and smaltintestines are especially affected
(4 6.), the compound infusion of senna, or the
infusion of rhubarb, combined according to the
circumstances of the case, either with the alka-
lies or their carbonates, or with vegetable bitters
and tonics, or with ipecacuanha, taraxacum, and
antispasmodics, as here directed, will generally
remo've all disorder. (See also F. 251. 391.
506. 562.)

No. 143. R Infusi Rhei. (vel Infusi Senna Comp.),
Aqua; Piroenla; aa 3 vj. ; Liq. Potas.sie ^^\ xx. ; E.\tracti
Taraxaci .3 j. ; Spirit. Myristica; 3 j- M..Fiat Haustus!,
mane vel hora somni sumenclu.?.

No. 144. B Infusi Scnnx Comp. 3 vss. ; SodiE carbon.
3 jss. ; Villi Ipccacuanlia\ .3 jss. ; Spirit. Amnion. Arom.
et Tiiict. llyoscvami iia 3 j. ; Tinct. Cardamom. Comp.
3;ij. M. Fiat Mist., cuju.s capiat Coch. iij. larga mane
nocteque.

No. 14.'). B Infusi CaUimba; (vcl Infusi GentianiE
Comp.), Infusi Sennie Comp.. Aa 3 ijss. ; Liq. Potassse
3 jss. ; Extr. Taraxaci 3 ss. ; Spirit. Pimento; (vel Myris.
tica;) 3 ij. M. Fiat Mist., de qua sumantur Coch. iij.
larga hora somni, vcl prime mane.

No. 14fi. }^ Extr. Colocynth. Comp. 3 ij. ; Saponis Cas-
til. gr. X.; I'ulv. Ipecacuanha; gr. vj.; Kxtr. Hyoscyami
3 ss. Contunde bene simul et fiant Piliila;xviij.,quarum
capiat binas hora somni quotidie.

No. 147. B Decocti Alots Comp. 3 "vss. ; Liquoris
Potassae (vel Carl). Sodffi) 3 j. ; Viiii Aloiis 3 vj. ; Extr.
Taraxaci 3 iij. ; Sjiirit. Pimenta; 3 ss. M. Capiat tertiam
vcl quartam iiartcm pro dose, et rcpetatur pro re nata.

No. 148. B Magiics. Suli>hatis 3 j. (vol PotassjE .Sul-
phatis 3 ss.) i Infusi Rosae Comp., Infusi Gentiana;

Comp. aa 5 vj. ; Acidi Sulpburici Arom. Til x
Sennas Comp. (vol Tinct. Aurantii) 3 j. — 3 ij.
Haustus, omni meridie capicndus.

; Tinct.
M. Fiat

In most instances of constipation depending
upon torpor of the small intestines, and dfjicient
bilianj secretum, a full dose of blue pill or of
calomel should be exhibited at bed-time, and a
common black draught the following morning,
at the commencement of the treatment, with the
view of promoting the secreting functions of both
the liver and the mucous follicles of the bowels ;
and a moderate action ought to be kept up for some
time subsequently by the remedies now adduced.

17. b. In those cases in which the large bowels
are chiefly in fault, the preparation of aloes va-
riously combined, the means already mentioned,
particularly l\ 1-16, 147., or those recommended
in the articles on the Colos, and on Cone, will
be generally found appropriate. In some in-
stances, however, it will be requisite to have
recourse to more powerful cathartics than I have
yet mentioned — particularly when irritability of
the stomach, or of the system generally, does not
exist — and to promote their action by eneraata.
The following, or F. 140, 141. in the Appendix,
may be employed : —

No. U9. R Pulv. Jalap, gr. xij. ; Pulv. Scammoniae
gr. V. ; PotassiB Sulphatis 3 j ; Olei Caryoph., et Ol. Ca-
nii, aa HI iij. Tere bene siinul, et fiat Pulvis in qiiovis
vchiculo idoneo sumendus.

No. 150. R Magnes. Sulpliatis 3 vj. ; Infusi Senna:
Comp. 3 ij. ; Tinct. Jalap. 3 j. ; Tinct. Opii HI vj. — x.
(vel Tinct. Hyoscyami 3 ss.) ; Tinct. Castorei, Spirit. Pi-
mentK, aa 3 j. M. Fiat Haustus.

No. 151. R Extr. Colocyntli. Comp. 3 ij. ; 'Saponis
Castil. gr. xij. ; Olei Crotonis gtt. iij. (vel Extr. Nucis Vo-
miciE gr. iij.) M. Fiant Pilulae xii. Capiat duas hora
decubitus.

No. 152. R IMannaj 3 j. ; Infusi Anthemidis 5 xij. ;
solve, et adde.Olci OUviE 5 ijss. ; JlagnesicE Sulphatis 3 jss.
Sit Eueraa.

18. c. In cases apparently depending upon
deficient tone of the muscular coat of the large
bowels, and imperfect propelling power of the
upper part of the rectum, I have seen benefit
derived from combining the spirituous extract of
nux vomica or strychnine with the pilula aloes
cum myrrha, or with the compound extract of
colocynth,as directed above in 1\ 151., in place
of the croton oil. When this state is connected
with deficient secretion from the intestinal mucous
surface (§ 7. /;.), small doses of the croton oil,
from one sixth to one half of a drop, combined
with some other purgative, and repeated daily, or
on alternate days, will remove obstructions from,
and restore the secretions of, the mucous follicles.
In cases also where the internal surface of the
intestines are loaded with a viscid mucous sordes
( j 7. g.), it acts more efficiently than any other
medicine, particularly when combined as above
(R 151), or with calomel or blue pill, and restores
more permanently the functions of the intestines.
I have recently met with several cases of con-
stipation consequent upon attacks of pestilential
cholera, and in nearly all of these I have inferred
the existence of not only imperfect peristaltic
action of the bowels, but also an accumulation
of viscid mucous, or albuminous sordes on their
internal surface, — an inference confirmed by the
state of the evacuations. The combination of
purgatives now alluded to has proved more effi-
cacious in removing this morbid condition, than
any other I have employed.

19. d. In children and young females, consti-
pation is generally attended, even if it be not

CONSTIPATION — Treatment. 409

caused, by deficient' secretion from the mucous
follicles, and by aii |iccumulation of mucous
sordes (the Saburra intestinalis of the older
writers, and the T£fiibarras Sahural and Einbarras
intestinal of French authors) on the internal
surface of the bowels. In these cases, a dose of
calomel, with either jalap or scammony, and
triturated with sugar, and followed by castor
oil, or the infusion of senna with salts, or by
the decoction of aloes, &c., according to the
circumstances of the cases, will- generally procure
full evacuations. But in many such. cases, the
repeated exhibition of these will be required
before the collected sordes can be removed ; and
even when the evacuations have assumed a
healthy appearance, it will be requisite to resort
occasionally to purgatives combined with tonics
and resolvents — such as senna, aloes, or rhubarb,
with gentian, cascarilla, cinchona, or calumba ;
and with potass, soda, &c., before the functions of
the bowels will be altogether restored.

20. e. When the fajcal retention assumes the
form of obstipation, and is attended with difficult or
imperfect evacuation ; or with frequent desire, and
tenesmus; and with hard, rounded, scybalous
discharges ; we may infer the existence of rigidity
of the longitudinal bands of the colon (j 7. e.) ;
and should combine anodynes and antispasmodics
with purgatives. I have commonly derived most
advantage from small doses of castor or olive oil,
exhibited frequently, in some carminative or aro-
matic water, with a little tincture of hyoscyamus
and ipecacuanha wine ; and from demulcent,
anodyne, and oleaginous clysters (F. 143, 144.
795.) Electuaries, also, consisting of the con-
fection of senna, with cream of tartar, magnesia,
extract of hyoscyamus, &c. (see F. 96. 98.J, will
generall)' prove more serviceable, in these cases,
than very active medicines. When the retained,
scybalous fieces produce irritation of the colon,
the frequent calls to stool, and the scanty, mu-
cous, and watery evacuations, may lead the prac-
titioner to suppose, if he rely upon the account
of the patient only, that diarrhoea, instead of
constipation, actually exists, and hence to adopt
an improper treatment. In these cases, the warm
or tepid bath, the addition of ipecacuanha, or
hyoscyamus, or both, to the purgatives given by
the mouth, and the use of clysters with infusions
of ipecacuanha and linseed, and with olive, lin-
seed, or almond oil, will generally procure the
evacuation of scybalous faeces. When the bowels
are distended by flatus, the operation of aperients
will be most assisted by gentle friction of the
abdomen ; and confidence to persist in the use of
it will be given by directing the friction to be
employed with some liniment (F. 298. 306.), or
with l\ 157. subjoined.

No. 153. R Olei Ricini recentis3 j.— 3 ij. ; tcrecum Vi-
tello Ovi unius, et adde terendo, Vini Ipccacuanhje Tl] x.;
Tinct. Hyoscyami Til xv. ; Tinct. Castorei HI xx. ; Aquse
Pimentse 3 xj. M. Fiat Haustus, 4ta vel Sta quaque
hora sumendus.

No. 154. R Potassa; Bitart. in Pulv. 3 j. ; Soda? carbon,
exsic. (vel Magnesiee Calcinatae) 3 iij.; ConfectioiiisSennse
3jss. ; Ccnfectionis Rutje 5 ijss. ; Extr. Hyoscyami
gr. xij. ; Pulv. Ipccacuanhse gr. ij.— iij. ; Tinct. Capsici
5 ss. ; Syrup. Zingiheris q. s. ut fiat Electuarium, cujus
capiat partem quartam 4tis vel 5tis horis donee pleni-
dejecerit alvus.

No. 155. R Sodfe Sulphatis, Manns Opt., aa 3 j,i solre
leni cum calore in AquK Menthse Virid. 3 vjss., et adde
Tinct. Senna; Comp. 3 j- ; Vini Ipecacuanhie 3 j. ; Tinct.
Capsici 3 ss. ; Spirit. Carui 3 ij. M, Capiat Coeh. larga
quatuor tertiis vel quattis horis.

410

CONSTIPATION — Treatment.

No. 156. R; Olei Amygdalae Olei Ricini, Mannae Opt.,
aa 3 jss. ; Aq. Pimentae 3 xj. M. Fiat Haustus, 4tis, 5tis,
vel 6tis horis sumendus.

No. 157. R Unguenti Cetacei 3 jss. ; Olei Carui et
Tinet. Opii, aa 3 jss. Misce, et fiat Linimentum, cum
quo illinatur abdomen, urgente flatu.

21. B. a. In the more obstinate or prolonged
cases of constipation, which have resisted the
above, or any other means usually employed to
procure evacuations, we should endeavour to
ascertain, by enquiring into the previous state of
the patient's digestive and intestinal functions,
and by examining the abdomen, rectum, and parts
in the vicinity, the probable cause of obstruction.
The account which may be furnished of the
appearance of the evacuations heretofore, and of
the facility with which they had been evacuated,
as well as of the sensations felt before or at the
time of evacuation, will very materially guide
the judgment of the practitioner in concluding
respecting the existence of organic disease of the
colon or rectum, or in the vicinity of the latter.
Frequent attacks of diarrhsea, tenesmus, or dy-
sentery, previously to the occurrence of con-
stipation, or of pain in the course of the colon, or
along the sacrum, should always lead us to sus-
pect narrowing, or thickening, or both, in some
part of the colon or rectum (§ 9. d.). In such
cases, we should endeavour to solicit fajcal dis-
charges by oleaginous and saponaceous clysters,
and frictions of the abdomen, rather than by
purgatives taken by the mouth ; and we ought
not to be too officious in the use of these ; but
should so study the feelings of the patient, as to
prevent irritation and febrile disturbance — the
harbingers of inflammation — from coming on. In
these cases particularly, examination of the state
of the rectum, and the lower part of the colon, by
the introduction of the long flexible bougie, as
recommended by Dr. Willan, should not be
omitted ; and if any stricture exist within the
reach of this instrument, its gradual dilatation
should be attempted. If a stricture be reached,
it may be of service to use a hollow bougie,
along which enemata may be thrown up so as
to pass beyond the seat of obstruction, which
might otherwise not be overcome by them. In-
stances have been met with, in which stricture
and organic disease of the colon have apparently
existed for some time without constipation having
been complained of ; and yet the exhibition, when
constipation did take place, of acrid purgatives in
large and repeated doses, has been soon followed
by an unfavourable issue, which, however, might
not have been much longer deferred by any treat-
ment whatever. Cases illustrative of this occur-
rence have been recorded by Home, Sterry,
Annbslev, &c. (See references.)

22. b. In almost every instance in which the
bowels still remain obstinately costive after two
or three doses of purgative medicine have been
given, but without any urgent symptom being
com])lainod of, it will be more advantageous to use
gentle means, to trust chiefly to enemata, and to
wait patiently the result, than to prescribe medi-
cines which will irritate and invert the action of
the upper part of the digestive tube without
reaching the seat of obstruction. If, notwith-
standing, symptoms of inflammatory action begin
toappciir; or if the stomach become irritable;
or if the pulse be oppressed, hard, or constricted ;
or if the patient be plethoric and of a sanguine or I

irritable temperament, venaesection, or the appli-
cation of leeches to the abdomen, or both, should
be resorted to, and hot poultices and fomentations,
or the warm turpentine epithem, or a blister, be
afterwards placed upon the belly. The patient
may then be left quiet for several hours, in expect-
ation of the action of the purgatives previously
given; or, if the stomach be irritable, soothing
and anti-emetic remedies (F. 178, 179.357.) only,
or a full dose of calomel with opium or hyoscy-
amus, should betaken, and after a few hours the
enema may be repeated. In cases of obstinate
constipation, unconnected with contraction of the
colon or rectum, a large dose of calomel, either
alone, or with opium or hyoscyamus, may be
exhibited, and repeated once or twice, at distant
intervals ; each dose being followed either by
castor oil, or by the common black draught, or
by half an ounce of turpentine with an equal
quantity of castor oil in any suitable vehicle.
But where inflammatory disease, or lesions con-
sequent upon inflammation, are suspected to exist
in either the colon or rectum, calomel, or even a
full dose of blue pill, will often aggravate the
mischief, unless emollient enemata be frequently
thrown up. Indeed, I believe, from the expe-
riments and observations I have made respecting
the action of calomel on the alimentary canal —
from remarking its effects in irritating and in-
flaming the inner surface of the colon and rectum
when taken in large doses — and from the history
of the previous ailments, and treatment of many
of those who have had stricture of the rectum or
colon — that a very large proportion of such cases
has been brought on by the fi-equent use of
calomel as a purgative.

23. c. When we believe that constipation is
owing to a torpid or paralysed state of tiie mus-
cular coats of the large bowels, and the accuinu-
lation of hardened fajces consequent thereon
(§ 9. a.), oleaginous purgatives given by the
mouth ; in some cases, a full dose of calomel
followed by a turpentine and castor oil draught ;
and, subsequently, oleaginous, saponaceous, and
terebinthinate enemata ; are generally the most
appropriate means. If, however, these fail, then
small but repeated doses of castor, olive, or almond
oil ; frequent demulcent enemata ; the aspersion
of cold water over the abdomen or lower ex-
tremities ; or injections of cold water, may be
tried. (.See § 26.) If there be great inflation or
ffEcal distension of the colon, friction, with the
carminative liniment prescribed above (li 157.),
may also be employed, with various otiier internal
and external means recommended in the articles
on Colic and Colon. In aged females especially,
hardened faeces sometimes collect to such an
extent, and are lodged so firmly in tiie rectum
and lower part of the colon, as to require removal
by mechanical means. Cases of this kind iiave
been detailed by SciiuniG, Ptrrr, Jiisnoi'iucK,
Seciievlrel, AVhite, &;c., and have occurred in
my own practice, as well as in that of many
others. They require the careful introduction
of a mnrrow-spoon, or some similar instrument
into the rectum, to break down the fasces ; and
subsequently tiie means just stated, particularly
oleaj^inous and terebinthinate injections thrown
up by the pump apparatus now in general use,
which should be provided with a large and very
long pipe, or with a long, hollow, and flexible

CONSTIPATION.— TUEATMENT.

bougie, which ought to be passed as far as pos-
sible up the rectum.

24. d. If alvine obstruction be apparently
owing to organic, malignant, or other diseases
about the uterus, its appendages, the vagina, or
rectum (^10.); ov to spasmodic constriction of
the sphincter ani excited by inflammatory irritation
in its vicinity, or by hasraorrhoids, the warm bath,
semicupium, or the hip-bath ; the vapour of iiot
water and narcotic decoctions directed to the
anus; anodyne and relaxing injections; and the
extract of conium or hyoscyamus, made into
either a suppository or an ointment, with the
addition of a little of the extract of belladonna;
may be prescribed, along with such other mea-
sures as the circumstances of the case may
require.

25. e. When constipation is dependent upon,
or associated with, di.-ease of the spine, or in-
flammatory irritation of the membranes and en-
velopes of the chord, leeches should be applied
near the place where pain is complained of; or
the patient may be cupped in the vicinity, kept
quiet, and in the horizontal position ; and the
action of the bowels promoted by the means
stated above (§ 16, 17.), and by terebinthinate
injections. If inflation of the bowels exist, the
carminative liniment may be employed ; and if
tenderness, tension, or pain of the abdomen be
complained of, leeches, followed by fomentations,
&c. as already advised (§ 22.), should be re-
sorted to.

26. C. Besides the above, other means have
been recommended by authors in various states
of the disease, and found of much service when
appropriately prescribed. Joerdems advises the
frequent administration oi assafwtida in enemata,
and, in cases of deficient secretion and healthy
action of the colon, it is certainly of essential
use, either alone or in conjunction with purg-
ative medicines. Starke recommends the in-
spissated oi-gull, both in the form of pills and in
clysters. In the latter form, it is calculated to
prove an excellent adjuvant of other means ; and
when combined with aloes, taraxacum, soap, ex-
tract of gentian, &c. (F. 559. 562.), it is very
serviceable in restoring the healthy functions of
the bowels, and digestive organs generally.
Wenut directs repeated clysters of the decoction
of gratinla to be thrown up. Numerous writers
liave advocated the application of cold, in cases
of obstinate constipation. Schenk, A. Fonseca,
Blankard, and Laison advise the patient to
walli or stand upon a marble pavement or slab ;
and Brassavolus states that Savanarola cured
the Duke of Ferraia, by making him walk bare-
footed over a cold wet marble floor. Steven-
son, Falconer, Percival, and Spence direct
the affusion of cold water over the lower and
upper extremities, and adduce cases wherein the
practice had been successful after other measures
had failed. Kite, Bartram, Saxcassim, and
ScHMiDTMANN rccommend cold epilhems, and
the affusion or aspersion of cold water, over the
abdomen ; and Kaehler, Korb, and Brandis
advocate the administration of cold clysmata, in
addition to the employment of cold externally.
The cold and tepid shoicer hath, the cold plunge
bath, and warm and tepid bathing, have severally
been resorted to in aid of other measures, and
are frequently of use, — the former particularly

411

.in habitual constipation, the latter in cases at-
tended by difficult and imperfect evacuation, and
seemingly dependent upon rigidity of the longi-
tuidinal bands of the colon. Electricity -and
gaivauispi iiave been employed successfully by
Kite, Sioaud la Fond, Grapengi£sser, and
('larkson ; and the injection of tobacco smoke,
and of a weak infusion of the leaves of tobacco,
has been advised by Von RIertens, Vogel, and
other authors referred to, when discussing the
treatment of Colic and Ileus (ivhich see). The
decoction of barberry ; -powdered charcoal (Mit-
chell and Daniel), in the dose of one, two, or
three table-spoonsful given every hour in milk
or lime water; frictions of the abdomen (Quel-
MALz) ; inunction of it with linseed or olive oil
( Riedlin,&c.) ; fomentations consisting of senna
leaves made hot and moist by boiling water, and
placed over the abdomen (Petit) ; purgative ex-
tracts ; tinctures, and infusions, applied to this
situation, either in the form of ointment or foment-
ation (Schenck, Altbert, &c.) ; and enemata
containing the potassio-tartrate of nj;(imouv(ELiAs),
have also been employed. The exhibition o( emetics
was advised by Hippocrates, Praxagorus,
C;1:lius Aurelianus, and Alexander Tralles ;
and of ipecacuanha orantimonial emetics by Stoll,
Sims, Sumeire, Deplace, and Hosack. I have
seen benefit derived from inunction of the abdomen
with an admixture of castor and linseed oils, to
which three or four drops of croton oil had been
added. In a great proportion of the cases of con-
stipation which have occurred to me since 1817,
when I first adopted the practice, very certain and
immediate advantage has been derived from a full
dose of calomel (either with or without opium or
hyoscyamus), followed in a few hours by half an
ounce of oil of turpentine, and an equal or some-
what larger quantity of castor oil, taken either in
a cup of milk, cr in a glass of some aromatic
water. The action of these has usually been
promoted by an injection containing castor, olive,
or almond oil ; and, if the operation has not
been sufficiently copious, another dose of castor
oil has been given, and the enema repeated.*

* The following synopsis exhibits a succinct view of the
treatment : — 1. If the pulse be hard or constricted, and if
there be pain, increased on pressure, bleed generally or
locally, or both — apply blisters or hot fomentations, or
the cold effusion, or cold epithems, &c., on the abdomen ;
afterwards exhibit purgatives, enemata, &c. 2. If con-
stipation seems to arise from diminished secretion and
exlialation, give calomel or blue pill, carbonates of the
alkalies, jalap, the purgative oils, senna, camboge, ela-
terium, croton oil, &c , according to circumstances. 3. If
it depend upon a rigid fibre and habit of body, combine
purgatives with relaxants and nauseants — with ipeca-
cuanha, antimony, colchicum, soda, hyoscyamus, &c. ;
prescribe emollient and relaxant medicines in i)reference
to thoae that are acrid ; and give them with antispasmo-
dics and sedatives, i. When it arises from torpid peri-
staltic action and lessened secretion, conjoin tonics, gum
resins, and bitters, with purgatives and aperients ; myrrh,
assafcetida, galbanum,&c.,with aloes; sulphate of quinine,
or ext. of gentian with aloes; the alkaline solutions,
with tonic infusions; use friction with stimulating lini-
ments to the abdomen, or along the spine ; resort to the
cold salt-water bath or shower bath, and the tonic and
aperient mineral waters of Cheltenham, Leamington,
Viihy, and Carlsbad. 5. When it is attended by ac-
cumulations of hardened faeces in the colon, have recourse
to copious soapy or oily clysters — to the introduction of .a
marrow-spoon to break down the fa?ces — to tl'e injec-
tions of cold water, &c., by the valvc-apparatus, with a
long bougie attached to the pipe — to the aspersion of
cold water on the abdomen, or the application of cold to
the lower extremities, &c. G. If it proceed from organic
change of the large bowels, or of parts affecting them,
solicit evacuation by emollient and relaxant enemata, and

412 CONVULSIONS

27. ii. The prevention of a recurrence of the
disease should be strictly guarded against, par-
ticularly after active cathartics have been given
to remove it. Purgatives, aperients, or laxatives,
combined with stomachic bitters and tonics
( F. 187. 266. 872.), ought to be taken daily, and
afterwards on alternate days, until the functions
of the bowels are fully restored. The patient's
diet should be light and nutritious; all astringent
and indigestible substances avoided ; and, if the
abdominal secretions be deficient, an occasional
dose of blue pill, or hydrarg. cum creta, and a
course of taraxacum, with deobstruent laxatives
and tonics (F. 390. 510. 873.), pre5cribed. Sub-
sequently a course of Leamington or Cheltenham
mineral waters, or the artificial Seidschutz,
JMarienbad, and Carlsbad waters, and in some
cases the Pyrmont and Spa waters, will prove of
much benefit. The shower bath, upon getting
out of bed, or the cold salt-water bath, will
further tend to promote the digestive and defascat-
ing processes. Costive persons, with a large or
pendulous abdomen, should wear a broad belt or
bandage around it, which will serve to promote
the functions of the bowels. The patient should
carefully avoid the remote causes of constipation,
attend daily to the first intimations to stool, and
have an early recourse to medicine when such
intimations are delayed beyond the usual time,
AVhen the bowels require the assistance of me-
dicine to preserve them in a regular state, aloes
may be combined with ma-tich and Cayenne
pepper, or with a bitter extract, myrrh, and
assaloelida, and taken daily about two hours
before dinner.

?' BiBLlOG. AND Rei'ER. — fh'ppocra/es, Uifi vovtrm^ iii.
Opp.v.p.4yi. — Ccelius Aurelianus, Opp.pp.243. 529. — Alex.
andcr Trallcf, lib. ii. cap. 44. — Ballonius, Opp. i. p. 40. —
Schenk, Observat. 1. iii. n. 285, — Salmuth, cent. i. obs. 24.,
cent. ii. obs. G.5. 98., cent. iii. obs. 26. ib.—Blankard, Col-
lect. Med. et Piiys. cent. vi. No. 68. — Panarolus, Ja-
trolog. Pentecost, i. obs. i. — Smctius, Miscellan. p. 561. —
Bonet, Sepulchret, 1. iii. s. xiii. obs. 11. p. 589. — Triccn,
Observ. Med. p. 2.5. and .56. — Morgagni, Epist. xxxil. de
Alvi Adstrictione. — Ciil/isrn, in Act. Soc. Med. Havn.
i. and ii. p. 329. — Aas/,-on>, in Ibid. ii. p 9. — Brendct,

Observ. Aiiat. Med. dec. i. n. 20 A. F. IFaltficr, De

Intest. Angiistia. Lips. 1731. — Qiielmalx, De Frictione
Ab'lominis, &c. Lips. 1749. — Ltetitaud, Hist. Anat.
Med. 1. i. obs. S.'92, 293. 301— A. Fonscca, De Tuenda \'a-

letud Sancassani, in Hn/.'er, Bibl. Med. Pract. vol. iii.

p. 601. — C. G. I.udtrig, Dc Caiisis Ohstructionis Alvinoe,
4to. Lips. 1770. — relit, Traite de Malad. Chirurg. t. ii.
p. 101., et t. iii. p. 47. 103., et Mem. de I'AcaJ. de Chirurg.

1. p. 239. — Sauvnges, t. ii. p. 363 Devil/iers, in Journ.

de Med. t. iv. p. 257. — Marleaude Grandvilliers, in Ibid.
t. xiii. p. 226. — Laisoi), in Ibid. t. Ixxxvii. p. 3.54. — CtiUen,
Materia Medica, vol ii. p. 496. — Rocschlniib, Magazin.
b. iv. No. 7. — Er/inrd, Do Prajternat. et rara Obstipat.
Alvi Causa, &c. Erf. 1790. — Stoeicic, Aniuis Med. vol. i.
p. 12.5.— .B/c/c/;-, Med. Bemerkung.p. Vli.—Sloll, Kat. Med.
par. ii. p. 135. vol. vii. p. 1.54. — tVeikard, Vermischte Scriften,
b. ii. p. hi.— Starke, Klin.Iiistit. p. 174.— Bai/lic, in Trans.
of Soc. for the Improvement of Med and Chirurg. Knovi'-
ledge, vol. ii. No. 14. p. 174. — Meckel, N. Arrhiv. b. i.
No. .3., ct Acad, de Berlin, &c. 1759, p. 30.— Stevenson,
Edin. Med. Essays, Sec. vol. v. p 893. — Lorry, Hist, de Soc.
de Med. vol. ii. — Burjigrave, Medicin. Piille, p. 232. —
Cruick.ihank.i, Anat. of Absorb. Vessels, p. 119. — Bei'l,
Memorab. Clin. vol. i. fasc. 1. No. 3. — TItcdcn, N. lic-
merkung, b. iii. p. 76. — Ford, in Loud. Med. and Phy.sic.

Journ. vol. iv. p. .390. — Kite, in Ibid. vol. viii. p. 164

Lcske, Auserl. Abhaiidl. b. i. p. 61 Ji'edel, Stark's Ar.

chiv. h. vi. p. G73.—J(icdlin, Millenarius, No. 301. ct .536.
— Sims, Observ. p. 20. — Sumeire, Journ. de Med. t. Ixi.
p. 369 — (W(V'r,Manuel de Mcd.PratujUO, y.Wl —Moeller,
in Baldingcr, N. Magazin. b. xx. p. 178 Osiuiider, N.

suppositories ; soothe local and constitutional irritation,
proscrvc the functions of the stomach, and give the al-
kaline solutions with conium, belladonna, &c. — (From llie.
Author's ihort Notes tj hiv Lectures delivered j'rom 18Ji4
to lb29.)

— Pathology of.

Denkwiirdigkeiten, b. i. st. 2. p. 130 Falconer, in Mem.

of Med. Soc. of Lond. vol. ii. p. 72 _Sherwen, in Ibid.

vol. ii. p. 9. — Kaehler, in Stark's Archiv. b. ii. st. 2.

No. 2 — Grape7tgeisser, Versuche, &c. p. 100 Aliberl,

in Mem. de la Sue. Mt'd. d'Emulation, t. i. p. 182. 443

nillan, Miscel.- Works by A. Smith, &c. Lond. 1821,
p. 446. — Daniels, in Philadolph. Med.Journ. vol. v. p. 119.

IVendt, ill Annalen des Klin. Institut. 1 heft Sechevcrci,

in Journ. Gencr. de Med. &c. t. xix. p. G. — Hufeland, in
his and Iliinly's Journ. der Pract. Heilk. Nov. 1S09,
p. 130 — Portal, m Mem. de I'Institut. Nat. de France,
1S07. — Po7nma, in Journ. de Med. Contin. July, 1810,
p. 74 — Spence, Med. Trans, of Coll. of Phys. vol. iii.
p. 99 — Gerard, in Dimcaii's Ei\\n. Med. Comment, vol. x.

p. 44. — Warren, in Ibid. p. 255 Helsham, in Ibid.

vol. xiii. p. 2H2. — Bis/ioprick, in Ibid. vol. xx. p. 340. —
Jiosack in Duncan's Ann. of Med. 1796, p. 310., and Lond.
Med. Kep. t. xvii. p. 77 Moss?nan, in Ibid. 1797, p. 307.

— Clarke, Trans, of Irish Acad. vol. vi. p. 3 E. Nome,

Trans, of Soc. for Med. and Chirurg. Improvement,
vol. ii. p. 182. — i?arfe)-, Observ. 39. — Korb, in Uichter's
Chir. Bibl. b. viii. p. 120. — Mttrsinna, Beobach. b. i.
p. 141. — Bateman, Art. Constipation and Costivcness, in
Rees's Cyclopaedia. — Joerdcns, in Hufeland' s Journ. der
Pract. Heilk. b. xvii. st. 2. p. Vl.—Elias, in Ibid. b. x. St. 1 ,
p. \\<d.— Mitchell, N. Y. Med. Repos. 1800. —Stcrry, in

Lond. Med. Repos. May, 1823 Crampton, Dub. liosp.

Reports, vol. iv. p. 305 Hoivship, On Dis. of the Lower

Intestines and Costiveness, &c. 8vo. Lond, 1820. — Reece,
On Regulating the Stomach and Bowels, &c. 8vo. 2d edit.

1827 Green, Edin. Med. and Surg. Journ. vol. ix. p. 166.

— Oiidnay, vol. xvi. p. 383. — Clarkson, in Ibid. vol. xvi.
p. 475. — Annesley, and Author, in Researches on Diseas.
of India, &x. vol. ii. p. 50. et scq. — Valentin, in Bull, des
Ann. des Scien. Med. t. x. p. 74. — Bompard, Traite des
Malad. des Voies Digestives, &c. 8vo. Paris, ls29, p. 280.
— Staniland, Lond. Med. Gazette, vol. xi. p. 245.

CONSUMPTION. See Pulmonary Cox-
sumption, and Mesenteric Consumption.

CONTAGION. See Infection.

CONVULSIONS. — Syn. iTtatj-jAo^. Gr. Spasmi,
Clonici, Motiis Couimlsivi, Distensiones Nervo-
rum, Conductiones, Auct. \'ar. Convulsion,
Spasme, Fr. Zucknngen, Ger, Convulsioni,
Ital, Convulsion Fits.

Classif, 4, Class, Nervous Di.sea.ses ;

3, Order, Spasmodic Affections (CuUen),

4. Class, Afl^ecling tiie Nervous Func-
tion ; 4. Order, Affecting the Sensorial
Powers (Gwrf). II. Class, III. Order
(Author, in Preface).

1. Deein. Violent and involuntary contrac-
tions of a part, or of the whole of the body, some'
times with rigidity and tension (tonic convulsions) ;
hut more Jrequently with tumultuous agitations,
consisting of alternating shocks{c\omccon\n\sions) ;
that come on suddenly either in recurring or in
distant paroxysms, and after irregular and un-
certain intervals.

2. Convulsions have attracted a due share of
attention from the medical writers of all ages.
IIippocr^\tes states, that " convulsions arise
either from repletion or evacuation" (Aphor.
sect, vi, §39.); and Galen, whilst he admitted
the propriety of referring them to these two mor-
bid states, argued for a third, namely, irritation
occasioneil by a morbid humour. yETius adhered
to a similar arrangement, but considered that
the third of tliese pathological conditions per-
formed the principal part. Subsequent writers,
chiefly copiers or commentators on Galen,
adopted his views, Z.\cutus Lusit.\nus imputed
mucJ! importance to the second morbid state of
Galen, viz, excessive evacuation; and consi-
dered tliat a positive or relative dryness of the
nervous and muscular .system was occasioned by
it. The writings of Willis and Sylvius Dell-
lioii made some alterations in tiie received doc-
trine of the origin of convulsions, by referring
more than their predecessors had done to the
nervous system and animal spirits, and less to

CONVULSIONS — Forms of

the influence of morbid humours. It was not, I
however, until the appearance of the writings of
F. Hoffmann, that a spirit of accurate mves-
tigation was manifested in this department of
medical inquiry. This writer, to whom our
science still continues under great obligations,
regarded convulsions as a consequence chiefly of
a morbid state of the spinal chord and its mem-
branes,— an opinion which has been adopted by
many, and which numerous facts seem to sup-
port, in respect of several manifestations of these
complaints, although it cannot so frequently be
shown that this part of the voluntary nervous
system is that primarily affected.

3. The opinions respecting the nature and
relations of convulsions, entertained during the last
century, and what has passed of the present, have
been so numerous and vague, that the advantages
resulting from a review of them could by no means
compensate for the limits they would occupy. Such
of them as deserve notice will be referred to here-
after. It may, however, be remarked respecting
them, generally, that no two writers of reputation
agree as to either the import of the word, the
diseases coming within this denomination, or the
manner of arranging and considering them. Under
such circumstances, the systematic and eclectic
■writer might be placed in much difficulty, if he
had not extensive and diversified experience to
guide him. Upon this, however, my chief reli-
ance is placed, even while I endeavour to profit
by the labours of my predecessors, — some of them
my followers in the adoption of important curative
means in these affections.

4. If, in defining convulsions, we state it to be
" an abnormal action of muscular or fibrous parts,"
we at once make it synonymous with spasm, and
embrace a most numerous class of diseases, viz.
those forming Dr. Cullen's order,. Spasmodic
Diseases, as well as many of those in which
spasm is merely a part of the morbid state. If
we define it to be " an irregular or abnormal
action of voluntary mvscles," we shall comprise
all those maladies, which usually put on nearly
a regular form or type, owing to certain pecu-
liarities of the spasmodic action and concomitant
phenomena, as tetanus, epilepsy, &c. But if we
adoptthe more confined and precise definition given
above, we shall include those disorders only which
assume no regular type ; but which, whilst they ap-
proach, on the one hand, those of a regular form,
often pursue, on the other, very eccentric courses,
and even anomalous states. It is impossible to
consider the diseases of the frame in a way true to
nature, and at the same time as abstract entities
• — as species perfect and distinct of themselves.
They are individually, in truth, merely certain
morbid states, lapsing on the one side insensibly
into others, to v/hich, although most intimately
allied in every re^spect, different names have been
but too arbitrarily assigned ; and passing on the
other side into affections otherwise denominated,
although not materially differing in their natures.
Thus, if we make spasm the essential character
of one great family of diseases, we may divide it
into subordinate orders, genera, and species, ac-
cording to the parts affected, and the functions
concomitantly disordered, and the permanency,
the rigidity, the relaxations, and the frequency of
recurrence of the spastic action. But still the
essence of disorder will be very generally the

413

same ; and each of these subdivisions — each of the
manifestations of the particular morbid states
made the basis of distinction — will so insensibly
glide into each other, as to defy the possibility of
drawing lines of demarcation between them. The
practitioner will be unable, on many occasions,
to detect in practice the specific dift\;rences as-
sumed ; and will continually meet, as I have in
many hundreds of instances, with cases which he
cannot refer to one species more than to another,
and which are as much eclampsia as epilepsy, or
as much what are usually called cotivulsions as
either the one or the other. If we take the charac-
ter of the spasm, in respect of permanency, rigidity,
relaxation, and recurrence, as a basis of arrange-
ment of all the diseases attended by abnormal
action of voluntary muscles, we shall have
every grade,- passing imperceptibly from the
most acute form of tetanus tiirough cramp,
epilepsy, eclampsia, convulsions, &c., down to
the most atonic states of chorea and tremor.
Also, if we consider the affections called con-
vulsions, and which are usually irregular in their
forms, with reference to the character of the
abnormal contraction of the muscles, we shall
perceive it in some cases of the most violent and
spastic nature, frequently of some continuance,
the relaxations being of brief duration, or scarcely
observable ; and in others nearly or altogether
approaching to tetanic. These constitute the
more tonic form of convulsions, from which there
is every possible grade, down to the atonic or
most clonic observed in chorea or tremor. Thus,
then, abnormal actions of muscular parts, like all
other morbid actions, may, in respect of grade,
be either above or below tiie healthy standard —
tonic and clonic marking each respectively ; but
between which tliere exists every possible de-
gree ; these terms being therefore entirely relative,
and conveying no definite and unchanging mean-
ing. But, besides varying remarkably as to
grade, the abnormal actions of voluntary muscles
may be attended by numerous phenomena giving-
them specific characters. Thus, when accom-
panied with complete insensibility, or any other
superadded morbid condition, they have been
denominated epileptic, hysterical, &c. ; and,
from this circumstance, they assume certain types,
but of no very constant or immutable kind. When,
however, they are not so associated, they constitute
a simpler state of disease, and put on less regular
forms, aflPecting either the whole of the voluntary
muscles, or a greater or less number of them.

5. I. FoKMS. — From this, therefore, it is to be
inferred that, although Dr. Cullen, and many
others, have considered convulsions as character-
ised by the clonic nature of the spasms — by the
alternation of contraction and relaxation without
the control of the will — yet this does not univer-
sally obtain, they sometimes assuming states ap-
proaching to tetanic, and every degree of violence,
as well as length of duration. The more regular
and specific forms of convulsion, as epilepsy,
liysteric fits, raphania, hiccup, tetanus, rabidity,
Sec, are discussed in separate articles; I shall,
therefore, consider at this place only those simple
and irregular states of convulsion which do not
fall within its more specific manifestations.

6. Simple convulsions present great diversity
of character. They have been already shown to
diflPer widely in violence and degree; and they

414

CONVULSIONS — Local.

vary as greatly in duration, modes of accession,
and recurrence, as well as in the number of parts
affected by them. Hence, tliey may be acute or
chronic — most frequently the former ; -partial or
general; continued, recurrent, or intermittent ;
uncertain, in their accession, or periodic ; and
they may, moreover, attack a number of parts
in succession. The circumstances and causes
which originate them will also impart to them
certain characters, whicli, although frequently
difficult of detection, should not be overlooked.
Thus, they are either idiopathic or symptomatic,
most frequently the latter, even when the primary
lesion illudes observation. But these diversities
of form, although most deserving of attention,
can only partially serve as a basis for the prac-
tical consideration of convulsions. I shall there-
fore view them — 1st, In respect of their partial
or local occurrence ; 2d, As to their general mani-
festations ; 3d, As they affect infants and cliildren ;
and, 4th, As we observe them in connection with
the puerperal states : 1 shall also notice them as
associated with, or consequent upon, other acute
diseases.

7. i. Partial on Local Convulsions : —
Many of the disorders which have been imputed
to convulsion of individual parts, fall more appro-
priately under the denomination of spasm. I
shall therefore briefly notice only such as, from
the alternation of relaxation and contraction,
appear to approximate to the convulsive state.
A. Involuntary contraclile parts are more sub-
ject to spasmodic action, than to that which
may be said to be really convulsive. Whether
or not certain of the phenomena presented in
various diseases of the alimentary canal, as gas-
trodynia, pyrosis, rumination, retchings, colic,
borborygmi, ileus, the tormina of dysentery, &c.,
are more properly convulsive or spasmodic,
must be entirely a matter of opinion, to which
but little practical importance should be attached,
as they are both modifications merely of the same
proximate condition. This remark applies equally
to the abnormal actions sometimes presented by
the urinary bladder and uterus ; and it is proba-
ble that palpitations of the heart, and angina
pectoris, are chiefly manifestations of convulsive
contractions of this viscus. (See Angina Pecto-
ris, and Heart — Palpitations of .) That hiccup
is altogether owing to convulsive actions of the
diapliragm, cannot be doubted. (See Hiccup.)

8. B. Voluntary muscles and parts present the
most unequivocal appearance of partial or local
convulsions ; although several local affections, de-
nominated convulsive by some writers, are, more
strictly speaking, spasm or cramp of particular
muscles. — n. Tlie muscles of the eye-lids, owing
either to the contraction of an ill habit, or to
irritation of the ophthalmic branch of the fiftli
pair of nerves, are sometimes clonically con-
vulsed— forming the nictitatin of authors. — b.
Tlie muscles of the eye-halls arc also not infre-
quently similarly aflected, particularly in infants
and children — occasioning, parli(!ularly during
slc'-p, rolling of the eyes. This state of local
convulsion is common during dentition, and dis-
orders of the stomach and bowels. Either a more
severe state of convulsion of these muscles, ap-
proaching to spasmodic contraction of one or
more otlliein, or a paralysis of tlieir antagonists,
will occasion distortion of the eyes, or strabismus,

with or without irregular oscillations of the iris,
dilated pupil, &c. ; as in inflammatory and organic
affections within the cranium, and in verminous
disorders. — c. Twitching convulsions of the mus-
cles of the face, or those inserted into the lips;
retraction of the angles of the mouth, giving rise
to what has been called the risus sardonicus ; are
often observed, but generally as a symptom of
the invasion or actual existence of most danger-
ous diseases ; as inflammation of the encephalon,
or of the diaphragm, and various organic changes
affecting the substance of the brain. Twitchings
of the muscles of the face, however, sometimes
occur in persons of a nervous and irritable tem-
perament, or with an excited brain, without any
apparent disease. — d. Convulsive movements of
the tongue are seldom observed unconnected with
irregular movements of other parts, unless in the
diseases novv named and in apoplexy. — e. Slight
convulsive actions of the muscles of the lower jaic,
giving rise to grinding of the teeth in sleep, are
very common occurrences in persons with worms,
or other diseases of the alimentary canal ; or ex-
cited circulation of the encephalon. I have seen a
case of clonic convulsion of the muscles of the lower
jaw, this part being in a state of constant motion,
alternately to either side, owing to the contractions
of one side taking place when relaxation occurred
in the other. — f. Trismus, or spasmodic con-
traction of these muscles in infants, arises from
disorders of the prima via, the impression of
cold, or irritation of the umbilicus, but does
not strictly fall under the head of convulsions.
— g. A clonically convulsed state of the
muscles of the neck are sometimes, but rarely,
observed, producing convulsive tremor, or shak-
ing palsy of the head, which is aggravated on
certain occasions of mental perturbation, and
nervous or vascular excitement. (See Palsy,
Shaking, and Tremor. — h. The abnormal
actions which approximate more closely to
the permanent or spastic contractions, and
affect one or more of the cervical and adjoining
muscles, are much more common, and are
often induced by a current of cold air, by
over-straining, or by inflammatory irritation
about the bodies, or intervertebral substance of
the upper cervical vertebrae ; or from disease
about the medulla oblongata or base of the
brain ; or from irritation of remote parts — as of
the genital organs of the uterus or ovaria ; or
from strangulated hernia, — an instance of which
last has been observed by myself. In all such
cases, the head is drawn more or less to one side,
or backwards, or forwards ; but similar flexures
of the neck often are occasioned by the paralysis
of muscles on the side from which the head is
bent, the tonic or natural action of the unaffected
muscles drawing the head from the paralysed
side. In the one case, however, the muscles are
rigid and strung like a cord on the contracted
side, and more or less pain is complained of
cither in them or in the vicinity, particularly on
attempts to bend or turn the head or neck in an
opposite direction ; whilst, in the other case, these
symptoms are wanting. 'These are more pro-
perly cases of spasm than of local convulsion,
as the contraction seldom alternates with relax-
ation, but is commonly more or less permanent.
However, cases sometimes occur, which are
intermediate between permanent spasm and con-

CONVULSIONS — General.

415

vulsion, especially as a symptom of the diseases
last referred to. — /. Convulsive movements in the
pharynx and asophugus, impeding or preventing
deglutition, are frequent in liysterla, and in the
last stage of several fatal diseases. — k. They also
affect the muscles of the larynx, the diaphragm,
and other respiratory muscles, either separately,
in rapid succession, or nearly simultaneously.
Some of these affections are transient, and the
result of slight causes ; as in sneezing, coughing,
sighing, sobbing, &C.: others are extremely dan-
gerous, owing to the nature of the parts affected,
the severity and continuance of the convulsive
movements, and the circumstances in which they
supervene ; as in spasm of the glottis, spasmodic
crcnip, certain states of asthma, with severe fits
of coughing, singultus, &c. — /. Convulsive ac-
tions also occur in the muscles of the abdomen ;
as in hysteria, common and lead colic, and in
consequence of intestinal worms. The most re-
markable instances of true convulsions of the
abdominal muscles merely, that I have observed,
have occurred in adult persons infested by the
large round worm. — m. The muscles of the spine
sometimes experience convulsive actions, but
more frequently spastic contractions, occasioned
by hysteria, disease of the bodies of the vertebraj
or membranes of the spinal chord, injuries of ad-
joining parts, strangulated hernia, acute rheu-
matism, the passage of biliary or renal calculi
along the ducts, and inflammatory irritation of
the uterus or ovaria. — n. Either one or both of
the upper e.itremities are occasionally affected
by convulsions, more commonly both. The
fingers are generally clenched around the thumb,
which is drawn upon the palm ; the arm being
either extended forcibly, and the hand turned as
in pronation, or the fore-arm bent upon the arm,
or both these occurring in rapid alternation.
Such are the more tonic convulsions of the upper
extremities ; but their muscles also experience
slight and extremely clonic contractions; as the
subsultvs tendinum often observed towards the
close of fevers and diseases of the brain ; the
more tonic or spastic convulsions, particularly
when affecting one arm only, also arising from
lesions of some part of the encephalon, or of the
upper portion of the spinal chord. — o. Convul-
sions of the loiver extremities are characterised
by analogous movements, and chiefly affect the
flexor and extensor muscles. The toes are bent
downwards, and the legs and thighs either drawn
upwards or extended, or both the one and the
other alternately.

9. Convulsions of voluntary muscles may occur
as now described, or in two or more situations, or
even in different or opposite parts, either simul-
taneously or in succession. They may affect one
side of tlie body only, the other being in its natural
state, or paralysed. They much less frequently
attack either half transversely.

10. ii. General Convulsions. — General
convulsions observe no certain 7node of accession.
On some occasions they attack suddenly ; but
they are much more frequently preceded by pre-
monitory signs, especially in children and chronic
cases, — a knowledge of, and attention to, which
may be made available in preventing their oc-
currence. They are also sometimes recurrent, or
succeed each other, with more or less rapidity.

11. A. The premonitory signs are vertigo and

dizziness, irritability of temper; flushings, or alter-
nate flushing and paleness of the face ; lunihious
or other spectra floating before the eyes ; various
noises in the ears ; partial loss of sight or hearing ;
restless or unsound sleep, or uncommon weight
or drowsiness ; fulness or prominence, and roll-
ing of the eyes ; clenching, or grinding of the
teeth, clenching of the hands, &c. during sleep ;
a tumid appearance of the countenance and
hands; coldness or cramps of the extremities;
slight tremors, shivering, horripilation, shudder-
ings or horrors ; nausea, retching or vomiting ; or
pain and distension of stomach and left hypo-
chondrium ; unusual flatulence of the stomach
and bowels, or other dyspeptic symptoms ; pains
in the loins or back ; frequent sighing or sobbing •
numbness of various parts ; stammering or im-
peded utterance, loss of memory, and absence
of mind ; palpitations, or slowness and irregu-
larity of pulse ; slow, laborious, or irregular respi-
ration ; and sometimes, a copious discharge of limpid
urine. In some instances, leipothymia, or threatened
syncope, precedes the general convulsions.

12. B. a. The more tonic seizure. — The con-
vulsive movements constituting the paroxysm
generally follow rapidly upon one or more of the
above signs, and vary remarkably as to violence
and duration. During their continuance, the
countenance is very much distorted ; the eye-balls
are prominent, full, wild, staring, and rolled in
all directions ; the eyelids are either open, or ra-
pidly shut and opened ; the patient grinds and
gnashes his teeth, and sometimes foams at the
mouth, or protrudes the tongue. The alternate
contractions and relaxations of the whole volun-
tary muscles, and contractions and extensions of
all the limbs, are performed with the utmost irre-
gularity, rapidity, and with so great force, as often
to require the united strength of several persons
to preserve the patient from injuring himself. In
these struggles, the teeth, or even the bones of
the extremities, have been, in some instances
broken. The respiration is laborious, interrupted,
and sometimes accompanied by a hissing noise.
The countenance, and indeed the whole scalp,
are sometimes tumid, bloated, or red, and often
leaden or livid towards the close of the fit, parti-
cularly in plethoric persons, when the respiratory
actions are much impeded, and the affection ori-
ginates in cerebral disease. In other cases the
face is pale, and the pulse weak, or small and
constricted. The urine and fajces are occasionally
voided with violence during the paroxysm : occa-
sionally large quantities of limpid urine are passed.
In these, the pulse is generally full, strong, and
commonly slov/ or irregular. In many instances
the general sensibility and consciousness are but
very slightly impaired, particularly in the more
simple cases, and when the proximate cause is
not seated in the encephalon ; but in proportion as
this part is affected, primarily or consecutively,
and the neck and face tumid and livid, the cere-
bral functions are obscured, aiid the convulsions
attended by stupor, delirium, &c., or rapidly pass
into, or are followed by, these states.

13. h. The more clonic convulsions. — Such are
the common manifestations, of convulsions, when
they are not occasioned by inanition ; the pa-
roxysms, however, varying greatly in 'violence,
duration, and frequency of recurrence, according
to the degree of vital energy, and numerous other

416

CONVULSIONS— General.

circumstances. But when they arise from, or
are associated wilh, exhaustion, excessive dis-
charges, and evacuations of the vascular system,
they assume a somewhat modified cliaracter.
They are then not attended by sopor ; the general
sensibility and cerebral functions being but little,
or not at all aflecled. The pulse is frequent,
small, weak, broad, or open ; the features are but
slightly distorted ; the countenance is pale and
collapsed ; and the limbs and extremities cold,
and much less rigidly convulsed than in the
tonic or more spastic seizures. In many cases,
the convulsive movements resemble a succession
of general shocks, succussions, or shudderings,
sometimes of great violence, and often of con-
siderable continuance, occasioning the bed or
room to shake, and terminating the life of the
patient : in others, they consist of constant tossings
of the limbs and trunk.

14. [C. Duration and recurrence. — The pa-
roxysm may cease in a few moments or mi-
nutes, or continue for some, or even many,
hours. It generally subsides rapidly, the patient
experiencing, at its termination, fatigue, head-
ach, or stupor ; but he is usually restored in a
short time to the same state as before the seizure,
which is liable to recur in a person once aft'ected,
but at uncertain intervals. After repeated at-
tacks, the fits sometimes become periodic (the
convulsio recurreiis of authors). In adult females,
they commonly accompany the menstrual periods.
When they arise from organic disease within the
cranium, each successive interval is generally
shortened, until their recurrence is so frequent
that the patient is scarcely recovered from the
languor, or other symptoms, consequent on one
seizure, until he has another, which at last either
ends in profound coma, or terminates life.

15. D. The modiJicatioDS of convulsions are
extremely numerous. In some cases, the respi-
ratory muscles are much affected, and the fit is
accompanied with yelling and shrieks, evidently
not proceeding from pain (the convulsio ejulans,
or shrieking convulsion). In other instances, the
abnormal movements shift from one part to an-
other, or attack various muscles in succession.
In these, the seizure is comparatively slight, and
the cerebral functions not remarkably disturbed ;
the convulsio enatica of Dr. Good. In rarer
cases, the seizure assumes the form of convuhive
tremor, as remarked by Dr. PnicHARO ; is at-
tended with a hot perspiring state of the head,
vertigo, and slight stupor ; and continues one,
two, or three hours.

16. a. Besides these, various other forms of
convulsion occur, particularly in persons under
the influence of a morbidly excited imagination,
or religious enthusiasm ; and in females endowed
with the nervous and irritable temperaments, with
great mobility of the muscular system, and who
are affected by nervous or vascular excitement of
the generative organs. On many occasions, tiiese
seizures have been propagated to a number of
persons by sympathy. The convulsions which
became almost epidemic in the west of Scotland,
in 1742, and were occasioned by religious enthu-
siasm, are not only instances of a peculiar form
of this affection, but also among the most striking
on record of the influence of imagination, and of
sympathy, or of imitation, in disordering the
functions of tlie body, A number of persons

were attacked nearly at the same time, when
hearing the addresses directed to the imaginations
and passions of their hearers by the followers of
Whitfield ; and always when impressed by the
denunciations of vengeance and hopes of sal-
vation which they set forth. The mental agony
which was thereby induced, gave rise, in many,
to the most violent tremblings and agitations of
the body, which were frequently preceded by
faintings, and followed by convulsions, and sub-
sequently by sobbing, weeping, and crying aloud.
In some cases, the convulsions produced epistaxis,
which generally terminated the seizure. Such
appears to have been the usual course of the
paroxysm, according to the meagre accounts
which have been furnished of it. (See Edin. Med.
and Surg. Journ. vol.iii. p. 442.) The convul-
sions desciibed by Mr. Cornish as having been
prevalent in Cornwall in 1813 and 1814, owing
to the same causes, hardly differed in any respect
from the above.

17. 6. The convulsions which were prevalent
in some of the Zetland Isles during the middle
and towards the close of the last century, but
which have seldom occurred there since that
period, seem to have had some resemblance to
the foregoing, as well as to hysteria. Dr. Whyit
has referred to the frequency of convulsions in
these islands ; and has adduced the extreme fa-
cility with which they were propagated among
young women, as a proof of the existence of a
wonderful sympathy between the nervous sys-
tems of different individuals. The convulsions
now alluded to, commonly attacked adult females
when at church ; but men and young girls were
not altogether exempted from them. They are
described very nearly as follows, by gentlemen
who had frequently witnessed them: — Persons
affected, generally fall down in apparent fainting
or swooning fits, and soon afterwards utter wild
cries and shrieks, the sound of which puts all
who are subject to the disorder in the same situ-
ation. Tlieir limbs and bodies are tossed about,
the most frightful screams being uttered by them
all the while. Their heads are also thrown from
one side to the other, and their eyes are fixed and
staring. In this manner they roar and struggle
for five or ten minutes, and then rise up without
recollecting a single circumstance that happened
to them, or being in the least fatigued by the
exertions made in the fit. Females are most
commonly attacked in a crowded church, and on
occasions of public diversion and merriment.

18, Similar instances of the spread of con-
vulsions, by the infection of sympathy or imi-
tation have been recorded by writers, and cases
of it have occurred within the observation of the
author. Dr. IIavgarth has adduced a remark-
able occurrence of this description. — Twenty-
three females, from 10 to 25 years of age, and
one lad of 17, who had all intercourse with each
other, were seized, in 1796, in Anglesea, with
slight pain of the head, or of t!ie stomach and
left side, followed by twitchings or convulsions
of the upper extremities, continuing with little
intermission, and with much violence, for a con-
siderable time. The disorder was not so violent
in bed ; but it continued in some cases during
sleep. The pulse was moderate, the bowels cos-
tive, and the general health not much impaired.
There was usually hiccup ; and, when the con-

CONVULSIONS, INFANTILE — Symptoms and History of.

417

vulsions were inost violent, giddiness, with loss of
hearing and recollection. During convalescence,
the least fright, or sudden alarm, brought on a
slight paroxysm. (See Ciiouea and Related
Affections, &c.)

19. iii. Infantile Convulsions. — Convul-
sions often attack infants of a delicate and irri-
table frame, and those who are seized by severe
internal or constitutional disease, or are suffering
some concealed visceral irritation. They occur
most frequently in children under four or five
years of age, and particularly during dentition.
They decline in frequency from this epoch to the
commencement of the second dentition, or about
the seventh year, when they again are often met
with. i\Jr. NouTn doubts thai any increase takes
place at tlie seventh year. The above is the re-
sult of my experience, which in great measure
agrees with that of Beaumes, Tissot, and others.
As infantile convulsions present various peculiar-
ities in their causes, phenomena, complications, and
consequences, and are besides among the most im-
portant morbid conditions which come before the
practitioner, I shall consider ihem apart.

20. A. Premonitory signs often usher in the
attack, but occasionally no such symptoms are
observed. I suspect, however, that they are
more commonly altogether overlooked, than en-
tirely absent. They consist chiefly of manifest-
ations of geneially increased irritability. This
is shown by the temper, if the child be a (ew
montlis old or upwards ; by want of sleep at night,
and heaviness in the day, or by perfect insomnia.;
by a ligliter and shorter sleep than usual, the
child starting up on the slightest noises, or as
from a frightful dream, with fits of screaming
without evident or sufficient cause ; by alternately
flushed and pale countenance or unwonted ani-
mation of tlie face and eyes, followed by languor
and heaviness ; by a half closed or open state of

and hence these signs must often be common to
both, and also to some other infantile diseases.
This is shown by their frequency in remittent fever,
and other inflammatory irritations of the gastro-
intestinal mucous surface of children.

21. B. The paroxysm of convulsions in children
is similar to that occurring in adults. In tlie
most severe cases, there is a violent, involuntary,
and alternating or convulsive action of all the
voluntary muscles extending to some internal or
involuntary parts ; in which, indeed, the affectioa
often seems to originate, or which appear to be
those first affected. In plethoric infants, the face
and scalp are tumid, reddened, and subsequently
livid ; the eyes are distorted and staring, or turned
up beneath the upper eyelid, leaving only the
schlerotic visible ; the respiration is impeded and
laborious, but very rarely attended by foaming
at the mouth and protrusion of the tongue, unless
the paroxysm be epileptic. The whole surface
often becomes slightly violet-coloured towards
the close of the fit, and the hands tumid. In
many instances, particularly in weak or exhausted
children, the seizure is much less violent, the
countenance being pale and collapsed, and the
convulsions more clonic. There are sometimes
only Iwitchings of the muscles of the face, and
alternate contractions and relaxations, or rapid
shocks, of a few parts, or of only one half of the
body, or of various parts in succession, with slight
blueness about the eyes and mouth ; but more
frequently the wltole body is convulsed, and the
countenance distorted and haggard. In some
cases, the thumbs are drawn into the palms, and
the great toes towards the soles. The mental
faculties, and general sensibility, in the slight or
clonic convulsions, are generally not interrupted.
They are also, however, frequently obscured, but
only during the height of the paroxysm ; and
sometimes even entirely abolished in the severe

the eyelids during slumber, with startings and j recurrent convulsions attending cerebral disease
twitchings ; by fixed, vacant, staring eyes, the | — the ec/«m/;sia of some authors (§24.).

pupils being either contracted or ddated, or fre-
quent oscillations of the iris, without being in-

22. C. The utmost diversity exists as to the
duration and recurrence of the fit. In some cases

fluenced by the admission of light, or contraction i it is only momentary or of a very few minutes'

of one pupil while the other is dilated ; by stretch-
ings or rigid extensions of the limbs ; by hiccup, or
irregularity of breathing, or short gasps, followed
by long laborious inspirations ; by twitchings of
the fingers, or clenching of the hands, or pressure
of the thumb upon the palm, the fingers being
extended and separated from each other, or fre-
quently moved about ; by the sudden relinquishing
of the breast soon after having sought it eagerly,
and the throwing back the head, with an expres-
sion of anxiety, and an appearance of difficult
deglutition ; and by fulness of the upper lip, with
a pinched nose and countenance, and slight blue-
ness below the eyes and about the mouth. Rlany
of these symptoms, designated by the vulgar,
" inward Jits," may with justice be attributed to
inflammatory irritation of tlie arachnoid, as indeed
contended for by Parent, [Martinet, Lalle-
iMAND, &c.', and, in my opinion, especially of the
arachnoid of the base and internal surfaces of the
brain. UnACHET and North have enumerated
them as premonitory of convulsions, which they
loubtless most frequently precede ; but in a great

duration. In other instances' it continues for se-
veral hours, with frequent remissions. It may
likewise cease, and shortly afterwards return, and
thus subside and racur at short but irregular in-
tervals for several times, and at last cease alto-
gether, or terminate life. Or the first seizure may
be so severe as to be fatal. These recurring fits
are often at last attended by insensibility, which is
not altogether, or even not at all, recovered from
in the intervals. This form of the malady is
more common in children than in adults, except-
ing as it occurs in the puerperal states, or towards
the termination of tumours and abscesses in the
brain. As the convulsive movements constituting
the fit become less and less violent and constant,
and respiration fuller and freer, the natural ap-
pearance of the surface returns, and the child is
enabled to cry ; it afterwards falls either into a
refreshing sleep, or, if the convulsions have a
cerebral origin, into a stupid or lethargic state of
various duration.

23. D. There is a species of spastic or tonic
convulsion, which is but rarely met with, affect-

many cases convulsions hold the same relation to j ing- chiefly the extremities. It seems more nearly
inflammatory and febrile attacks in infants, as , allied to spasm than convulsion, into which,
rigors do to the same diseases occurring in adults; I however, it sometimes passes: and occurs, chiefly,
Vol. I. ^ E e

418

CONVULSIONS, PUERPERAL— Description of.

in very young children, and in those approaching
to puberty, particularly those who are nervous
and irritable. I have seen but few instances of
it ; but it has more frequently been seen by
MM. Jadelot and Tonnelle. It consists of
rigid contraction of the upper and lower ex-
tremities, of the former only, but more frequently
of both. The hands are' slitrhtly bent on the
forearm, and the feet are stretched in the same
axis with the leg. The spastic action of the
muscles continues for several hours, or even days,
then ceases, and returns, and often thus recurs
frequently at short intervals. The intellectual
faculiies, the general sensibility, and the muscles
of the trunk, are not affected ; and the pulse and
natural functions not materially disturbed. The
cases of it which have occurred in my practice,
have all been evidently owing to the irritation of
worms, or morbid matters in the alimentary canal,
or to dentition.

24. E . Another form of convulsions is much more
frequently met with in children, to which the name
of Eclampsia has been given by Rosen, Sauvages,
Brachet, and others, and which has been con-
sidered as infantile epilepsy by some, and, with
more justice, by others, as convulsions occurring
in the more robust children as a consequence of
cerebral congestion of an active form. But it
differs from epilepsy, in the absence of foaming at
the mouth, by the irregular and frequent re-
currence of the attack, by its longer duration in
most cases, and by its uniform connection with
evident signs of fulness of blood, or acute disease

in the brain. This form is seldom preceded by
precursory symptoms of any continuance. The
child cries, its face and scalp become red and
tumid, it loses consciousness, and is seized with
violent convulsions, or with tremor and rigidity,
or a succession of spastic shocks of the limbs.
In a few seconds, or minutes, or even hours,
the seizure subsides ; but is generally renewed
at short intervals; the head remaining hot and
p-iined after each return of the fit, which never
terminates by a critical sleep of sliort continu-
ance, and in restoration of the healthy functions,
as in epilepsy, unless assisted by active treat-
ment, but is frequently followed by profound
stupor or complete insensibility. From the fore-
going it will be evident that eclampsia is merely
a more severe form of convulsion, differing from
others only in respect of the severity or tonicity
of the muscular contractions, the more complete
abolition of sensibdity and of the cerebral func-
tions, and its more uniform dependence upon
congestion of the brain and its consequences
($21.). The eclampsia of children is in every
respect similar to the convulsions of the puerperal
states (§29.;.

25. 7''. 'J'here are certain phenomena connected
with the accession and the course of the convul-
sive fit that require attentive observation, as they
furnish indications of the pathologi(;al state oc-
casioning the seizure, and, indeed, form tlie basis
for rational indications of cure. These liave in-
timate relation to the origin of liie paroxysm
cither in re])]etion or inanition — in congestion, or
in ansL'mia of the cerebro-spinal masses ; in whicli
latter the convulsions of children not infrequently
originate, as shown by Dr. M. Hai.i, and Dr.
Cioorii, ;md subse((uenlly by others, and as i have
liad frc<|uent opportunities of remarking for many

years. When the convulsion is attended with a
congested state of the circulation in the head, it
will generally be readily recognised, both from the
history of the case-, and from the premonitory and
concomitant symptoms. The warm, tumid scalp
and face ; the flushed countenance ; the con-
tracted pupils and suffused conjunctiva ; quick,
full, or hard pulse, particularly of the carotids ;
are evident signs of an excited circulation in the
brain, not infrequently either accompanied with,
or running into inflammatory action. When the
countenance and scalp are swollen, full, dark, or
livid ; the fontanelle elevated and tense ; the
eyes distorted, prominent, vacant, and stupid ;
the pupils dilated ; the veins of the head and
neck large and dark ; the pulse slow, irregular,
or oppressed ; the respiration laborious ; the ves-
sels within the cranium are evidently congested.
Dr. John Clarke, and many other writers, im-
pute the convulsions of children to irritation or
organic change, either directly or indirectly, in-
duced in the brain or its membranes, particularly
in the arachnoid, according to M. Brachet, It
will be seen, when treating of the proximate
cause of convulsions, that, although this may be
most frequently the case, it is by no means uni-
versally so. For we occasionally meet with con-
vulsions consequent upon exhaustion, and even
anaemia, as in the last stages of chronic diarrhoea,
or other diseases ; and after large or repeated
depletions, where there is no evidence of irrita-
tion of the arachnoid or of organic change. In
many such cases there may occur notwithstand-
ing, especially during the height of the paroxysm,
temporary and sliglit congestion of the head, as
shown in the article Blood, (§54 — 61.) ; but,
still, evidence of anamia of the brain, and, in-
deed, of the general system, will be furnished in
the depressed and relaxed fontanelle ; in the pale,
collapsed, and pinched features ; in the reten-
tion of consciousness and unimpaired general
sensibility ; in the bloodless and dull appearance
of the conjunctiva and cornea ; in the state of
the pulse in the carotids, and the low temper-
ature of the head, and in the pale, shrunk,
wasted, and often bloodless condition of the
whole surface.

26. There is a disease to which infants are
liable, that consists of a spasmodic contraction of
the muscles of the larynx and of the extremities,
and which has been confounded with convul-
sions, or with spasmodic croup, and variously
denominated. As the muscles of the larynx are
chiefly affected, and as the disorder consists of
spastic rather than convulsive action, it is treated
of in a separate articlcr (See Larynx, Spasm

OF.)

27. iv. Puerperai, Convulsions. — Convul-
sions may come on («) during the latter months
of pregnancy ; (/>) during parturition ; and (c)
during the first fortnight after delivery. They
may bc- partial or general, most commonly the
latter; and they may assume various shades of
tonicity, from a state of tetanic violence to the
more clonic form, characterised by alternating
contraction and relaxation ; but they usually
present very nearly the same phenomena as
eclampsia — being attended by loss of conscious-
ness, and recurring paroxysms, between which
sensation is not restored.

28. A. Premonitory symptoms commonly usher

CONVULSIONS — Complications op.

419

In the seizure ; but, in some cases, they are either
absent, or so brief in duration, or so slight, as to
evade detection. Chaussieii thinks that they
are scarcely ever wanting altogether. The
patient usually complains shortly — sometimes
for several days — before the attack, of lassitude,
depression, and a feeling of indisposition which she
cannot well describe ; frequently of disorder of
the stomach ; often of weight or pain in the head,
or of drowsiness, vertigo, and sparks, or various
dark or bright objects, floating before the eyes.
These symptoms are renewed at intervals during
a day or two, and are occasionally attended by
embarrassment of speech. To these usually are
superadded, shortly or just before the seizure, a
change in the expression of the countenance ;
partial or occasional failure of sigiit, or loss of
sight; sometimes loss of hearing; haggard, va-
cant, and fixed state of the eyes, with a dilated
pupil ; ringing or other noises in the ears ; some-
times most acute and splitting pains in the head,
with a flushed neck and face ; generally sickness,
pain, oppression, and anxiety, at the stomach ;
thirst ; a full and quick pulse ; subsequently a
slower pulse ; and swelling of the neck and
countenance ; tetanic stiffness of the wrists ;
cramps in particular muscles or parts ; twitch-
ings of the muscles of the face ; shocks or
shudderings through the frame ; altered respira-
tion ; loss of consciousness ; and all the phenomena
constituting the developed seizure. Dr. J. F.
OsiANDER states that he has seldom observed a
tumid state of the face and hands wanting as a
premonitory symptom. If the convulsions occur
during parturition, the pains often become feeble
and frequent before the seizure,

29. B. The complete seizure. — To these succeed
involuntary contractions of the muscles of the face
and jaw, instantly followed by spasmodic succus-
sions, or general convulsions of a violent or tonic
character; sometimes approaching to tetanic, but
commonly closely resembling eclampsia ; or the
universal convulsions of the epileptic or hysterical
paroxysm. The respiration is laborious, imperfect,
sonorous, and hissing,- — frequently with foatviing
at the mouth, — and thetongue is often protruded ;
the eyes are injected, prominent, fixed, staring, or
rolling ; the countenance and head tumid, red, or
livid ; the limbs are strongly convulsed, and tossed
about ; the heart beats strongly ; and sensibility
and consciousness are entirely abolished. After
a short time the convulsion subsides ; respiration
becomes less laborious, and the countenance less
livid ; but the comatose stupor continues, some-
limes with slightly stertorous breathing; when,
after an indefinite, but generally a short, interval,
the spasmodic succussions and general convul-
sions return as before, or with slightly modified
severity or duration, and subside into stupor as
before. Thus they may recur two or three times
— more frequently, several or many times —
when the patient either quickly awakes, uncon-
scious of what has passed, as it from a slumber;
or passes into a more comatose state ; or recovers
partially ; sight and hearing, or speech, or both,
being lost for a time. Or she may experience
some one of the unfavourable terminations here-
after to be noticed.

30. It may be generally remarked, that, upon
the accession of puerperal convulsions, a flux of
blood takes place to th? head and superior ex-

tremities ; the veins of the lower limbs becoming
proportionately empty, and the pulsation of their
arteries being comparatively small and weak.
The worst forms of the attack are often attended
by a firm spasmodic constriction of the cervix
uteri, preventing the expulsion of the foetus. M.
Menard states, that, in the majority of cases of
death by convulsions previous to delivery, the
child has been found dead, the contraction of the
features and extremities denoting that it had par-
ticipated in the affection of the mother : this,
however, wants confirmation. In some instances,
the child has been unexpectedly born during the
violence of the convulsions, as if expelled by
them with unwonted celerity.

31. C. Modijications. — In persons of a nervous
temperament, local pain or irritation, or even ex-
haustion alone, may induce that state of cerebral
afl^ection upon which convulsions are consequent,
without the supervention of plethora, and active
congestion of, or determination of blood to, the
brain, characterising the great majority of cases.
In these persons, the seizure is sometimes preceded
by sinking, leipothymia, or fainting ; the counte-
nance is neither tumid nor livid ; the eyes and
face are unsuftused, but wild — often spaikling,
staring, or rolled irregularly ; the pulse is small,
hard, or constricted ; the urine is frequently
copious and pale; and the agitations and tossings
of the limbs greater, but less rigid or spastic,
than in the mixed epileptic and apoplectic forms
described above. In these cases, there is evi-
dently cerebral irritation, or erethysm ; and, during
the paroxysm, abolition of consciousness: but the
patient generally either partially recovers her
sensibility between its exacerbations or recur-
rences ; or awakens out of this state entirely
restored, and without experiencing any of those
sequelae which are left by the more congestive
attacks. In other instances, seizures occur, pre-
senting characters intermediate between these ;
but the first described state is by far the most
common. From this it may be inferred that
convulsions, in any of the three periods con-
nected with child-bearing, will evince modified
phenomena, according to the constitution, tem-
perament, habit of body, predisposition, and pre-
vious ailments of the patient. In the plethoric,
epileptic, irritable, sanguine, and robust, it will
present the characters of eclampsia or epilepsy
— the m.ost common — or of apoplexy or coma ;
and in the hysterical, the nervous, the delicate, &c,,
it will assume these now noticed, which approach
those of a severe hysterical attack. The con-
vulsions which come on in the puerperal states
from large losses of blood, are either of this kind,
or of one closely resembling it, or intermediate
between it and the epileptic.

32. V, Convulsions associated wiTir other
jNIanifestations of Disease. — Convulsions may
occur on the invasion, during the course, and at
the crisis or decline, of a great number of acute
diseases, particularly in children under eight years,
about the period of puberty, and in females of
a nervous and su-ceptible constitution. Their
connection with irritations, &c., in the prima via,
and with organic diseases in, or affecting the large
nervous masses, is considered at anotiier part (§ 37.
44, 45.) ; but their association with some other
maladies reejuire a more especial notice in a prac-
tical point of view, a. The invasion of various

E e 2

420

CONVULSIONS — Diagnosis of.

acute distempers is often attended by convul-
sions. Indeed, in some of the severe diseases to
which young children are liable, particularly the
exanthematous fevers and inflammations, convul-
sions usurp the place of the cold stage or rigors
which usher in these diseases in adults, and are
generally preceded by coldness of the surface.
When occurring in this manner, they should be
regarded as indicating one of three things, viz.
a morbid susceptibility of the nervous system,
and predisposition to disease in the cerebro-spinal
axis ; or an approaching developement of febrile
reaction and of eruption, if the patient be of a
sound constitution ; or else an imperfect evolu-
tion of both, with a disposition to visceral irritation,
inflammation, or effusion, particularly of the brain
or abdominal viscera, if the habit of body be in
fault, or if there exist any hereditary disposition,
or vice remaining after previous disease.

33. b. The course of various diseases sometiares
becomes associated with occasional or recurring
convulsive seizures ; often of a partial, or of an
irregular, peculiar, or anomalous cliaracter ; but
frequently, also, sucli as those desci'ibed under
general convulsions (§ 12, 13.). Children, and fe-
males about the period of puberty, are most liable
to these complications. We observe these seizures
in hooping cough and croup ; in the remitting
fevers of infants ; in mania, and febrile insanity ;
in inflammatory and numerous organic diseases
of the brain ('§ 37. 44. 45.) and spinal chord;
in verminous complaints, and other disorders of
the alimentary canal ; in organic lesions and
calculi of the kidneys and urinary bladder ;
and in states of nervous and vascular excite-
ment or irritation of the female organs. In all
these complications, eitiier active congestion or
determination of blood to the head, or irrita-
tion of the cerebro-spinai axis and membranes,
or both these states, may be presumed to exist;
active congestion being occasioned by impeded
return from, with increased impetus of the cir-
culation to, the brain and medulla oblongata ;
irritation of these parts being generally propa-
gated thither from some portion of the organic
nervous circle, and through the medium of this
circle, in which it had been primarily excited.
We not infrequently observe convulsions at-
tended or followed by mania and insanity, or
even supervene in the course of these mental
disorders. When this is the case, the convulsive
seizure is commonly of a tonic and acute form,
and approaches nearly to eclampsia and epilepsy,
constituting the muniacal convulsions of authors.
The convulsions which occasionally are observed
in females, in connection with irritation of the
sexual organs, are evidently owing to the propa-
gation of disorder, through tlie medium of the
organic or ganglial, to the spinal nerves, or to the
chord itself, or even to the brain ; as well as to the
extent to which these various parts of the cerebro-
spinal system are thereby influenced ; and the
various forms which the convulsions thus origi-
nating commonly assume, are to be imputed to the
existing state of local or general plethora, or to the
degree of determination of blood to the hea 1 with
wliich the superinduced irritation is attended.
When we reflect upon tlic connection of the
organic nerves with the spinal, and especially on
the mode of that connection with the brain itself
and tlie re-t of the cerebro-spinal system, we shall

not be surprised that irritation of the extremities
of the organic nerves, either in some one of the
female organs, or in some part of the prima via,
excites in one person, according to peculiarity of
temperament, hereditary predisposition, habit of
body, or state of vascular plethora, convulsions
of a spastic or tonic character in the limbs and
trunk, the cerebral functions being undisturbed ;
in another person, convulsions either of a clonic
or irregular form, consciousness also being
retained ; or either of these forms, or both of
them variously or singularly mixed, with partial
or complete deprivation of sense and mental
manifestation, or with a comatose or maniacal
delirium superadded. Nor should it be a matter
of wonder that irritation thus originating gives
rise to various other abnormal nervous and mus-
cular phenomena, such as catalepsy, ecstasy, hys-
teria, &c.

34, c. Convulsions sometimes also usher in
the crises of fevers and other acute diseases.
This occurs most frequently in delicate or hyste-
rical females, the abnormal contractions assum-
ing a variety of forms, and often an hysterical
character ; but it also not infrequently is observed
in the male sex, especially in young and delicate
persons. This association of convulsions is ge-
nerally dependent upon a severe affection of the
brain in these fevers, and attended by either coma
or delirium ; and, although they may indicate
a favourable change, particularly when accom-
panied with, or immediately followed by, other
critical phenomena, or when they put on the
true hysterical form, yet they maybe the outward
signs of an exasperation of the cerebral or cerebro-
spinal affection, particularly when the mental
faculties and general sensibility are not soon
afterwards restored. Other morbid associations,
as with worms, diseases of the brain and spinal
chord, &c., may be considered as causes of con-
vulsions rather than complications.

35, II. Diagnosis. — Simple convulsions may
with difficulty be distinguished from epilepsy and
hysteria. They cannot readily be mistaken for
tetanus or rabidity. There are many cases,
which the nature of the exciting cause, and the
history of the case, show to be different from true
epilepsy, and yet they cannot easily be distin-
guished from it during the height of the pa-
roxysm ; and the remark applies equally to the
hysteric fit. In fact, convulsions present so many
and so slight grades of difference, as to the
spastic contraction of the muscles, and the fre-
quency and rapidity of its alternation with relax-
ation,— as to the jn-esence of, or immunity from,
cerebral disorder, as well as to the nature and
extent of such disorder, — are so intimately
allied in respect of their causes, of the i)articular
system of the frame upon and by which these
causes produce their sensible effects, and of the
nature of these effects as far as they become
symptoms or signs of the particular lesion which
occasioned them, that the difficulty of diagnosis
is veiy great in many instances, excepting to the
acute and experienced observer, whilst it is suflfi-
ciently easy in others. — a. Generally, however,
simj)le convulsions will be readily distinguished
from epilepsy, by the retention of consciousness
and general sensibility in the former, excepting
in the height of the paroxysm in the severer or
more plethoric cases, as in eclampsia and puer-

CONVULSIONS— Terminations — Prognosis.

421

peral convulsions, in which both are lost ; by
the general absence of the consecutive sleep or
sopor of epilepsy ; by the irregular and frequently
recurring form of tlie seizure ; by what is known
of its origin and connection with obvious causes,
and by the mode of its attack and of recovery from
it. There are also various symptoms which,
although common to eclampsia, puerperal con-
vulsions, and epilepsy, are yet peculiarly - cha-
racteristic of this last ; and we find, in adchtion,
other phenomena which simple convulsions sel-
dom present, particularly the frightful scream
on the accession of the epileptic fit, tiie ante-
cedent aura or peculiar premonitory signs, the
very sudden and unexpected seizure when tiie
aura is wanting, the expulsion of the seminal
and prostatic secretions, as well as of the alvine
excretions ; the more frequent occurrence of
foaming at the mouth, and severer affection of
tile respiratory muscles; the more leaden appear-
ance of the countenance, and the more common
recurrence of tlie paroxysm at a. stated time, than
in convulsions, particularly after the first sleep,
or when the patient awakens or is rising in the
morning. (See Epilepsy — Ditignosis.) — 13. Con-
vulsions are readily distinguistied from hpsteria,
by the antecedent copious discharge of pale
urine, the globus hystericus, and the borborygmi ;
and by the alternate crying and laughing attend-
ing the seizure of the latter. Some instances of
simple convulsion, arising from irritation of the
female organs, will, however, very nearly ap-
proach, if not altogether run into, the hysterical
character ; as we also see many cases of puer-
peral convulsion differing but little from epi-
lepsy, excepting in the frequent recurrence of
tiie paroxysm in the former before the patient
has recovered from tlie sopor consequent upon
the antecedent fit, and in one or two of the
diagnostic signs noticed above. — y. The continued
or permanent nature of the spasms in all the
forms of tetanus, and the absence of any tendency
to obscuration of the general sensibility and men-
tal faculties, during tlie whole unremitting dura-
tion of this dreadful disease, are sufHcient diag-
nostics between it and convulsions. — J. Rabidity
catniot be mistaken for this affection, if the
history of the case, the uncommonly increased
sensibility of the whole frame, the dread of fluids,
and unimpaired cerebral functions, characterising
rabies, be attended to ; for, although convulsive
seizures occur frequently in it, they are produced
by so slight external or mental causes — by every
attempt at swallowing liquids — that their nature
and origin cannot be for a moment doubted.
(See Rabidity.)

36. HI. Terminations or Consequences, and
Prognosis. -^ J. Convulsions, in any of the
forms now placed before the reader, may termi-
nate, (a) in health; (6) in some other disease;
or, (f) in imm.ediate dissolution, a. Their ter-
mination in health may be marked by no peculiar
phenomenon, beyond the non-recurrence of the
seizure. In other cases tliey are followed by
critical evacuations, particularly hagmorrhage
from the nose, mouth, or ears, after which they
may never recur, or which may produce an
immunity from them for a time. Vomiting and
diarrhoea, or tiie accession of the catamenia, may
likewise prove critical.

37. b. They often ava followed by other diseases ;

or rather the original disorder or change of struc-
ture, of which convulsions are merely a part of
the sensible and outward signs, may, from its
increase, or extension to adjoining parts, occasion
other or additional phenomena more or less inti-
mately allied to convulsion, as palsy, apoplexy,
coma, loss of speecli, or of sight, or iiearing,
ciiorea, or mania, delirium, idiotcy, &c., each of
which may pass into the otlier, or be variously
associated with one another. Tims, loss of sight,
Iiearing, speech, and idiotcy, may be the con-
sequences in the same case. Also, either of these
consecutive phenomena may arise from tlie cere-
bral congestion, and its effects, produced by tlie
frequent recurrence or by tlie severity of the fit,
particularly wlien tlie respiratory functions are
much impeded in it, and the system is plethoric
and relaxed. My limits will not admit of illus-
trations of these facts, either from my own ex-
pt-rience, or from the other sources which are
referred to at the end of the article ; but they
are of common occurrence, and may, after con-
tinuing for a longer or shorter time — in some
cases for many years — in others for a very short
period — either be recovered from, or terminate
existence. In some cases, convulsions are fol-
lowed by a state of leipothymia, trance, or
complete syncope, which, when profound and
continued, may be mistaken for dissolution, and
endanger premature interment. There is reason
to suppose that, in some countries where inter-
ment usually follows death at a much shorter
period than in Great Britain, this dreadful fate
has overtaken the patient. In other instances,
lethargy, or torpor, terminates the paroxysm,
which, in rare instances, has been of long dura-
tion, and also may be mistaken for death. ^Vhilst
the convulsions of childhood more commonly
give rise to, or terminate in, loss of one or more
of the functions of sense, in chorea, in idiotcy,
or in hydrocephalus ; those attacking adults are
more disposed to pass into either apoplexy, coma,
palsy, or mania : and whilst the convulsions of
the former class of subjects are more frequently
the consequence of irritations affecting the ab-
dominal viscera, those of the latter, excepting in
females, are more generally the result of disease
within the cranium or spinal column, often at a
certain stage of its progress.

38. c. Their terminaiioa in death takes place
either through the intervention of one or more of
the diseases noticed above as their consequences,
or, more directly, from the extension of convulsion
or spasm to the respiratory muscles, inducing
asphyxy, or from an overwhelming congestion or
effusion of blood in the brain. This sudden un-
favourable change more commonly occurs in
puerperal convulsions than in other forms, ex-
cepting when they proceed from abscesses or tu-
mours within the cranium. Death may also occur
from accidental suffocation during the paroxysm.

39. jB. The Prognojis of convulsions depends
chiefly on what is known of their causes, on the
antecedent and consecutive phenomena, on the
history of the case, and the degree in which
the functions of the brain and nervous system
are affected during and after the fit. a. If the
convulsions occur in children, without fever or
any primary or cerebral disturbance, and ap-
parently from worms, disorder of the prima via,
&c., a favourable opinion may be entertained,

Ee 3

422

CONVULSIONS — Causes op.

But when they are preceded by head-affection,
by fever, followed by strabismus, stupor, or loss
of one or more of the functions of sense ; when
they are prolonged or recurrent ; or are followed
by signs of any of the unfavourable terminations
noticed above, much danger should be appre-
hended. Indeed, all cases depending upon cere-
bral disease are attended by more or less danger,
which, in some instances, become most imminent,
particularly when the symptoms of hydrocephalus
are present. — b. In adult persons the prognosis
is equally unfavourable, when tlie affection is
evidently the result of cerebral disease, or of
organic changes — and when the fits become
more and more frequent, or severe, with more
marked cerebral disturbance, either attending
upon, or following them. On the other hand,
when they are symptomatic of disorders of the
prima via, or of the generative organs, a favour-
able opinion may be entertained. — c. Puerperal
convulsions, however, should never be considered
devoid of danger, more especially when they oc-
cur after delivery ; or in consequence of great
exhaustion of vital power, or of uterine hae-
morrhage. When they are slight, are unattended
by stertorous breathing, or by paralytic or apo-
plectic symptoms, and when parturition is so far
advanced as to readily admit of its completion by
art, less danger may be feared. But the prog-
nosis of convulsions generally must be inferred
from a careful review of the diversified circum-
stances of individual cases, especially in respect
of their remote and efficient causes, and of their
disposition to terminate in either of the ways
pointed out.

40. IV. Appearances on Dissection of
FATAL Cases. (See Brain, § 4 — 133.), Epilepsy,
and Spinal Chord.

41. V. Remote and efficient Causes. —
i. The remote causes of convulsions axe numerous;
but they often require a certain original or ac-
quired predisposition of system to insure their
operation ; and various influences which may
only predispose to them in some persons, may
even excite them in others. A. Predisposing.
There is every reason to suppose that the off-
spring may derive constitutional predisposition to
convulsions from the parents. Persons of a ner-
vous and irritable temperament, — of a delicate
frame, and largely developed head (Desessartz),
— of a relaxed and soft fibre, and plethoric vascu-
lar system, — children whose fontanelles are very
late in closing, — those who are naturally of a
quick, sensitive, and unstable disposition, and
wlioso physical and moral constitutions are
readily impressed, — are predisposed by original
conformation. Those infants who have experienced
injury of the cranium during parturition (Smei,-
lie) ; persons who have early, prematurely, or
inordinately indulged in venereal pleasures —
who have placed no restraint on their passions,
particularly anger, — who have become debi-
litated by any cause (Autenhietu), — who have
had their cerebral organs unduly and too early
excited, and before tlie process of developement
was sufficiently far advanced; the present state
of civilisation and precocious mental improve-
ment; the greater irritability of the system ac-
companying the epochs of dentition ; the irritable
and plethoric states attendant upon pregnancy ;
habitual determination of blood to the head ;

previous attacks of convulsion, either before or
after puberty, or in a former pregnancy ; at-
tempts to conceal pregnancy, and the mental
distress and shame attending it in unmarried
women ; exhaustion of nervous or vital power by
increased discharges, long continued pain, or
want of sleep; all luxurious indulgences; too
much sleep ; inanition and want ; prolonged lac-
tation ; fluor albus, Sec. ; and certain electrical
states of the air, by which the nervous system is
influenced, and rendered more susceptible of im-
pressions and excitement ; are the chief causes
which generate a predisposition in the frame. It
has been remarked by Dr. Ramsbottom, and
other writers, that puerperal convulsions were
most frequently produced during warm electrical
states of the atmosphere.

42. B. The exciting causes of the various forms
of convulsion are very numerous ; and they act
in different ways in producing their effects. I have
already stated, that irritation of a part of the or-
ganic or ganglial nervous system will be trans-
mitted by the communicating branches to the
spinal nerves, and produce convulsive actions of
the muscles they supply, without the brain expe-
riencing any evident lesion ; whilst, in other cases,
the irritation maybe conveyed to the brain, either
directly by the organic nerves, or through the
medium of the spinal chord, the cerebral func-
tions suffering accordingly. But irritation or
organic change of any of the parts contained
within the cranium will also occasion convulsions,
the general sensibility and mental manifestations
being then more or- less obscured or perverted
during the paroxysm or subsequently. These
facts, which might be illustrated by numerous
cases, the history and results of which 1 have
attentively observed, naturally point to a division
of the causes, Jirst, into those which act upon
some portion of the organic nervous circle, or the
viscera which it supplies ; and, secondlii, upon
the cerebro-spinal system itself. But, although
it is useful to make this distinction, particularly
for practical purposes, yet it should not be over-
looked, that irritations affecting the former would
rarely be followed by convulsions, unless the
latter possessed a marked disposition to disease,
as far as regards increased susceptibility and
proneness to experience alterations from the
healthy condition of its circulation.

43. a. The exciting causes which act more
immediately upon the organic nervous systetn, and
through it upon the spinal nerves or brain, or
both, are the following: — a. In infants and
children, the retention of the meconium ; a mor-
bid state of the umbilical chord ; unwholesome
milk, or improper feeding ; acid or acrid sordes,
and various diseases of the alimentary canal ; an
overloaded stomach ; suppression or retention of
the urine ; accumulated flatus, or morbid secre-
tions, and the presence of worms, occasioning
irritation of the bowels ; the ingestion of acrid
substances — as very irritating purgatives (Gohl
and Lentilius), or emetics (Riedlin), — acrid
enemata ; noxious or indigestible substances taken
as food ; acidity of the prima via ; dentition at
either of its epochs, particularly cutting the eye
and molar teeth ; the iri'itation of pained or carious
teeth ; and calculi in the urinary organs, &c.
(3. In persons about, or subsequently to, puberty ;
and occasionally in children, organic diseases of

CONVULSIONS — Causes of
the stomach, bowels, or collatitious viscera ; af-
fections or lesions of the heart ; constipation, colic,
ileus, and intus-susception ; incarcerated or stran-
gulated hernia (Ghaaf and myself); organic
change of the kidneys, and suppression of urine ;
manustupratio or inordinate sexual intercourse;
and nervous and vascular excitement, orotherdis-
eases of the female organs, particularly the ovaria
and uterus. — y. In puerperal females, a loaded
stomach or disorder of this organ brought on by
indigestible or unsuitable articles of diet, particu-
larly shell-fisli (Clarke) ; rapid or premature
distension of the uterus during pregnancy ; long-
continued and exhausting labour ; excessive, fre-
quent, and inefficient pains; distension of the
urinary bladder, during or after parturition ; a
loaded state of the bowels, excessive depletion or
flooding; venereal indulgences during the last two
months of utero-gestation.

44. h. The causes which act more directly on the
cerebrospinal nervous systemnre — a. the improper
exhibition of narcotics, and of spirits and various
quack medicines, by the lower classes, to infants
and children ; the admission of a strong light,
or the impression of loud noises on very young
infants ; the continuance or excess of pain ; in-
juries received on the head during, or subsequently
to birth ; fear, and sudden fright, or fearful dreams, j
— B. In adults more especially, and in childien j
also, the most common causes of this description
are, the influence of imagination and imitation ; i
the action of the sun's rays on the head ; exces-
sive mental labour or anxiety ; extreme bodily
sufferings, or long watching ; injuries of the brain,
spinal chord, or nerves; irritation of nerves by
tumours, abscesses, or by ligatures in operations,
or injuries of them by wounds and accidents ; in-
cipient curvatures of the spine (Wiciimann, Bo-
net) ; the impression of excessive or long con-
tinued cold, or of a cold bath ; the influence of
particular odours on some constitutions; the abuse
of spirituous liquors ; the influence of various
poisonous substances on the nervous system, be-
longing to the animal, vegetable, and mineral
kingdoms, as nux vomica, and nearly all the class
of narcotics ; deleterious gases, and metallic fumes,
as the nitrous oxide, sulphuretted hydrogen, &c.,
the vapours of mercury and lead ; and the irri-
tating and inflammatory operation of many mineral
preparations and acrid vegetables (see Poisons) ;
all emotions of the mind which excite the nervous
power, and determine tiie blood to the head, as
joy, anger, religious enthusiasm, excessive desire,
&c. ; or those which greatly depress ihe nervous
influence, as well as diminish and derange the
actions of the heart, as fear, terror, anxiety, sadness,
distressing intelligence, frightful dreams, &c. ; nu-
merous lesions of the encephalon or its membranes,
particularly eff'usions of fluid, abscesses, tumours,
ossific deposits, and various other adventitious form-
ations— indeed, nearly all the organic changes
described in the articles on the Brain, Epilepsy,
and Spinal Chord ; also exhaustion from pre-
vious disease, particularly by large losses of blood
(Schroeder) ; inanition and want (Amatus Lusr-
TANus) ; the erect position suddenly assumed;
lightning (Giiapf.ngiesser) ; abscesses about the
neck ; the suppression of eruptions and discharges,
particularly on the head or from the ears ; the
syphilitic poison ; and repulsion of gout or rheu-
matism.— y. In puerperal females, many of the

423

causes now mentioned are especially productive
of convulsions, particularly anxiety or distress of
mind in unmarried females; violent slrainino-
during labour; andsudden changes from the hori-
zontal to tlie sitting or erect postures.

45. ii. The efficient causes have been partially
alluded to. Their nature may be in some mea-
sure inferred from what has been stated above.
It seems evident, from a careful consideration of
the exciting causes, of the character and progress
of the symptoms, and the lesions usually detected
on dissection, that convulsions arise from several
pathological states, the grosser or more palpable
parts of which only we are enabled to recognise
by the senses; and that, in addition *to these, a
certain susceptibility of the nervous system, par-
ticularly of the cerebro-spinal centres, is requisite,
nevertheless, to the full development of the
seizure. It is extremely probable that convul-
sions frequently arise from some considerable
change in the state of the circulation within the
cranium, and that such change may be either
active cerebral congestion, — in some cases con-
nected with general plethora, but in others not thus
associated, and, even in a few, accompanied with
marked deficiency of blood, — or local or general
anaemia. Moreover, it may be presumed that the
seizure very ofien is accompanied with but little
disturbance of the cerebral circulation or func-
tions at its commencement; and that it chiefly de-
pends upon irritation, in some manner induced in
the organic nerves, and, through them in the spinal
nerves, either partially or generally. We have no
proof of the circulation of even the spinal chord or
its membranes being disordered in these cases, al-
though it may be afl^ected in convulsions, either
primarily or consecutively. In cases which more
manifestly proceed from disease within the cra-
nium, and that of an organic kind, as from tumours,
abscesses, aqueous effusion, &c., it by no means
follows that the circulation in the brain is gene-
rally, or even at all, either accelerated or con-
gested, although these lesions may safely be as-
sumed in many instances. In some cases even of
organic change, the general amount of circulation
in the head seems, as far as we can judge from
symptoms, much below the natural standard, and
yet convulsions will supervene ; whilst in others,
signs of inflammatory action of the membranes are
apparent. In many cases, moreover, judging from
the states of pre-existing disease, from what is
known of the operation of various causes, and from
the symptoms connected with the head, — the weak
and small pulsation of the carotids, the antecedent
fainting or leipothymia, the low temperature of the
scalp, and pale, sunk, and pinched features, — it
may be inferred that the vital endowment and the
circulation of the brain are momentarily deficient,
both in activity and in quantity.

46. Therefore, while I subscribe to the justice
of the aphorism of Hippocrates, that convulsions
arise from repletion or inanition as respects the
circulation within the cranium, I would qualify it,
and add, that they often originate tlius, but that
either of these states forms a part only of the
changes that produce them, even when most irre-
fragably present, — that in many cases the circu-
lation in the brain is not materially disturbed,
whilst the spinal nerves are affected either by ir-
ritation conveyed to them from the organic ner-
vous system, or from the spinal chord itself, more
Ee 4

424

CONVULSIONS — Treatment.

frequently the former, — that even when the brain
is disordered, general convulsions will avise only
when the disorder extends to, or influences the
parts more immediately related to, the locomotive
actions of tlie body, as the spinal chord or its mem-
branes,— and that we cannot contemplate the
origin of convulsions in any vv'ay, and leave out of
view changes primarily induced in the organic
nervous or ganglial system — which changes will
more readily produce, than be produced by, dis-
ordered circulation in the cerebro-spinal, organs,
Wc know that the movements of the foetus in utero
are automatic — are the consequence of irritations
affecting the organic rferves, extending to the spinal
nerves, and through them, inducing motions of the
limbs. To the production of these, any change in
the brain or spinal chord is not required ; and a great
many cases of convulsion have a similar origin,
the difference being only as to the grade of irri-
tation relatively to the susceptibility of the patient,
and to the effect produced. As to the opinion
entertained by the older humoral pathologists,
from Galen to Willis, that a morbid state of
the fluids also occasions convulsions, some im-
portance may be attached to it. ^Ve do not, how-
ever, find convulsions much more prevalent when
the blood is manifestly morbid, unless in those cases
where a previous, and at least an ecjual, change
has been produced upon either the organic, or
the cerebro-spinal nervous systems. The convul-
sive movements that occur in common and pesti-
lential cholera, in malignant fevers, in rabidity, and
in organic lesions of the kidneys, with suppression
of urine, are proofs of this position. That, hovvever,
a morbid state of the blood sometimes constitutes a
concurrent proximate cause of certain diseases, in
which convulsions ei;her incidentally occur, or
form a part of the circle of advanced phenomena
or effects, may be admitted, in the absence of suf-
ficient evidence to the contrary ; for, when the
blood itself is primarily changed, we may with
reason infer that convulsions will sometimes mani-
fest themselves as a part of the effects thereby pro-
duced upon the nervous system ; but I believe that
convulsions seldom arise from this cause only.

47. VI. TreatiMent. — i. Of Convulsions
GENERALLY. The means of cure in all cases of
convulsions are directed with the view, 1st, of
subduing the fit, when called to a patient labour-
ing under it: and 2nd, of preventing its return.
A. To subdue tlie paroi'iisiit,h is necessary to have
prompt recourse to active measures: but these
should not be employed indisciiminately, and
without taking quick cognisance of the cause, and
the existing pathological states as far as they
may be readily ascertained. The circumstances
principally to be observed by the practitioner,
arc the juesence or absence of active cerebral
congestion and sopor, the existence of general
vascular plethora, the temperature of the head
and lov/er exliemities, the pulsation of the carotids,
and the character of the countenance and of
the convulsive motions. These may be ascer-
tained in a very few moments, and at the same
time that iiK[uiry is being made into the cause of
the seizure, and the peculiarities of the case, as
respects the age, constitution, and habits of the
patient.

48. (I. A person in convulsions ought to be
])laced so as to breathe an open cool air, and
to facilitate the restoration of one of the earliest

functions disordered ; arid no more attendants be
permitted than are absolutely necessary. Those
susceptible of, and liable to, nervous affections,
should not be allowed to remain in the same
room, or even in the same house, with the patient
while in the fit.— 6. When the habit of body and
the cerebral symptom^, &c., present no contra-
indication, general 'or local blood-leiting, or both,
•should be resorted to,, and carried as far as cir-
cumstances may warrant. When the cerebral
congestion is very active and extreme, the jugular
vein may be opened ; but the depletion should
never be pushed too far, with an expectation of
stopping the convulsions ; nor should it ever be
cariied to deliquium, for the system may be
thereby injured, and a return or immediate recur-
rence of the seizure be favoured by it. Revulsive
bleedings, as from the feet while they are held in
warm water, may be preferred, if the seizure be
connected with difficult or suppressed menstru-
ation. Local depletions, in other instances, are
best practised by cupping behind the ears, par-
ticularly in children, and upon the nape of the
neck, and between the shoulders. In other in-
stances, when the biain is not affected, — when
the head is cool, and the carotids are pulsating
neither more fully nor more strongly than natural,

— the state of the spinal column should be care-
fully enquired after, by pressing a warm sponge
along and between the vertebra; ; and the abdo-
minal regions and the evacuations ought to be
daily examined. If signs of inflammatory action
exist in either of these quarters, particularly if
they be connected with plethora, general and local
depletion — preferably the latter, when plethora is
wanting — should be resorted to. But there are
many cases, especially those produced by copious
evacuations, by inanition, and the exhaustion of
painful and protracted disease, where depletion
would be most injurious; and there are inter-
mediate grades, in some of which local blood-
letting might be either beneficial or of no advan-
tage, according as the case approaches nearer to
the one extreme than the other. When the con-
vulsions a.rc partial, then local depletions are to be
preferred.

49. c. There are certain states of convulsion,
in which it at first seems difficult to determine as
to the propriety of resorting to blood-letting !in
any way. One of the uiost common of these, is
that characterised by a pale and somewhat sunk
countenance, and by tonic convulsions. 'I'his
appearance may mislead the practitioner, if he do
not examine carefully into other symptoms. If,
in addition to those, the carotids pulsate strongly,
the tempeiature of the head be increased, the
pupils contracted, and the brows knit, we should
suspect inflammatory iriitation of the arachnoid

— notwithstanding the absence of all plethoric
or asthenic signs — and resort to depletions, and
the means about to be noticed. (See also Bh,\in
— Treatment of Injlannnation of its Membranes.)
Another state sometimes occurs, with very violent
general convulsions, a broad, open, throbbing, and
frequent pulse ; pale countenance and surface,
often with sopor or delirium, or both. 'I'hese
symptoms may mislead the inexpeiienced, and
depletions — occ.isionally the very cause of the
mischief — may be inqiroperly (Mniiloyed to re-
lieve it. But when the history and symjitoms of
the case arc more minutely examined, wc shall

CONVULSIONS
find precisely that state which is described in the
article Blood ($^3 — 60.),- and that, instead of
congestion, there is generabanaimia, with cerebral
irritation, combining with the physical condition
of the brain, to determine to it tiie greater part
of the blood in the system.' In other cases, there
is apparently ana3mia of the brain, at least at the
commencement of the fit; and either conscious-
ness is retained, or it is lost from the slate of-the
cerebral circulation. These forms of seizure may
be called amcmiai ; inasmuch as they arise either
from a general deficiency of blood, or from
anajmia of the brain, although the vessels of this
organ soon become partially congested from the
impeded respiration, and interrupted circulation
through the lungs and heart, at tlie commence-
ment of the paroxysm. In these, a very opposite
treatment to depletion is required. 'J'he ob-
servations of Latham, Hai.l, Goocn, jVortii,
and the author, on this important practical topic,
have, however, induced the practitioners of the
present day to resort to blood-letting in convul-
sions in a much more discriminating manner than
formerly.

50. d. Next in importance is the judicious
employment of cold and heat — of cold in the
form of cold allusion on the head and spine, and
of heat in that of warm bath or semicupium.
An appropriate use of these is more generally
serviceable, and often less dangerous, tlian deple-
tions. The cold affuiion to the head, and, in
cases where there seems to be irritation of tiie
spinal envelopes, along the vertebra? ; and cold,
in the form of epithems, evaporating lotions,
pounded ice to the head, when convulsions are
produced by inflammatory action in the brain or
spinal chord; are among the chief forms in which
this agent is admissible. The cold bath, although
advised by Currie, Loeffler, Beau.mks, Bay-
NARD, and others, is, in my opinion, a hazardous
experiment during the paroxysm, and sometimes
even in the interval. The unrm bath, or semi-
cupium, is frequently of much service, and par-
ticularly when there is either high nervous irri-
tation ; a dry harsh skin, or cold surface or ex-
tremities ; and my experience accords with that of
IIiiLBRONN, Henrischen, Doerner, and Stutz,
respecting the propriety of adding a quantity of
the .fixed alkalies, or their carbonates, to the
water. When the head is much affected, either
by inflammatory irritation of the membranes or
active congestion, cold affusion, or cold epithems
or lotions, may be employed whilst the patient is
in the warm bath, or is using the semicupium
or pediluvium. In slight cases of convulsion,
the aspersion merely of cold water over the
face, head, or neak, is often of service. Large
draughts of cold water were recommended by
Hoffmann ; and they, as well as water ices, and
cold clysters, have been several times employed
by myself with much benefit. Cold injections are
praised by Lanchans and IMahx. Cold affusion,
cold aspersion, and cold epithems, have been
prescribed by C'uurie, Dipont, Doemi.ing, and
others ; but the two former were usually directed
by them to the surface generally, instead of to the
head, — a circumstance which accounts for the
disuse into which it had fallen, when the practice
was revived some years since by the author.

51. e. If the patient can swallow, and the
musclesof the jaw are not much affected, crt(/(«)((e

— Treatment. 425

medicines should be given by the mouth ; but in
most instances it will be preferable to delay
them until after the seizure. But I have under
no circumstances been prevented from directing
a cathartic and antispcismodic enema to be thrown
up. Either of F.131 — 136. may be employed
and repeated, if it be not retained, as is frequently
the case. When purgatives can be taken, a full
dose of calomel, either alone or with jalap, fol-
lowed soon afterwards by an active cathartic
draught or mixture, consisting of senna, tincture of
jalap, carminatives, and antispasmodics, paiticu-
larly the preparations of ammonia and camphor,
is, upon the whole, the- most appropriate. J5ut
under every circumstance the operation of these
should be promoted by enemata. When we
wish to produce an active derivation from the
head and spine, as well as alvine evacuations,
the croton oil, elaterium, ol. terebinthinaj, &c.,
may be employed. But, where the object is
chieffy to bring away offending secretions, and
other causes of irritation, and at the same time to
allay disordered action in the prima via, calomel,
jalap, rhubarb, and senna, are, perhaps, the best
purgatives we can employ. Their action will,
in all instances, be much increased, and a marked
change be often produced in the disease, by an
occasional dose of the ol. terebinth, and ol.
ricini, assisted by the enemata already recom-
mended. If convulsions arise from ivor7ns in the
intestines, anthelmintic purgatives, during both
the paroxysms and interval, should not be omitted.
Calomel may generally, with due address, be
exhibited during the fit, and subsequently other
anthelmintics may be given. Bergius and
Barton prefer the Spigelia Marylattdica in such
cases ; but the other means adopted in verminous
disorders may be employed according to cir-
cumstances. Emetics are sometimes of service,
when exhibited upon the first intimation of the
seizure, particularly if there be indications of
gastric irritation from offending or noxious ingosta,
and acid sordes, or if the paroxysms assume a
periodic form. Sciienck, Scii.effeb, Rigel,
Conradi, IIufei.and, and Smith, advise them
chiefly in such cases. Thom recommends them
to be exhibited to the nurse, when convulsions
attack infants.

52. f. Antispasmodics are sometimes produc-
tive of instant relief, when employed in large
doses, early in or upon the first intimation of the
fit, particularly when it arises from debility, or
irritation in the prima via, or morbid nervous
susceptibility; but they seldom can be taken
in the paroxysm, unless it be slight, or arise
from exhausting causes, and then they are
often of great service, especially if they be com-
bined with restoratives and opium, conium, or
hyoscyamus. The ffithers, camphor, musk, assa-
foetida, valerian, the preparations of ammonia,
bismuth, zinc, &c., are amongst the most effica-
cious in these cases. When inflammatory irri-
tation seems to exist in the membranes of the
brain, they are obviously contra-indicated ; but
congestion of a passive nature, especially when
the pulsations of the carotids are not strong or
hard, and the temperature of the head is not
increased, should be no reason for omitting them.
An extensive experience, however, of the effects
of the spirit of turpentine in convulsive diseases,
has convinced me that it is the most efficacious

426 CONVULSIONS

and the safest antispasmodic that can be em-
ployed for their removal. It' it be given in doses
so large as to act as a purgative, an<l seldom or
rarely repeated, it is remarkably beneficial in
the eases which arise from cerebral congestion or
irritation ; but when the seizure is connected
with anaemia, or exhausted vital power of the
brain, or general debility, it ought to be exhibited
in small doses, often repeated, and be combined
with restoratives and aromatics. Michaelis,
SciiMALz, Albers, Hargens, Conradi, Heil-
BRONN, and Wiedemann, strenuously advise, in
all convulsive affections, large doses of the fixed
alkalies, either alone or alternated with opium.
Of the antispasmodic action of these substances,
as well as of their soothing operation on the
dii^estive mucous surface, there can be no doubt.
If the convulsions arise not primarily from or-
ganic disease within the head, I believe that
opium thus combined will often be of great ser-
vice, and particularly when they proceed from
the nervous susceptibility and muscular irrita-
bility often connected with debility, exhaustion,
and excessive evacuations. The good effects of
alkalies in disorders of the digestive functions, and
the frequent origin of convulsions in these dis-
orders, or their connection with them, must be
admitted. Moreover, the alkalies, combined with
opium, or hyoscyamus, conium, or belladonna,
and ipecacuanha, &c., are among the surest
means we possess of allaying irritations affecting
the nervous system. Stutz, Bruninghausen,
DoERNER, and Henrischen, employ them also
in fomentations to the abdomen, in baths, and in
enemata ; they using an ounce of the caustic
alkali to about a quart of water for the foment-
ation. I have prescribed the alkalies frequently
and largely in the convulsions of children with
much benefit. Other antispasmodics, and dif-
ferent modes of applying those in common use,
have been adopted by various writers ; but as
these are better suited to fulfil the second inten-
tion of cure, I will notice them hereafter.

53, g. Anodynes and narcotics are often of the
most essential benefit, when appropriately pre-
scribed and combined, or preceded by other
suitable remedies. They are seldom of service
in the convulsions proceeding from active con-
gestion and organic disease within the head ; but
when the affection is connected with irritation in
otlier parts, or when the disorder of the brain or
its membranes consists chiefly of irritation, they
sliould not be omitted. They are seldom of use,
— sometimes even injurious, in puerperal con-
vulsions, and ought to be given with caution to
very young children. In cases where the pro-
priety of exhibiting them is doubtful, any un-
pleasant operation will be prevented by com-
hining them with camphor, or with aromatic
tinctures or spirits. I have derived great advan-
tage from employing them externally, selecting
for this purpose opium or helladoniia, in the
form of embrocation or plaster — generally the
former — applied during the paroxysm over the
epigastrium and abdomen, and combining them
with rubefacient and stimulating substances, as
camphor, ammonia, Cayenne pepper, &c., or with
any of tiie liniments or plasters in the Pharmaco-
I)fjcias, or in the Appe)}di\ , suited to the case ( F.108.
297. 307.). The practitioner should, however,
be cautious in the employment of the more active

Treatment.

of these narcotics, even externally, as very dan-
gerous effects have resulted from them. Dr,
Thackeray found that tobacco steeped in brandy,
and placed over the epigastrium, produced a most
dangerous state of vital depression.

54. h. lievitlsants and counter-irritants are of
great service in all states of the disease accom-
panied witii cerebral congestion, or irritation of
the membranes of the brain or spinal chord. Si-
napisms to the extremities ; rubefacient liniments
(F. 299. 305.), and embrocations, particularly
those with Cayenne pepper, horse-radish, isic;
the turpentine fomentation ; the immersion of the
hands and feet, or the lower extremities, in a salt
and mustard bath ; dry cupping on the nape of
the neck, occiput, between the shoulders, or
along the spine ; are the preferable means of this
description. These will often, of themselves,
shorten the seizure ; but if they fail of having
this effect, after slight redness of the skin has
been produced, advantage will frequently arise
from placing over it a liniment or embrocation
containing opium, or the acetate or hydrochlorate
of morphia, or any of the other anodynes in use,
either of which may also be employed in the
form of plaster, combined with antispasmodics,
&c.

55. i. Convulsions arising from exhaustion,
hccmorrhagy, inanition, &c., require restoratives,
stimulants, 6cc. in small quantity, and frequently
exhibited, with strict attention to the temperature
of the head, which should be lowered whenever
it rises above natural, by cold applications. (See
Abstinence — Treatment of; and Blood — De-

Jiciency of, § 48, 49.) The combination of hyos-
cyamus with gentle tonics ; the preparations of
opium, conium, or hop, with those of ammonia
and camphor ; the preparations of valerian or as-
safoetida with the carbonates of the alkalies; the
hydrochlorate or acetate of morphia, with the
aromatic spirits and tonic tinctures; and emollient
and antispasmodic enemata, are most appropriate
to those cases. In these, as well as in the more
clonic forms of convulsions, the preparations of
iron, particularly the ammonio-tartrate of iron*,
alone, or combined with hyoscyamus, will be of
much service. The occurrence of these affec-
tions towards the close of febrile or acute diseases
(§ 13. 33.), particularly when they manifest signs
of greatly depressed vital power, requiies nearly
similar remedies, or such as exert a still more sti-
mulant and antispasmodic operation. The sul-
phate of quinine, with hyoscyamus and camphor ;
the decoction of cinchona, or infusion of arnica or
serpentaria, with liquor ammonia; acetatis and
ajther ; warm negus, with aromatics ; and stimulat-
ing embrocations or liniments over the epigastrium,
maybe resorted to in these cases. If convulsions
occur in the course, or towards the crisi.'i oj fevers,
the treatment must altogether depend upon tiie
state of the cerebral functions, and the disposition
that may be evinced towards spontaneous or
critical evacuations, to tiie promotion of which
our means should be directed ; taking care, at the
same time, to guard the head from mischief, by
employing local depletions, cold affusion, cold

* A most valuable .ind beautiful preparation very lately
introiluccci by Mr. Aiken ; and from its very pleasant,
sweet taste — resembling that of liquorice — extremely
well adapted for children. Dose from half a grain to five
or six grains. , ,,

CONVULSIONS

epithems, and internal and external revulsants, if
it exhibit appearances of congestion or inflamma-
tory irritation ; and warm diaphoretics, gentle
tonics, and antispasmodics, and other means of
supporting the manifestations of vital power in the
nervous systems, and of promoting the secreting
and excreting functions.

56. k. When convulsions are produced by
narcotic or acro-narcotic poisons, the immediate
evacuation of the noxious substance by the
stomach pump, or by emetics, the cold affusion
ou the liead, followed by stimulants and anti-
spasmodics, green tea, or coffee, stimulating
enemata, and frictions of the surface, are chiefly
to be depended upon. If they proceed from the
fumes of lead or mercury, antispasmodics, tonics,
stimulants, strychnine, or nux vomica, with
purgatives, are most serviceable, particularly when
assisted by the warm bath, and by frictions
of the surface afterwards with stimulating lini-
ments. Serpentaria, the arnica montana, and
camphor, are often beneficial remedies in those
cases.

57. /. Convulsions either of a partial, a general,
or irregular and anomalous form, arising from
irritation of the female organs, require local
depletions, cooling aperients, and antispasmodics ;
the internal use of soda and nitre ; cold clysters ;
the cold affusion or aspersion ; the tepid bath ; or
the shower bath, while standing in warm water ;
and draughts of cold water. In a case of general
convulsions arising from inflammatory iriitation
about the neck of the uterus, with leucorrhoea, I
directed the patient to take a lemon ice, or to
drink as much as she could of cold spring water
upon the intimation of the seizure ; and she has
hitherto done so with uniform benefit. Having
seen her during the paroxysm, and perceiving
that she retained her consciousness, cold water
was given, and swallowed with some difficulty.
The benefit was almost instantaneous. If the
convulsions be connected with diflicult, or sup-
pressed menstruation, general or local depletions,
and afterwards the warm general or liip bath,
full doses of the preparations of assafcetida and
ammonia, particularly the tinct. ammon. comp.,
the spir. ammon. foetid., or the tinct. guaiaci com-
posita, also camphor, and the boracic acid, or tiie
biborate of soda, have proved the most effectual
remedies in my practice. But tlie means already
advised to prevent congestion or irritation within
the cranium, should be resorted to upon the
first intimation of the fit. Bleeding by leeches
from the inside tops of the thighs are indicated in
these cases ; but it can be practised only in the
interval.

58. B, The prevention of the paroxysms is to be
attempted, with due attention to the remote and
proximate causes, the former of which should be
removed as completely as possible, aud the latter
energetically but cautiously combated ; recol-
lecting always that convulsions are the outward
manifestations of certain lesions of the nervous,
acting on the muscular, functions; and that our
knowledge of such lesions extends not beyond
the inference that they consist of depression or
exhaustion of vital power, or of irritation, or of
congestion, and occasionally, of two or all these
states conjoined, some one of them predominating
over the others, and being associated with addi-
tional and even opposite changes. Many of the

■ Treatment.

427

means already noticed are requisite in the intervals,
as well as in the paroxysm, especially when
judiciously modified to the circumstances of the
case. a. Vascular depletion is often required,
and in similar states of disease to those already
pointed out ; but it should be directed with great
circumspection, and to a moderate extent, unless
the signs of active cerebral congestion, or of
inflammatory irritation, or of general plethora, be
unecjuivocal. If, however, opposite states obtain,
viz. exhaustion, and deficiency of blood, very
different means must be employed. In most
instances of convulsions, the quantity of the
circulating fluid is not so frequently either much
above or much below the usual proportion, as
the influence, — vital or nervous, or by whatever
name it may be called, — by which the distri-
bution of blood throughout the frame is regu-
lated, is disturbed so as to determine or attract
a larger proportion to one part than to an-
other. In no peculiarity of constitution is
the old doctrine, " ubi irritatio, ibi fluxus,"
more frequently illustrated tiian in that in
which convulsive complaints are most commonly
observed ; and, in these diseases, we are
continually finding fluxion one of the earliest
consequences of irritation. I have long thought,
and on several occasions contended, that, in the
common routine of practice, blood-letting is too
indiscriminately employed to remove such
determinations or irregular distribution of the
circulating mass; and that, although it sometimes
succeeds, owing to its being associated with other
and more appropriate means, it often fails, or
even augments the mischief, by increasing the
debility and susceptibility of impressions from
exciting or irritating causes, that generally cha-
racterises the nervous system of persons subject
to convulsive seizures. Therefore, when the
abstraction of blood is really necessary, it should
be performed in such a manner, and be ac-
companied with, or followed by, such medicines
as are most likely to ctjualise the circulation ;
and it is chiefly in this way that many of those
about to be noticed are productive of any ser-
vice in the disease. Local depletions, in mo-
derate quantity, repeated according to circum-
stances,— from the nape of the neck or occiput,
when the head is affected, and along the spine, if
irritation of the membranes of the chord is
suspected, — and assisted by such other means as the
case may require, are more generally applicable
in the intervals than large venisections.

59. b. There are few remedies more beneficial
in convulsions than mild purgatives, or ape-
rients, taken daily, and conjoined with tonics
and antispasmodics. Active purgation, if long
persisted in, will lower the vital energy, and
thereby favour the return of the fits ; but the
more deobstruent and eccoprotic medicines of
this class, particularly when thus combined, may
be given, so as to procure two or three faeculent
evacuations daily. Thus prescribed, purgatives
will increase the patient's strength, and often
procure a prolonged immunity from the seizures.
Aloes, with quinine or iron, and camphor; or
with myrrh, assafoetida, the tonic extracts, &c.,
and occasionally with blue pill, or with extract
of hop, hyoscyamus, or conium (F. 450 — 471.) ;
soma, with gentian or bark, the preparations of
ammonia, Eether, &c. (F. 266. 872.) ; and either

428 CONVULSIONS — Treatment.

of these with the liquor potassas, or the alkaline
carbonates, are most to be relied on. But ad-
vantage will accrue from elianging the forms and
mode of combination and exhibition of purg-
atives from time to time, and from assisting them
with such other remedies as the special charac-
ters of the case may require. A full dose of
calomel, followed by the turpentine draught
(§ 51.), may occasionally be resorted to ; and
enemata will also be of service. In every in-
stance, the appearance and quantity of the dis-
charges, intestinal and urinary, should be ex-
amined ; and when the sensibihty of the bowels
seems to be increased, oleaginous or mild purg-
atives, with alkalies and hyoscyamus, ought to be
preferred. ]Moi!Gagm recommended, as an ape-
rient, two ounces of the ol. amygdal. dulc. to be
taken every night, — a medicine well suited to
cases of this description ; buttheol.olivae, ol. iini,
or tiie ol. ricini, and even the cod or tusk liver oil,
may also be tiius used. Where we find the
tongue mucli loaded or furred, active purgatives,
particularly full doses of calomel, with cathartic
extracts, &c., aie especially required in the first
instance ; and mild laxatives, with tonics and
antispasmodics, subsequently.

60. c. In many cases, particularly when the
convulsions proceed from inflammatory irritation
of the membranes of the brain or spinal chord,
bleeding and pnrgatives will be advantageously
followed by an alterative course of mercury,
pushed as far as to affect the gums, and by low
diet. JNIuch tact is, however, required in deter-
mining as to the cases and period of treatment, in
which this practice should be adopted. It is
admissible only when the disease proceeds from
the pathological state just mentioned, or is con-
nected with a syphilitic taint, or has originated
in the abuse of spirituous liquors, &c., and the
too great indulgence of the appetite for food ;
and it will be injurious in cases of exhaustion,
unless combined with active tonics and nutritious
diet. Ph'm.mer's pill, the hydrarg. cum creta, or
the blue pill, may be given, in small and frequently
repeated doses (from half a grain to a grain of the last,
thrice a day), with anodynes, as conium, hyoscy-
amus,ext.humuli, and small quantities of camphor.
In more doubtful cases, or when we suspect that
efl'usion of fluid has supervened upon disease of
the membranes, the bichloride of mercury may be
prescribed, either in the compound tincture of
cinchona, or with the compound decoction of sar-
saparilla, or diuretic mlusions or spirits, according
to the symptoms and circumstances of the case.

61. (/. Various antii,pasmodics and tonics, be-
sides those already adduced, have been directed,
chiefly in the intervals ; and others in more com-
mon use have been employed in novel forms.
The cupri ammonio-siitphas has been prescribed by
Home, Duncan, and liiANciii; the nitrate of'
silver, by Powell and Hall; the animal oil of
dippel, by IIkhz ; the oil of rue, by Ahuahaim-
soN ; cdjnput oii, by 'I'iiunhkug ; the misletoe, by
CoLiiATcn and Homk; and the preparations of c/;/r,
by Goousiu, JIell, Beaumes, Dikjuid, VVimte,
and many more. Kiieus has advised the trunk
of the body to be enveloped in camphorated
cloths, if we suspect convulsions to arise from
intestinal worms. Waiiiiuik; has recommended
musk in large doses, combined with vitre ; and
SiDitEN and I'liANKFuuTiiu the internal use of

mix vomica, apparently upon the principle of
Hahnemann, \hdi\. similes si mi lihus curantur. Ca-
zals directed about half a drachm oitrisnitrate of
biimuthio be taken in the twenty-four hours, with
castor. VoGEL thought that benefit has been de-
rived from the flowers of the white lily ; and Baker,
Pallas, Thom, and Home, entertained a similar
opinion as to the effect of the cardamine and
anemone pratensis, artemisia, and the radix pcconiue.
Digitalis was employed by Siiaal ; emollients, by
KoRTU.M ; ipecacuanha, by Plenk ; and various
narcotics by the majority of authors, chiefly in
combination with stmiulating antispasmodics, in
order to insure their effect. Of the substances
now enumerated, the most deserving of notice
seem to be the preparations of zinc, bismuth,
musk, and the misletoe. Of the former of these
I have had much experience ; but, upon the
whole, they are inferior to camphor, valerian, assa-
fa^tida, ammonia, and the athers, judiciously com-
bined and assisted by other remedies, particularly
when taken upon the first intimation of the
seizure. If the disease be the result of exhaustion,
or inanition, and particularly if it assume a
periodic form, the preparations of cinchona, the
sulphate of quinine, iron (Buechner, Reidlin,
Loeffler, Hutchinson, Elliotson, &c.), espe-
cially the sesquis-oxide in large doses, or the
ammonio-tartrate, and the arsenical solution with
potash, are the most appropriate remedies, either
alone, or with aperients, or antispasmodics, or
anodynes and narcotics, according to the pecu-
liarities of the case. I have, for many years,
employed the infusion of green tea, if the convul-
sions arise not from inflammatory action within
the head, and generally with great success. 1'hc
good effects of the medicines now mentioned,
when they produce any, are to be imputed chiefly
to their influence in overcoming the susceptibility
of the nervous system, giving tone and energy to
the moving fibres, and increasing the secreting
and excreting functions. In order to insure their
effects, they should be varied and changed from
time to time, and differently combined with one
another.

62. e. There is scarcely any anodyne or nar-
cotic substance, that has not been employed in
convulsions. The preparations of opium, of poppy,
of belladonna, (Stoll, BEKcaus, isic), of conium
(Stoerck, &c.), of hyoscyamus, stramonium
(SroERCK, SiDREN, VVadenberg, &c.), and to-
bacco, (RiVERIUS, C'URRIE, TliACKEUAY, Ha^-

GAUTii, &lC.), have been prescribed in various
modes and states of combination — with aperients,
or stimulants, or tonics, &c. — internally and ex-
ternally— in enemata, and in sujjpositories. The
most successful modes of exhibiting either of
these substances in convulsions, are internalli/
with camphor, assafa-tida, or the carbonates of
the alkalies ; and externally, either in the form
of liniment, embrocation, or plaster on the epi-
gastrium, or along the spine, combined with the
substances just menlionetl, or with any of the
liniments or planters iii the Pharmacopctias, or in
the Appendix.

63. /'. Various derivatives or revulsants have
been used in the intervals, as well as in the paroxysm.
Blisters may be employed ; but they are not so ge-
nerally appropriate as the production of a number
of pustules by means of the tartar emetic ointment
or solution (F. 749.), or of the crotou oil, rubbed

CONVULSIONS — Treatment.

429

upon the inside of the thighs, or on the epigastrium,
or along the spine. Several writers have directed
blisters to the head ; but the pathological states
admitting of their application in this situation are
comparatively rare, and require the most intimate
knowledge of disease, and appreciation of symp-
toms for their recognition. It is only when the
vital energy of the brain is profoundly sunk, or

sliould lead the physician to recommend such
moral regimen as the circumstances of particular
cases may seem to require. The above facts, as
well as the circumstances recorded by Boeh-
11 A AVE, of almost all the girls and boys in the
hospital of Haerlem being seized by convulsions
from their seeing a girl who iiad been frightened
into them, will alone show the importance of

exhausted, and not suppressed by congestion, or | separating the affected from females or other
active determination of blood, or the pressure of i susceptible persons. There can be no doubt

effused fluids, or adventitious formations, that a
blister on tlie scalp can be of any service. When
applied to the nape of the neck, or behind the
ears, or between the slioulders, they are seldom
of much use, unless kept open for some time.
The pea or mezereon issue in the insides of the
thighs, and antispasmodic liniments or plasters
along the spine, or over the epigastrium, are
sometimes useful auxiliaries.

64. g. Electricity and galvanism have been
proposed in convulsions ; but I agree with Gra-
PENGiESSER in thinking them hazardous, h. Cold
bathing has been very commonly recommended ;
but it requires discrimination. It will benefit
ciiiefly those cases which are unconnected with
organic lesion, and which depend upon general
debility and susceptibility of the nervous system.
In these the salt water bath should be preferred,
and its use commenced in the tepid state, the
temperature of successive baths being gradually
reduced. The cold shoiver bath is more generally
applicable, particularly upon getting out of bed ;
and when it cannot be resorted to, the patient
ought to sponge or bathe the whole head with
cold water every morning. The strictest atten-
tion should, at the same lime, be paid to the state
of the digestive functions, and of the alvine eva-
cuations. Cutaneous excretion also ought to be
promoted ; for, not only are all the other func-
tions thereby improved, but contingent disturb-
ance of any of them, and the irregular distribution
of blood, in which convulsions often originate,
are less likely to take place whilst the circulation
in the surfaces is uninterrupted. It is probably
from this mode of operation, as much as from
their antispasmodic action, that service has been
obtained fi'om several diaphoretics, particularly
the kermes mineral, and other antimonials, recom-
mended by Unzeh, GuLnnAND, Struve, and
Harder. ;'. Warm batlis, hip baths, semicupium,
&c., when any advantage is derived from them in
the intervals, act chiefly in this manner. But I
believe that they will seldom be productive of
much benefit, unless in cases connected with sup-
pressed eruptions, or the exanthemata, or with
irregular or diflicult menstruation, and with dis-
orders of the digestive canal in children ; and in
tliese the effects of warm batiis will be much
enhanced by stimulating or irritating frictions of
the surface immediately upon coming out of
them.

65. k. The almost epidemic prevalence of con-
vulsions during slates of religious enthusiasm and
mental excitement, as shown by the occurrences
already referred to (§ 16 — 18.), and by the seizures
that aflecled many of the Jansenists who made
pilgrimages to the grave of Deacon Paris, during
the persecution of this sect in 1724, as well as by
the convulsions at one time so uncommonly fre-
quent in the Methodist meetings in various parts
of Cornwall, as described by Mr. Cornish,

that simple hysterical or epileptic convulsions
occurring in one among a crowd of females will
often occasion convulsive seizures in others, par-
ticularly in those of a delicate frame and nervous
temperament, although they may have never
previously been similarly disordered. I have
met with such an occurrence more than once.
Indeed, the number of these attacks on the public
occasions referred to, is a suflicient proof both of
the influence of the mind in producing them, and
of the propriety of the immediate separation of a
person thus seized, as was judiciously and suc-
cessfully practised by Dr. Havgartii. The
propensity to become affected by convulsions
from seeing one in a fit appears to have been well
known to the Romans, and from its frequency
on occasions of public assembly, as much as fioni
other considerations, they obtained the name of
I\Iorbus Comitialis, which has been understood
as applying only to epilepsy, but which I be-
lieve had a much wider signification, and com-
prised all convulsive seizures. That fear or
terror will not only occasion convulsions, but
also remove them, or at least often prevent tiieir
accession, might be inferred <i priori, even if it
were not proved by experience. The actual
cautery employed by Eoeriiaave soon put a
stop to them in the hospital at Haerlem : and
their prevalence in certain of the Zetland Isles
was said to have been arrested by the uncere-
monious ducking inflicted upon two or three of
those affected ; the fear of being treated in the
same way having effectually prevented others
from being attacked.

66. /. Regimen. — The circumstance of those
convulsions which arise iii crowded assemblies
from mental excitement and religious impressions
being often ushered in by faintings, and signs of
congestion of the cavities of tiie heart, of the large
vessels, of the lungs, &c., should suggest the
avoidance, by susceptible persons, of warm and
crowded assemblies, where the foul and moist air
conspires with moral emotions in depressing the
nervous power, and in favouring congestions of
the heart's cavities and large vessels ; as well
as the propriety of removal to the open air^ and
of having recourse to antispasmodic stimulants
upon the approach of the sinking and oppression
at the epigastrium and prascordia, which often
usher in the fit. The importance of administer-
ing to the mental affections and emotions — of
relieving as much as possible anxiety or de-
spondency— ought to be pointed out to those
concerned, and the patient encouraged strenu-
ously to resist the invasion of the paroxysm.
Persons subject to convulsions should never
receive indulgence on account of them, but be
made to know that they may be warded oflT, by
not yielding to the feelings which often favour or
produce them. Regular hours of rest, of recre-
ation, and of eating, should be adopted ; seden-

CONVULSIONS OF CHILDREN— TREATMENt.

430

tary habits avoided ; exercise in the open air
taken daily, and both the mind and body duly
occupied without fatiguing either the one or the
other. In some cases, depending upon disease
of the brain or its membranes, the appetite is
morbidly increased, and much more food is
taken than is requisite to the wants of the frame.
Others- are connected with indulgence in spirit-
uous liquors. It is almost unnecessary to add,
that unless these excesses be guarded against,
and the diet and regimen duly regulated, medical
treatment will not be efficacious.

67. ii. Treatmentof Convulsions in Infants
AND Children. — A. Many of the measures al-
ready recommended in the paroxiism may be also
employed in this class of patients ; but in a suitable
form and wiih strict reference to existing patho-
logical states. Where we observe the indica-
tions of cerebral irritation and congestion (§2 1.24.),
cupping on the nape of the neck, behind ttie ears
or occiput ; the warm bath or semicupium, with
cold afusion ; cold epithems, &c., on the head,
the hair having been removed or cut close ; a
dose of calomel, or of calomel and scammony if
the child can swallow, and a cathartic and anti-
spasmodic injection ; are suitable remedies, The
jugular vein may be opened in robust or well-
grown children ; but care should be taken not to
bleed them to syncope, as a return of the con-
vulsions may be thereby occasioned. Children
ought to be blooded with great caution during a
fit ; for, although I cannot go so far as to say,
with Harris, that it is dangerous to bleed in
the paroxysm, yet I believe that the convulsions
will occasion a hurtful quantity of blood to flow
without any immediate effect, if the evacuation
be pushe 1 with the view either of subduing them,
or inducing syncope. It is as improper as it is
futile to lay down any rules as to the extent to
which depletion may be carried. It is obvious,
that when the child is plethoric, the head large
and hot, the eyes suffused and prominent, the
carotids throbbing, &c., it may be practised
freely, even in the fit, without risk.

68. a. Convulsions sometimes proceed from
the nature of the ingesta. If this be the case,
and if the abdomen be distended, an emetic
sliould be exhibited without delay. Seizures not
infrequently arise during the period of dentition
from indigestible or irritating substances in the
prima via, and in such cases often commence in
simple flatulent colic. After an emetic has been
exhibited, or even independently of it, a purga-
tive, if it can be taken, should be prescribed,
along with carminatives or antispasmodics, and a
clyster thrown up. In cases of this description, I
have found a dose of calomel, with soda or potash,
or the hydrarg. cum cieta, followed by cither
of tlie following mixtures, a carminative enema,
and friction witii an antispasmodic liniment on the
abdomen or spine, the most successful means.

No. 1")^ H Magnesias C.-iIciiiatc'c 5 RS.;SacchariAlbi 3 j.;
Olei Anisi 111 v. ; tere bone simul, ct adilc Aqua> I'cpniculi
I)ul. 5 jss. ; Spirit. Ammnn. I'atid. HI xv. ; Pulv. Uliei
gr. xvj. ; Syrup. Pajiaveris 3 ij- l''iat Mist., rujus'.ciipiat
coch. unum, vol duo minima, tertiis vcl quartis lioris.

No. l-")!). ]\ Olei Uiciiii 3 iij — ^ ss. ; Olei Terebinth.
3j.— 3ij.; tere cum Vitel. Ovi, et adde Aq. Fconicnli
5 ss.— 3 j. ; Syrup. I'apaverislet syrup, llosie aa 3 ij. M.
Fiat Mist., cujus sumat partem quartam vcl tertiam, ter-
tiis vel quartis horis.

69. h. Clysters, containing valerian, assafcetida,
or a terebinthinate substance, triturated with the

yolk of egg, and any of the carminative waters,
to which oleum ricini or ol. oliva; may be some-
times added, are the most appropriate to those
cases. Much discrimination is required as to
the choice and continuance of cold applications to
the head, particularly if the warm bath or semi-
cupium be simultaneously resorted to. These
combined means should never be left to the dis-
cretion of a nurse, at least without the personal
superintendence of the practitioner in the first
instance. In general, as soon as the temperature
is reduced, and the features become pale and
shrunk, or the fonlanelle (if unclosed) level, or at
all depressed, whether the convulsions, or sopor,
when present, disappear or not, the application of
cold to the head, in any form, should be left off,
to be again resumed when the symptoms requiring
it recur.

70. c. During dentition, or even before the
teeth approach the margin of the gums, free
scarijications ought to be practised, and repeated
as soon as the scarified parts cicatrise, otherwise
the obstacle to the passage of the teeth will be
thereby increased. If general or cerebral ple-
thora be not present, or has been removed, and
the bowels have been fully evacuated, any of the
alkaline or earthy carbonates, with aqua focni-
culi, or aq. pimenta;, asther, camphor, &c,,
with the extract of conium or hyoscyamus, or the
syrup of poppies, or small doses of laudanum,
may be prescribed with the view of soothing
the susceptibility and irritability of the frame at
this period. Form. 347. 442. 865. have been
ordered by me very generally in such cases, at
the Infirmary for Children. In very young in-
fants, convulsions may be occasioned solely by the
retention and accumulation of acid and acrid
sordes in the prima via. These are readily re-
moved by a dose of calomel, followed by olea-
ginous or other purgatives, the semicupium, and
clysters. Tissot and Sharp state that they have
been produced by the retention of the meconium,
owing to spasmodic stricture of the sphincter ani.
This is, however, a rare occurrence. Emollients,
oleaginous laxatives, the semicupium, clysters,
and anodyne liniments, are appropriate to such
cases. It has been repeatedly contended for by
most of the older, although denied by many mo-
dern writers, that the anxieties, the more violent
passions, and the irregularities of the nurse, may
change her milk so as to disorder the digestive
organs, and thereby give rise to convulsions in
delicate infants. This fact is established by re-
peated observation. I perfectly agree with Mr.
North, who has taken a very judicious view of
this subject, (hat it should never be overlooked.
The obvious remedy in such cases is to change
the nurse; and, if this cannot be done, to remove
as far as may be the cause of disorder ; to promote
her digestive and excreting functions ; to tran-
quillise or subdue any mental disturbance or
febrile action that may affect the state of the
milk, and to prescribe for the infant aperients
with soda or ammonia, or other aniacids and
antispasmodics. I have often employed the oxide
of zinc or trisnitrate of bismuth with soda, or the
pulvis creta; compos., and either the pulvis ipe-
cacuanhaj comp., or small doses of conium or
hyoscyamus, with much advantage in these cases ;
or simply the bi-borate of soda in camphor mixture,
or a(i. fccniculi.

CONVULSIONS OF CHILDREN— Tbeatment.

431

71. d. The cold bath is a very doubtful re-
medy in the seizure : it is much less efficacious
than the cold affusion on the head ; and when
the child retains its consciousness, it even some-
times aggravates the mischief. Of the recom-
mendation of Dr. Bronn, to employ gradually
increased pressure on the epigastrium during the
fit, I have had no experience : it, however, de-
serves a trial.

72. e. Of the use of blisters in convulsions, as
well as of alkaline rubefacients, as the liquor am-
monia?, no favourable idea should be entertained,
as they require the utmost discrimination, and
are far from being unattended by risk : for, al-
though they will often cut shoit the paroxysm, yet
they will also occasionally produce so violent irri-
tation and inHammalion as to be rapidly followed
by sphacelation of the integuments. This is liable
to happen particularly in ill or insufficiently fed,
in delicate and irritable children ; in those of a
gross or fat habit of body, who have been al-
lowed to feed upon the richer sorts of animal
food too exclusively ; in the state of vital ex-
haustion observed in the latter stages of dis-
ease, as well as in the early periods when the
pulse is very quick, irritable, or sharp, the skin
dry and burning, and the cerebral organs much
excited or oppressed ; — under such circumstances,
I have usually directed a liniment composed of
equal quantities of the liniment, saponis et opii
(jjrf. Pilar.), and of tlie liniment, terebinthinae,
or either of F. 308. 311. to be rubbed on the
epigastrium and abdomen, or along the spine.
TnuNBERG advises the cajuput oil to be applied
to the epigastric region during the fit ; Herz
directs the animal oil of dippel to the same region,
and Abrahamson the oil of rue. Either of these
will frequently cut short the paroxysm, but I can
assert, from a very extensive experience, that the
liniments I have recommended are the safest and
most efficacious.

73. /. When convulsions occur in the invasion
of any of the exanthemutous fevers, or upon tlie
retrocession of the eruption, the treatment must
depend, in a great measure, on the habit and
strength of body, and the extent to which the
brain is affected. If cerebral congestion or irri-
tation, with general heat of surface exist, local
depletions, the cold aflTusion on the head, whilst
the patient is plunged in a warm bath, to which
some vegetable or mineral alkali has been added,
cooling aperients, cathartic injections, the tartar-
emetic ointment and solution F.749. rubbed on the
spine, and diaphoretics, are generally most service-
able. After the bowels have been freely evacuated,
the carbonate of soda and nitrate of potash, given
in mucilaginous vehicles ; the spirit, aetheris nitrici,
with the liquor ammonia; acetatis in camphor
julep, &c.; may be prescribed. If the skin be
cool, and the pulse weak, or if the fit have occurred
after the disappearance of the eruption, salt and
mustard may be put in the bath ; and if the coun-
tenance be pale and collapsed, and the cerebral
functions not materially disturbed, warm and
cordial diaphoretics, as the preparations of ammonia,
camphor, serpentaria, &c., exhibited from time to
time. Frictions of the surface, immediately after
the patient is taken out of the bath, will generally
promote its good effects.

74. g. If convulsions occurin the course o( hoop-
ing cough or crmip, we may conclude that conges-

tion, or inflammatory irritation of the membranes
of the brain, has supervened, and should direct
local depletions, the cold affusion on tlie head,
semicupium, and the carbonates of the fixed al-
kalies, with opium, hyoscyamus, or belladonna,
in minute doses, unless the patient is already
much reduced by repeated or large evacuations,
when we may infer that the convulsive seizures
are connected with anaemia, and should prescribe
the treatment already described in relation to this
state (i 55.).

75. h. The convulsions which occur so fre-
quently as a consequence of chronic or severe
bowel complaints, and of exhaustion from other
diseases, and which have been too frequently
imputed to dropsical eflPusion in the ventricles,
require cordial antispasmodics, tonics, and light
nutritious diet. Although sometimes attended
by more or less effusion, arising from the phy-
sical condition of the cranium and its contents,
and serving to prevent any vacuum from being
occasioned by the deficiency of blood in the
cerebral vessels, yet the convulsions should not be
viewed as proceeding from tlie effused fluid, but
rather from the irregular and imperfect supply of
blood to the cerebral structure.

76. i. The seizures that follow great losses of
blood in children are generally characterised by too
active determination of this fluid to the cerebral
structure ; and require the head to be kept cool
and elevated, the bowels to be acted upon, and re-
storatives, antispasmodics, cordials, and tonics to
be administered with the extract of poppies, conium,
or hyoscyamus, according to the peculiarities of the
case.

77. h. If convulsions follow the disappearance
or repulsion of chronic eruptions, we should
dread the existence of inflammatory irritation of
the membranes of the brain or medulla oblongata
or spinalis, with a tendency to serous effusion.
Local depletions, the warm bath ; frictions of the
surface, particularly of the part whence the
eruption had disappeared, with irritating lini-
ments ; the use of sinapisms, and deobslruent
purgatives, as calomel, &c.;'are chiefly to be con-
fided in.

78. /. When the seizures have recurred several
times, particularly in infants, and are attended by
dilated pupil, squinting, slow pulse, &c., their
connection with hydrocephalus may be inferred.
In such cases, even local depletions should be
employed with caution : but in many instances
they may still be resorted to, in small quantitj' ;
and followed by alterative doses of calomel or
hyd. cum creta, diuretics, small doses of digitalis
with spirit, ajther. nit. and the use of the liniment
(F. 31 1.) to the head and loins both in the fit and
in the interval.

79. iJ. The preventive treatment, — a, in ple-
thoric,iat, and gross-living children, should chiefly
consist of a proper regulation of diet, as advised
by Beaumes. Farinaceous food ought to be
adopted, with only an occasional indulgence of
the less stimulating meats. ]\'o rational plan of
treatment, however, can be attempted with the
view of prevention, without strict reference to the
remote and proximate causes of the afl^ection ;
the former of which should be carefully avoided,
and the latter removed by suitable treatment.
When we detect cerebral irritation, or determin-
ation of blood to the brain, or active congestion.

CONVULSIONS, PUERPERAL — Treatment.

432

cupping, as already directed ; the daily affusion
of cold water on, and a constantly cool state of,
the head ; a moderate, but continued, action on
all the secreting and excreting organs ; tranquil-
lity, and the abstraction of all excitement of the
mind and senses ; a bland and low diet ; the use of
revulsants, and warm clothing on the lower extre-
mities ; are the most appropriate remedies.

80. b. In very delicate children, where no
evident inflammatory irritation witliin the head
exists, a tonic treatment is obviously requisite.
The sesquioxide or ammonio-tartrite of iron may
be given, either alone, or with other antispas-
modics, or any of the other preparations of this
metal. The sulphate of quinine, or the prepara-
tions of cinchona, with liq. ammoniac acetatis, and
a little of any of the compound spirits of am-
monia; suitable diet, attention to the state of the
bowels, and change of air, will also be of service.
Calomel, in fiequently repeated doses, either alone
or witli purgatives or anodynes, has been most
injuriously resorted to by practitioners, upon the
mistaken notion that convulsions are always
connected with irritation within the cranium,
and that this medicine alone can remove this
slate ; whereas, if calomel be prescribed in small
and frequently repeated doses, it will actually
increase the susceptibility and irritability of the
body generally. When, however, it is given in
full doses at distant intervals, or only occasion-
ally, and either combined with jalap or some
more active purgative, or followed by cathartics
and enemata, it is a valuable remedy. Where
the bowels are thus judiciously acted upon from
time to time, and particiilarly if this be accom-
plished by a terebinthinated draught, tonics, com-
bined with antispasmodics and anodynes, will be
of the greatest benefit, especially if there be no
disorder of the cerebral functions to forbid their
exhibition. The sulphate or oxide of zinc, or the
sulphate of quinine, or the oil or other preparations
of valerian, or assafoetida, musk, &:c., with either
conium, hyoscyamus, or the extract of poppy ; the
Ionic decoctions and infusions.with the alkalies ; and
various other remedies already recommended in the
intervals (§ Gl. 75.), may be severally employed,
according to circumstances, after purgatives have
been duly prescribed, and the stools have become
natural.

81. c. When we have reason to infer that
the convulsions proceed from intestinal luorms,
calomel with camplior, and the otlier cathartics
noticed above ; the occasional exhibition of an
active terebinthinate draught, followed by ene-
mata, containing aloes, assafoetida, camphor,
&c., and subsequently, by the preparations of
iron, as well as any other of the remedies and
modes of combining them described in the
article \\'oums, may be directed. It is generally
remarked by the German writers, that worms
never form in the alimentary canal previously to
weaning, if the milk be healthy ; and the observa-
tion is confirmed by my experience. It is there-
fore, after this period, that convulsions can be
referred to this cause.

82. (/. 'I'lie marked hereditary and amftiln-
liontil lendenctj to convulsions in the same family
of chihlien, and the very frequent connection of
this affection witii cerebral irritation, or with
dropsical effusion in the ventricles, or between
the membranes, in such cases, have presented

difficulties to every practitioner. I believe that
the disease, when occurring in this manner, has
been too frequently ascribed to inflammatory
action, and a too lowering treatment adopted.
Mr. Hill recommends the arsenical solution,
with musk, in these cases ; and I doubt not their
utility, if carefully employed ; but other tonics
and antispasmodics, particularly the weaker pre-
parations of bark or calumba, with tlie liquor
potassaj, and small doses of conium, or syrup,
papav., or opium, if the child be not too young,
and if the watchfulness or erethysm of the brain
be present, will be found still more serviceable,
especially if the head be kept cool, the secretions
and excretions carefully promoted, and the kidneys
occasionally excited by the addition of diuretics
to the tonics, as the spir. a;ther. nit., digitalis,
syrup, scillas, &c„ or by the application of a
suitable liniment (F. 311.) to the loins. In several
cases of tliis description, I have directed, after
other means had failed, and while tonics, as now
prescribed, were given, tlie hair to be cut off,
and the liniment to be rubbed upon the head
immediately after the cold affusion. In cases
connected with inflammatory irritation of the
membranes, local depletions, the cold affusion,
&c. (§ 67.) should precede the above treat-
ment.

83. e. The diet and regimen of childi'en that
have once experienced a seizure of convulsions,
ought to be carefully attended to. The stomach
ought never to be overloaded, either by the
mother's milk, or by its ordinary food, which
should be always recently prepared, and easy of
digestion. As crying often brings back the
seizures in infants and young children, it should
be prevented as much as possible. When
tlie bowels have been sufficiently evacuated
by the medicines suggested, from one to three
grains of the hydrurgyrum cum creta, either
alone, or witli the carbonates of the fixed alkalies
may be given at first every night and morning,
and afterwards every night, or every other or
third night. Tlie head should be always ele-
vated ; and whilst in bed or indoors, it ought to
have no other covering upon it than that with
which Nature has provided it. On no occasion,
should the warm fur or beaver hats, which are
very improperly worn by children, be used ; nor
ought the mental powers to be prematurely or
inordinately excited. In a word, the head should
be kept always cool, the mind tranquil, the lower
limbs warm, and the bowels open. A free, tem-
perate, and healthy atmosphere, with occasional
change of air is also as necessary as medical
treatment.

84. iii. Treatment of Puerperae Convue-
sioNs. — The more frequent occurrence of convul-
sions in a first pregnancy, during a protracted
labour in those who have experienced them pre-
viously ; the period of the puerperal state, and
the progress of the labour and slate of the os uteri
when they do occur ; the characters they asuuic —
whether those of eclampsia, of epilepsy, of hys-
teria, or of simple clonic convulsion; the causes
which induce them, the circumstances connected
with them, and the fact that they, more than any
of the other forms of convulsion, are the result of
active (letennination of the blood to the head —
which, however, is merely the effect of irritation
primarily seated in the abdominal viscera; are

CONVULSIONS, PUERPERAL — Treatment.

433

nil to be taken into consideration in tlie treatment
of them. The intentions of cure are the same in
this as in the foregoing states of convulsion ; and
they should be promptly fulfilled.

85. A. In order to cut short the seizure, — a.
After having resorted to suitable means to protect
the tongue, as the introduction of a cork between
the teeth, iStc, blood-letting from the arm, but
preferably from the jugular vein, when it can be
easily performed, should be employed, and carried
at once to a decided extent relatively to the
vigour and habit of body of the patient ; and
it should be repeated after a short interval, if the
convulsions recur, and there be no circumstances
to forbid it. Simultaneously with the flow of
blood, or immediately after it, the aflusion of cold
water or the application of a bladder of pounded
ice on the head, and the exhibition of ten grains
of calomel, and from five to ten grains of camphor,
previously reduced to a powder by a few drops of
spirit, with or without an equal quantity of musk,
and sliortly afterwards of two or three drops of cro-
ton oil, should never be omitted. These medicines
may readily be administered, by mixing them in
sweet butter, and introducing a portion i'rom time
to time over the root of the tongue, upon the end
of an ivory letter folder, or upon the handle of a
spoon. A cathartic and antispasmodic enema
(F. 141. 119.) should also be thrown up without
delay ; and immediately repeated, if it be re-
turned. The combined effects of these will sel-
dom fail of producing a solution of the paroxysm.
Aly experience of the excellent effects of cam-
phor is fully confirmed by Dr. Hamilton, al-
though CnAussiEH expresses an unfavourable
opinion of it, and of all heating antispasmodics ;
and the recently published observations of Mr.
JMiciiELL are strongly in favour of musk, vvhich
he gives in doses of from one to two scruples.
Depletion may be carried fuither in those states
of the disease which assume the characters of
eclampsia, or which are attended by great fulness
about the head, or stertorous breathing, than in
almost any other malady. Chaussier advises,
after general depletion has been practised, local
bleeding from the nape of the neck and occiput,
or from the epigastiic region.

86. 0. As to the propriety of prescribing opium
in puerperal convulsions, very opposite opinions
have been given. Petit, Hamilton, JMerhimax,
and Deweks consider itmostinjurious ; Manning
and Bland recommend it, and Leake and Burns,
with a judicious discrimination, state, that when
the disease is not accompanied with fulness of the
vessels of the head, it may be exhibited with ad-
vantage after biood-letting. In this decision I con-
cur, and add, that it should always be given either
with camphor, as directed by Stoerck, or with
the carbonates of the alkalies, as advised by
Stutz and Bruninghausen, or with both ; more
particularly when the convulsions occur from
excessive irritability, or previously to the period
of full gestation, or after delivery, or when they
assume chiefly the characters of iiysteria. Rinck
applies it to the abdomen, and Hufeland to the
soles of tiie feet.

87. y. Some difference of opinion exists as to
the propriety of exhibiting emetics in this disease.
Denmas is in favour of them, but IMauriceau,
Chaussier, and Hamilton condemn them, unless
after blood-letting, and when the seizure has

Vol. I.

been excited by improper ingesta, — the only cir-
cumstances under which, in my opinion, they
should be given, and in which Dr. Blundell
also recommends them. Of the good effects of
active cathartics there cannot be the least doubt.
I have always observed, as Dr. Merriman has
stated, that the stools procured by them are morbid
and offensive.

88. J. The next practical point of importance
is, whether or not the patient should be imme-
diatehj delivered ; and on this the sentiments of
the most eminent accoucheurs are at apparent,
rather than actual variance. No person will
deny that the state of the uterus is connected
with the cause of the seizure ; therefore it
would obviously seem requisite to remove that
state. But the objectors reply, that convulsions
also occur after delivery, when this state of uterus
no longer exists : I have, however, never met
with any, of several cases of convulsions after
delivery for wliich I have prescribed, that did
not arise from analogous causes of irritation, viz.
an over-distended urinary bladder, the retention
of the placenta or of coagula in the uterus, or
the accumulation of fascal or irritating matters in
the bowels. I therefore would adhere to the
opinion I have often given, namely, if the above
means have failed, and if the labour be so far
advanced as to enable the accoucheur to deliver
immediately without force or injurious interfer-
ence, then let it be done. If the labour be not
so far advanced, but yet the os uteri is consider-
ably dilated, then the membranes may be rup-
tured, particularly if they be very tumid, — if,
indeed, they have not been already ruptured,
which is often the case, — and either full doses of
the hiborate of soda ('c)j. to 3 ss.) given, or the
ergot of rye. If the os uteri be rigid or undilated,
the former of these will be preferable. If, how-
ever, the labour has not proceeded far, then
any interference, excepting by the exhibition of
medicinal substances, may be more injurious
than beneficial. La Motte, Osborne, Leake,
Hamilton, Dubois, Ashwell, Nauche, jMi-
GUEL, Burns, Osianders, father and son.
Duces, and Ramsbotham, are favourable to as
early delivery as possible without violence ;
whilst Bland, Gar'thsiiore, Baudelocque,
Hull, Gardien, Denman, and Blundell, are
against forcible dilatation of the os uteri, and
attempts at delivery in the early stage of labour.
After all, the difference is more in words than in
intention ; for the general object is to hasten
delivery, without injurious interference, if the
labour be so far advanced as to render the attempt
prudent; and those who have espoused either
side have stated their opinions with such excep-
tions and limitations, and with so little precision,
as to leave the subject nearly where they found
it, and to render it no easy matter to ascertain
under what circumstances they would either have
recourse to art, or trust to nature. When the
treatment already recommended fails, or is fol-
lowed by an exasperation of the convulsions, —
which will very seldom occur if it have been
judiciously directed, — then I conceive that the
active interference of art should be called to our
aid. There is, perhaps, no subject on which
opinions are stated to be so much at variance as
on this, — each succeeding writer placing those of
his predecessors in opposition, even where no real
Ff

434

CONVULSIONS, PUERPERAL —Treatment.

difference exists, and thereby bewildering the in-
experienced, in order that he may have the credit
of giving a decision respecting it.

89. £. Chaussieu recommends, in rigidity of the
uterine orifice, the application of a pomade con-
taining helladniina, with a view of rehixing the
spastic contraction, wiiich, he states, is not Hmited
to this part, but extends to the vvliole of the organ.
I beUeve, liowevtr, that the body of the womb is
generally free from spasmodic contraction. This
preparation consists of two drachms of the extract
of this narcotic, softened with an equal quantity
of water, and triturated with about an ounce of
prepared lard. A piece, the size of a small nut,
is to be introduced into a female syringe, open at
the extremity, and conveyed to the os uteri, where
it is to be applied by pushing onwards the piston.
In about half an hour the rigidity subsides, and
the labour proceeds. Of this practice I have no
experience, M. Chaussier discourages any other
attempt at dilatation of the os uteri, as irritating
the parts, and inducing a recurrence of the con-
vulsions.

90. ^. I have never omitted, in any case
treated by me since 1819, to employ the effusion
of a stream of cold water on the head, and the
injection of turpentine clysters, sometimes with
camphor, assafostida, or valerian, and the results
have been most satisfactory, — a much less quantity
of blood having been detracted than is usually
required in such cases. I am not aware that
either of these two remedies had ever been em-
ployed in puerperal convulsions, until long after
I had given publicity to the practice, — a prac-
tice which I know to have been recommended
very recently by those, who, at that time, ridi-
culed it. In the more rare stales of the disease,
which are attended by a weak quick pulse, pale
features, and hysterical symptoms, enemata con-
taining valerian, assafoetida, or camph ir, are very
serviceable. In those which assume the comatose
or apoplectic characters, hliaiers applied to the
nape of the neck, and siimpisms to the ankles and
calves of the leg;, are useful adjuvants of the
measures already recommended.

91. >). In all cases occurring previously to,
during, or after parturition, the state of the blad-
der, and of the bowels, ounht to be carefully
enquired into. Early in 1823, I was called to
the Queen's Lying-in Hospital, by the house
pupil, to a patient who hud been seized with
puerperal fever on the second day alter delivery,
but was convale-;cent from it, when she was at-
tacked by convulsions, brought on by a distended
urinary bladder. I found that the urine had
been drawn off, and that she had been blooded
once largely. The case was one of extreme
severity and dang(-r ; the convulsions were unre-
mitting, and attended by profound coma and
asphyxy. The vein was re-opened, and, while
the blood flowed, a stream of cold water was kept
playing upon the vertex, and, at the same time,
a clyster with turpentine and camphor was
thrown up. Thus, the three most powerful — the
almost only, remedies to be confided in, were
simultaneously in operation. The patient rapidly
recovered. Purgatives were given by the mouth,
upon the solution of the convulsions ; deglutition
liaving been entirely abolished during the whole
seizure. This was one of the earliest cases in
which I liad ventured ujjon the simulUiiieous

employment of these powerful agents, the use of
them in succession having been generally adopted
by me previously. I allude more particularly to
this case, because of its uncommon severity ; of
its occurrence soon after a most dangerous dis-
ease, as late as nine days after delivery, in a pub-
lic institution, and at a time when my public
recoimiendation of the practice apparently re-
ceived but little attention ; although it will not
now be looked on with scepticism.

92. &. 0( other remedies but little may be said,
as they should be viewed as auxiliaries merely.
I have already expressed myself favourably of
camphor (§Q5.). Burns condemns it ; but, when
exhibited after depletion, and at the same time
with the cold affusion on the head, and cathartic
and antispasmodic clysters, it is a valuable me-
dicine. Under the same circumstances, musk,
assafoetida, and the other antispasmodics, will
also be of use ; for all risk of their injurious action
on the brain is prevented by the cold affusion,
whilst they co-operate with the terebinthinate in-
jections to excite the contractions of the body of
the uterus, and remove spastic constriction of its
neck. Of the ergot of rye, my experience is
limited. I have given it only in one case of this
disease, and then it was combined with biborate of
soda, — a medicine undeservedly fallen into dis-
repute-^ but which I have prescribed for many
years. The labour in that case proceeded rapidly,
and the patient recovered. Much difference of
opinion exists as to the effects of, and propriety of
giving, the ergot in convulsions. If the os uteri be
dilated, and the external parts free from rigidity,
blood-letting, the cold affusion, and cathartic
injections, having been actively but unsuccess-
fully employed, there can be no doubt of the pro-
priety of exhibiting it. Opinions will always be
at variance as to the benefits derived from sub-
stances recently introduced into practice ; for, as
all medicines are remedies only from theii appro-
priate use, experience of their operation is required
to asceitain the circumstances in which they are
truly of service. In a case of puerperal convul-
sions— I believe the first in which the ergot was
exhibited — Dr. BRiNCKLEgave it after the means
usually adopted had failed. Twenty minutes
after the first dose had been taken, uterine action
came on, and the patient recovered. It is strongly
recommended by Dr. Waterhduse, of Philadel-
phia, and by Mr. Miciiei.l.

93. (. In cases of unyielding rigidity or callo-
sity of the OS uteri, Van Swieten advised an in-
cision to be inade through its margin. Dubosc,
and, subsequently, Lauverjat, BoDiN,and Cou-
Toui V, who considered it perfectly justifiable after
blooddetting, the warm bath, and other means
usually employed, had failed, have had recourse
to this operation. ]\L Coutoui.v has recorded
four cases (two of which are quoted by M. Mi-
guel) in which it was resorted to ; three of these
recovered. The death of the fourth he imputed to
the circumstance of it having been too long de-
layed. M. N.(uciiE also favours this operation in
the above circumstances, especially if emollient
and narcotic injections into the vagina have failed
to relax the rigidity.

94. K. The warm hath, and emollient _/(»;;ie/it-
ations, followed by the use of an anodyne liniment
on the abdomen, have been recommended by
Denman and Nauche j and the tepid bath by

Capuron, after bleeding has been practised.
Much advantage will accrue from assiduous fric-
tions of the abdomen, more particularly if tliey
be performed with an anodyne and antispasmodic
liniment (§ 53, 54.). independently of the use
of a warm or tepid bath ; for either of these can
seldom be used with advantage in the circum-
stances of puerperal patients. In every case the hair
should be cut closely oft'. This may be done in a
very few minutes ; but shaving the head is merely
a loss of time. Bunxs, Rvan, and Clarke advise
tlie application of a blister on tiie head ; but I be-
lieve that it will be required only in extreme cases ;
it certainly ought to be ventured upon only in such,
where the coma is profound, and the pulse weak,
and the patient sinking. The advantages stated
to have been derived by Dr. Clarke from acrid
cathartics, and clysters, are confirmed by my own
experience. If the convulsions occur immediately
after delivery, the placenta should be removed,
and the existence of internal hjemorrhage enquired
after — if at a later period, the state of tlie urinary
bladder and bowels, as well as of the womb, de-
mands attention. In ail such cases, active puroa-
tives and cathartic clysters are especially required,
but the choice of them should be made with due
reference to the state of constitutional power, and
to the presence or absence of cerebral congestion,
or of exhaustion and nervous susceptibility.

95. X. When the convulsions attack epileptic
females, they generally have all the characters of
epilepsy or eclampsia, generally with unremitting
sopor and stertorous breathing passing almost into
aspiiyxy ; and they require the treatment described
above. When they occur in hysterical females,
they may also assume the same forms, and demand
the same method of cure ; or they may present
the features of simple hysteria, particularly bor-
borygmi, quick pulse, &;c., with very slight cere-
bral affection. In these latter cases, the nervine
remedies mentioned in the next paragraph will be
adopted with advantage, especially after the cold
affusion on the head. Cold enemata may be also
thrown up, as advised in Hysteuia. In the ma-
jority of these seizures, neither bleeding nor arti-
ficial delivery is required, unless cerebral conges-
tion supervene, or the patient be strong or plethoric.
9G. fx. Convulsions in the puerperal states
may occur from great exhaustion, from want and
inanition, and losses of blood. In these, the prac-
titioner should trust chiefly to the cold affusion,
performed only momentarily ; to the keeping of
the head cool and elevated ; to sinapisms on the
lower extremities; to the exhibition of camphor,
ammonia, the vegetable alkalies, and musk, with
small doses of opmm, or of the aethers with hy-
oscy.'imus or coniuni ; to the administration of
valerian, assafoetida, or turpentine clysters; to the
warm bath ; to anodyne frictions of the abdo-
men ; and to as early delivery as may be safely
attempted ; the vital energies being supported by
gentle cordials during the remissions. If the
seizure be complicated with hcemorrliage from the
uterus, or hasmatemesis, prompt artificial delivery,
tlie turpentine clyster in the first instance, and
turpentine draught in the second, are the most
certain means.

97. B. The prevention of puerperal convul-
sions is of great importance. 'J'he means calcu-
lated to attain this object can be put in practice
only when the premonitory symptoms (§ 28.) ma-

CONVULSIONS, PUERPERAL — Treatment. 435

nifest themselves. — a. If these indicate fulness
of the vessels of the head, bleeding from the arm,
or cupping on the nape of the neck, will be ne-
cessary ; and in every instance the liowels are to
be freely evacuated. There are few cases of the
disease, at whatever period it may occur, entirely
unconnected with fa;cal accumulations; and al-
though this state of the bowels may not excite
the attack, it certainly remaikably disposes to it.
Cathartics should therefore be given by the
mouth, and their action promoted by clysters.
Dr. Blundell advises an ipecacuanha emetic to
be taken in the first instance ; and, where there
is a loaded or disordered stomacii, this practice
may be adopted. In addition to these, the warm
bath may be used ; and if, notwithstanding, signs
of active determination continue, the cold affusion
on the head, or cold applications, should be also
resorted to, either previously, at the same ti)pe
with, or subsequently to, the warm bath. Dr.
Home and Dr. Blundell favour the exhibition
of digitalis in such circumstances.

98. b. If the premonitory symptoms be charac-
terised by leipothymia or sinking, rapid weak pulse,
particularly of the carotids ; coolness of head,
sunk features, &c.j — the internal use of camphor,
or musk, ammonia, assafoetida, the aethers, the
warm bath, with small doses of opium, purga-
tives, sinapisms, blisters, and the turpentine fo-
mentation applied on the abdomen, are the most
approved means of prevention.

99. c. If the patient have had two or three
attacks at some former period, and if the above
preventive treatment have not rendered the acces-
sion of the disease less probable. Dr. Blundell
advises the membranes to be punctured.

100. C. During c()»i;a/esce«ce, the states of the
urinary bladder and of the bowels should be care-
fully watched, and evacuated ; the diet regulated ;
and both body and mind kept tranquil. If cere-
bral symptoms continue for some time afterwards,
the head should be preserved cool, and sponged
with cold water night and morning, and a blister
applied to the nape of the neck, and kept open
for some time, whilst a course of eccoprotic and de-
obstruent purgatives is continued for several days.

BlBLIOG. AND KeFER. — i. CONVULSIONS IN GENERAL.

Hippocrates, Aplior. sec. vi. ^ Si', vol. i. p. 101. edit. Vanaer
Linden. — Galen, De Locis Affect. 1. iii. c. 6. — Oribasius,
Synop. 1. viii. c. 16. — Paulus JEgineta, 1. iii. c. 19.— Zaca/w*
Lusitanus, Prax. Hist. 1. i. cap. 11., ). v. cap. 2. — Willis,
De Pathologia Cerebri, cap. i. i. — Baillou, Op. omnia,
vol. iv. p. \oi. — Amatus Lusitanus, cent. vii. cur. 11.

{Inanition.) — Bonet, Sepulch. 1. i. sect. xiii. observ. 26.

Morgagni, De Sed. et Caus. Morb. ep. x. art. 21. Hoff.

mann, De Cunvulsionibus, in Oper. vol. iii. p. 31., et
Supp. vol. ii. p. 2. — Collbatch, Sur le Gui de Chene, in
Malad. Convuls. Paris, 1719. — Bsynnrrf, On Hot and
Cold Baths, &c. Lond. 1722. —J. Juncker, De Morb.
Spasmodico-Coiivulsivis, &c. Hals, 1739. — Monro, in
Edin. Essays and Observ. vol. iii. p. 55\. — Schroeder, De
Convulsion, ex Hsemorrhagia nimia oriundis. Marb.
1752. — Mar.r, De Motibus Convulsivis, &c. 4to. Hala?,
1165. — Stall, Rat. Med. par. iii. p. il2. — Stoerck, Do
Stramonio, Hyoscyamo, &c. Vien. 1762; et Ann. Med.
vol. i. p. 1.5 — IVedenberg, De Stramonii Usu in Morb.
Convul. Ups. Ylli. — Sidrcn, De Stramonii Usu in Malis
Convuls. Ups. 1773; et in Act Med, Suec. t. i. — Whi/tt,
Works, -ito. p. 582.— //owe, Clin. Exp. Hist, and Diss. «.c.
Svo. p. 15.J. — Evans, in Med. Observ. and Inquiries, vol. i.

art. 11. — Gulbrand, in Act. Hog. Med. Hann. b. i. p. 26.

Bell, in Edin. Med. Comment, vol. i. p. \1Vi .— Goodsir, in
Ibid. vol. i.p. 4b/. — Warburg, Medic. Beobachtung. No. 10.
— Clarke, in Jled. Facts and Observ. vol, viii. p. 275. — Pal-
las, Reisen durch Russland, ii. p. 387. — Vnzer, in Hamb.
Mag. b. viii. p. 369. — Bergius, Mat. Med \). 121. — Ariiot
Edin. Med. Essays, &c. vol. vi. p. 634.— J. Smit/i, Ed. Med!
Comment, vol. iii. p. 316.— P. Dugud, in Ibid. vol. v. p. 84.
— White, in Ibid. vol. vi. p. 330.— Armstrong, in Ibid, vol
ix. p. 301. — Aiders, Edin. Annals of Med. vol. vii. p 406
Ff2

43G

From abscess of the ear) ; et Horn's Archiv. b. i. p. 329.

— Conrad), in 'Hufelarul's Jouin. der Pract. Heilk. b. vii.
St. 2. p. 6.—Hargens, in Ibid. b. vii. st. 1. p. IH.—Doer-
ner, in Ibid. b. xv. st. 4. p. 94. — Henrisc/ien, in Ibid.
b. XV. St. 4. p. 79. — Mic/iaelis, in Ibid. b. iii. p. 344. —
Wiedemann, in Ibid. b. vi. p. 418. — Slriwe, in Ibid,
b. xxiii. st, 4. p. S. — Sc/imalz, in Ibid. b. xi. st. 4. p. 169.

— lieil/ironn, in Hiifehind und Harles N. Journ. der
Ausl. Med. Chir. Lit. b. ii. st. 1. p. IHl.—Powe/, in Trans,
of College of Phvs. of I>ond. vol. iv. art. 8. — Lathnm, in
Ibid. vol. vi. p. 248. — Cornish, in Loud. Med. and Physi-
cal Journ. vol. xxxi. p. 373. — Loefflcr, in lUchter'iChw.
Biblioth. b. viii. ^.IS'i.—Krebs, Medicin. Beobachtun-
gen, b. ii. heft 2d. — Sumeire, in Journ. de M^d. t. xxi.
p. i>'-2i.—Diipont, in Ibid. t. xxxii. p. ]30.—Parn/, Mem.
of Med. Soc. of Lond. vol. iii. art. 8. {Compression of the
carotids.) — Bianchi, in Brera's, Comment. Medici, dec. i.
t. ii. art '2.— Grapengiesser, Versuche, p. 9S. — Plen/.; in
Abhandl. der Joseph-Acad. b. i. p. 318. {Ipecacuanha.) —
Thunberg, De Oleo Cajeputi. Ups. 1797. — Herz, Briefe,
St. 1. art. \. — Abraha7nson, \n, Meckel'?, N. Archiv. b. i.
St. 3. ait.2\. — Huf eland, Bemerkung. iiber Blattern, &c.
p.5i9. — Fran!tfurter, Med. Wochenbl. b. v. p. 229.—
Sauary, in Diet, des Sciences Med. t. vi. par. ii. p. 197. —
P. Jolly, in Diet, de Med. et Chirurg Prat. t. v. p. 473.—
Naumann, in Encvclopad. Worterbuch der Med. Wis-
sensc-h. b. viii. p. 341. — Thackeray, in Med. and Phys.
Journ. vol. x. p. 410., and vol. xii. p. [){)S.— Barton, in Ibid,
vol. viii. p. 428. ; Edin. Med. and Surg. Journ. vol. iii. p. 441.

Clarke, in Ibid. vol. v. p. 2o8. — Hill, in Ibid. vol. v. p. 318.

Thomson, in Ibid. vol. xiv. p. 614. [Dissections in.) —

Haygarth, Of Imagination as a Cause or Cure of Dis-
orders. Bath, \V,W. — Portal, Anatomie Medicale, t. iv.
p. 69. et seq. [Results of Dissections in.) — Dessesartx, in
Journ. do Med. t. xlvii. p. 114. — Rinck, in Stark's Archiv.
b. V. p. 3S9. — Kortiim, in Hnfeland's Journ. der Pract.
Arzneyk, b. iv. p. 381. — Cazals, in Journ. Gener. de Med.
Dec. 1810, p. 371. [Bismuth.) — Schacffer, in Huf eland's
Journ. der Pract. Heilk. Feb. 1810, p. IdS.—Gebel, in Ibid,
b. xvii. St. 3. p. 103. [Musk inlarge doses.)— Berge,'mMe±
Chir. Rev. vol. xxv. p. 501. — Denny, in Ibid. vol. xxvii.
p. 485. Lee, in Lond. Med. Gaz. vol. xxi. p. 11.

ii. CowuLSioNs OF CniLnREN. — Harris, De Morbis
Infantum, p. \m.— Rosen, Traite de Malad. des Enfans,

;ivo. Beaumes, Traite des Convulsions dans I'Enfance,

8vo. Paris, 1805.— Cap//;-on, Des Maladies des Enfans, 8vo.
Paris, 1813, yt.Wl .—Gardieu, Traite de Malad. des Enfans,
t. iv. ; D'Accouchemens, 3d ed. p. 239. — J. Clarice,
Commentaries on the Diseases of Children, 8vo. p. 80.
( Too cxclusiveli/ referred to cerebral irritation.)— Jacqiies,
in Journ. Gener. de Med. t. xxix. p. 280. — Bronn, in
Ibid. t. xxxi. p.iBl. — Piorry, De I'lnitation Enecphal.
des Enfans. Paris, 1823. — f7H(/c;-!/'00(/, On Diseases of
Children, by Merriman. Lond. 1827, p. 9.i3. — Brachet,
Sur les Convulsions des.Enfans, 8vo. Paris, 1824. [A good
book, luith too partial a leaning to cerebral irritation.) —
J. North, Practical Observat. on the Convulsions of In-
fants, 8vo. Lond. 1826. [An able and judicious work.)

iii. Pleuperal Convulsions. — J. i,pa/.-f. On the Acute
Diseases of Females, &c. 6th edit. p. 338. (Convul.from
licsmorrh. and inanition ivell treated of.) — Manning,
On Female DLseases. Lond. 1775, p. 357. — Deinitan, lii-
Irod. to Practice of Midwifery, 5th ed. \). 569.— Hai/iill,,ii,
Edin. Ann. of Med. vol. v. p. 318. — Coutouly, iu Juurn.
CJener. de Med. t. xxxii. p. 157. — Fritx, De Convuls.
«;ravid. et Parturientium. Wirceb. 1810. — Michaelis, in
Siebold's Lucina, b. vi. p. 37. — Briick7na7in, in Horn's
Archiv. Jan. 1811, p. 10. — Gasc, Memoires sur diveis
Points d'Accouchemens. Paris, 1810. — Gardien, Traite

Complet d'Accouchein. t. ii. p. 418 Stutz, Michai-lis,

Wiedemann, and Bruninghausen, in Hufeland's Journ.
&c. b. X. No. 4. ; and in Lond. Med. and Phys. Journ.
vol. V. p. 473. and 5.57. — J. F. Osiander, Deutsche Zeit.
schrift f. Geburtskiinde, b. ii. St. 3. p. 538 — J. L. Boer,
Abhandl. und. Versuche Geburtsliuf Inhalts, &c. .'v-c. 1791,
li. iii. p l'.)2 —Hufcland, Journ. der Pract. Heilk. Dec.
IKIG. — M'agner, De Eclampsia Kxquisita in Partu.
Morb. 1817. —J. Clarke, in Trans, of Irish College of
Phy.«. t. i. p. .3nl.— Merriman, On Difticult Parturition,
^vith Remarks on the Manageui. of Labours, 8vo. Lond.

1820, p. 135 Deivees, in .\mer. Med. Record, No. iii.;

and in .Johnson's Jled.. Chirurg. liev. June, 1820, p. 128.

— Brinckle, Philadelphia Med. Journ. vol. vi. p. 12C. —
Goupil, in Journ. des Progrfes des Scion. Med. t. iii. p. Ifil.

— Diiges, in Rev. M.'d. t. i. 1826, ]). .'JTS. ; et Manuel Ob-
htet. Paris, 18.'30, p. 27.5. ; et Diet, de Med. Prat. t. vi. p. ,537.

— Chanssier, Sur les Convulsions qui altaq. les Fenimos
Enceintes. Paris, IH^i. — Miguel, De Convulsions chcz
les Femines Enceintes, cu Travail, &c. 8vo. Pari.s 1S24.
—Blundrtl, Lectures, in Lancet, vol. xiv. p. 484. et 510 —
Burns, Principles of Midwifery, (Ith ed. p. 484. — 7f//i7M,
Manual of ."Midwifery, 2d ed. ]). 285.— Michcll, On Dif-
ficiilt Parluiitioii, and the Use of Ergot of Rye, &c. 8vo.
WZK—Nauchc, Des Maladies prop, aux Fcmmes, ^-c. 8vo.
J'aris, 1829, )>. 449.

CORI'UI-ENCY. Sec Oue&viy,

COUGH — Causes OF.

COUGH. — Syn. B^^, Gr. Tifssis, Lat. Bei,
Good. Pneusis Tussis, Young. Der Hiisten,
Germ. Tou.v, Fr. Tossa, Ital.

Classif. — 2. Class, Diseases of the Respi-
ratory Function ; 2. Order, Affecting the
Lungs (Good). II. Class, III. Order
{Author).

1. Defin. Violent and sonorous e.xpxilsion of
air from the lungs, preceded, rapidly followed bi/,
or alternating loith, quick inspii-ation.

2. I. Pathologv. — Dr. Cui.len and several
other nosologists have considered cough as chiefly
a symptom, which undoubtedly it is most fre-
quently ; but I agree with Dr. Young and Dr.
M. Good in believing that it is entitled to be
viewed on some occasions, as an idiopathic affec-
tion. Dr. Good, however, has ranked it as a
genus, and comprised under it various affections,
which are either merely slight forms of Bronchi-
tis, or the results of organic changes in the
Lungs, and wiiich I have treated of in these
articles, and in those on Bronchohriicea, Ca-
tarrh, and Influenza. He has, moreover, sub-
divided it into more varieties than can easily be
recognised iu practice, and has viewed Hooping-
cough as a species of the genus, instead of a
distinct disease.

3. Causes. — Cough, in either of the forms
about to be particularised, commonly attends dis-
orders of the air-passages, and of parts in their
vicinity, particularly of the larynx ; also those of
the lungs, and their membranous coverings ; and
sometimes diseases of other organs by which the
respiratory functions are affected sympathetically
— or rather, from continuity of tissue or nervous
communication. It is thus occasioned by affec-
tions about the fauces, tonsils, pharynx, and neck ;
by the irritation of dentition ; by diseases of the
oesophagus, particularly when inflammation and
ulceration of this part extends to, or penetrates,
the membranous part of the trachea (Kappel-
HouT, ]\Ir. Byam, and myself) ; diseases of the
spine and its contents (Wichmann) ; by creta-
ceous or calcareous formations in the ramifica-
tions of the bronchi (INIorgagni, Bonet, Baillie,
Portal, and myself in several cases, two of
which occurred in gouty subjects) ; by all or-
ganic changes of the thoracic viscera ; by the
accidental passage of foreign substances, solid or
fluid, into the air-passages; by the lodgment of
the eggs or larvae of insects in the same situation
(VoGEL and Percival, &c.) ; by the irritability
of parts attendant upon the nervous temperament
and debility; by the influence of irritation and
imagination, — a cause which did not escape the
observation of the acute IMontaigne; irregular or
misplaced gout ; the irritability of the parts con-
tinuing some time after measles, or infinnimations
of the air-passages or lungs ; disorders of the di-
gestive organs, particularly the stomach and liver,
&c. (WiNTHER, Stein, Percival, &c.); by ac-
cumulations of bile in its receptacle ; by the irri-
tation of worms ; by the repulsion of cutaneous
eruptions, and the healing of old sores, and sup-
pression of chronic or accustomed discharges.
From this enumeration it is evident that cough is
chiefly a symptom of numerous pathological states,
which will be found very fully desciibed under
different heads, as indicated above. The epidemic
cough noticed by some writers falls under the
article Influenza. In the act of coughing, the

COUGH — Causes — Treatment.

437

lungs are passive; and in the idiopathic states of
tlie disorder they are not organically affected ; the
disorder being chiefly seated in the trachea, laninx,
and vicinity. In very many cases, the irritation
occasioning the cough exists chiefly in the posterior
fauces and pJiari/iir, and extends no further than
the epiglottis and rima glottidis.

4. i. A. Dry Cough occasionally occurs in an
idiopathic fonn, — a. From exposure to cold in
any form ; the attendant symptoms not amounting
to complete Catarrh ; and it may, or may not, in
a very short time terminate with slight mucous ex-
pectoration. AVhen, however, it arises from this
cause, it usually runs the course described in that
article. — b. It is occasionally produced by acrid
or acid fumes and gases, or by various foreign sub-
stances inhaled, or accidentally passed, into the
trachea, and from several of the other causes
enumerated above (§3.). — c. It also, in some
cases, — first noticed by jMontaigne, and well de-
scribed by WnvTT, — presents a strictly iiervous
character, particularly in nervous, hysterical, and
irritable persons. — d. In those especially, and
also in feeble or delicate constitutions, a short,
frequent, and dry cough is sometimes met with,
without any disease of the lungs, air-passages, or
other organs ; and the only change that can be
detected is slight redness at the margin of the soft
palate, or in the posterior_/W»«s ; sometimes only
in tiie phanjiix ; and occasionally near the ton-
sils ; but this is not uniformly, although frequently,
observed. Here it is obvious that the irritation
of these parts extends to the glottis, or to the epi-
glottis only ; and that it is eitiier strictly local, or
connected with slight derangement of the stomach
and prima via. In the former case it is idiopathic,
in the latter symptomatic, or at least a complicated
ailment.

5. B. Dry cough is more frequently symptom-
atic— a. Of the first stage of diseases of the
larynx, trachea, and lungs; of organic changes
of the large blood-vessels of the chest ; and
sometimes of complaints of the more superior of
the abdominal viscera. — b. It is frequently oc-
casioned by elongation of the uvula, and the irri-
tation this part produces about the root of the
tongue and epiglottis. But when the uvula is
elongated, there usually is also more or less co-
existing irritation about the posterior yizufes and
pharynx, extending to the glottis or epiglottis.
And it should be, moreover, kept in view, that
these ailments are principally dependent upon,
even although they may not be always produced
by, disorder of the stomach and digestive organs
generally. — c. In many instances, also, it will
be found that the cough is owing to irritation of
the mucous surface of the stomach and xsojiliagus,
altjiough it may not extend so far as to be ap-
parent in the pharynx, or be so severe as to occa-
sion redness of this part. — d. Cough is often
produced by diseases of the liver, ditid by collections
of bile in tiie gall-bladder and hepatic ducts. In
many of such cases, the cough is severe and
spasmodic, often very obstinate and of long dur-
ation; the symptoms of hepatic disorder being
sometimes so slight as to escape detection, unless
the attention of the practitioner is awakened to
the connection; the chief indications of its exist-
ence being the loaded or furred tongue, pains
about tlie diaphragm, fulness at the epigastrium,
and indigestion. — e. Lastly, dry cough is often

occasioned, in young and delicate patients, by the
irritation of worms in the prima via. The more
particular consideration of these associations will
be found in the articles on the diseases of which
the cough is merely a symptom,

6. ii. HuniiD Couoii, — a. may follow upoa
the preceding ; or it may occur primarily from
the usual causes of catarrh. In such cases, it is
merely a slight form of that affection, the matter
expectorated being mucous or serous, and the
cough unattended by manifest febrile or con-
stitutional disturbance. This form of cough is
very liable to recur, or become chronic, m deli-
cate persons, during the winter (uinter-cough') ;
or from vicissitudes of season and weather ; and,
like the former variety, the irritation exciting- it
may be chiefly seated in the pharynx and vicinity,
or in the larynx and trachea. In many cases the
serous, or sero-mucous secretion, following the
cough, entirely proceeds from the fauces and
vicinity. — h. In old persons, however, it is se-
creted chiefly by the bronchial surface, and is
then, particularly in its more severe forms, the
affection described under the name of Bronchor-
rh'Xa. — c. Humid cough is generally less frequent,
but more prolonged, and recurs in severe par-
oxysms. It is sometimes complicated with rheum-
atism and gout. It also presents the same
pathological relations as described in connection
with the dry variety ; but it is not so often symp-
tomatic of diseases of the abdominal viscera, as
the foregoing. — d. In the old and weak, humid
cough is usually very severe, owing chiefly to the
want of vital power of the respiratory organs, and
of the system generally, to throw ofi' the mucus
secreted in the air-passages ; and which is either
very abundant, from the relaxation of the ex-
treme vessels ; or very tenacious, from absorption
of its more fluid parts, during its retention on the
surface that secreted if, or from both conjoined.
In such cases, the paroxysms of coughing are very
severe and prolonged ; and the affection is liable
to be exasperated upon every change of season
and weather. — e. In other cases of humid
cough, the exacerbations are also very severe,
particularly in the morning ; but the excretion is
thin and frothy. This is observed most frequently
in persons addicted to intoxicating beverages;
and in those debilitated by sexual indulgences.
When humid cough depends upon hepatic dis-
ease, it often assumes this form.

7. II. Treatment. — i. A.The idiopathic states
of dry cougli require demulcents, emollients, with
diaphoretics and narcotics, or anodynes (see F.
238. 244. 389. 426., and R 98. and 99. at p. 297.).
The conium, hyoscyamus, solanum, oenanthe,
and phellandrium aquaticum (Theussink and
Frank), may severally be employed, and the
functions of the abdominal viscera improved by
suitable means. But the pathological states, as
well as their causes, on which this form of cough
depends, should be investigated, and the treat-
ment modified accordingly. — a. If it follow the
impression of cold in any form, the treatment
described in the article Catarrh (§ 15.) will
be appropriate. — b. If it be produced by tiie in-
hiilation of irritating fumes, or the molecules of
either mineral, vegetable, or animal matters float-
ing in the air, the removal of the cause, and the
use of demulcents, emollients, and emetics, and
subsequently narcotics, are most to be depended

Ff 3

438

upon. — c. When it assumes a nervous character,
particularly in hysterical and delicate females, the
state of the uterine functions, and the existence of
irritation in some part of the digestive tube, or in
the sexual organs, or spinal chord, should be en-
quired after, and the treatment directed according
to the information acquired. In many such cases,
the exhibition of a gentle purgative, and after-
wards small doses of camphor, ipecacuanha, am-
monia, oxide of zinc and trisnitrate of bismuth,
hyoscyamus, extract of hop or poppy, the carbonate
of soda, &c., variously combined, will be of service.
If there be evident debility, and the cough assumes
a periodic form, the preparations of bark or of iron,
the sulphate of quinine, or gentle tonics, with
anodynes and narcotics, will be required. The
cold bath, which has been much recommended
by VVhytt, will also prove beneficial. — d. When
it proceeds from irritation of the^'awces or pharynx,
demulcents, emollients, &c., with ipecacuanha, or
with diaphoretics and anodynes, will be required.
But the greatest advantage will be derived from
the use of cooling and astringent gargles, and sto-
machic purgatives (F. 266.).

8. B. The sijmptomatic occurrence of cough must
be treated as pointed out in the articles on the
primary affections occasioning it. — a. If it be re-
ferred to the respiratory organs, the means ap-
propriate to their diseases must not be departed
from. — h. AVhen we observe elongation of the
uvula, either witii or without signs of irritation of
the pharynx, disorder of the digestive functions
may be inferred ; and, after having had recourse
to purgatives, cooling and astringent gargles,
prussic acid, and mild stomachics will be useful.
— c. The dependence of cough upon diseases of the
biiiary organs, whilst it suggests a treatment
chiefly directed to these diseases, will also indicate
the propriety of ascertaining, with as much pre-
cision as possible, their nature. If indications of
accumulated bile in the gall-bladder and he-
patic ducts are detected, calomel or blue pill,
with, or followed by, purgatives, and a course of
alteratives, taraxacum, &c. will be requisite. In
some cases, a gentle dose of either of these cholo-
gogues will produce copious discharges of morb:d
bile, and the immediate disappearance of a con-
stant, severe, dry, and harsh cough, of which
alone the patient has complained. In others,
repeated and large doses will be required to ac-
complish this object. In all these, purgatives
should be exhibited until the tongue becomes
clean. If tenderness or pain exist in the region
of the liver, with febrile symptoms towards even-
inc, or restlessness through the night, blood-let-
ting, general or local, ought to precede other
measures ; and the hepatic disease should be
treated with reference to the form it presents,
and as described in the article on Diseases of the
LivEn. — d. When the cough is attended by a
tumid abdomen, and other signs of worms, the
treatment recommended in such cases, according
to their numerous modifications, must be cm-
ployed.

9. In almost all the idiopathic and symptomatic
forms of dry cough, more advantage will be ob-
tained from demulcents than from heating or
stimulating expectorants, which should always be
laid aside when there is evident vascular excite-
ment of a sthenic or tonic kind. 'i'liosu ex-
pectorants, however, which are of a mild nature,

COUGH — Treatment of.

or which act chiefly by exciting slight nausea, will
generally be of service, particularly when com-
bined with emollients, diaphoretics, and narcotics ;
and there are few conditions, in which the pre-
parations of antimony or ipecacuanha, with liquor
ammonia; acetatis, and the warm bath, will not
be extremely beneficial. In this variety of cough,
also, appropriate medicines, exhibited in such a
manner as will favour a prolonged impression on
the palate and pharynx — as in the form of loienge
or linctus — will thereby have their effects mani-
festly promoted ; and advantage will also accrue
from wearing warm, antispasmodic, or rubefacient
plasters between the shoulders, both in this and
the humid variety of the affection.

No 160. R Confect. Ros. Canin. et Confect. Rosje Gal.
aa 3j.; Olei Amygdal. Dulc. 3 vj. ; Syrupi Papaveris
AIbi 3ss. ; Spirit. jEther. Nit. 3ij ; Acidi Sulplnir. ilil.
3jss.; Pulv. IpecaciianliEe gr. ij. M. Fiat Linctus, de
quo sumatur pauxillum subindfe.

No. 161. R Emplast. Picis Comp. part. ij. ; Emplast.
Ammoniaci (vel Emp. Ammon. cum Hydrarg.) et Em-
plast. Opii aa part. i. M. Fiat. Emplastrum perlargum
inter scapulas imponendum.

10. ii. Humid cough, when it presents the cha-
racters of slight catarrh, requires the treatment
described in that article. — a. If it frequently
recur, or become chronic, or assume the form of
winter cough, the more tonic demulcents, as the
decoction of Iceland moss, or of the sea moss,
with lemon and candy, — the misturaferri compos,
with a decoction of liquorice root, — attention to
the digestive and excreting functions, — warm
clothing, — and careful avoidance of exposures
to the vicissitudes of season or weather, — are most
to be depended upon. — b. When the cough
occurs in old persons, with increased secretion
obviously from the bronchi, gentle tonics, and ex-
pectorants, as myrrh, galbanum, assafoetida, ben-
zoin, the oxide or sulphate of zinc, the terre-
binthinates, camphor, ammonia, the balsams, and,
indeed, the whole of the treatment described in
the articles on Chronic Bronchitis (§ 91.) and
BnoNcnoRniicEAare most appropriate. — c. When
it is complicated with gout or rheumatism', purg-
atives, combined with tonics or stimulants, in
order to carry off collections of morbid bile, and
other vitiated secretions ; and afterwards the
medicines now enumerated, or the preparations of
ammonia or camphor, combined with colchicuni,
will generally afford marked relief. The depend-
ence of this variety upon the diseases already
noticed as occasioning the other form of cough,
requires the several measures pointed out with
reference to each of them (§8.). — d. If the cough
be very severe, in old and exhausted persons, and
in those who have injured their constitutions by
venereal indulgences, a tonic and stimulant
treatment, and the remedies instanced in this
paragraph in increased doses, will be requisite.
It will be found in these, as well as in broken-
dmen drunkards, that the cough will be aggravated
by remedies which in any way depress the vital
energies. In these last, the cough is frequently
connected with hepatic disease, the treatment of
which will depend upon its nature; but, although
depletion may be occasionally required for the
primary malady, the powers of life must be at the
same time supported.

11. In this variety, generally, the mild ex-
pectorants, with demulcents ; the jelly of sub-acid
iiuits ; the inhalation of emollient, stimulating,
or astringent vapours (see Bronchitis, § 76. 98.) ;

CRANIUM AND ENVELOPES — their Lesions. 439

the use of acid beverages ; warm, rubefacient, sti-
mulant, and tonic plasters ; the warm bath, made
gently stimulating by salt and mustard ; a light,
demulcent, and nutritious diet, with strict atten-
tion to the functions of the stomach and bowels ;
change of climate, or of air, and a judicious
choice of residence according to season, with
gentle but regular exercise, and warm clothing ;
are severally of advantage, and some of them of
the utmost importance. (See Bronchi, § 104.).

BiBLiOG. AND Refkr. — Femel, Consil. xxiv. — Forest,

xvi. n. 1— fi Hoist, Opera, vol.ii. p. 128. — Willis, Phar-

niacop. Ration, par. ii. sect. i. cap. 4. — Montaigne, Essais:,
1. i. cap. '20. — Bunet, Sepiilctiret. Anat. I. ii. s. iii. obs 11.

— Morgngni, De Scd. et C;ius. TVIorb. epist. xv. art. 22, '23.

— Strin, De Tussi Stomachali Humida. Argent. 1749 —
Winther, De Tussi Stomachali, &c. Marb. 1719. — Mai-
ler, De Tussi. Goet. 1749.— IVhytt, Works, 4to. p. iS'2.

— BUcliner, De Tussi Humida, &c. Halfe, 17fi3. — Finek,
De eo, quod Tussi proprium est et Communi. Bamb.
1779. — Kappelhonf, Scctiones Cadaverum Pathologica?,
p. 5. — I'ogel, Beobaclitungen, Sec. No. 7. — Portal, Anat.

Med. t. V. p. 4:5 Percival, Essays, &c. vol. i. p. 27'2. ; and

Med. and Phys. Journ. vol. iv. p. fi.'j. — Miidge, On Coughs,

^•c. 8vo. London, 1789 Doublcday, Med. Observ. and

Inquir. vol. V Douglas, Sn Ibid. vol. vi. yiAfiS. — Bell,

Duticnn'a Med. Comment, vol. xiv. p. 307. — Frank, In-
stitut. Clinica Vilnensis, ann. ii. p. 27. — Wicliiriann, \n
Loder's Journ. b. it. st. 1. p. 31. — Young, Introduct. to
Med. Literature, 8vo. p. 181. — Staitger, Trans, of Med.
and Chirurg. Soc. vol. i. p. 13. — M. Good, Study of Med.
by Cooper, 3d edit. vol. i. p. 580. — Brooke, On Liver
Cough, Trans, of Irish College of Phys. vol. iii. p. 245.

COW-POX. See Vaccination.

CRAMP. See Convulsions (§ 4.), Sp.asm,

and Tetanus.
CRANIUJM. — SvN. Kpavi'ov (from xpavoj, a
helmet, as defending the brain from injury).
Die Hirnschale, Ger. Le Crane, Fr. Cranio,
Ital. The Skull.

Classif. Pathology. — Special Pathologii
— Morbid Anatomy.

1. The cranium and its envelopes, the scalp
and the pericranium, are often the seat of diseases
which are of much moment, not only as respects
these parts themselves, but also as regards the
important organs and membranes which they
contain.

2. L Diseased Appearances of the Enve-
lopes OF THE Craniu.m. — Thesc are princi-
pally the same as are observed in analogous
structures in other parts of the body. Nearly
the same changes are remarked in the scalp, and
subjacent cellular tissue, as in the integumental
coverings of other parts ; and in tiie pericranium,
as in other parts of the periosteum. These struc-
tures, forming the envelopes of the cranium, will,
therefore, require but little remark.

3. A. The scalp is subject to the same inflam-
matory states as other parts of the body ; and
these require the attention of the physician, from
their occasional extension to the bones of the

.cranium and membranes of the brain. Liflam-
mations of the scalp vary in character with the
condition of the vital energies and digestive and
biliary organs. Sometimes this structure is the
seat of active phlegmonous injiammation, but
more generally of the erysipelatous. AVhen ery-
sipelas attacks the scalp, a copious exudation of a
serous or sero-albuminous fluid takes place in its
subjacent cellular tissue. Occasionally this tissue
is affected by inflammatory action of an unhealthy
kind, but limited in extent, and closely resem-
bling carbuncle, and of which I have met with
some cases in children. The scalp is also par-

ticularly liable to certain specific inflammations
of a chronic kind, especially to pityriasis, porrigo,
sycosis, lepra, psoriasis, eczema, rupia, and
syphilitic ulceration. I'umours, generally en-
cysted, sometimes form beneath the scalp, most
frequently between it and the tendinous expan-
sions of the occipito-frontalis, and other muscles
attached to the pericranium. These expansions,
and the muscular structure attached to them,
and perhaps occasionally the pericranium also,
are often the seat of rheumatism and rheumatic
inflammation. They are not infrequently, also,
affected by common inflammation and its con-
sequences, particularly after external injuries.
Dropsy of the cellular tissue beneath the scalp,
independently of inflammation, is very rare. It
has, however, been observed in young subjects,
and received the appellation of hydrocephalus er-
^er/nis, and xdema capitis,

4 .B. The Pericdamum is subject to the
same changes as the periosteum in other parts of
the body ; amongst these are chronic and Sj.ecific
inflammations, giving rise to thickening of the
membrane; to nodes, frequently terminating in
suppuration and exfoliation of the subjacent part
of the bone ; and, in cases still more chronic and
slight, to unnatural deposits of bone upon the
external surface of the skull. (See Periosteum
— Injiammation of.) Inflammations of an acute
or sub-acute character sometimes, also, attack
this structure, and, when not arrested in their
progress, give rise to its separation from the
bone ; and not infrequently, owing to the exten-
sion of the morbid action through the tables of
the cranial bones, to a corresponding separation
of the dura mater from the diseased part of the
skull. It seems probable that morbid action of
any kind is seldom continued long in the peri-
cranium, without the dura mater, which performs
the office of an internal periosteum, suft"erinor iu
a corresponding degree, and ultiuiately trans-
mitting the disease to the subjacent membranes,
and even to the brain itself. Specific inflamma-
tion also of this structure, of a most painful and
dangerous kind, occasioning death of the portions
of bone beneath the parts chiefly affected, is
produced by syphilis and the inordinate and pro-
longed use of mercury.

5. IL Morbid Changes IN THE Cranium. —
The bones of the cranium are subject to various
diseased appearances, many of them having a
close reference to the state of the system, and its
morbid dispositions, and still more so to those
slowly formed lesions which frequently affect
the brain and its membranes. — A. Enlargement,
or rather distension, of the bones of the cranium,
is frequently an attendant upon chronic hydro-
cephalus, and the hypertrophy of the brain some-
times accompanying rickets. When the accu-
mulation of fluid is great, and has taken place
before ossification is far advanced, this process
frequently commences at several more distinct
points than in the healthy state, thus generating
as many distinct bones. In the majority of these
cases, although the surface of the cranial bones
is greatly extended, there is a general deficiency
of the ossific deposit, rendering the skull more
than usually thin. The Museum of Guy's Hos-
pital contains the cranium of an hydrocephalic
man, who lived to the age of 29 years. Its cir-
cumference is 33§ inches. There is also in the
F f 4

440

CRANIUM — Morbid Chaxges in.

Museum of St. Thomas's, the skull of a child of
two years, that measures 29 inches.

6. B. Deficient' deposit of bone, as now re-
marked, is often connected with the foregoing-
lesion ; in which case it is commonly general, the
whole cranium being more or less thin as well as
enlarged ; but the thinness may also, although
less freqiiently, accompany a natural-sized skull.
The deficient deposit, or thinness of bone, may
also be partial. In this case, partial or cir-
cumscribed accumulatious of serum, or tumours,
generally exist beneath the part of the cranium
thus changed; and we have reason to believe that
it is to the pressure exerted by these that the
unusual thinness is to be imputed. It should,
however, be kept in recollection that the cranial
bones vary exceedingly in thickness, without
having seemingly diverged from the healthy state.

7. C. Imperfect ossification is chiefly a lesion
of early age, being merely a slow or impeded
developement of the bones, arising from one or
both of the following causes : — a. From deficient
powers of the constitution, in which the process
of ossification either generally or locally in re-
spect of the cranium participates ; b. From the
distension arising from the accumulation of fluid.
The imperfect ossification in such cases may con-
tinue to the age of three, four, or five years, and
generally consists merely of a more than usual
openness of the sutures, or a deficient deposit of
bone at the parts most remote from the centres
from which the ossific process proceeds. In
.some cases, however, the imperfection exists in
about the middle of one of the bones ; a patch of
membrane, or a narrow stripe being surrounded
by bone. When these patches or clefts in the
bone are considerable, or remain for any time
unfilled up, a portion of the membranes often
protrude, forming large watery tumours, owing to
the pressure of fluid eflTused between or under-
neath the membranes, — a circumstance which
occasionally obtains. An interesting case of this
description, successfully treated by ligature, has
been recorded by Mr. E. Thompson. The ma-
jority of these cases are congenital, but the pro-
trusion is often not noticed until long subsequent
to birth. Sometimes a portion of the brain itself
protrudes, forming a congenital hernia cerebri.

8. D, The bones of the cranium may be
insufficiently evolved. In tiiis case they are
generally formed with more than sufficient ra-
pidity, and their sutures are closed prema-
turely, so that they cannot give way before the
growing brain, which thus becomes, with the
case enclosing it, imperfectly evolved. The
cranium may thus appear unnnturally small, as
is sometimes observed in idiots and epileptics ;
but this state may arise not only from early
closing of tlie sutures, but also from imperfect
developement of the brain itself. Microcephalia
was considered by IIippocrates as a cause of
idiotcy ; and facts, showing that great diminution
of the size of the head is very generally con-
nected with weakness or privation of intellect,
have been adduced by Ghidinc, (jam., Si'uiiz-
iiKiM, Gkorgk']-, and many others not believers
in the doctrine of Gai.t,.

f). E. The sliape of the cranium is often some-
wliiit changed by these and other causes. Wiien
the cranium is much tlefiormed, it is more com-
monly a congenital vice arising either from the

pressure in utero of a deformed pelvis, pelvic
tumours, &c. ; or from deficient developement,
early disease of the embryo, and monstrosity ; or
from congenital change of the structures which
it contains. But deformity of the cranium may
also take place after birth, from deficient or irre-
gular developement .of the brain, or from the
eflfusion of fluids in the cranial cavity. The early
closing, also, of some sutures, and the protracted
closing of others, whereby the yielding of the'
bones is prevented in one part, and facilitated in
others, are often productive of deformity. Rickets,
dropsy of the brain, softening of some of the
bones, particularly of the base, whereby it is
thrust tip into the cavity (Otto), cretinism,
&c., are all often productive of deformity. A
species of deformity has several times come be-
fore me, and generally attended by epilepsy, and
idiotcy, which I have seldom seen noticed. This
consists of qbliquitii in the halves of the cranium ;
one half being much more depressed, both at the
top and base of the skull, than the other. This
deformity is sometimes thus simple, consisting
only of comparative elevation and depression of
the sides of the cranium. But I have observed
it more commonly connected with an equal
obliquity posteriorly and anteriorly ; the elevated
or depressed half either receding or advancing
much more than the other. In cases of this de-
scription, the cranium has also presented a certain
angular form, so that I have been led to de-
nominate the appearance, the diamond-shaped
obliquity or deformity of the skull.

10. F. Hypertrophxi , thickening or enlarge-'
ment of the bones, assumes two principal forms.
1st, Tliat of a superabundant deposit of the ossific
matter, giving rise to uncommon density, and to
the disappearance of the diploe, and converting
both tables of the skull into one dense bone,
resembling, but much harder than, ivory. Tliis
appearance of the cranial bones is almost na-
tural to the negro. It is observed, also, in per-
sons advanced in life, who have been 'subjected
to laborious employments, physical and mental ;
and it is often seen in epileptics, in maniacal epi-
leptics, and in some who have been long insane.
It may or may not be accompanied with increased
thickness of the bone. Greding found the skull
too thick in 151 out of 196 insane persons;
and Georget observed it one twentieth and up-
wards too thick in 430 out of 500, belonging to
the same class of patients. The second form of en-
largement is rather the result of a loose or spongy
formation of the bones, in which, although most
remarkable in the diploe, both tables of the bone
often participate more of less. In this form, the
actual quantity of bony matter is not much
augmented. Increased thickness of the bone
generally obtains here, and sometimes reaches an
enormous extent, and closely resembles in ap-
pearance a piece of pumice stone.

11. G. Irresrnlar deposits of ossific mailer are
very frequently observed on both the internal and
external surfaces of the cranial bones, particularly
the former. '1 hey are often found adjoining
the sutures, sometimes with a mammilaled ap-
pearance on the external surface. On the internal
surface, they frequently assume an irregular bo-
tryoidal form ; sometimes they present large
masses, particularly on the frontal bone, and
encroach considerably upon the cavity. Not

CRETINISM.

441

infrequently these deposits are prolonged into the
form of irregular processes : occasionally the pro-
longation is in the seat of particular parts or pro-
cesses, as in the clinoid process. These exostoses
are sometimes very prominent and acute. In
some instances they encroach upon the foramina
through which the nerves and vessels pass. In
these cases, symptoms of pressure or of irritation
are present, and vary according to the seat, form,
. and extent of the ossific deposit. Epilepsy, in-
sanity, irregular convulsions, spasmodic contrac-
tions, and neuralgia, are amongst the most pro-
minent effects of these productions.

12. H. Vascular engorerement \s sometimes ob-
served in the cancellated structure forming the
diploe, in cases where great congestion, or very
active inflammation, has existed in the head, mem-
branes, or pericranium ; the vessels passing from
or into the bone being congested, and the diploe
of a deep or purplish red colour.

13. /. A softened state of the diploe is not
infrequently observed in cases where active in-
flammation has affected the pericranium, or dura

•mater, and extended to the bone. In these cases
the tables of the bone are more friable than
natural. A similar appearance is also observed
when the system has been much contanMnated by
carcinomatous disease.

14. K. Ulceration of the cranial bones is also
upt uncommon ; and is generally attended with
more or less absorption, exfoliation, and the de-

' posit of irregular bony spiculae. I'lceration and
absorption result very frequently from lupus, and
tjie formation of bony spiculae generally attends
upon osteosarcoma.

15. L. Caries, or death, of the bone is not in-
frequently observed to follow upon inflammation
extending from the pericranium, or dura mater, to
the bony structure. It is a very common con-
sequence of inflammation of the ear long neglect-
ed, or imperfectly treated. It may be limited to
either of the plates, or it may extend to the whole

' thickness of the bone. In either case, the dead
pait is detached from the living by the absorption
which takes place around it, and in the surround-
ing inflamed and ulcerated parts. Owing to this
process, a distinct line of separation is frequently

.formed, and tlie dead portion is completely ex-
foliated. While the dead bone is being removed in

~ tliis manner, or after its removal, if the dura mater,
which acts as the periosteum of the internal table,
is hot destroyed, new bone is deposited, and thus
the mischief is often repaired. — I have met with
two such cases in children.

16. M. Fungus cranii, or medullary sarcoma
of the bones of the skull, is occasionally observed.
Is has been described as occurring on the top of
the cranium by Crell, Sandifort, Wisiiart,
AuERCROMuiE, Landmanx, and Otto. A dis-
tinct tumour is often produced by it on the in-
ternal as well as the external surface of the skull,
— the part forming a spongy growth. It is more
rarely met with about the base of the cranium.
It may originate in the bones, or their internal or
external periosteum ; but, in whichever of these
it may commence, it soon involves tliera all.
AVhen originating in the bones, it usually assumes
the characters of osteosarcoma, and those of fungus
when it commences in the pericranium or the dura
mater.

17. N. Perforations of the cranial bones are

also observed, generally as a consequence of the
pressure of internal tumours, of an encysted,
scrofulous, or fungoid description, attached to the
membranes underneath, or of aneurisrtis, .kc.
Cases of this description are recorded by Pal-
LETTA, Le Clerc, llicjiTER, Pelletan, and
Otto. After artificial perforations of the skull, as
after trephining, and fractures with loss of bone,
osseous matter is sometimes regenerated, radiating
from the surrounding divided surface of bone.
The exuberant formation of ossific matter after
fractures of the cranium is sometimes productive of
serious efl^ects. (See^ll.)

18. 0. Depressions and fractures require litllc
notice further than that they are the most fre((uent
causes of inflammation, and its consequences in
the surrounding membranes, and contained or-
gans, and of irregular bony depositions. De-
pression of the superior and lateral bones of the
skull may take place in early age to a very great
extent, and remain through life, without affectino-
the mental manifestations. Several instances of
this have come before me, in some of wiiich the
depression was fully larger and deeper than the
bowl of a large table-spoon. One of my earliest
and most talented friends has a depression to this
extent in one of the parietal bones, from an ac-
cident in childhood.

BiBLioG. AND Refer. — ie C/erc, in Hallcr's Biblioth.
Chirurg. t. i. p. 469. — Kavfmann, De Tutnore Capitis
Fungoso, &c. Helmst. 1743. — Sandi/ort's Exercitat.
Acad. I. ii. t. 3. — Siebold, in Arnemnnn's Magazin fiir
die Wundarzneiwiss. Got. 179?, vol. i. part iv. p. 389. —
Cheston Browne, in Philosoph. Transac. vol. Ixx. p. 323.
— Home, Trans, for Improvement of Med. and Surg.
Knowledge, vol. iii. — Sand/fort, Observ. Anatom. Pa-
thol. 1. iii. cap. 9. t. 9., et I. iv. cap. 10. ; et Museum
Anatom. vol. ii. t. 61,62. — Blumenbach, De Anomalis et
Vitiosis quibusdam nisus formativi Aberrationibus Com-
ment, p. 17. — Esquirol, in Diet, des Scien. Mid. t. xxiii.
p. 521. — Georget, De la Folie, &c. Paris, 1820, p. 478.
— J.aiid7nxmn,Commeni. Patholog. Anatom. &c.4to. Lips.
1820. — Pine/, Sur les Vices de Conformation du Crane
dcs Alienes ; in Bullet, de la Socict. Philomath. Ann.
t. iv. p. 103 — 109. — ll'cnxel, Ueber den Cretenismus.
Wien. ISfB. — Baillic, Engravings, &c. fasc. x. — J. p.
Frank, Opiiscula Posthuma, p. 102. t. 4 — 6. 8vo. Vien.
1824. — Krebel, De Anatomia Patholog. Ossium Capitis,
8vo. Halje, 1823. — Otto, Verzeichniss der Breslauer
Anat. Prikparatensamlung, No. 163. 165. 210. 3057. 3068.
8046. &c. — Palletta, Exercitat.- Patholog. vol. i. p. 127.—
Abercrontbie, Path, and Pract. Researches on Diseases of
the Brain, &c. 'EAm. W2S. — Bright, Medical Reports,
SiC. t. ii. p. 686, &c. — Cruveilhier, Anatomie Pathologiquc.
Levr. 8vo. Paris, 1830, fol. — BalHngall and Russet, in
Transact, of Med. and Chirurg. Soc. of Edin. vol. i. ]>. 68.
74. — E. Thompson, in Lond. Med. Kepos. vol. xxii. p. ooo.
{Very ititeresting.) — (See also Art. Cranium, m Plonc~
qtiet'i Med. Digesta ; and in Olio's Lehrbuch der Pathol.
Anat. des Menschen, &c. Berl. 1830.)

CRETINISM. — Syn. Cugots, Struma Tyro-
lensium, Gautier. Cretin, Cretinisme, Ft.
Classif. — 6. Class, 1. Order (Good).
I. Class, IV. Order (Author),

1. Defin. — Imperfect formation or develope-
ment of the cranium, and the whole of the body,
witli mental imbecility, and physical imperfection ,
varying chieflii in degree.

2. This state of imperfect physical and mental
developement, rather than of diseased action, was
first noticed by Plater among the poor of Ca-
rinthia and the Valais, where, and in the valleys
of the lower Alps and Switzerland, it is endemic.
But it is not peculiar to these places ; for it has
been observed in the valleys of the Pyrenees by
Raymond, in some parts of Salzbourg by Kxolz,
and in various other localities in the central and
southern countries of Europe, as well as in
Chinese Tartary, according to Sir G. Staunton.

442

]M. De Saussure, Ackermann, Fodere, Iphof,
Erhard, the Wenzels, and Knolz, have given
us the best description of this state of mental
and bodily deformity, in respect both of its na-
ture and cause>;. Tlie brief account of it by Dr.
Good is both imperfect and erroneous, and must
have been written in perfect ignorance of the de-
scriptions of the above eminent observers, as well
as of others deserving of perusal. lie very inaccu-
rately associates it with bronchocele on the one
hand, and with rachitis on the other, with the
former of which it is not necessarily, although very
frequently, connected, and from the latter it is
totally distinct.

3. I. Description. — Cretinism presents va-
rious modifications in kind, and every inter-
mediate grade between that extreme degree of
physical and mental debasement which is cha-
racterised by the utmost deformity and entire
absence of mental manifestation, the organic or
vegetative functions only being performed, and
tliat condition which may be considered as very
nearly approaching the healthy constitution of
man. There are certain circumstances which
distinguish cretins from other idiots, viz. a. They
present certain bodily deformities, which are sel-
dom or never observed in other idiots ; and, b.
Their physical and mental infirmities are always
the result of endemic causes.

4. In general, some degree of goitre is attend-
ant on cretinism, but not invariably. Professor
Knolz states, that it is sometimes absent, and
occasionally slight, the thyroid gland being en-
larged in no greater proportion than several other
glands are in the same subject. The stature is
seldom above four feet and a half, often much
less ; the cranium is deformed and has a conical
shape — the forehead being thrown backwards,
narrowed, and flattened, and tlie occiput being
nearly on a line with the neck ; the flesh is soft
and flaccid ; the skin wrinkled, yellowish, or
pale and cadaverous, dirty, and covered by
chronic eruptions ; the tongue is thick, and hang-
ing out of the mouth, which is open, large,
and slavering; the lower jaw is elongated and
prominent; the eyelids are thick, the eyes red,
small, but prominent, watery, and frequently
squinting; the nose is flat ; and the whole coun-
tenance is idiotic or expressive only of lascivious-
ness. The belly is large and pendulous ; the
neck either short and thick, or long and thin ; the
limbs crooked, short, distorted, &c. ; and tlie gait
imperfect and waddling. 'I'he senses are more
or less defective, or altogether abolished ; the
cretin being often deaf and dumb, and those who
possess the faculty of speech expressing them-
selves imperfectly and with difficulty. The in-
tellectual functions are cither entirely absent or
imperfectly developed, whilst the organic or
vegetative functions are in a state of increased
activity: cretins being voracious, lascivious, and
addicted to masturbation. They appear to have
no oilier enjoyment than eating and sleeping ; and
their insensibility is often so great that they obey
not the calls of nature. In some instances, the
bodily deformity is not so remarkable as that now
described; imbecility, fiacoidily of the soft solids,
with bronchocele, constituting the extent of in-
firmity.*

• The followiriK account of the " Feres," or cretins of
Salzbourg, is abridged from that given by Trofessor

CRETINISM — Description of.

5. The cretin, like most idiots, seldom attains
an advanced age; indeed, few of them reach up-
wards of thirty years. Clayton remarks, that
although they die early, they soon present the
appearance of age. They are usually of the
lymphatic temperament, with light hair and grey
eyes ; the female cretin having enormously large
and pendulous breasts. The less debased among
them marry, rarely with one another, but do not
propagate cretinism, the predisposition only to it
being derived by the oflfepring from the parents.
Malacarne (Mem. de I'Acad. de Turin) attri-
butes the mental debasement to the contraction
of the bones of the cranium, which prevents the
cerebral organs from acquiring their natural
dimensions and functions ; and Ackermann
espouses a nearly similar opinion. The con-
formation of the body is generally stated not to
be congenita], although, at birth, the cretin may
appear weak, puny, or sickly. It usually comes
on gradually from birth ; and M. De Saussore
states, that children who, living in the localities
where it is endemic, and are not affected at eight
or ten years, generally escape it ; and that infants
who are brought into these districts at a very
early age, are equally subject to it with those
who are born in them.

Knolz : — The whole body is stunted, its height not ex-
ceeding four feet. Tliei"e is a total want of due proportion
between its different parts : the height of the head, with
reference to the rest of the body, being 1-lth or 1-Gth, in-
stead of l-Sth, the natural proportion. The neck is strong,
and bent downwards. The mamm^ are very voluminous
and pendent; the upper limbs reach below the knees;
the arm is shorter than the fore-arm ; the chest narrow ;
the abdomen hemispherical, and of a length not exceed-
ing the height of the head ; the penis and scrotum come
down to the knees ; the thighs are, with the haunches, of a
greater width than the shoulders, and are shorter than the
legs, the calves being almost wanting; the foot is small, and
the toes partly distorted; the lower extremities are shorter
than the upper half of the body. In tlie head, the mas-
ticating organs, the lower jaw, and the nose, preponderate
consideralily over the organs of sense and intelligence.
The skull is depressed, and forms a lengthened and angu-
lar ellipsis ; the receding forehead presents, internally,
large frontal sinuses, to which the brain has yielded apart
of its place ; the top of the head is not vaulted, but flat-
tened ; the occiput projects but slightly, and runs almost
even with the nape of the neck, as in ruminating ani.
mals. The face is neither oval nor round, but spread out
in width ; the parts of which it is composed being wide
and short, and the maxillary bones projecting greatly.
The forehead is narrow, flattened, and low ; the eyes are
unusually far ajiart, diverge slightly, and are small, and
seated deep in the orbit ; the pupil is contracted, and not
very sensitive to light; their external angles arc situated
higiier than the internal; the eyelids, unless when drop-
sically swollen, are flaccid and pendent ; the look is a
fixed stare without expression, and turns with indiffer-
ence from all that is not eatable. The root of the nose is
widened and depressed, the bones of the nose square ; the
zygomatic bones are wide, and extremely projecting :
the external ear is large, stands out from the head, and
hearing is very defective. The elongated form of the
lower jaw of the cretins, and their thick and padded lips,
make them resemble ruminating creatures more nearly
than man. 'I'he tongue is thick, and rather cylindrical
than flat ; the saliva is continually running from the
angles of the mouth. Enlargement of the thyroid gland
is recognised as one of the signs of cretinism ; but its size
is no sure guide to the extent of the existing infirmity.
The throat jnesents, also, other obstructed glands. The
thorax is generally narrow and flat ; the abdomen is
usually distended with gases, and largely developed to-
wards the chest ; the flesh of the extremities is flabby ;
the knee of an irregular shape, and usually bent ; the
fingers are very long and lank, and the nails very small.
The upper part of the vertebral column licing directed
more or less forward, and the lower part, with the basin,
being pushed backward, the sacrum assumes a more ho-
rizontal, and the other pelvic bones a more vertical
position, than in the healthy formation. Besides the
masticating and digestive organs, those of generation are
also strongly developed, especially in the male. (Mn/ecin.
Jarhuckcr lies li. It. Mslcrr. Stnatcs, b. i. st. 1. 1829, p. S6.)

CRISIS

6. II. Causes. — The principal, if not the
only, cause of cretinism is dwelling, during in-
fancy and childhood, in deep, narrow, moist, and
malarious valleys, situated at a lower level than
3000 feet above the ocean, where the air is
stagnant, and tiie solar beams intercepted by the
mountains. ftllM. Ferrus, Georget, and the
authors already referred to, state, that cretins
become numerous in proportion as the valleys
sink below this elevation. In addition to those
causes, may be added the poverty, ill-feeding,
drunkenness, indolence, dirtiness, sensuality, and
low debauchery of the parents, — circumstances
tending to the production of an infirm and de-
formed offspring ; the inactivity and filth into
which children who begin to evince signs of
cretinism are allowed to sink, and the influence
of water holding calcareous and other mineral
substances in solution. ]Mi\l. De Saussure
and FoDERE, however, deny tiiat the water is
concerned in the production of this infirmity ; but
MM. Bally and Rambuteau show that much
is owing to it in the causation of cretinism, as well
as Broxchocele (see that article). I'he last
named authority states that the offspring of the
natives of Valais, who intermarry with persons
from the Italian side of the Alps, are more subject
to cretinism than those born of native parents ;
that females who have husbands from the higlier
Alps seldom have children aflected by this in-
firmity ; that wherever cretins are seen, goitre is
also prevalent ; but that the latter is found in
places where the former does not exist; and,
consequently, that the same causes that occasion
goitre, when present in an intense degree, also
produce cretinism.

7. III. The Treatment of this infirmity is
necessarily preventive rather than curative, and
consists of the amelioration of the physical and
moral condition of the parents ; of the removal
of infants, as soon as signs of the malady manifest
themselves, to more elevated and open localities,
and to mountainous districts, to enjoy a purer air
and stronger light; of obliging them to exert
themselves in some useful and suitable employ-
ment, and to pay attention to personal cleanli-
ness ; of frequent ablutions, followed by active
and stimulating frictions of the whole surface
of the body ; of the use of stimulating tonics
(Eruard); and of allowing them a stimulating
and strengthening diet, with a large proportion
of animal food. Josias Simler, who wrote in
1574, states that the malformation, constituting
the physical infirmity, is sometimes congenital ;
and probably it is so occasionally. In such cases,
it is not likely that much advantage will accrue
from any means. JM. Rambuteau, however,
states that it is scarcely ever congenital ; but it is
not unlikely that experienced observers may pre-
dicate, from the appearance of the newly born in-
fant, whether or not it is likely to become the
subject of this dreadful infirmity — may observe
that state of developement and formation, which,
if not actually the incipient malady, is predis-
ponent to its occurrence.

443-

Iphof, De Cretenismo. Viteb. 180-t. — Michaelis, in Blu-

menbach's Biblioth. b. iii. p. fi+0 I'irey, in I)ict. Sciciic.

Med. t. vii. p. 3\o. — Georget, Diet, de INIedeciiie, t, vii.
p. 184. — Hambuteau, in Ibid. t. vi. p. ISfi. — F. Sensbnrg,

Der Cretinisinus, 8vo. Wurzbourg, 182j C. Loiidc,

Diet, de Med. Prat. t. v. p. 550. — J. J. Knolz, in Bulletin

des Scien. Med. t. xxi. 18.30, p. Si'O J. Johnson, Change

of Air, or tlie Pursuit of Health ; being an Excur.sion
throuph France, Switzerland, and Italy, &c. 8vo. Lond.
18j1, p.56.

BiBLio<;. AND Refer Storr, Alpeureise A'orborei.

tung, par. Iv. — De Smtssure, Voyage dans les Alpes.
Gendv. 17SG. — Clayton, in Mem. ot the Lit. and Philos.

Soc. of Manchester, 1790, vol viii. art. 13 Ackermann,

Uel)cr die Kretinen, &c. Gotha, 1790, 8vo. — Fodiri, Sur

le Goitre et le Crttinisrae, 8vo. Turin, 1792 Erhaid,

in Hufeland'a Journ. der Pract. Heilk. b. xiv. st. 2. p. 80.
—J. et C. Wenzel, Ucber den Cretinismus, Vien. 1802

CRISIS. — SvN. KpiVt?, a judgment or decision
(from HpiW, I judge or determine). Judicium,
Jiidicatio, Lat. Entsclteiduiig der Krankheit,
Ger. Crise, Fr. Ciisi, Ital.
Classif, — Prognosis.

1. Crisis may be defined a sudden change dur-
ing the height of a disease, tending either to re-
covery or to death. Critical changes have been
much regarded in the prognosis and treatment of
diseases, from the time of Hippocrates, who first
mentioned them, and the days on which they
occur, down to the present period. Asclepiades,
and the methodists, however, denied their in-
fluence, and disputed the existence of critical
days. Galen and his followers attached great
importance to them. It is recorded, that, having
been called to a patient — a young man — with two
disciples of Themison, Galen prognosticated a
favourable change by a critical haemorrhage. The
opinion was ridiculed by the two methodists, who
advised blood-letting ; but it was soon verified,
for the patient had a copious epistaxis, after which
he recoveied. It is unnecessary to allude to the
writers who have contended for the importance of
tliis subject : they comprise most of the eminent
names in medicine, from Hippocrates to Cullen,
PiNEL, Frank, Hildenbrand, and Krevssig.
The titles of many hundred volumes that have
been written upon it might be adduced in proof of
the consideration attached to it : and although
much more has been imputed to critical evacu-
ations, and days, particularly by the humoral
pathologists, than legitimately belongs to them,
and granting that too devoted an attention to
them has induced many to adopt injudicious in-
dications, and weak measures of cure, yet some
reputation will be acquired' from the prognosis
which an acquaintance with them will enable the
physician to give ; and much benefit will result to
the patient from the treatment which this know-
ledge will suggest.

2. Since the overturn of the humoral pathology,
the doctrine of critical evacuations has undeserv-
edly fallen into disrepute, although the eminent
writers who contributed most to the overthrow
are amongst its most rational and warm espousers.
In our own country, at the present time, too little
attention is paid to these evacuations, and still
less to the periods at which they occur. There
can be no doubt that the former is the most im-
portant ; but the latter part of the subject should
not be disregarded. Alter all that has been urged
in favour of, or in opposition to, the doctrine, I may
conclude that, in temperate climates, a number
of diseases, particularly fevers, run on for certain
periods with regularity, and, after an exasperation
of the symptoms, or some violent perturbation of
the economy, terminate by evacuations of different
kinds, which tend to remove the train of morbid
actions, and to restore the healthy functions. In
other cases, the exasperation of disorder is fol-
lowed by imperfect evacuations, occurring in an
irregular manner ; whilst in some it gives rise to

444

CRISES — DEscniPTioN of.

additional phenomena of a dangerous or fatal cha-
racter : hence crises have been denominated sa-
lutary and complete, imperfect and fatal. It was
considered by the older writers requisite to a sa-
lutary crisis, that the evacuations constituting it
should be attended by favourable symptoms, and
be copious and manifest ; and not only appropriate
to the disease, but also consistent with the state of
the patient. An imperfect crisis was considered
belter or worse: the better state alleviating the
malady; the worse rendering it more severe and
dangerous, from the supervention of metastases
and complications. Having described the phe-
nomena which are critical, I shall next notice tlie
periods of disease at which they are most frequently
observed.

3. I. Crises manifest themselves, — 1st. On the
SKIN : ^1. by sweats ; B. by acute or chronic erup-
tions. 2d. In the cellular tissue: A, by
swellings in various parts ; ^. by boils and car-
buncles ; C. by gangrene ; and D. by purulent col-
lections. 3d. In the glands : B, by buboes ; B.
by swelling of the parotids ; C. by salivation ; D.
by a flux of urine. 4th. On the mucous suu-
FACES : A. by increased excretion — a. from the
nose; b. from the bronchi, &c. ; c. from the sto-
mach (vomiting) ; d. from the bowels (diarrhoea) ;
B. by sanguineous exhalation — a. by flux — a. the
haemorrhoidal ; /3. the menstrual; b. by hasmor-
rhagy ; a. from the nose (epistaxis) ; /3. from the
bronchi (haemoptysis) ; y. from the stomach
(haematemesis) ; J', from the intestines; e. from
the uterus (menorrhagia) ; ?. from the urinary
organs (hsmaturia).

4. 1st. A. Sweats are salutary crises in continued
and bilious fevers, in inflammations of the lungs
and liver, in bronchitis, and less frequently in
rheumatism. Fracastori describes an epidemic
putrid fever which generally terminated favourably
in this manner. Acute dropsy, particularly ana-
sarca, when caused by interrupted perspiration,
sometimes disappears after copious sweats. This
evacuation is usually preceded and indicated by a
soft, full, open puUe ; by a diminution of the al-
vine evacuations ; by softness, and occasionally
slight itching, of the skin ; and by increased colour
of the cheeks, A salutary sweat should be dis-
tinguished from such as are limited to the fore-
head or face, and the neck or breast, whilst the
rest of the body is dry ; or those which cover only
the lower extremities : these constitute merely
partial or incomplete crises, and merely diminish
the violence of disease.

5. B. Eruptions. — Miliary and vesicular erup-
tions only are critical : the others are merely
symptomatic, or even from a part of the disease;
as erysipelas, purpura, petechia;, &c. A miliary
eruption is favourable, if the symptoms subside,
if the patient feels an itching or pricking, if they
be general, and do not appear before the seventh
day: if they be unattended by fulness of the sur-
face ; and if their subsidence be followed by vomit-
ings, hiccup, or convulsions, they indicate a fatal
termination (Landrk-Beauvais). Sometimes a
miliary eruption comes out at diflcrent periods,
and prolongs the disease, when partial relief fol-
lows it, each appearance being an incomplete
crisis. Many chronic eruptions may not only I)e
complications of visceral disease, but occasionally
imperfect crises, — they alleviating the internal ma-
lady. They arc more rarely completely salutary.

6. 2d. A. Swellings of various parts, as of the
face or neck, the hands, the lower extremities,
&c., have been considered as partial crises in ataxic
and gastric fevers, and in exanthematous diseases. —
jB, Boils are critical in some complaints, par-
ticularly towards the termination of acute diseases,
especially small-pox. — C. Gangrenous pustules or
anthrax occur in malignant or pestilential fevers ;
gangrenous escars also are met with in similar
cases, as well as in typhoid or adynamic fevers ;
particularly about the sacrum, and in places
which have been blistered, or pressed upon. If,
in such cases, the febrile symptoms subside upon
the sphacelation, and if the gangrenous change
be rapidly and distinctly circumscribed, it may be
favourably critical ; but if the symptoms continue,
and the pulse becomes more frequent, weak,
small, and soft, the local mischief is entirely symp-
tomatic, and indicative of an unfavourable ter-
mination.— D. Purulent collections are indicated
by the continuance of the disease without any
considerable evacuation, or exhaustion; by a sense
of chill, horripilation or rigor, occurring at inter-
vals, without any manifest cause ; by the dis-
charge of much clear urine ; by partial sweats ;
by a softness of the pulse; by a remittent or hec-
tic fever, and by flabbiness of the soft solids. The
favourable changes of this nature occur in the
extremities, and suppurate easily and rapidly.
Those that are unfavourable take place in some
internal viscus.

7. 3d, A. Buboes chiefly belong to pestilential
fevers; but they are occasionally observed in the
adynamic fevers of temperate climates. They in-
dicate a favourable or fatal crisis in the manner
s'ated with respect to gangrenous escars. — B.
Sicellings of the parotids occur in low or malignant
fevers ; and appear either alone, or with other
critical changes. They are commonly preceded
by a slight rigor; by severe headach, stupor,
noises in the ears, and deafness, with paleness,
swelling, and sometimes redness of tiie coun-
tenance. Tills occurrence is rarely critical, and,
of itself, furnishes no sure indication of the issue :
if accompanied with favourable changes, it be-
comes an additional sign of returning health ; but
if the swelling is slow, or disappears in a very
short time, the other symptoms still continuing,
it is a dangerous circumstance. — C. Salivation
was noticed by Sydenham as a principal critical
evacuation in the fevers of 1667 and 1668; and
it occurred in the epidemic that prevailed at
Breslaw in 1700. It occasionally supervenes in
some forms of cynanche,and in bilious and gastric
fevers. — D. The urine is sometimes discharged
copiously at the height of febrile and inflammatory
diseases ; and is to be viewed as a favourable
occurrence. It is usually clear when recently
evacuated, but deposits soon afterwards a whitish
or rose-coloured sediment. The symptoms indi-
cating this discharge are very obscure. Some
authors have noticed the " pulsus 7niiurus," whicli
consists of every three or four successive puls-
ations being progressively diminished. A sense of
weight below the hypochondria ; of gravative
tension in the hypogastrium, and of heat in the
urinary organs, is stated by M. Landre-Beauvais
to precede this evacuation.

8. 4th. A. n. CVci/srt, or sero-mucous excretion
from the nose, is sometimes critical in continued
fevers; but little importance is to be attached to

CRISES — Description of.

445

it. — 6, Mucous excretion from tlie 6?-o«c/i( is fre-
quently a partial ciisis in several fevers, and in
inflammations of the thoracic viscera (see Buonchi
and Ia'ngs). — c. Fi)»!ii(»os are rarely indications
of a perfect crisis; they occasionally, however,
favour the devclopement of those changes which
precede a favourable termination of disease. They
are sometimes ushered in by a bitter taste in the
mouth, yellowish fur on the tongue, suborbitar
pain, and headach, nausea, salivation, coldness
of the extremities ; and frequency, and occasion-
ally intermissions, of the pulse. — </. Diarrhira and
copious alvine evacuations are favourable crises in
nearly all acute, and even in some chronic dis-
eases. But it is necessary that they should be fa:-
culent or bilious, and homogeneous — not watery
or flocculent : if they approach to a natural, or
have a yellowish brown colour, and are followed
by abatement of fever, &c., a favourable crisis
may be confidently looked for. The chronic dis-
eases, in which they indicate a change tending to
health, are congestions and inflammations of the
liver and spleen, hypochondriasis and melancholy,
slight or incipient dropsies, rheumatism, and gout.
They are usually preceded bif borborygmi, with
slight flatulent distension of the abdomen ; flatu- ]
lence and eructation ; a sense of tension and I
uneasiness in the lumbar region ; flying pains in
the extremities ; and a developed but unequal
pulse, occasionally with irregular intermissions.

9. B. Sanguineous ejhalatio7is are ohexicnUcaXm
the more inflammatory states of fever, and in the
phlegmasia;. Accordmg to Hoitmann and Lan-
dre-Beauvais, discharges of blood from the nose,
the hemorrhoidal vessels, or the uterus, are equally
salutary in ardent fevers. In general, these
haemorrhages are preceded by depression of the
morbid temperature, and erethism of the skin ;
by slight horripilations of the limbs; by a more
open and lebounding pulse ; and a sense of heat,
pruritus, and tickling, in the part whence the
evacuation is about to proceed. — a. The menstrual
Jinx is sometimes a rapid crisis in fevers and
phlegmasiae. It is indicated by dull heavy pains
in the loins, groins, and tops of the thighs ; by
tension in the hypogastrium ; heat and pruritus
of the genitals ; pallor of the face, and a dark
circle round the eyes ; swelling of the breasts ;
pale, scanty urine ; honipilation, and erithism of
the skin ; and by a quick, sharp, and unequal
pulse. Very frequently the menses appear at
the regular period, or a little earlier, or later, in
fevers and inflammations, without affording any,
or but imperfect relief. In these cases, they
should not paralyse the activity of the treatment.
When they occur at or before the usual time, are
abundant, and are attended by evident benefit,
they should be considered as critical : but if they
are delayed, or are difficult or scanty, they are
imperfect crises, and should not interfere with
the measures which the circumstances of the case
may require. — b. The hiBmorrhoidal Jiux is often
critical in inflammatory fever, pneumonia, hepa-
titis, and other phlegmasia?. Stahl states that
a return of this discharge is sometimes favourable
in inflammations of the brain, and particularly in
hepatitis, nephritis, melancholia, hypochondriasis,
and mania. The observation is certainly correct.
This evacuation is indicated by pains in the loins
and the groins ; by a sense of uneasiness and
pressure towards the anus and perineum ; by fre-

quent desire to pass the urine and go to stool ; by
flatulence and borborygmi, slight pallor of the
face, and fulness of the hypochondria ; and
by fulness and inequality of the pulse as to
strength. — c. Critical epistuxis was considered of
great importance by the older physicians, who
paid much attention to the symptoms indicating
its accession : these are, redness, witlt slight tume-
faction of the face and eyes ; reddish or brilliant
objects floating before the eyes ; the involuntary
shedding of tears ; weight of the temples, and
beating of their arteries ; deafness, or noises in
the ears; slight delirium, or vertigo ; a sense of
tension in the neck, with distension of its veins ;
a dull pain in the forehead, and at the root of the
nose, or an itching and tickling in the nostrils ;
a quick, hard, full, and an unequal pulse; fre-
quent and slightly laborious respiration ; some-
times with tension or oppression, without pain,
at the prajcordia. Occasionally, pallor, and con-
striction of the whole surface, coldness of the
lower extremities, and horripilations, also jjrererfe
a critical epistaxis. This crisis is most common
in young persons, and adults whose vital energies
have been previously unimpaired, and who have
been subject to this evacuation. It occurs most
frequently in summer and autumn ; in the more
inffammatory states of fever ; in the acute phleg-
masia affecting the super-diaphragmatic organs ;
and rarely in hepatitis. If the discharge consists
of a few drops only, it is an alarming symptom ;
and although it be copious, if not soon followed
by amendment, it is unfavourable. When ex-
cessive, and attended by syncope, convulsions,
loss of power, partial or cold sweats, and cold ex-
tremities, it is a fatal sign. A syncope, however,
which terminates the epistaxis, is often followed
by recovery (LakdreBeauvais) .

10. d. Hctmoptiisis, h<ematemesis, hematuria,
and intestinal h<jcinorrhagy, are always false or un-
favourable crises. They are generally preceded
by tension and tenderness of the hypochondria ;
and supervene most frequently in adynamic, malig-
nant, and pestilential fevers ; in confluent small-
pox, scarletina maligna, and- in scurvy : they oc-
cur less frequently in females than in males.

11. A. The above are the phenomena which
have usually been considered critical by the older,
and which are admitted by the best modern,
medical writers ; as well as the symptoms which
indicate their accession. There are, however,
still some circumstances connected with them de-
serving of notice. — n. The liamorrhagic evo^fu-
ations occur most frequently in the spring, or in
dry summers, in persons from 15 to 35 years of
age, of a sanguine or irritable temperament, and
in acute complaints. — b. The cutaneous evacu-
ation is most common in summer and autumn,
in robust and fat persons upwards of 30 years of
age, and in continued, remittent, and intermittent
fevers. — c. A critical diarrha'a is merit frequent
in autumn, in persons of a bilious temperament,
and in remittent and intermittent fevers.— rf. Dis-
charges of urine are observed in all ages, in all
seasons, particularly winter and spring, and in all
acute diseases.

12. B. Critical evacuations are — a. rare, in
persons enfeebled by age, or by some other ante-
cedent disease ; in very moist and very cold, or
very hot climates ; during remarkably sudden
and great vicissitudes of weather ; and especially

446

CRISES — Causes.

when the vital energies are much reduced by a
lowering and an evacuating treatment. — b. They
are not always simihir in the same diseases ; and
they vary in respect of tlie nature of the discharges,
and of the periods at which they tai<e place, as
well as of the organs by which they are produced.
A favourable change in gastric, bilious, and ady-
namic fevers, is often attended by alviae dis-
charges of a homogeneous, fluid, yellowish, yel-
lowish brown, or brownish black appearance, —
in inflammatory fevers, in young men, by epi-
staxis, often occurring on the seventh day, — in
these diseases, in young women, by a copious
flow of tiie catamenia taking place on the same
day, — and in men of middle age, by sweats, or by
some other discharges coming on the fourteenth,
or at a subsequent period. Catarrhal and bron-
chial complaints terminate with expectoration, or
with sweats, or a copious flow of urine, &c.

13. C. The duration of critical evacuations is
very uncertain. The haemorrhagic, the alvine,
and the urinary, seldom continue longer than
twelve or twenty-four hours, sometimes even much
less. Sweats and expectoration are occasionally
of no longer duration ; but, in the majority of in-
stances, these two evacuations are prolonged se-
veral days before the disease is entirely subdued.
Purulent collections and gangrene may take place
in a few hours, but they generally require a much
longer period.

14. D. Critical discharges cannot be changed
or determined in their route or period of eruption,
by art ; and when they supervene, they cannot
be safely interfered with, unless they threaten
life by their excess. If they be interrupted by
accident, or by an injudicious nnd meddling
practice, they are followed by unfavourable me-
tastases and complications, or sequelae, some-
times terminating in organic change, and death.
Thus, when the perspirations which occur upon
the change in fevers, and some of the exanthe-
mata, are interrupted, effusion often takes place
from serous surfaces, or into the cellular tissue.
The most active vascular depletions can never
compensate for the suppression of an abundant
menstrual or haemorrhoidal flux, occurring at the
acm6 of acute diseases; — the eftects of art are
here unequal to those produced by nature. Hence
the advantage of recognising critical evacuations,
even although we may not otherwise confide in
them. Altiiough it is tlius important to attend to
them in our prognosis, and especially in the treat-
ment, when signs of tiieir accession appear, or
when they are actually present, yet the ex-
pectation of their occurrence ought never to
interfere with or prevent the adoption of judicious
intentions and means of cure. I2ven granting,
with ILMiNn.MANN,that they are not to be imitated
by art, still they furnish several useful indica-
tions. " Qno nalurn lergit, en dncendiim est,"
may occasionally be adopted, after a cnrcful con-
sideration of tlie changes of wiiich they are the
eflPects, but not the causes. Mucii mischief has
accrued from considering critical evacuations as
the causes, and not as the consequences, of
clianges that take place in the economy at tlie
acm6 of acute diseases. IIkii. has touched upon
this fallacy, but has not considered the nature of
the changes of which critical evacuations are the
effects, or attempted to explain the manner of
their accession.

15.11. Causes, &c. — A. We have seen that crises
take place chiefly from eliminating or excreting
surfaces and organs; and that they consist of a
copious irruption of either previously suppressed
secretions and excretions, or an accustomed san-
guineous evacuation ; but the causes which oc-
casion, and the changes which precede them, are
not so readily recognised. When we consider of
what they consist, especially in relation to the
fact of their occurrence only in maladies charac-
terised in their earlier stages by interrupted se-
cretion and excretion, and by morbid excitement
of the vascular system — the vascular excitement
being perpetuated and variously mollified by sus-
pension of the visceral functions now mentioned,
or by local irritation, or by both — we shall arrive
at a tolerably accurate inference respecting the
causes of crises, and the importance that ought to
be attached to them. There are few facts in pa-
thology better established than that vascular ex-
citement, when it reaches a certain height, or
assumes an inflammatory form, impedes, inter-
rupts, or even arrests, the natural functions of
secreting or glandular organs ; whilst a lower
grade of excitement, unattended by inflammation,
generally increases the functions of the organ
thus affected. Therefore, when excitement con-
tinues to be expressed chiefly in the vascular sys-
tem generally, secretion and excretion continue
impeded or entirely suspended ; and the effete
materials, which, under other circumstances, are
continually being removed from the circulation,
accumulate in it, perpetuating and modifying the
vascular excitement until it becomes exhausted,
and until the accumulated noxious materials in
the blood irritate the viscera destined to remove
them, and thus incline the balance of excitement
from the general vascular system to eliminating
organs. Hence the occurrence of critical evacu-
ations at the acme of acute diseases ; and hence
their importance as indications of change in the
states, — 1st, of vital power; 2d, of vascular
action ; 3d, of the circulating fluid ; and, 4th, of
the functions of secreting and excreting viscera. As
crises have been neglected or confided in accord-
ing as they agreed with the doctrines of the day,
and have, in modern times, shared the fate of the
pathology on which they had been so long graft-
ed, I shall attempt to illustrate this view by a
reference to one of the very common circum-
stances in which they are observed. A person
exposed to the causes of autumnal fever of a
bilious and remittent form, experiences during
the earlier stages the \isual symptoms of impeded
or interrupted secretion and general vascular ex-
citement, with evening exacerbations. In con-
sequence of interrupted action of the emunctories,
the blood contains an increasing proportion of
efl^ete materials, particularly of the elements out
of which bile is formed. These for a while in-
crease and modify the vascular excitement, or,
when excessive in quantity, or especially noxious
in quality, even tend to exhaust or depress it ;
but they, at liie same time, being appropriate
stimuli to the biliary and depuratory viscera, serve
to restore their impeded functions, to turn the
balance of excitement in favour of them, — thereby
to reduce the moibid vascular action, to cleanse
the circulaiiig fluid from its impurities, and to
change in other respects its condition j and thus
the disease terminates with an apparent collapse,

CRISES

followed by a copious discharge from the bowels,
consisting of morbid bile, and of tiie excretions
from the intestinal mucous surface — the products
of the noxious matters which had accumulated
in the blood, but which is now being eliminated
from it by a renovated, as well as an increased,
secreting and excreting function. Now, this pro-
cession of morbid phenomena is consistent with
what I have repeatedly observed in both temper-
ate and warm climates ; and shows that the an-
cients were not so far wrong as many of the mo-
derns suppose, when they believed that critical
evacuations were beneficial chiefly because they
conveyed a morbid matter out of the system ; and
therefore could never be perfectly compensated
for, or imitated by, art.

16, But it may be objected, that this explana-
tion is based entirely upon the opinion that the
circulating fluid becomes altered, owing to inter-
ruption of the various secreting and excreting
functions ; and that it cannot obtain in those
cases wherein no such interruption appears to
occur. In this case, it is very probable that cri-
tical changes are effected in a great measure by
the vital influence of the frame. Even according
to the foregoing view of the subject, the agency
of the vital endowment must not be left entirely
out of consideration; for, without its reaction,
through the instrumentality of the different inter-
nal organs with which it is associated, upon the
morbid matters affecting it, those matters could
not be separated from the circulation and expelled
from the system. It seems, tiierefore, more than
probable that crises consist, in the majority of
cases, of more than the simple excretion of the
accumulated effete matters from the circulation —
such excretion being merely the effects of an
anterior and still more important and more constant
change. The attentive observer of the pheno-
mena successively occurring during the progress
of disease must have sometimes remarked, in those
maladies especially, wherein the vital manifest-
ations are particularly implicated, certain pertur-
bations or struggles occurring at their acme, either
followed by recovery, but without any very mani-
fest evacuation — at least to the extent of explain-
ing the circumstance ; or passing into exhaustion
and death, sometimes without any organic change
to account for the issue. In such cases, we can
merely infer, that the vital endowment of the
frame resists or opposes changes in the state of
the structures with which it is associated ; that it
does so successfully in the former, and unavail-
ingly in tlie latter, of these cases; and that, un-
less its energies are overwhelmed by very power-
ful and noxious causes, as occasionally is ob-
served, it thereby tends to prevent the dissolution
of this association to which such changes might
directly or indirectly lead. This vital manifest-
ation— whether denominated the " via medicatriv
natnrce," or vital resistance, or vital reaction, &;c.
- — most certain! J' obtains in a very large propor-
tion of diseases, and is instrumental in the de-
velopement of those changes, which immediately
or mediately conduce to recovery, and which, in
the more extreme cases, are attended by various
phenomena indicating the vacillating predomi-
nancy of vital and functional power, or of organic
disease ; the acquired ascendency of either over
the other occasioning, as the case may be, a
■favourable or an unfavourable crisis. That such

— Causes. 447

a struggle for the ascendency should manifest
itself favourably at certain periods, or on deter-
minate days, in preference to others, can be ex-
plained only by considering it a law of the living
economy identical with, or related to, the periodi-
city of vital action observed in tlie healthy, and
still more apparently in the diseased, functions.

17. B. Numerous illustrations of the following
propositions might be adduced, in addition to that
now advanced: — a. Evacuations occurring at
the height of acute diseases are often among
the first indications of, and are, indeed, occasioned
by, the subsidence of local or general vascular
excitement. — 6. In many febrile diseases, crises
are brought about by the excretion — under the
influence of vital reaction or resistance of the se-
creting viscera — of the effete matters accumu-
lated in the blood, or upon internal organs and
surfaces, owing to interrupted excreting function,
as shown above. — c. When a crisis is attended
by apparent collapse or change of action, this
may arise either from the vital reaction of inter-
nal secreting organs occasioning a derivation from
the periphery to the more central parts of the
frame, or, from the previous exhaustion or sub-
sidence of the vascular excitement allowing the
secreting and excreting organs to resume their
functions when excited by their appropriate
stimuli in the accumulated elements of their
respective secretions. — d. When crises consist of
sanguineous fluxes or discharges, they are occa-
sioned, in great measure, by the vascular plethora
consequent upon impeded secretion, together with
local determination to, or congestion of, such mu-
cous surfaces or organs as are most disposed, by
original conformation, previous disease, or esta-
blished function, to these changes. — e. That a
favourable crisis may manifest itself in one organ
or function, or in two or more, either simultane-
ously or successively, as by sweats, or by alvine
or urinary discharges, or by expectoration, &c. —
_/. When, during the progress of disease, the
aqueous and albuminous elements of the blood
become excessive, or when noxious matters accu-
mulate, and are not eliminated in the form of
crises as above stated, or by medical aid, they may
so affect the capillaries in the parenchyma of the
organs, or in serous surfaces, as to give rise to vari-
ous organic changes and efi'usions. These may be
viewed as unfavourable crises, determined to vital
organs and internal cavities, arising from deficient
vital energy, or vital resistance and reaction, or pre-
disposition, or constitutional vice of some organ or
part; each of which may obtain either alone, or
with local or general plethora produced by inter-
rupted secretion, &c.

18. C. Critical terminations are observed most
frequently in the more inflammatory, the bilious,
the gastric, and the intestinal forms of k\ey ; in
the different phlegmasia?, in some heemorrhagic
diseases, and more rarely in chronic maladies.
They are more commonly remarked in some epi-
demics than in others; and are seldom apparent,
as justly remarked by Lentin, in putrid or ma-
lignant diseases, and, I may add, in the pestilen-
tial fevers of warm climates. In these, the de-
pressing and contaminating influences of their
causes, and of tiie states of the secretions upon
the nervous energy, on the circulation, and subse-
quently upon the soft solids, so far subdue the
vital influence as to render its resistance unavail-

443

ing in the morbid strife ; and it becomes insuffi-
cient to separate and throw off the polluting
matters which ultimately increase so as altogether
to overpower it. The chronic maladies in which
crises are sometimes met with are — mania, hypo-
chondriasis, melancholy, and idiopathic dropsies.
But there are numerous circumstances which pre-
vent their occurrence in the above diseases. In
this country they are more rarely observed than
they would otherwise be, if the treatment of the
diseases in which they commonly occur were left
more to nature.

19. D. Amongst the most frequent causes f/iat
prevent the developemtnt (j/" oises, particularly sucii
as are favourable, may be enumerated — old age ;
the lymphatic temperament, and leucophlegmatic
habit of body ; previous disease, and disposition
of structures or organs to organic change. Con-
stitutional or local vice ; the scrofulous, gouty, or
rheumatic diathesis J exhausted vital power; in-
anition or general cachexy, particularly from innu-
tiitious or unwholesome food; and a too lowering
or depletory mode of treatment relatively to the
constitution and circumstances of the patient, not
only obstruct the developement of regular or fa-
vourable crises, but render them imperfect or un-
favourable. The large depletions, and the copious
and repeated alvine evacuations, very generally
resorted to in the early stages of acute diseases,
even although they may frequently ward off a
fatal issue, often manifestly prevent the accession
of regular crises, — 1st, by debilitating the patient,
and thereby rendering the vital resistance insuffi-
cient for their full evolution; and 2d, from the
circumstance of these means of cure being substi-
tuted or artificial evacuations or crises, and
preventing by anticipation and substitution those
which are natural.

20. And here a most important question sug-
gests itself, viz. Whether or not it is better thus to
substitute artiJicial,J'or the mere chance of the ac-
cession of natural eoacuations? As respects the
phlegmasiae, and many diseases, — particularly
those, on the one hand, in which vascular
action is excessive, and those, on the other, in
which it is insufficient, and the vital powers are
greatly depressed, — there can be no doubt of die
propriety of resorting to artificial means to pre-
serve an organ from the disorganising tendency
of excessive action, and to raise the prostrate
powers of life. Besides it is excessive and not
moderate and judicious measures, which obstruct
tlie evolution of favourable crises : the latter are
even requisite aids to nature, in bringing about
salutary changes, and a felicitous termination of
disease. In respect however of many forms of
fever, I believe tliat the vimia diligentia of tlie
practitioner is as often injurious as it is beneficial,
and that it disturbs those changes which can be
effected only by time, and sometimes disposes
to metastasis, complications, and unfavourable
crises, by depressing the vital energies, and
checking salutary changes at the early periods
of their evolution, and before they become fidly
manifested. This fact was established by Ilii.-
UKMiiiAND in respect of the typhoid and adynamic
fevers wliich were epidemic llirougli (iermany
from IBIO to 181G. lie observed, tliat a much
greater number of cases recovered when left in
a great measure to nature, tiie physician interfering
no further thaa to preserve vital organs from

CRITICAL DAYS.

dangerous congestions, than when a medicina
perturbatrix was adopted.

21. III. The Critical Days (Dies indicatorii)
are those on which favourable changes usually
occur. They are either simply or especially cri-
tical. The third, fifth, seventh, ninth, eleventh,
fourteenth , seventeenth, twentieth, twenty-seventh,
thirty-fourth, and fortieth are critical days; the
seventh, fourteenth, twentieth, and twenty-se-
venth being those which are especially critical.
Galen, and some other writers mention the
fortieth, sixtieth, eightieth, hundredth, and hun-
dred and twentieth ; but these are more doubtful,
and can apply only to chronic diseases. The
third, fifth, ninth, and, by some writers, the
eleventh, and seventeenth, are often called inter-
calary days : on these, crises less frequently occur.
The intervening days are non-critical or vacant,
on which salutary changes very seldom take
place. FonESTus, De Haen, Bordeu, and
various other authors, have entered upon calcula-
tions respecting the terminations of acute diseases
on particular days ; and it results therefrom, that
about three- fourths have observed regular periods.
These periods are, however, not always the same
in similar diseases. They vary with the age, the
constitutional powers, the temperament, and the
regimen of the patients. They are earlier, and
much more uniformly observed, in robust persons,
than in those who are weak and advanced in age.

22. I'hat critical changes should so frequently
occur on the days specified, cannot be explained
otherwise than in the way attempted by Cullen.
He remarks that, from the universality of tiie tertian
and quartan periods in agues, we cannot doubt of
there being in the animal economy a tendency to
observe such periods ; and the critical days above
mentioned are consistent with this tendency, as
all of them mark either tertian or quartan pe-
riods. These periods, are, however, not promis-
cuously mixed, but occupy constantly their several
portions in the progress of the disease ; so that,
from tlie beginning to the eleventh day, a tertian
period obtains ; and from the eleventh to the
twentieth, and perhaps, longer, a quartan period
is as steadily observed.

23. In entering thus fully into the exposition
of the doctrine of crises, according to my belief,
as deduced from observation, and the recorded
experience of the best authors, I would recom-
mend a judicious, but not a too partial, attention
to them, excepting in fevers where morbid action
has so far advanced that a determinate course
must be reckoned upon ; but, when any vital
organ is threatened by disease, either originating
in it, or attacking it consecutively, as in the pro-
gress of fevers and of the exanthemata, or when
the vital powers are greatly reduced, although
favourable crises may occur, they cannot be
reckoned upon, and the expectation of them
ought not then to prevent the adoption of deci-
sive measures. When, however, they do super-
vene under such circumstances, the knowledge of
the facts connected with them becomes of real
importance, inasmuch as it acquaints us that the
means of cure ought to be directed in such a
way as not to iinj)ede or interrupt, but to de-
velope and piomote them. Their occurrence on
certain days, in preference to others, should also
induce us to watch the phenomena of disease at
these periods with the utmost attention. It is true

CROUP-

that critical days have been denied by many of
the moderns, upon the ground of their not having
observed them. But, as Dr. Cullen has well
remarked, the fault is in the physician. He who
will not observe closely and comprehensively,
should not throw discredit on the results obtained
by the more accurate and attentive enquirer. Au-
thorities in matters of opinion are of little value ;
but in matters of fact, as in this case, they are
testimonies — are positive evidences ; and whoever
will take the trouble to refer to several hundred
authorities collected by Ploucquet, or even to
those below (nearly all of which he has omitted),
will find them sufficiently conclusive.

BiBLioG. AND Refer Hippocrates, Opera, eJ. J'an-

der Linden, t. i. p. 437. 6SG. et passim.— Galen, De Dicbus
Decretoriis, l.iii. — Oribasius, Synop. 1. vi. c. 1. — Fra-
caslori. Opera, passim. — Wekerii, Practica, l.ii. cap. 6 — 1 5.
Ven. 1644. — Baglivi, Prax. Med. 1. i. c. 9. — Sydenham,
Opera Universa. Ed. Lugd. Bat. I72G, p. 163. — F. HcffT-
mann, De Nat. Crisium, &c. Hala;, 1706. — Etlmulter,

De Crisi et Tumor. Crit. Lips. 1717 Mead, Works,

p. 200. — .S7a/j/, De Periodis Acutarutn, &c. Hala;,
1708. ; De Autocratia Naturte. Hala?, 1696. 4to. ; ct
De Synergia Nat. in Med. Hala, 1695, 4to. — Boer-
haave, Instit. ^931. — G. Martine, On the Periods and
Crises of Diseases. Lond. 1740. — Busson, ErgO a recta
Crisium Doctrina et Observat. Medicina certior. 4to.

Paris, 1741 Delius, De Diebus Intercalaribus in Ad-

vers. fasc. iv Hebenstreit, Vis Vitce ad judicandos Mor-

bos, seu de Motibus Nat. Criticis, 4to. Lips. 1749 —
Bordeu, Recherches surles Crises, in CEuvres Completes,
Paris, 1818, p. 209. — Van Swictcn, Comment, vol. ii.

p. 464. — Lentin, Beytrage, p. 21 De Huen, De Diebus

Criticis et Crisibus variis. Rat. Med. vol. i. cap. iv. p. 50.
— Soetmnerring, De Perturbat. Critica et Crisi. Mov.
\7S6.—Frlchardt, Veritas Doct. Cris. Marb. 1796.— Re'il,
Memor. Clinica, fasc. ii. p. 28. — Cullen, Works, by Thom-
son, vol. i. p. -593. — Hecker, Ann. der Pr. Med. Jul. et

Aug. 1820 Henke, Specielle Pathologic, b. i. p. 21 —

Cappel, De Viribus Corp. Hum. qua? dicuntur Medica-
trices. Goet. 1800. — ^. T. Kichter, Die Specielle The.
rapio, b. i. p. 57. — Spre7igel, Institutiones Medicae, vol.iv.
p. 16. — Hahnemanii, in Htifeland's Journ. der Pract.
Heilk. b. xxii. st. 3. p. 12. — J. P. Frank, De Curand.
Hominum Morbis, vol. i. p. .56. — Landre-Beaimais, .Se-
miotique, &c. Paris, 1813, 2d ed. ; et in Diet, dcs Sciences
Wed. t. vii. p. 370. — Hildenbrand, Institut. Practico-SIe-

dicae, &c. vol. i. p. 66 Fourcaull, in Mem.de la Socicte

Med. d'Emulation, t. ix. p. 411. — Kreyssig, in Encyclo.
pad. Worterbuch der Modicin. Wissenschaften. b. viii.
p. 646.

CROUP. — Syn. Afectio Orthopnoica, Baillou.
Angina Strepitosa, Ghisi. Angina Infantum,
AVilcke. Cynanche Stridula, Wahlbom. An-
gina Siijfocatoria , Bard. Angina Infantum
Strangulatoria, Russell. Cynanche, vel An-
gina Tracheatis, Cullen, Johnston, Rush, &c.
Asthma Infantum Spasmodicum, Simpson. Suf-
focatio Siridula, Home. Asthma Acutum In-
fantum, Millar and Cookson. Morbus Strangu.
latorius, Starr and Rosen. Morbus Truculeniiis
Infantum, Van Bergen. Angina Polifposa,
Michaeiis. Angina Memhranacea, Auct. Var.
Cynanche Laryngea, Dick, Orlhopnira Mem-
hranacea, Laudun, Tracheitis Infantum,
Albers et Frank. Angina Laryngea Exitda-
toria, Hufeland, Laryngo-Trachtite, Blaud.
Empresma Bronchlemmitis, Good. Cauma
Bronchitis, Young. Die Hi'aitige Briiune,
Huhnerh'usten , Germ. Trachtite, Croup, Fr.
Strypsiucka, Svved. Croup, or Roup, Scott.
Hives, Amer.

Ci.AssiF. — 1. Class, Febrile Diseases; 2.
Order, Inflammations (^Cullen), 3. Class,
Diseases of Sanguineous Function ; 2.
Order, Inflammations (Good). III. Class,
I. Ordeu (Author, in Preface).
1. NosoLOG. Defin. — Accelerated, difficult,
uheezing, or ihrill respiration ; short, dry, constant, \
Vol. I.

Its Pathology. 449

clangous or barking cough ; hoarse or altered voice ;
pain and constriction abave the sternum, with symp'
tomatic inflammatory fever; frequently, towards
the close of the disease, expectoration of membranous,
albuminous, or glutinous substances, occurring in
children.

2. Patholog. Defin. — Inflammation of the
trachea, sometimes of the larynx and trachea, and

frequently also extending to the large bronchi, oc-
casioning albuminous and membranous exudation,
more or less spasm of those parts ; and terminating
either in suffocation or exhaustion of vital power,
generally in a few days, or within the period con-
stituting an acute malady.

3. Lit. Hist. — Although we had no precise
account of croup until the work of Home ap-
peared, yet there cannot be any doubt of its oc-
casional occurrence among children from the
earliest ages ; and that it was confounded with
other diseases affecting the throat and air-pas-
sages. Hippocrates states, " Angina Gravis-
sinia quidem est, et celerrime interimit, quae
neque in faucibus neque in cervicequicquam con-
spicuum facit, plurimum vero dblorem exhibet,
et difficultatem spirandi, quae erecta cervice obitur,
inducit. Hsc enim eodem etiam die, et secundo,
et tertio, et quarto strangulat." And Baillou,
after describing an afliection of the respiratory
passages, observed in Paris, in 1576, with the
nature of which he was unacquainted, remarks,
" Chirurgus aflFirmavit se secuisse cadaver pueri
ista diflicili respiratione et morbo (ut dixi) incog-
nito sublati : inventa est pituita lenta, contumax,
quae inslar membrance cujusdam arteria aspera
erat obtenta, ut non esset liber exitus et introitus
spiritui externo : sic suffbcatio repentina." That
the above observations strictly apply to croup,
there can be no doubt. Dr. Blaip., of Cupar
Angus, first mentioned, and shortly described, the
disease by its present name, in his medical papers
published in 1718. Gmsi noticed it, as it pre-
vailed in the north of Italy in 1747, by the ap-
pellation of Angina Strepitosa; Starr, in the
Philosophical Transactions for 1749 and 1750,
by the name of Morbus >Strangul/itorius ; and
WiLCKE, as it occurred in Sweden during some
years preceding 1764. After the descriptions
furnished by Home, and his Swedish contempo-
raries, Halen and Wahluom, it received a place
among specific diseases, and became the subject
of a number of works, and even of controversial
discussion. The treatises of Sijipson, in 1761,
and of Millar, in 1769, on the acute asthma
of infants, gave rise to this latter occurrence, es-
pecially on the Continent. These authors, having
observed the more spasmodic states of this dis-
ease, described them under the above designa-
tion ; subsequent writers differing widely as to
their being distinct maladies, or merely varieties
of inflammatory croup, with predominance of the
spasmodic symptoms. This point was warmly
contested in the numerous productions which the
prize offered by Napoleon, in 1807, called forth.
My opinions respecting it will appear in the se-
quel.

4. I. History of the Forms and Progress of
THE Disease. — Croup has been viewed, since its
description by Home, as an inflammation of the
interior surface of the trachea and larynx. Some
authors have divided it into three distinct' va-
rieties, namely, 1st, Catarrhal croup, or a slighter

450

form of the disease ; 2 J, Nervous or Spasmodic
croup, or a slighter state of the inflammation,'
occurring in nervous and irritable temperaments,
which influence the form and issue of the dis-
ease, giving rise to a spasmodic form of it ; and
3d, Injiammatory croup, or that in which the
inflammation of the air-passages is carried to
a greater height, and is always attended by the
production of a membranous exudation. The
opinion that croup consists of an acute inflam-
mation, occasioning the production, in a number
of cases, of a false membrane ; in others, of an
albuminous concretion of various degrees of den-
sity ; in some, of a viscid mucous secretion, and
of the inflammatory lesions of the mucous mem-
brane itself, already described (see BnoNciii, &c,
§ 3, 55.); has been attacked by MM. (juer-
SENT and Bretonneau, who consider that the
formation of a false membrane is the distinctive
character of croup ; and that those cases in which
it is not formed, are merely what they term false
croup. I agree with M. Bricheteau in con-
sidering that the distinction here contended for is
calculated more to puzzle the inexperienced, than
to advance our knowledge. The experiments of
Schwilgue, Jurine, Albers, Schmidt, and
CiiAussiER, as well as pathological observation,
prove that the form of disease called false
croup by the above authors proceeds from a simi-
lar state of morbid action as that denominated
the pure disease, and is merely a modification
resulting from less intensity of the inflammation,
peculiarity of the temperament and habit of
body, the causes occasioning it, and the greater
predominance of the spasmodic or nervous states.
'J'he experiments of the authors now referred to
demonstrate, that the injection of irritating mat-
ters into the air-passages sometimes produces
simple inflammatory irritation ; in others, a thick,
viscid, mucous exudation ; and in many, parti-
cularly in young animals, a complete false mem-
Drane. These differences of opinion, which are
not confined to the writers now mentioned, but
extend to many of those quoted in the course of
the article, will appear, from what is about to be
advanced, as more apparent tlian real, 'i'hat the
disease should present numerous modifications,
approaciiing acute bronchitis on the one hand,
and identical with laryngitis on the other, and
varying characters according to the portion of
the air-passages chiefly affected, the temperament,
habit of body, severity of inflammatory action,
and association witii other diseases; is an in-
ference to which it priori reasoning may lead
every practitioner. Without adopting the con-
fined views of some writers, or the hypothetical
doctrines of otiiers, 1 shall be guided chiefly by
an extensive experience in the disease, and con-
sider it under tlie following heads : — 1st, The
symptoms and progress of true croup ; 2d, The
varieties or modifications of the disease most fre-
quently observed ; and 3d, 'i'he com))licated and
consecutive forms.

5. i. The iisuai. Form and Frociucss of
TRUE Croui'. — Tiie simple and usual form of
croup generally commences with more or less of
precursory symjjtoins, and runs its course in a few
days. It has been divided by authors into dif-
ferent stages or periods, more, 1 believe, with the
view of giving precision to tiieir description, and
to the treatment recommended, than from any

CROUP — History of its Progress.

marked change in the character of the symptoms.
M. GoELis has divided it into four stages, viz.
1st, the invading or catarrhal stage ; 2d, the in-
flammatory period ; 3d, the stage of the albu-
minous exudaiiou ; and 4th, the period of immi-
nent suftbcation. A nearly similar division has
also been adopted by Dr. Cheyne. The diffi-
culty of determining these various stages must be
evident ; and yet the advantages arising from a
division of the disease into distinct periods must
be evident, — not so much, however, for the pur-
pose of description, as for the more strict appro-
priation of the means of cure. Premising, there-
fore, that croup, particularly this form of it, is
strictly progressive, with no great change in its
features, until towards its close ; and that, there-
fore, all divisions of its course are merely arbi-
trary, and without any positive grounds in nature ;
I shall notice, 1st, its precursory signs ; 2d, its
developed and confirmed state ; and 3d, the state of
collapse and imminent suffocation.

6. A, The precursory period, period of in-
vasion (Goersent), of irritation (Rover-Col-
lard), catarrhal stage (Goeias), febrile period
(Duces). These precursory signs are some-
times well marked, and of a distinctly catarrhal
nature, as observed by Goelis ; occasionally
they are slight, chiefly of a febrile description ;
and either from this circumstance, or from the
shortness of their duration, attract but little
notice. The febrile symptoms, when present,
consist chiefly of alternating chilliness and heat, or,
in the more acute cases, of slight chills, followed
by heat of skin, frequency and hardness of pulse,
slightly flushed countenance, want of appetite,
headach, excited or variable spirits, alternating
with sadness, lassitude, &:c. Often, in place
of these, or in addition to them, there are a
short cough, hoarseness, sneezing, coryza, some-
times moroseness, and all the signs of common
catarrh. Upon examining the pharynx and
mouth, no trace of inflammation can be de-
tected in this form of the disease ; but the tongue
is generally white, and loaded at its base. The
eyes are watery, red ; and the eyelids darker than
usual. These symptoms are sometimes only of a
few hours' duration, or they may be present for
two or even three days. In very young children,
they may be so slight as to escape detection,
whilst a somewhat different train of phenomena,
such as heat of skin, chilliness alternating with
heat, frequent short fits of coughing during the
night, want of sleep, restlessness, indications of
uneasiness about the throat, furnished by the fre-
quent application of the child's hand to this part,
&c. manifest themselves. The importance of
ascertaining the invasion of the disease have led
several writers to pay much attention to its pie-
cursory symptoms. Vievsseux has attached
much importance to the catarrhal signs, and
change in the voice. But these are not by any
means constant ; and, even when present, may be
merely the commencement of a slight catarrh ;
indeed, there is no symptom wliicli can be relied
upon, as indicating its approach, until the disease
is nearly fully formed.

7. B. The developed state of the disease (the
Injiammatory, of Cheyne and IIosack). — After
the above symptoms have existed for a longer or
shorter time, or in a more or less marked manner,
hoarseness, if it have not previously existed)

CROUP — IIisTORr OF ITS Prorress.

451

sometimes a peculiar slirillness or puling of the
voice ; ditticult, sibilous, sonorous respiration ;
and an unusual, dry, loud, clangous or ringing
cough, as if passing tlnougli a brass tube, or
sometimes resembling tiie barlcing of a puppy ;
are observed. Tliis croupal cough scarcely ad-
mits of description, although it is readily recog-
nised after having been once heard. Tiie
succussions constituting it are followed by a dry,
hissing, slow, sonorous inspiration, resembling tlie
sound produced by a piston forced through a dry
pump, or by a crowing noise similar to that
emitted by a chicken in the pip. Ex])iration be-
tween the cough is more easy than inspiration,
but with precipitation ; the pulse is frequent and
hard ; the skin hot or burning ; the face flushed,
sometimes covered with perspiration ; the eyes
are watery and prominent ; the carotid arteries
beat strongly, and the jugular veins are tumid.
The head is now generally thrown backwards ;
and the child, either by its speech or attitudes,
expresses a feeling of anxiety, with pain and con-
striction about the traciiea and larynx, which are
often slightly tumitied externally. The above
symptoms, which usually first appear during the
evening' or night, generally somewhat subside

vomiting follows the cough, and particularly
when the excretion of glaii-y, albuminous, and
membranous matters accompany it, a momentary
relief is obtained, sometimes followed by pro-
gressive diminution of all the urgent symptoms.
Deglutition, particularly of fluids, is sometimes
difKcult, especially when the larynx is affected,
and induces the fits of cough and strangulation.
These symptoms seldom continue equally intense
during the whole of this stage, but present several
slight remissions, particularly at its commence-
ment, and in the less severe cases. Throughout
this period, and, indeed, during the whole disease,
the bowels are constipated, and the urine in small
quantity, of a high colour, and generally albu-
minous. The stethoscope generally furnishes no
further information in this stage than a louder
sound than that already heard ; unless when the
disease extends to the large bronchi ; when a dry,
tubular, or bronchial respiration, unaccompanied
with crepitous dilatation of the pulmonary cells,
but attended with perfect resonance of the thorax,
may be detected.

8. C The third stage, or that of collapse and
threatened sriffocation (the Suppurative, of Ho-
sACK and Ciieyne), may commence from the

early in the morning, excepting the frequency of first to the seventh day from the invasion, ac-
the pulse, the hoarseness of the voice, peculiarity ■ cording to the intensity of the disease, and con-
of the cough, and the sibilous inspiration. This j stitution of the patient. This period is charac-
remission sometimes continues the greater part ! terised chiefly by the absence of any remission,
of the day ; but after falling asleep, or towards j and the increased severity of all the symptoms,
evening, all the symptoms become more severe 1 particularly the acceleration and diminished
than ever; and the difficulty of respiration, the ' power of the pulse and respiration. The pulse is
sense of suffocation, the anxiety and distress, are now small, weak, irregular, unequal, or even in-
increased. The patient constantly applies the
hand to the throat, which is sometimes painful
to the touch ; the countenance is bloated ; the
pulse still remains frequent, hard or small ; the
cough is short, precipitous, convulsive, ringing,
and followed by a crowing, or shrill or hissing
inspiration ; and at the commencement of this
stage is generally dry, or attended by a scanty
mucous or sanguineous expectoration ; subse-
quently it becomes husky and suffocative, some-
times with fruitless attempts to excrete what is
felt in the trachea. The patient constantly
changes his position ; breathes with great diffi-
culty, all the respiratory muscles acting with
great force ; and at eacli inspiration, the tumid
larynx descends rapidly towards the sternum,
whilst the epigastrium is drawn upwards and in-
wards ; and, during expiration, the former is car-
ried towards the maxilla, and the latter comes on
a plane with the surrounding surface. If any re-
mission at all occur now, it is much less evident.
All the symptoms become more severe. The cough
is now more difficult, suppressed, or strangulating ;
the suflbcation accompanying it more imminent,
and the stridor or hissing noise of inspiration fol-
lowing it much louder : sometimes it is followed
by vomiting, and the excretion of a glairy mucus,
occasionally containing flocculent or membranous
shreds. The pulse is now very frequent, con-
tracted, sharp, and small. The cheeks and lips
are, particularly during the cough, somewhat
livid, or extremely pale and tumid. I'heie are
also great irritability and somnolency, but no
delirium. The hissing, sonorous, and croupy
character of the inspiration increases ; and the
voice, which was shrill or hoarse, often becomes
broken, whispering, suppressed, or puling. When

termittent ; the cough is less frequent, less audible,
suppressed, but suffocative. The voice is whisper-
ing, low, or entirely abolished ; and the speech
quick, imperfect, or lost ; the motions of the
aliE nasi and the parietes of the chest are forcible
and remarkable, and accompanied with a similar
descent and ascent of the larynx and epigastrium
to that already described (§7.). The head is
constantly thrown back ; perspiration flows from
the forehead ; the eyes become sunk, and lose
their animation ; the countenance often assumes
a leaden hue ; the tongue is dark and loaded,
and its edges and the lips are purplish ; the sur-
face of the body is covered with a cold viscid
perspiration ; the feet and hands swell ; the skin
is extremely pallid, and shows the veins through
it, particularly those of the neck, which are lar^e
and distended ; and the stools are dark and offen-
sive. The patient very seldom recovers from
this state ; but he sometimes obtains momentary,
much more rarely permanent, relief, owino- to
the expectoration of a portion of the albuminous,
membranous, and nnico-puriform matters ob-
structing the larynx and trachea. Wlien the
excretion is free, recovery sometimes takes place
slowly ; but where it is scanty, or when the dis-
ease has extended downwards through the bron-
chi, as it usually does when thus severe, the issue
is commonly fatal. In this case, the patient tosses
about in great distress : he seizes on objects around
him, and grasps them convulsively for a moment •
he throws his head back ; seizes his throat as if
to remove an obstacle to respiration ; makes forci-
ble efforts to expand the lungs; and after a longer
or shorter period of such distress, seldom above
twenty hours, expires, sometimes with signs of
convulsive sufibcatiort, but as frequently with
Gg2

452

coatiaued increase of the foregoing symptoms,
and evidence of exhaustion of the vital energies,
and in a state of lethargy. The stethoscope gene-
rally furnishes information in this period of the
extension of disease to the larger bronchi. This
extreme state of disease seldom lasts longer than
tvirenty-four hours. In young children, convul-
sions sometimes occur, and occasionally terminate
life.

9. D. Such is the usual course of the more se-
vere cases of common and uncomplicated croup,
when left to nature, or unmitigated by treatment.
In its slighter grades, hoarseness, with a hard
rino-ino- cough, followed by a crowing or stridulous
inspiration, present chiefly in the night and remit-
tino- in the day, are almost the only symptoms ;
the respiration and pulse being but little disordered
in the intervals, and the febrile symptoms not
very acute. But even these very favourable
cases may experience sudden and dangerous ag-
gravations ; whilst, on the other hand, the severe
and acute disease now described may be soon
ameliorated by early and decided treatment at its
commencement, or by the discharge of tubular,
membranous, or puriforra matters, at its more ad-
vanced periods.

10. E. The duration of the disease depends
upon the vital energies of the frame, and varies
from two to eight or nine days ; but I have seen
it terminate somewhat earlier,and prolonged much
later when partial or scanty expectoration takes
place from time to time. A fatal issue is most
common on the fourth day. I believe that it very
rarely assumes a chronic state, preserving at the
same time its essential characters ; although a
somewhat different opinion has been advanced by
GoELis. The cases, however, which he has ad-
duced as instances of the chronic disease, are
evidently either the partial removal of the more
inflammatory, with recurrence of the more spas-
modic, symptoms ; or slighter relapses ; or the
extension of the inflammatory action to the larger
hronchi, and its continuance in this seat for a
longer period. Alrers admits that it may be-
come chronic, and supposes that the false mem-
brane may sometimes adhere to the inflamed
surface, and be gradually absorbed ; recovery at
last taking place, without the excretion of the
albuminous substances in such cases. These oc-
currences, although not impossible, are at least
very rare. Hii.denbrand supposes, on the other
hand, that it may become chronic after the ex-
cretion of liie albuminous exudation ; inflamma-
tory irritation still persisting in a lower grade, and
terminating at last in ulceration. This is a mucii
more probable occurrence ; and I believe that I
have met with it on two or three occasions, but I
have never been able to verify it by dissection.
In such cases, the disease continues in a slighter
grade for several weeks, and is characterised by
frequent remissions and exacerbations, emacia-
tion, muco-purulent expectoration, slight sore-
ness in the trachea, and the usual symptoms of
traclieal consumption ; the patient sometimes
sinking at last, or occasionally recovering by judi-
cious means.

11. ii. The Modifications of Cnoup. — The
forms which the simple or uncomplicated disease
assumes are attributable, as already hinted, to
the jmrticular part of the air-passagos chiefly
afl'ectcd, to the temperament and habit of

f CROUP — Modifications of.

body of the patient, and the intensity of the
causes.

12. 1st. Croup with predominance of the acutely
injiammatory symptoms(t\\e Acutely Inflammatory
Croup of several modern authors). — This is
merely the more acute or severe form of the
disease, occurring in robust plethoric children
of the sanguine temperament, who have been for
some time weaned, and have had their first teeth,
and during cold and dry states of the air. It is
commonly preceded by chills, and horripilations,
and in older children by distinct rigors ; and is
characterised by the more continued and unremit-
ting severity of the symptoms, by tlie strength of
the pulse, heat of skin, great difficulty and force
of respiration, the vascular injection of the cheeks
and lips, the highly inflammatory appearances of
blood taken from a vein, &c. (a.) When the
inflammation chiefly, or even partly, implicates the
larynx (the Laryngeal Croup of Guersent and
others), tiie strangulation, cough, and all the
symptoms connected with respiration, voice, and
speech, are extremely severe ; pain is felt in the
larynx and upper part of the trachea, and there
is sometimes slight swelling in this situation. In
young children convulsions, and in older children
delirium, occasionally occur towards the close.
The disease terminates in from twelve hours to
five or six days, but most commonly in two or
three days. (6.) When the inflammation is co7i-
fined to the trachea (the Tracheal Croup of several
Continental writers), the cough is at first dry,
shrill, or sonorous, as if passing through a brass
tube, and accompanied with sharp and lacerating
pain in the course of the trachea, sometimes with
slight tumefaction. The patient speaks in an
under tone, but there is little hoarseness, and the
voice and speech are not lost, or at least not so
much affected as when the disease is seated
partly or chiefly in the larynx. Heat of skin,
and the usual symptoms of severe inflammatory
fever, are also present. As the disease advances,
the cough becomes more frequent and severe,
but without the distressing sense of sufl^ocation
attending the foregoing modification ; nevertheless
there is still much difficulty of respiration in the
intervals between the cough, sometimes with a
species of rattle similar to tiiat of bronchitis. The
fits of cough are often followed by vomiting, or
the rejection of membranous shreds, with a thick,
glairy, and sometimes sanguinolent or purulent
mucus. The excretion of this substance generally
is productive of much relief, which is increased
after each discharge, unless the inflammation has
extended down the ramifications of the bronchi ;
and then the respiration continues extremely dif-
ficult, and the disease assumes all the characters
of an acute bronchitis, and frequently terminates
unfavourably. Tiie progress of cases of this de-
scription is usually not so rapid, nor tiie termi-
nation so fatal, as of those affecting the larynx
chiefly. All the symptoms evince less severity,
especially when treated early ; and it sometimes
continues twelve or fifteen days, but usijally from
five to nine. When its severity merely is sub-
dued, the inflammatory action not being alto-
gether removed ; or when, from accidental causes
or the fault of the constitution, it passes down the
bronchi ; it may be much more prolonged, and
approacli the chronic character ; but it will then
present many of the features of the most severe

CROUP

bronchitis, into which, indeed, it will thus pass ;
and as was stated in respect of that disease,
whilst bronchitis may be followed by croup, the
latter malady may thus occasion the former.

13. 2d. Croup with predominance of bronchial
$ymptoms (the Cynanche Tracheulis Humida of
Rush ; the Mucous Croup of some modern authors.)
— This form is not infrequent in young children of
the lymphatic temperament, who are fat and flabby,
with a white soft skin. It is often met with soon
after the period of weaning, and in those who are
brought up without the breast. It commences
with coryza, and the other symptoms of catarrh,
and often with little fever. After these signs have
been present for some time, or sometimes without
these being so marked as to attract attention, it
generally attacks the child in tlie evening or
during the niglit, and manifests itself in a decided
manner by the sudden occurrence of a hoarse,
suffocating, dry, sonorous, or shrill cougli, wiih
a sibilous inspiration. 'l"he seizure is usually
severe, and is attended with manifest alarm to the
patient. The countenance is pale, and covered
by perspiration, and the lips are violet. Several
slighter fits succeed to this first attack ; the voice
remains hoarse and low, the respiration sibilous
and slightly difficult ; but a remission usually
takes place in tlie morning, and there is gene-
rally but little return of the croupal cough until
evening and night, when it recurs, but often in
a slighter degree. In some cases the invasion
is more gradual ; the remissions but slight, or
hardly evident, and the accession of expectoiation
much earlier ; the disease approaching nearer, as
respects its seat and character, to acute bronchitis.
There is but little fever, the skin is not much
warmer than natural, and the powers of life are not
remarkably depressed. The throat and pharynx
are unaffected. After the first, second, or third
day, the cough is no longer dry, its fits become
shorter, it is sometimes accompanied with a mu-
cous rattle, and begins to terminate in the expec-
toration of a thick glairy mucus. The disease
now assumes many of the features of, or passes
into, bronchitis. I\I. GuEnsHNx considers that
this is merely a false or bastard croup. I be-
lieve that it is a milder form of the disease ; and
that it consists of a slighter degree of the inflam-
matory irritation of the same parts which are
aflected in the true croup ; but that, in conse-
quence of the much less severity, or some other
modification, of the diseased action, and constitu-
tion of the patient, glairy mucus merely, instead
of an albuminuos exudation of a firm consistence,
is thrown out ; and that, when the features of
bronchitis are assumed, the inflammatory action
has extended down as far as the small bronchi.

14. 3d. Of croup with predominance of spas-
modic and nervous stjrnptoms (the Lari)ngis7nus
Stridulus of Good ; Spasmodic Croup of Wicn-
MANN, ISIicn.\ELis, DouBLE, &c. ; and the Acute
Asthma cfLfants of Simpson and ^Millar). This
variety of croup has been described by German
and French authors, under the name of Millar's
Asthma, and has given occa.sion to much discus-
sion relative to its being a variety of croup, or a
distinct disease. Of its being the former, how-
ever, there cannot be the least doubt. It occurs
chiefly in children who are weak, in itablc, sub-
jects of worms, and of the nervous temperament;
and conies on most commonly in the night, often

MODIFICATIONS OP. 453

during the patient's first sleep, frequently without
well-marked premonitory symptoms, excepting
languor, listlessness, headach, fretfulness, and
sometimes a short tickling cough ; and these may
be slight, or of short duration. The child is sud-
denly wakened by great difficulty of breathing,
cough, and general agitation, and continues thus
afTected for some time ; the .symptoms gradually
subsiding towards morning, or being more quickly
relieved by the cough terminating in vomiting.
This form of the disease always presents complete
remissions during the day, with exacerbations in
the evening and night, and thus assumes a regular
type ; but the remissions often become less com-
plete and of shorter duration, the exacerbations
more frequent and prolonged, and the cough,
difficulty of respiration, general agitation and
convulsive movements attending them, more se-
vere. There is little or no increase of animal
heat or fever, nor actual pain in the larynx and
trachea, but a sensation of constriction and un-
easiness. The countenance is generally pale in
the remissions, and sometimes tumid and livid
in the exacerbations, during which the respiration
becomes sonorous, laboriuus, convulsive, and
croaking ; the extremities are usually cool. The
cough continues dry, and accompanied with
marked irritability, until the favourable ter-
mination of the disease ; when slight or moderate
glairy expectoration takes place, but without any
membranous substances mixed with it. The
pulse is very variable; sometimes small, frequent,
and constricted ; occasionally slow ; but gene-
rally at last unequal, weak, or intermitting. The
urine is paler than in the common and more in-
flammatory slates of the disease, in larger quan-
tity, and sometimes deposits a nebulous sediment.
In this variety, the nervous and spasmodic symp-
toms are present from the commencement ; in the
former, they appear chiefly in the two last stages ;
the more common and inflammatory croup some-
times thus passing into the spasmodic.

15. Such are the usual characters of the well-
marked spasmodic variety of croup ; but cases of
so pure and unmixed a form are comparatively
rarely met with in practice ; as the intermediate
shades between the state of disease now described
and either of those preceding, are more commonly
observed, at least in this metropolis and vicinity.
I have scarcely ever seen a well-defined case un-
connected with dentition ; or one terminate fatally
without the occurrence of convulsions in its ad-
vanced stages, or towards its termination ; and it
has very commonly presented evidence of cerebral
congestion. On dissection of fatal cases, M.
GuERSENT slates, that albuminous concretions —
sometimes extensive, but more frequently con-
sisting of small isolated patches — are found in the
larynx ; whilst Millar and Rush detected little
or no lesion of the air-passages. In the very few
opportunities I have had of examining the state of
parts in the more purely spasmodic cases of
croup, an adhesive glairy fluid, with patches of
vascularity, were observed in the epiglottis and
larynx, and a similar fluid was found in tlie lar?e
bronchi. Congestions of the brain, particulady
about its base and medulla oblongata, and of the
lungs, cavities of the heart and large vessels,
were also found ; but these were most probably
consecutive changes merely.

16. iii. Complications OF Cuoup. — A. With
Gg3

454

CROUP — Complications of.

Cynanche maligna. This complication is distinctly j and larynx. The croup which has been described

alluded to by Johnstone, Witheuing, Cullen,
and several contemporary authors ; and is common
in the epidemic visitations of this disease, or of
anginous scarlatina ; the greater number of fatal
cases exhibiting soft fragments of false membranes,
of a greyish or ash colour, covering the larynx and
trachea, and a livid appearance of parts of the
subjacent mucous membrane. This is one of the
most dangerous complications of the disease. 'I'he
affection of the air-passages is here consecutive,
and the difficulty of swallowing usually precedes
the characteristic symptoms of croup, which are ge-
nerally accompanied with great foetor of the breath.
— a. In many instances of the malignant sore
throat, the exudation thrown out from the inflamed
surface forms a pellicle co-extensive with the spread
of the inflammatory process from the fauces to the
pharynx and air-passages. In some cases, ulcer-
ation, and slight apparent sloughing, occur in the
central parts, and those first affected ; whilst the
surrounding surface, and parts subsequently dis-
eased, become covered by a soft and easily la-
cerated exudation. In rare cases the inflam-
mation commences in the pharynx (^Cynanche
Pharyngea), and spreads to the fauces on the one
side, and down the larynx, trachea, and oeso-
phagus on the other. In these, the pellicular
exudation formed on the inflamed surface very
nearly approaches that of croup ; oftener, how-
ever, it is of a darker and dirtier colour, softer,
and not so continuous ; whilst in some cases
it is formed in patches, is similar to thin
sloughs, and is interrupted in parts by a dark,
foul, but not concrete secretion ; the subjacent
mucous surface being of a dark, livid, or brick-red
colour, or ulcerated, or even partially sloughed.
Sloughing, however, or even ulceration, although
mentioned by several writers, is comparatively
rare ; the more frequent commencement of the
faucial or pharyngeal complication of croup being
attended by the pellicular or concreted exudation
now mentioned, without sloughing, 'i'he above
changes are most remarkable in the pharynx, and
are slighter in tiie larynx and trachea ; the ex-
udation being there somewhat paler, and from its
colour and appearance very generally mistaken,
both while adherent to, and whilst being detached
from, the inflamed surface, for sphacelated sloughs,
particularly as observed in the throat, and described
as such. The complication, with cronp,of various
states of angina or sore throat — malignant, or epi-
demic— whether commencing in the pharynx, or
in the fauces, and extending to the pharynx, is not
uncommon. Epidemic visitations of it have occur-
red in very modern times, and have been described
by Hamilton, Deslandis, Eouroiois, Bre-
TONNEAu, Trousseau, Moronval, Emangard,
ScHMiDTMANN, and others. — 0. In some cases
the affection originates in the inusils (Cyinivche
Tonsillaris, &c.) and extends to the adjoining parts.
In the croup epidemic in 15uckinghamshire in
1793, and described by Mr. Rumsky, thecroupal
symptoms were stated to have been coeval with
" inflammation and swelHng of the tonsils, uvula,
and velatum pendulum palati ; and large films of
a wliite substance were formed on the tonsils."
iSimilur appearances have likewise been noticed by
Feiiuiah, Hosack, JVIackkn/ie, llonKRTS(>N,and
BouiuiEoisand by myself : thepellicularcxudation
extending over the fauces, down into the pharynx

by Louis, HuFELAND, and otiiers, as occurring in
adults, was thus complicated. The complication
with the malignant sore throat has been observed by
me bothin its simple form and in its association with
scarlet fever. Some years since, I attended, early
in the winter, some of the children of a numerous
family residing a few miles from town, in a low
and damp situation. They had had scarlatina,
with very severe sore throat, two or three years
previously. On this occasion, one of the oldest
was seized with malignant angina, extending to
the pharynx, and along the Eustachian tube to the
ear, with foetid respiration, and irritation of the
larynx, producing a constant tickling cough. A
similar affection spread to four of tlie younger
children, and in two of them it was complicated
with croup; the symptoms of which were severe,
continued, and well marked in one, and more spas-
modic and intermittent in the other. In these,
ash-coloured exudations covered the greater part
of the fauces and tonsils, and extended down into
the pharynx. They recovered with difficulty, by
the means hereafter to be noticed.

17. B. Croup may be also complicated with
Thrush. — Cases of this description are rare. I have
seen only two of which I have taken any account.
This association has also been observed by .Tu-
niNE, Double, Pinel, and Royer-Collard,
who notice the adynamic or ataxic character of
the fever accompanying it ; the adynamic state
being the consequence chiefly of this associated
disorder, supervening upon pre-existing disease,
generally of the digestive mucous surface, and
often, moreover, in a weak and cachectic system.
The patches of pellicular exudation in the mouth
and throat characteristic of thrush, had extended
down the pharynx, larynx, and part of the oeso-
phagus, in these cases ; death having been oc-
casioned by the consequent irritation, and frequent
recurrence of spasm of the larynx. In the only
one I had an opportunity of examining after death,
there was little or no inflammation in the trachea ;
but there was considerable vascular injection of
the pliarynx, epiglottis, and larynx, which were
covered by a cream-like exudation, their mucous
membrane being softened. The trachea and bron-
chi contained some flocculent viscid mucus ; and
the digestive villous surface, particularly in the
upper part of the oesophagus, stomach, and por-
tions of the small intestines, was softened and in-
flamed. In all the foregoing complications, the
affection of the larynx and epiglottis is generally
more remarkable than that of the trachea.

18. C. With the exanthematous fevers. — a.
Croup sometimes comes on during the eruptive
fever, or efflorescence of measles; when it oc-
casionally assumes more of the remitting and
spasmodic character, and is seldom very severe
or dangerous. In this case it generally subsides
as the eruption becomes abundant. But it also
supervenes upon the extinction of the eruption ;
or it does not appear until during or after de-
squamation ; and, in some instances, not until
advanced convalescence. When this occurs, the
inflammatory fever soon passes into an adynamic
state, and the disease assumes a severe form, with
spasms of the larynx, often terminating with
convulsions and suflbcation. In one instance of
this kind that occurred in my practice, much
swelling and oedema of the throat appeared ex-

CROUP — Terminations — Prognosis.

455

ternally, and aggravated the symptoms ; recovery,
however, unexpectedly took place, with a free
discharge of glairy mucus, and concrete fragments
of membrane. In another instance, emphysema
of the throat occurred, and gradually extended
over the neck, chest, and face. Permission was
not obtained to examine the body, so that the
channel through which the air had passed from the
respiratory passages into the cellular tissue could
not be exactly ascertained. — b. The complication
wilh small-pox has been very particularly noticed
by PiNEL, Albers, ViEussEux, and Rover-
CoLLARD, and is not uncommon. It usually
occurs in the more severe cases, particularly when
the disease is confluent, and generally comes on
slowly in the suppurative stage. In the more
malignant cases, the difficulty of respiration is ex-
cessive ; the voice very hoarse or suppressed ; the
paroxysms of suffocation are extreme ; the cough
dry, or giving issue merely to a small quantity of
dirty serum, or muco-sanguineous or dark sangui-
neous matter ; and the attendant fever adynamic.
On dissection, a membranous substance is seldom
found in the larynx ortrachea, but merely portions
of a semi-concrete matter, with spots of intense in-
flammation in these parts, the epiglottis, and large
bronchi. — c. The complication with scarZe^yei'er is
never met with excepting thisdisease be associated
with sore throat, especially when malignant or epi-
demic (§ 16.) ; and it is then a frequent cause of
death. — il. The association, or rather the super-
vention of croup on erysipelas, particularly of the
head and face, occurring in adults, has been ob-
served by FoRESTUs, (Opera, 1. xv. obs. 20.),
Latour, Stevenson, and Gibson (Trans, of Med.-
Chirurg. Soc. of Edin. vol. ii. p. 95.), and in seve-
ral instances by the author. In those cases, the
inflammation and characteristic exudation spread
from the fauces to the air-passage.

19. D. With other diseases. — a. Croup is some-
times associated with acute bronchitis ; and when
it terminates fatally, it is often in consequence of
extension of the inflammation to the bronchi, and
thence to the substance of the lungs, pneumonia
thus also supervening. But the croup may also,
although much more rarely, be consequent upon
bronchitis. — b. It may occur in the course of
pertussis, and it then usually assumes the re-
mittent and spasmodic or the bronchial forms. —
c. Lastly, it may be associated with wsophagitis ;
but when this is the case, the inflammation with
albuminous exudation usually commences in the
pharynx, and extends down the cesophagus, and
to the larynx. This is not an infrequent occur-
rence in children under two or three years of
age ; as, indeed, ]M. GuERSENxhas remarked ; the
larynx and epiglottis being the only parts of the
air-passages affected ; and these chiefly with spasm,
from the irritation of the portions of false mem-
brane covering or coming in contact with them.

20. II. Terminations and Prognosis. —
Croup may terminate — 1st, in recovery ; 2d, it may
pass nito or excite some other disease, — a return
to health, or a fatal issue, taking place mediately
through it ; 3d, in death, either from exhaustion
of the vital energies, or from suffocation. A. A
return to heailh is indicated by the mild form of
the disease ; by the quiet res[;iration whilst the
cough is absent ; by the moderate excitement and
frequency of tiie pulse ; by a looser cougii and a
more natural state of voice, followed by expec-

toration of viscid mucus, and membranous frag-
ments ; by a copious and general persjiiration on
the third day, the symptoms being moderate ; by
epistaxis on the second, third, fourth, or fifth
days ; by the absence or subsidence of violent at-
tacksofspasmof theglottis,andsuftbcation ; bvthe
simple and uncomplicated state of the disease ; and
the absence of exhaustion, or of great frequency or
irregularity of pulse, and of other signs of adynamia.
21. B, It may excite additional disease, or pass
into some other malady, — a circumstance which,
although not necessarily fatal, may greatly in-
crease the danger. The morbid state of the
system, and general depression of vital power
accompanying most of the complications now
noticed ; the more constant affection, and dispo-
sition to spasmodic action of the larynx, in all
of them ; the interruption caused to the respira-
tory processes, and the attendant or consequent
congestion of the lungs, as well as the marked
disposition they create to consecutive disturb-
ance ; greatly augment their danger generally.
The disorders consequent upon the simple and
complicated states of croup are both direct and
indirect. The direct are — a. Extension of inflam-
matory action to the bronchi and substance of
the lungs, — generally an unfavourable event, and
indicated chiefly by the unremitting persistence
of the symptoms, by deep suflPocating paroxysms
of cough, great frequency of pulse, lividity or
leaden hue of the countenance, by the dark
tinge of the lips and tongue, cold clammy per-
spirations, somnolency, and all the characters
of asthenic Bronchitis (§ 37.). When the
bronchial affection does not appear until during
convalescence, it is more slight, unless the causes
have been energetic, and it presents more of the
usual characters and states of that disease. The
consecutive occurrence of either pneumonia or
any of the forms of bronchitis should be carefully
enquired after, by observing the symptoms, and
examining the chest by auscultation. — b. P2xten-
sion of disease to the sub-mucous and follicular
structures, occasioning inflammation and ulcer-
ation of these tissues, with symptoms of laryngeal
or traciieal consumption upon the subsidence of
croup, is a much more rare occurrence than the
preceding ; but, when it takes place, a muco-
puriform expectoration accompanies and follows
the characteristic discharge and signs of croup,
with pain and irritation in the larynx and trachea,
recurring exacerbations of suffocating cough, and
difficulty of breathing, chiefly of a spasmodic
description, particularly when the inflammatory
irritation is seated in the larynx or epiglottis,
and the usual symptoms of hectic. The very
marked tendency, also, of the disease to relapse,
is in a great measure owing to the persistence of
a slight degree of inflammatory action in the large
bronchi, or in the trachea and larynx, for some
time after the membranous exudation on the
diseased surface has been thrown oft'; the dis-
oider being readily aggravated upon exposure to
the exciting causes. This disposition of the dis-
ease to return diminishes with the length of time
that has elapsed from the subsidence of the ori-
ginal attack, but docs not altogether disappear
for many wteks, or even for months, especially
in some constitutions, and in the Inst and first
nionllis of the year; and even more than one
relapse may take place in weak, irritable, and
G g 4

456

CROUP — Diagnosis.

nervous frames, but generally in a more spasmodic
form. — c. Besides producing these, it may occa-
sion, although very rarely, abscess in the vicinity
of the larynx or trachea. I believe that dilata-
tion of the bronchi is a much more frequent re-
sult.— d. Of the more indirect terminations and
consequences of this disease, congestions of the
encephalon, giving rise to convulsions and effusion
of serum in the ventricles, or between the mem-
branes, are the most important. In many cases,
particularly in delicate and nervous children, the
convulsive movements seem to commence with
the spasmodic actions of the laryngeal muscles,
and the strangulation thereby occasioned ; the
head and neck being thrown back, and all the
limbs convulsed. Life is in some cases thus ter-
minated by asphyxy. Jurine, Vieusseux, and
myself, have met with cases of hydrocephalus
following the disease ; but they are not common.
22. C. Danger is to be dreaded, when fever is
very high early in the disease, and when respir-
ation is permanently audible, cooing, and labo-
rious, or as described above (§ 7.). When the
disease goes on to the third stage, notwithstand-
ing the treatment ; when it presents any of the
complications (§ 16.) and consecutive affections
(§ 21.) already noticed ; when the discharge of
the characteristic exudation does not take place,
or when the expectoration of fragments of it is
not followed by any relief ; when the counte-
nance becomes livid or leaden, the eyes sunk,
the lips and tongue dark, and the pulse very fre-
quent, small, weak, and irregular; and the other
symptoms of vital exhaustion appear ; great danger
exists. A fatal issue is to be expected when
the patient presents the appearances described as
characterising the third stage, particularly those
noticed as marking its close {§ 8.).

23. III. Diagnosis. — The hoarseness, and the
loud, sonorous, and ringing cough ; the forcible
and difficult inspirations; flushed face; injected
and watery eyes ; the frequent and hard pulse,
with thirst and inflammatory fever, tiie heaving
of the thorax and motion of the trachea, in the
developed stage; and the husky choking cough,
the whispering voice, and wheezing respiration,
&c. of the third stage ; sufficiently distinguish this
disease from any other. When it is uncomplicated,
nothing beyond a slight redness is ever observed
in the throat ; and there is little or no pain upon
deglutition, unless the larynx be much affected.
— a. Croup can scarcely ever be mistaken for
Cynanche maligna, or C. Pharyiigea, or any other
form of sore throat, as long as these affections do
not extend to the larynx ; as the great difficulty
of deglutition, and the but little disturbed state

to simulate croup; and in many cases it even
amounts, as already stated, to a slighter form of
the complaint, which usually disappears as the
eruption becomes matured ; but attention to the
symptoms will readily show the nature of the
disorder, and how far the affection of the larynx
and trachea should be viewed as a symptom, or
as an important complication of the exanthema-
tous disease. — c. Croup may readily be distin-
guished from bronchitis, by its sudden and severe
attack ; its occurrence in the evening and at
night ; its remissions ; the hoarseness, and the
ringing, dry, and frequent cough ; the difficult
inspirations, and impeded respiration ; the altered
voice and speech ; the sensations and symptoms
referrible to the trachea in the former, and to the
sternum and chest in the latter ; and by the
absence of expectoration until late in the disease,
when it is membranous or tubular, and not
mucous and inuco-puriform, as in bronchitis, until
after the discharge of the membranous exudations.
These characters will also serve to indicate
the supervention of croup on bronchitis, — an
occurrence which is sometimes observed, although
much more rarely than that of bronchitis on
croup. — d. Laryngitis is with greater difficulty
distinguished from croup than the foregoing, and
in many respects there is little or no difference.
The practical importance of the diagnosis may
not appear great, but it is sufficiently so to war-
rant an accurate distinction. 1st. True laryngitis
occurs in adults ; seldom, in children, in any other
form than associated with either the simple or
complicated states of croup. 2d. It is a purely
inflammatory disease, attended by a fixed burning
pain in the larynx, increased on pressure and
examination ; and, when attacking adults, never
gives rise to a false membrane, unless it be
superinduced in the specific and epidemic forms of
cynanche, and then it assumes modified charac-
ters. 3d. It more frequently terminates in the
manner characterising acute inflammations, viz.
ulceration and suppuration, than when the larynx
is affected in croup. 4th. It is more acutely
and constantly inflammatory, the symptoms are
more continued, and it is more benefited by a
purely antiphlogistic treatment, than croup.
5th. It much oftener passes into the chronic
form, than the latter disease. (See Labvnx —
Injlamnuitions of.) — e. Chronic laryngeal and
tracheal injiammation — the laryngeal and tra-
cheal consumption of some writers — resemble
croup, in the hoarse voice, harsh dry cough, and
the difficulty of respiration ; but their progress is
much slower, and less acute than croup ; they
do not present the violent paroxysms towards

Idren

of respiration, independently of the obvious af- | night ; they seldom or never are observed in
fection of the throat, &:c., are sufficient to distin-
guish between them. When, however, portions
of the concreted exudations in these affections
irritate the glottis, they occasion a short, tickling,
dry cough ; and even excite, in some cases, stran-
gulating spasms of the larynx, nearly resembling

nd ulceration of these parts of the air-
passages is always found in fatal cases. — f.
Croup may also be confounded with the diffusive
inflammation which sometimes attacks, either
primarily or consecutively , the cellular tissueabout
the throat, or with abscessesin the same situation ;
croup, "particularly when it is complicated with ' either of which may involve the larynx and mem-
these maladies. If, however, it be thus associated, branous part of the trachea, or so afii?ct them as
the croupal characters, in addition to the appear- | to give rise to croupal symptoms ; but the ex-
ances in the throat and pharynx, will be too evi- i ternal appearances, the difficult deglutition, the
dent to be misunderstood ; the descriptions already | state of the throat, and the history of the case,
given of these complications being sufficient to' will at once show the differences existing between
point them out. —ft. During the ei'uptive fever of i them. — g. Pertussis and croup can hardly be
TOC((s/»(s, the tracheal affection is often so great as , mistaken for each other; the invasion, chai-ac-

CROUP — Causes op.

457

ters, and progress of both diseases being so very
different. The prolonged whoop, the unchanged
voice, and the occurrence of the cough in con-
vulsive paroxysms after a meal, terminating in
vomiting and a copious discharge of a clear and
glairy fluid ; the complete intermissions, respira-
tion, voice and speech remaining unaffected ; the
almost entire absence of fever, and the much
more slight and chronic form of the latter disease
in its uncomplicated state ; are sufficient distinc-
tions. Croup may, hovt-ever, occur in the course
of hooping cough ; but then its characteristic
symptoms will make it apparent to the attentive
observer, and point out the nature of the resulting
association. — h. The effects following si/ftsfanres
that have escaped into the trachea often resemble
croup; but may be distinguished from it by the
sudden occurrence of pain and suffocation ; by the
frequent change of the exact seat of uneasiness
with the change of the situation of the foreign
body ; the dryness of the cough, and the violence
of the strangulation; and by tlie irregularity, the
completeness, and sometimes the long continuance
of the intermissions. When a foreign substance
passes into the glottis, and is retained there, suffo-
cation is generally occasioned either from the size
of the substance, or from the spasmodic constric-
tion of the muscles of the larynx occasioned by
it. — i. Hysteria may also simulate croup; but
the age of the patient, the history of the case, and
the local and general symptoms, if attentively ob-
served, will indicate the nature of the affection. —
k. The spasmodic states of croup closely approach
to convulsive spasm of the lari/nx ; but the absence of
cough and fever, the brief fits of strangulation, the
complete intermissions, the spasm of the thumbs and
toes, the purplish countenance, and the general con-
vulsions,willdistinguish that affection from any form
of croup. (SeeLARVNx — Coiivulsive Spasm of.)

24. IV. Causes. — A. a. Croup is more fre-
quent in cold and moist climates than in those
which are warm. Rapid and frequent vicissitudes
of season, weather, and temperature, have consi-
derable influence in producing it. Hence its
prevalence in the valleys of Switzerland and Savoy,
in this country, particularly on its eastern side ;
in the other north-west countries of Europe ;
and in North America. But the middle, and even
the south of Europe, are not exempt from it. M,
Valentin has shown its frequency in the middle
and southern provinces of France, Goelis in Vi-
enna, and Ghisi in the north of Italy. SirjAnirs
M'G rigor notices its prevalence — probably in a
complicated form, from its occurrence also in
adults (§ 25.) — at Bombay, in 1800. According
to the information given by J urine, Lentin,
Cheyne, and others, we might be led to infer that
it has been more common in very modern times
than formerly : the difl^erence may, however, be
owing to its having been mistaken for some other
affection. I believe that it has not been so fre-
quently met with during the preceding five years,
as it was about twenty or thirty years ago. M,
J URINE remarks, that, although the table he has
given of the number of cases from 1760 to 1807,
shows a nearly progressive increase, yet he has
observed, at Geneva, no increase during the
last eighteen years preceding the dale of his
work. The following evidence, nevertheless,
would render it evident, that, in some countries
at least, croup is more prevalent now than for-

merly. According to the i nformatlon given by
Dr. CooKSON, a practitioner of forty years' expe-
rience in Lancaster had never seen it until 1760.
Dr. Friedlander (^Journ. de MontpeUier, No.
IX. p. 276.), states, that it has become yearly
more prevalent in Vienna; and that the physician
to the Hospital for Children, who had treated,
from 1774 to 1817, nearly 60,000 children, did
not meet with a single case in the three first years
of his practice, saw it but rarely during the next
six years, and yet treated 1665 cases of it in the
last five years of this period. Similar facts are
also furnished by Dr. Goelis. Although croup
occurs at all seasons of the year, it is most preva-
lent in those which are cold and moist, or when
the alternations of temperature are sudden and re-
markable. I have observed it more frequently in
the months of January, February, March, April,
November, and December, especially if east or
north-east winds prevail after heavy or continued
falls of rain. I believe that the above results are
nearly in accordance with those furnished by
JuRiNE, Crawford, Michaelis, Double, and
Bricheteau.

25. b. The great susceptibility of early age, and
the narrowness of the larynx previously to
puberty, have generally been supposed to favour
the occurrence of croup. M. Blaud, however,
denies that this latter circumstance has any in-
fluence in causing it. This is doubtless the case
in respect of the production of the disease, but
not as regards its severity and danger, both of
which it evidently increases. It is rare to meet
with croup until after the child has been weaned :
I have, however, seen it in children at the breast,
as early as three, four, five, and six months of
age ; but much more frequently at this age in
those who have been brought up by hand ; and
in a still greater number of instances, at from
seven months to upwards of a twelvemonth, in
those which have been recently weaned. M.
Duces states, that he met with an instance of it
in an infant of a few days old. The age at which
the disease is most common is, according to my
expeiience, from one yearto nine. But it not
infrequently occurs at both an earlier and a
later period. Van Bergen states, that it is often
observed from the age of two to five years inclu-
sive : Home assigns from fifteen months to twelve
years: Crawford mentions some cases from
fifteen months to two years, but gives the age of
from two to eight as the most common: Cheyne,
from sixteen months to twelve years ; Salomon,
from two to five years inclusive ; Michaelis, from
fifteen months to ten years ; Zobel, from the latter
months of suckling to nine years ; Vieusseux,
from seven months to ten years: Bernard, from
one to six years ; Barthez, from two to ten ;
RujisEY, till fourteen ; and Caillau, from
eighteen months to eleven years. The foregoing
applies only to the simple and uncomplicated dis-
ease. When it occurs in a complicated form, or
consecutively upon anginous affections, particu-
larly upon inflammation of the pharynx, tonsils,
or fauces, or on the exanthematous diseases, it
may, and, indeed, occasionally does, occur in adult
subjects, and in infants of a more tender age.
The cases published by JM. Louis, and denomi-
nated by him croup in the adult, were instances
of the anginous complication. Although the oc-
currence of uncomplicated croup in adults is very

458

CROUP —Causes of.

rare, cases have been observed by Hosack, Mit-
chell, Mills, and Latour.

26. c. M. Blaud and Dr. Albers observe,
that boys more frequently contract the disease
than girts, owing to tlie greater exposure of the
former to its exciting causes. Tiiis opinion has
been opposed by MM. Double and Royer-
CoLLARD ; whilst Dr. Jurine states, that of
ninety-one cases he treated up to 1808, fifty-four
were boys, and thirty-seven girls ; and of twenty-
eight cases which occurred in 1808, eighteen were
boys, and ten girls. According to his observation,
also, the greater number of cases occurred at the
ao-e of two, three, and four years ; and next at
one, five, and seven. This accords with my own
experience, which is further supported by that of
Goelis, who, from 1797 to 1808, treated 252
cases of the disease, of which number 144 were
boys, and 108 girls.

27. (/. The nervous and sanguine temperaments,
or a mixture of the two — the spasmodic charac-
ters predominating in the former, the inflammatory
in the latter — with a tendency to a fulness of
habit, seem to predispose to croup. That it will,
however, often come on independently of ple-
thora, cannot be disputed. I have seen it in
infants of about four months old, brought up by
hand ; and even in these, soon after having lost
much blood in the treatment of other diseases,
especially when cold easterly winds occur in the
spring or autumn, after heavy falls of rain.
Cheyne, and some others, conceive that an here-
ditary tendency exists in croup. But this is not
made out: for, as M. Desruelles has judiciously
remarked, the only proof that can be brought in
support of it, is the circumstance of two or more
children being seized with it in the same family ;
an occurrence which may be explained by the
susceptibility of age and temperament, being often
necessarily the same in several of them ; and by
their being exposed to the same agents, and placed
under similar circumstances.

23. e. The localities in wliich this disease seems
most prevalent are those wliich are low and moist,
near the sea, on the banks of large rivers or lakes,
or near marshes, in the depths of low valleys, or
at the bases of precipitous mountains. Hence
the endemic character, which some writers have
imposed on it, but which is not strictly applicable ;
for, although it is more frequently observed in the
above situations, yet it is also often met with in
places very oppositely circumstanced; and it cannot
therefore, strictly be said to be an endemic disease.

29./. The epidemic prevalence of croup has
been contended for, and denied, by writers.
Some consider it as entirely sporadic and acci-
dental ; others suppose that it may become epi-
demic consecutively upon catarrhal epidemics,
and that it has no other claims to such a cliarac-
ter ; whilst many believe that it occasionally ap-
pears in an epidemic form. That it has so oc-
curred in former times appears evident. Baillou
manifestly observed it in an ci)ideiiiic form, in
Paris, in 1570; Giiisi, at Cremona, in 1747;
Starr, in Cornwall, in 1748; Hosenstein, in
T'psal,&c., in 1762; Van Behoen, in Frank-
fort, in 1764; AVai.iip.om and I^aeck, in some
parts of Sweden, in 1768 and 1772; Barkir and
iMosT, in some places in the United States; Aui kn-
iiiKTii, alStiitgardt, in 1807 ; Aliuhs and others,
in parts of Saxony, in 1807 and 1808 ; Sciimidt-

MANN, in 1811 ; and various other writers during
the last fifty years. My own observation would
lead me to infer, that, although croup is generally
a sporadic disease, occurring occasionally at all
seasons, yet it sometimes assumes epidemic fea-
tures, both in respect of its simple state, and its
complications with other species of angina, par-
ticularly at periods when they or catarrhal affec-
tions prevail — the seasons favourable to the
production of these diseases most frequently occa-
sioning this malady also. This opinion derives
support from the numerous facts furnished by

RUMSEY, PiNEL, JuRINE, GoELIS, AlBERS,

Royer-Collard, Bricheteau, Bretonneau,
and other writers referred to at the end of this article,
30. g. Several authors, particularly Wichmann,
Boeiimer, Field, Rosen, Goelis, Lobstein,
Guersent, Louis, Shultz, and G, Gregory,
have adduced facts to show that the disease may
occasionally prove infectious. The two early
Swedish writers comtemporary with Home, namely,
Halen and Wahlbom, assert its infectious nature.
On the other hand, this property is denied by
Chalmers, Michaelis, Tiiilenius, Double,
and Albers. It has most indubitably manifested
this property when it has prevailed epidemically,
and when associated with cynanche maligna, and
some other exanthematous or anginous affections.
On several occasions, however, of its occurrence
within a short time, in two or more members of
the same family, it has evidently proceeded from
the same causes acting upon similar states of sus-
ceptibility and disposition. But even tlie simple
form of the disease has appeared in children who
have slept in the same bed with another affected by
it. Two or three such cases have occurred under
my own observation ; and others are recorded by
GoELis, and some other authors now mentioned.
Whether or not it was produced in these cases by
inhaling the air respired by the affected child, or
by the causes above stated, may be disputed.
Yet it is probable that the air which has been re-
spired by the affected may sometimes be a con-
current or determining cause of it in others.

31. B, Although the foregoing may be consi-
dered as predisposing causes merely, yet they are
very commonly the onlye.TcJfin^ cowses which can
be detected. There is no doubt, however, that the
causes which occasion common catarrh and
bronchitis sometimes also give rise to croup. It is
also not infrequently excited by, or at least conse-
cutive of, bronchitis, hooping cough, the various
forms of cynanche, measles, erysipelas, and scarlet
fever ; and it occasionally also appears during ad-
vanced convalescence from these, especially the
latter ; and, indeed, from other acute diseases. Also
running against the wind, crying, and exertions of
the voice ; cold acting in any manner, or upon any
part of the body, particularly upon the neck and
throat ; having the hair cut short during cold or
windy weather ; habitual exposure, and the laying
aside the accustomed covering of the neck and
chest; and even accidental attempts at swallowing
substances of an acrid nature, or of a very high
temperature ; have sometimes produced croup.
The retrocession of the above eruptive diseases,
and the suppression of other eruptions, or of dis-
charges, secretions, and excretions, are amongst
its most fre(iuent causes.

32. V. 1'atiiology or Croup. — i. Lesions
observed in fatal cases, A precise idea of the

CROUP — Pathology of.

459

organic changes which take place in the course
of the disease is necessary to enable us to devise,
at the commencement, appropriate means, both
for their prevention, and for their removal when
prevention is unattainable. The lesions observed
in fatal cases, and present in all, to a greater or
less extent, may be referred to two heads. —
1st. Inflammation with tumefaction, redness, in-
jection of the blood-vessels, and slight softening
of the mucous membrane of the air-passages.
2d. An albuminous exudation in the form of a
false membrane, or a thick, glutinous, and stringy
mucus, or both. (See Bronchi and Air-Pas-
SAGES — Lesions of, § 12.) A, The former of these
is usually observed, varying, however, in respect
both of intensity, and extent of surface affected.
In some cases, they are limited to the upper part
of the trachea ; in others, they extend to the
larynx, or to both the larynx and first divisions
of the bronchi, or to the latter merely ; and, in
complicated cases particularly, or when the dis-
ease assumes a seemingly epidemic, or even infec-
tious character, the inflammatory states now
enumerated, with the characteristic secretion,
exist also in the pharynx and fauces, and advance
downwards to the ramifications of the bronchi.
In the most acute forms of the disease, the
mucous surface of the trachea and larynx assumes
the above inflammatory appearances in the course
of a few hours. In the second stage of the dis-
ease, it becomes streaked, or partially covered by
an albuminous, and sometimes a sanguinolent
exudation ; and in the last stage, this exudation
has concreted to a more or less complete mem-
brane ; the inflammatory states of the surface
underneath still remaining, but in a less distinct
manner, and occasionally in patches or streaks
only. In some cases, the injection of the vessels,
and tumefaction of the surface, are but slight, yet
the exudation of a thick concrete membrane exists
to a considerable extent ; in others it is thin and
scanty, or almost entirely consists of a thick tena-
cious mucus.

33. jB. The morbid exudation varies much
in consistence, in quantity, and the extent of
surface covered by it. In some complicated or
consecutive cases, already alluded to, a false
membrane has formed from the fauces to the last
ramifications of the bronchi. MM. Bretonneau
and Bricheteau have observed it without any
breach of continuity throughout the whole of this
extent. I have never met with an instance
where it was so extensive, without interruptions,
particularly in the bronchi and about the larynx.
In the greater number of the pure uncomplicated
cases of the disease, the concretion exists princi-
pally in tiie upper part of the trachea. In tlie
more acutely inflammatory, it extends to the
larynx and epiglottis ; in others, to the first rami-
fications of the bronchi; and in a few, in both
directions. In the complicated cases, and in
those of an apparently epidemic and infectious
nature, the throat is equally affected, constituting
the Diphtherite, or the Infiammution pelliculaire
of'M- Bretonneau. This false membrane is
whitish, greyish white, or passing to a greyish
yellow. Its thickness varies considerably.
JMichaelis and Bard consider a line and half, or
two lines, to be its utmost thickness. I have
certainly seen portions quite as thick, but not
thicker, and sometimes evidently consisting of

two or more distinct layers. It is thickest in the
posterior and superior part of the trachea, and
thinnest about the larynx and epiglottis, when it
extends thither, and in the lowest and anterior
part of the trachea. Its consistence and tenacity
also vary extremely, not only in different, but
also in the same case. It is almost universally
softest where it approaches the bronchi, where it
generally passes into a thick glutinous mucus.
The more consistent and firm it is, the more per-
fectly is it moulded upon the surface from which
it was secreted. But when the consistence is
slight, it forms merely membranous shreds, or
soft polypous concretions, intermingled with a
thick glutinous mucus. The interior of those
exudations is generally covered with a whitish
tenacious mucus ; and their exterior, or the surface
which has been in contact with the inflamed
mucous membrane, is sometimes dotted with
minute specks of blood. In some cases, these
concretions are found still adhering to the surface
on which they are formed ; in others, they are
eitiier partially or altogether detached from it by
a puriform mucus.

34. The state of the exudation varies with the
stage of the disease, the intensity of the inflam-
mation, and the treatment which has been adopted.
Thus, when a child dies very early in the malady,
instead of the albuminous coating above described,
a tenacious, or reddish, frothy mucus is only
found. In this comparatively rare case, the
spasm of the air-passages attending the inflam-
mation, together with the obstruction occasioned
by this mucus, has produced asphyxia. It seems
that this glutinous exudation becomes more con-
densed, and moulded into a false membrane, or
partially assumes this state, as the disease advances.
(See Bronchi and Air-Passages.)

35. C. In many cases, instead of a mem-
branous exudation, a viscous, niuco-puriform
matter lines the trachea only, or both the trachea
and larynx, as remarked by Frank, Vieusseux,
Valentin, Double, Desruelles, Bricheteau,
Blaud, and Odier. This substance is whitish,
greyish, or yellowish grey, and occasionally floc-
culent. It is not infrequently formed in con-
siderable quantity in the more acutely inflamma-
tory cases (§ 12.), and particularly in those
which terminate fatally in some hours. It seems
as if the quantity of thick viscous matter thrown
out on the inflamed surface, together with the
spasm of the trachea and larynx, occasioned suf-
focation before it could be condensed into a
membranous substance. Cases of tliis description
have been particularly noticed by M. Hoybr-
Collard, and have occasionally come before
me in practice. I liave sometimes also observed
a thick, stringy, and adhesive matter, of a greyish
white colour, in the superior and posterior part of
the trachea and larynx, obstructing the passage,
the mucous membrane underneath being nearly
altogether exempt from redness and tumefaction.
In some instances, this matter has presented a
muco-puriform character, varying m its shade of
colour, but extremely thick and adhesive. A
similar appearance has been remarked by Des-
ruelles, Double, Blaud, and Brichetau.
Owing to the absence of the usual marks of
inflammation in the situation where this accumu-
lation has been met with, it may be presumed
that the inflammatory marks had partly dis-

460

CROUP — Pathology

appeared after the discharge of tliis matter; its
secretion promoting the resolution of the inflamma-
tory action, the remaiaing signs of which had
vanished after death ; the accumulated secretion
which had been instrumental in occasioning disso-
lution alone presenting itself, the powers of life
having been insufficient for its excretion. I have
suspected, from observing tlie progress of other
cases, that the inflammatory action sometimes had
commenced in the bronchi, and extended upwards
along the trachea, and that the secretion now
noticed had been chiefly furnished from the larger
bronchial ramifications, and had become so thick
and adhesive when it arrived at the upper part
of the trachea and larynx, as not to have been
expelled by the cough, but to have excited spasm
of the glottis, and thereby produced suffoca-
tion. In some instances of this description, more
decidedly inflammatory appearances were ob-
served in the larger bronchi than in the trachea.
It is probable in these, that the secretion found
in the latter situation proceeded chiefly from the
former, and that the injection of the vessels in the
mucous lining of the trachea had disappeared after
death.

36. D. Any very remarkable lesion of the tissues
subjacent to the mucous surface has not been
found, unless the disease has terminated in tracheal
consumption. It has been a question whether
or not the false membrane formed in croup
is capable of becoming organised, and united to
the surface that has produced it. We have no
conclusive evidence of such an occurrence, al-
though SoEMMERiuNG, Albers, and Bkicheteau
are inclined to believe it possible. The other
morbid appearances are chiefly the consequences
of the interrupted functions of respiration and
circulation through the lungs; such as' con-
gestion of this organ and of the brain ; hepatisation
of parts of the lung; emphysema of this viscus ;
and, in very young children, enlargement of the
thymus gland. The lesions observed in the com-
plications of the disease, as far as they have not
been already noticed, more strictly belong to the
particular maladies with which it is occasionally
thus associated ; where they are described, and in
the article Membrane.

37. ii. Nature of the Dhease. — Different opin-
tions have been entertained as to its inflammatory
nature in all cases, the exact character of the
inflammation, and the extent to which spasm of
the upper parts of the air-passages may contribute
to its production. The very slight inflammatory
signs sometimes found in the part covered by
the false membrane ; the absence of these as well
as of any fluid or concrete exudation, in other
cases ; the circumstances junder which the disease
has sometimes made its appearance, and tlie ab-
sence of phlogistic symptoms in its course, an
albuminous exudation eitlier forming notwith-
standing, or not at all; have induced several
writers to consider it as not merely an inflamma-
tion of the upper part of the air-passage, but a
disease of a peculiar nature, more or less con-
nected with llie state of the system, although prin-
cipally affecting the trachea and freijuently the
larynx, and large bronchi also. The opinions
of JlooEitY, Hahi.es, llECKEii,and many others,
amount to this merely ; and they seem not far
from the truth. I liave lemarked, that, although
croup assumes the more unequivocally inflamma-

tory form n strong and plethoric children, it
does not most frequently affect them, unless they
be of the sanguine or irritable temperament ;
that it presents every shade or modification from
this, to the least phlogistic and most manifestly
spasmodic form ; that even its most inflammatory
state may assume a spasmodic or nervous cha-
racter after large depletions, which, while they
diminish, as under every other circumstance of
disease, the phlogistic diathesis and symptoms,
increase the nervous aud spasmodic ; and that,
even when the first seizure has been of the inflam-
matory form, yet the relapses, or subsequent
attacks, which are sometimes repeated several
times at irregular intervals, have generally pos-
sessed more of the spasmodic character.

38. Another fact, which I have uniformly ob-
served, appears important ; namely, that the
quantity of fibrine and crassamentum in the
blood taken from the patient, and of albumen in
the urine, have been great in proportion to the in-
flammatory type of the disease, and the disposition
to form a false membrane ; whilst in the more
spasmodic varieties, in which an albuminous
exudation is seldom found, or at least but
sparingly, and the urine is more copious and
limpid, and less, or not at all albuminous, the
blood has presented a smaller or less firm crassa-
mentum. These facts evidently show, not only
that the state of the blood is different in these
forms of the disease, but that the condition of the
organic nervous or vital power, upon which the
appearances and constitution of the circulating
fluid so closely depend, is also dift'yrent ; and,
moreover, that the manifestations of both the one
and the other will vary in the different modi-
fications of croup, conformably with these results.
The combined and reciprocative operation of the
nervous influence, and the condition of the cir-
culating fluid, will give rise according to the
state of the frame, and the nature and combin-
ation of the exciting causes, to constitutional as
well as local phenomena; to a state of febrile
action, which will be inflammatory in, generally,
the majority of cases, nervous in others, and pre-
sent more or less of gastric, or even of adynamic
symptoms in some, particularly when the disease
occurs in a complicated or epidemic form. The
importance of attending, during the treatment of
particular cases, and of their different stages, to
the characters of the constitutional disturbance
— to the attendant fever, will be evident, as indi-
cating not only the means to be adopted, but
also the nature of the local mischief. Thus, in
the cases attended by inflammatory fever, the
exudation is abundant and rapidly formed ; in
that manifesting the nervous form, it is either
scanty, imperfect, or consists of a little glairy
fluid, — the spasmodic character predominating,
and cerebral symptoms sometimes supervening ;
and in that presenting the adynamic and gastric
form it is spreading, — being seldom limited to the
trachea and larynx, but often extending to the
pharynx, fauces, the mouth and even to tlie nostrils
on the one hand, and down the (esophagus and
bronchi on the other. It is in this last form that
the disease presents itself wiien it is epidemic or
infectious; and although the adynamic (or the
malignant character, according to .1. P. Frank)
often manifests itself early, yet the antecedent fe-
brile symptoms very evidently evince high action.

CROUP — P

39. There is one important point not sufficiently
adverted to by authors, viz. the very early period
at which the tracheal exudation is often poured
out, in the inflaminatory states of the disease ; the
symptoms marking the first or premonitory period
being those indicating the local developement of
the malady. Thus, a healthy child has evinced
no disorder for several days, or the disorder has
been so slight as to escape observation — it may
even be more than usually lively and alert on the
day preceding the night on which it is most se-
verely attacked ; and yet, if an emetic be that
instant exiiibited, a large quantity of thick, glairy,
sanguineous, and gelatinous matter will be brought
away from the air-passages ; showing that, in
many instances, the early advances of the inflam-
matory action is slow and insidious ; that the cha-
racteristic seizure often does not occur until the
exudation has accumulated to a considerable ex-
tent in the trachea, or the inflammation has ex-
tended to the larynx ; and that it is partly owing
to the retention of this matter, — which is evidently
thrown out in a fluid form, — that it concretes into
a false membrane, each successive discharge some-
times forming a distinct layer. AIM. Gendrin,
An DEAL, and other pathologists, have remarked,
that the inflammatory action which gives rise to
the albuminous exudation on the surface of mucous
membranes is of a sub-acute, rather than of an
acute kind. I believe that this is the case in
respect of the inflammation of the trachea and
larynx, in croup ; and that the formation of a false
membrane is the result not so much of the sthenic
or acute character of the local action, as of the
abundance of albumen and fibrine in the blood,
— a circumstance which partly accounts for the
frequency of relapses in some children (§41. o.),
and justifies IIarles, Hecker, and others, in
considering the disease to consist of a peculiar
form of inflammation. Some writers, however,
suppose that the very acute symptoms, and rapid
termination of many cases, militate against these
opinions ; but it should be recollected that, even
in the most severe cases, the inflammatory action,
when it commences in the trachea, often exists for
several days, in the manner already noticed, until
it has either extended to the larynx, or produced
such a quantity of albuminous exudation as will
obstruct respiration, or induce, by its irritation,
spasm of the air-passages, — these eftects being
the chief causes of the severity and rapid ter-
mination of the disease. This will become more
evident, when we consider the consequences of
interrupted respiration upon the frame — whether
the interruption proceed from the mechanical ob-
struction occasioned by the exudation and false
membrane, or the frequent recurrence or con-
tinuance of spasm of the larynx and trachea ; or
from inflammatory action, and its consecutive
exudation extending down the bronchi ; or from
two or all of these combined. These conse-
quences are, in fact, the third stage of the disease ;
the symptoms of which are the usual phenomena
resulting from obstructed respiration, interrupted
circulation, and congestion of the lungs ; imperfect
action of the air upon the blood, and the circu-
lation of this fluid in a nearly venous slate, with
congestion of the cavities of the heart, and impeded
return of blood from the head. The circulation,
moreover, of imperfectly arterialised blood to the
nervous systems occasions lethargy, with sinking
of the vital powers, and increases the disposition

ATHOtOCy OF. 461

to spasmodic action of involuntary parts, and to
convulsive movements of voluntary organs ; all
which (the former especially) become so promi-
nent a character of the malady in its advanced
stages, and often terminate existence. Thus it will
appear manifest, — and the fact is of great prac-
tical importance, — that the severity, rapidity, and
danger of croup, are not the immediate conse-
quences of the activity or acuteness of the inflam-
matory action ; but of the exudation to which it
gives rise, and of the conformation and functions
of the parts which it affects.

40. Duval, Jurine, Albers, and Schmidt,
have considered it worth ascertaining, in how far
the disease could be artijicially produced in the
lower animals ; and whether or not, when thus
produced, inflammation exists to the extent of
accounting for the phenomena, or gives rise to a
false membrane. They injected into the trachea
of fowls, dogs, cats, sheep, wolves, &c., various
irritating substances, as the bichloride or peroxide
of mercury (Schmidt) dissolved in spirits of tur-
pentine, and solutions of iodine, and nitrate of
silver ; they moreover made these animals inhale
the fumes of sulphuric and hydrochloric acids ;
and the results were just what might have been
anticipated, viz. that in some cases, inflammation
without any exudation was produced ; in others, a
fluid, or more or less concrete exudation was found
in various quantity ; and in all, the matter in the
air-passages was not sufficient entirely to obstruct
the access of air to the lungs; thus confirming the
opinion justly contended for by Cullen and others,
that a great part of the phenomena and conse-
quences of the disease is to be attributed to spasm
of the larynx and trachea. Schmidt succeeded
in producing a false membrane only in youno- ani-
mals,— a fact in accordance with the spontaneous
occurrence of the disease previously to puberty, and
to be referred to the more albuminous state of the
blood often observed at this period. It may be of
importance to know that croup — identical in its
phenomena and organic changes with the disease
in the human subject — occurs also in several of
the lower animals, especially before they are fully
grown. Its occurrence in chickens is well known
by the name of " Pip." Dupuy, Rush, Valentii^,
YouATT, and others, have observed it in horses
and dogs ; Double, in lambs and cats ; and
Ghisi and Gohier, in cows. In some of these
animals it has even occurred as an epidemic.

41. Pathological Conclusions. — Another point,
of greater importance than it may at first seem, is
whether or not the matter concreted and moulded
on the inflamed mucous surface be exuded by this
tissue itself, or secreted by the follicular glands
with which it is so abundantly supplied. M.
Grimaud has adopted the latter alternative. From
particular attention I have paid to this subject,
some of the results of which have been stated iu
the article Bronchi (§ 11, 12.), I would draw the
following inferences relative to it, and to the
pathology of croup generally: — (a) That the
mucous membrane itself is tiie seat of the inflam-
mation of croup ; and tiiat its vessels exude the
albuminous or characteristic discharge, which,
from its plasticity and the effects of temperature
and the continued passage of air over it, becomes
concreted into a false membrane ; — (h) That the
occasional appearance of blood-vessels in it arises
from the presence of red globules in the fluid when
first exuded from the inflamed vessels, as may be

462

CROUP— Treatment of its common Forms.

ascertained by the exhibition, upon the approach
of the symptoms, of a powerful emetic, which will
bring away this fluid before it has concreted into
a membrane ; these globules generally attracting
each other, and appearing like blood-vessels, as the
albuminous matter coagulates on the inflamed
surface ; — (c) That the membranous substance is
detached in the advanced stages of the disease,
by the secretion, from the excited mucous follicles,
of a more fluid and a less coagulable matter, which
is poured out between it and the mucous coat ;
and, as this secretion of the mucous cryptae be-
comes more and more copious, the albuminous
membrane is the more fully separated, and ul-
timately excreted if the vital powers of the re-
spiratory organ and of the system be sufficient to
accomplish it; — (f/) That sub-acute or slight
inflammatory action may be inferred as having
existed, in connection with an increased propor-
tion of fibro-albuminous matter in the blood,
whenever we find the croupal productions in the
air-passages ; but that tiiese are not the only
morbid conditions constituting the disease ; — (e)
That, in conjunction with the foregoing, — some-
times only with the former of these in a slight
degree, — there is always present, chiefly in the de-
veloped and advanced stages, much spasmodic ac-
tion of the muscles of the larynx, and of the trans-
verse fibres of the membranous part of the trachea,
which, whilst it tends to loosen the attachment of
the false membrane, diminishes, or momentarily
shuts, the canal (of the larynx) through which the
air presses into the lungs ; — (/) That inflamma-
tory action may exist in the trachea, and the exud-
ation of albuminous matter may be going on, for a
considerable time before they are suspected, — the
accession of the spasmodic symptoms being often
the first intimation of the disease ; and these, with
the effects of the pre-existing inflammation, give
rise to the phenomena characterising the sudden
seizure; — {g) That the modifications of croup
may be referred to tlie varying degree and activity
of the inflammatory action ; the quantity, the
fluidity, or plasticity of the exuded matter; the
severity of spasmodic action ; and to the pre-
dominance of either of these over the otheis in
particular cases, owing to the habit of body, tem-
perament, and treatment of the patient, &c. ; —
(/i) That the rnuco-purulent secretion, which often
accompanies or follows the detachment and dis-
charge of the concrete or membranous matters,
is the product of the consecutively excited, and
slightly inflamed, state of the mucous follicles,
the secretion of which acts so beneficially in de-
taching tlie false membrane; — (i) That a fatal
issue is not caused merely by the quantity of the
croupal productions accumulated in the larynx
and trachea; but by tiie spasm, and the necessary
results of interrupted respiration, and circulation
through the lungs; — (Ic) That the partial de-
tachment of fragments of membrane, particularly
when they become entangled in the larynx, may
excite severe, dangerous, or even fatal spasm of
this part, according to its intensity relatively to
the vital powers of the j)atient; and that this oc-
currence is most to be apprehended in the com-
plicated states of the malady, where the iiifl:uii-
matory action, with its ciiaraeteristic exudation,
spreads from tlie fauces and j)harynx to tlie la-
rynx and trachea; tlie larynx being often ciiieily
afl^'cted in sucii cases ; and from its irritability
and conformation giving rise to a more spasmodic

and dangerous form of the disease ;^(0 That the
danger attending the complications of croup is
to be ascribed not only to this circumstance, but
albo to the depression of vital power, and the
characteristic state of fever accompanying most
of them, particularly in their advanced stages ; —
(?n) That irritation from partially detached mem-
branous exudations in the pharynx, or in the
vicinity of the larynx or epiglottis, may produce
croupal symptoms in weak, exhausted, or nervous
children, without the larynx or trachea being
themselves materially diseased ; and that even the
sympathetic irritation of teething may occasion
the spasmodic form of croup, without much in-
flammatory irritation of the air-passages, par-
ticularly when the prima via is disordered, and the
membranes about the base of the brain are in an
excited i state ; — («) That the predominance in
particular cases of some one of the pathological
states noticed above (g), as constituting the dis-
ease, and giving rise to the various modifications
it presents, from the most inflammatory to the most
spasmodic, may be manifested in the same case,
at different stages of the malady, particularly in
its simple forms, and in the relapses which may
subsequently take place ; the inflammatory cha-
racterpredominating in the early stages, and either
the mucous or the spasmodic, or an association of
both, in the subsequent periods ; — (o) That the
relapses, which so frequently occur after intervals
of various duration, and which sometimes amount
to seven or eight, or are even still more numerous,
may each present different states or forms of the
disease from the others ; the first attack being
generally the most inflammatory and severe, and
the relapses of a slighter and more spasmodic
kind ; but in some cases this order is not observed,
the second or third, or some subsequent seizure,
being more severe than the rest, or even fatal,
either from the inflammation and extent of ex-
udation, or from the intensity and persistence
of the spasmodic symptoms, — most frequently
from this latter circumstance. The above in-
ferences, however minute or trite they may seem,
should not be overlooked, as they furnish the
safest and most successful indications of cure,
and are the beacons by which we are to be guided
in the treatment of the disease.

42. VI. Treatment. — i. The curative Treat-
ment OF Croup. I shall first state the method of
cure on which I would chiefly rely in the difl'erent
modifications of the disease ; and afterwards notice
some of the remedies which have been recom-
mended by various writers. Several of these are of
great benefit in certain circumstanoes of the dis-
ease ; but we can seldom depend upon any one of
them: it is on a judicious combination and se-
<|uenceof means that we should chiefly rely ; and
upon the adaptation and co-ordination of these in
particular cases. The intciit'wiis nj cure are — 1st,
to diminish inflammatory and febrde action, when
present; and to prevent, in these cases, the form-
ation of a false membrane, or the accumulation
of albuminous matters in the air-passages ; ■ — 2d,
when the time for attempting this has passed, or
when it cannot be attained, to procure the dis-
ciiarge of these matters ; — 3d, to subdue spas-
modic symptoms as soon as they appear; and 4th,
to support tlie ])owers of life in the latter stages,
so as to prevent the recurrence of sjiasms, and to
enable the system to throw off the matters exuded
in the trachea.

CROUP — TnEATMENT

43. A. Treatment of the comnwu and infiam-
inatory Croup, — a. If the practitioner see the
patient in the Jirst stage (§ 6.), particularly if
hoarseness, or a rough cough, with other catarrhal
symptoms, be present, it will be proper to give an
active antimonial emetic, with the view of ful-
filling the Jirst of the above intentions. This will
often bring away a considerable quantity of a
tliick, glairy, and sometimes slightly sanguineous
matter from the trachea, and will give immediate,
although generally only temporary, relief. If the
matter discharged from the air-passages present
the above appearances; if the child be pletlioric,
the pulse at all excited, and the countenance
flushed; we sliould not be deceived by the calm
following the full operation of the emetic, but
should have recourse to blood-letting. In the
majority of instances, cupping between the shoul-
ders or on the nape of the neck, or the application
of leeches on the sternum, to an extent which tlie
age, habit of body, and strength of the patient may
warrant, will be preferable to venesection. Under
these circumstances, particularly when the nausea
occasioned by the emetic has hardly subsided,
the abstraction of little more than an ounce, or
an ounce and a half, of blood, for every year
that the child may have completed, will be borne.
In town practice, the local is preferable to general
blood-letting ; but the latter will be adopted, with
advantage in the country, amongst plethoric and
robust children. The advantages of depletion
and antiraonials are attributable to their influence
in arresting the inflammatory action, and, from the
consecutively accelerated absorption of fluids into
the circulation, to the relative diminution of the
albuminous constituents of the blood. I have in
several cases directed, after a moderate depletion,
and after the operation of an emetic, a piece of folded
flannel to be wrung out of hot water, and freely
sprinkled with oil of turpentine, or with either of the
Zi«i;nenfs(F 296. 3 11.), and applied around the neck
and throat. This application has given instant relief.

44. Immediately after depletion, and an emetic,
the best internal medicine undoubtedly is calomel
and James's Powder — from three to five grains of
the former, and two or three of the latter being
given. This powder may be repeated every
second, third, or fourth hour, until two or three
doses have been taken. After the first dose, the
child should be put in a tepid bath, and be allowed
as much tepid diluents as the stomacli will bear, in
which carbonate of soda may be dissolved, and
which may be rendered agreeable with syrup. If
the powders, given to the extent now mentioned,
have not acted upon the bovvels, castor oil, or some
other purgative, assisted by an emetic, should be
administered. These means, aided by the turpen-
tine epithem applied around the neck, will seldom
fail of cutting short the disease. If, iiovvever, it
still proceed, the means to be employed in the next
stage should be adopted according to the circum-
stance of the case.

45. b. The second or developed stage is that
in which medical aid is most frequently resorted to ;
and at this period, conformably with what has
been stated ( § 39.), the disease is actually further
advanced than the symptoms indicate. At its
commencement, however, the frst intention of
cure should be attempted ; but the most decided
means will be now requisite to attain its fulfil-
ment. These should be put in practice, even
although the treatment already recommended

OF ITS COMMON FoRMS. 463

may have been employed in the preceding stage.
An active antimonial emetic should be instantly
exhibited, so as to produce full vomiting ; and
immediately upon the conclusion of its operation,
blood-letting, general or local, must be resorted
to. The abstraction of a greater quantity than
that indicated above (§ 43.) will seldom be more
beneficial, nor, indeed, will it be borne without
producing syncope, which, in children, especially,
should be avoided, as favouring the supervention
of convulsions or reaction. But it may be requi-
site, particularly when the patient has not lost any
blood during the preceding stage, to repeat the
depletion. On this, or on any luture occasion of
repeating it, local blood-letting, in the situations
and mode already mentioned (§43.), is now to
be preferred. If they have not been prescribed
previously, the calomel and J ames's powder should
be given every two or three hours, until tliree or
tour doses are taken ; and the adjuvants directed
to accompany and to follow this medicine in the
first stage, should also be employed in this.

46. Having thus carried depletion as far as
seems prudent, and fully evacuated the prima via,
if a very obvious improvement have not taken
place, or if the suffocating seizures recur not-
withstanding, dry cupping may be resorted to, and
afterwards either a blister should be applied be-
tween the shoulders, on the nape of the neck, or
on the epigastrium, but never on the throat, or the
turpentine epithem ($ 43.) ought to be applied
around the neck. If symptoms of febrile excite-
ment still attend the seizures, an emetic should be
given, so as to excite vomiting again, and be re-
peated until it has this effect fully. If the urgent
symptoms and fever still continue, vomiting may
be excited a third or fourth time at intervals of
two or three hours. The tartar emetic is, upon
t!ie whole, the best medicine for tiie pui'pose in
the early or inflammatory states of the disea.se,
and may be given in doses of half a grain, in
simple solution, to a child two or three years old,
as advised by Dr. Ciieyne, and repeated at about
half an hour, or sooner, if vomiting be not induced,
il. GuERSENT prefers ipecacuanha, and advises
blood-letting to precede the exhibition of emetics.
\\'here the inflammatory action is considerable,
this method may be adopted; but where we may
expect to bring away the exuded matter by means
of an emetic, before it has concreted into a mem-
brane, it will be as well to exhibit one without
delay, and to keep up a constant nausea by the
same medicines given in frequent and small doses,
liut I have seen the tartar emetic not only tail in
producing vomiting, but also prove injurious by
causing dangerous vital depression.

47. If the symptoms continue notwithstanding
tiie judicious use of the above means, we should
infer the formation of a false membrane, unless
the exacerbation be altogether spasmodic — the
breathing and voice becoming natural, or nearly
so, in the intervals. The measures to be employed
now should have reference to the separation
and discharge of the concrete exudation, and the
removal of spasmodic symptoms — to the fulfil-
inent of the second and ikird intentions proposed.
JJleeding, even if the state of the patient would
admit of it, would not promote these intentions ;
and the exhibition of calomel or mercurials,
excepting wiili the view of pronioting all tlie
abdominal secretions and excretions, and thereby
to derive from the diseased organ, would not

464

materially assist our views, inasmuch as it is im-
possible thereby to affect the system of children
so as to prevent the formation of coagulable
lymph. In this case, we should assist the oper-
ations of nature in detaching the false membrane.
It has been stated, that this is accomplished by
the effusion, by the excited follicles, of a fluid
matter between the concrete substance and the
mucous coat ; therefore those medicines which
have usually the effect of increasing and render-
ino- more fluid the raucous secretion of the air-
pa'ssages, should now be prescribed. But care
should be taken not to exhibit these or any other
expectorants, too early, or until depletion has been
carried sufficiently far. They are most service-
able about the termination of the second, and the
commencement of the third stage. The medicines
best calculated to act as expectorants in this dis-
ease are, the preparations" of squills,' of ammo-
niacnm, of senega, the carbonates, and the sulphu-
rets of the alkalies, and camplwr. The oxymel or
syrup of squills may be given, either alone, or
with some one of the sulphurets, or with senega,
and generally to the extent of keeping up a slight
nausea, unless the excerbations of cough and
suffocation be severe, when full vomiting should
be produced by their means. I prefer the emetic
effect at this period to be obtained by squills ; as
antimony lowers too quickly the vital power, which
ought now to be supported, so as to enable the
diseased organ to throw oflf the morbid matter
formed upon its surface. A mixture, consisting of
decoction of senega, with vinum ipecacuanhas and
oxymel of squills, may also be adopted with equal
advantage. When tlie medicines fail of exciting
vomiting, the pliarynx should be irritated by a
feather." I have seen very much benefit derived
from this simple means ; and have considered it
more beneficial than any other, in the third stage,
in promoting the discharge of matters from the
trachea. Jurine also places great reliance on it.
When severe exacerbations, with spasm and threat-
ened suffocation, occur, it is always most advan-
tageous to produce instant vomhing. The sulphate
of'zinc has been advised by RI.Gueksknt, and tlie
sulphate of copper by Dr. Hoffmann, for this pur-
pose. In this state of the disease, I have applied
the warm turpentine epitheni mentioned above
(§43.), around the neck, with almost instant benefit.
48. During this and the preceding stages, the
inhalation of watery and medicated vapours may
be resorted to. At the commencement of the
disease, vapours of an emollient kind are most
beneficial ; but when we wish to promote ex-
pectoration, camphor may be added to the sub-
stance used in this way. Home, CnAWFOisD,
Peahson, IlosEN, PiNEL, and Goelis, have ap-
proved of this practice. When spasmodic symp-
toms manifest themselves, inhalation, assisted by
the tepid or warm bath, is often of use; but anti-
spasmodics siiould also be prescribed with the
other medicines, or in enemata. I have never
seen any permanent advantage derived from nar-
cotics given by the mouth, except from opiuin or
syrup of poppies, combined witii antispasmodics;
probably owing to their lowering the vital ener-
gies, wiiich arc always much depressed when
nervous symptoms appear. Great care should be
always taken in exhibiting opiates in clysters to
children : in very young children tiie practice is
attended by much risk. Opiates are given to
(greatest advantage with ipecacuanha, as iu

CROUP — Treatment of its common Foums.

Dover's powder, or with camphor, or calomel, or
with both. I have likewise found camphor, with
James's powder, and hyoscyamus, of much benefit
in some cases in which I have prescribed it. The
hydrosulphuret of ammonia may likewise be tried
in both this and the next stage of the disease.

49. In many cases, the judicious use of blood-
letting, calomel, antimony, &c. will cut sliort the
disease, even although the patient may not have
been treated until this period has been far ad-
vanced ; and in others, the active use of these
means may give rise to very alarming depression of
the vital energies, eVen when they may have suc-
ceeded in removing the cause of obstruction and ir-
ritation in the air- passages. In these, stimulants,
an tispasmodics.and restoratives must be immediately
resorted to, but with great caution, lest the inflam-
matory action may be reproduced by their means.*

* The following case will illustrate the above observ.
ation, and may prove instructive to the less experienced
reader. I have extracted it verbatim from my note-book,
with the remarlcs suggested at the time appended to it ; —
William Hodson, aged five years and a half, was seized,
on the 17th of Nov. 1S21, with hoarseness, fever, and a
ringing, dry cough. The mother opened its bowels with
salts, and gave it some antimonial wine. The following
day, in the evening (ISth), I saw it. There was much
fever, with flushed countenance, and a constant, hard,
and ringing cough, witii a sibilous noise on respiration.
Pulse frequent and hard ; skin harsh and dry ; great
restlessness, tossing, dyspnoea, with hoarseness, and the
characteristic breathing of croup. 1 directed blood-letting
from a vein in the arm ; and the blood was allowed to
flow in a full stream till approaching syncope was indi-
cated, seven ounces being abstracted ; and the following
powders were directed to be taken every ten minutes, till
full vomiting was induced ; and subsequently every three
hours: —

No. 102. R Hydrarg. Submur. gr. xxx. ; Antimon.
Pot.-Tart. gr. iij. ; Pulv. Ipecacuanhae gr. vj. Misce
bene, et divide in Pulv. viij.

Early in tlie morning of the 19th I again saw the child.
The powders had been given, as above, until full vomiting
had been produced ; and one powder had been taken subse.
qucntly. The sense of suffocation had disappeared after
the vomiting. The matters ejected contained much thick,
ropy-mucus, with membranous shreds of firm coagulated
lymph floating in it. The cough and croupy symptoms
had disappeared ; the voice was clear, and the respiration
easy ; but now the cnild ccmiplained of distressing sick-
ness, with frequent vomituig and purging : the stools
\Vere first bilious, offensive, copious, and liEculent ; but
they had now become watery. The pulse was extremely
frequent, so as scarcely to be counted ; and so small and
thready as hardly to be felt at the wrist. The counte-
nance was pale and sunk ; the skin cool and moist ; and
all the symptoms of sinking of the powers of life, very
manifest. The powders were discontinued, and the fol-
lowing mixture directed: —

No. 103. R Aq. Cinnam. 3 iijss. ; Spirit. Ammon.
Aroni. 3 jss. ; Tinc't. Opii lUxv. ; Syrupi SciUae 3 iij- M.
Two teaspoonsful of this were to.be taken every ten or
fifteen minutes, until a decided effect from it was evident.
After four or five doses, the stools and sickness were re-
strained, and the child fell into an easy and sound sleep,
A blister was now applied to the sternum, which was
to be 'removed at the end of four liours, and poulticed
with a bread-and- water poultice. Thesemicupium to be
employed afterwards, and at bed-time. Three grains of
calomel, witli one of James'g powder, to be taken at
night, and tlie mist, camphora;, with liq. ammon. .icct.,
vinum ipecacuanha;, and syrupus papaveris, every three
hours. Linseed tea or barley water, witli sugar-candy or
li(|Uorice for common drink.

20th All the symptoms of croup had disappeared ; but

tliere was still some cough and fever, with occasional pa-
roxysms of difficult breatliing. The bowels had been open
this morning ; pulse 120, and small. Antimonial wine was
added to the mixture ; and an injection directed, with as-
safu'tida, sjiiritus tcrcbinthiiuB, oleum ricini, and camphor,
III the evening. — He had had no return of the paroxysms
since the injection, which was retained above an hour,
and had procured two evacuaticms. Pulse 116; cough
less frequent ; skin more natural. The blistered surface
had risen in some parts, and was inflamed in all.

Krom this time he continued to recover : diaphoretics,
demulcents, aperients, and the semicupium, being em-
ployed uiilil convalescence was complete.

yi'(7»(o7..s- — It is by no means unusual to find a recurrence
of the iiillairiiiiatory and local symptoms after they have
bceu apparently most completely subdued by means similar

CROUP — '■ Treatment of the Spasmodic Form. 46>

extremities. I have, however, seen more advan

50, c. The tveatment of the tliird stage, either
when the patient has not been earlier seen, or
when previous measures have failed, should be
directed with the view of fulfilling the seciuul and
third indications of cure, and at the same time
with due reference to the J'ouyth — the preservation
of the exhausted nervous and vital powers. The
chances of recovery are now very few, but these
few should not be neglected. J\Iuny of the reme-
dies, already mentioned, especially eipectorants,
should also be exhibited in this stage ; and these
ought occasionally — particularly when the symp-
toms become very urgent — to be given so as to
exert a speedy emetic action ; and be combined
with antispasmodics — with either camphor, am-
monia, ajtiier, musk, valerian, assafoetida, the oxide
of zinc or trisnitrate of bismuth, the sulphurets of
the alkalies, &c.; and the same medicines, or the
infusion of valerian, may also be prescribed in
eneniata, especially when spasmodic or nervous
symptoms are predominant. When emetics are
exhibited in this stage, those substances which are
required in smaller doses in the remissions, in order
to act as nauseants or expectorants, are amongst
the most eligible — particularly squills, senega,
the sulphate of zinc. The inhalation of the vapour
of ammonia, camphor, or rether, in that of warm
water ; or of the fumes of warm vinegar, either
alone, or with camphor ; is sometimes productive
of benefit in this period. Some advantage may
also be derived from sternutatories blown into tiie
nostrils, as advised by Lentix, and Thilenius.
I have seen, in two or three instances, tlie
sneezing occasioned by them favour remarkably
the discharge of the false membranes from the
trachea ; common Scotch snufi" having been used
for this purpose.

51. The tepid bath may be resorted to both in
this and the preceding stage, once- or twice daily,
or according to circumstahces ; and either the sul-
phuretof potassium, or the carbonates of potash or
soda may be put in the water ; and, if a tetidency
to collapse becomes apparent, the bath sTiould be
■warm, and some mustard may also be addedt
JBUsters between the shoulders, or on the sternum,
may likewise be tried ; but they always require
great discrimination and care, in order to avoid un-
pleasant consequences from them, 'i'hey should
not, in this stage, remain on longer than from
four to eight hours. Home and Thilenius advise
them to be applied to the* neck; Lentin and
GoELis, to the neck and sternum ; and Royer-
CoLLARD, between the shoulders-or on the arms ;
Maercker states, that he has derived, but little
benefit from them. Olbers and Rover-Collard
speakfavourably of sinapisms placed on the lower

to those employed in the foregoing case; and even after the
powers of life, and all local inflammation and febrile ac-
tion, had been equally depressed. This recurrence of the
acute symptoms seems owing to cither an over active use
of stimulants, or an injudicious choice of them in the
collapse occasionally following the decided use of blood-
letting and antimony. Sometimes it arises from exposure
to cold, or a current of cold dry air ; and then, generally, a
distinct chilliness or rigor is previously felt. Occasionally
1 have traced it to too early recourse"to food, or articles
of a too stimulating and indigestible description. In-
attention to the state of the bowels will also dispose to it;
and even a blister applied too near upon the scat of disi
ease has evidently produced such an effect, especially in
thin irritable children. In no case would I permit a
blister to be placed upon the throat, so firmly am I per-
suaded that mischief is occasioned from it in this situation.
Vol. I.

tage accrue from rubefacient liniments(F. 299. 304.)
orepithems, applied on the epigastrium and chest,
or between the shoulders. During this, as well as
the preceding stage, a cathartic action should be
exerted upon the bowels, unless the medicines pre-
viously exhibited occasion diarriioea, or dysenteric
syirrjjtoms, RIedicines of this description are be-
neficial, as active derivatives from the seat of dis-
ease, and as evacuants of morbid secretions. Calo-
mel, with jalap, may ba given, either alone, with
musk, or some other antispasmodic medicine; but,
in every instance, the occasional exhibition of an
enema should not be neglected. Olbers, Albers,
anil J urine, strenuously advise large doses of
musk to beexhibited ; and Kendrick and Royer-
CoLi.ARD, assafwtida to be administered in clysters.
The ajfusion of cold water on tiie head has been
sometimes resorted to by IIarders, Schmidt,
and myself, when the preceding means have
failed, particularly if congestion or other'cerebral
symptoms have supervened, and the exacerbations
have assumed chiefly a spasmodic form.

52. B. Treatment of the humid and spasmodic
forms of croup. — a. In the humid or bronchial
form of the disease, the intentions of cure are, — .
1st, to subdue inflammatory action ; 2d, to remove
the matters exuded from the air-passages; 3d,
to calm spasmodic action; and, 4th, to support
vital power. These can be attained only by bleed-
ing, general or local, as already advised, but never
from the throat itself; in the early stages by
antimonial emetics, and subsequently by those con-
sisting of ipecacuanha or sulphate of zinc ; by ca-
lomel, with James's powder, as prescribed above j
and afterwards with other purgatives, as scam-
mony or jalap; by cathartic enemata ; by e.\ler-
nal dericuliies ; and, lastly, by antispasmodics and
diffusible stimulants. Of tliese, individually, little
need be added to what has been already advanced.
]More advantage seems to be derived from purga-
tives, in .this, than in' any other form of the dis-
ease. I have sometimes seen them bring away a
thick, gelatinous, glairy secretion, similar to that
discharged- from the air-passagesin the advanced
stages. Their operation should be'promoted by the
administration of purgatives in antispasmodic clys-
ters, as extract of colocynth with assafcetida, va-
lerian, or camphor ; and if spasmodic symptoms
become urgent, the sulphurets or carbon-
ates of the alkalies, and either of the various
antispasmodics already mentioned, may also be
taken by the mouth, particularly camphor,
with James's powder, or Kermes mineral, or ipe-
cacuanha, with spirits of nitre, aether, or other dia-
phoretics. The medicated te/«'rf or moderately uwrw
batlt, blisters, the turpentine epilhem applied
around the neck and throat, rubefacient liniments,
the inhalation of simple or medicated vapours, may
also be resorted to in the manner detailed above.
In the last stage, when the powers of life indicate
exhaustion, ammoniacum, senega, oxymel of
squills ; and camphor, assafcetida, musk, ammonia,
the ajthers, &c. in full doses ; and rubefacient and
stimulating frictions, liniments and baths, with
the rest of the treatment already recommended at
this period ; are the chief means in which we can
confide.

53. /). In the spasmodic form of the malady
the indications of cure are very nearly the same
as now stated j but the treatment will neces-
Hh

466

CROUP — Treatment of its Complicated I'orms.

saiily vary with the extent to which inflammatory
irritation may be supposed to exist either in or
about the hirynx, particularly soon after the ap-
pearance of the disease ; or about the medulla
oblongata, in its more advanced course. In that
state of constitution in which this form is most
frequent, bleeding is seldom required beyond that
procured by a few leeches applied to the nape of
the neck, when we infer the presence of inflam-
matory irritation in tlie above situations. In this
modification, whether occurring primarily, or in
relapses, unlispasinodics, given both by the mouth
and by clysters, are indispensable ; but emetics, and
afterwards cathartics, medicated tepid or warm
baths, and inhalations, the turpentine epithem ap-
plied around the neck, blisters, or rubej'ucient
frictions and liniments along the spine and over
the epigastrium, and the cold affusion on the head,
also constitute important parts of the treatment.
The antispasmodics most to be confided in are,
the sulphurets and carbonates of the alkalies, va-
lerian, assafoetida, ammonia, camphor, musk, the
preparations of asther, the oxide of zinc and trisni-
trate of bismutli, and the liquor ammonia; acetatis,
with excess of ammonia. Mr. Ki.mbell states,
that he has derived most advantage from the in-
ternal use of arsenic, or sulphuret of potassium,
aided by regular attention to the bowels, the
shower bath, and by blisters or anodyne frictions
on the spine. Of arsenic I have had no experience
in this affection ; but I have given the preparations
of bark, and used the other remedies he has men-
tioned, with advantage. If the above means do
not soon remove the disease, irritation about the
base of the brain or medulla oblongata should be
suspected, and leeches ought to be applied on the
neck ; and calomel, with aperients, or with musk or
camphor, exhibited once or twice daily, injections
being also employed : cerebral symptoms should
be always enquired after, and energetically treated
when delected.

54. C. Treatment of complicated and con-
secutive Croup. — The treatment of the various
complications of the disease must be directed
according to the general principles now sketched;
and with strict reference to the nature of the
associated malady, to the period of the primary
disease at which it appeared, to the characters
of the attendant constitutional disturbance, and
of the prevailing epidemic, and to the well-ascer-
tained fact that local inflammations supervening
in the course of continued or eruptive fevers,
although they require depletions, do not admit
of them to the same extent as those which occur
primarily.

55. a. The association of croup with in-
Jlammation of the throat, and exudation of lymph
in this situation, whether originating in the
pharynx, wiiicli is rarely the case, or extending
thither and to the air-passages from tiie fauces
and tonsils, is one of the most frequent forms in
which the disease presents itself, particularly
when epidemic or infectious, and is, therefore,
deserving of particular notice. But the treat-
ment must, in great measure, depend upon the
degree in which eitiicr stiienic or astlienic in-
flammatory action and fever may be considered
to exist. Although great increase of vascular
action is present al the onset, in the majority of
such cases; yet it is often attended by deficient
vital power, and exhaustion soon takes place.
Even ill the most sthenic cases, the treatment j

which would have been of service at first is soon
no longer admissible ; whilst in other cases, and
in some epidemics, very marked adynamia is
manifested from the commencement. Much
depends on the precision with which the exact
nature of the case and the state of vital power
are ascertained, and on having early recourse to
judicious measures. As to the predominance of
either of the states of morbid action alluded to, the
frequency and tone of the pulse, the colour of the
exudation in the throat, and of the parts sur-
rounding it, and the continuance of the disease,
are the chief guides. If the inflammation and
exudation commence in the tonsils and spread
downwards, if the exudation be of a light colour,
and the inflamed parts of a lively hue, the pulse
being strong, full, and not very quick, depletions,
general or local, the use of emetics and nauseants,
and the rest of the antiphlogistic treatment, are
required ; but the further the disease departs
from these characters, the darker and dirtier the
exudations appear, the more livid and deeper the
colour of the inflamed parts, the quicker, softer,
and weaker, the pulse, the more should anti-
phlogistic measures be relinquished, unless in
some cases to a moderate extent, and at the very
commencement of the complaint ; and the more
ought we to have recourse to camphor, ammonia,
the decoction of senega, ammoniacum, &c.

56. h. The nearer the complicated disease, in its
local and constitutional manifestations, approaches
to the malignant form, the more extreme is the
danger, and the greater necessity is there for the
exhibition of tonics and stimulants. In such cases,
the decoction of senega, the infusion of serpentaria,
or mixture of ammoniacum, may be prescribed,
with camphor, and any of the compound spirits of
ammonia: or the decoction of bark, with liq.
amnion, acetatis and tincture of capsicum; or the
sulphate of quinine, with infusion of roses, and the
aethers ; or either the chlorate of potassa, or the
hydrochlorate or sesqui-carbonate of ammonia, with
camphor, musk, myrrh, assafoetida, &c. in suitable
vehicles. When the paroxysms of sufTocation be-
come urgent, senega, preparations of squills, or F.
402., may be given in doses sufficient to produce
vomiting, and repeated according to circumstances ;
and active stimulant and antispasmodic clysters be
thrown up. The vapour of camphor and warm
vinegar may also be employed, and various stimu-
lating and arotriatic fumigations resorted to. The
mouth and throat should be frequently gargled, or
washed, by means of a sponge fixed to the end of a
piece of whalebone, with a solution of the chloru-
rets, or of the bi-borate of soda in camphor mix-
ture; or with a weak solution of nitrate of silver, — •
a scruple to an ounce of distilled water, — as first
advised by Mr. Mackenzie ; or with Goulard
water, as suggested by Dr. Haimimon ; or with
the chloric acid or chlorine in decoction of bark,
or other stimulating detergents ; and sinapisms or
embrocations with Cayenne pepper, or rubefacient
liniments (F. 3U0. et cet.), may be applied on the
nape of the neck, oron the lower part of the chest,
and on tiie epigastrium. In tlie conqilications of
the disease with angina maligna, observed by
LoEi-ir.EK and Hretonneau, powdered alum was
directed by them to be blown into the throat ; and
various other astringent and antiseptic powders may
be employed in the samemanner. When the cha-
racteristic eruption of scarlatina accompanies the
affection of the throat and air-passages, the treat-

CROUP — Remarks on various Remedies employed in.

467

tnent must be directed according to the same
principles. In all cases of angina, attended with
membranous exudation, whether the attendant
constitutional disturbance present sthenic or
asthenic characters, the local treatment advised
by Mr. JMackenzie should be adopted upon the
appearance of the exudation on the tonsils or
fauces, and a large blister should be applied early,
as being the most efficacious means of preventing
the extension of this form of inflammation to the
pharynx, air-passages, or oesophagus.

57. c. The tieatment of the complications ivitli
aphthce, or tviih any of the eruptive fevers, will
depend, as much as the foregoing, upon the state
of vital power characterising the constitutional
afTection. The appearance of croupal symptoms
in the course of small-pox — particularly confluent
small-pox — will require nearly the same medicines
as have now been recommended {§ 56.) ; and the
washes advised to be applied to the mouth and
throat will be equally serviceable in the aphthous,
as in the variolous complication. When croup is
consequent upon either measles, or hooping cough,
vascular depletion is more frequently required
than in almost any other complication, excepting
that with inflammation of the throat of a sthenic
kind, whether attended by albuminous exudation
or not.

58. -D. The affections consequent upon croup — or
the states of disease which itexcites, or into which it
passes — acquire not only appropriate remedies, but
also the application of them with strict reference
to the primary malady, and the means by which
it was combated. When it runs on to bronchitis,
the latter affection commonly assumes the asthenic
form, generally terminates fatally, and requires
tlie treatment described in the art. Bronchitis
(§70. et seq.}. Its passageinto pneumonia'is attend-
ed with similar results ; and depletions, unless they
have been previously neglected, are not well borne

59. Remarks on various Rejiedies advised,
AND ON THE Opinions of Authors respecting
THEM. — a. Nauseants and emetics. In the first
stage of the disease, and in the commencement of
the second, I have sometimes found that tartar
emetic, given so as to produce and prolong a state
of nausea, has so completely relieved the croupal
symptoms as to prevent altogether ihe necessity of
having recourse to blood-letting : and that in other
and more severe cases, the same medicine, exhibited
so as to produce vomiting, and to continue the
nauseating effect for some time afterwards, and
thereby to prevent reaction supervening upon the
emetic operation, has been followed by a similar
result. Emetics have been much recommended
after blood-letting, and the inhalation of vapour,
and vvhen the exudation is presumed to begin to
loosen, by Home, Lentin, Darwin, Maercker,

PORIAL, S.IIITH, HeCKEU, ViEUSSEUX, RuMSEV,

&c. When the patient has not been visited suf-
ficiently early, this plan is certainly judicious. But
when he is seen in the first stage, it will be better
to attempt to prevent the formation of the false
membrane, by exhibiting nauseants or emetics in-
stantly, as now advised, and, unless the inflammatory
symptoms are very severe, before having recourse
to blood-letting. This early exhibition of emetics is
sanctioned by CRAvvfORD,CiiEYNE,PiNEi,,nosACK,
Thompson, Hufeland, Albers, Schwilqle, &c.
Dr. Gaisler prescribes, on the invasion of the
disease, tartarised antimony and oxymel of col-
chicum. Whilst vascular excitement continues,
either this combination, or the antimony only, in
repeated doses, as suggested by Chevne and
MicHAELis, is the best emetic; but when we
wish to detach the membranous exudation, the
preparations of squills, alone, or with ipecacuanha,
are preferable. In the more spasmodic form of the
disease, ipecacuanha, as Goelis remarks, is as
suitable an emetic as can be adopted : but when

sulphate of zinc, given with stimulants and anti-
spasmodics, or F. 402., or thesulphate of copper (En-
cj/c/og.t.xxii.E. p. 10.), are to be preferred. Goelis
recommends emetics in the first stage of the least
inflammatory forms, and generally in the third

When diarrh(xa or dysenteric symptoms are pro- j it is found necessary to exhibit such a medicine in
duced, in the latter stages, by the means used to | the last stage of the disease, or when it is associated
remove the disease, we shall generally find the with angina maligna, or attended by symptoms
preparations of opium, and the warm bath, as of depressed vital power, senega, squills, or the
hereafter to be noticed, of much benefit. A con- ' ' " ' ■ . ; . - .

siderable number of cases, particularly those
complicated with sore throat, terminate in sinking
ov exhaustion of vital power, and not by suffocation.
This circumstance should be kept in view in the
treatment of the last stage ; and its earliest in-
dications be met with suitable stimulants and
tonics (§ 56.). In cases presenting imminent
suffocation, the question of tracheotomy should be
entertained ; but at the same time, with the re-
collection, that either exhausted vital power, the
extension of disease to the bronchi, and the ac-
cumulation of viscid or concrete exudations in
them, or inflammatory action, or emphysema of
the lungs themselves, may tend, individually or in
combination, to preventthesuccessof the operation,
independently of the immediate contingencies to
which it is liable. (See § 74.) *

* I may here adduce a summary of the practice adopted
liy the most experienced physician in France in this dis-
ease— the senior physician to the Hospital for Children
in Paris. It will be seen how closely it agrees with mv
own, in a similar institution in London : —

W. Jadelot considers croup as a kind of angina of the
air-passage ; presenting more violent symptoms, and
having true paroxysms, separated by well-marked inter-
missions of a special character. He admits different
degrees of the disease, without changing its nature.
ISleeding by leeches, and emetics, are the agents he most

frequently employs in its treatment. Emetics alone have
often sufficed to stop the disease, especially in weak, pale,
or bloated subjects ; but, in opposite cases, he insists on the
application of leeches, and allows the blood to flow until
the child becomes pale, and the pulse loses its strength.
After the bleeding, he causes vomiting, several times in
succession, at intervals of two or three hours ; and the
practice is attended by the greatest success, relief being
very apparent after each vomit.

AVhen the croup has arrived at the second period, with-
out having been opposed, and the presence of a false
membrane is suspected, M. J. directs leeches to be ap-
plied ; but, the moment they fall off, he hastens to produce
vomiting : and it is in this case that he employs, by
spoonsful, every ten minutes or quarter of an hour, the
mixture called anticroupal*, un'il full vomiting is pro-
duced. He insists, also, upon the use of errhines, and of
derivatives applied to the skin and intestinal canal.

When the disease is very rapid, it has been a question
whether or not we should commence by bleeding, or bv
an emetic. W. J.'s opinion is, that we should first bleed",
if the child be robust, and if it present signs of congestion
towards the superior parts ; on the contrary, he would
commence by vomiting, when the subject is p'ale and ex-
hausted, and there is little heat or fever. ( Ratier's
Medical Guide, 4'C.)

* B Inlusi Polygalae Senegae 3iv. ; Svrupi Ipecacuan-
ha- 5j. ; Oxymel. Scillae 3iij.; Antimon. Totassio-Tart.
gr. jss. Misce.

Hh 2

468

CROUP — Remarks on various Remedies employed in.

stage ; but he prohibits them in the second or in-
flammatory stage, and when suftbcation is threat-
ened towards the close of the disease. When,
however, potassio-tartrate of antimony is employed,
and nausea is kept up in the intervals between the
emetic operation, as I have recommended above,
bleeding being also employed, tlie reaction dreaded
by this experienced writer will not come on. His
objections to an emetic in the paroxysms of suffo-
cation occurring towards the close of tlie malady
may be well founded, were antimony or even ipe-
cacuanha to be then prescribed ; but, when zinc,
squills, and senega, are conjoined with stimulants
and antispasmodics, and their operation accele-
rated by irritating the pharynx, I have seen the
air-passages thereby freed from the substances
obstructing them, and t!)e patient saved.

60. B. Bleeding, general or local, or both,
although indispensably requisite in the great ma-
jority of cases, is not always of service. Rujisey
and Muggins remarked its injurious effects in
the complicated cases they treated ; and the more
nearly the disease approaches to the spasmodic,
and the febrile symptoms to the adynamic cha-
racter, particularly in the complications, the more
likely is it to be of little benefit, or even injurious,
unless the state of action and habit of body evi-
dently require it. In the more inflammatory
states, it should be promptly and fully performed ;
the use of nauseating medicines generally pre-
venting the necessity of having recourse to very
large or injurious depletions. Gmsi, Home,
Crawford, Rosen, and others, have preferred
general blooddetting at the commencement ; and
Bavlev, Miudleton, Balfour, and numerous
writers, have recommended the jugular vein to
be chosen. Trebeh, HiRsruriELD, Werner,
GoEi.is, and IMalfatti, very experienced physi-
cians in Vienna, employ local depletions, except-
ing in the most inflammatory cases ; and I agree
with them, diflering only in preferring cupping to
leeches. As to the period at which it should
ba resorted to, I believe, with Goelis, that little
will be gained by resorting to it before inflam-
matory action is manifested, or after excitement
has subsided. A suppressed and apparently weak
pulse, early in the disease, is often rendered full
and hard by venaisection, and a repetition of the
operation required, — a circumstance evincing
the importance of interpreting aright the state of
the circulation. Of forty-seven cases treated by
GoELLs, in 1808, seven were blooded from a vein ;
thirty-four by leeches only; and six were not
blooded at all. The average quantity of blood
that I have found requisite to take, altogether, as
nearly ns I can calculate, is about five ounces in
children of three years, seven or eight in those
of five or six, and about ten ounces in those
from ten to twelve. This result relates chiefly to
those not seen until the second stage of the more
inflammatory or common forms of croup. I have
met with cases in which blood-letting iiad been
chiefly confided in, and been carried to the utmost
extent ; but it certainly had seldom or never cured
the disease, when thus employed, and even some-
times had been evidently injurious. The cele-
brated VVashinc;ton was said to have died of
croup. He lost, at the age of sixty-eight, about
ninety ounces of blood in twelve hours. An
attentive perusal of the cases published by Dr. S.
Jackson (/Imer, Juurit. of Med, Sciences, vol, iv.

p. 361.) will show the inefficiency and injurious
effects of excessive depletions.

61. y. Calomel and inercurial inunction have
been most strenuously recommended, the former
especially, since it was first prescribed by Rush,
and in larger doses by Stearnes, Marcus,
AuTENREiTH, Anderson, J. P. Frank, Blegbo-
RouGH, Neumann, Michaelis, and others, who
gave it every three or four hours. Hamilton di-
rects it, in full doses, every hour or two hours at
first, and subsequently at longer intervals; Hecker
advises it in small doses ; and Wigand states that it
is of no use. Chevne prescribes it with James's
powder ; Harles and others, with the officinal pre-
parations of antimony; ScnyEFFER, with emetics
and musk ; Schluter, with oxide of zinc and other
antispasmodics ; MicHAiii.is and Neumann, with
expectorants; Archer, JNIarcus, and Hufeland,
with decoction of senega, and mercurial inunction
about the neck : and Aucustin, with opium. In
the stages attended by excitement, it is best con-
joined with James's powder, or potassio-tartrate of
antimonj', as prescribed above ; andsometimes with
opium, or Dover's powder, and subsequently, if
it be given at all, with purgatives ; expectorants,
antispasmodics, &c. being exhibited in the in-
tervals. GoELis conceives that it is useful in
diminishing the tenacity of the croupal exudation,
and in retarding its formation. He moreover
supposes, that tlie daily exhibition of a small
dose of this medicine subdues the diathesis, or
constitutional disposition to contract the disease ;
and when croup has been prevalent, and appeared
in one of a family, he has given about a grain at
bed-time daily to each of the other cliildren.

62. S. Blisters and counter-irritants have been
already mentioned ; but there are certain points,
particularly as respects the period and manner in
which they ought to be employed, that require to
be noticed. There are very few writers who have
not recommended blisters in croup, but quite as
few have done so with the wished for precision.
On this subject, Goelis is more practically
niinute than any other writer ; and in many re-
spects his experience coincides with my own. I
believe that most advantage will be derived from
as early an application of a large blister, as is
consistent with the previous employment of blood-
letting. Directly after the first depletion, there-
fore, one should be applied in either of the
situations advised (§ 46.); a piece of fine tissue
paper being placed between it and the skin. It
ought to be removed upon the appearance of
redness of the cuticle, and a warm bread and
water poultice placed over the part, and fre-
quently renewed. If blisters be used in the latter
stages, they should be watched with great care,
and be allov.'cd to remain for a few hours only,
and not a minute after slight redness is produced.
1 believe that the dangerous effects sometimes
occasioned by them are owing to the want of
these precatitions, and to having recourse to them
at a lime when the vitality of superficial ))arts is
soon exhausted, owing to vital depression and to
deficiency of blood, conse<iucnt upon excessive
depletion. Tiie liberal use of calomel, parti-
cularly when it has not been carried oft" by pur-
gatives, may also, by increasing the irritability of
the tissues, dispose to unfavourable results from
blisters. If prescribed at all, they should be of
full size ; they ought never to be applied over the

CROUP — Remabks on vauious Remedies employed ix.

throat, as recommended by some writers ; and, in
very young and delicate children, it will be better
not to place them over leech-bites. In the latter
periods, I prefer to blisters the use of warm poul-
tices, on the surfaces of which Cayenne pepper
and scraped camphor are sprinkled in quantity
sufficient to produce redness of the cuticle ; or the
application of warm cloths, moistened with either
of the liniments, F. 300. 307, 308. These are
particularly useful upon the removal of the patient
iVom a warm bath, especially in the compli-
cations of the disease. The turpentine epithem
already advised applied around the neck has
proved, in my practice, more successful than any
other remedy, constitutional or local. It may
be employed at anj' period of the disease, and is
highly beneficial in all its forms. Sinapisms have
been directed by many to be applied to the ex-
tremities ; but I have seen more harm than benefit
produced by them, from the distress and crying
they occasioned.

&i. E. Internal and external emollients !\Te some-
tinies useful auxiliaries, particularly in the first
stage. The decoction altheeffi, the mist, amygdal.
dulcis, tiie inspissated juice of the sambucus niger,
mucilages, with liquor ammonias acetatis, vinum
ipecacuanha;, and syrup (see F. 47. 389.), may
be used internally ; whilst warm fomentations,
with decoction of camomile flowers and poppy-
heads, are applied about the throat, and frequently
renewed, upon the occurrence of hoarseness,
cough, and diflicult respiration. These have the
clTect of retarding the approach of the latter and
more dangerous states of the malady, even when
they fail of rendering more efficient aid. Lentin
advises camphor to be applied to the chest ; but it
will be more beneficial to employ it along with
the fomentations, which may extend over both
the throat and the upper part of the chest ; or it
may be placed upon warm poultices, as advised
above, particularly in the more spasmodic and
complicated states of the disease.

64. ^. Cold epithems on the throat have been
employed by some writers, and particularly by
Field. They appear to have been of little service
in his cases. I am unable to give any opinion
respecting them from my own experience. They
seem not to be equal to warm fomentations. Goei.is
states, that they are dangerous means to resort to ;
and alludes to cases where they were injurious.

65. >i. Semicnpium and pediluvium are useful
modes of derivation, in the first and second stages
especially. But salt, mustard, and, in some cases,
a little of either of the fixed alkalies, or of the sul-
phurets, should be added to the water, and its
temperature gradually increased as immersion is
prolonged. Great care is requisite in removing
the p.'^tient from the bath, to prevent any chill.
In many cases, it will be preferable to wring as
dry as po-sible large pieces of flannel out of warm
water prepared as above, and to wrap them round
the lower limbs of the patient, changing them fre-
quently, or prolonging the use of them, according
to circumstances, and preserving the bed-clothes
from moisture.

66. &. Tepid ajjd warm bathing are of service —
the former in the early stages, the latter in the ad-
vanced periods, of the disease. Goelis advises
the tepid bath of about 23° or 24° of« Reaum. ;
and to be rendered antispasmodic by using a de-
coction of chamomile flowers and poppy-heads ;

460

or irritant, by adding some caustic alkali ; or both
antispasmodic aad derivative, by a combination of
these substances, according to the circumstances of
the case. I have, in a few instances, used these
baths, upon the recommendation of this writer, and
certainly with marked advantage, but I have in-
creased their temperature in the latter stages of the
disease, rendering them, at the same time, more ir-
ritating by the addition of an alkali. In the early
periods, however, the emollient and antispasmodic
form of bath seems preferable, particularly when
the patient breathes the vapour rising from it.
The dnration of immersion should seldom be
shorter than twenty minutes, unless circumstances
should prevent it ; and I am convinced that it
may be prolonged to two hours with advantage,
in some instances. In a case despaired of, I caused,
upon the recommendation of Goei.is, the child to
be put in a bath consisting of a decoction of cham-
omile flowers and poppies, to which some caustic
alkali was added. It was kept there for twenty-
five, and on a second occasion forty, minutes. It
ultimately recovered. Care must be taken that
the temperature of the bath does not fall during
its continuance. As soon as the patient is lemoved,
and the skin dried, he should be placed in warm
flannel, or in a blanket ; and perspiration encour-
aged by diaphoretics suited to the nature of the case
and stage of the disease ; in the early stage by anti-
mony or ipecacuanha, so as to excite slight nausea,
or occasionally vomiting, if requisite; in the latter
periods, with liquor ammoniae acetatis, given insuffi-
cient quantity to produce the same effects, or,if sink-
ing be apprehended, with camphor, ammonia, &c.

67. (. Purgatives have been given with different
intentions ; — either as mere evacuants of retained
secretions and excretions ; or as active derivatives
from the seat of disease. Home, DESEssAnTZ,and
MicnAELis, seem to have resorted to them with
the former intention; Hamilton, Pinel, and
AuTENREiTH, with the latter view ; Crawford,
Thompson, and others, prescribing also enemata.
JMy own experience is decidedly in favour of this
class of medicines ; and of employing calomel,
jalap, scammony, &c., and extract of colocynth,
with assafffitida, &c. in enemata (§ 51, 52.).

68. Sudorifics are of use only in the early pe-
riods of croup. James's powder, and the other
preparations of antimony, subsequently ipecacu-
anha, and liquor ammonia; acetatis, or the one
combined with the other, and given to the extent
of exciting nausea, in conjunction with emollients
(§ 63.), are important auxdiaries. Goelis re-
marks, that Dover's powder is seldom productive
of any benefit ; and tiiat sudorifics are never of
service in the last stages. Gentle f//'ap/!(i/«(s, early
in the disease, is undoubtedly beneficial, when the
patient drinks freely of emollients ; but he with
justice adds, that very copious sweats only in-
crease the disposition to form false membranes of
a firm and adherent kind, owing to the evacuation
of too large a proportion of the watery parts of the
blood. In these opinions, Trerer, Hirschfield,
and most of the Vienna physicians, agree.

69. K. Expectorants. — Under this head may
be ranked an important part of the remedies pre-
scribed in croup. The inhalation of vapours has
already been noticed. The experienced Goelis
places much confidence in them during the first
and third stages ; in the latter of which they often
increase the cough, but they favour the discharge

H h 3

470

CROUP — Eemauks on various Remedies employed ik.

of false membranes, by increasing the mucous
secretion by aid of which they are thrown off.
I have mentioned (§ 47.) the expectorants in which
my experience has led me to confide. There are
very few which have been more generally recom-
mended than senega. Archer, Barker, Valen-
tin, ROYER-COLLARD, LeNTIN, MaERCKER, CaR-

EON, &c. recommend it after bleeding. Dr.
Archer, who attributes the greatest virtues to this
medicine, advises it to be given at the same time
.as calomel, in frequent doses, until it excites vo-
miting or purging. Goelis and Treber remark,
that, although a good remedy in the third stage, it
is by no means possessed of those specific virtues
attributed to it by Dr. Archer ; and in this 1
agree with them. It is a useful medicine in the
complications of the disease with malignant sore-
throat or scarlatina. Squills are chiefly trusted to
by Huf ELAND, RuMSEY, and Maercker, in the
latter periods. They should not be exhibited in
the more inflammatory states of the malady, until
after depletions have been carried sufficiently far,
and we wish to procure the expulsion of the con-
crete exudations formed in the air-passages. They
oucrht to be exhibited in small doses in the re-
missions, and pushed to the extent of producing
vomiting when paroxysms of suftbcation occur.
After the membranous substances are removed,
squills should be altogether laid aside. The sul-
phnret of potassium has been recommended by
Professors Serf, Chaussier, Mercier, and
Hecker, in doses of about four grains, given every
three or four hours. It is sometimes of much
service after depletions. It may be combined
with camphor, or small doses of ipecacuanha.

70. X. Antispasmodics have been very generally
prescribed, and particularly by Michaelis, Pinel,
ScHwiLGUE, Vieusseux, &c., after the decided
use of antiphlogistic remedies. Home, Cheyne,
and Goelis, consider that these medicines are of
little use in common and inflammatory croup. I
am, however, convinced, from extensive experi-
ence, that, when the inflammatory symptoms are
altogether, or even nearly, removed by antiphlo-
gistic medicines, when the disease passes into a
spasmodic state, or presents from the conmience-
ment a predominance of such symptoms, and when
increased irritability becomes manifest, a judicious
exhibition of antispasmodic medicines is often at-
tended with benefit. Mush, either alone or with
other medicines, with calomel (MiciiAiiLis and
Wioand), with squills, sulphuret of potassium, or
other expectorants, and with camphor or ammonia,
in the last stage of the malady * ; valerian and its

* The chief danger in croup often proceeds from the
spasm with which the respiratory passage is affected In
the progress of the disease. The ohstruction of the tube
by tlie false membrane and effused matter seldom of itself
Cduses suffocation ; but rattier this lesion, combined with
spasm of the muscles of the larynx and membranous por-
tion of the trachea ; and, in many cases, exhaustion is
superadded, or even constitutes the most important
change. Depletions alone will not overcome this dis-
position to spasmodic action, which is generally <)l)served
to supervene at intervals ; the periods elapsing between
the paroxysms varying according to the strengtli and
constitution of t\n: child and the severity of the disease.
Uiit in many cases the spasmodic actiim is more frequent
and more dangerous, and the more likely to become as-
sociated witli convnlsions, the weaker the constitution
and powers of life, and the more those powers have been
reduced by copious depletions. After moderate depletion,
therefore, and in many cases even previously to any, such
medicines as possess an antispasmodic power, by first
acting as nauseants, are of great benefit. M. Kimbeli,
seems to have partly adopted this view of the disease and
of it» treatment ; but 1 am confident he has carried it

preparations, assafatida, or any of the other me-
dicines of this class mentioned above, may be em-
ployed, either alone, or with expectorants and
opiates, particularly when the energies of the
system begin to be depressed, or the complaint
assumes from the first a spasmodic character.

71. Of those medicines which are antispasmodic
from their sedative operation, the most important
are colchicum, opium, hyoscyamus, hydro-cyanic
acid, digitalis, and tobacco. Cotchicum may be
given combined with calomel, in the early and in-
flammatory states of the disease, or with ammonia
or camphor, at a later period ; but it ought, in
young children especially, to be exhibited with ex-
treme caution, — in very small doses, and care-
fully watched. It came into fashion in this and
other diseases of the air-passages a few years since,
and was, for a time, much employed ; I then saw
some cases of croup in which it had been very
injuriously employed, from having been given in
too large doses for the age of the child, or too
long continued, or combined with other depri-
ments, as antimony, &c., or exhibited after very
large depletions. I can most truly assert, that I
have seen at least two cases of croup, in which
death was to be imputed to this substance, rather
than to the effects of the disease ; and yet it is
sometimes of use when combined as I have now
advised. Of digitalis 1 have had no experience
in this complaint ; if exhibited at all, it should be
conjoined with calomel. Hi^dro-cyanic acid has
been employed in some cases which I have seen ;
but the same objections I have urged against col-
chicum apply to it, when prescribed for young
children. In older patients it is sometimes of
benefit, combined with camphor, or oxide of
zinc, or other stimulating antispasmodics, in com-
bating the irritability and disposition to spasmodic
paroxysms in the latter stages. Opium was much

much too far. If his success has been equal to what he
conceives it to have been, the cases which he has met with
have been unusually slight. There is no doubt of bleed-
ing, blistering, purging by calomel, &c. &c., having been
pushed to hurtful lengths in many cases, or inappro-
priately employed ; and the same maybe said as to other
means, which have tended more to exhaust the vital
energies than to cure the disease ; and there can be no
doubt of the disposition to spasm becoming greater, and
of its consequences being more to be dreaded, the lower
the powers of life sink ; for, with such sinking, the general
sensibility and irritability of the frame increase. But I
cannnot conclude that those means could have been dis-
pensed with in any considerable number of the cases which
have fallen under my observation, and in which I have
never omitted also to employ antispasmodics of the most
active nature, from a conviction that the disease partly de-
pends upon spasm. Mr. K.'s observations as to the treat-
ment of the disea-e are to the following effect ; — "I never
bleed or blister a child in croup : I have never thought it
requisite to do so, since I have adopted the plan alluded
to ; although sucii auxiliary practice would be in no other
respect incompatible, than as tending to invalidate the
general strength. »The treatment I alhido to consists in
confining the child to a uniform and rather warm tem-
perature, giving an emetic of ipecacuanha, and, in an
hour after, commencing the following mixture : —

No. IGt. R Pulv. Valerianae 3ij.: Oxymel. Scillsejj.j
Tinet. Ojiii gtt. xx. ; Aqua; Destillats ,5 j. Misce.
I administer a teaspoonful every hour, if the child is from
two to five years old ; if from five to eight, every five and
forty minutes, so as to maintain the anodyne effect of
opium, and thesub-nauseant, expectorant, antispasmodic
effects of the squill and valerian, until the symptoms are
removed ; which commonly happens in ten or twelve
hours, and which I have never seen protracted beyond
eight and forty. On their subsidence, I have, in general,
given a brisk dose of calomel and jalap."

Mr. K. likewise recommends the above treatment in
hooping cough and in catarrh ; and in those cases which
are unconnected with inflammatory action, it is not inap-
propriate. In the slight and more spasmodic states of
croup, it also will prove very beneficial.

CROUP — Prophylactic Tueatment

employed, after depletions, by Kendrick and
HuGGANs. It may be used both externally and
internally (as may the preparations of morphia),
with aromatics, camphor, or assafoetida, musk,
&c., in the states of the disease now mentioned.
Henbane, and extract ofpoppi), may also be em-
ployed under similar circumstances and forms of
combination. Tobacco has been prescribed in
croup, in various modes. Dr. VANDEnBURcii
and Dr. God.man recommended a plaster covered
wiih Scotch snuff to be applied across the top of
the sternum ; and myself and others have em-
ployed tliis substance, with the view of detaching
the false membrane by exciting sneezing and an
increased secretion of mucus. The smoke of to-
bacco has also been directed to be inhaled, in
order to remove spasm, and promote expectora-
tion, by its direct operation in the air-passages ;
and others have advised the patient to smoke a
cigar, with the intention of producing nausea, as
well as the other effects last enumerated. After
depletion, and when the disease is about its acme,
the powers of life not being materially exhausted,
a cautious use of this means may be serviceable.
In the case of children who cannot use a cigar,
the smoke of one may be blown around them,
and in this way it will have a sufficient effect.
Cloth moistened with an infusion of tobacco may,
under some circumstances, be applied over the
throat, and its effects carefully watched ; but this
measure is not without hazard, particularly after
lowering remedies have been used, or in an ad-
vanced stage of the malady.

72. y.. The preparations of ammonia have been
much employed in all the states of croup. Caus-
tic ammonia, in doses of three or four drops, given
every hour ; ammoniacal liniments being at the
same time applied about the throat; has been ad-
vised by some writers, in order to promote the
excretion of the concrete exudations in the third
stage of the disease. The sesqui-carbonate of ammonia
has been more generally employed. M. Rechou
prescribed it both internally, and externally in
ointments to the throat. In the latter stages, as a
useful antispasmodic stimulant, it may be some-
times of service ; it is very advantageously com-
bined with camphor, or even with calomel, in the
complications of croup with angina maligna, or
with any of the eruptive fevers. M. Chamerlat
has recommended the hydro-chlorate of ammonia
to be taken internally, and applied to the fauces,
when the disease is associated with inflammation
of the throat. The cupri ammonio-sulphas and
the hydro-sulphnret of ammonia, have also been
prescribed in doses suitable to the age of the pa-
tient. They may be sometimes of service in the
more spasmodic states ; but I have had no expe-
rience of their effects in this complaint.

73. V. M. Valentin has recommended the ap-
plication of the actual caittery upon each side of
the throat, in the most severe forms of the disease
when it is at its acme. Moxas seem to be pre-
ferable to the actual cautery ; and, if this practice
should be adopted, it might, perhaps, be advan-
tageous to follow it by fomentations placed over
the trachea. M. Dupuvtren employed in one
case, referied to by Guersent, a small rod of
whalebone covered by pieces of sponge, which
was introduced into the pharynx in order to re-
move the partially separated portions of false
membrane lodged in that situation, or partly

471

thrown out from the larynx. In the advanced
stage of croup complicated with angina pharyngea,
this contrivance is calculated to succeed.

74. f. Tracheotomy. — There does not seem to
be a chance of success from this operation in any
case wherein the treatment developed above has
failed. The practitioner, however, may be called
to a case so late in the disease, and where the
suffocation is so imminent, that the propriety of
having recourse to it may be admitted : but, even
in these, the chances are infinitely greater against
than in favour of its success; and if benefit can
be obtained from any measure, it is as likely to
accrue from the energetic exhibition of suitable
emetics as from tracheotomy. Cases have doubt-
less been recorded of the success of the operation
in croup ; but these are so very few, compared to
the number in which it has failed, that I per-
fectly agree with Goelis, Cheyne, Roveu-
CoLi.ARD, Porter, Wood, and many others, in
concluding that it should seldom or never be at-
tempted in this disease. Of the propriety of
having recourse to it in certain states of laryn-
gitis, &c. there can be no doubt ; and it may,
with some slight grounds of hope, be resorted to
when croup is chiefly confined to the larynx and
upper portion of the trachea ; also, perhaps, in
some cases of its consecutive occurrence upon in-
flammation of the throat with membranous exuda-
tion ; and when we infer, from the general symp-
toms and the signs furnished by the stethoscope,
that the bronchi and lungs are unaflfected ; but in
that period of the simple as well as of most of
the complicated forms of the disease, in which
only it should be attempted, and when internal
treatment has failed, I believe that the superin-
duced lesions in the bronchi, lungs, circulating-
fluid, and nervous system, are such as to preclude
hopes of its success. IMoreover, the feelings of
the parents regarding it, and the reputation of the
physician and operator, are not to be kept out of
view. " Ad tracheotomiam," says Goelis, " om-
nium reniediorum incertissimum confugere res
ardua est ; parentes abhorrent, ayersantur agnati
et periclitatur medici farma, quem, infausta si
fuerit operatio ac votis illudens, lacrymis multis
velut homicidam prolis amatai detestantur pa-
rentes."

75. ii. Prophylactic Treatment, &c. — A.
Goelis states, that he never saw a child with por-
rigo and other chronic cutaneous afl^eclions at-
tacked by croup whilst they remained fully de-
veloped, even when this disease was most preva-
lent. He therefore advises the having recourse to
any form of issue, when an attack is dreaded. I'o
resort, however, to emetics, to anlimonial medi-
cines,to counter-irritants, todepletions, to confine-
ment in-doors one half of the year, and other
measures which have been advised, is attended
with gieater mischief than to allow the child to
run the slight risk there is of his having the disease.
The case, however, is dift'erent in respect of a
child who has once suffered an attack. The lia-
bility of croup to recur, even several times, after
intervals of various duration, renders precautions,
under such circumstances, very requisite. The
chief of such measures are — removal from the
predisposing and exciting causes (§ 24 — 31.);
change of air and locality ; the use of the shower
or cold bath every morning, the skin being well
rubbed with a hard or coarse cloth afterwards ;
Hh 4

472

CROUP— Diet and Regimen,

the wearing of flannel next the skin, and of a
neckcloth in winter and spring ; light nourishing
diet, with strict attention to the secretions and ex-
cretions ; immediate recourse to medicine upon the
appearance of catarrhal or croupal symptoms;
and a careful avoidance of exposure to cold and
moisture. When croup occurs in one child of a
family residing in situations where it prevails,
more will probably be attacked. In such cases,
removal to a healthier air is requisite. When it
is prevalent either in a simple or complicated
form, aad particularly when the locality also in-
creases the risk of seizure or relapse, the occa-
sional exhibition of small doses of calomel and
James's powder, or of hydrarg. cum creta with
the carbonate of soda, or the having recourse to
either of tliem every second or third night, may
be tried. In this country, care should be taken
not to expose children to the north-east winds of
spring, particularly when they follow heavy
rains, &c.

76. B, The Diet and Regijien, in the more
acute and inflammatory forms of croup, should
be strictly antiphlogistic ; and all food siiould be
withheld until the stage of exhaustion supervene,
when, if light nourishment can be taken, or be
desired, it should be given. In the more spasmodic
or prolongedforms, light food m.aybe taken in small
quantity. The best beverage of which the patient
can drink is a very weak decoction of marsh-
mallows and liquorice root, to which a little candy
and bi-borateof soda are added. The temperature
of the room should be moderately and equably
warm.

77, C. During Convalescence, change of air,
as soon as it can be safely permitted, is especially
beneficial; and strict attention ought to be paid to
the prophylactic means stated above (§ 75.), in
order to prevent a relapse or recurrence of the
malady. These precautions are required during,
and for some time after, recovery from the com-
plications and consecutive affections of croup, as
well as from its simple forms. In the winter and
spring months especially, the convalescent should
be kept in apartments moderately and as equably
warm as possible.

BiBLioG. AND Refer. — Hippocrates, Coacse Prano-
tiones, cap. iii. edit. Vamler Linden, vol. i. p. 5.55 — Bai/ti-
nius, Epid. Ephemcriil. l.ii. p. 197. 201.— P. iVn!H-,Miscel.

Observ. in tlie Practice of Physick, &c. Lond. 1718

G/ii.si, Lcttere Mediche. Cremona, 1749, art. 2. — Starr, in
Pliilosoph. Transact. No. 495. for 1749 and 1750 — Simp-
son, De Asthmate Infantum Spasmodico. Ed. Svo. 1761.

— Tf'ilcke, De Angina Infantum Recentior. Annis Ob-
scrvata. Upsalse, 17G4. — /'«« Bergen, De Morb. Trucu-
Icnto Inf. &c., in Nov. Act. Nat. Curios, t.ii. p. 1.57. Lips.
17G1. — Home, Inquiry into the Nature, Cause, and Cure of
Croup. Edin. \76!y.—Halenius, in Fortsattningof Provin.
Doctorernas BerUttelscr. Stockholm, 1765. ( Contagious.)

— Wahlhom, in Ibid. p. I HI. (Contagiovs.) — Bard, in
Amer. Philosoph. Trans, vol. i. p. 322. — Millar, Observ.
on the Asthma ami lloopinK Cough, Kvo. hond. 1709.

Crav'ford, De Angina Kfridula. Edin. 1771 Hnsscl,

The (Economy of Nat. in Acute Dis. Lond. 1775. —
Ilttsli, On tlin .Spasm. A.sthma of Children, &c. I,ond.
J770. — Mic/iaclis, De Angina Polyposa. Goet. 177H. —

-J. .Jolinstonc, On the Mallg. Angina, with Kcmarks on
Angina Tradicalis. Worcest. 1779 — Baylcy, Cases of
Ang. Trachealis. N. Y. 1781, 8vo. — Bosenstein, Kindcr-
krankheiten. Kd. 1798, p. (7.3. — Cookson, Do Astlnnate
Acuto Infantum. Edin. 17«0, Svo. — Pearson, Med.

F.ncts and Observat. vol. vii. art. 10 Dixon, in Med.

Comment, vol. ix. p. 254. — Anderson, On Calomel,
in Croup, in Duncan's Annals of I\Icd. vol. iii. p. 451., and
vol. iv. p. 4.59., ,nnd vol. vi. p. .'IWB. — Archer, in Ibid.
vol. iv. p. 511. — Disncij, On the N.iture and Cure of
Cynanche Tmchoalis, 1794. — Alexander, On the Croup.
Lond. 1793. — Ferriar, Medical Histories, &c. vol. iii.

art. 4 Field, in Mem. of Med. Soc. of Lond. vol. iv.

p. 151., and vol. v. art. 20 Smith, in Ibid. vol. vi. p. 74.

aicgborovgh mi.Guitskell, in Trans, of Med, Soc. vol. ii.

— Ru7nsey, in Trans, of Soc. for Improvement of Med.
Knowledge, vol. ii. art. 3. — Harles, in Hvfelamts Journ.
d. Pr. Arzneyk, b. vi. p. :M). — Loefler, in Ibid. b. iii.
p. G97. —Hujelatid, Ibid. b. ix. st. 2. p. 180. ~ Lentin,
in Ibid. b. ii. p. 1G7.; et Beytrage, b. i. p.300.,b. iii.'p. 199.

— Maerclcer, in Hufeland's Journ. der Pract. 'Heilk.

b. XIX. St. 3. p. 83 — Hiifeland, Ibid. b. xix. st. 1. p. 177

Hecker,\\.\-x.. st. 3. p. \2. — Darwin, Zoonomia, vol. ii.

— Bush, On Cynanche Trachealis, in his Med. Inquiries
and Observat. Lond. 1789, 8vo. — laughan, in N. Y.
Med. Kepos. vol. iii. p. ZiO. — Barker, in Ibid. vol. vi.
art. 3.— Po; to;, Memoire sur Plus. Malad. t. iii. p. 65.

— J. M'Grigor, in Edin. Med. and Surg. Joutn. vol. i.
p. 282 Reckon, in Journ. Gcner. de. Med. t. xx. p. 3.

— Michaelis, in Ihifcland and Hitnbfs Journ. der Pract.
Heilk. 1809, st. G. p. 44. — ScMilter, in Ibid. July,
1821, p. 124.— Wigand, in Ibid. Feb. 1810, p. IGI.—
Hecker, Von der Entziind im Halse, &c. Berl. 1809. ; et
Annalen, Dec. 1810, p. 512. — Wichma7in, Ideen zur
Diagnostik, b. ii. p. 103. ; et in Hufeland's Journ. d. Pr.
Arzneyk, b. ii. p. 27.— Giraudy, De I'Angine Trachcalc.
Paris, 1811 — Eschcnmayer, Die Epidem. des Croups zu
Kirchheim, 1807, 8vo. Stut. 1811. — Cheyne, Pathol, of

the Memb. of Larynx and Bronchia, 8vo. Edin. 1809

Rogery, in Journ. Gen. de Med. t. xxxviii. p. 1.53

Heim, in //o/vj's Archiv. 1810, p. 379 Neumann, in

Ibid. Mart. 1811, p. 234. — Seha-ffer, in Ibid. July, 181 1,
p. 155. ; et in Hufeland's Journ. d. Pr.'Heilk. Nov. 1810,
p. 80. —Double, Traite du Croup, 8vo. Paris, 1801.—
Chaussier, in Journ. de Med. Contin. May, 181 1 , p. 74., et
Dec. ■p.'lbn.—Leeson,'m Med. and Pliys. Journ. Nov. 1801.
Wainwright, in Ibid. April, 1800. — 'iVillan, Reports on
Dis. of London. Lond. 1801, 8vo. — Latour, Blanuel sur
le Croup. Paris, 8vo. — C/ia?nerlat, Journ. de Med. &c.
t. xxvii — Boycr-Collard, in Diction, des Sciences Med.
t. vii. p. 412. — Chevalier, in Transac. of Med.-Chirurg.
Soc. vol. vi. p. 151 — Herder, in Journ. Univers. des Sc.
Med. &c. t. xiv. p. 225. — J. A. Albers, Comment, de Tra-
cheitide Infantum, &c. 4to. Lips. 1816. (Obtained the prize
given by Napoleon.) — L. A. Goelis, Tract, de Rite Cogno.
sccnd.i et Sananda Angina Membranacea, Svo. Vien.1813.

— Grimaud, in Journ. Compli^m. des Diet, des Scien.
M(?d. Jan. 1822. — Author, in Lond. Med. Repository,
vol. xix. p. 46. — Schmidt, Journ. des Progres des Scicu.

Med. t.ix. p. 244 Lobslein, in Memoir, de la Soc. Med.

d'EmuIation, t. viii. p. 500. — I.ouis, Meraoires Anato-
mico-Pathologiques, 8vo. Paris, 1S26, p. 203. ; et in Ar.
chives Gener, do Med. t. iv. p. 5. et369. (In the adult.) —
Beddelin, in Pliiladelpli. Journ. of Med. Science, vol. v.
p. 201. iSn?rffi'i.^—Ho.tf}iiiinii, in Ibid, vol.vi. p. 409. {Sulph.
cupri.) — ; altntin and H 'igard, in Lond. Med. Repos. vol. i.
p. 122. 285. 48. — Serf, in Ibid, vol.iv. p. 143. 464. (PotasscB

sulphur.) — Schmidtmann, Observ. Med. vol. ii. p. 24

Editor of Quarterly Journ. of For. Med. vol. v. p. 618;

— J. B. Lacroix, D'Une Epidemie de Croup, &c. Svo.
Paris, 1822. ; et in Nouv. Journ. de Med. t. xiv. p. 176. —
Godman, in Journ. de Progres des Scien. Med. t. xiv.
p. 249. — Blaud, Nouv. Rech. sur la Laryngo-Tracheite,
kc. 8vo. Paris, 1823. ; et in Nouv. Biblioth. Med. t. iv.
p. 40 — Billard, in Archives G(?ner. de Med. t. xii. p. 544.,
et t. XX. p. 491 — Quvrard, in Ibid. t. xii. p. 631. (Epi-
demie.)— Guersent, in Ibid. t. xvii. p. 493 Bretonneau,

in Ibid. t. xiii. p. 5., et t. xxiii. p. 387. 519. (Comp. with
ang. pharyngea.) — Tilleneuvc, in Ibid. t. xviii. p. 308.
( ]Vith ang. pharyng.) — Horteloiip, in Ibid. t. xviii. p. 57.

— Bourgeois, in Ibid. t. xix. p. 134. (Comp. wtth ang.

faitc.) — Giraudet, in Ibid. p. 586 Trousseau, in Ibid.

t. xxi. p. .541. (Comp. with Scarlatina.) — Einangard,
Amer. Journ. of J'el. Sciences, vol.vi. p.l8I. — Fander-
burgh and Godman, in Ibid. vol. ii. p. 480. — S. Jaci.son, in
Ibid. vol. iv. p. 3G1. — Hosack, On Croup, in Essays on var.
Subjects of Med. Science, vol. ii. p. 133. N. Y. 1824. 8vo.
— Balliard, in Journ. Hebdom. t. iii . p. 1 13. — Deslandes, in
Journ. des Progres des Scien. Med. t. i. p. 152. — Moronval

et Lavicz, in Rev. Med. t. ii. 1825, p. 147 Mackenzie, in

Edin. Med. and Surg. Journ. vol. xxiii. p. 29+ Robert.

son, in Ibid. vol. xxv. p. 279 Pretty and Sym, in Med.

and Physical Journ. for Jan. 1826 G. Gregory, in lliid.

Oct. 182.5. — J. Hamilton, Edin. Journ. of Med. Sciences
for October, 1826. — Matins, De Cynanche Tracliealia,
Svo. Edin. 1830. — Guersent, in Diet, de Mederine, t. vi.
p. 211.—//. M. J. Desruelles, Tr.iite Tliioriq. et Pratique
du Croup, &x. Svo. Paris, IS21.— T. Gui/iert, Rccherches
NouvcUcs sur la Croup, et sur la Coqueluche, Sec. Svo.
Palis, 1824. — P. Bretcnncau, Sur la Dipbthcrite, ou In-
Ham. Pelliculaire connue sous Ic Nom de Croup d'Angine
Maligue. etc. Svo. Paris, 1826. — TK //. Porter, On tlie
Surgical Pathol, of the Larynx .and Trachea, with rela-
tion to the Operation of Bronehotoniy, &c. Svo. Dublin.
182G. — Kimbell, in Lancet, vol. xvii. p. 160. — Brichetcau,
Prc'cis Anal, du Croup, et de I'Angine Couenncuse, Ike,
et Rap. sur les Memoir, env. au Concours sur le Croup,
&c., par Royer-Collard, Sec. Svo. Paris, 1826. — Jurine,

ill Rapport d\\ Royer-CoUard, in Ibid Mills, On the

Morbid Appear. oY the Trachea, &c. Svo. Dub. 1829.

— Wood, in Transac. of Med. and Chirurg. Society,

vol. xvii. p. 169 Bou', in Brit, and For. Med. Rev.

vol. iv. xi.'iVi. — Hatin, in Ibid. vol. vi. p. 530,

DEBILITY — Division of its Conditions.

CYANOSIS. See Blue Disease.

CYNANTHE MALIGNA. See Scarlet Fe-
ver ; and Pharynx, Iiijiammations of.

CYNANCHE PAROTID^A. See rARoxiD,
Injiammation of.

CYNANCHE FHARYNGEA. See Pha-
rynx, Iiijiammations of.

CYNANCHE TONSILLARIS. See Ton-
sils, Iiijiammations of.

CYNANCHE TRACHEALIS. See Croup.

CYSTITIS. See Urinary Bladder, Injiam-
mntions of.

DEAFNESS. See Ear, Diseases of; and IIear-
iNo, Disorders of.

DEBILTTY. — Syn. Adi/namia, Asthenia, Ato-
nia, Delnlitas, Lat. Die Schu'dsclie, Sclnmsch-
heit, Ger. Dtbilile, Astlienie, Fr. Debolezza ;
iUi\. Vital Depression, Diminished Vital
Power or Energy.

Classif. — General Pathology; Patho-
geny. — Special Patiiolooy. I. Class.

1. Defin. — That departure from the licalthy
condition ofthej'rame, which consists (fa diniinu-
tiun of its vital energies — of an enfeebling of its
pouers, manifested in numerous conditions and
grades throughout the whole frame, or more or less
remarkably in particular systems or organs.

2. Debility is a state of vital manifestation inti-
mately connected with the nature of disease ; and
in whatever acceptation it has been understood, it
has been admitted by every physician who has
looked beyond the grosser and more palpable
changes superinduced in the economy, as not only
a most important pathological condition, but as
often constituting what is, in the common language
of medicine, disease itself. It often performs a
principal part in the commencement, and towards
the close, of the most severe maladies ; and its
modifications are amongst the most difficult in
pathology to detect and to interpret ariglit. Se-
veral of the appellations it has received have
been more or less restricted to certain of its con-
ditions; as adynamia, to want of muscular or
animal power; atonia, to deficient vital tension
and tone of circulating and exh.aling vessels ;
asthenia, to depressed energy of organs essentially
vital, &c. ; but as the distinctions between them
have never been made with sufficient precision,
and have seldom been preserved, and as they have
all been used synonymously by the best modern
writers, they will be thus received at this place.

3. It might appear interesting to ascertain the
varieties and grades of debility ; but this is a
matter of no easy accomplishment, if not entirely
beyond the reach of our powers. Debility is,
besides, a relative term ; and of its extent or de-
gree of departuie from tliat condition of vital
power requisite to the perfect performance and
continuance of the functions, we can form no
very precise idea, even were we agreed upon the
standard of power by which the comparison
should be made. Of its numerous grades and
manifestations, from the slightest departure from
health to the utmost consistent with existence,
there can be no cjuestion ; and therefore they
cannot be otherwise than arbitrarily appreciated.
This will appear obvious to any one who will
refer to the numerous varieties into which Vccel
and Sauvages have divided asthenia.

4. Divisions of. — It will be preferable,
therefore, to consider debility in respect merely

473

of its principal conditions relatively to the oper-
ation of the chief causes which induce it ; and
in order to elucidate its morbid relations, and its
influence in producing and perpetuating further
disease, to enquire into its manifestations and
effects on the various general systems and organs
of the body. I'he majority of pathological writers
iiave found great difficulty in considering this
subject, and scarcely any two have agreed as to
the manner of discussing it, or as to its nature.
Some have viewed it as the negative of excit-
ation, or a minor degree of that state of excite-
ment induced in the system by the agents sur-
rounding and acting upon it, — by privation, or
change of the factors of life (Hartmann). This
opinion, which may be traced to the Stvictnin
and Lamm of Tiiemison ; but which was first
insisted on, in a manner at all accordant with
the doctrine of solidism, by Brown, and variously
modified and illustrated by his contemporaries
and followers ; led to the division of this grand
pathological state into two forms, — direct and
indirect debility. This division was adopted by
Darwin ; ami Rush followed the same track,
denominating the former debility from aiistractinn,
the latter debility from action. IIasori and To.m-
3IASINI hardly even modified the doctrine of
Brown, when they divided it into primary and
secondary ; the former arising from contra-stimu-
lating, the latter from stimulating, impressions.
BuoussAis followed a similar arrangement, but
considered that it is primary in very few instances,
and only from the abstraction of stimuli. 'J'he sim-
plicity of these divisions is their chief recommend-
ation ; but it is carried so far as to be inconsistent
with the complexity of those derangements to
which the human frame is subject. This feeling
seems to have induced Boisseau to impute it to
three sources : 1. To a complete or prolonged ab-
straction of the accustomed stimulus; 2. A dimi-
nution of the reciprocal stimulating influence of
the organs ; and 3. To the inordinate excit-
ation of a part, rendering the others incapable of
acting with energy. M. Brachet, adopting
similar views to my own, but several years after
mine were published, both in the London Me-
dical Repository and in my Physiological Azotes,
refers debility either to diminution of the action
of the cerebro-spinal system, enfeebling the func-
tions over which it presides, or to depression of
the functions dependent upon the influence of
the organic or ganglial nerves ; the weakness of
the nervous system arising, as he thinks, either
from deleterious states of the blood, or diminution
of its quantity, Hufeland divides it into fj-i/e,
and apparent or /'ii/se; the one from change of
the nervous sensibility, the other from oppression
of the vital powers. Dr. Geddings, the most
recent writer on the subject, considers debility,
1st, as direct, when arising from the abstraction
of stimuli, or the operation of contra-stimuli, or
such substances as " directly enfeeble the organ-
isation ; " 2dly, as indirect, or that resulting
from exhaustion, and "from deterioration of the
nutritive molecules of the blood ; " and, 3dly, as
metastatic, or that form proceeding from inordi-
nate irritation of one organ leaving the others in a
minor state of excitation. It is impossible to
examine the conditions of debility with any de-
gree of precision abstractedly from their principal
causes. I shall, therefore, witii due regard to

474

DEBILITY ■— Primary,

this connection, consider, 1st, The primary or
direct states of debility ; 2dly, Its consecutive or
secondary conditions ; and, 3dly, Those forms,
consisting not only of depressed, but of otherwise
morbid or vitiated, vital manifestation — or com-
plicated debility. After having discussed these
topics, with reference to general dehility, the more
special or partial states of debiliti/, and its conse-
quences, will be brought into view; and the sub-
ject pursued in its relation to general and special
pathology.

5. 1. Conditions or Debility. — i. Priimahy
Debility (Direct, Brown; True, Hufeland ;
from Abstraction of Stimuli, Rush and Boisseau).
This state of debility is not so frequent as is com-
monly supposed, although by no means so rare
as Broussais and his followers contend. ]Many of
the cases commonly imputed to it strictly belong
to tlie other conditions specified above (§ 4.).
Primary debility may be, (a) Original, or con-
genital; and (b) Acquired. — A. The former of
these is observed in the children of exhausted,
dissipated, or aged parents, — especially the male
parent, — and is familiar to every common ob-
server. It also presents itself in the infants of
those who are of a strumous diathesis, although
generally in a slighter grade, and more frequently
obscured by concurrent disease of particular or-
gans. This form of debility seldom continues
long without being followed by some specific
malady, which it either remarkably favours, or
even more directly produces, — causes, which are
innocuous as respects infants of originally sound
stamina, variously affecting, and ultimately blight-
ing the debilitated offspring.

6. B. Acquired debility presents itself to our
notice in every stage of life. If it supervene in
infancy and childhood, it may be, to a certain
extent, perpetuated in the constitution through
life. But, in whatever period it may occur, it is
most frequently the consequence of the abstrac-
tion oj' stimuli necessary to the excitation and per-
petuation of the vital manifestations to a requisite
extent. — («) The infant that is not sufficiently,
or is injudiciously, or unnaturally lumrished, if it
escape any of the maladies to which it is thereby
disposed, becomes pale, languid, soft, and en-
feebled, or altogether diseased: it wastes; its
flesh is flabby ; its growth is impeded ; and it at
last is tiie subject of anajmia, or of tubercles, or
of worms, or of disease of the digestive canal, of
the mesenteric and other glands, or of the joints
and bones. But insufficient or inappropriate
nourishment affects all periods of life in nearly a
similar manner. A fish diet through life gives
rise to a weaker conformation of body than
food of a mixed kind. This was proved by Pkhon
in respect of the natives of Van Diemen's Land.
Similar effects follow an exclusively vegetable
diet, although not to so manifest a degree. It
should, however, be admitted that those who
are obliged to live on one kind of food alone
are more liable to experience insufficient su])-
plies of it. — (b) The abstraction of the ani-
mal xcarmth is another cause, occasioning a
modified, and, as it were, an acute form
of debility, followed by peculiar effects, which
are fully described in the article Cold. —
(f) 1 he privation of solar light has a marked
infl\ience on the vegetable creation ; plants
being pale, sickly, and imperfectly developed,

and their proper juices scantily and insuffi-
ciently elaborated. An analogous effect is
produced by the same cause on the animal crea-
tion, and particularly on man — the body becom-
ing pale, sickly, and etiolated ; the senses
remarkably acute ; the general sensibility and
muscular irritability much heightened ; the or-
ganic actions readily influenced by the slightest
external agents*; and the circulating fluids thin,
watery, and deficient in albuminous constituents,
and red globules, and in quantity. Facts illus-
trative of this occurrence are adduced in the
article on anaimia, which is thereby produced.
(See Blood, Deficiency of, § 41.) The phy-
sical and mental debility resulting from confine-
ment in dungeons and dark cells is to be attri-
buted to the exclusion of light, restricted diet,
want of exercise and of free air, and to moral
causes combining with these in depressing the
vital powers, and ultimately producing disease of
a low and dangerous form. — (d) Intimately con-

* The remarkable and authentic history of Casper
Hauser, by the President Von Feuebbuch, furnishes
striking illustrations of the above. The accounts which
have been recently published of this person should be at-
tentively perused by every pathologist and philosopher,
as being most singular and instructive. Casper Hauser
was kept, from infancy until he was eighteen years of
age, in a perfectly dark cage, without leaving it ; and
where he neither saw a living creature, nor heard the
voice of man. He was restricted from using his limbs,
his voice, his hands, or senses ; and his food consisted of
bread and water only, which he found placed by him
when wakening from sleep. When exposed in Nurem-
berg, in 1828, he was consequently, at eighteen years, as
if just come into the world ; and as incapable of walking,
discerning objects, or conveying his impressions, as a
newly born infant. These faculties he, however, soon
acquired; and he was placed under an able instructor,
who has recorded his history. Darkness had been to him
twilight. The light of day at first was insupportable,
inflamed his eyes, and brought on spasms. Substances,
the odour of which could not be perceived by others,
produced severe effects in him. The smell of a glass of
wine, even at a distance, occasioned headach ; of fresh
meat, sickness, &c. ; and of flowers, painful sensations.
Passing by a churchyard with Dr. Daumer, the smell of
the dead bodies, although altogether imperceptible to
Dr. D., affected him so powerfully as to occasion shudder,
ings, followed by feverish heat, terminating in a violent
perspiration. He retained a great aversion, owing to
their disagreeable taste and smell, to all kinds of food
excepting bread and water. When the north pole of a
small magnet was held towards him, he described a
drawing sensation proceeding outwards from the epigas-
trium, and as if a current of air went from him. The
south pole affected him less ; and he said it blew upon
him. Professors Daumer and Herrmann made several
experiments of this kind, and calculated to deceive him ;
and, even although the magnet was held at a consider-
able distance from him, his feelings always told him very
correctly. These experiments always occasioned per-
spiration, and a feeling of indisposition. He could detect
metals placed under oil-cloths, paper, &c., by the sens-
ations they occasioned. He described these sensations as
a drawing, accompanied with a chill, which ascended, ac-
cording to the metal, more or less up the arm ; and were
attended with other distinctive feelings, the veins of the
hand exposed to the metal becoming visibly swollen.
Tlie variety and multitiulo ofobjects which at once came
rushing upon his allcnticin wlicu he thus suddenly came
into existence — the unaccustomed impressions of light,
free air, and of sense — and his anxiety to comprehend
them — were too much for his weak frame and acute
senses : he became dejected and enfeebled, and his nerv-
ous system morbidly elevated. He was subject to spasms
and tremors ; so that a partial exclusion from external
excitements became for a time requisite. After he had
learned regularly to eat meat, his mental activity was
diminished : his eyes lost their brilliancy and expression ;
the intense application and activity of his mind gave way
to absence and indifl'erence ; and the quickness of appre-
hension bi'canie diiniiiislicd. Whether this change pro-
ceeded from tlic iliange of diet, (jr from the (lainful
excess of excitemcMit which preceded it, may he ques-
tioned. My limits admit not of my adding more. The
whole account is most important — the more so, as the
physiological facts stated in it may be relied on.

DEBILITY — Consecutive.

475

nected with this cause and its effects is tlie pri-
vation of fresh air and exercise. When muscular
action cannot be performed under favourable cir-
cumstances, particularly as respects the requisite
renewal of air, the circulation languishes, and
suffers deterioration ; the developement of the
locomotive organs is either impeded or pre-
vented, and they are no longer in a fit state for
the execution of the acts of volition. By a want,
also, of a requisite renewal of air, the stimulat-
ing constituent of it becomes diminished, and re-
placed by directly sedative gases, and by vapours
loaded with the effluvia of the system that respires
it, or of those which may respire it in the same
place ; the extent of the stagnation or confine-
ment of air, and of the causes of deterioration,
proportionately heightening and accelerating the
depressing effects thereby produced upon the
frame. — (e) It is extremely probable, that what-
ever, in its passage through the digestive canal, or
circulation through the body, abstracts o.iygen
from the siistem, will be also, to a certain extent,
a cause of debility, as supposed by Humboldt.
The causes of scurvy may be partly of this de-
scription ; as well as those of several other dis-
eases.— (f) A not uncommon cause of de-
pressed vital power is the young sleeping icith the
aged. This fact, however explained, has been
long remarked, and is well known to every un-
prejudiced observer. But it has been most un-
accountably overlooked in medicine. I have,
on several occasions, met with the counterpart
of the following case : — I was, a few years
since, consulted about a pale, sickly, and thin
boy of about five or six years of age. He ap-
peared to have no specific ailment ; but there
was a slow and remarkable decline of flesh and
strength, and of the energy of all the functions —
what his mother very aptly termed a gradual
blight. After enquiry into the history of the
case, it came out that he had been a very robust
and plethoric child up to his third year, when
his grandmother, a very aged person, took him
to sleep with her ; that he soon afterwards lost
his good looks ; and that he had continued to
decline progressively ever since, notwithstanding
medical treatment. I directed him to sleep apart
from his aged parent ; and prescribed gentle
tonics, change of air, &c. The recovery was
rapid. But it is not in children only that de-
bility is induced by this mode of abstracting vital
power. Young females married to very old
men suffer in a similar manner, although seldom
to so great an extent ; and instances have come
to my knowledge where they have suspected the
cause of their debilitated state. These facts are
often well known to the aged themselves, who con-
sider the indulgence favourable to longevity, and
thereby often illustrate the selfishness which, in
some persons, increases with their years. — (g) It
is extremely possible that whatever conducts the
electi-icitii of the body from it will occasion direct
debility. With this view I have long been in
the habit of causing females who used steel sup-
ports to their stays to lay them altogether aside.
The experiments on Casper Hauseu confirm this
supposition. — {h) Intimately related to the causes
consisting of abstraction of requisite stimuli,
and to the effects resulting therefrom, seem to
be the privation of those excitants to which the
frame has been long habituated ; although these.

as well as their effects, may be considered as
falling more strictly under a different section of
this subject. The privation, by whatever cause,
of those states of electrical tension whicii exist in
healthy conditions of tlie body, and fright, or
prolonged fear, may also occasion primary de-
bility.

7. C. But the vital power is enfeebled by another
class of causes — by agents which f^eem directly
to depress it below its healthy standard. These
agents have been called contra-stimulants by the
Italian physicians of the school of RAsoni. — (a)
Several of those, however, when employed in
sufficiently small quantities, actually excite the
parts to which they are applied ; and it is only
when they are used in large doses that an oppo-
site effect — violent depression and even annihi-
lation of life — is produced. A minute quantity of
prussic acid, or of tobacco, excites the organic
functions ; a large quantity instantly destroys
life : and the remark applies, to a certain extent,
to nearly all the more energetic narcotics ; al-
though many of them, as well as several other
agents, whilst they depress the vital manifest-
ations generally, also excite or irritate particular
organs or tissues. Tartar emetic, acetate of lead,
oxalic acid, colchicum, stramonium, belladonna,
&c. furnish illustiations of this fact. — (b) The
primary effects of terrestrial ejjiuiia or malaria,
and of the itifectious emanations proceeding from
the diseased, as from those affected by plague,
yellow fever, typhus, and pestilential cholera,
are evidently most acutely debilitating, even
although these causes may also, and at the same
time, act by irritating certain organs or tissues.

— (c) \'arious mental emotions are also very
powerful depriments of vital power, such as fear,
anxiety, grief, longings after objects of affection,
nostalgia, &c., particularly if they be of long
continuance : they retard all the organic func-
tions, and at last wither the whole organisation.

— (rf) W^hatever impedes respiration, owing to
the effects of this function upon the circulation,
and on the blood itself, and consecutively upon
the organic and cerebro-spinal' nervous systems,
also depresses the vital power in a very remark-
able manner. Among the causes of primary
debility. Dr. Geddings has included anccmia.
There can be no doubt of the existence of de-
bility, when the blood is deficient or impure ; but,
instead of being the cause, anemia is the effect
of debility.

8. ii. Consecutive or Secondary Debiliiy
may arise in two ways : (a) from increased ex-
citation of an organ, occasioning proportionate
diminution of the energy of others — sympathetic
debility, or debility from an irregular distribution
of the vital endowment ; and (b) from the exhaus-
tion occasioned by previous excitement. — A.Syrri'
pathetic Debility {Debilitas Spuria, Hufeland ;
Metastatic Debility, Dr. Geddings.) WMien it is
considered that the organic or ganglial nerves alone
supply the blood-vessels, and the secreting organs
and surfaces ; that they communicate very freely
with each other, and with their chief centre, the
semilunar ganglion ; that they are formed into
numerous plexuses, rendering thereby the con-
nection between them still more close; and that
they are intimately related to the cerebro-spinal
system, through the medium of communicating
nerves ; the mutual dependence of action between

476

D E BI LIT Y — Complicated.

the various organs of the body may be easily
explained. If, moreover, it be granted, as I
have endeavoured to prove in another work, that
the most important vital phenomena, — as di-
gestion, assimilation, circulation, secretion, ani-
mal heat, generation, &c. — in short, that life
itself, with all those manifestations of it now par-
ticularised, and which have usually been called
organic — result from the influence exerted by the
ganglial nervous system, through the instru-
mentality of the vessels and structures upon the
circulating fluid they contain, and reciprocally
by this fluid upon the nerves ramified in the
parietes of the vessels, and upon the ganglia
themselves, through which it must necessarily
circulate, — the agency of this system in the pro-
duction of the numerous phenomena of debility
must be evident. From this view of the sub-
ject, and taking into account the various func-
tions of dissimilar textures, and, under certain
circumstances, the combined influence and re-
action of the cerebro-spinal system and senso-
rium, the numerous relations of disordered ac-
tions, as respects the manifestations not merely of
debility, but of disease generally, may be more
satisfactorily traced.

9. When one organ or general system is simply
excited, without being otherwise diseased, the
functions of other organs, with which it is more or
less intimately related by means of the ganglial
nerves, undergo a relative degree of change ; for
as we exalt the vital manifestations in one or more
parts of the series, we diminish them in equal pro-
portion throughout the remainder. These views
were first stated in the London Medical Bepositori/,
for i\Iay, 1822, and fully illustrated in my Phy-
siological Notes, published in 1824 ; and have
since been adopted by Boisseau and Geddixgs.
A due application of them is of the utmost im-
portance in pathology and therapeutics, as well
as in ascertaining a large proportion of the forms
of debility, particularly those presented to us in
the course of many acute and chronic diseases:
thus irritation of the mucous surface of the sto-
mach or bowels enfeebles the rest of the frame ;
and inordinate excitation of any other secreting
organ diminishes the nutritive and animal func-
tions in an equal degree, and so on as respects
various other viscera and structures, as more fully
explained when describing the states of vital
energy connected with the nature of disease. (See
art. Disease.)

10. B. The Debility of Exhaustion, or from ex-
citement of a part, or of the body generally (In-
direct Dchilitii, of Brown). — This form of debility
arises from all agents, mental or physical, which
excite the actions of a part, or of the system, above
its normal state. Many of these causes act with
great rapidity and intensity, others very slowly
and insidiously ; and whilstsome simply change the
f^rade of vital action, others seem to alter it in kind.
'J'heir effects vary remarkably with the suscepti-
bility of the organ and constitution on which they
act, and. the frec|ucncy of their repetition ; each
successive application being generally less efficient
than the preceding, if it be delayed until the ac-
tion of the previous one has terminated. The
circumstance of stimuli being productive of ex-
haustion, or indirect depression of vital power, to as
great extent below the standard of health, as the
previous excitement rises above it, as fully shown

by Brown, Darwin, and Rush ; and that sti-
muli must be repeated in larger quantity to pro-
duce the same eflects, although presenting certain
exceptions, are important facts as respects this
pathological condition in particular, and disease
in general : as long, also, as the repetition of the
stimulus follows so quickly and regularly as to an-
ticipate the appearance of the consecutive debility,
the unavoidable consequences of its abstraction
will not appear, at least for a very long time. But
they ultimately will supervene in a most severe,
and often dangerous, form, when such an event
takes place ; and if it does not occur soon, the
prolonged excitement will ultimately terminate
in organic change. Drunkards and opium-
eaters often furnish proofs of the latter fact ; and
persons who indulge in an occasional debauch
only, or who undergo great physical or mental
exertions, feel the truth of the preceding positions.
There is one cause, however, which requires to be
particularised on account of its mode of operation
and consequences : this is excessive sexual indul-
gence. It occasions a loss of vital power through
the medium of the discliarges, independently of
the exhaustion consequent upon the previous
nervous excitement. Its depressing cfTects arc,
moreover, experienced by all the organs, but es-
pecially in the ganglial and cerebro-spinal nervous
systems ; and are often foUovi'ed by the most se-
rious results in both male and female.

11. iii. Complicated Debility. — I have con-
tended, in the article Disease, that the vital
manifestations of an organ, or of the frame gene-
rally, may be modified, not only in grade, but also
in A/)!f/. If this be admitted, it follows that de-
bility, originating in either of the ways now shown,
may be either simple, or associated v/ith an other-
wise morbid state of vital action. Upon a review
of practical facts, we shall find that the more sim-
ple states of debility most frequently occur either
primarily — especially from agents abstracting vital
power — or indirectly, from causes which over-excite
the nervous influence, or which abstract as well as
exhaust vital power ; such as the one last adduced
(§ 10.). But the condition now under consider-
ation is more generally the result of causes which
either irritate in a slow and continued manner
some particular tissue or viscus, or modify the
sensibility of an organ, or change its secreting or
nutritive actions, or even vitiate the condition of
the circulating fluids. Whilst the preceding forms
of debility are mostly met with in the commence-
ment of diseases, or constitute the early stages
of those ailments consisting almost entirely of
simple asthenia, but which are often mistaken for
structural maladies, this condidon is observed
chiefly in the progress, or towards the close, of
many acute and chronic complaints, some of
which arc of a specific or malignant character;
and it may arise out of cither of the foregoing
varieties of debility, especially when much pro-
longed. That which becomes so remarkable in
the course of typhus, or yellow fever, of plague,
or of syphilis, cancer, scrofula,. &c., consists not of
a simple <lepression or exhaustion of vital power
merely ; for this power is also specifically modi-
fied even from the commencement of these dis-
eases ; — the sensibility and organic contractility
' are changed ; the secretions and nutrition are in-
I terrupted, or much aft'ectcd ; and although the
I debility may be the same as to grade in several

DEBILITY— Speciai, Manifestations and Effects. 477

Such of those causes as are of an intense kind
and are most injurious to life, — vvliieh modify
while they depress its manifestations, — have their
impression rapidly propagated througliout this
system, and to the structures and organs which
it actuates ; whilst those of a slighter kind, or
slower operation, may exert their effects in parts
of it only, or chiefly, and more or less partially, in
otiicr viscera. Viewing this system, therefore, as
that upon which the greater number of causes de-
pressing their vital manifestations first exert their
action, and consequently as the point whence the
depressing eflects proceed, I shall briefly consider
these effects in each of tiie principal functions,
organs, and structures.

14. -B. The circulating systems aud Jluids are
affected according to the intensity of the depress-
ing causes relatively to the energy of the system
at the time ; and the ultimate results vary with
the successive ciianges that supervene in it and
the associated nervous systems, and secreting and
eliminating organs. — (a) In simple debility, tlie
heart's action is languid, or slow ; but readily ex-
cited by stimuli. If the debility be chronic, the
parietes of its cavities may ultimately become
wasted or thinned, or even softened, and the
cavities themselves dilated. In the advanced
stages of acute or complicated debility, the heart's
action is generally very quick, soft, weak, small,
and unequal or irregular; and in chronic cases,
its substance softened, flaccid, or even dilated. —
(b) The arterial vessels lose some portion of their
tone ; but excepting in as far as they react on
the impulse of the heart on the blood, tliey
are not otherwise affected until debility arrives at
an advanced stage, or is acute or complicated.
When this occurs, arterial action may even be-
come very much increased, particularly as re-
spects the frequency of the pulsation communi-
cated by the heart's contractions, whilst the vital
power of the system generally is remarkably
depressed. In such cases, the pulsations are
broad, open, quick, and very easily compressed ;
or they are small, weak, soft, and thready. Acute
and complicated debility, thus presenting the ap-
parent incongruity of great depression of vital
power, with morbidly excited vascular action, is
not infrequently observed in the advanced stages
of those diseases in which the circulating fluid
becomes contaminated by injurious matters in-
troduced into it from without, or generated in it,
in the manner explained in the article Ui.ooi)
§ 110 — 144.). In these, although the general
manifestations of life are enfeebled to the utmost,
jet the action of the heart and arterial system is
excited by the irritation produced by the con-
laminated blood circulating through them, and the
low grade of vitality still existing is thereby soon
exhausted. — (c) The manifestations of debility
on the blood itself, — in occasioning plethora
when the vital depression is so slight as not to
diminish digestion and assimilation, — in favour-
ing irregular distributions, or determination cf
blood, in its more chronic states, — in producing
ancemia, when its grade is still lower, or when it
is more prolonged, and the assimilative functions
especially affected — and in giving rise to con-
tamination of this fluid, when it impedes the
secreting, eliminating, or excreting functions, —
will be found discussed in that article. — (</) De-
bility seldom exists long, or in a marked form ,

or all of them at certain of their stages, yet is the
vital endowment otherwise modified in each, and
in such a manner as to present specific characters
whereby they may be severally known and dis-
tinguished, without taking the grade of vital mani-
festations into the account. It is this form of debility
which may be imputed to what has been called, in
general terms, by BnEnA.the evolution of matters
injurious to life: and it very often arises from
causes, which, by the nature of their impression
upon the living frame, not merely depress, but also
otherwise vitiate, the conditions of life in all the
systems and organs of the body, as shown by the
effects produced by the morbid effluvia of typhus,
yellow fever, and other malignant diseases.

12. II. The stecial Manifestations and Ef-
fects OF Debility. — I have hitherto been con-
sidering asthenia in its gen«-a/ co/u/i/w/is; I have
now to view it in its specific or partial states. In
doing this, I shall only attempt an imperfect out-
line of its relations to the principal general systems
and organs of the body, and endeavour to show
that one or more of them may manifest this state
in a greater degree than the rest, or in a modified
form ; and that in this manner much of the varied
phenomena of disease may arise ; but that neither
of them can experience it to a great extent, or for
a long lime, without either a similar state of dis-
ease extending more generally, or some other
morbid condition springing out of it, — conse-
(juences which must necessarily result from the
intimate union of the difierent organs by the
organic nervous and vascular systems, as well as
from the mutual dependence of their functions,
and the reciprocity of vital inffuence.

13. i. Debility of the ge}ieral Systems, — A.
The close connection of the organic, or ganglial
nervous system v/ilh the manifestations of life has
been in several places insisted upon ; and con-
formably with this opinion, and with intimate
views of the origin and nature of morbid actions,
debility cannot exist in a marked degree without
this system being primarily affected. But of the
extent of this affection we can form no estimate,
excepting from the effects upon the functions of
those organs which it influences. I have long
considered, and on various occasions endeavoured
to show, that the ganglial and the vascular systems,
by their resulting and reciprocal actions, are the
factors of life ; and that the part which the former
consecjuently and necessarily performs in the
causation and removal of morbid phenomena is
most immediate and important. If we examine
closely the manner in which causes invade the
frame, we shall find, a great proportion of those
which produce any of the states of vital depression
already noticed make their impression in such a
manner as to leave no doubt of their action being
primarily exerted upon this system, thereby prov-
ing its very close connection with life. It is, how-
ever, evident that the impression made in this
quarter will not remain for any lime limited to it;
but will extend in the first instance to those parts
which are most intimately associated with it, and
dependent upon it for the regular performance of
their functions. This a priori inference is actually
demonstrated by observation ; for we find the cir-
culating, the digestive, and the assinalative func-
tions, immediatelv enfeebled by causes which can
operate in no other way, and through no other
channel ihau the nervous system of organic life.

478

without the venous circulation becoming thereby
affected. The depressing agents, indeed, which
act most severely upon the frame, give rise to
impeded circulation or congestions of blood
through the veins as one of their more imme-
diate effects upon the economy, as shown in the
article Congestion of Blood, (e) The Uimphatic
and absorbent vessels even escape not the con-
sequences of debility, particularly when it arises
from original conformation, or deficient and un-
wholesome food. Tliis is shown by scrofulous
diseases of tiie glands, in the mesenteric consump-
tion of children, and some states of dropsy, (See
Lymphatic System.)

15. ii. Debilitii of the Functions of associated
Organs. — The functions about to be particularised
are depressed by, (a) Causes whicii lower the
vital actions of the foregoing systems in a general
and severe manner ; and (6) by such as operate
immediately upon these organs themselves. The
former, being more general, and more intense in
their operation, are immediately followed by
arrest or remarkable disturbance of the functions
in question; wiiilst the latter causes usually,
but not always, over-excite and thereby exhaust
these functions, and, by the frequency of their
repetition rather than by their intensity, produce
their effects more slowly and partially, yl. The
digestive and secreting organs are amongst the first
to experience debility, however induced. This
may arise from the evident dependence of their
functions upon the ganglial system of nerves.
But they may be especially affected, and may
continue so for some time, without other parts of
the frame evincing much disorder, particularly
when the debihty has been slowly and indirectly
produced. The more special manifestations of
debility in the stomach, the liver, the duodenum,
and bowels, usually begin in this way ; and they
have severally obtained, according to the forms
they assume, the names of indigestion, torpor of
the liver, flatulence, constipation, colic, &c. —
these being the more common effects, although
several others may be adduced. When debility,
either of an acute or chronic form, affects ciiiefiy
the digestive organs, the abdominal secretions and
excretions are more or less disordered — are usually
in smaller quantity and vitiated quality. But
this is not the only result ; they are generally re-
tained on the surfaces and situations where they
are secreted, until tiiey undergo various changes,
and acquire irritating properties. This is well
illustrated by many of the functional diseases
of tiie liver and bowels. (See Ctxhm, Colon,
Concuetions, Constipation, Liver, Worms,
&c.)

16. B. The respiratory and nssimilaling func-
tions manifest debility in various v/ays ; the re-
spiratory by frequency, shortness, and quickness
of action, and diminution of the changes usually
produced upon tlie blood and air resi)ire(l ; the
assimilating function by the thin and watery
state of the blood, by the deficiency of its (|uan-
tity, or of its red pari ides, as in amemia, and, in
sligiiter cases, by the milky or oleaginous con-
dition of the serum, Wiicn debility is slight or
recent, or when it has been gradually induced ijy
stimulating agents, nutrition is not very mate
rially affected ; it may even be ])nrtially in

DEBILITY— Manifestations of*

fatty matter in the circulation, and its deposition
in the adipose structure, thereby increasing the
bulk of the body. But when the vital energies
are more remarkably depressed, either in acute,
chronic, or complicated cases, the nutrition of all
the structures and organs, particularly of adipose,
cellular, and muscular parts, is more or less
arrested.

17. C. The vital manifestations of the cerebro-
spinal nervous si/stewi, and organs of sense, may be
remarkably enfeebled, without the rest of the
frame being materially affected : but they may
also be uncommonly active, although all the
other functions of the body are debilitated.
Idiotcii and certain states of insanity are often
met with unconnected with any marked depres-
sion of the physical powers; and, on the other
hand, particularly in chronic debility attended by
emaciation and quickened circulation, the powers
of mind are frequently very acute. The slightest
change in the freedom, activity, or quickness
of the circulation in the brain and spinal chord,
and in the purity of the blood, will materially
affect the character of the phenomena associated
with debility of these organs, or of the body
generally. As long as the circulation is unim-
peded, and the blood sufficiently purified by the
einunctories, debility will be attended by great
activity of all the senses, and increased irrita-
bility of all the muscles. Hence arise various of
its forms, familiar to every observer of disease,
— that u'ith increased sensibility (the Debilitas ad
Sensum of some writers), and that u'/(/t augmented
irritability (ihe Irritable Debility o{IlvrEi,AT<:D and
other German authors, — the " Mobiliiy" of Dr.
Cullen) ; both which forms constitute increased
susceptibility, or excitability, of the cerebro-spinal
system, and of the organs they influence. When,
however, retarded circulation occurs in this sys-
tem, or if the blood itself be rendered inappro-
priate to its state and functions, by the super-
abundance of unassimilated materials, or if it be
insufficiently purified by the emunctories, debi-
lity, whether thus limited or universal, will be
attended by a proportionate degree of torpor (the
Torpid Debility of Hufeland), as well as by ady-
namia of all the organs dependent upon this sys-
tem ; instances of which are sufficiently common
in many acute diseases. In this way the va-
rious manifestations of debility in the mental
faculties, the general sensibility, and the mo-
bility of the frame, in different cases and com-
plications of disease, may be explained, — par-
ticularly if the various organic changes which so
often supervene or become associated with this
state of vital power, and with either of the con-
ditions of the cerebral and general circulation
now alluded to, be called into aid. The causes
also, the nature of their impression, and their
mode of operation, will remarkably modify the
slate and duration of cerebral asthenia. These
are chiefly, (o) Such as act immediately on this
system, — as inordinate mental exertions, the de-
pressing passions and emotions, excessive fatigue,
and narcotic poisons. (6) Those which act indi-
rectly or mediately, — as the intenae or prolonged
impression of cold on the surfaces, terrestrial and
infectious miasms, the actions of various sedative
or contra-stimulant agents, and the abuse of the

creased, owing to impeded or imperfect secretion | sexual organs ; all which occasion modified or
and assimilation, the consetiuent abundance of ( even different effects, 'i'he organs of sense, as

DEBILITY OF THE WHOLE FhAME.

479

well as other parts immediately controlled by
the cerebro-spinal system, have their functions
enfeebled and impaired in proportion to the de-
bility it experiences. But they may also be
individually affected, and in various degrees,
without this system being materially disordered.
Such occurrences generally arise from the oper-
ation of local causes, — as over-excitement of
the organ, and exhaustion of its sensibility bv its
peculiar stimuli ; as weakness or loss of sight
from over-exertion, or the intense or prolonged
action of light ; and loss of hearing from great
noises, &c.

18. D. The muscular structures, from their
connection with the ganglial and cerebro-spinal
systems, necessarily experience the effects of de-
pression of the energies of these systems, varying,
according to its acute and chronic form, its degree,
its simple or complicated state, and the progress it
has made. But debility seldom originates in, or
is limited to, these structures. Its earliest and
simplest manifestations in them are diminished
tone, flaccidity, wasting, particularly of volun-
tary muscles ; lowered, or in some cases, mor-
bidly increased irritability, according as the nerv-
ous systems experience a diminution or increase
of their susceptibility (§ 17. J ; occasioning, in
some cases, irregular and tremulous motions,
and a disposition to spasmodic or convulsive
action, but more frequently defective energy of
contraction, or power of continuing and repeat-
ing it, in both the involuntary and voluntary
classes of muscles. In the more acute, or the
more advanced and complicated states of ady-
namia, the insensible tonic contractility of mus-
cular fibres are in a great measure lost ; their
vital cohe-ion is also so much diminished as to
admit ot their being more easily torn ; they are
incapable of performing even a portion of their
functions ; and their contractions are feeble, vi-
bratory, or oscillating, productive of the utmost
fatigue, sometimes of death ; and the least ex-
ertion, even that requisite to preserve the body
recumbent upon one side, cannot be sustained
for a few minutes. These extreme states of
debility occur in the most dangerous and severe
cases of disease, as in adynamic fevers, scurvy,
&c., and when the circulating and secreted fluids
have become sensibly changed from their healthy
condition.

19. E. The sexual organs, whilst they partici-
pate in the vital depression of the general systems,
are often themselves chiefly affected. It is by
no means uncommon to meet with instances,
particularly in the male sex, of the most com-
plete debility of these organs, amounlmg some-
times to entire loss of function, from precocious
and inordinate excitement and indulgence ; there
being little or no other disorder, excepting en-
feebled mental manifestation, in some cases. In
others, however, all the organic and cerebro-spi-
nal functions have become remarkably weakened,
although not to the extent experienced by the
organs in question. (See Impotency.)

20. iii. The Manifestations of Debility in parti-
cular Tissues are less evident than in the general
systems and associated organs ; and they are later
in becoming evident. It is usually not until
they are extreme, long-continued, or complicated,
that they are remarkable. — («) The cellular
tissue at first evinces deficient firmness and elas-

ticity, with softness, and, as debility increases
loss of its vital cohesion : it at last presents a
tendency to oedematous or serous infiltration, and
even to haemorrhage, owing to weakness of the
extreme vessels terminating and originating in
it, and the insufficient support it yields them.
When it is thus changed, the spread of other dis-
eases through it is thereby remarkably promoted,
and an unfavourable termination hastened, — as
in cases of diffusive inflammation, erysipelas, punc-
tured or poisoned wounds, &c. ; its vessels having
lost their power to limit the extension of inflamma-
tion by forming coagulable lymph. — (6) Mucous
membranes are amongst the earliest of the parti-
cular tissues to'experience the effects of debility,
thereby increasing and perpetuating many of its
phenomena. At first their functions mei'ely are
impeded ; their secretions either diminished, or
imperfectly excreted, or increased from relax-
ation of their vessels, or in other respects vitiated.
As debility, whether of them especially, or of the
frame in general, advances, vital cohesion be-
comes impaired, and they yield not the requisite
support to their vessels; whence result softenino-,
haemorrhage from their surface, ecchymosis,
asthenic ulceration, atrophy, &c. — (c) The se^
rous tissues undergo a partial diminution of their
cohesion, and permit an aqueous or serous fluid,
in some extreme cases tinged with blood, to
escape through their exhaling pores. — (d) The
erectile textures at first evince greater suscep-
tibility, particularly when debility has been in-
duced by inordinate excitement of the sexual
organs ; but as it increases they lose their peculiar
functions. — (e) The Jibrous tissue also experi.
ences relaxation, becomes lass elastic, and more
readily yields than in health, giving rise to almost
spontaneous dislocations, — results which have
occurred in the chronic debility caused by mas-
turbation, as remarked by Sir Astley Cooper
and Mr. Copland Hutchison, and by myself in
one case. — (/) The osseous texture occasionally
experiences, in children, an imperfect deposition
of ossific matter, or even absorption of a great
part of that already secreted ; and, in aged per-
sons, the removal of the animal matter which
gives due cohesion to this structure: and, (o)
The cor)ieous tissues are often variously changed ;
the hair either falling out, or becoming thin, weak,
or grey ; the epidermis inclined to exfoliate, and
rough or scaly ; and the nails thin, long, crooked,
or irregular.

21. III. Debilitv of the whole Frame.

Debility seems, as already stated, most frequently
to originate in the ganglial and vascular systems,
which I have viewed as the chief factors of life •
the digestive, assimilative, excretory, and cerebro-
spinal organs being subsequently affected. But
t may also commence in, and continue for a con-
siderable time limited to, either of these, or even,
although rarely, to one or more of the individual
tissues. When existing thus locally, it usually
springs from local and indirect causes, and is at
first of a slight grade, the functions of the part
merely being impeded : but, as it continues, the
rest of the economy becomes implicated in various
degrees, owing to the reciprocity of vital action
and function existing throughout the frame.
With this universal diffusion of asthenia, tlie part
primarily disordered may still continue affected
in a greater degree, exhibiting the changes of func-

480

DEBILITY — Symptoms— Diagnosis.

tion, and even of structure, now briefly sketched
in respect of the principal systems, organs, and
tissues, according as they may be implicated ; but
in many instances, the debility becomes, co-ordi-
nate throughout ; and in rare cases, the part
originally aftected even partially recovers its
powers upon some other organ having its vital
energies more remarkably depressed.

22. IV. Characteristic Signs, &c. — When
asthenia is thus general and fully developed, the ex-
ternal aspect of the body, and all the vital functions,
are affected ; the extent and specific characters of
ailment furnishing important pathological as well
as therapeutical indications to the practitioner : —
The countenance is pale, thin, or collapsed, some-
times bloated and discoloured : the eyes lose their
animation, and sink in tlie sockets, and they are
surrounded either by a dark or bluish, or by a
tumid and oedematous, circle ; the expression of tiie
features is languid and depressed ; the lips are
pale ; the tongue watery, moist, soft, broad, and
sometimes tremulous.andtiie papilla: depressed and
wasted ; the voice and speech are weak, or nearly
lost ; the voluntary muscles lose their powers,
and hence, in extreme cases, the continued supine
posture, the inability to retain a position on either
side, the sinking down in bed, and the falling of
the head on the breast or on either shoulder. Tlie
surface of the body has its temperature diminislied,
is sometimes partially covered with a cold or
clammy perspiration, becomes soft and flabby,
occasionally of a more lurid or dirty hue, or pale
and waxy, particularly in complicated debility ;
the firmness and elasticity of the soft solids are
lost, and they either present a leucophlegmatic
appearance, or they are remarkably emaciated, —
tlie latter being particularly the case when the
circulation is accelerated. The functions of the
stomach and bowels are impaired, or altogether
suppressed ; and hence the want of appetite, the
constipation, and emaciation, — which last afl'ects
first the adipose tissue, and next the cellular and
least vitalised structures. \Vhen the depression
is very great, the vital attraction requisite to the
nutrition and healthy cohesion, especially of the
more remote and superficial parts, being necessa-
rily diminished, the function of absorption gains
the ascendancy; and the less perfectly animalised
constituents, particularly the adipose substance
and the effete elements, are carried back into the
circulation ; and thus, in some states of disease.

headach ; noises in the ears, either with or with,
out impaired hearing ; weakness of the limbs, and
relaxation of the ligaments of the joints, with
tremors, occasionally convulsive movements, or
local paralysis; and ultimately low or quiet de-
lirium.

23. V. Diagnosis. — A distinction has usually
been made between real and spurious debility.
'The latter term, however, implies a contradiction.
But as it is the morbid condition, and not the
name imposed upon it, that requires notice, I may
briefly allude to it. The state of system, to which
this name has been applied, would be better ex-
pressed by denominating it oppression of vital
power; this, or nearly similar appellations (" o/)-
pressiovirium," " debilitas ah oppressiotie"), having
been employed by several modern pathologists.
The vital manifestations may be generally or par-
tially oppressed by whatever impedes their free
reaction in removing the impression produced
by injurious agents, or by whatever arrests the
function of an important secreting organ or vital
emunctory, whereby the vascular system becomes
overloaded, and consequently oppressed through-
out, as well as in the organ whose functions have
been interrupted. The distinction will be more
easily understood by a reference to facts. —
During pneumonia, the lungs perform their func-
tions in respect of the blood imperfectly, and the
various secretions and excretions are diminished.
Hence the quantity of the circulating fluid is in-
creased ; the circulation through the inflamed
lung rendered difficult ; the functions of this
organ impeded, and the vessels generally dis-
tended beyond their power of reaction upon
their contents, so as to restore the suspended
functions. In such cases, the pulse is sup-
pressed, and not much accelerated; but it con-
veys the sensation of a confined limit of puls-
ation, thereby suggesting the idea of a sustained
state either of tonicity which the systole of the
ventricle cannot much affect, or of distension
upon which the elasticity of the vessel reacts
imperfectly in the intermissions between the sys-
toles. That this state actually obtains is shown
by the effects of blood-letting in changing the
character of the pulse, in removing the feeling of
oppression, and in partly restoring the strength.
Inflammations of other organs — as the liver,
brain. Sec. — also furnish instances of oppression
of vital power. In all these, however, the state

the body continues to live upon itself, until the of the surface of the body, and other symptoms

functions are restored, or life extinguished ;
the external soft solids, attached to, or covering,
the bones, meanwhile becoming remarkably ex-
tenuated. In general, the pulse is frequent, soft,
small, and easily compressed : the action of the
heart is weak, and leipothymia or syncope occur
upon exertion, or on quickly assuming the erect
posture. Ilespiration is frequent, inij)erfect, or
anxious or diflicult, and the motions of the thorax
are slight and confined. The functions of the ce-
rebio-spinal system are more or less enfeebled ;
and, with the changes described above (§ 17.),
present the following phenomena : — Loss of me-
mory ; inability to prosecute a lengthened chain of
discussion, or to fix the attention long on one sub-
ject ; sometimes weakness, with hebetude of all
the faculties; an unpleasant feeling of languor, and
exhaustion, with a sense of anxiety referable to
the priecordia and pit of the stomach ; vertigo or

above noticed as characterising true debility
(§22.), do not exist. In fevers, also, the re-
action following the impression of the exciting
causes is very generally attended by oppression
of the powers of life, owing, in some cases, to an
overloaded state of the circulation from inter-
rupted secretion, &c. ; and, in other cases, partly
to this circumstance, and partly to the depressing
influence produced by these causes still continu-
ing, and, jointly with the increase in the quan-
tity of the circulating fluid, favouring congestion
of internal secreting and vital organs. Hence,
in several forms of these diseases, a complicated
pathological state is the result ; viz. depressed,
followed by oppressed, vital power, as soon as
attempts at reaction begin to be made, in order
to overcome the injurious impressions, and

! changes occasioned by the exciting causes.

I This suppression of power may arise out of true

DEBILITY — CoNSEQUEN'CES an

debility, may be associated with it, and terminate
in it, in its worst and complicated states.

24. The DuHATioN of debility is extremely
various. It may, particularly when acquired
and slight, be remarkably long, or continue
through lite, which it may not even abridge.
When rapidly and primai-ilij produced, or ge-
neral and intense, or complicated, it is usually
acute as respects its continuance ; but when
consecuthe, or partial, or the result of irritation
of particular textures, it is prolonged into the
chronic state; its duration depending greatly
upon its degree, and both being extremely va-
rious.

25. VI. Pathological Relations. — i. The
Consequences and Terminations of debility
are, (u) Impeded or interrupted secretion ; (b)
Changes of the circulating fluids ; (c) ^'arious
states of irritation or inflammatory action, in par-
ticular organs or tissues; (d) General reaction
of the vascular system, associated with various
grades of vital power, from the lowest, or most
asthenic, to its highest, or most sthenic form, with
their modifications ; (e) Changes in the firmness,
elasticity, nutrition, colour, form, and vital cohe-
sion of the soft solids, and, in some instances,
ultimately in the hard solids also; (f) Effusions
of fluids (aqueous, serous, sanguineous, &c.) from
mucous or serous surfaces, or in cellular or pa-
renchymatous structures ; (g) The production of
numerous forms of organic change ; (h) The form-
ation of new or adventitious tissues or produc-
tions, as tubercles, tumours, melanosis, cancer,
hydatids, worms, gangrene, &c. ; and, (i) lastly,
Death, which may occur directly from the intense
action of the depressing cause, but more com-
monly through the medium of one or more of the
changes now enumerated, the first and greater
part of which often taking place consecutively.

26. ii. Associations or Debility. — Asthenia
is very frequently connected with some other
morbid condition, implicating either particular
parts, or the system generally. Amongst these
are the consequences now enumerated {§ 25.);
but the most important are, (a) Tlie association
of depressed with otherwise modified or morbid
states of the vitality of the system ; (b) with a
vitiated condition of the blood and secreted
fluids, either or both of which constitute the com-
plicated debility already mentioned (§ H.) ;
(c) with a disposition to solution of the textures
generally, or of a part n.erely, as in malignant
fevers ; (</) with congestions, and chronic or
acute inflammations of particular organs or struc-
tures, as in complicated forms of fever, erysi-
pelas, diffusive inflammations, dyspnteiy, &:c. ;
(e) with intestinal worms, hydatids, and various
malignant and adventitious formations.

27. A kuowledge of the pathological relations
of this most important and singularly over-looked
condition of vital power is necessary to the prac-
titioner, inasmuch as it enables him to entertain
enlarged and connected views of disease, by the
aid of which he may the better comprehend such
states of di-oi-dered action as cannot be readily
assigned to any particular ty[,e or specific form,
owing to their imperfectly marked characters,
the a>sociated disturbance of different organs and
structures, and the want of prominent symptoms
whereby tliey may be ascertained. Debility not
only constitutes, in its more intense fornis, dis-

^ OL. I.

D TEnMiNATiONS — Treatment.

481

ease itself, and a most serious part of many of
the most dangerous maladies, but it also predis'
poses the body to be affected by the numerous in-
jurious agents to which it is constantly exposed.

28. iii. The Tredisposition to be affected by
the exciting causes of disease, arising out of debi-
lity, will necessarily vary with the form and grade
it assumes, and the circumstances in which it has
originated. This proposition is too evident to re-
quire illustration. But when the debility proceeds
fr'oni irritation of one or more structures abstract-
ing vital power from the rest (§ 9.), it may not
increase, but may, in some cases, diminish,
predisposition, particularly when it is attended
by exalted sensibility and accelerated circulation.
Thus the debility attending irritation in any part
of the respiratory organs even diminishes the
disposition to be affected by malaria, and infec-
tious or epidemic agents. So much, however,
of what constitutes liability to diseases is owing to
the temperameat, diathesis, the modes of life,
and habit of body, as well as to general or local
debility, that the exact share of each can rarely
be ascertained. General debility, either in its
direct or primary form, or as consecutive of
over-excitement, disposes the system to be affected
by terrestrial emanationSj vicissitudes of season
and weather, and infectious efHuvia. The more
local or partial states of debility, particularly
when existing in secreting organs and the asso-
ciated structures, render them liable to conges-
tions, inflammatory irritation, to disordered secre-
tion and excretion, to spasmodic or convulsive
movements, to effusions, to various states of in-
flammation, and organic change, with the ot!rerco«-
seqxtences and associations of debility above enu-
merated (§ 25, 26.), upon exposure to causes
which disturb the balance of vital manifestation
throughout the frame in a sudden or violent man-
ner, or which impede the assimilating and depura-
tory functions, and thereby disorder the vascular
actions and the circulating fluid. (See Disease
— Causes o/'.)

29. VII. Treatment. — In attempting to re-
move debility, our means should be directed with
a strict i-eference to its form, grade, and com-
plication. These, however, are so numerous,
that pr-ecise rules of treatment cannot be laid
down; the only attempts of this kind that can be
made, falling more appropriately under those
diseases of which depressed vital power forms an
essential part. (See especially the First Class
of the author's classification.) In the treatment
of debility, in either its simple or associated
states, there is a particular class of remedies, viz,
tonics, which are mor-e beneficial than any other ;
although many articles belonging to other classes,
as diffusive stimulants and antispasmodics, may
often be prescribed, and with great advantage.
Tonics, which have derived their name from
their influence in augmenting the tone of con-
tractile parts, owe the principal part of their
good effects to their elevating, in a gradual
manner, depressed vital power, hardly up to, and
seldom or never above, the healthy standard ;
and to the permanency of their action. By their
repetition befor'e the eflects of the pr'cvious dose
have subsided, the beneficial influence ultimately
is propagated throughout ; and as soon as one or
more important functions are restored, the rest
participate in the change, and the whole assume

li

482

a regular discharge of their offices, owing to the
reciprocity of vital influence and function exist-
ing throughout tiie economy. Much, indeed, if
not more, is also due to the partial absorption
into the circulation of their active constituents ;
and to their direct action on the vessels, the dif-
ferent tissues, and on the blood itself. Although
various diffusive stimulants and antispasmodics
produce beneficial effects in several states of
debility, yet tiiey are generally much less service-
able tlian tonics, and in many instances are even
injurious, chiefly from the quickness and little
permanency of their action, from their proneness
to over-excite and over-heat the system, and
consequently to indirectly depress its energies.
Hence, in order to perpetuate their restorative
effects, it becomes requisite to repeat them more
frequently ; and thus a habit and desire of
excitation is generated, which, if not gratified, is
followed by insupportable exhaustion. How-
ever, in many states of disease, they are beneficial
from the rapidity of their action, and are useful
adjuncts to more appropriate means. As all the
agents which restore the vital energies vary not
only in the grade, the rapidity, and the per-
manency of their action, but also in respect of
the organ, or the system, or tissue, on which
their influence is chiefly exerted, it becomes a
most important object in practice to ascertain
the part primarily and chiefly affected, and to
prescribe them according to our knowledge of
their mode of operation,

30. Before adopting measures to remove de-
bility, we should ascertain, 1st, The causes in
which it has originated ; 2dly, Whether or no
it may not be apparent merely, — the consequence
of oppressed and not of depressed, vital power ;
3dly, If it proceed or not from irritation of a par-
ticular part, abstracting the due energy from
others; 4thly, Whether it be sinijjfe or complicated ;
and, 5thly, If it be associated with any local mis-
chief or chani^e of structure. Having ascertained
these important points, the next object is the choice
of agents, and appropriation of them to the states
of debility presumed to exist. It is chiefly to the
neglect of a pathological analysis similar to the
above, of the cases which occur in practice, that
the abuse of tonics in diseases of debility is chiefly
to be attributed.

31. i. Primarij Debility should be treated,
conformably with the injunction now given, with
strict reference to its cause, to the particular
form it has assumed, and the organs or parts
chiefly affected. If it have arisen from abstrac-
tion of the stimuli necessary to health, these
should bo restored ; if from depressing aeents,
whether physical or moral, these should be
counteracted as far as may be. — (a) When de-
bility is manifested more especially in the viscera
immediately influenced by the ganglial and vas-
culiir systems, it very generally proceeds from one
or other of these classes of causes; and, besides
their removal or counteraction, recjuircs, accord-
ing to the rapidity and the intensity of their
operation, the most carefully selected remedies.
If the vital depression be rapidly progressive or
very great, diffusive stimuli, as camphor, amnu)nia,
th'; a!tliers, serpentaria, ainica, &c., will he re-
quisite in the first instance, until it is an-estcd,
wlien tonics will bn more serviceable ; but, with
the first indication of reaction, stimuli of every

DEBILITY — Treatment of Primary.

kind should be laid aside, lest the consequent
excitement should be carried to an inordinate
height by their means. The propriety of pre-
scribing tonics appropriately to the states and
grades of debility, as insisted on by Hoffmann
and TiioMANN, cannot be doubted ; but opinions
will differ widely as to those which are more
suitable to certain conditions. When the vital
depression affects the action of the heart more
particularly, after momentarily exciting the ol-
factory and respiratory nerves, as well as those
of the stomach, by means of the volatile and
diffusive stimulants, as the aethers, ammonia, and
aromatic spirits, &c., the more permanent tonics
should be employed. If there appear to be a
deficiency of blood in cases of this description,
the preparations of iron will be most serviceable,
and will be advantageously combined with
myrrh, cinchona, gentian, willow-bark, casca-
rilla, and the carbonate of potassa. If the or-
ganic nervous influence be depressed, without
any manifest deficiency of blood, either of these
vegetable tonics may be taken, with the fixed
alkalies or their carbonates, or with the mineral
acids, according as it may be desirable to pro-
mote the secretions, or to impart tone to the ex-
treme vessels. When we wish to excite the
functions of the viscera generally, and particularly
when the blood does not undergo the requisite
changes as it circulates through the different
assimilating and depuratory organs, the chlorates
of potassa and soda (the oxymuriates) will be
found of much use. I have employed them for
several years with much benefit, at the Infirmary
for Children, in diseases of debility affecting
chiefly these organs, as well as the preparations
of iodine, especially the iodides of potassium and of
iron. The bitter tonics, combined with aperients,
will also prove of great service in similar cases.
The marked advantages of associating indivi-
dual medicines selected from each of these two
classes, — first made known to me by the writings
of Hoffmann, and confirmed by repeated
observation, — are brought about both by their
increasing the action of the secreting and excret-
ing viscera when thus conjoined, and by their
improving thereby the condition of the circulating
fluids, as well as permanently exciting the vital
influence. In some cases, the combination of
small doses of the extract of nux vomica, or of
strychnia, with aloes and myrrh, has proved
equally beneficial. It was in pathological states
similar to those now under consideration, that
phosphorus was prescribed by Conradi and
others, that the inhalation of oxygen gas was
strenuously advised by Beddoes, and that elec-
tricity and galvanism were generally recom-
mended by Continental writers. But I per-
fectly agree with Grapengeisser, in viewing
these as calculated to be injurious where there
exists any increase of irritability, either locally or
generally, or where any vital organ is con-
gested.

32. When debility is the consequence of the
injurious impression of some powerful agent, as
terrestrial or infectious eflSuvia, it will often be
most advantageous to interrupt the succession of
morbid phenomena by the exhibition of the most
active tonics in large doses, and in conjunction
with warm cordialx. All the more intense states
of primary debility proceed from impressions

DEBILITY — Treatmekt of Consecutive.

483

made by sedative causes upon the ganglial sys-
tem, and may be removed by counter-agents
directed to the same system, before consecutive
changes have advanced far, or the functions
of the emunctories and tlie state of the circulat-

bowels, not proceeding from inflammatory irrita-
tion of their mucous suiface, chloride of hme,
or cusparia, caUiniba, quassia, or cascarilla, with
the alkahne carbonates, &c. are generally of service.
When tlie debility of these organs is attended by

ing fluid have been disordered to the extent of torpor of the liver, or accumulations of bile in
giving rise to the early phenomena of febrile the gall-bladder and hepatic ducts, deobstruent

reaction. Thus, the more stimulating emetics,
immediately followed by powerful tonics, or ca-
tiiartics preceded by or combined with warm
tonics, will often prevent the accession of fevers,
when exhibited before the cold stage, or rigour,
has commenced ; and, in some cases, although it
have commenced, if it have not terminated in
excitement. But, in these cases, the tonics and
other excitants prescribed should be of such
kind, and in such quantity, as will make a power-
ful impression on the nervous system of organic
life, and as are calculated to restore the suspended
secretions. The preparations of cinchona, or
the sulphate of quinine, combined with the hot
spices, as capsicum, or with camphor, or with
ammonia, and prescribed in large doses after an
emetic, and followed by a purgative conjoined
with the same stimulants, are the most eligible
in such cases. The preparations of arsenic,
the sulphates of zinc and iron, piperine, the
hydrochlorate of ammonia, the chlorates, and va-
rious other tonics, are also appropriate in cases
of primary debility, especially when assisted by
the cardiacs now mentioned ; but they are less
efncieut than the foregoing in removing the vital
depression primarily induced by the exciting
causes of fevers.

33. When asthenia aflects especially the capil-
lary vessels, and the crasis of the blood is deficient,
or when haemorrhages take place unattended by
vascular excitement, the more astringent tonics
should be given with sulphuric acid ; and if
the loss of tone be excessive, these should be
associated with cardiacs and aromatics, and alter-
nated with moderate or full doses of the more
energetic terebinthinates, and balsams ; morbid
secretions being duly evacuated by the preparations
of rhubarb.

34. (b) Debility manifested chiefly in the
associated organs of digestion can never be per-
manently removed unless the secretions and ex-
cretions be duly promoted ; and, for this purpose,
the combination of tonics and aperients alluded
to above is the most efficacious. But this prac-
tice should not be resorted to whilst irritation,
or active congestion of, or determination of blood
to, any of these viscera exists, lest we thereby
convert such disorder into inflammatory action.
In such circumstances, the more heating tonics, or
those which contain most of resinous or oleaginous
constituents, are the least appropriate. Where
irritation of the digestive mucous surface is com-
plicated with debility of these organs, mild tonic
infusions may, notwithstanding, be exhibited with
benefit, especially those of calumba, gentian, cin-
chona, quassia, &:c. ; and may be combined with
acids, or with small or moderate doses of the
nitrate of potash, or the carbonates of potash
or of soda, or with both the nitrate and car-
bonate. It is chiefly in cases of this description
that diflusive stimuli and heating tonics, so much
and justly inveighed against by Brovssais, Otto,
and Philips, are injurious. When asthenia is
associated with a somewhat lax state of the

purgatives should precede the exhibition of tonics
and stomachics. If it be associated with worms,
purgatives, and afterwards chalybeate tonics, are
required.

35. ii. Treatment of Consecutive or Secondary
Debility. — A. It will generally be found, when
the debility arises _yrom irritation of some organ
or secreting surface, that tonics or stimulants,
unless such as are mild, and contain but little of
an essential oil or other heating constituents,
combined with deobstruents and anodynes, will
prove either of no service, or injurious, from
favouring the supervention of inflammatory action
and organic change. Similar effects are also apt
to follow the exhibition of tonics, when debility
is attended with congestion of some internal viscus,
or obstruction of secreting organs : and they will
seldom be of any benefit until these affections
are in some measure removed ; unless the powers
of life are incapable of themselves of restoring
the tone of the circulation and the suspended
secretions, by developing a healthy reaction. In
such cases, local depletions, and remedies calcu-
lated to excite secretion and excretion, should
precede, or even in some instances accompany,
tlie exhibition of gentle tonics, which ought to
be prescribed in conjunction with deobstruents,
assisted by change of air and a light nutritious and
farinaceous diet.

36. jB. The debility which follows over-ex-
citement, or which consists of exhaustion of -power,
requires means proportionate to its degree and
form. The most intense grade of exhaustion
occurs in the last stages of adynamic or malignant
fevers, and of some other acute diseases ; and often
demands not merely permanent excitants, but the
more active stimuli, as camphor, arpmonia, serpen-
taria, arnica, wine, spirits, fethers, &c., to prevent
the rapid extinction of life : whilst other states of
exhaustion, especially such as are slower in their
accession, or follow local inflammations, spas-
modic or hagmorrhagic diseases, and the less
severe forms of fever, admit only of the more
gentle tonics; and even these, particularly if they
be not cautiously prescribed, may reproduce the
disease which occasioned the debility, especially
if it was inflammatory or htemorrhagic. It is
not uncommon to find acute inflammations re-
kindled, or chronic inflammations follow the
acute ; and relapses of fevers, or visceral en-
gorgements, or obstructions, supervene, when the
exhaustion has been treated by heating tonics or
stimulants, or by a premature use of a too full or
stimulating diet. On the other hand, too strict
exemption from all restorative means has been
not infrequently followed by permanent general
or local debility, or by very slow recovery : and
it has often favoured the accession of other acute
or chronic diseases ; exhaustion predisposing the
system to be impressed by their exciting causes.
In the more diflicult and doubtful circumstances
of this form of debility, it will be, upon the whole,
judicious to trust chiefly to wholesome air and
suitable diet; and, if tonics or stimulants are

I i 2

484

DEBILITY — Treatment of Complicated axd of Local.

necessary, <o select those which are the least
heating, and to exhibit lliem along, or alternately,
with such medicines as will promote the secre-
tions and excretions most requning aid, and with
internal and external derivatives from the prin-
cipal seat of disease. In cases of this description,
particularly in the young, and in those who
previously enjoyed a sound constitution, the
returning energies of life generally stand but
little in need of a spur; they require rather a
judicious guidance, especially in respect of the
digestive, tlie secreting, and excreting func-
tions.

37. iii. Complicated Dehiliti), oi that condition
of the frame which consists not merely of a de-
pressed, but of an otherwise morbid state of vital
power, has been ascribed above — 1st, to \m-
wholesome food, and to imperfect assimilation ;
2dly, to an impure or altered state of the cir-
culating fluid, occasioned by impeded or dis-
ordered secretion and excretion ; and, 3dly, to the
absorption of morbid matters into the blood,
eitlier from some one of the mucous surfaces, or
from parts of tliC body in which they have been
generated. The operation and effects of tiiese
sources of contamination have been fully insisted
on in the articles Absorption', and Bi.ood
($ 110 — 151.). The indications of removing them
may be resolved into the following: — 1st, To
cut off tlie supply from the sources of contami-
nation ; 2d, 'i'o raise the powers of life, as ex-
pressed chiefly in the ganglial and circulating
si/stems, by the means pointed out under that head
(§ 31.) ; 3d. To promote the depuratory actions
of the emunctories.

38. A. The propriety of endeavouring to ac-
complish the first of these intentions cannot be
questioned ; but, when the contaminating matters
are formed in some part of the system, as in
various malignant diseases, apparently local at
their commencement, it frequently cannot be put
in practice, or the period at which it might have
been attempted with any prospect of success
may have passed, and the other intentions are
our only resort. — B. The second indication is to
be fulfilled by the remedies already noticed
(§31.), and the treatment recommended in the
article Blood (§ 157.); particularly by the
alkaline chlorates ; the preparations of bark, of
iodine, of iron, of arsenic, or of zinc ; by as-
tringents and antiseptics, as the acetic and citric
acids, &c. ; by the preparations of the bitter roots
and woods, or of the aromatic and tonic barks,
with li([uor potassa;, or the alkaline carbonates,
in the more chronic diseases, and with the sul-
phuric, the hydrochoric, or nitric acids, in the more
acute maladies, and with warm spices, &c. ; and
by the gum-resins, the balsams, the terebinthinatcs
and camphor, ))rescribcd according to the cir-
cumstances of the case. — C. But whilst we are
endeavouring to elevate vital energy by those
and other means, we should also fulfil the third
intention, by associating, or alternating, them with
the more tonic and stomachic purgatives, or will

its manifestations in the' ganglial and vascular
sijstems, and in the digestive viscera, has been
already noticed ; and is still more particularly
discussed in the articles Blood, Colon, Indiges-
tion, &c. — A. Debility of the cerebrospinal or-
gans,mmi be treated according to the causes that
have occasioned it, and the characters it presents.
The causes, whether moral or physical, should be
removed or counteracted as far as possible ; and
if it have arisen from mental excitement, repose
and agreeable amu=ement should be inculcated.
(«) When it is characterised by increased sen-
sibility, the bitter infusions with liquor potassaj
or the carbonates of soda or potash, with conium
or hyoscyamus ; the preparations of iron ; cha-
lybeates ; vegetable tonics and aromatics, with
small doses of opium or the preparations of mor-
phia ; cold or shower baths; sea-bathing, change
of air, &c., mental tranquillity, and agreeable
employment, are amongst the most etiicacious
means. (/;) If it be attended by increased
irritability or mobility, the mineral acids, alone
o r with bitter infusions ; the preparations of cin-
chona; the acetic acid; Hoffmann's anodyne,
valerian, assafoetida, musk, or vegetable tonics, with
opiates or anodynes, the hydrocyanic acid, the
Iceland moss, ass-milk, alkaline or tepid baths,
&c., are suitable remedies, (c) If the debility be
great, and particularly if it be attended by torpor
or depression of the sensibility, depending neither
upon cerebral congestion, nor upon a plethoric
state of the vascular system, the warm or diffu-
sible stimulants, combined with permanent tonics ;
aromatics and cardiacs; iodine, strychnine, or the
extract of nux vomica in small doses ;. coffee ;
camphor or phospiiorus in minute quantities ;
warm salt water bathing ; the shower bath ; chlo-
rine fumigating baths; the use of astringent and
camphorated washes to the head and surface of
the body; the nitro- hydrochloric acid bath, or
sponging the surface of the trunk, or even the head
itself, with a tepid wash, containing these acids,
may be tried and associated with the foregoing,
or other internal remedies, according to the pecu-
liarities of the case.

40. JB. The sexiini ofgYHis are debilitated — (a)
from imperfect developement depending upon
their interrupted evolution, or upon general as-
thenia; and (/;) from over-excitement. 1\\& first
of these causes seldom occurs in the male, but not
infrequently in the female (see Chlorosis, and
RIfnstrvation), and in such cases requires the
constitutional treatment there described. The
second cause is common to both sexes, although
perhaps more so in the male than female. When
it has tlius originated, and exists merely in a slight
degree, without amounting to impotency, the or-
gans will recover their energies soon after marriage,
if regular and abstemious habits be adopted. In
other circumstances, and in severer cases, attention
should be paid to the generiil health : the mind
ought to bo occupied by interesting pursuits ; the
])atient should rise early in the morning, and use
the shower bath, or local aspersion or affusion, and

warm and stimulating diaphoretics, as the abdo- live regularly. If the causes in which it originated

inmal or the cutaneous secretions niay re(iuire to
be promoted.

39. iv. Debility afl'ccling chicjly associated or-
gans,nr particular te:ilnres, requires nearly similar
means to tho'-e already advised, according to the
grade and form it may assume. The treatment of

be relinquished, the; sexual function will soon
be restored. The tonics which are the most effi-
cacious in cases of this description are, the tincture
of the sesqui-chloride of iron, taken in the infusion
of quassia, or of chamomile flowers; the tincture
of iodine; coflee; and the extract of conium,

DEBILITY — Treatment,

485

with the preparations of clacliona, cascarilla, or
iron, &c. (See I.-mpotknlv, and Steiui.itv.)

41. C. The manifestations of debility in the
cellular, the mucous, and other tissues, must be
treated according to tlie principles already stated.
When asthenia in any of its various forms affects
the digestive mucous surface, the treatment already
noticed (§34.) is applicable. ]f it be attended by
liaimatemesis, mala;na, or intestinal hieniorrhage,
the terebinthinates, and sulphuric acid, either
alone or with tonic decoctions, or the acetate
of lead with acetic acid and opium, are the most
energetic. If it manifest itself chiefly in the re-
spiratorii mucous membrane, the astringent tonics,
the rtiineral or vegetable acids, the inhalation of
the fumes of astringent and tonic substances (see
Bi'.ONCHi, § 100.), sponging the chest daily with
tepid or cold astringent lotions, change of air, sea-
voyaging, and horse exercise, are amongst the
most salutary measures.

42. V, Of the various constilutumal and local
diseases with which debility is commonly associated
(§25, 26.), little or no mention need be made at this
place, as they are particularly noticed elsewhere.
i may, however, remark, that inflammations oc-
curring in a debilitated and cachectic state of the
frame, more especially if the debility be of that
complicated kind described above (§ 1 l.),are cha-
racterised by deficient energy of all the functions
actuated by the organic nervous system, and by
imperfect tone of the vascular and capillary sys-
tem itself (see Inflamm.aiions — Asthenic Forms
of) ; and that they seldom admit of the large de-
pletions which are indispensable in the healthy or
sthenic states of those diseases. The inflammations
which not infrequently supervene in the course of
adynamic fevers, and certain forms of erysipelas,
as well as various other associations of the patho-
logical conditions now under consideration, fully
illustrate this position. Such asthenic forms of
complicated disease, however greatly increased
the general vascular action attending them may
be, require the powers of life to be supported,
and, in many cases, po\verful tonics and stimulants
to be exhibited, even at the time that it may be
necessary to resort to local or derivative bleedings
in order to prevent the disorganisation of the viscus
especially affected. In all such maladies, the
pulse is remarkably quick, ofti.n full, but soft and
compressible — a state which, although resulting
from depressed vital energy, is too generally viewed
as evincing a very different condition ; and de-
pletions, often the very cause of the great frequency
of the pulse, are resorted to, in order to render it
slower — to perform an impossibility : the im-
portant pathological facts, that great quickness
of pulse is the consequence of debiliiy, and that
the most tumultuous and morbidly increased
vascular action is very frec[uently associated with
the utmost depression of vital power, being either
unknown or overlooked.

43. vii. The treatment of the debilitij attending
convalescence from disease has been partly an-
ticipated, particularly at §36.; but I may here
offer a few additional remarks on this import-
ant subject. — a. The great susceptibility of the
system to impressions from external agents or
mental emotions, attending the debility of the early
stage of convalescence, should make the prac-
titioner cautious as to its management. Expo-
sure to cold, the premature exhibition of stimu-

lants or of too heating tonics, too great indulgence
of the appetite, and inappropriate food, may oc-
casion relapses, may favour the supervention of
other diseases, and may thereby superinduce dan-
gerous or irremediable organic change. This is no
infrequent occurrence after fevers, particularly
the exanthematous, and after inflammations of the
viscera. Such unfavourable results proceed not
merely from the above causes, but also from in-
attention to the secretions and excretions ; the
patient often relinquishing too soon the use of
those means which are still requisite to enable the
weak powers of life to perform their various func-
tions. The laying aside the use of medicines too
soon is even still more frequently productive of
mischief in convalescence from chronic diseases,
particularly those of the bowels and liver, and
dropsies. In these, the use even of the same
means that removed the complaint is often neces-
sary for a considerable time afterwards, either in
different doses or in modified forms. Daring the
whole period of recovery, the causes which pro-
duced the malady ought to be carefully avoided ;
and the physician should prescribe the diet and
regimen of the patient, and such other measures
as may seem to him calculated to ensure the
object proposed. The articles of diet should at
first be bland, digestible, and in small quantity,
which may afterwards be gradually increased ;
and, with the returning powers, the farinaceous
food first adopted may be added to weak animal
decoctions, — or to milk, particularly asses' milk.
Subsequently white fish, boiled; or chicken, rab-
bit, game, or the lean of well-fed mutton, may be
taken, at first in small quantity, and without heat-
ing condiments. Although white fish or flesh may
not be more readily digested than game, venison, or
mutton, yet they are generally not so heating as the
last-mentioned article, or as beef. Before wine, or
any other exciting beverage be allowed, the effects
of the gentle and tonic bitters, in the form of in-
fusion, should be first observed ; and if these oc-
casion no febrile excitement, nor accelerate ihe
pulse, a little old wine, particularly Hermitage,
sherry, or East India jNIadeira, may be taken in
water with the principal meal.

44. b. The temperature of the room, and the bed
and body clothing of the patient, ought to be
duly regulated according to his habits, and the
peculiarities of the case, and with strict regard to
ventilation. Subsequently, change of air and
suitable exercise should be prescribed ; at first
in a close or open carriage, according to the
season, and afterwards on foot, or on horse-
back ; the last of which, and sea-voyaging, being
the best suited to convalescents from pulmonary
diseases.

45. vii. Moral Eegimen, and other means. —
A. There are various other remedies that may be
resorted to in the more urgent cases of debilitv ;
but these are pointed out in the articles on the
specific diseases, of which debility forms an im-
portant part. — a. The internal use of tar water,
once so inordinately lauded, and subsequently so
very undeservedly neglected, and medicated
baths, may, however, be here noticed. I have
had several opportunities of observing the pood
effects of a course of tar water, or of an infusion
or decoction of pine tops and shoots in simple
debility, and in complaints chiefly to be referred
to this state of vital endowment, — i*. The idea that

Ii3

486

DEGLUTITION, DIFFICULT.

the skin is entirely incapable of absorbing fluids in
which it may be immersed, has led to the neglect
of medicated baths. But it should be recollected
that, independently of any power of absorption
this structure may possess, — and which I be-
lieve it possesses under some circumstances, and
in respect of various agents, — it is a living, an
active, a finely sensible, and, as to the nature and
extent of its functions, an important organ ; and
that it is very susceptible of impressions by whicli
not only its own functions are modified or altoge-
ther changed, but the actions of other organs are
variously affected in consequence of the nervous
and vascular connections and functional relations,
which bind the different parts of the economy into
one indivisible whole. Entertaining such views,
I believe that cold, tepid, warm, or medicated
baths ; that lotions or washes, or stimulating
liniments and frictions applied to the surface, —
the former in slighter cases, the latter in tiie more
urgent ; are not infrequently beneficial in dis-
eases of debility, when judiciously employed,
and with due reference to antecedent or existing
visceral disorder. Sea or salt water bathing- ;
shower baths ; camphor and chalybeate baths ;
warm, tepid, or cold baths, either general or
local, of iodine, or of iodine and carbonate of
potassa; baths of decoctions of willow or oak
bark, sometimes with the addition of an alkaline
carbonate ; washes witii camphor water, rose
water, and vinegar, applied to tiie trunk ; or
sponging the surface daily with a mixture of
these, at a temperature of about 60° ; or with a
small proportion of the nitric and hydrochloric
acids in water at a temperature of 70° to 80°;
are respectively of much service, when suitably
prescribed.

46. JB. Mural treatment, or attention to such
mental impressions and emotions as are cal-
culated to promote the physical means resorted
to, is particularly beneficial in restoring the vital
powers, especially v.hen tiie nervous systems
manifest a more than ordinary share of depres-
sion and its attendant disorders. The manner
and bearing of the physician, when calculated to
inspire confidence, will of themselves do much in
fulfilling the intentions of his prescriptions. Tlie
faith reposed in the remedies resorted to will often
accomplish as much as they are piiysically capa-
ble of performing, and not infrequently much
more. In order to inspire tliis feeling, the phy-
sician should liirnself evince a calm, and, in cases
of great danger and depression of the vital
energies, a cheerful confidence. Hope, in what-
ever form it may be excited, and in every degree
to which it can be elevated, is a most powerful
agent in combating diseases of debility ; wliilst
its opposite, despondency, — the consequence and
the cause of debility, — is one of the greatest evils
we have to guard against in these maladies.
Every practitioner whose range of observation
has comprised the malignant diseases of warm
climates, or of temperate countries, must have
remarked, that when tiie patient dreads, and still
more if he entertains a sentiment of, an unfavour-
able issue, or if he be apathetic and careless of
the event, the very worst sign of depressed vital
power lias appeared, and the most active moral
and physical stimulants are liicn required ;
whilst, on tlie oilier iiand, a firm confidence in
the physician, and ardent desire of recovery, arc

the best aids by which his endeavours can be
seconded,

47. C. Travelling, — owing to the exercise, the
change of air, the continued succession of novel
and exciting objects presented to the senses, the
agreeable occupation, without exhaustion of the
mind which attends it, and the amusing and ex-
hilarating matters incidental to it, — is one of ilie
most efficacious means of restoring the depressed
or exhausted powers of the frame, especially the
enfeebled functions of the digestive organs and
of tlie nervous system ; and nearly allied to it,
a.re pleasant society, va^l\ona.\ amusements, and va-
ried, interesting, but not fatiguing, bodily and
mental employments.

BiDLioG. AND Refer. — Celsus, l.iii. cap. 4 Aretieus,

Curat. Acut. l.ii. c. 3. (Human and ass ?>iilk.) — Avicemia,

Canon. 1. i. fen. 2. doct. 2. cap. 29 Alberti, De Atonia.

Halie, n\G.— Hoffmann, De Morbis ex Debilitate Flbra-
rum oriundis. Lugd. Bat. 1737. — Biichncr, De Debilitate
Part. Corp. Solid, ab imminuta earum Cohesione pendente .

Hal. 1749 Lztdiiiig, De nimia Animi Defatigatione,

Causa Debilitatis in Morbis. Lips. 1762. ; et De Debil.
Corporura Curationem impediente. Lips. 1758 — J'ogel,
Defin. Generum Morb. Goet. 8vo. llGi. — Sauvages,
Nosologia Methodica, vol. i. p. 699. Amst. 1768. — Cal-
dani, Institut. Pathologias, &c. 8vo. Berl. \T!G.— Withers,
Observat. on Chronic Wealiness. York, 1777, 8vo. —
Lentin, Beytrage, p. 81. {Chalybeatebaths.)—J. Brunonis,
Elementa Medicinas. Edin. 1780. ; and his Works, by his
Son, 8vo. passim. — Saunders, in Edin. Med. Comment,
vol. m.—Nicolai, De Debil. Vera et Spuria. Jense, 1791.
IVidemann, Diss. Sistens Vitia Genus Humanum Hodier-
num Debilitantia. Jenaj, 1792. — Haase, De Debil, Vera
et Spuria. Lips. 1792. — Wedekind, De Debil. Mixt.i.
Heidelb. 1797.— Danrin, Zoonomia, or Laws of Organic
Life, 8vo. l797. — fVh)tc, Observat. and Experiments on
the Willow Bark. Bath, l79S,.—Fieliz, in Richter's Chi-
rurg. Biljlioth. b.vi. ^.7\7. {The willow bark.)— Hill, On
the Use of Oxygen, or Vital Air, in the Cure of Diseases.
Lond. IfiOQ.—Hcinecken, Ideen, &c. p. 76. (The marriage
of the old xuith the young. )—Ploucquet, De Rite Formanda
Indicatione Antasthenica. Tub. 1799. — Marcard, Be-
schreibungvon Pyrraont,b. ii. p. 22. ( The Pypnont waters
recommended.) — Horn, Beitrage zur Medicin. Klinik,
b. ii. p. 293. (Specifies four grades.) — Thoviann. Annales
Wurceb. &c. b. i. p. 43. (The propriety of distinguishing
the forms, and appropriating the remedies) — Marcus,
Priifung des Brown- Systems, b. i. st. 4. p. 37. (The
greater the debility, the more penetrating and volatile e.r-
cifanls.) — Schrcycr, in Baldinger's N. Mag. b.'.viii. p. 546.
( Baths of decoction of bark.) — Grapengeisser, Versuche,
&c. p. m. — Beddoes, On the Med. Use, &c. of Factitious
Airs. Bristol, 1796, 8vo. — Conradi, in ll//fcland'& Journ.
der Pract. Hcilk. b. vi. p. 385. — Otto, De Keniediorura
Incitantium Abnsu. Franc. 1804. — Wulther, Disquisitio
Rationis Morb. ad Statum Corp. Asthenicum. Jenre,
1801. — W. I'ogt, De Pareseos et Methodi Pareticae
Dignitate. Viteb. 180.5. — /?)•<•;•(/, Annotazioni, &c. vol. ii. —
Graefe, in Horn's Archiv. Sept. 1810, p. 149. (Chalybeate
baths.) — Myl/us, Hufeland und Himly, Journ. der Pract.
Heilk. Nov, 1809. p. 24. (Decoction of raw cqjffec.)-~Jaeger,
Ueber die Natur. u. Behandlung der Krankhaften
Schwiiche des Menschlichen Organismus. Stutt. 1807.^
C. Sprengel, Institutiones MedicEE, vol. iii. p. '90. Amst.

1813 P. C. Hartma7m, Theoria Morbi, seu Pathol. Ge-

neralis, &c. 8vo. Vind. 1814 Harles, Handbuch der

Acrztlichen Klinik, b. i. p. 2.50 Shearman, On Hist.

and Treat, of Chronic Debility, &c. 8vo. Lond. \%2\.— l'an
Coetscm, MediciiKi- 'rhcorcticjc Conspectus, 8vo. G;md.
1825, p. 81, — L. H. Friidlirmler, rundamcnta Doctrine Pa-
lhol<)gic;K>, Svo. Lijis. 1S2S, p. 98. — Boiiseau, art. Asthenic,
in Diction. Abrege des Sciences Medicales — J. C. Itoehe,
in Diet, (le Med. ct Chir. Prat, b.iii. yi.hQi. — Brachet,
Mcinoire sur r.-Vstlu'nio, Svo. Paris, 1829. — Hiifcland,
Kncyclopad. Wijrterbuch der Medicin. Wissen. b. i.
J). 4.53 Uedtlings, On the Pathological States denomin-
ated Astlicni.-i, Deliility, &c. in Amer. .Tourn. of Med.
Sciences, vol. ix. p. 315. — (See also the Bibliography and
JliJ'trcnccs of the art. Disease, and the art. Dehilitas,
in Ploucquct's Medicina Digesta, vol.i.)

DEULUTITION, DIFFICULT. — Svn, Dys-

pliagia (from Ju?, difficulty, and '^a.yai, I eat
or swallow), Deglulitio difftcilis vel iiapedita,
Auct. Schweres SchUngen, Ger. Dysphagie,
Vr. Dysphagy. Difficulty of Swalloioing.
Classit. — 1. Class, Diseases of the Di-
gestive Function; 1. Order, Aft'ecling

DEGLUTITION, DIFFICULT

the Alimentary Canal (Good). Special
AND General Pathology ; Symptom-
atology (^Author, (5)"c.).
1. Difficult or obstructed deglutition is an oc-
casional symptom of several diseases, and a con-
stant concomitant of a great variety of organic
changes, affecting the fauces, the pliai-ynx, the
asophagiis, or parts in their immediate vicinity ;
and which are discussed under these heads, par-
ticularly in the article on the CEsophagus. After
having noticed the only idiopatliicfonn in which
dysphagy can strictly be said to occur, I shall
arrange those pathological states of which it is an
important phenomenon, and with reference to the
places in which they are more appropriately de-
scribed, and to the principles and means of cure.

1. Primary or Idiopathic Dysphagv. Ner-
vous Quinsey, Heberden.

Classif. — II. Class, I. Order (Author).

2. Defin. — Difficulty of swallowing, occurring
suddenly, and accompanied bij a choking sensation.

3. i. Tiiis form of dysphagy is not infrequently
observed. It generally takes place when the pa-
tient is apparently in good health ; and chiefly in
irritable, nervous, or weak constitutions. It is usu-
ally induced by violent gusts of temper, or mental
emotions, or by dread of its accession ; and is occa-
sionally so severe as to threaten suffocation. When
it affects the oesophagus, it gives rise to a sensation
resembling that occasioned by the retention of an
extraneous body ; and matters attempted to be
swallowed are either retained for some time, or
rejected. When the pharynx is principally
affected, deglutition is generally attended by a
sense of choking. It may continue only for a
minute or two, or it may be prolonged for seve-
ral days or even months, difficulty being present
in various degrees upon each attempt at receiv-
ing substances into the stomach ; or it may be
remittent. It is often accompanied by the re-
tention of flatus in the oesophagus, probably by
spasm ; the difficulty of deglutition being increased
by the flatulent distension, but removed upon the
discharge of flatus. It resembles in this the
globus hystericus ; but it differs from hysteria
in the circumstance of its occurrence in males as
well as in females, and independently of any of the
other characteristic symptoms of that affection.

4. ii. The Treatment of primary or idio-
pathic dysphagy should be directed with the
view, 1st, of relieving the existing difficulty;
and, 2dly, of preventing its recurrence. — (a) The
first object may be attained by swallowing slowly
cold or iced fluids ; by cold applications to the
neck or throat ; by cathartic, anodyne, and anti-
spasmodic cnemata ; and by camphorated lini-
ments, or antispasmodic and anodyne plasters
placed on the sternum or throat. (6) The re-
currence of the affection will be prevented by
the internal use of vegetable bitters and tonics,
with the alkaline carbonates ; by nai'cotics or
antispasmodics combined with ipecacuanha ; and
by a free action kept up for some time on the lower
bowels, by means of the resinous or other purg-
atives conjoined with vegetable bitters, and pro-
moted by clysters. The other means, mentioned
hereafter (§ 16.) will also prove useful adjuvants.

II. Symptomatic and complicated Dysphagy.
Classif. — General Pathology; Thera-
peutics, &c.

5. Difficult or obstructed deglutition is an occa-

■iTS Pathology,

487

sional or constant attendant upon a variety of func-.
tional disorders, and of organic changes. 1st. It is
often symptomatic of hysterical, hypochondriacal,
flatulent, and asthmatic affections. 2d. It is con-
stantly attendant upon tetanus and rabidity. 3d. It
is sometimes produced by organic change seated in
parts about the base of the brain or cranium, the
medulla oblongata, or upper part of the spinal
chord. In all these symptomatic states, the parts
immediately concerned in the function of degluti-
tion are seldom, and not necessarily, affected organ-
ically : but in the following there always exists
either inflammatory action, or its consequences, or
some structural change, in the parts by which food
is conveyed into the stomach, or in their imme-
diate vicinity. The preceding may be called
symptomatic forms of dysphagy ; those which are
to follow, complicated states of this affection. Un-
der this latter may be arranged, 1st, Dysphagy
from congenital malformations ; 2dly, From in-
flammation, or structural lesions of the mouth
tongue, fauces, pharynx, or tonsils ; 3dly, From
diseases of the epiglottis or larynx ; 4thly, I'lom
inflammations or structural lesions of the oeso-
phagus, or of the cardiac orifice of the stomach ;
5thly, From tumours pressing upon the pharynx,
or on the oesophagus. On each of these I shall
add but few remarks.

6. i. Symptomatic or Sympathetic Dys-
phagy.— A. Of spasmodic or fatulent diseases.
Difficulty of swallowing occasioned by hysteria,
hypochondriasis, spasmodic asthma, dyspepsia,
and even rabidity, is in a great measure to
be ascribed to a flatulent distension of a por-
tion of the oesophagus, with spasmodic con-
striction of other parts of this tube, and disposition
to convulsive or spasmodic action of the muscles
of the pharynx, either upon certain occasions of
their being excited by the mind, as in hydro-
phobia, or upon attempts at performing their
usual functions. In many instances, particu-
larly those connected with asthma, indigestion,
or flatulence of the digestive canal, the difficulty
is attributable rather to the ascent of flatus in the
CKsophagus, preventing the transmission of food
into the stomach, than to spasmodic action of the
muscular parts concerned in the process. In
these cases, the patient feels much pain, with a
sense of distension or pressure under the sternum,
and in the course of the oesophagus after swal-
lowing,

7. B. Dysphagy may be occasioned by struc-
tural lesion about the base of the brain or cervical
portion of the spinal chord, or about the base of
the cranium. In such cases the paralysis may
be more or less complete ; and it may be
limited to the muscles of the pharynx and
upper part of the oesophagus (Bonet, Portal,
Baldinger, and myself), or it may have ex-
tended to them from other parts. Numerous
cases illustrating these positions have been re-
corded. The participation of the muscles of
deglutition in either general or partial paralysis
is very commonly observed in apoplexy, &c. ;
and the occurrence of this form of dysphagy, in-
dependently of organic change, or rather from
congestion about the base of the brain, is shown
by its occasional accession in the advanced
stages of fevers. Paralysis of the muscles con-
cerned in this function may also be produced by
wounds of the nerves of the face (Palletti), by

I i 4

488

DEGLUTITION, DIFFICULT — Diagnosis.

lightning (Patehson), and by severe cold (Bleu
land). It is, however, most frequently caused
by the slow developeraent of tumours, or cysts,
or other structural changes about the base of the
cranium, wliereby either the nerves supplying
these muscles are compressed at their origin or
in their course, or a portion of the brain or of the
upper part of the spinal chord is injured.

8. ii. CoirLicATED Dysphagy, or difficult
deglutition from structural ciiange affecting the
parts immediately concerned in this function,
comprises a great variety of lesions. I shall
merely enumerate them witii reference to their
seat ; their nature, morbid relations, and treat-
ment, being fully discussed under more appropriate
heads.

9. A. Diispliagyfrom con genital malformation. —
Extreme smallness, or enlargement of the tongue ;
the termination of the pharynx, or of the oeso-
phagus, in a cul-de-sac, or obliteration of the
oesophagus ; the division of this part into two
canals, and its communication with the trachea ;
are the chief malformations which interrupt de-
glutition ; and are of very rare occurrence in
otherwise well-formed infants. Cases, however,
have been recorded by Blaes, Van Cuych, Mi-
chel, BiLLARD, Martin, A. Cooper, and An-
dral. In these, death, necessarily resulting from
inanition, took place in from three to nine days.
A slight interruption to deglutition very frequently
arises from congenital fissures of the soft and hard
palates.

10. B, From diseases ofihe mouth and throat, —
(a) Inflammation or chronic enlargement of the
tongue; ranula; sublingual calculus (Guentiier) ;
and aphtha3, ulceration, tumours, and excres-
cences about the base of the organ (Reidiin,
Van Swieten, Tode, and Inglis) ; are not infre-
quent causes of dysphagy. Cases of chronic en-
largement of the tongue, impeding deglutition,
unconnected with malignant disease, and con-
tinuing for many years, are recorded by several
writers. I have seen an instance of this kind,
that had existed from infancy to nearly middle
age. These and other affections, with the treat-
ment appropriate to them, are particularly no-
ticed in the article upon the Diseases of, and the
Indications furnished by, the Tongue. — (6) Tlie

fauces and tonsils not uncommonly occasion dys-
phagy. Inflammation, suppuration, ulceration, or
destruction of thesoft;;u/n/e, or of theiivula; great
relaxation of the latter part ; inflammation, abs-
cess, chronic enlargement, and ulceration, of the
tonsils ; fungous and other tumours and polypi of
the maxillary sinus, or posterior nares ; various
tumours or excrescences attached to the palate
or tonsils (Schmidi-, Tiiilenius, &c.); and the
severe effects of mercury, or the sudden arrest of
salivation ; are generally attended by more or
less of dysphagy. — (c) VVhen the pharynx is iha
seat of inflammation or of its consequences, or of
the lesions now enumerated, or of malignant
disease (Klrgaradec, and myself), deglutition
is commonly much more imi)eded than when
only the fauces are aflected ; and in some in-
stances it is extremely dilficult or nearly impos-
sible. In such cases, the e])iglottis and larynx
are more or less irritated, and, by the conse-
(|uenl disorder of the respiiatory actions, the dys-
piiagy is still further increased. Foreign, and
particularly pointed or sharp, bodies lodged in

I the pharynx, are also sometimes causes of dys-
phagy.

11. C. Dysphagy from disease of the epiglottis
and larynx. — (a) Inflammation, ulceration,
and entire destruction of the epiglottis, or indur-
ation, incurvation, and the removal of it by
wounds, will occasion difficult deglutition, as in
the cases recorded by Maynwaring, Schurig,
Bonet, Desgranges, Tonanni, and Larrey.
— (h) Also inflammation and ulceration of the
larynx, ossification of its ligaments, and dis-
placement of the OS hyoides, are generally attended
by dysphagy. The possibility of the occurrence
of this last cause, although observed by Val-
salva, and JiIollinelli, has been doubted ; but
the instance of it noticed by Sir C. Bell (6'((/g'.
Ohserv. p. 160.), and the case wherein it was
caused by swallowing a large hard substance,
recorded by Dr. RIugna {Annali Univers. di
Med. Nov. 1828.), put the matter at rest. Frac-
ture of this bone by external violence has pro-
duced not only an impossibility of deglutition,
but even more serious consequences, as shown in
the cases published by Dr. Marcinkowski and
M. Lalesque (Journ. Ilebdom. Sjc.). — (See La-
rynx — Diseases of.)

12. D. Diseases of the oesophagus, and cardiac
orlfce of the stomach, will impede or altogether ob-
struct deglutition. Inflammations and their con-
sequences, as softening and ulceration, induration,
thickening, stricture, and purulent collections
between the coats of these parts ; also partial
dilatations, sacs and diverticula, or even large
pouches, either with or without thickening and
stricture of the part of the oesopiiagus immediately
below the dilatation (Blasius, Haller, Meckel,
ftloNRO, Ludlow, C. Bell, Odier); polypous
or fungous excrescences or tumours of various
kinds in some portion of this canal, or in the
cardiac orifice of the stomach ; or scrofulous,
callous, cartilaginous, osseous, carcinomatous, or
scirrhous degeneration of these parts; or merely
enlargement or ulceration of their mucous glands;
and spasm, rupture, or perforation of the oeso-
phagus, or the lodgment of foreign bodies in it ;
are severally causes of dysphagy ; and are fully
described in the articles on the Pathological Ana-
tomy of the Digestive Canal ; and on the Dis-
eases of the Oesophagus, as well as in those of the
Stomach.

13. E. Tumours pressing upon the pharynx, or
npon the 'rsophagus, — as bronchocele, or other
tumours or abscesses near the throat and in tlje
neck ; tumefaction of the lymphatic and secreting
glands below the jaw, and at the top of the
sternum ; aneurism of the subclavian or carotid
arteries, or of the aorta before it passes into the
abdomen ; enlarged bronchial glands, tumours of
various kinds, and abscesses in the posterior
mediastinum ; exostoses or other diseases of the
cervical vertebra;, and purulent collections be-
tween them and the oesophagus (Carmichael,
myself, and others) ; also abscesses formed be-
tween, or involving, the trachea and oesophagus
(Hav and myself); dropsy of the pericardium
(Bang); and enlargement of the liver; have
severally been observed to occasion dysphagy.

14. iii. The Diagnosis of dysphagy requires a
few observations merely. — (a) In idiopathic, as
well as in the sympathetic dysphagy, the difficulty
takes place suddenly, disappears as suddenly, re-

DEGLUTITION, DIFFICULT — Treatment.

489

mits or intermits, and is generally attended either
by convulsive efforts, by choking sensations, or by
flatulence, dyspepsy, or various nervous symptoms,
particularly when it is connected with hysteria,
hypochondriasis, &c. — {!>) In cases of atonic
or parali)tic dysphagy, solids are more easily
swallowed than liquids ; but the process is often
very slow, and the difficulty great. — (c) When
it proceeds from disease of {he fauces, the cause
is obvious to the sight ; and frequently also when
it is induced by the state of the i)harytn\ In this
latter case, as well as in dysphagy from lesions of
the epiglottis and lury)ix, or from tumours or fun-
gous excrescences develojied in, or pressing upon,
the pharynx, or from inflammatory diseases of it,
or of the upper part of the oesophagus, substances
are often forcibly ejected into or through the
nostrils, upon attempts at deglutition, owing to the
spasmodic action of the muscles of the pharynx.
— (rf) When dysphagy is caused by a diminution
of the canal of the asophogus, either from thick-
ening of its parietes, or from tumours pressing
upon it, &c., difficulty of swallowing solids is
first felt, and this at last is followed by a dif-
ficulty of swallowing fluids ; the interruption to
this function proceeding gradually and slowly.
When the obstruction is seated low in this tube,
or about the cardiac orifice of the stomach, pain
is usually felt under the sternum after swallowing :
and the matters are afterwards regurgitated into
the mouth, owing either to a sudden reaction of
the parietes of the canal, or more commonly to
their inverted peristaltic action. (See art. Qiso-
ruAGus — Diseases ii/.)

15. iv. Ti'.EATMENT. — It must bc cvident that
the treatment of sympathetic and complicated
dysphagy should be conducted strictly according
to the pathological state on which it depends, as
far as that may be ascertained. Hence a tolerable
knowledge of the means applicable to it, in every
circumstance in which it presents itself, is to be
acquired only by a reference to the articles where
the various lesions occasioning it are described, in
respect of their nature and cure.

16. A. Siiinpathetic diisphagy — (a) of spas-
modic or fat u lent disorders, requires very nearly
the same treatment as already recominended in
the idiopathic form of the disease. If it accom-
pany hybteria, swallowing, slowly, cold or iced
fluids, and cold applications to the neck, will soon
afford relief; but it will afterwards be necessary
to have recourse to tonics and cooling aperients,
witii other means suited to the peculiarities of the
case. The instances in which Tode and Wicn-
jiANN found quassia so beneficial, were probably
of this kind, or the idiopathic form already no-
ticed.— (/)) When dysphagy is connected with
fiulident dyspliugy, or with asthma, or palpitations

of the heart, relief will generally be_ obtained
from anodynes or antispasmodics combined with
refrigerants, or from vegetable tonics with alkaline
carbonates and aperients. Blisters, or rube-

drocianic acid may be substituted with advantage.
Besides these, the cupri ammoiiio-sulphas, the pre-
parations of camphor, -with those of henbane or
conium, may also be exhibited. In every form of
dysphagia not depending upon organic change,
purgatives, and cathartic and antispasmodic ene-
mata, will be productive of more or less benefit.

17. (c) Dysphagy, from jniralysis or atony
of the mu>cles of deglutition, should be treated
according to the principles stated in the article
Palsy. If it be occasioned by congestion about
the base of the brain or spinal chord, general or
local bleedings, active cathartics, and external
derivatives, must be einployed. Congestion having
been removed, large doses of camphor, as advised
by Hoffmann ; stimulating linctuses and gargles ;
sialagogues ; electricity and galvanism ; exciting
liniments or blisters to the neck or throat, as
suggested by Loeffi.fh; as well as moxas and
issues; may be severally employed. Dr, Bakton
recommends the zanthoryUim in cases of this de-
scription. Thunberg and Baldinger advise the
cajuput oil to be rubbed on the neck ; Gahdanne,
sitiapisms to be applied on the same part; and
Franck, the actual caittery.

18. B. Dysphagy from organic change of the
parts directly concerned in the function of deglu-
tition requires means the most diversified, ac-
cording to the nature of the lesions to which it is
attributable. — (a) When it is congenital, but
little can be done excepting in the slighter forms
occasioned by cleft palate, or by adhesion of parts
within the mouth. In these, the expert surgeon
may afford complete relief. — (/>) Difficult deglu-
tition from diseases of the tongue, fauces, tonsils,
or larynx, is of itself of minor importance ; but as
respects the primary lesion, of the utmost mo-
ment, requiring the most energetic measures
pointed out in their treatment. (See these arti-
cles.)— (c) Dysphagy from inf animations, or
their usual consequences, whether seated in the
pharynx, the asophagus, or the cardiac orifice of
the stomach, should be treate<l according to the
sthenic or asthenic form they may assume. Af^ter
general or local depletions, -especially cupping
between the shoulders or over the sternum,
emollient, cooling, and febrifuge linctuses ought
to be taken at short intervals. I have prescribed,
with advantage in such cases, especially w'hen
ulceration has been suspected to exist, lintuses
containing the nitrate of potash, or the hydro-
chlorate of ammonia, or the biborate of soda, or the
carbonates of the fixed alkalies with the nitrate of
potash and ipecacuanha, in addition to the other
means described in the articles on the diseases of
these organs. When foreign bodies are lodged in
the pharynx or oesophagus, appropriate ineasures
shmdd be resorted to, either for extracting them,
or for pushing them onwards into the stomach. —
(d) ^Vhen dysphagy is occasioned by tu7nours
developed in, or pressing npon, the asophagus or
cardia, it is not always that their nature, or even

facient plasters, or either of the ammoniacal, the thgjf existence, can be fully ascertained. If their

compound galbanum, or the cummin plast
with opium or the extract of belladonna, applied
over the sternum or throat, will also materially
assist the internal remedies. Heinecken advises
the preparations of zinc, which, as well as the
trisnitrate of bismuth, may be tried in this form of
dysphagy. He also recoinmends the distilled
water of the laurocerjuus, for which the hy-

presence be inferred, or when they are deve-
loped in external parts, or if the diathesis be scro-
fulous, then iodine may be prescribed internally
as well as externally, with potash, conium, &c.*

* I was consulte<1, in 18'2fi, in the case of a young lady
born in India, but who had resided some years m Lon-
don The glands in the neck, and underneath the sternal
ends of the clavicle and sterno-maetoid muscles (as well

490

DELIRIUM.

If abscesses have formed between the upper part of
the oesophagus and cervical vertebrse, or between
the forrmer and the trachea, or about the pharynx,
an unfavourable issue might possibly be averted
by incisions made into them. If aneurisms press
upon ,the gullet, the treatment recommended
when discussing Diseases of the Arteries should
be put in practice. — (e) When thickening of the
parietes of a portion of the oesophagus, with more
or less of stricture or scirrhus of this canal, or of
thecardia of thestomach, is thecauseof dysphagy,
cupping, or leeches applied over the sternum ;
issues and moxas in the same situation, or in each
side of the neck ; the linctuses recommended
above (§ 18. c.) ; mercurial and other alteratives,
with conium, hyoscyamus, camphor, &c. ; the
iodide of mercury, or the iodide of potassium,
internally and externally ; the carbonates of
the alkalies, or the liquor potassae in emollients,
&c., with various other means noticed in the
article on the CEsophagus, (nay be employed. If
these fail, a careful trial may be made of the bougie;
but the utmost attention should be paid not only
to the manner of using it, but to the effects pro-
duced by it ; for if the stricture be connected with
sacs, pouches, or diverticula, or hernia of the inner
coats through the muscular, or even with simple
ulceration, — changes which not infrequently take
place in the part immediately above the strictures
— much mischief may result from even a cautious
introduction of a bougie. The frequent and ob-
vious connection of dysphagy with scrofula shows
the propriety of prescribing the medicines found
most serviceable in that disease, particularly when
occurring in the scrofulous diathesis : and in such
cases, the chloride of calcium or of barium, conium,
liquor potassa;, and especially the preparations of
iodine, should be fully tried.

19. C. The treatment advised by the best writers
on this and its related affections consists of much
that has been now stated; in addition to which,
however, I may briefly add, that, the chloride of
barium has been recommended by Kerksig ; cold
and iced Hiiids, by Tode and Montat ; conium,
by WicHMANN, CoLLOMB, HuFELAND, and John-
ston ; hyoscQamus, by Withering ; opiates, by
Fehkein and Conradi ; the liquor potassa', by
Halleu; emetics, by Ferrein ; and local bleed-
ings, by Franck and Bang. Calomel and some
other preparations of mercury have been pre-
scribed by Sequira, Stevenson, Engelhard,
Brandis, and others, — to the extent of producing
salivation, by Kramp, JNIuncklev, Brisbane, and
FARQiniARsoN — in tkefomi of mercurial ointment,
either alone or with the volatile liniment, rubbed
over the sternum and throat, by Dobson, Patten,
Kerksig, and Wathen — internally, with anti-
mony, by Van Geun — and with aloes and
camphor, by Haller, Patten, Bang, and
Brandis, who contend strenuously for the occa-
sional origin of dysphagy in suppressed rheuma-
tism and repelled eruptions, and also recommend

as in various other parts of the body), were so greatly en-
larged as to impede deglutition and respiration. She had
been treated by several eminent practitioners ; but the
tumours had increased. In consultation with Mr. An.
NEsi,EY, who had reiiuested mo to see her, a course of
iodine was recommended; and the iodide of potassium
was employed, chietiy internally, for eight or nine months,
wiih occasional intervals not exceeding a fortnight each.
The glandular enlargements gradually subsided, the cat-
Jimenia appeared, and ahe perfectly recovered. She is now
well, and married.

external derivatives and irritants, as sinapisms,
issues, setons, blisters, repeated or kept open, &c.
The surgical measures to be resorted to in various
circumstances of the disease are fully discussed in
the writings of J. Hunter (Trans, of a Soc,
jor the Imp. of Med, and Chirurg. knowledge,
vol.i. art. 10.), Desauet, (Surgical Works, ^c),
Richter, (Chirurg, Biblioth. b. xii. p. 11.). C.
Bell (Surg. Ohserv. Hjc), and S. Cooper
(Surgical Dictionary, cS'c).

20. D, The diet should be chiefly farinaceous,
excepting in the nervous and spasmodic forms of
the disease ; and it ought always to be easy of di-
gestion, and taken without any heating condiments.
All substances which irritate or excite by their
direct or indirect action, are injurious. The
stomach also should never be loaded ; and in every
circumstance, the secretions and excretions ought
to be carefully regulated and promoted by gentle
and appropriate means.

BiflLiOG. AND Refer. — Fernelii, Opera Pathol. Lugd.
Bat. 1G45, f. '20i.—Ettmullcr, Opera Mcdica, vol. i. p. 37.

— Beidlin, lAn. Med. 1696, p. 67. {Hysteria.) — Schurig,
Chylologia, p. 257. ( Ulcerated epiglottis.) — Morgagiii, De
Sed. et Caus. Morb. epist. xvii. 19, 10. 25., xviii. 22.,
xxviii. 10. — Lieutaud, Hist. Anatom. Bled. 1. ii. obs. 804 .

— Mnynwaring, Med. Facts and Observat. vol. i. —
Paterson, in Ibid. vol. viii. art. 6. — Haasc, De Causis
Diff. Deglutitionis. Goet. IISI . — Satidifurt, Mus. Ana.
tom. vol. ii. tab. 107. ct seq. — Giitit/ter, iii Med. Wochen-
blatt. 1783. p. 555. — Mangel, Biblioth. Pract. 1. iv. p. 860.

— J'an Swicten, Comment, ad § 728 Haller, Opuscul.

Pathol, obs. 78. — Bleuland, Observ. Anatomico-MediCEe
de Sana et Morbosa ffisophagi Structura. Lugd. Bat..

1785 Engelkart, De Dysphagia. Lund. 1796. — Bang,

in Act. Reg. Soc. Med. Havn. vol. i. p. 246., et vol. iv.
p, \-Q. — Tode, in Ibid. p. \^'-2. — Portal, Corns d'Ana-
tomie Med. t. iv. p. 535. — Thilenius, Med. und Chirurg.
Bemerkungen, b. i. p. 47. — Stevenson, in Med. and Phys.
Journ. Lond. July, 1802. — Jo/inslon, in Mem. of Med.
Soc. of Lond. vol. ii. art. 17. — Collonib, Medic. Chir.
Werke, obs. 10. — Jl'ic/i7naiin, Ideen zur Diagnostik, b. iii.
p. 176. — Withering, E<iin. Med. Comment, vol. xvi. p. 262.

— Farquharson, in Mem. of Med. Soc. of Lond. vol. ii.
p. 357. — IVathen, in Ibid. vol. i. p. 286. — Sequira, in Med.

Obs. and Inquir. vol. vi. p. 138 Palletti, Nuovo Giorn.

della piu Recent. Lat. Medico-Chir. t. vi. p. 163. — Berger,
in Act. Helvet. vol. vii. art. 6. {Hysteria.) — Ludlow, in
Med. Obs. and Inquir. vol. iii. p. 85. — Dohson, in Ibid. vol.

vi. — Brisbane, Select Cases, p. 77 Baldinger, N. Maga-

zin, b. viii. p. 175., et b. xvi. p. 162. — Tlimiberg, De Oleo
Cajeputi. Upsal. 1797. — Schteffer, in Hufeland und
Himly's Journ. der Pract. Heilk. Feb. 1810, p. 117.—
Krauss,\\\ Ibid. Oct. 1811, p 116. — Heinechen, in Ibid.

May, 1811, p. Idi.—Micliaiilis, in Ibid. Feb. 1812, p. .53

Franck, Act. Instit. Clin. Vilnensis, vol. iii. p. 86 — Pat-
ten, in Auserl. Abhandl. fiir Pract. Aerzte, b. xiii. p. 396.

— Desgranges, in Journ. de Med. Contin. t. iv. p. 130

Conradi, in Aniemann's IMagazin. b. i. p. 78. — Lcclieverel,
in Journ. Gt'ner. de Med. t. xxii. p. 135. — Double, in
Ibid. t. xxiii. p. oW.—To7ianni, in Atti di Siena, vol. iii.
p. 232. — Larrey, Rclat. de I'Expedit. en Egypte, sec. viii.

— Hopfengacrtner , in Hujehmd's Journ. der Pract. Arz.
neyk. b. vi. p. 558. — Sclmiidt, in Hufcland's, Journ der
Pract Heilk b. xxii. st. 2. p. 64. — Kerksig, m Ibid. b. viii.

St. 4. p. 194 Hufeland, in Ibid. b. ix. st. 3. p. 86.— Ingli.t,

in Kdin. Med. and Surg. Journ. vol. i. p. 34. — C. Bell, Surg.

Observ. )). 80. — Meckel, Man. d' Anatomic, t. iii. p. 377

Carmichael, in Trans, of Irish College of Phys. vol. iii.
p. 170. — Monro, Morbid Anatomy of the Human Gullet,
&c. 2d ed, p. 242. — Hay, Trans, of Med.-Chir. Soc. of
Edin. vol. i. p. 24.3. — Kergaradec, in Archives Gi'ner.fde
Med. t. xii. p. 12il—Brig/it, Medical Reports, &e. vol. ii.
part ii. p. 460. {Hysteric.)

DELIRIUM. — SvN. Paraphrosyne, Para-
jtlironia (from Trapa, enoneously, and <f>povta;,
I understand), Auct. var. Paracope, Swediaur.
Irvereden, Aherwilz, Germ. Delire, Fr. De-
lirio, Ital.

Ci.AssiF. — Pathology ; Syinptomatnlogy,
1. Delirium has been defined : — Disorder of the
inlelleclual ]>oicers, with or without derangement
of the moral sentiments. But this delinition is too
extended and vague, and embraces the whole
circle of mental diseases. J. Franck, and some

DELIRIUM

other palliologists, have restricted it by adding —
this disorder assuming an acute form. Several
writers, retaining the precedingextended definition,
have divided delirium into the acute, and the
chronic; the former consisting of various morbid
slates of the brain, attended by mental dis-
turbance and fever — the latter of mental alien-
ation, unattended by fever or active bodily disorder.
Chronic delirium, therefore comprises all those
states of disordered mental manifestation treated
of in the article Insanity. Acute, or febrile deli-
rium refers to those morbid affections of mind
supervening in the course of febrile, inflammatory,
and some chronic diseases, and which have been
denominated symptomatic, or si/mpathetic, deli-
rium ; and those which are produced by acute
diseases, or injuries of the brain or its membranes,
and by intoxicating or narcotic substances, and
which have been termed idiopathic delirium by
some writers. 7'he common acceptation of the
word delirium, and that in which it has been used
by the best authors, accords with the acute form
as occurring in the manner now stated; and in
tliis light 1 shall also view it. But it is more
doubtful in how far it is ever an idiopathic af-
fection. Indeed, in many of the diseases in which
it is admitted by all to be a symptomatic or sym-
pathetic disorder, its more immediate dependence
upon a morbid state of vital endowment and cir-
culation in the encephalon is as manifest as in
some of those which have been viewed as idio-
pathic. The distinction, therefore, cannot be
maintained, especially as it appears to have been
founded upon a mistaken idea, viz. upon the sup-
posed existence, in the reputedly idiopathic form,
of inflammatory irritation or action of the brain or
its membranes ; which action does not obtain in
the other. That delirium is most frequently
occasioned by such a pathological state, cannot be
doubted ; but it is equally certain that it some-
times also proceeds from a different condition ; and
that either of them — either inflammatory action,
or simple disturbance of the cerebral functions
without inflammation — may exist in each of the
divisions thus distinguished, — in the idiopathic as
well as in the sympathetic form. If the dis-
tinction in question be still retained, it would be
more accordant with the generally admitted ac-
ceptation of tlie word idiopathic, to consider, as J.
Frank has done, all the manifestations of delirium
as symptomatic, excepting when it is occasioned
by intoxicating and narcotic substances : but,
when it proceeds from inflammation of the brain
or its membranes, whether primarily or con-
secutively induced, to view it merely as a symptom,
but by no means a constant, although a very
general symptom, of this state of disease.

2. Delirium, as well as other cerebral af-
fections, has been too generally imputed to inflam-
matory action ; and the state of the ganglial or
organic nervous power, which evidently influences
both the functions and the circulation of the
brain, has been entirely overlooked, particularly
as respects this affection. There can be no doubt
of the difficulty of appreciating correctly the na-
ture or extent of the disorder which this part of
the system experiences. But this circumstance
surely does not preclude us from tracing ulti-
mate phenomena to their true origin, instead of
stopping at intermediate efiects ; nor from in-
ferring, from the nature of these phenomena, and

— Phenomena. 491

of the causes which increase or remove them —
from ihe juvaniia and tadantia — certain general
conclusions respecting the condition of that power
whence morbid conditions primarily emanate ;
each successive eflect being the cause of further
change, until organic lesion, and ultimately death,
result. Believing, therefore, on physiological
grounds, that delirium is often the consequence
of changes in the state of organic nervous power
— of the functions of that part of the organic or
ganglial system supplying the encephalic organs —
influencing in some cases, one or more of the
mental manifestations, without any appreciable
change of vascular action or of structure ; in
others, both function and circulation ; and in many,
not only function and circulation, but organization
also ; and that our knowledge of these changes, of
their signs, and of their various related circum-
stances, are too imperfect to enable us to come
to accurate conclusions ; but that we should pro-
ceed nevertheless with the aid of the dawn of
knowledge now opening upon us ; I shall briefly
consider, first, the phenomena and diagnosis of
delirium — afterwards its pathology and treatment
conformably to the doctrine now alluded to.

3. i. Phenomena. — A. The invasion of delirium
is generally preceded by sleeplessness, headach,
vertigo, heaviness of the head, noises in the ears,
change of voice, absence of mind, forgetfulness of
pain, by an air of surprise, and acuteness of the
senses; the eyes are brilliant and intolerant of
light ; the head is often hot, the face flushed, and
the circulation of the brain more or less increased.
In some cases, however, these symptoms are either
altogether absent, or inappreciable; and in others
the countenance is collapsed, pale, and cool, and
the eyes sunk. To the foregoing phenomena suc-
ceed those which constitute delirium, and which
vary remarkably in character and intensity. lu
many cases, particularly when there are few or
no signs of augmented determination of blood to
the head, a simple agitation or merely absence of
the mind, or reverie, or wandering from the ob-
jects before it, or a slight incoherence in the
ideas, is all that is observed;- but from this slight
state of affection, we meet with every grade and
form of mental disorder — sometimes with fright,
visions or illusions, often connected with present
objects ; occasionally with hallucinations, or the
reproduction, in confused or unconnected forms,
of previous impressions ; — in certain cases, with
the most furious mental and physical agitation ;
in others, with the greatest depression and the
most sombre taciturnity ; — in one case, with tears
and signs of great mental distress: in another,
with a lively but incongruous current of ideas, or
even with laughter and gaiety.

4. B. Delirium is frequently present at first only
during the intermediate states between sleeping
and waking, which patients in acute diseases ex-
perience ; the mind still perceiving objects, but
imperfectly. In this state tlie patient appears to
dream aloud ; and when fully awakened, returns
rational answers to questions put to him ; but he
soon lapses into a state of dreamy incoherence, or
into that of more complete delirium. This con-
dition nearly approaches that of coma vigil, into
which it often passes. In some instances, this
state is characterised by a loss of recollection of
all objects observed, and of all ideas with which
the mind had been stored during the greaterperiod

492

DELIRIUM— Diagnosis.

of life, and by the recovery of the memory of I paroxysm of intermittent delirium varies from
languages and of ideas acquired at a very early one to several hours; but the continued form,
age, and long forgotten. Thus old persons, when particularly when occasioned by disease within
delirious, although their minds are blanks as the head, may last several days, or even many
respects every thing present, or which have be- weeks. Sometimes, as in the more severe ce

come known to them from youth or manhood,
will talk of matters which had interested them
previously to such periods, and sometimes in a
language which they liad then spoken, but of which
objects and language they had no recollection
long before their delirium, nor retained any after
their recovery. Here, again, the remarkable si-
milarity between several manifestations of de-
lirium and dreams is strongly evinced ; the objects
and ideas about which the unconscious mind
is engaged in the states of both delirium and
'dreaming being frequently those which iiad made
a vivid impression in youth, which had become
erased by the cares and employments of life, but
which are recalled during certain conditions of
the brain. The production of these in incongruous
forms, and the giving utterance to the morbid
conceptions formed of them, constitute hallu-
cinations ; whilst, owing to the nearly inconscious
state of the mind, the imperfect and erroneous
impressions made by surrounding objects on the
senses of the patient, give rise to inconclusive and
unconnected conceptions, in consequence of the
morbid condition of the brain, and occasion the
illusions characterising the delirious afl'ection.

5. In addition to disorder of the mental powers,
the organs of locomotion are remarkably affected.
In the low or quiet delirium, and in the less
dangerous states, in which the brain is only
functionally deranged, the muscles are either
somewhat agitated, or very much enfeebled, and
the voice is very weak or nearly lost. In more
severe cases, the voice and the muscular force
are greatly increased ; the patient, however,
sinking into a state of profound collapse after
a few violent efforts. In the most dangerous
form of delirium, particularly when it proceeds
from organic disease of the brain or its mem-
branes, it is attended, but more frequently
followed, by general convulsions, by spastic con-
tractions of one or more of the voluntary muscles,
by entire loss of consciousness and sensibility, or
by paralysis.

6. C. Delirium, as M. Georget has remarked,
may be continued or intermittent, even in the
continued affections of the brain. When it is
intermittent, it usually returns with the ex-
acerbation of fever that takes place in the evening
and night. When the patient recovers his rea-
son, he is generally weak and exliausted ; his
senses are readily and painfully impressed by
their respective stimuli ; and he complains of
tiiirst, and pains of the head and limbs. If liie
delirium has been slight, and consciousness has
not been entirely abolished, he retiiins more or
Jess recollection of what had passed during its
continuance. But when it has been intense, or
of some duration, he has no knowledge of wiiat
has occurred. The epidemic appearance of de-
lirium mentioned by Quet.mai.z (De Kpidern.
Mentis Alienatione. Lips. 1752.) and xIIichaei.is
(Med. Pnict. Biblioih. b. i. St. 1.) is to be
imputed to the prevalence of those diseases in
which delirium is apt to supervene, and espe-
cially in that form on which it is most fre-
quently an attendant, The duration of the

rebral cases, it alternates with profound coma.
When it terminates fatally, it generally passes
into coma; but in some instances the patient
recovers his reason for a few iiours before dis-
solution.

7. ii. Diagnosis. — It is of the utmost im-
portance that delirium should not be mistaken
for insanitii, and especially that the delirious
patient should not be removed to an asylum for
the insane. On two occasions I have seen such
a mistake made, and about to be acted upon,
when my opinion was requested. But these
cases recovered perfectly: to one of them — a
professional man — the removal to an asylum,
or the supposition even of being insane, might
have been ruinous. 'J'here can be no doubt that
delirium often passes into insanity, especially
when it has been caused by inflammatory states
of the brain, and by fevers with determination
to the part ; or when it occurs in persons here-
ditarily predisposed to insanity ; but until it has
assumed tlie features of that form of mental dis-
order, it certainly in no respect should be viewed
and treated as such.

8. The causes and circumstances originating
delirium are often of themselves sufficient to
show its difference from insanity. Its occur-
rence in the advanced stages of acute diseases,
or of chronic maladies when the powers of life
have become exhausted and febrile action of an
acute kind has supervened, is especially cha-
racteristic of delirium. The insane patient has
all his senses, as well as his digestive, assimila-
tive, and locomotive powers, but little or not at
all impaired. His mental faculties and intelli-
gence are also but paitially deranged. M.
Georget has very justly remarked that tlie mental
disorder of the insane is often confined to a
single faculty ; and even in the most extended,
or maniacal affections, the faculties are rather
perverted, or insulated, and without the bond of
association, rather than extinguished. The most
maniacally insane person wills and reasons, and
is not always absurd in his actions. But in the
delirious, all the cerebral functions are severely
affected. His sensations are imperfect and in-
correct, his ideas unconnected, his passions
disordered, his voluntary motions irregular, feeble,
and defective ; his intelligence and recollection
nearly abolished ; and he is impassive to all
that surrounds liim. Whilst the delirious \>ailent
presents many of the physical signs of exhausted
vital energy, or of the gravest state of disease,
the insane has all the appearances of utiimpaired
health, particularly in the early stages of insanit)',
and before consecutive organic change has taken
))lace. In the former, the sensations and percep-
tions are more or less abolished ; in the latter,
they are but little or not at all impaired, — the
judgment only, or conviction of the under-
standing respecting them, being erroneous, 'i'lie
false conviction of the insane is too strong to be
removed by the evidence of the senses : the
sensations and perce))lions of the delirious are
always too weak, even when consciousness is
partially present, to become the basis of sound

DELIRIUM — ITS Pathoi.ogv,

493

conclusions. Hence the Insane person cannot be i organic nerves supplying the vessels of the

convinced by objects seen, heard, and understood
by him, in opposition to his perverted judgment
respecting tbeni ; and the dehrious patient per-
ceives objects so faintly, if lie perceives them at
all, as to be unable to distinguish between such
as are in any respect similar, or to recognise

brain.

11. B. Delirium characterised hy depressed or
exiiausted vital power, and ntorbidlii excited vas-
cular action, is by far the most common form ;
and is very frequently observed in the advanced
progress of continued, remittent, intermittent,

one person from another. Besides the circum- i malignant, and exanthematous fevers; of acute

stance, also, of delirium being generally an acute,
and insanity a chronic affection, it may be re-
marked, that in the former, when occurring from
inflammatory states of the encephalon, or from
fevers complicated with such states, the return to
the healthy function is often so slow as to occa-
sion fears of the supervention of the latter. In
some instances, however, the restoration from
febrile delirium has been quick, and the mental
manifestations have become even more active than
previously to the seizure.

9. iii. PATiioi.ocy. — It is of the utmost prac-
tical importance to distinguish the different ibrms
of delirium, particularly in respect of the grade
of va>cular excitement and vital power, and the
existence or non-existence of inflammatory ac-
tion, for, without such a step is previously taken,
no rational method of cure can be adopted. I
shall therefore attempt to make this distinc-
tion.

10. A. Delirium attended by exhausted nervous
and vital influence is sometimes occasioned by ex-
cessive hasmorrhages or venisection, by inanition,
prolonged lactation, and profuse seminal or other
discharges, by old age, hysteria, fear, &c. It
also occasionally supervenes from exhaustion
in the last stages of some acute and chronic
diseases, or from whatever directly or indirectly
depresses the powers of life, as shown in the
article Debility. In many such cases, how-
ever, although the vital energies are sunk, yet
the brain is more or less excited relatively to
the other parts of the body ; and in some, the
state of deliiium is connected with an impure or
contaminated condition of the circulating fluids,
particularly when it occurs in the advanced
course of malignant diseases. The delirium,
also, which is caused by excessive pain, by
capital operations, by the suppression of the ap-
pearances of pain or suffering, or by the appre-
hension of the consequences of operations, and
which ]\I. DupuvTREx has very appropriately
denominated nervous delirium, chiefly falls under
this form of the affection ; and to it may be
added many of the instances of delirium caused
by excessive irritation in remote but related
oigans or parts, as consumption, ulcerations of
the bowels, worms, &c. Allhongh it is often
obvious tliat a relatively increased determination
of blood to the head exists in some cases of this
form of delirium, yet it may be inferred, with
equal justice, that a deficient supply of blood to
the brain obtains in others. This conclusion
may be legitimately drawn from the pale, cool,
shrunk features, sunk eyes, the weak and small
pulsation of the carotids, the effects of various
kinds of treatment, and the absence of increased
or even common vascularity of the brain upon ex-
amination after death, in some cases of this form
of delirium. This opinion has been supported by
JM. GroROET and several other pathologists,
without having been imputed by them to its
obvious source, viz. exhausted power of the

nflammations ; and of several chronic diseases,
particularly when they pass into the acute form.
It may also be occasioned by any of the nar-
cotic or acro-narcotic poisons, or from their ex-
hibition in enemata ; and in some temperaments
and constitutions, by a small quantity of those in
common use, — as by opium, stramonium, bella-
donna, &:c. I have more than once seen it pro-
duced even by the preparations of hop and
hyoscyamus taken in moderate doses. Its oc-
currence from the medicinal exhibition of various
narcotic and poisonous substances is noticed by
various writers ; — from cicuta, by Wepfer and
Smetius (Miscell. p. 569.) ; from belladonna, by
Pei.aiigus and Valentini (De Maniacis ah Usu
Bellad. (^c.) ; and even by the superacetate of
lead, by Stole (IJui. Merf. par. vii. p. 317.) and
Knight (Land. Med. and Phifs. Journ. vol. iv. p.
286.). — DiosconiDEs (Mat. Med. 1. iv. cap. 63.),
Westi'hal (^Pathol. Dccmoniaca, p. 33 — 36.),
and Horn (Arcliiv. Nov. 1811, p. 540.), have
noticed the occurrence of delirium from hyoscya-
mus exhibited in clysters. Poisoning by various
substances, as the Lolium temulentum, and some
of the narcotics just mentioned, generally occa-
sions delirium. It may also arise from indigest-
ible substances taken into the stomach. In all
these cases, in addition to the states of the sys-
tem connected with the appeaiance of this
affection, there is generally increased excite-
ment of the circulation in the brain, relatively
to that in the rest of the body ; and not infre-
quently an impure or altered state of the cir-
culating fluid, 'i'he delirium occasioned by the
protracted use, and the sudden disuse, of narcotics
or spirituous liquors, by erysipelas, and retro-
cedent exanthemata, is of "this kind, between
which and delirium tremens there is often a close
resemblance.

12. C. Delirium occasioned hy inflammatory
action of the brain or its membranes, when the
inflammation takes place primarily, is seldom
attended by very manifest exhaustion of vital
power, at least to the extent of the preceding
forms. When, however, the inflammatory action
is very general throughout the brain or its mem-
branes, or when it supervenes on continued
fevers or erysipelas, and is attended with serous
eflusion, vital depression is more apparent, and
its termination in, or alternation with, coma,
more common. This state of delirium, particu-
larly when it proceeds from concussion or ex-
ternal injuries, is often plirenitic or maniacal —
the Delirium ferox of authors — as respects the
exaltation of muscular force. It is occasioned by
all the causes staled to produce inflammation of
the brain, particularly suppression of critical or
accustomed evacuations, eruptions, or discharges ;
anger; the exciting passions ; metastasis of specific
inflammations ; the ingestion of spirituous li(iuors,
&c. Whilst the protracted use of intoxicating
beverages, &c. occasions delirium tremens, unac-
customed intoxication sometimea produces the

494

delirium now being noticed, by inflaming the
brain. This form of the aftection is often com-
plicated with convulsions, contractions of the
limbs, paralysis, &c., particularly when the sub-
stance of the brain is organically changed ; and
is, when thus attended, very much more dangerous.
(See Brain — Injiammations of, § 164.)

13. iv. Lesions observed in fatal Cases. —
In the /est form of this affection, scarcely any,
or no evident change, is found in the brain or its
membranes, beyond either a somewhat increased
or diminished vascularity, occasionally with a
slight increase of the consistence of the cerebral
substance, or of the fluid in the ventricles. In
many cases, all the parts within the cranium are
apparently sound. In the second variety, and
wherever delirium is unattended by marked dis-
order of the muscular actions — when it is
without extreme prostration, or convulsions, or
paralysis — the chief changes are, increase of
the consistence of the brain, and of the fluid
contained in the ventricles, injection of the pia
mater, sometimes with infiltration of serosity, and
occasionally a somewhat deeper shade of colour
in parts or the whole of the cerebral substance.
M. Georget remarks that pathological investi-
gations do not confirm the opinions of[ some
authors, who impute the cause of delirium and
convulsions to inflammation of the arachnoid ;
and that even epileptics and the insane seldom
present the appearances usually caused by
arachnitis. They have probably confounded in-
flammation of the membranes and periphery of
the brain with the usual manifestations of de-
lirium ; and thus imputed the changes observed
in the former to the latter. In the third form of
this affection, or when it is attended by the lesions
of muscular action noticed above, the appear-
ances observed are more completely those usually
found after inflammation. Indeed, delirium fre-
quently occurs, but not uniformly, or even gene-
rally, in nearly all the inflammatory diseases
of the brain or of its membranes, and occa-
sionally in the advanced stages of the organic
changes limited to parts of this organ. (See art.
Brain.)

14. v. Prognosis. — Tiie great diversity of the
results furnished by post mortem investigations
will show the diflSculty of appreciating aright the
conditions of the brain in delirium, and of coming
to a correct conclusion as to its issue. When it
is sympathetic of disease of remote organs, the
worst opinion should be formed of the result.
Delirium occurring in the advanced stages of
diseases of the lungs, stomach, or bowels, is a
most dangerous symptom ; and when it super-
venes in slow and consumptive maladies, it rarely
remits, and death is not far distant. It seldom
appears as a sympathetic affection, until the
powers of life are greatly depressed, and the pulse
is very much increased in frequency and dimi-
nished in tone. Dr. Gii.riERT (Krankheiten der
Franzos. Arm, p. 48.) observes, tliat delirium
prevailed in the fevers which accompanied tlie
French wars in Germany, in proportion to the
frcr|uency and weakness of the pulse, — a fact
fully supporting the inference at which I had
long ago arrived. On the other hand, when it
appears in an intermittent or slight form, or from
the operation of the less intense causes upon de-
licate and nervous constitutions, and without

DELIRIUM — Prognosis — Treatment.

other grave symptoms, although evincing the
severity of affection, it is not, in itself, a danger-
ous occurrence. AVhen it follows capital oper-
ations, or severe injuries of any kind, it very
often indicates the developement of inflammatory
action of the brain of a most dangerous or rapidly
fatal form. Delirium is most frequent in females,
in the nervous temperament, and in young per-
sons above the age of eight or ten years ; but it
is, in such cases, a less unfavourable symptom.
It is seldom observed previously to the fourth or
fifth year, — convulsions usurping its place at an
earlier age : but, when it occurs thus early in
life, it is a sign of great febrile excitement, with
either determination to, or acute inflammation of,
the membranes or periphery of the brain. If it
be continued, or alternate with coma ; or if it be
complicated, with extreme prostration of muscular
power, or with convulsions, spastic contractions,
paralysis ; the existence of inflammation of the
brain, to the extent of producing organic change
and extreme danger, may be inferred. Pererius,
Piso, and many other writers, have contended
that furious and sad or fretful delirium is more
unfavourable than that which is tranquil or lively ;
and the observation seems to be nearly correct.
The prognosis of sympathetic delirium should,
however, not be founded so much upon its form, and
the other symptoms referrible to the cerebro-spinal
system, as upon the nature of the primary malady ;
for it is not the delirium which is in itself dan-
gerous, but the disease upon which it supervenes ;
the circumstance of its occurrence evincing the
very sinking condition of vital power. M. Georget
truly states, that the sudden cessation of delirium
and agitation, attended by want of recollection of
the previous state, by great debility, irregularity
of the action of the heart, and loss of temperature
in the extremities, nose, and ears, is a most un-
favourable omen ; and often accompanies the
termination, by gangrene, of inflammation of some
important organ, always indicating approaching
dissolution. When delirium accompanies fevers,
particularly those with determination of blood to
the encephalon, or inflammations of the brain or
of its membranes, it often yields favourably to
epistaxis, copious alvine discharges, and other
critical evacuations. (See art. Crises.)

15. vi. Treatment. — When the inexperienced
practitioner, in his endeavours to obtain inform-
ation as to the treatment of this affection, finds
remedies of the most opposite kind very con-
fidently recommended by writers, — venssection
by one, bark and stimulants by another, emetics
or purgatives by a third, and digitalis, antimo-
nials, &c. by a fourth^ — he is at a loss how to
act ; and arrives at the conclusion, that it one be
right, the others must necessarily be wrong.
The fact, however, is, that all of them are partly
right, but also partly wrong. The circumstance
of this affection having been hitherto viewed
without reference to the very difl'erent states or
grades of vital energy with which it is often asso-
ciated, or to the condition of circulation in the
brain, and its division into idiopathic and symp-
tomatic,— either of these divisions presenting
the different forms I have endeavoured to dis-
tinguish, — has led to, and perpetuated, the
empirical manner in which it has been treated.
It is necessary to ascertain not only the origin
and morbid relations of tiiis affection, but the

DELIRIUM

phenomena attendant upon It at the time of in-
vestigation ; more especially the condition of the
secretions and excretions, the temperature of the
head, the state of the pulse in tiie carotids and
temples, the appearance of the countenance, and
the state of muscular power and motion. These
will at once indicate to the observing practitioner
the existing patliological condition causing the
affection, — will enable him to assign it to one
or other of the forms above distinguished, and
thereby to prescribe for it appropriate remedies.

16. A. The frst form of this affection (§ 10.)
will be most benefited by quietude, gentle re-
storatives, and nourisiiment ; by a moderately
cool, pure, and frequently renewed air; by the tepid
afl'usion on, or cooling applications to, the head,
if there be any increase of its temperature; by
warm pediluvia ; by camphor conjoined with refri-
gerants and cardiacs, or with sedatives ; and, if
the vital depression be very great, the head cool,
and the carotids pulsating weakly, by the prepar-
ations of quinine or bark, of assafcetida, valerian,
rausk, camphor in large doses, with those of am-
monia, opium, &c., exhibited by the mouth, and
in clysters : or by small quantities of mulled
wine or negus. In the more purely nervous deli-
rium, or when it occurs from operations, anxiety,
fear, and injuries of parts at a distance from tiie
head, opium, given by the mouth, or in enemala,
as recommended by W. Dupuvtren, will be most
beneficial. If it be attended by mucli agitation,
narcotics — as opium or hyoscyamus — in full
doses, either alone, or with camphor, assafcetida,
soda, or ammonia, &c. ; the acetate or hydro-
chlorate of morpliia, with aromatics and cardiacs ;
quietude, in a cool, well-ventilated, and darkened
apartment ; the tepid affusion on, or cold-spong-
ing, the head, if its temperature be increased ; and
warmth to the lower extremities ; are the chief
remedies.

17. B. In the second form of tiiis affection
(§ 11.), if there exists signs of determination
of blood to, or of congestion in, the head, bleefl-
ing by cupping, or leeches applied behind the
ears and below tiie occiput, the affusion of a
stream of cold water on the vertex, and purging,
are amongst the most efficient means that can be
employed. If the delirium be attended by stupor,
or tendency to coma, or by suhsuUus tendinum,
picking of the bed-clothes, &c., blisters to the
nape of the neck, and the treatment advised in
the article Coma, will be requisite. If the deli-
rious stupor be not removed by the more usual
remedies, and if it have arisen from erysipelas of
the head, incisions of the scalp of the occiput, as
recommended by Copland Hutchison, may be
practised. When there is no very consider-
able heat of the head, or when the extremities are
cool, and the morbid secretions have been purged
off, full doses of camphor (F. 494. 496. 903.
906.) may be exhibited. If the pulse be very
weak, and the prostration of strengtii very great,
the preparations of quinine or of bark, or of am-
monia, camphor, assafcetida, valerian, musk, &c.,
with aromatics and cardiacs, or even wine in the
form of negus, should be resorted to. When,
with tlie vital depression and increased vascular
action characterising this form of delirium, there
are appearances of a morbid state of the cir-
culating fluid, wc should endeavour to rouse the
vital energies at the same time that we excite the

TnEATMENt. 495

secreting and depurating organs, by exhibiting
camphor with the cholrates (the oxymuriates) of
the alkalies (see F. 439, 845. 847. 928.), and
the resinous purgatives with bitter tonics and
stimulants (F. 492. 504. 572.). In such cases,
the treatment recommended in the articles Blood
(($156.e«se(/.) and Feveh, will also be "appropriate.
As soon as stupor and a tendency to coma appear,
in addition to the medicines now suggested, ca-
thartic and stimulant enemata (F. 139. 149.), or
an active purgative draught (F. 216.), should be
exhibited, and repeated according to circum-
stances ; and if these fail, blisters, sinapisms,
rubefacient cataplasms or liniments, may be re-
sorted to. The terebinthinates have been em-
ployed by me since 1819, with great benefit, in
this and some other forms of febrile delirium.
The practice has lately been favourably noticed
by Dr. Graves {Med. and Surg. Journ. vol. ii.
p. 782.), If the head be cool, and the pulse,
particularly in the carotids, be weak, small, and
very frequent, either in this or the preceding
form, all revulsants from the head, even the
keeping it elevated, or warm pediluvia, will be
injurious ; and may convert, as Dr. E. Gilchrist
{Edin. Bled. Essays and Observ. vol. iv, p. 358.
et seq.) long ago remarked, a tranquil, into a most
violent, delirium, which may soon terminate in
fatal exhaustion. In both the Jirst and second
forms of this affection, the practitioner should
not be induced to resort to lowering measures,
merely because the muscular force is moment-
arily increased, and the patient is violent, restless,
and agitated. If, with this state, the pulse is
very frequent, small, weak, or irregular, and the
head not very hot, a restorative and soothing treat-
ment will be more beneficial. I have repeatedly
observed, that this form of the afl^ection, when su-
pervening on protracted and exhausting disease,
has been almost immediately subdued by small
quantities of warm spiced negus ; by camphor, with
capsicum and opium or hyoscyamus ; and by fre-
quently sponging the head with cold or tepid water,
when its temperature has been increased, or by the
tepid affusion.

18. C. The third or inflammatory form of
delirium should be treated in every respect as
described when discussing inflammation of the
brain or its membranes. (See art. Brain.) Ge-
neral and local bleedings, cold affusions and
apphcations to the head, &c., are indispensable
in it. If the delirium be complicated with stupor,
or coma, convulsions, contractions or paralysis
of muscles, &c., vascular depletions and active
alvine evacuations should be followed by external
derivatives of a permanent kind ; by incisions of
the scalp ; by issues, open blisters, moxas, the
use of the tartar emetic ointment, dry-cupping,
&c. ; whilst the secretions, &c. should be pro-
moted by mercurial and other alteratives, and
the bowels fully evacuated from time to time
by a cathartic draught (F. 216.), and enema
(F. 149.), In every form of the affection, the
patient should be irritated as little as possible by
opposition, but indulged as much as is consistent
with safety,

19, D. I shall conclude by noticing the treat-
ment recommended bi/ some authors. — (a) The
topical application of cold has been advised by
every writer on this affection, particularly since
Bartholinus so strenuously recommended it

496-

DELIRIUM — Theatment.

(De (Jsu Nivis Medico, cap. 25.). It may be
prescribed in the form of cold aftusion, pounded
ice, cold epithems, evaporating lotions on the
head, or simple sponging. If, however, it be con-
tinued too long, or after the morbid heat has been
subdued, and the features have shrunk, it vyill be
injurious, by depressing the nervous energies too
low, and favouring the supervention of coma,
or violent agitations, terminating in fatal ex-
haustion. It is required chiefly in the third
form of the disease ; but in the Jiist and second
forms, when the temperature of the head is in-
creased, it should be cautiously employed, or the
tepid affusion substituted for it. In these, how- ^
ever, I iiave preferred that the scalp should be ,
sponged witii a tepid and very weak solution of
the nitro-hydrochloric acid. — (b) Camphor has
been nearly as universally prescribed. BiJcHNEn
( De Pr(Estaiitia Camphorce in Deliriis. Hal.E,
1763.), and Tode (in Soc. Med. Hann. Coll. ii.
No. 34.) especially recommended it, — the latter
with mineral acids. It is a most excellent remedy
when judiciously exhibited. If given at all in the
third form of the affection, it should be in small
doses, with nitre and antimony, or with digitalis.
In the first form, it may be prescribed in larger
quantity ; and in the second, especially if there be
stupor or coma, or a morbid state of the blood,
in still larger doses, with tonics, antiseptics, aro-
inatics, and cordials. — (c) Opium or Ityos-
Ci/amits is noticed by Percival (Land. Med. and
P/ii/s. Journ. vol. i. p. 443.), GouBiEn (Journ.
de Mtd. t. Ixxxv. p. 244.), DuVuytren, and
KoRTUJi (BeiitrUge zur Pract. Arzneiiwiss. No.
9.). In some states of the Jirst and second
forms of the affection, when it is purely nervous,
or is attended by much agitation, watchfulness,
&c., either of these medicines may be employed.
In the more doubtful cases, either of iheni may
be safely exhibited with camphor and James's
powder. In the third form, particularly when it
assumes a maniacal or violent character, and after
depletions have been carried as far as may be
thought prudent, and the bowels have been freely
evacuated, I have repeatedly seen a full dose of
opium or hyoscyamus, given either alone, or with
antimony, or James's powder, and camphor, pro-
duce the happiest effect. Any unpleasant symp-
tom that may result either from too large doses of
these narcotics, or from their inappropriate use,
will readily be removed by the cold or tepid af-
fusion on the head. The acetate or hydrochlorate
of morphia, taken in a full dose of the spirits of
pimenta, or in any other aromatic spirit, lias
proved equally beneficial with opium, in my prac-
tice. The external employment of opium has been
found very successful in delirium, by V. Ciii-
ARuiiGi (SulC Uso Esterno deir Opio, 8vo. I'lor.
1797.), Ward (Loud. Med. and F/ii/s- Journ.
vol.i. p. 441.),and Pehcivai. (//n(/. p. 444.), who
have used it in the form of liuimcnt (,"j. triturated
with 5 j. of adip. praip.), either with or without
camphor. — (d) Purgatives have been jusily
praised by all writers on this affection. The
ancients prescribed them in very large doses, and
preferred the hellebores, which, with calomel and
those I have already particularised, should be oc-
tivdy exhibiled, according to the strength of the
patient. When the debility is great, they must
be associateil with a tonic and stimulant treat-
ment.— (e) Emetici bavo been mentioned by

several writers ; and when delirium proceeds from
the ingestion of narcotic, indigestible, irritating, or
poisonous substances, or is connected with the
accumulation of saburrae in the upper portions of
the digestive tube, they are then requisite. — (f)
Antispasmodics and cordials, particularly valerian
(Warburg, Med. Beobacht. No. 16.), assafoetida
(Wanters, Journ. de Med. t. Ivi. p. 115.),
musk (KoRTUM, loc. cit.), warm negus, and
similar medicines, have been recommended ; and
are often of service, when the powers of life are
much depressed. — ("■) Blisters have been ap-
plied to the head much too indiscriminately : .1
have seen them prove most injurious in this
situation. Dr. £. Gilchrist, one of the best
writers of his time, directs them both to the head
and to the insides of the legs. 1 believe that they
will prove beneficial in the former situation, only
when the powers of life are sinking fast, and the
delirium is attended by stupor, a cool head, and
sunk or collapsed features, as in cases of low or
adynamic fevers. When this affection is con-
sequent upon febrile determination of blood to the
head, blisters on the insides of the legs, ^c. may
be useful derivatives; but they often occasion so
much pain and irritation in this situation, as to
thereby counteract, particularly in tlie turbulent
state of delirium, any good they might otherwise
produce. — (h) Of the sedatires or contra-stimu-
lants prescribed by writers, the preparations of
antimony, particularly James's powder — digitalis,
and the nitrate of potash, are the most deserving
of notice. Wherever the delirium is connected
with increased vascular action in, or determination
to, the head, these medicines are of more or less
service when judiciously combined with other ap-
propriate remedies. Withering (O/i Digitalis,
p. 33.) and Patterson (Med. and Phys. Joimi.
vol. v. p. 442.) strenuously advise the preparations
of digitalis ; but they, as well as those of antimony,
require much caution, if ventured upon in the
delirium attendant on low or malignant fevers.
It is chiefly in the maniacal or third form of this
affection that they are most beneficial, and in it
they should be exhibited in a decided manner ; but
in the Jirst and second, particularly in the de-
lirium of typhus, they are generally injurious. —
(J) The actual cautery on the nape of the heck,
and moxas, have been advised by JNl. Valentin
(Med. and Phys.. Journ. vol. xix. p. 432.), and
several otlier Continental writers. — (k) Dr.
Grant (On Fevers, 8vo. 1771.) recommends the
patient to be allowed to dress and sit up when he
feels anxious to do so; but this, and several ju-
dicious observations of this writer, are more fully
adverted to in the article on Ficver. The ob-
servations made on convalescence from Jnjianima-
tioiis of the Urain', and from Fever, are perfectly
applicable to the management- of convalescence
from delirium. (See these articles.)

BiiiLioc. A NO Refer. — P. M. J)c Ilcrcdia, De Nat.
Deliiii, pjiisquc Cavisis, Opor. t. iii. p. '278. — Vein; De
Deliriis ex Voiitrieiilo. Vx. UM>9. —Borr/innvc, liittitut.

§ .'Jdii, ct ccl Stuhhs, in IMiilos. Trans. No. .'}(>. — VnJi

Swk-tcn, CouuncMt. vol. ii. i^Hm. — I'crcr/t, Oiur.st. Med.
xii. — Tcichmiycr, De Dcliriantium Furore et Demen-
tia, -Ko. Jeiup, l'S!i. — Q?ic/»ta/x, De K|iiclcmic:i Mentis
Alienatioiie. I^ips. 1752 ; ct De Delirio ex Ijaclatu.

I/ips. ly.M Jllic/incr, De Deliriis, Vitain et Mortem

nriTsapicntibus. Hal. 17.'j7 ; ct De lleeticorum Deliriis
Malo Online oriundis. Ilalae, 17G"). — ./. Cnobluc/i, De
I'araphrosvne, et Different, suis, in lUillrr's Kililiotli.
Med. I'r.-ic't. vol. ii. )>. V2i. — Baimier, De Delirio Hy.ste-
I rico. Erf. noS. — Niain, Dc Delir. Hysterica KrC. I7ii2.

DELIRIUM WITH TREMOR. 497

short time after its cause has ceased to act.
The " Delirium Ehrimum " of D.vnwix and some
other writers, or the delirious affection which is
immediately consequent upon intoxication, is an
example of this ; it sometimes subsiding in a fevy
hours, or in a day or two, when not injudiciously
interfered with : but this is only an occasional
occurrence, and cannot be trusted to. This state
of delirium, when directly produced as.it com-
monly is, by intoxication, is not always cha-
racterised by tremors at the commencement ;
Snowden and Carter. Delirium Ebriositatis, j but, when thus accompanied, it is often mistaken

— Plfeniiiger, De Precipuis Deliriorum Causis. Stuttg.
1779. —Gilibert, Advcrsar. Med. Pract. p. 256. {Front in-
anilion.) — Parry, in Mem. of Med. .Soc. of Lund. vol. iii.
p. 77. — Bang,\u Act. Reg. Soc. Med. Hauii. vol. ii. p. 76.,
vol. ill. p. VSl. {Front Dicntal cinotions.) — Raiio'e, in Ibid,
vol. ii. p. 13. — Esquirul, m Diet, des Scien. Med. t. viii.
art. Delire. — J. Frank, Praxeos Med. &c. par. ii. vol. i.

sect. i. p. 654 Georgct, in Diet, de Medeciiie, t. vi.

p. 395.

DELIRIUM WITH TREMOR. — Sv.n. De-

'lirium Tremens, Sutton. Brain Fever, Pear-
son. Brain Fever of Drunkards, Armstrong.
Mania I'l Temulentia, Klapp. Mania a Potu,

. Blake. Idiopathic Delirium ; Delirium treme-
fuciens. Author. La Folie des Ivrognes, Delire
Tremhlant, Fr.

■ Ci-AssiF. — 4. Class, Nervous Diseases:
1. Order, Affecting the Intellect (Good),
I. Cl.\ss, IV. Order (Author).

1. Defin. — Delirious illusions, with constant
tremor of the hands and limhs, watchfulness, and
grea tj'req uenci/ of p u Ise .

2. I. Distinctions. — This form of delirium is
variously modified, according to the causes n
which it originates, and the habits and constitution
of the patient. Although it is here divided into
two species ; the one being evidently connected
with infiammatory irritation of the arachnoid, or

for the true form of delirium tiemens, into wliich,
however, it not infrequently passes, chiefly owing
to the cause in which it had originated. It is
generally attended by extreme irritability, often
by great violence, and sometimes by general
spasms and constant vomiting. The head is
usually hot, and the face flushed. This species
of idiopathic, or primary delirium, is caused, not
only by the use of intoxicating liquors, opium,
&:e., but also by the excitement of the cerebral
organs by intense or prolonged study, particularly
when piosecuted under the influence of depressing
causes. Dr. J. Johnson states, that he has seen
deliiium tremens in young ladies, whose mental
poweis had been exhausted by this cause ; and

with excited vascular action in the membranes of ' most probably it was this species of disease
the brain, and associated with great irritability — ■ that he had observed, as the treatment which

the other consisting chiefly of this last state, attended
by exhausted nervous energy ; yet it often pre-
sents intermediate forms or modifications, which
cannot be referred to the one species more than
to the other. Nevertheless a distinction should
be made, inasmuch as the predominance of the
characters of either species will indicate the
propriety of employing more or less of that
treatment which is appropriate to it ; for owing
to the want of such a distinction, the delirium
which arises chiefly from intoxicating liquors
has been too generally treated after one fashion,
and in too empirical a manner, merely because
it has presented one or two characteristic symp-
toms,— its numerous other phenomena being en-
tirely overlooked. Thus, when the disease arises,
as it commonly does, from the abuse of intoxi-
cating liquors, it may assume more or less of the
features of either species, according as it is
directly or indirectly produced by this cause ;
but if it be viewed as a consequence of inflam-
matory action only, or as proceeding from
nervous exhaustion exclusively, the conclusion
will in either case be only partially correct, and
the practice founded upon it frequently in-
jurious.

3. i. Delirium with Tremor and e.xcited
A'^AScuLAR Action in thb ISIembranes of the
Brain (Encephalitis Tremefaciens of J. Frank).

4. Defin. — With great terror and irritability
of temper, and violence upon being opposed ; a fre-
quent full, or hard pulse; countenance often wild
orjlushed, and the head hot.

5. This species of delirium forms the connect-
ing link between that wiiich is purely nervous,
and that depending upon inflammatory action of
the membranes and periphery of the encephalon

he found successful in it, is essentially the same
as that which is most beneficial in this affec-
tion. Delirium with tremors is also, in some
rare instances, chiefly occasioned by excessive
venereal indulgences, or masturbation; most
probably, however, assisted bj' various concurrent
causes.

6. ii. Delirium with Tremor fro.m exhaust-
ed Nervous Power (the true Delirium Tremens
of modern writers, and D. Traumaticum, or D.
Nervosum, Dupuytrex).

7. Defin. — With a morbid recurrence of the
patient's ideas to his avocations; a frequent, iveak,
or small pulse ; cool, humid, or perspiring surface ;
and loaded, but moist tongue.

8. This disease was very generally con-
founded with phrenitis, until Dr. Sutton directed
attention to it as a specific affection, requiring a
peculiar treatment. As Dr. Rvan has remarked,
it most probably constituted a large proportion of
the cases named " Demonomania " by the writers
of the 16th and 17th centuries. It had not, how-
ever, altogether escaped attention, previously to
the notice taken of it by Dr. Sutton. Dr.
Pearson, of Newcastle, had written, for piivate
circulation, a small tiact respecting it ; and cases
illustrative of its nature and appropriate treat-
ment had been shortly before published by Dr.
IM'Wiiirter (Med. and Phijs. Journ. vol. xviii.
p. 153.): Dr. Saunders had also mentioned it
in his lectures, delivered at Guv's Hospital, about
the close of the last century ; and that mani-
festation of it observed after external injuries is
stated by Dr. Blake to have been noticed in
Dr. Coi.les's Lectures on Surgery, with an accu-
rate reference to its chief, although apparently
the predisposing cause, and to the means of cure

That it may run into, or form a slight grade, or I which repeated observation has shown to be moit
modification, of inflammation of these parts, in successful.

some cases, I will not dispute ; but that it always 9. II. Causes, 6cc Whilst the former state

is strictly inflammatory, is opposed by the fact of delirium is often directly occasioned by drunk-
that it will often subside spontaneously, in a | enness, this is as frequently indirectly produced
Vol. I. K k

498

DELIRIUM WITH TREMOR — Causes — Symptoms.

by the same cause ; the one being immediately
consequent upon or acconripanying intoxication,
the other commonly resulting from the abstraction
of the accustomed stimulus, after an habitual or
continued indulgence in it, or after a protracted
fit of ebriety. A slight form of it, or merely tre-
mors of the hands or limbs, with deficient nervous
power, and occasional illusions, will sometimes
appear after habitual tippling, without intoxication
having once been produced. The use of intoxi-
cating liquors, and the neglect of sufficient food ;
a protracted debauch, followed by sudden pri-
vation, or by depressing causes; large or repeated
depletions employed to remove the headachs or
stupor of drunkards, or tiie first species of this
delirium ; the treatment indicated by the diseases
witii which such persons may be affected; the
debility caused by the diarrhoea or cholera some-
times consequent on intemperance ; the shock
arising out of severe injuries, particularly frac-
tures ; exposure to cold, a course of mercury, and
the puerperal state*; are principally concerned
in the production of this affection. That the
delirium which has been called " D. Trau-
matlcum " by British writers, and " D. Nervosiun"
by DupuYTUEN, is in every respect the same as
that now being considered, is proved by the fact
of its appearance chiefly in persons of intemperate
habits, by identity of phenomena, and by the
effects of various modes of treatment upon both
being alike.

10. Although the chief cause of delirium tre-
mens is evidently the abuse of intoxicating, espe-
cially spirituous, liquors, yet this is not the only
cause. It may also be occasioned by the
drugged beverages prepared in Eastern countries,
particularly in the East Indies, when too freely
indulged in ; and by the excessive use of opium".
But it is chiefly when sobriety has followed a
protracted debauch ; and when, during the first
days of the abstraction of the accustomed sti-
mulus, the additional causes mentioned above,
come in aid of the efl^cient cause, — when the
habits and indulgences of the patient have pro-
duced that state of the nervous system which
readily passes into serious disease upon its being
influenced by depressing agents ; that true delirium
tremens takes place. Inattention to this fact, by
nearly all the writers on the disease, excepting
Dr. Blake, has led to serious misapprehensions.
Practitioners have too generally concluded that
the delirium of drunkarils is always of the same
kind ; and have overlooked differences very ge-
nerally subsisting between that immediately pro-
duced by intoxication — the Jirst species of this
affection ; and that indirectly occasioned by it
— the second species, or true delirium tremens.
An occasional, or even a single indulgence in
intoxicating liquors to excess will sometimes give
rise to the former; a repeated, liabitual, or pro-
tracted indulgence is requisite to the appearance
of the latter. The frequency of this affection,
particularly in the lower classes, justifies the
attention recently paid to it ; and I believe that
it is more common now than formerly, owing to
the cheapness, and facilities of procuring spirituous
li(|Uors. Jktween 1820 and 1832, I treated 21
eases, about two-thirds of which were in consult-

• I have seen three cases in females, and these were
habitual drunkards : the disease appeared in two of them
a lew days after delivery.

ation with Mr. Houlton, Mr. EAtiNWEtL, Mr.
WiNSTONE, Dr. Riding, and Mr. Painter; the
others in dispensary and private practice. In some
manufacturing and trading towns, it is of frequent
occurrence. In the United States of America, it
is, however, much more common than in this
country. Dr. S. Jackson states, that he has
treated upwards of 200 cases; Dr. Carter, of
Philadelphia, mentions nearly the same number;
Dr. Ware says, that he has seen more than
100; and Dr. Wright, that he has received, in
the institution at Baltimore, from 60 to 70 cases
annually. But it is evident, from the details they
have furnished, in the works referred to at the
end of this article, that tiiey have included under
the same head delirious affections immediately
consequent upon intoxication ; and that, owing
to this circumstance, has arisen much of the
contrariety of opinion respecting the nature and
treatment of the disease, which is as remarkable
amongst physicians on the other, as on this, side
of the Atlantic.

11. III. Symptoms. — The phenomena of de-
lirium tremens vary remarkably, from the slightest
forms of nervous tremor with spectral illusions,
and accelerated pulse, to the most alarming state
of vital depression, muscular agitation, and
mental alienation about to be noticed. Dr.
Blake has marked out three stages into which
the disease may with propriety be divided. It
should, however, be recollected, that they are not
always obvious or clearly defined ; that they
exist only in those cases which supervene on the
abstraction of the intoxicating stimulus ; that the
first stage is wanting in those that more imme-
diately follow intoxication, and consequently in
most, if not all, the ^'?'sJ species here described;
and that, in the species now being considered, it
is but seldom brought under the cognizance of
the physician, — medical aid being seldom required
until the second period is developed. As the
treatment may be more precisely stated when the
disease admits of a division into stages, I shall
adopt that suggested by Dr. Blake, and which
differs but little from that which has been fol-
lowed by Dr. Lyon, Dr. IIyan, and Dr. Bark-
iiausen.

12. The Jirst stage of true delirium tremens
frequently appears from two to eight or nine
days after a protracted debauch, or a prolonged
fit of intoxication; and is commonly attended by
slight febrile action, and gastric derangement,
often aggravated by some accidental cause, ex-
ternal injury, or contingent ailment (§ 9.),
generally the immediate effect of excesses ; but
the length of time which elapses between the
abstraction of the accustomed stimulus, and the
commencement of the symptoms, is often uncer-
tain. The first indications of the disease are,
according to Dr. Blake, a peculiar slowness of
the pulse, coldness and clamminess of the hands
and feet, general debility, and diminution of the
animal temperatuie. In addition to these,
nausea and occasional vomiting, particularly in
the morning; much diminution of appetite, and
aversion from animal food ; excessive perspiration
from trivial exertion; frightful dreams; vertigo,
and sometimes ciamps of the extremities, are
complained of. The bowels are often consti-
pated, but sometimes open, or even relaxed, and
the tongue is tremulous, furred, and moist. In

DELIRIUM WITH

most cases, the peculiar tremor of the hands is
present in this stage ; but in a few it is not re-
marked until the next. The spirits are much
depressed; the patient sighs frequently ; his coun-
tenance is anxious and dejected ; he complains
of oppression of the prajcordia ; is anxious about
his affairs; and is either restless and watchful, or
has short and broken slumbers. This state seldom
continues longer than a few days. It is gene-
rally of longer duration in the old or worn-out
drunkard, than in the younger and more robust,
in whom it may be followed by increased vascular
action in one or two days.

13. 'i'he second stage commences with restless-
ness, a peculiar wildness of the countenance,
and a hurried anxious manner ; marked suscepti-
bility of the nervous system, and irritability of
the muscular system ; great excitability of temper,
acceleration and smallness of the pulse, and
various mental illusions and alienations. The
heat of the surface of the trunk increases, but
the hands and feet retain the same coldness and
clamminess already noticed. The mental de-
lusion becomes more constant as this stage is
developed, and is generally of a low or melan-
cholic kind, with continued reference to the
patient's ruling passions and occupations, and
anxiety respecting them. lie sees objects where
their presence is physically impossible ; is con-
tinually haunted by frightful creatures, or oc-
cupied with most extravagant ideas, and is
constantly endeavouring to avoid them. He
now becomes altogether deprived of sleep ; the
restlessness and quickness of manner increase ;
the countenance is more anxious ; the tongue is
more deeply furred ; the tremor of the hands
and tongue continue, without remission ; the
bowels are either constipated, or, if relaxed, the
evacuations are very dark and offensive ; the
urine is scanty ; the pulse is soft, or small, and
ranges between 100 and 120 ; the pupils are con-
tracted, but the eyes are not intolerant of light ;
and the patient is talkati\e, constantly occupied
with the objects of his delusions; he cannot be
kept in one place ; and, when opposed, is violent
and noisy. Ihis stage usually continues from one
to three or four days ; when it terminates, either
in a general mitigation of symptoms, or in more
profound collapse of the vital powers, thereby
constituting the third stage.

14. The third period, m the slighter or more
favourable cases, is ushered in with mitigation of

the foregoing symptoms; yawning, drowsiness,
and profound sleep, which generally terminate
the disease ; but in the more dangernus cases, the
preceding phenomena become more severe, and
accompanied by more complete depression of
vital power, and increased irritability of mind.
The patient makes violent and excessive struggles,
which are attended by very copious perspiration.
As the malady advances, and the energies sink,
the coldness and clamminess of the hands and
feet, which had been extending upwards during
the second stage, spread over the whole surface ;
and the pulse becomes still more frequent, small,
weak, or thready, and sometimes can hardly be
counted ; the tremor increases in the hands, and
often invades the whole frame ; and is rather
a constant trembling, more nearly resembling
that occasioned by severe cold, than the sub-
sultus tendinum of typhus, or the nervous rigors

TREMOR— Diagnosis. 499

of some other affections. Tiie perspiration be-
comes more and more cold, and exhales a pecu-
liar smell, which is, as Dr. Hodgskin has re-
marked, between a vinous and alliaceous odour.
The countenance is commonly pale and anxious ;
the pupds veiy contracted ; the tongue loaded,
furred, and often brownish at the centre and
root, and occasionally red at the point and edges ;
the patient talks incessantly, and with great
rapidity ; the delirium increases in violence ; and
the mind is excessively irritable, and continues
so until shortly before death, when a calm takes
place. In some cases, instead of this calm oc-
curring, the patient is carried off in a convul-
sion.

15. Modifications, 6;c. — Such is the more com-
mon form of true delirium tremens ; but whilst it
sometimes occurs in slighter grades, in which the
symptoms differ but little from simple nervous tre-
mor, excepting that they are associated with mental
illusions, great restlessness, and talkativeness, it
also presents more severe forms, in which the phe-
nomena approach those characterising the former
species, or the delirium ebriosum, in which the
vascularexcitement generally, and thatof the brain
in particular, is greater, and relatively of a more
sthenic kind. At the commencement and second
stage of this state of the disease, the pulse is tenser
and harder or fuller, the skin drier on the trunk,
the delirium more violent, and comprehension
less quick, than in the other cases. The eyes,
also, are injected ; the temperature of the head is
somewhat increased; and the tongue is often dry
or cracked, and red at its edges. In the last
stage, the skin is bedewed with a cold clammy
perspiration ; the pupils are contracted ; the pulse
very small and frequent, often scarcely percepti-
ble ; the stomach is irritable, and the delirium
becomes low and muttering. The tremors are
constant, but the watchfulness is sometimes in-
teirupted by short restless slumbers, which afford
no relief; or it ends, in some cases, in a condition
approaching to coma, passing at last into fatal
convulsions. Thus some cases of the second form
of the disease very nearly approach the first, and
differ from it chiefly in being caused indirectly,
instead of directly, by intoxicafion. The second
species is, however, sometimes consequent upon
the first, particularly when treated by too copious
depletions ; the vascular excitement of the one
passing insensibly, but often rapidly, into the pro-
found collapse marking the latter stages of the
other ; and this may even occur, although the
delirium at the commencement was not attended
by tremors. It should also be recollected, that
the three stages into which true delirium tremens
has been divided, are not always separated by any
obvious limits, or even so distinctly defined as
generally observed and stated above ; the pheno-
mena often supervening in so gradual and con-
tinuous a manner, as to render it difficult to
determine the end or commencement of eacli,
without much attention to all the symptoms ami
to the history of the case.

16. IV. Diagnosis. — This disease, which is so
difficult to describe, wlien once seen, can never he
forgotten. It may, however, be mistaken for the
first species, for phrenitis or inflammation of the
membranes and periphery of the biain, for the
delirium of fever, and for confirmed mania or
insanity. — (a) It is to be distinguished from the

K k 2

500

DELIRIUM WITH TREMOR —Prognosis — Pathology,

first species (the encephalitis tremefaciens) of this
kind of delirium, by its coming on a short time
after a protracted intoxication, instead of im-
mediately upon it; by its being caused indirecily,
instead of directlij, by the abuse of intoxicating
liquors ; and by the pulse being stronger and fuller,
the head hotter, the face more flushed, the surface
of the trunk warmer, the delirium more violent,
and the patient more irritable, the tongue drier
and redder, and the vascular excitement com-
paratively greater and more sthenic, in the /jrsf
species (§3.), than in the second ; although oc-
casionally a few cases of the latter approach these
characters of the former. — (6) The same dif-
ferences, but in greater degree, exist between
delirium tremens and phrenilis, in which are
wanting the cold, copious, clammy, and peculiar
perspiration, the soft pulse, and the moist tre-
mulous tongue and hands. The impatience of
light, and fulness of the vessels of the eyes, which
accompany the latter, are not present in the
former. The illusions, also, of delirium tremens
are peculiar, and are accompanied with an
anxious, fearful, and constant reference to con-
cerns which had previously interested the patient
in a particular manner. He can recognise his
friends, and return a rational answer to some
questions ; and he is more tractable and ma-
nageable, when not irritated or opposed, than in
phrenitis. — (c) This affection may be readily
distinguished from the delirium of fever or typhus,
by the history of the case — it being the primary
and the most prominent ailment ; delirium gene-
rally supervening late in fever. In this disease,
the patient is quick in his movements ; is agitated
and talkative ; is desirous to be up ; walks about,
when permitted, in a hurried manner ; is anxious
to follow his occupation, or to avoid, or to find
out, or to chase away, some spectral illusion that
haunts him ; and is violent when opposed : in the
delirium of fever, the patient is prostrate, his
countenance less wild, his delirium is lower and
quieter, ar.d seldom attended by attempts to get
out of bed, &c. (See Delirium, §3. 7. 10.) In
the former, there is a marked tremor of the hands,
&c. from the beginning, and the patient in the
last stage seems to search after objects wliich he
thinks he sees creeping over his bed, or floating
before him : in the latter, the peculiar tremors are
wanting; but there are subsultus tendinum, and
picking at the bedclothes, or floccitation. — (d)
From maniacal insanity it is to be distinguished
chiefly, as stated above(/)), by the great frequency
and softness of pulse; by the copious, cold, and
peculiar perspiration ; the tremulousness ; by the
liistory of the case, — this being an acute, the other
a chronic malady. When, however, it occurs in
the puerperal state, in which I have seen it, the
dilficully of distinguishing it from the mania
sometimes supervening at that ];eriod may be
considerable : the tremors, the greater frequency
of pulse, and more copious and colder perspir-
ations, will point out the nature of the affection,
and will lead the physician to treat it according
as the symptoms indicate a greater or less pre-
dominance of nervous exhaustion over vascular
excitement.

17. V. Prognosis.' — A first attack, in a con-
stitution not yet much injured by the cause of
the disi:ase, generally terminates favourably. 1
liave seen even a third attack end so ; but its

more frequent recurrence, particularly if it be
attended by signs of vascular irritation or erethism
of the encephalon (§5. 15.), or by dryness of the
tongue, and its complication with some other
disease, are circumstances indicating great danger.
A want of correspondence in the pupils, and the
supervention of subsultus tendinum or convul-
sions, or of low and muttering delirium, tiie pulse
becoming quicker and smaller, are generally fatal
signs. It is aUo more dangerous when caused by
opium, than when proceeding from intoxication.
On the other hand, a general mitigation of the
symptoms, less frequency of pulse, with quiet or
sound sleep, are indications of a favourable ter-
mination being at hand. In all cases, however,
a cautious prognosis should be given, particularly
in broken down constitutions ; for success may
elude our best ett'orts, even when most anticipated;
and lecovery may take place in the most ap-
parently desperate circumstances.

18. VI. Pathology. — A. The appearances on
dissection have furnished only negative inforruation
as to the nature of the disease. In the true
delirium tremens, the membranes of the bvain
evince but little change ; the chief lesion con-
sisting of slight opacity of the arachnoid, es-
pecially at the base of the bruin and vicinity.
The pia mater is somewhat injected, and a slight
efi'usion of serum is occasionally observed in the
ventricles. These appearances are, however, not
constant ; but they are more marked, and more
manifestly inflammatory, in those cases which
have accompanied or directly followed intoxi-
cation (§ 3.). In these, the vessels are often
much congested, particularly those of the velum
interpositum, the arachnoid thickened, and the
serum more abundant, and occasionally even
sanguineous. The stomach generally presents
appearances of chronic gastritis, the villous mem-
brane being either thickened or softened, or both,
and the villi effaced. The liver is variously
diseased, — often enlarged, granulated, of a
yellow or fawn colour, or presenting the fatty
degeneration. The lesions, however, of the
stomach and liver, are coincidences only, or
changes contingent on the habits of the patient,
and not necessarily connected with the pathology
of this disease.

19. B. The nature of this disease has been a
suljject of much discussion with modern writers,
in consequence of no clear distinction having been
made between that form of delirium with tremor,
which is the result of vital, and particularly
nervous, exhaustion ; and that which depends
chiefly upon excited circulation, vascularerethism,
or inflammatory action, within the heiid. Although
numerous instances will present themselves in
which the former as well as the latter pathological
stale exists, the one, however, predominating over
the other ; yet the fact of cither being present,
almost solely, if not altogether so, perhaps, in a
still greater nundjer of cases, should not be over-
looked, as it has been fully demonstrated, both by
the post mortem appearances, and by the juvantia
and la.'dantia during life. It is most jjrobably iu
consequence of having noted the changes ob-
served principally in the first species, or in such
instances of the second as approach it the nearest,
that Dr. Cluiti uuuck and Dr. Biught have
viewed this latter as the conse(]uence of inflam-
matory action in the arachnoid and pia mater.

DELIRIUM WITH TREMOR — Treatment.

501

1 believe, however, that inflammatory irritation, al-
though sometimes an attendant on this aflection,
is not necessarily connected with it, and certainly
is not the pathological state which produces it ;
and that, when present, it is not the only con

ammoniiE acetatis witli excess of ammonia, and
camphor julep. Purgatives are well borne : they
may be given energetically, and be often re-
peated, in this state of the disease; but they
should always be associated with stimulants and

dition which is requisite to the development of restoratives, and their action promoted by enemata
its pathognomonic chaiacters; exhaustion or de-
pression of botli the nervous and sensorial powers
being equally necessary to its supervention. It
is probable, also, that the vital and nervous de-
pression is increased by the morbid impression
produced by accumulated secretions of a vitiated
kind in the biliary system, and on the digestive
mucous surface. Tins conclusion is deduced
from a carefal comparison instituted between the
symptoms, the agents controlling them, and the
morbid appearances observed upon dissection.
From this it may be inferred that the pathological
states in true delirium tremens, and in thedelirium
of typhus, are not wiilely different. It is probable
tiiat ihe state of tlie blood, the presence of con-
gestion, and the greater affection of the substance
of the brain, and of the organic functions, in the
latter than in the former, may occasion all the
difl^erencesof symptoms which exist between lliem ;
the vital exhaustion being nearly the same in
both, or perhaps greater in typhus, and tlie ner-
vous disturbance being more prominent in de-
lirium tremens.

20. VII. Treatment. — Very opposite means
of cure have been resorted to in delirium with
tremor, owing to the circumstances above stated
{§ 2.), and to the evidences of general as well as
of local vascular excitement in some cases, or of
nervous and sensorial exhaustion in others, or
even of their co-existence with more or less pre-
dominance of either patiiological condition. When
it is considered that the inability to distinguish
between such manifestations of the disease as de-
pend in a great measure upon vascular excitement
within the head, and those which result almost or
altogether exclusively from exhausted nervous
and sensorial power, must, in some cases, lead to
an unsuccessful if not an injurious treatment, the
necessity of investigating these points, of en-
quiring into the history of each case, and of
arriving' thereby at a correct diagnosis — which
can be reached only by a strict reference to the
existing pathological condition causing the morbid
phenomena — before entering upon the treatment,
will be evident. Having pointed out the means
most beneficial in each of the species of tiiis de-
lirium above distinguished, the practitioner may
apply them accordingly, and adopt more or less
of either method, in order to meet the predomi-
nating characters which intermediate or more
anomalous cases may present.

21. A. Of the Jiist species, or that ivith increased
vascular e.icitemeiit. — This form of tlie disease
requires moderate depletion, preferably by cup-
ping, or leeches applied behind the ears, and
below the occiput ; cold washes or lotions, or the
tepid or cold affusion, to the head, whenever its
temperature rises above the natural standard ;
the tepid bath, or the surface of the body to be
sponged with tepid water ; purgatives combined
with cordials, &c., if the nervous power be much
depressed, or if the attack be occasioned by in-
toxication, particularly calomel with camphor or
ammonia, or with both ; aperient and antispas-
modic enemata (F. 137. 149.) ; and the liquor

contammg assafa'tida, the terebinthinates, &c.
When the affection is caused by spirituous
liquors, we should be extremely cautious not to
carry the depletion, although local, too far; anrl
upon the first indication of the subsidence of
vascular excitement about the head, we should
endeavour to anticipate, and prevent the con-
sequent depression which will otherwise ensue,
by exhibiting, in addition to the ammonia-cam-
phorated medicine now recommendnd, moderate
doses of opium, or of laudanum, with the view
of quieting the perturbation of the frame, and
inducing sleep.

22. In the cases of this form of the disease, in
which the vascular excitement either is not so
great as to require bleeding, or has been somewhat
reduced by this practice, emetics may be im-
mediately exhibited. Dr. Ki.app, and other
American writers, prescribe tartar emetic in fre-
quent doses, in those cases which are referrible to
the present species of affection, until it either has
an emetic action, or nauseates and purges the
patient ; and Dr. Blake confirms the result of
my experience, as now stated, in recommending
emetics of sulphate of zinc, assisted by the ad-
ministration of antispasmodics and stimulants,
such as aether, camphor mixture, colfee, &c.,
with the application of cold to the head, while the
surface of the body and extremities are sponged
with tepid water ; and, in some cases, bleedinsf,
without being pushed so far as to increase de-
bility. This treatment is, however, most appro-
priate when tlie affection is the direct result of
intoxication ; but when it arises from other
causes (§ [>.), vascular depletions, purgatives,
cold applications to the head, and a more sparing
use of stimulants, are most appropriate.

23. B. Treatment of ihe second species, or true
delirium tremens. — a. During the first stage we
should endeavour to cut short the disease, by
exhibiting, every hour, very small doses of lauda-
num in effervescing draughts, with the sesquicar-
bonate of ammonia, in camphor mixture; or the
opium with full doses of camphor and ammonia ;
and by administering clysters, with assafoetida,
camphor, and tinct. opii. Dr. Carter, of Phila-
delphia, advises the mistura assafoetidae with tinc-
tura opii to be taken every hour or two. Dr.
Blake recommends the accustomed stimulus in
moderate quantity, and at short intervals : but it
may occasion a too violent reaction, utiless the
head be guarded by having frequent recourse to
the tepid or cohl affusion on it. In some cases,
however, warm spiced negus or punch may be
allowed, especially in exhausted and old drunk-
ard-. This is the only period in vvhicli blisters
should be employed — if employed at all. The
nape of the neck, or the epigastrium, is the pre-
ferable place on wliich to apply them. Anodyne
and stimulating liniments (F. 297. 308.) rubbed
over the epigastrium are, however, more effica-
cious. In some cases, a warm bath will preceile
the use of liniments with marked benefit.

24. Of all the cases of the disease I have seen,
there has not been one that has not indicated the

Kk 3

602

DELIRIUM WITH TREMOR — Treatmknt.

propriety of prescribing cathartics, in order to
remove accumulated secretions. From the quan-
tity of very dark, offensive, bilious evacuations
which they have procured, — often not until after
their repeated exhibition, and even in cases
where the bowels had been opened or relaxed,—
I have concluded that collections of vitiated bile
in the gall-bladder and hapatic ducts have fa-
voured the supervention of this peculiar affection.
Under this conviction, I have always exhibited,
as -early as circumstances would permit, an ac-
tive chologogue purgative, generally a bolus con-
sisting of about ten grains of calomel, with as
much camphor, and a grain of opium, in conserve
of roses • and, in a few hours afterwards, a warm
stomachic and aperient draught, followed in
an hour or two by an enema (F. 135.). The
advantages arising from conjoining camphor, or
large doses of ammonia, or capsicum, or other
stimulants, with purgatives in .this disease, are
manifest ; for, by these or similar means, we shall
succeed either in arresting its progress, or in pre-
venting the depression which might follow copious
evacusUions — fears of which have paralysed the
treatment of it. In all cases, but especially in
diseases accompanied by low or melancholic de-
lirium, accumulations of vitiated bile or other
secretions should be suspected and be removed :
nor should we infer, from having at first failed in
procuring their discharge, that no such disorder
exists; for the most active, and even the most
judiciously selected, cathartics may long fail in
evacuating the thickened and morbid contents of
the gall-bladder and hepatic ducts, particularly
when their excitability has become exhausted by
spirituous potations.

25. h. In the second stage — if it supervene
notwithstanding the above means, or if the pa-
tient be not seen until it has appeared — the
treatment should be commenced by the ex-
hibition of the calomel, camphor, &c., as pre-
scribed above (§ 24.), if they have not been
already exhiliited,' or if they have not procured
copious, dark, and offensive stools ; and evacu-
ations ought to be promoted by warm and sti-
mulating aperient draughts, and by purgative
enemata containing assafoetida, camphor, .Sec,
or consisting of F. 130. 149. The greater number
of the cases I have seen had been treated by able
practitioners, according to the plan advised by the
best writers, but without success — although
purgatives had been given where the bowels
had" not been sufficiently open. In all these,
this treatment was immediately put in practice,
and assisted by cordial draughts containing some
one of the ammoniated spirits, and sethers, &c.,
and by the enemata already alluded to. As
soon as alvine evacuations were procured by these
means, opium, either alone, or with ammonia or
camphor, or with both, was prescribed in full
doses, and repeated according to its effects ; and
although they were all severe cases, one only
terminated fatally.

26. At this period of the disease, the tvarm
hath, at a temperaluie of about 90=*, will assist
materially in tranquillising the patient, and pro-
moting the effects of opium. Dr. VVuumit, of
Iialtiniore, strongly recommends it ; but it is not
a new practice in delirium tremens, as he sup-
poses ; and he is favourable to the use of Dover's
powder, which, however, is more suitable to the

preceding species. Although opium should be
given in full or decided doses, combined as stated
above, — (in from one to three or four grains — the
smaller quantity being repeated twice or thrice,
the larger not oftener than once, and after a
longer interval), ■ — it should not be persisted in,
unless sufficient time be allowed to elapse after
each dose ; for, as Dr. Pearson has observed, if
it does not succeed after its exhibition at first in a
decided manner, it increases the intellectual con-
fusion and danger. Some of the American phy-
sicians have recommended enormous doses of this
medicine. Dr. S. Brown gives from 3j. to ^ss.,
or even more, of laudanum for a dose. Dr. S.
Jackson prescribes from ten to fifteen or even
twenty grains of solid opium every two hours ;
and states, that four ounces of good laudanum
having been given in twelve hours, partly by
mistake, a sound sleep of twenty-four hours'
duration, and perfect recovery, were the result.
I only am surprised that the sleep was not that
of death. These are not solitary instances of the
extravagance, if not rashness, of some American
practitioners ; nor, indeed, has the practice of
giving excessive doses of laudanum in this affec-
tion been limited to them. When we find thirty
or forty leeches ordered to be applied to the throat
of a child five or six years old in croup, and
repeated oftener even than once, and the bleed-
ing promoted, should we wonder that death
ensues ? Feats of hardihood in medicine are too
often the consequence of clerical and practical
ignorance; and they may be allowed to meet
their own reward, as long as they are not ob-
truded into the annals of our science, and thereby
set forth to the inexperienced as examples to be
followed. But when this distinction is conferred
on them, it becomes the duty of those who record
the progress of medicine, to note also, and to
oppose, its backslidings by the severest repre-
hensions.

27. I believe that large and frequently re-
peated doses of opium in this disease, as Dr.
Wright, of Baltimore, has remarked, favour the
supervention of coma, convulsions, or paralysis ;
and that the effects of an excessive quantity of
this drug very nearly resemble the phenomena of
the last stage of the disease, particularly towards
its fatal close. This fact should not be over-
looked, and should lead us to distinguish between
the consequences of an injudicious treatment,
and the worst features of the malady. It is the
abuse of opium that is here argued against ; its
truly medicinal exhibition that is contended for, —
given in a quantity which sound sense will dictate,
and after accumulated and morbid secretions and
excretions have been removed, the discharge of
wiiich might be imjiedod, or interfered with, by the
immediate employment of this valuable remedy.
I consider opium as necessary to the cure of this
disease, as bark and analogous medicinces are to
the cure of ague ; but, as in their case, the
morbid coUuvies, which has at least disposed the
system to be affected, and aggravated the malady,
should be removed, in order that recovery may
be ensured and be permanent.

28. In this stage of the disease, particularly
when the delirium is attended by much agitation
or violence, it is necessary to obtain an influence
over the patient's mind by moral means. All
irritating contentions, however, should be avoided ;

DELIRIUM WITH TREMOR — TnEAtMEKT.

503

and the patient's wishes, when not likely to prove traumatic delirium in that state of constitution

injurious to him, be indulged. By thus granting '■•■•■ • ■ ■

what is less material, he will more readily submit
to what is important; but he ought not to be
left a moment without an attendant. Coercive
measures will generally be found unnecessary,
if soothing and indulgent but firm treatment be
adopted, and the warm bath be occasionally
resorted to. In a majority of instances, the above
means will be followed by a remission of tlie
symjjtoms, and a disposition to sleep will mani-
fest itself, — sometimes, however, accompanied by
nervous rigors. Opium should now be left off,
or its dose much diminished ; and the patient
kept as quiet as possible. His first slumbers are
often short, broken or interrupted by startings, or
terminated by fright. If he awaken alarmed,
his distress should be soothed, and a moderate
dose of opium with warm spiced negus or punch
may be given him; these will generally secure a
sound sleep, from which he will awaken in a
rational state of mind. Afterwards it will only
be necessary to support the strength by light
and nutritious diet, and gradually diminish the
quantities of the restoratives that have been
prescribed.

29. In cases characterised by much vital de-
pression, very frequent pulse and cold surface
occurring in old and habitual drunkards and
broken constitutions, a liberal use of cordials,
and even a moderate quantity of the accustomed
stimulus, in addition to the opium, should be ad-
ministered from time to time ; particularly if the
head be cool, the face pale, and the action of
the carotids not strong. On the other hand, in
those cases which were described (§ 15.) as ap-
proaching the first species of the disease, cupping,
or the application of leeches on the occiput,
or nape of the neck, or behind the ears, will be
requisite early in this stage ; and full doses of
calomel, and the rest of the yiirgative treatment,
with cold applications, or tepid afl'usions on the
head, should be more actively employed, and
precede the exhibition of opium. In this state
of the disease, opium often aggravates the symp-
toms, unless it follow a judicious use of these
remedies ; and other excitants are equally in-
jurious. In these cases, James's powder, or
antimony, either previously to, or conjoined with,
camphor and opium, will also be productive of
much benefit.

30. That state of the disease which comes
on after external injuries or operations (§9.), I
have imputed chiefly to the previously intem-
perate habits' of the patient. It requires the
same treatment as the more nervous or vitally
depressed cases now alluded to (§29.); and, as
well as these, wdl be remarkably benefited by
small clysters containing moderate doses of lau-
danum, administered alter the bowels have been
sufficiently evacuated, and repeated according to
circumstances. This treatment has been much re-
lied upon by M. Dupuytren ; but if it remove not
the disorder, after sufficient time has been allowed
for its operation, camphor may be added to it ;
and ammonia, musk, fether, &c. be given in suit-
able vehicles ; or a moderate quantity of the
patient's favourite beverage allowed him, as sug-
gested by Dr. Colles. Of two cases recently
reported {Med. Gazette, vol.vii. p. 287.), which
confirm the view I have taken of the origin of

which intemperance induces, opium failed in
one; and hydrocyanic acid, which was tried in
the other, was equally unsuccessful.
I 31. c. If the third stage appear notwithstanding
[ the above treatment, little hope of recovery can
be entertained, as most likely serous effusion has
become superadded to exhausted vital and nerv-
ous influence. Nevertheless, medical aid should
not be withheld, ospecially if the patient have
not received it in the earlier periods, or have
been treated injudiciously. The hair should be
removed from the head, and either a blister ap-
plied, or one of the liniments (F. 299. 308.) rubbed
upon it. A blister, sinapism, or other rubefacient,
should also be applied over the epigastrium ; and
camphor, ammonia, musk, capsicum, &c. liber-
ally administered ; restoratives and stimulants
being also exhibited in clysters. JMercurial lini-
ments containing camphor may likewise be rubbed
upon the inside of the thighs, and the warm bath
resorted to.

32. d. Certain mades nf practice have been em-
ployed, to which a brief reference may be made.
Dr. Klapp, and some other physicians of the
United States, have recommended tartar emetic
in frequent doses, until it nauseates and purges
the patient ; but this treatment is more appro-
priate in the first species, or in such cases of the
second as approach it most nearly (§ 15.) Dr.
Speranza, of Parma (Ballet, des Scieit, Med.
Sept. 1830.), directs leeches to the head and anus,
applies ice to the scalp, and gives calomel and
jalap, and subsequently hydrocyanic acid. This
method is obviously suited only to the first species,
and would be injurious in most instances of the
second. From the preference he has given to
the appellation adopted by J.Frank, — Ence-
phalis tremefaciens, — I would infer that he has
never prescribed it in the true delirium tremens.
Dr. A. L. PiERSOx (JV. Eng. Journ. of Med.
and Surg. vol. ix. No. 2. Ap. 1820.) states, that
he gave very large doses of digitalis (sixty drops
every three hours) after bleeding, and the pa-
tient recovered ; but tiiis was evidently a case
of this first form of the disease. Dr. Pauli in-
forms us that he has prescribed from three to six
drachms of fresh ox-gall, in aromatic water, half a
glass of brandy each morning, and two grains of
the watery extract of opium at night, in forty-
three cases, and has lost only one (Med. Gazette,
vol. ix. p. 776.). The propriety of having re-
course to moderate quantities of the stimulus to
which the patient has habituated himself, in the
depressed periods of the disease, and especially
in those cases which present the more marked
signs of exhausted nervous and vital power, has
been insisted on by Dr. Bi.ake, Dr. Ryax, tS;c.
and admitted above, as well as by others; and
quinine, capsicum, the preparations of hop, and
various aromatics and cordials, may be also used
as adjuvants of opium.

33. e. During the treatment, little or no nourish-
ment is desired, or even required : arrow-root
and sago, with a little brandy or wiiite wine, may
however, be given from time to time, particu-
larly if the patient wish it. When he becomes
convalescent, the diet should be very light, but
nutritious; and a suitable beverage, in moderate
quantity, be allowed. During recovery, the state
of the digestive functions ought to be attended
K k 4

DENTITION, DIFFICULT — Pathology of.

504

to, and promoted by tonics, and by aperients
whenever the bowels are torpid. I have never
known or lieard of an instance wherein the state
from which the patient has escaped, or tlie re-
presentations of the medical attendant or friends,
has effected a reformation of the habits which pro-
duced the disease. However, the physician should
discharge his duty, by stating to him the conse-
quences that will accrue from persisting in themT

BiBLioG. AND Refer S. B. Pearson, Obscrv. on

Braiti Fever. Newcastle, 18U1. — M'Whirter, in Med.
and Pliys. Joiini. vol. xviii. v- 153. — T. Sutton, Tracts
on Delir. 'I'remeiis, &c. &c. Svo. Lend. 1813. — Ar7n-
strong. On Brain Fever from Intoxication, in Edin.
Jicd. and Surg. Journ. vol. ix. p. 58. 14(3. — Xicol, in Ibid.
June, 1821. — A- L. Pierson, in N. Eng. Journ. of Med.
and Surg. vol. ix. 1820. — S. Brotvn, in Amer. Med. Re-
corder, April, 1822 K/app, in Ibid. vol. i. ; and Eclect.

Repert. vol.vii. p. 2,)2. — Snowdeii, in Ibid. vol. v. — Play-
fair, On Del. Trem., in Transac. of Med. and Phys. Soc.
of Calcutta, vol. i. p. 12-t. — Coates, in North Amer. Med.
and Surg. Journ. vol. iv. ; and in Johnson's Med.-Chirurg.
Rev. vol. viii. N. S. p. 457. — Cluttcrbuch, Lectures in
Lancet, vol.xi. p 376. — BarJchaiisen, in N. A. Med, and
Surg. Journ. vol.vii. — Lcveill^, Mem. siir la Folie des
Ivrognes, in Mem. del' Acad. Roy. de Med. torn. i. 4to.
Paris, 1828, p. \?.\. — Ki/nn, in Lond. Med. and Surg.
Journ. vol iii. p. 2'.'7. — Udis, in Archives Gen. de Meil.
t. XV. p. 430. — ./. lilahc, I'ract. Treat, on Delirium Ti e.
mens, S:c. Svo. 1830.; and in Edin. Med. and Surg. Journ.
Oct. 1823, p.501. — T. H. IVrinht, in Amer. Journ. of Med.
Sciences, vol. vi. p. 17. — S. Jackson,'m Ibid. vol. vii. \> 361.
— J. Carter, On Mania a Potu, in Ibid. vol. vi. p. ;;21. —
Ware, On the History and Treatment of Delir. Trem.
Svo. Bost. U. S. 1831. — a/gW, Medical Reports, vol. ii.
part i. p. 15, et seq. — Hingeston, in Lond. Med. Gaz.
vol.xi. p. 7. — Etiiotsvii, in Ibid. p. 466. — J. Johnson,
reported in Lancet for March 2 3. 1833.

DENTITION, DIFFICULT. — Syn. Dentitio
difficilis, Odniitio Dentitionis, Good. i)i/s-
odontiusis, Ploucquet. Difficult Teetlting.
Classif. — 1. Class, 1. Order (Good).
II. Class, I. OitDtn (Author).

1. Defin. — Slow or delaiied evolution of the
ieeih, irith signs of local irritaiion, and con-
stitutional disturbance, often with disorder ma-
nifested especially in the digestive organs and
nervous systems, occurring chiefly in weak or over-
Jed children.

2. A general view of the pathological relations
of dentition was exhibited in the article Age
(§ 10.) ; and, therefore, only that morbid con-
diiion of the process wiiich is unattended by
disease of an important organ, and is referrible
chiefly to this process itself, although often caus-
ing disease, or being accidentally associated with
it, will he here noticed.

3. i. Dentition, in the most favourable cases, is
preceded by slight .salivation, by heat and fulness
of the gums, occasional flushings, increased thirst,
restlessness or fretfulne.ss, and frequent endeavours

both late and slow in taking place, and is often
attended by signs of increased irritation, as red-
ness or tumefaction of the gums ; by various
cutaneous eruptions ; by greater fretfulness, some-
times sickness and feverishncss towards night,
with restlesness, fits of crying, and sudden starl-
ings from sleep. These inay be the only ailments,
which may subside either partially or altogether
as soon as the tooth has passed the surface, and
return shortly before others come in sight ; but
not infrequently, particularly in this class of
patients, disorders of the prima via, particularly
chronic diarrhoea, slight dysenteric affections, or
slow remitting forms of fever, obstruction or en-
laigement of the mesenteric glands, obstinate and
recurring coughs, tubercular degeneration in the
lungs or digestive tube, marasmus, &c., super-
vene more or less rapiilly,

4. ii. In children who are of a plethoric rather
than of a robust habit of body, and which Dr. J.
Clarice has, with much justice, ascribed to over-
feeding, the gums are often swollen and painful,
the face flushed, the head hot and pained ; and
all the symptoms of inflammation of the mem-
branes of the brain, or of inflammatory fever
Avith determination to the encephalon, frequently
supervene. In them, the symptomatic fever is
generally high, and attended by great thirst,
nausea, vomitings, constipation, and occasionally
by drowsiness or stupor, or by great irritability
and restlessness, or by both stales of disorder al-
ternately; sometimes by short broken slumbers,
from which the child awakens in a slate of alarm,
or in a fit of crying ; or by convulsions, di-
minished secretion of urine, and other signs of
cerebral affection. These are the usual con-
comitants and symptoms, or consequences, of
difficult dentition ; but they do not always stop
here ; for they often run on into more serious
disease, — such disease, however, occasionally
appearing more abruptly and without these pre-
cursory ailments, at least in such degree or dur-
ation, as to become objects of attention to the
attendants, or to lead them to resort to medical
aid. These maladies, althougli often occasioned
either partly or chiefly by dentition, when oc-
curring ill children at that epoch ; and whether
affecting the cerebral, the thoracic, or the ab-
doininal organs, or the skin ; are still more fre-
quently independent of this process, and therefore
cannot be further alluded to in connection with
it, than they have already been in another place
(see Age, § 10.); — and, indeed, in most instances
. . , in whicli a close connection between them and

to thrust things mto the mouth, evidently to allay difficult or morbid dentition is observed, it is that
iintation or itchmg. These symptoms generally i of concurrent effects of constitutional predis-
appcar about the third or fourth month, and pre- position and of anterior changes in the organic
cede the appearance of the teeth sometimes by ! functions ; the local irritation and sympathetic
several weeks; and occasionally subside, and re- I febrile disturbance either exciting morbid action

in such organs or tissues as, from hereditary con-

appear shortly before the tooth makes its way
through the surface. These signs of disturbance
are merely the necessary attendants on the form-
ative processes going on in the gum. Hut very
commonly in children of deficient vital power,
and occasionally in those which arc apparently
robu.a, or rather plethoric from overfeeding, den-
tition is either delayetl, or is attended by more
serious disorder, paitici larly while the canine
teeth are being protruded. In delicate children,
particularly those living in crowded towns, and
low and ill-ventilated localities, this process j.s

formation or vice, are disposed to it ; or aggra-
vating previously existing disorder, and rendering
evident what was before latent, or unobserved.
In these cases, therefore, dentition is to be looked
upon either as a principal, or as a concurrent
exciting cause of many of those diseases which
occur at the period of dentition — but a cause
most fre(|uently concurrent with improper feeding
and clothing.

5. iii. A natural or slightly difficult dentition
may be converted into serious disease, by the not

DENTITION. DIFFICULT — Treatment.

505

uncommon habit of giving the infant food when-
ever it cries from tlie irritation attending upon the
process, and thereby overloading and further dis-
ordering the digestive processes, which are already
disordered by the febrile disturbance generally
accompanying it; whilst determination of the cir-
culation to the head is favoured by the practice of
covering the head in-doors or when asleep, and by
wearing tiiick felt hats during mild or warm
weather. Brandis believes tliat difficult den-
tition is the consequence of obstruction of the
salivation which accompanies, and is salutary in,
this process : Heckeh, that it results from a mor-
bid state of this secretion : ^Mvlius, that it is the
effect of disorder sympathetically induced in the

never occurs when the operation is judiciously
performed ; when the lancet is clean, not carried
too deep into the gum, if lancing be performed
early in the process ; and when its edge is directed
rather outwards, as recommended by 31r. Mar-
ley. That the cicatrix may oppose the passage
of the tooth is certainly not proved ; but this, if it
did, is no objection, as a repetition of the opera-
tion, is often necessary, and generally beneficial.
M. Bitoi'ZET (Sur I'Kdiicut. Medic, des Enfaits,
t. i. p. 234.) -advises the surface of the gum to be
divided, from time to time, by the point of the
nail, — a practice which possesses the advantage of
not alarming the child, of being easily and readily
performed, and of delaying the closing of the

liver : Thom, that denlition often occasions an j divided part. But care should be taken not to
acrimony of the abdominal secretions, which perform it until the nails have been well cleaned.

react upon the original seat of disorder, and upon i 8, 'J'he propriety of allowing the infant to rub
the system generally ; thereby rendering it difficult ' the guius with hard substances has been ques

or morbid : AVigand, that the affections attendin
delaying, and otherwise disordering, this process,
are accidental complications merely ; and John
Clarke, that all such disorders are commonly
the consequences of pletiiora arising from over-
feeding. Now, in all these opinions, there is
much truth ; and one or other, or several of them
obtain in many instances, more, however, as con-
tingent and related effects of the local irritation,
than as causes of the difficulty of the process, —
which irritation is the chief or concurrent cause of
febrile disturbance, of disordered function, and at
last of more palpable disease, according to the
condition of particular organs at the time, and
constitutional or acquired predisposition.

6. iv. The inuplion of the second or permanent
teeth may also be delayed or attended by sym-
pathetic disorders, particularly in persons whose
viaxilla: are insufficiently developed, and when
the denies stipientes, and the canine teeth, are ap-
pearing. In delicate, nervous, and irritable sub-
jects, swelling of the parotid and sub-maxillary
glands, painful and sometimes periodic affections
of the ear or face, slight or recurring opthalmia,
irregular convulsions, or epilepsy, and chorea,
have, in some instances, been excited by this
cause ; and have disappeared upon the eruption
of the teeth, or the removal of the local irritation.

7. V. The Treatment of difficult dentition
should be directed with the intention — 1st, of re-
moving the local irritation ; and, 2d, of subduing
the sympathetic disorders associated with it. — A.
The local irritation requires scarification of the
gums whenever they are at all swollen or red ; and
particularly in the second stage of the process,
when the tooth has reached the surface, whether
there be redness and swelling, or not. The pro-
priety of this operation has been, however, called
in question, particularly by Sternberg, Storcii,
Tiio.M, and Brandis, on the plea of its inutility,
of it occasioning ulceration or disease of the cap-
sules of the teeth, and of the cicatrix which is
soon afterwards formed being absorbetl with greater
difficulty than the other parts. But these are by
no means valid objections — for its utility has been
proved by the experience of Harris, Cowrer
(^Aiiat. of' the Hum. Body, &ic.), Bromfield (O/j-
spri'rtf(07?s,^'c. vol. ii. p. 17.), Berdmore (Treatise
on the Teeth, (?)C. 8vo. Lond. 1770.), Hurlock,

RlEDLlN, W EDEKIND, KeNNEDV, MaRLEY, mySclf,

and most modern writers of experience : and, as to
the contingent ulceration of the gums, it seldom or

tiontd by Auzebi, Mari.ey, and others, from an
idea that they will hereby become more callous,
and absorded with greater difficulty. But the
truth of this is questionable. I believe that sub-
stances pressed frequently between the gums,
materially lessen the irritation and distressing
itching felt in them, and promote the flow of
saliva, —results of no mean importance in pre-
venting the supervention of sympathetic disturb-
ance. These results will be ensured, in cases of
existing irritation, by frequently moistening what-
ever substance is thus employed with biborate of
soda mixed in a little syrup of senna.

9. Besides the above, various other means have
been recommended in order to subdue the local
irritation: the chief of these are — a preservation
of a lax state of the secretions and bowels;
leeches, particularly behind the ears (Syden-
ham, Kortum, Stole, Leroy, Journ. de Paris,
1784.); internal emollients (Paulus ^Eginatus,
1. i. cap. 9., and Bekker, Hermet. liediviv.
p. 705.) ; various derivatives (Hvfeland) ;
calomel (Mylius and others); the alkalies
(Hecker) ; cold applied to the face (Wigand) ;
opium (Wedt;kind); and active purging (Van-
dermonde and Portal, Anat. Medicate, t. i.
p. 211.). The best means of promoting the se-
cretions and alvine evacuations are, small doses
of hydrarg, cum creta, conjoined with the dried
carbonate of soda, and, if the state of the bowels
requires it, with the pulv. jalapjp, given every
night. Leeches behind the ears, and cold ap-
plied to the head, should never be neglected
whenever the temperature of this part is in-
creased, and other signs of determination of the
circulation to it are observed. In such cases
active cathaitics, calomel with James's powder,
and the rest of the treatment recommended for
cerebral diseases, are necessary. Blisters applied
also behind the ears are the best external de-
rivatives ; but they should be removed as sooa
as redness is produced. Opium is very seldom ad-
missible ; but, if much irritation exist, the tepid
bath, and syrup oT poppies with small doses of the
biborate or the carbonate of soda, may be pre-
scribed. If the gums become ulcerated, biborate
of soda or sulphate of alun)ina, or the boracic acid,
in honey or syrup of roses, should be employed.

10. B. The sympathetic disorders should be sub-
dued as soon as they appear. — (a) If the head
indicate vascular excitement, the means already
specified (^ 6, 8.) should be directed ; and if

506

DIABETES.

the symptomatic fever, with or without determin-
ation to this quarter, be considerable, cooling
aperients, and saline and antiphlogistic diapho-
retics, are requisite, with the cold affusion on the
head, the tepid bath, &c. — (6) Constipotion, or
colicky affections, which are not infrequent
during this epoch, should receive immediate
attention; and aperients, emollient laxatives, —
as castor oil with two or three drops of oleum
anisi, hydrarg. cum creta with carbonate of
soda, — and, if requisite, purgative and anti-
spasmodic enemata, ought to be prescribed. — (c)
Care ought to be taken not to check a slight
diarrluEa ; but if it passes beyond this, emollients,
demulcents, refrigerants, diaphoretics, alteratives,
tonics, absorbents, &c. should be prescribed,
according to the circumstances of the case, and
be assisted by the semicupium, warm clothing
on the lower part of the body, and occasional
doses of rhubarb with magnesia and hydrarg-
cum creta. — (rf) In some cases, both vomiting
and purging, or a slight form of cholera, or of
choleric fever, supervene ; the stools being
greenish, spinach- like, and offensive, sometimes
terminating in a gelatiniform softening of the
mucous surface of the stomach and bowels, as
described by M. Cruveilhier ; but more fre-
quently without such disorganisation, as M.
GuERsENT has remarked. The classes of remedies
just now particularised are also admissible in this
affection. (See Choleric Fever of Infants, and
DiARRHffiA.) — (e) Watchfulness, irritability, fre-
quent starting from sleep, with crying, iScc- should
always be dreaded, especially when the canine
or anterior molar teeth are about to appear, as
not infrequently being the precursors of con-
vulsions, and indicating much sympathetic irri-
tation of the nervous system with disorder of the
digestive organs, and excited circulation in the
encephalon. On the other hand, somnolency,
particularly in plethoric children, evinces con-
gestion within the head, which may be readily
converted into inflammatory action ; or it may
terminate in effusion of serum : and either con-
dition may usher in convulsive spasm of the
larynx, the nature and morbid relations of which
have been so little understood. In all these
varying states and relations of disease, leeches
applied behind the ears, lancing the gums, purg-
atives, emollients, refrigerants, a cautious ex-
hibition of narcotics, laxative and antispasmodic
enemata, the tepid bath, cold or tepid affusion
on the head, rubefacient and anodyne liniments
(F.298. 308. 311.) rubbed along the spine, and,
in delicate children, gentle tonics, are requisite,
and should be modified according to the habit of
body, and the particular features of the case.
(See Convulsions in Children ; and Larynx —
Convulsive Spasm of.)—(f) The occurrence of
obstinate conghs at this period should suggest
attention to the state of the gums with the use
of demulcents and emollients, conjoined with
laxatives, external derivatives, and diaphoretics.
Leeches, also, ought to be resorted to, if the
cough be attended by heat of skin, quick pulse,
accelerated respiration, or if the child be ple-
tlioric. — (g) I'Wuplions, also, on the head, be-
hind the ears, or on any part of the surface, ought
not to be suppressed by external applications ;
but the functions of the abdominal and depu-
ratory organs ought to be promoted by alteratives

and gentle aperients, and the utmost cleanliness
of the skin preserved.

11. C. — (a) During dentition, the head should
be washed with cold water night and morning ; and
no other covering than that with which nature has
provided this part should be put upon it when
within doors or asleep; and on no occasion should
warm felt hats be worn, thin straw or white hats
being lighter and cooler. — (h) The diet should
be carefully attended to, and that only allowed
which is easily digested ; and even it ought to be
taken in moderate quantity. The child ought also
to be much in the open air ; and, if the process
threaten much constitutional or local disease, an
entire change of air will often be advantageous.

BiBLioG. AND Refer Hippocrates, Tli^l oSovTojwijf ,

Opera, cura t'ander Linden, \o\.'i. p. 590. — A'etius, Te.
trab. i. ser. iv. cap. 9. — Avicenna, Canon. I. iii. fen. 7.
tract, i. cap. 16. — De Castrillo, De Dentitione. Valadol,
1557. ; in Mailer's Bibl. Med. Pract. vol. ii. p.Ug. — Pa-
rans, Opp. Chirurg. 1. xxiii. cap. 67. — Ricdlin, Lin. Med.
lt)95, p. 406. — Ortlob, V)e Dentitione Puer. Difficili.
Lips. 1694. — Sydenham, Ojip. p. 248. —Harris, De Morbis
Acutis Infantum, p. 28. — Beurlin, De Dentitione Diffi-
cili. Altd. 17'20. — J. Hurlock, Practical Treatise upon
Dentition. Lond. 1742, 8vo. — Junckcr, De Dentitione
Difficili. Hal. 1745. — Vandermonde, An Infant. ^ Den-
tit. Convulsionibus vel Soporibus repetitus Catharticorum
Usus. Paris, \'bl.— Stall, Pra?lect. i. p. 247., iL p. 414. —
Wigand, Beitrage, heft. ii. p. 141. — J. Hunter, The Nat.
Hist, of the Human Teeth, &c. pp. 132. 234.— 7J. Blake,
On the Struct, and Form of the Teeth, &c. Dub. 1801.

— Wichmann, Ideen zur Diagnostik, b. ii. p. 3. — Wagner,
De Dentitione DifT. a dubiis CI. Wichmanni Vindicata.

Jen. 1798. — Thom^ Erfahrungen und Bemerk. p. 21

Storch, Kinderkrankheiten, t. ii. — Brandis, Versuch
ueber die Metastasen, p. 210. — Ludwig, De Dent. Diff.
Lips. 1800. — Ji'edekind, in Hi/feland's Journ. der. Pract.
Hcilk. b. ix. st. 1. p. 34. — Mi/lius, in Ibid. b. xxvi. st. 2.
p. 188 — Hecher, in Magazin fiir Pathol. Anat. und Phys.
b. i. — Hiifeland, Bemerk. ueber Blattern, &c. p. 341. —
Fox, On the Diseases which affect Children in the first
Dentition, in Nat. History of the Teeth. Lond. 180.3, 8vo.

— Bickat, Anat. Generale, t. iii. p. 88. — Beaumes, Traite
de la Premiere Dentition, et de Malad. qui en dependent.
Paris, 1805, 8vo Gardien, Sur les Mai. des Enfans, &c.

— M. Good, Study of Med. vol. i. p. 50 J. Kennedy, On

the Management of Children in Health and Disease, 8vo.
Lond. 1825, p. 297. — S. Palmer's Popular Illustrations of
Medicine, 8vo. Lond. 1829, p. 127.— T. C. Haden, Observ.
on the Management and Diseases of Children, Svo.

Lond. 1827, p. 132 Darwall, On the Management and

Disorders of Infants and Children, &c. 8vo. Lond. 1830,
p. 79. — Marley, On the Nature and Treatment of the
Diseases of Children, 8vo. Lond. 1830, P- 90. — Evanson
and Maunsell, On the Management and Diseases of Chil-
dren, Svo. Dublin, 1836, p. 196.

DIABETES. Excessive Secretion of Urine. —
Syn, AiaC>jT»i? (a siphon ; or from Siafai'va),
transeo). Lienteria Urinalis, Tabes Urinulis
Diarrhoea Urinosa, Hydrops ad Matula7n, Fro-
fluvium vel Nimia Profusio Urinie, Cito Emissio
Rerum qux bibnntur, Auct. Vet. Polyuria,
Seidel. Diabetes Anglicus, Mead and Sauvages.
Plithisuria Saccliarina, Diabetes Succharina,
Nicolas, Gueudeville, Hufeland. Diabetes
iVie//ifi(s, Cullen and Sagar. Dipsucus, Ilecker.
Phthysuria, lieU. M(;/((i(?-ia, ll.VVillis. Harn-
fiuss, Honigartige Ilarnruhr, Germ. Urinjiod,
Dan. Diabite, Fr. Flnsso d'Orina, Ital.
Urine-Flux.

Classif. — 2. Class, Nervous Diseases; 3.
Order, Spasmodic Disorders (Culten).
6. Class, Disease of the Excreting Func-
tion ; 2. Order, Affecting Internal Sur-
faces (Clood). I. Class, II. Ordeu (^k-
thor in Preface').

1. Defin. — Urine secreted of a sweet taste and
violet smell, generally in large quantity, loilh great
thirst, dryness of skin, debility, and emaciation.

2. This disease was but sligiitly alluded to by

DIABETES — Symptoms.
Celsus. AnET^fUs gave a tolerably complete
history of it, which the majority of his followers
merely copied. Alexander of Tralles added
nothing to either its pathology or treatment, ex-
cepting the drawing of a comparison between it
and lientery ; and Aetius, taking up the same
idea, states, that the one affection differs from
the other in as far as that the undigested aliments
pass ort", in the fotmer by the urine, in tiie latter
by the stools ; an opinion which was afterwards
adopted byFERNEL, Duret, Zacutus-Li'sitanus,
and othere. ButWiLLis was the first who advanced
a rational theory of the disease. Since his time,
opinions as to its pathology have been various, and
the remedies recommended still more diversified.

3. Even up to the present day, the term dia-
betes has been applied to various states of dis-
ease : — 1st. To that consisting chiefly of diuresis,
or morbidly increased flow of urine, without
reference to its quality ; 2d. To that in which
the urine is voided not only more frequently, and
in larger quantity than natural, but also of
changed quality, as respects certain of its con-
stituents, viz. albumen and urea, either of which
may be in excess ; and, 3d, to that in which a
saccharine matter is either superadded to the
other ingredients contained in the urine, or in
part replaces them. To the last of these morbid
states I shall limit the term diabetes, conformably
with the views of Dr. Prout and M. Renauldin.
The other morbid conditions of the urine will be
noticed when treating of the pathology of this
secretion. (See Urine.) Restricting, therefore,
the term diabetes to that state of the urine cha-
racterised by the presence of saccharine matter,
I have defined it accordingly. In consequence
of the very vague ideas which have but too
generally been entertained both as to the phe-
nomena requisite to constitute this malady, and
as to its various morbid relations, diabetes has
generally been considered with reference to the
quantity of the fluid secreted, without regard to
the circumstance alluded to by Dr. Parr and
others, and judiciously insisted on by Dr. Prout,
that the disease may exist for a long time, and
the urine be extremely saccharine, without much,
or even any, increase of its quantity; and, when
the urinary discharge is augmented much beyond
natural, that it is much easier to reduce it even
to the usual quantity, than to restore it altogether
to its natural quality.

4. I. Symptoms. — A. The urine of diabetic pa-
tients is generally of a pale straw or greenish
yellow colour ; of a faint and peculiar odour,
sometimes resembling that of hay or of sweet
whey or milk, or of violets. Its taste is always
more or less saccharine ; and its specific gravity
usually varies from 1*025 to 1-052. The quantity
of urea is seldom much diminished in diabetic
urine: Dr. Prout and Dr. Henry have never
observed it altogether absent; and iNIr. Kane and
INIr. IM'Gregor have found it in greater relative
proportion than in healthy urine, but masked by
the sugar or snccharine matter held in solution :
there is little or no lithic acid. The usual saline
ingredients in healthy urine exist in the urine of
diabetes, but in diminished quantity, whilst their
relative proportions continue nearly the same.
Dr. Watt has found a little blood in it ; but this
is a rare occurrence : it much more frequently
contains albuminous matter analogous to that of

507

chyle. Dr. Henry has given a useful table,
showing the quantity of solid extract in a wine
pint of urine of different specific gravities from
1*020 to I'OSO. The following abstract of this
table will enable the reader to ascertain the quan-
tity of solid matter diabetic urine may contain : —

Specific graTity com-

Quantity of solid ex.
tract in a wine pint.

Quantity of solid ex-

pared with 1000 parts
of water at 60".

tract in a wine pint.

grains.

oz. dr. scr. (»rs.

1020

382-4

0 6 12

1021

401-6

0 6 2 1

1022

420-8

0 7 0 0

102.J

440-0

C 7 1 0

1024

459-2

0 7 1 19

1025

478-4

0 7 2 18

1026

497-6

1 0 0 17

1027

516-8

1 0 1 16

1028

536-0

1 0 2 16

1029

655-2

1 1 0 15

1030

574-4

1 1 1 14

1031

593-6

1 1 2 13

1032

612-8

1 2 0 12

1033

(■32-0

1 2 1 12

1031

651-2

1 2 2 11 .

1035

670-4

1 3 0 10

1036

689-6

13 19

1037

7()8-8

13 2 8

1038

728-0

14 0 8

1039

747-2

14 17

1040

766-4

14 2 6

1041

785-6

15 0 5

1042

804-8

15 14

1043

824-0

15 2 3

1044

843-2

16 0 3

1045

862-4

16 12

1046

881-6

16 2 1

1047

900-8

17 0 0

1048

920-0

17 10

1049

939-2

1 7 1 19

1050

958-4

1 7 2 18

This table enables us to ascertain with consider-
able precision the quantity of solid matter voided
by a diabetic patient in a given time. Thus,
suppose 10 pints are passed in 24 hours, of the
average specific gravity 1-040, it is evident that
this will contain 10 x 1 ..4 ..2. .6=15 ..7 ..2, or
upvv'ards of a pound and a quarter of solid extract.
Diabetic urine, in a moderate temperature, be-
comes sour, smells like turned milk, and some-
times ferments. With the addition of a little yeast,
it readily undergoes the vinous fermentation,
yielding alcohol by distillation, the quantity of
which indicates the amount of saccharine matter
in the urine.

5. Besides the saccharine condition of the urine,
the next most striking and constant symptom is
its increased quantity. Sometimes the quantity
voided is enormous. P. Frank details a case in
which 52 lbs. were passed in twenty-four hours ;
and instances are by no means uncommon of
from twenty-five to thirty-five pints having been
discharged in the same time for weeks, or even
months together. In some cases the urine has
been said to have been nearly double the quantity
of the whole ingesta, — a circumstance which
has puzzled physiolojists to explain, and has in-
duced some to believe that, in addition to the
colliquation of the solids of the body, absorption
of moisture from the air actually takes place
during the disease in some cases, either through
the medium of the resjiiratory organs or cutaneous
surface, or both. I believe, however, that so
great a difference between the quantity of the
ingesta and urine, as here stated, is extremely
rare ; although a considerable excess has been
proved by Dr. Bahdsley ; and the experiments
of modern physiologists have shown that th«

508

DIABETES — Complications — Terminations — Dun atiox.

lungs may absorb moisture from the atmosphere,
although the skiu may be incapable of doing so.
6. B. The constitutional si/mptoms are often
ushered in by weariness and aversion from any
exertion ; by dryness and disagreeable taste in
the mouth, the saliva becoming white and frothy ;
and by a sense of weight, heat, or pain, in the
epigastrium, accompanied with alternate chills
and flushings, or burnings of the palms of the
hands and soles of the feet. To these supervene
dryness of the skin, much thirst, costiveness ; a
saccharine state of the urine, with, and sometimes
without, an increased secretion of it ; a craving
appetite, and all the symptoms constituting the
disease. In many cases, the urine has evidently
been saccharine, without much increase in its
quantity, long before the attention of either the
patient or practitioner had been directed to this
secretion. In other cases, the disease attacks
more suddenly, generally with dryness of the
mouth and throat; dry skin; a feeling of heat
and pain in the epigastrium, occasionally with
headach, commonly with aching of the back and
loins, and pain in the course of the urinary pas-
sages; sometimes, as mentioned by Ballonius,
a sense of cold in the loins is complained of. The
urine generally, now much increased in quantity,
presents the appearances already described, and
deposits no sediment. The breathing is short,
sometimes difEcult or oppressed, with a short
tickling cough ; sometimes muco-puriform ex-
pectoration, and flying pains through the chest.
The desire for drink and food increases ; the
skin becomes rough or scaly ; the tongue either
loaded with a dark-coloured fur, particulaily at
its base, or unnaturally clean, and of a dark red,
or purplish red hue ; the mouth foul, dry, and
clammy; the bowels constipated, the evacuations
being difficult, painful, dry, and often without
their natural odour. A hay-scent sometimes
issues from the body, as first noticed by Dr. La-
tham, and a similar halitus occasionally from the
lungs. As the secretion of urine increases, the
thirst and hunger become intolerant, and, in some
cases, the latter amounts to complete pica, as
stated by Sprkncki.. The sense of heat and
burning at the epigastrium is exasperated, and
extends in the direction of the urinary passages,
frequently with phymosis, and some degree of
uneasiness or inflammation about the external
orifice of the urethra. The secretion of the
prostate — but not the semen, as loosely stated by
some writers — is sometimes voided after the dis-
charge of urine ; and the patient loses his sexual
propensities and powers. To these symptoms
are generally added, chilliness, and great sensi-
bility of cold ; cold extremities, often alternating
with burning of the soles of the feet, and slight
ccdema; acid eructations, flatulence ; painful
muddy eyes ; indistinct vision; headach or ver-
tigo ; dyspnoea or cough, and weariness on the
least exertion ; a sense of sinking at the epigas-
trium ; weight and tenderness about the pra-cor-
dia ; frequent sighing; listlessncss; a weak,
forgetful, di-trusting, anxious, wavering, and
peevish state of mind ; and great dcprc-sion of
spirits. As the disease advances, the debility and
emaciation increase. The skin becomes rugous
and scaly, particularly over the abdomen ; and
the veins large and distended. The fauces and
tongue now assume a dark red tint, and are un-

naturally clean ; the gums spongy or partially
absorbed; the teeth loose, and the brealh foetid.
In some cases, aphthaj appear in the mouth, and
the gums ulcerate. Patients sometimes complain
of a sweetish or mawkish taste ; and the saliva
has been found to ferment briskly when a little
yeast was added to it. The pulse is at first but
little affected : occasionally it is somewhat hard
or frequent, particularly after a meal, or during
the febrile exacerbations which usually occur in
the advanced state of the malady. In the last
stages, the pulse is often quick, sharp ; or weak,
small, and compressible. It is, however, very
variable in different cases, or even in the same case.

7. C. The blood taken in the progress of the
disease generally separates into a loose, dark
crassamentum, containing a smaller proportion of
fibrine than the clot of healthy blood; and a
whitish or light-coloured serum, resembling whey.
Its analysis has been made by several eminent
chemists, with the view of detecting saccharine
matter in it. Nicolas and Gceudevilt^e consi-
dered it less anlmalised, and to contain a smaller
quantity of fibrine, than healthy blood ; but they
found no saccharine matter. Woi.easton, IMar-
CET, Henuv, and Phoit, also failed in finding
any of this matter in the serum ; whilst Riciiter
conceived that he could detect it by the taste,
and, with many other pathologists, believed that it
exists in small quantity in the blood, from which
it is so constantly eliminated by the action of the
kidneys, as never to accumulate to the extent of
being detected by chemical agents ; or that it is
concealed by its combination or admixture with
albumen. More recently it has been actually de-
lected in the blood, first by Ambrosiani, and more
recently by Mr.C.MAiTLANDand iNIr. M'Gregor.

8. i. Complications. — I have scarcely met
with a case of this disease which was entirely un-
complicated with pulmonic symptoms ; and a
similar remark has been made by Dr. Bardsley.
On this account I conceive that the appellation
given to the disease by Nicolas and Gceude-
viLLE, of Plttliisurie Suciee to be extremely ap-
propriate. It should, however, be conceded, that,
in many cases, other organs participate in func-
tional, and even in organic disease, particularly
the digestive mucous surfaces, and the liver. In-
dceii, it may be often looked upon as a result of
a breaking down of the system, often in con-
sequence of intemperance and illicit indulgences,
and exhaustion of the vital energies and assimi-
lative functions, whereby several, or even all, of
the organs concerned in the perpetuation of life
suffer more or less.

9. ii. Terminations. — If unchecked by treat-
ment, the debility increases, and pulmonic symp-
toms, with hectic fever, if they have not already
existed, seldom fall of appearing. Occasionally
the disease pusses into incurable dropsy. Not
infrequently the discharge is much diminished,
and more urinous, for a short time before death ;
and, in some instances, the patient is suddenly
cut oft" either by apoplexy, or, as observed by
Dr. Pitoui', by a jicculiar affection of the stomach
occasioned by improper food, or by over-disten-
sion of this viscus from the excessive quantity of
solid and fluid ingesla,

10. iii. DuiiATioN. — Diabetes generally con-
tinues for an indefinite time, according to the
suddenness or acuteness of the attack, the pre-

DIABETES — Organic Changes — Prognosis and Diagnosis.

509

vious health of the patient, the nature of the
exciting cause, the form of the complication, the
diet and regimen prescribed, and the means of
cure employed. It is always exasperated duiing
cold and moist weather. Frank stales, tiiat it is
also worse in autumn. IIiiCKEn, Thenaud, Du-
PUYTREN, and the author, have known it to con-
tinue, with intervals of injprovement, for many
years ; and Oosterdvck states that he treated a
case that terminated unfavourably in a fevv days.
Wiien the issue is fatal, it commonly runs its
course in a few months, and is seldom of shorter
duration than several weeks. I believe that the
disease not infrecpiently exists, for a considerable
time at least, without any very sensible increase of
the quantity of tiie urinary discharge, and that it
is hence often far advanced before it comes before
the physician; and that many cases which have
been believed or stated to have been cured, have
experienced merely a temporary benefit, — the
malady returning in all its severity from the
slightest exposure to its more common exciting
causes, or the least want of attention to the
requisite diet and regimen.

11. iv. Organic Changes are by no means
constantly observed after diabetes, even in the
urinayy urgmis ; and, when present in them, are
not such as may account for the disease ; but, as
Hecker has justly contended, are rather its effects
than its causes. Rutherford, Home, Duihiy-
TREN-, Segalas, and Dezeimeris, have found the
kidiiei/s somewhat enlarged and vascular. Bonet,
MoRGAGNi, Monro, Hertzog, Cawlev, De-
SAuiT, and Hecker, have observed them onlymoie
flaccid than natural : and Cruickshanks, Reil, .
Rutherford, Duncan, and Baillie, have re-
marked merely a more turgid state of their blood-
vessels; which Frank and Vetter have stated to
have been more lacerable than in the healthy
state. In rarer instances, one or even both
kidneys have been observed much smaller than
usual (P. Frank, iNIuller). Hydatids hove
been found, by J5eer, filling and distending
them enormously ; and calculi have been de-
tected in their pelvis by Baillou. Ruvsch and
Hecker met with cartilaginous induration of their
envelopes and cortical substance ; and Brodie
found their structure hard and gristly. RIuleer
mentions enlargement of their nerves; and Duncan
records a case in which the splanchnic nerves were
all enlarged to three or four times their natural
size. CoNRADi observed the pelvis of thekidneys
enlarged so as to contain a small orange; and
Ruysch, Rutherford, Reii., Hecker, and
Clarke, remarked considerable dilatation of the
ureters. Increased size of either the pelvis of the
kidneys, or of the ureters, or urinaiy bladder, or
even of them all, is not infrequent. In some
instances, the bladder is thickened, or contracted,
and slightly inflamed, and the prostate enlarged.
All the urinary organs, however, have been found
as frequently natural, even by the autliors now
mentioned, as presenting the above changes.

12. Next in frequency to enlargement and
flaccidity of the hidiicys, the mesenteric glands
have presented morbid appearances. INIascagni,
JuNCKER, lIiMi.v, Reil, Home, Cawley, and
Hecker, have found them enlarged, obstructed,
and otherwise changed ; but they also have been
met with perfectly natural, by the same authors,
as well as bv others. Rutherford and jMonro

have observed enlargement, softening, and in-
creased vascularity of the absorbent glands gene-
rally. The thoracic duct has, in a few instances,
been found greatly enlarged and dilated. The
lungs are, perhaps, as frequently diseased as any
other organ. 1 have never seen a case examined
in which tiiey were perfectly healthy. Luroih,
Segalas, Dupuvtren, and Horn, have severally
observed tubercles in every stage of their progress ;
ulcerations, tubercular excavations, hepatisations,
and i)urulent collections or disseminated vomiciK,
in the lungs, as well as inflammation of the
pleura, and its consequences — adhesions of the
pleura, &.C., of the pericardium and pleura, serous
effusion into the pleural cavity, i^tc. JM. Lurotii
detected, in addition to hepatisation of, and ex-
cavations in, the lungs, aneurism of the pul-
monary artery, the kidneys being sound. Similar
states of the pulmonary artery, lungs, and kid-
neys, were found in a case recorded by M.
Lobstein ; the lungs being extensively tuber-
culated, hepatised, and adherent to the thorax,
without any manifest thoracic symptoms durino-
life. The digestive organs have been next most
frequently diseased. Dupuytren and Segalas
have observed a more vascular state than natural
of the digestive mucous surface, but without any
organic change of the stomach, or intestines,
beyond dilatation of the former, and of the
duodenum. Rutherford and Baillie always
found the stomach healthy. The liier is more
frequently diseased. Mead states that it was
always altered in structure ; whilst Cullen,
Frank, arid Home, generally observed it natural.
Cawley and Hecker have commonly detected
organic change of this viscus. The spleen and
puncreus have seldom presented any lesion.
MicHAicLis, Conradi, and Hecker, detected
chyle imperfectly mixed with the blood in the
large vessels and cavities of the heart ; and the
same ^authors, and JNIahsh all, remarked a cho-
colate appearance of the blood in all the vessels.
Dr. Rutherford states that the blood was black
and fluid in all the cases he inspected. In the
cases I have seen examined, the mucous surface
of the stomach, and of the upper parts of the
small intestines, was rugous and vascular. The
lungs were congested or hepatised, or tuber-
culated and excavated, or their pleuras adherent.
The heart was flaccid, soft, and small ; tiie blood
dark and semi-fluid ; the kidneys congested with
dark blood, and somewhat large; the super-renal
capsules somewhat indurated ; and the renal
ganglia more than usually large. But these
changes are not uniformly observed ; several of
them were wanting ; and in one or two instances,
no decidedly morbid change was detected, beyond
the absence of the usual cadaverous and peculiar
odour generally perceived upon opening the ca-
vities. Upon the whole, therefore, post mortem
research has thrown but little ligiit on the nature
of diabetes, further than showing that it is the
result of a morbid condition of several, if not all,
of the digestive, assimilating, and excreting vis-
cera, and not cf any one of them.

13. II. Prognosis and Diagnosis. — A. Al-
though patients whose constitutional powers are
not greatly reduced, may sometimes live for many
years, under judicious treatment, in this disease,
yet should the prognosis be upon the whole very
unfavourable : a cure may, however, be effected

510

by appropriate means adopted early ; but this
result is comparatively rare, and should never be
considered as perfect, unless the healthy quality,
as well as quantity, of tlie urine be altogether
recovered, and the strength and bulk of tlie body
be restored. Partial, or even very great, relief is
often afforded ; but the malady after a while re-
turns, and may proceed without admitting of relief
to a fatal issue, or be again and again checked by
treatment. INIuch depends upon the patients
.themselves, and tlie strictness with which the
prescribeil regimen is followed ; for, as the disease
often originates in excesses, a return to them
upon partial, or tolerable, recovery, will bring
back the disease. When we find it complicated,
as it most commonly is, with organic disease of
the lungs, liver, or lymphatic system, a favourable
issue cannot be expected. Out of from twelve
to fifteen cases I have treated, I know of two
only at the present time that have perfectly re-
covered. One of these, a married woman, who
had previously been attended by an eminent
writer on the disease, has continued perfectly
well for six or seven years ; but although not yet
thirty-five, the catamenia, which had disappeared
before the development of diabetes, has not re-
turned. The chances may, perhaps, be estimated
at about five or six, or even higher, against the
patient ; but much will depend upon the quan-
tity and quality of the urine, the progress of the
disease, the age, visceral complications, constitu-
tional powers, the state. and functions of the skin,
the degree of emaciation, and circumstances and
character of the patient. I believe that the prog-
nosis should be much more unfavourable where
the urine is mellitic, than when it is not so changed,
however abundant it may be.

14. B. 'J'he Diagnosis of diabetes mellitus is very
readily formed from the sensible properties of the
urine. (See ihe Siimptoms, j 4. ; and art. Urine.)

15. ill. Cahsls — ^1. Predisposing. Here-
ditary predisposition to tins disease has been re-
marked by several autliors. Ur. PnouT has
observed it in (four instances. Isenfi.amm states
that he knew of seven of the descendants of a
diabetic patient, wlio died of the malady, INIon-

TON, i5ni3IlAi'F,, Koi.Lf), Hn'MENBACn, FitANK,

STOnEJi, and Clarke, also furnish similar facts.
Diabetes is more frequently met with in the male,
than in the female sex ; and in persons who either
are past the period of puberily, or are advanced
in years. The true diabetes mellitus is rare in
children, whilst alhuminous urine and enuresis
are frequent complaints in tliem. It is much
more common in cold and moist countries, par-
ticularly those in whicii the inhabitants live chiefly
on rye, or any other vegetable food, or ar<i imper-
fectly nourished, tlian in warm or dry climates :
and is hence oftcner met with in Great ]5ritain,
Ireland, Holland, Denmark, and Sweden, tiian in
France and (jermany; and in the western, than in
the ea'itern side of this island. .1. Frank states
that he saw a greater number of cases of it in
Italy, than in any part of Ciermany. Dr. Christie
observed it more frerpiently amongst the inha-
bitants of Ceylon, than in any ]iart of continental
India; and imputes it to the moist state of the
atmosphere, and tlieir poor vegetable diet. The
icrufulous diatliesis also predisjioses to it.

Ifj. li. The Exciting Causes are not 6o pre-
cisely Uitcertttined as the predisposing, and their

DIABETES — Causes and Nature of.

connection with the origin of the disease not so
obvious as could be desireil ; but the following,
acting eitlier individually or in conjunction, par-
ticulaily in the latter mode, maj-be considered
as most commonly productive of diabetes, where
a predisposition to it exists, either hereditarily, or
from visceral disease : — Continued or repeated ex-
posure to cold and moisture ; drinking cold fluids
when tlie body is over-heated ; suppression of an
habitual perspiration, by whatever means ; acid-
ulous or fermented liquors, particularly in malt
liquors, cyder, &c. ; the exhaustion arising from
excessive evacuations and morbid discharges, or
from undue sexual intercourse ; great bodily and
mental exertions ; the depressing passions, such
as anxiety, disappointment, &c. ; and whatever
occasions great exhaustion of the powers of life,
and of assimilation, is sometimes productive of this
malady. Besides these, authors have adduced
others as its occasional causes. Autenrieth
mentions the use of acids and acidulous fluids;
Boerhaave, Lister, Stedman, and Frank, the
abuse of diuretics and diluents ; Sydenham and
Senac, excessive horse exercise ; Ruysch, Che-
selden, and Latham, the existence of chronic
abscesses and carbuncles ; Frank, the carrying
of heavy weights ; Bennewitz (Ossann's Jahres-
bericht, &ic. July, 1828.) relates the case of a
female who was affected by the disease during
two successive pregnancies; Ploucquet and
others have observed it result from falls, and in-
juries on the back, loins, and hips; and Baillou,
Brexdel, Weber, Lanzoni, and Frank, the
drying up of chronic eruptions, exanthemes,
fluor albus, &c., or the suppression of haemor-
rhages. It may be suspected, however, of the
last named phenomena, that, instead of being
causes of the disease, they are actually the effects
resulting from the internal changes constituting
its early stages — diabetes, orthe internal changes
leading to it, having commenced previously to
the disappearance of the external disorders — for
it has been often remarked that sores heal rapidly
during tlie disease. Diabetes may, indeed, be
frequently considered a remote effect in the chain
of morbid causation ; functional or even structural
change of the assimilating viscera, particularly
the lungs and digestive organs, existing for many
montlis, or even years, before the increase, or the
saccharine state, of the urine has attracted attention.
17, C. The prmioiafe cause of diabetes is
still extremely obscure, although several authors
of deserved reputation have endeavoured to ex-
plain it. — 1st. It has been ascribed to a morbid
condition of the kidneys. This is the oldest
opinion that has been entertained respecting its
nature. The Cireek writers considered diabetes
to be owing to relaxation, debility, and increased
irritability of these viscera; the irritability being,
as they supposed, the cause of tiieir morbid
activity ; and tiie relaxation and debility allowing
the more liquid parts of the blood to jiass through
the excrelories without restraint or ciiange, and,
consequently, in a crude state, like the food in
lientery. The supporters of tiiis doctrine adduce,
in proof of it, those morbid ciianges that have
been observed in the kidneys, without agreeing
amongst themselves as to the particular changes
which really constitute the disease. Some con-
sider that they are essentially inflammatory.
But they overlook the facts, that decided and

DIABETES— Causes and Nature of.

fill

titiequivocal marks of inflammation of tlie kid-
neys are seldom found in diabetes ; and that
when these marks are observed in other diseases,
they have uniformly been accompanied by a
diminished, or an entirely suppressed, instead of
a more profuse, secretion of urine. Others, wiio
conceive that diabetes is a disease seated in the
kidneys, ascribe it to spasm without stating in
what tissues, or vessels, this spasm exists ; and
even without mentioning precisely whether the
spasm is in the vessels of the kidneys, or of other
parts. CAMERAnius first proposed this doctrine,
in which he was followed by Cullen, who after-
wards abandoned it, and ascribed it to " some
fault in the assimilatory powers." Gueudeville,
likewise, partially adopted this opinion, but con-
joined it with another which I shall have to
examine in the sequel, and stated that this disease
" is a consumption arising from a continual
spasmodic deviation of the unassimilated nutritive
juices to the urinary organs." Here, however,
the spasm is not ascribed to the tissues of the
kidneys, and we are left quite in the dark as
to the parts thus spasmodically affected. But
amongst the various supporters of the doctrine
that the kidneys are the seat of diabetes, there is
not one who has attempted to name the specific
affection or state of those organs which consti-
tutes the disease. Ruysch, Ritter, Stoeller,
Cruickshanks, Richter, and Good, have con-
sidered it as resulting from a morbid affection of
the kidneys ; and several of them, besides others
whom it is unnecessary to adduce, have con-
tented themselves merely with stating this very
vague opinion. Stoei.ler and Richter, however,
conjoin this undefined " morbid affection " with
depraved function of the skin ; and Good con-
siders that the morbid state is one of excitement.
He remarks that the whole of the phenomena,
observed during the progress of diabetes, are
consequent upon the renal mischief, and that it
is a much less complicated disease than has
hitherto been imagined. How far this is correct,
the experienced practitioner may decide for him-
self ; but it is not in accordance with my observa-
tions. It is certainly indisputed, and the observ-
ations of the most experienced physicians have
placed the matter beyond a doubt, that other
organs and parts manifest disease very early in
diabetes, and that the assimilating viscera and
circulating fluids are very evidently affected.
Now, the kidneys, being strictly eliminating
organs, or emunctories, removing matters which
are hurtful to the system from the blood, how
can we conceive that excitement of these organs,
the proximate cause of diabetes according to Dr.
Good and others, can occasion a diseased state of
other organs, diminished assimilating function,
and especially a morbid condition of the blood
itself, the morbidity of which it is the chief office
of these organs to prevent, or to remove if in any
way produced ? Dr. Woi.laston attributes dia-
betes to a change in the animal electricity of the
kidneys; and JNI. Dupuythen, to their perverted,
equally with their increased action. But the
remarks now offered are also applicable to these
opinions ; for the cause of these morbid states
must be sought after either in the kidneys them-
selves, or in some other quarter. If the kidneys
be primarily affected, how can the early disorder
of other viscera be explained ]

18. 2d. The disease has been imputed to a
morbid action of the stomach, or some of the as-
sistant chylopoietic viscera. Tiiis opinion has
derived support from the feeling of heat, pain,
and sinking, which is su generally and so early
complained of in this disease ; as well as from the
morbidly increased action of these viscera, par-
ticularly of the stomach. Dr. Mead ascribed it
to the liver, from observing the disease most fre-
quently in those who were addicted to the intem-
perate use of spirituous and fermented liquors.
Dr. RoLLO confines it chiefly to the stomach ; and
states that it proceeds from " an increased action
and secretion, with a vitiation of the gastric juice,
and probably too active a state of the lacteal ab-
sorbents, — while the kidneys and other parts of
the system are affected only secondarily." Ac-
cording to this hypothesis, the chyle is imperfectly
formed, and exists in the blood either in a sac-
charine state, or in such a condition as to be
readily converted into a saccharine fluid during
its circulation, and its passage through the kid-
neys. That it is not at once converted into a
sweetish fluid, and therefore that the morbid se-
cretion is not elaborated in the stomach and other
digestive viscera, seem to be proved by the cir-
cumstance of no saccharine matter having been
satisfactorily detected in the blood, by Wollas-
ton, Marcet, Bostock, Dupuvtren, Thenard,
Henry, Soubeiran, Vauquelin, Segalas, and
Mr. Kane. The mellitic matter may, however
exist already formed in the blood, as is sometimes
evidently the case in respect of urea, as has been
demonstrated by MM. Phevost and Dumas, and
be so rapidly eliminated by the action of the
kidneys, as never to accumulate it so as to admit
of ready detection by analysis; and that it does
so exist has been already stated (§ 7.), and that it
may even be found in the stomach of the diabetic
patient has been proved by Mr. IM'GnEGOR.

19. 3d. It has been supposed that a saccharine
and imperfectly elaborated chyle, instead of being
conveyed into the blood, is carried to the kidneys
and urinary bladder, by a retrograde action of the
absorbents. This hypothesis was first proposed
by Dr. C. Darwin, who conceived, that when a
greater quantity of inebriating fluid than usual is
drunk, at the same time tliat the lacteals are
quickened in their power of absorbing it, the
urinary branches of the absoibents, which are
connected with the lacteals by many anastomoses,
have their action inverted, and a large quantity
of pale, unanimalised urine is hereby discharged.
Where the ingurgitation of fermented or other
exciting liquors is continued, or occurs often,
the urinary absorbents at length gain a habit of
inverted action whenever the lacteals are stimu-
lated ; and a whole or great part of the chyle is
then carried to the bladder without entering the
circulation, and the body becomes emaciated ;
and the urine is necessarily sweet, and the colour
of whey. Numerous objections may be offered
to this hypothesis. It is altogether founded on
postulata ; and, moreover, it proceeds on the
gratuitous idea, that the chyle is generally a
saccharine fluid, nearly, if not altogether, resem-
bling the diabetic discharge. Now, such is not
the case ; for chyle contains, in health, but little
saccharine matter. Besides, the structure of the
lyiDphatics, and their connection with the vascular
system, is completely opposed to their retrograde

512

action. P. Fuank has very materially moulded
this hypothesis, and into a more plausible form, by
relinquishing the untenable idea of a retrograde
action of the absorbents. He conceives that
diabetes is a disease of the lymphatic system,
conjoined with excitement of the urinary organs ;
that it proceeds from stimulation of both these
by some virus formed within, or introduced from
wkhout, and producing a reverse effect to that oc-
casioned by the virus of the rabies canina ; so
that, while the latter produces a dread of liquids,
the former excites a constant desire for them: In
support of this doctrine, he adduces the opinion
of the ancients, that diabetes is occasioned by
the virus of a serpent called dipsas, and hence
the common name generally given by them to
this malady. That it may be excited by the bite
of reptiles, or even higher animals, is not impos-
sible. Dr. Latham mentions a case produced by
the bite of a rat; and it not infrequently arises,
as remarked by Cheselden and LAiHA:\r, from
carbuncles, or chronic abscesses, where it may be
presumed that a partial absorption of morbid
matter takes place. Frank supposes that the
morbid matter occasioning the disease acts by in-
ducing a morbid irritability of the lymphatic
system, owing to which every other part of the
frame is exhausted of its nutrition ; that the
fluids, thus morbidly absorbed, are rapidly con-
veyed into the circulation, particularly the chyle,
to the kidneys, which concur in the morbid ac-
tion ; that the cutaneous and other exhalations are
hence completely arrested ; and that the flux of
saccharine urine is thus produced. This is cer-
tainly a more plausible doctrine than that on
which it is evidently founded ; but, even conceding
the morbid excitement of the lymphatic system
and of the kidneys, the origin of this excitement
in a morbid virus or matter is much more gra-
tuitous, and the cause of the saccharine properties
of the urine is wholly unexplained.

20. 4th. Dr. Clarke, and more recently Dr.
Marsh, impute the disease, in a more especial
manner than has been done by other pathologists,
to the cutaneous surface, which, indeed, may be
viewed as an important organ of the animal eco-
nomy ; and they consider it " as a sweat driven
in upon the kidney-, where this morbid deter-
mination keeps up a profuse discharge." This
opinion seems to have been partially entertained
by RriTER, Sioeiler, and Kichter, who, whilst
they ascribed diabetes, as we have seen, in part to
a morbid state of the kidneys, conceived that a de-
praved function of the skin was also concerned
in its production. There can be no donbt that
suppression of the cutaneous functions is an early
change, and that it contributes to the perpetu-
ation and aggravation of the malady.

21. 5th. Others refer diabetes to a dyscrasy or
morbid condition of the blood, arising from a dis-
eased state of the assimilating powers of the frame.
I'his doctrine is not mateiially different from that
which was proposed by Wii.i.is and Svoeniiam,
and more recently by Place, Desaul-i-, and
Latham ; and, as well as being more accordant
with the procession of morbid phenomena, has a
more obvious relation to the exciting causes, ter-
rninations, and morbid apj)earances in fatal cases,
than any of the theories now reviewed. Accord-
in'^ to this doctrine, diabetes is not to be im))Uted
to the derangement of a single organ or system of

DIABETES — Causes and Nature or.

vessels merely, but rather to defective energy of
the whole frame, particularly impeding the ad-
vanced stages of the processes of digestion and
assimilation. That the blood is not in a healthy
state, and the chyle imperfectly assimilated to it,
as well as the crasis of the whole circulating mass
deficient, 'is sufficiently manifested in the appear-
ances which the blood presents when taken from
the patient during life, and when observed in the
vessels after death. Upon examining specimens
of the blood taken from diabetic patients, MM.
Henry and Soubeiran found the quantity of its
fibrine and albumen one fourth less tiian is as-
signed to healthy blood by Berzelius and
Darcet; and Bachetoni remarked that oil of
almonds passed off with the urine, unchanged in
its passage through the digestive and assimilating
organs. The state of the blood, also, in the veins
and cavities of the heart, is somewhat peculiar —
generally being semi-fluid, sometimes resembling
treacle, and very dark-coloured. That this state
is not primary, but is a consequence of deficient
vital energy of the organic nerves, and of the
assimilating organs, in connection with impeded
exhalation and secretion from all surfaces and
organs excepting the kidneys, seems most pro-
bable. HuFELAND supposes, that, owing to the
changed action of the kidneys, and the unassimi-
lated state of the chyle with the blood, the former
of these fluids, with the nutritious parts of the
latter, containing the saccharine principles, are
excreted with the urine, and occasion tiie phe-
nomena of the disease. This opinion, in its ge-
neral bearing, comes as near the truth, perhaps,
as any that has been offered ;. but still it admits of
reference to antecedent disorder.

22. 6th. According to the experiments of Mr.
M'Gregor, the healthy stomach generates sac-
charine matter to a limited extent, and the sto-
mach of a diabetic patient produces it in excess.
Li the healthy person, this matter undergoes
further changes in the progress of assimilation;
but, in the diabetic, it undergoes no such changes,
but is carried with the chyle into the circulation,
and is eliminated by the kidneys. Owing to defi-
cient or exhausted influence of the nerves supply-
ing the assimilating viscera and vascular system,
the chyle and saccharine matter contained in it
are notpeiTeclly changed into blood, nor are the
nutritious parts of the blood attracted by, and
identified witii, the various structures. This im-
perfect performance of the assimilating functions
must necessarily be attended by deficiency of all
the secretions and excretions excepting the uri-
nary, particularly the cutaneous, the pulmonary,
the intestinal, and the hepatic, as both classes of
functions are under the influence of the organic
system of nerves. Thus a redundancy of mellitic
matter and of imperfectly el aboratcii chyle must
be the result, a portion of which v\iil be carried
off' by the kidneys, as in ordinary circumstances ;
for as long as these cnuinctories retain their
powers, they are the appropriated safety-valves of
the vascular .system, by eliminating watery, sa-
line, and other matters, when they become exces-
sive. These states and changes account for the
simple excess of urine ; the more watery and un-
assimilated parts of the blood being carried off by
the kidneys, instead of being secreted from the
cutaneous, the respiratory, and intestinal surfaces;
and the action of the kidneys, being once excited

DIABETES ~ Treatment.

513

in the maimer now stated, becomes excessive,
from the superabundance of the imperfectly ela-
borated and stimulating matters contained in the
blood circulating tiiiough them. The saccharine
matter in the urine evidently arises from the mor-
bid action of the digestive organs, forming in the
first instance an excess of saccharine ..matter.
That jthe formation of this matter depends chiefiv
upon an exhausted, irf connection probably with
a perverted, state of energy of the nervous or or-
ganic life, may be inferred fron>»the nature of the
predisposing and exciting causes ; and this state
of organic nervous energy may not only give rise
to an excess of this matter, but may also prevent
the due assimilation of it, and of the chyle which
contains it ; the unassiniilated matters either re-
taining, or still further assuming, the mellilic com-
bination in the course of the circulation, and in
their passage through the kidneys. But what-
ever disorder of these organs may exist is only
consecutive upon, or increased by, the saccharine
matter in the blood, and which obviously ex-
cites them to increased action. That a morbid
slate of organic nervous influence thioughout the
digestive and assimilating organs and tissues, and
of the blood, exists in this disease, is shown by its
principal phenomena, and liy the fact that diffusive
inflammation followed bleeding in two instances
recorded by Dr. Duncan.

23. IV.Treatmknt. — The means of cure em-
ployed in this disease have been varied exceed-
ingly, according to the opinions entertained re-
.specting its nature. Many remedies have also been
resorted to empirically, without reference either to
their mode of operation, or to the presume'd pa-
thology of the malady.' As it will bg useful ta
the practitioner, I will first exhibit a succinct
view of the difl^erent modes of treatment, which
liave been recommended, venturing such remarks
as my experience enables me to suggest ; and,
afterwards I shall proceed to state the plan which
has seemed most successful in my practice.

24. i. View of the Treatment proposed bii Authors.
— In estimating the degree of success which'
writers state they have derived from various re-
medies, it should be kept in recollection that other
morbid states of the urine, besides that which is
characterised by the presence of saccharine matter,
particularly those consisting of excess of albu-
men and urea in, conjoined with augmented
discharge of, the urine, have been considered as
constituting a variety of diabetes, — the diabetes
insipidus; and that, owing to this circumstance,
many of the methods of treatment, which have
been stated to have cured diabetes, have been
successful only so far as respects a less difficult
and dangerous form of disease, and one which is
frequently no closer related to true diabetes than
as respects the increased quantity of the urinary
secretion.

25. A. Astringents have been recommended by
inany writers, and various remedies belonging to
this class have received approbation, 'i'he greater
number of the mineral, and some of the vegetable
acids have been used, either alone or in combin-
ation with other medicines. — a. Gilby, Earni^st,
Scott, and Brer a h-;ve employed nitricacid, some-
times with much benefit. Brera recommends
the internal use of this acid to be conjoined with
mercurial inunction. 1 have given it combined
with opium, the patient at the same time using the

Vol. I.

warm bath and animal diet. Some advantage
was derived from this treatment for a considerable
time ; but the disease returned, I have likewise
conjoined the nitric with the Inidrocliloric acid, in
equal quantities, and employed it internally com-
bined with opium, and externally in the form of
the nitrn liijdroclduric lotion applied warm over
the epiga>tiium and loins. This has certainly ap-
peared a very beneficial treatment; but as it was
not confided to alone, but conjoined with other
means which I shall adduce in the sequel, it is
difficult to determine the degree of benefit derived
from it.

26. B. The phosphoric acid, both alone, and in
combination .with, or neutralised "by, other sub-
stances, has been recommended by Nicolas,
Guedevit.le, Latham, Sharkey, and Venables.
Dr. Sharkev speaks favourably of the phosphate
of soda. It has tjie advantage of preserving a
free state of. the bowels, whilst it tends in a very
marked manner, to diminish the flow of urine ;
but I believe that more advantage will be derived
from it, as well as from the phosphate of iron,
which has been strenuously recommended by Dr.
Aexables, in the excessive discharge of albumin-
ous urine, — an affection frequently observed in
young-subjects, — tlian in the disease under con-
sideration.

27. y. The sulphuric acid and its salts have re-
ceived the sanction of numerous writers, who have
generally prescribed them in combination with
preparations of chinchona, aromatics, opium, &c.
I liave exhibited the acid with the-sulphate of zinc,
and with the sulphate of quinine, as one part of
the treatment adopted in the cases which have oc-
curred to me ; and, as from a large, proportion of
the means employed, benefit was derived from it
for some time. The sulplutte of alumina hsLsheen
prescribed in a variety of forms, but most fre-
quently dissolved m whey, by Dover, Brocklesby,
H-EHz, LiN'DT, and many others. But its want of
efficacy has been satisfactorily shown by Brisbane,
OosjERDYK, and Frank; the last of whom car-
ried the use of it to a large extent, in order to test
its effects. Dr. Wintringiiam applied the suU
phate of alumina, dissolved in vinegar, as an
epithem on the loins. The s}dphate of iron and
the bi-sulphate of potash have likewise been em-
ployed in this disease. The latter of these pos-
sesses the advantage of acting as a deobstruent
aperient, and is hence often of much service. Dr.
Fraser entertains a favourable opinion of the
former.

28. J. Several other astringents, as sumach,
kino, catechu, in the form both of tincture and de-
coction,/fHie-uafec, &c., have been recommended ;
but they seern to have been of no further service
than auxiliaries to other means. The aqua calcis,
used as common ilrink, either alone or with milk,
has been praised by Willis, Schutz, Jarrold,
Fothergill, Watt, and Frank. Although as-
tringents have been very generally employed,
some doubts have been thrown upon their utility
by Amatus Lush am s, and others. Sydenham,
however, expresses himself favourably respecting
them when conjoined with aromatics and opiates,
— a mode of exhibiting them which is certainly
the most preferable, and the only way in which I
have employed those now enumerated (§ 42.) in
this disease.

29. B, Tonic astrins^ents have received much

' LI

514

DIABETES — TREATMENt.

attention, particularly from Stoeller, pEnuiAn,
Morton, Fahxer, Frank, and others. Amongst
those, cinchona, in decoction with the elixir of
vitriol or with simarouha, or in powder with the
MOrt ursi, in doses of a scruple, or half a drachm
of each, with half a grain or a grain of opium,
and repealed every four or five hours; and the
preparations of iron, either alone or with cinchona
or cascarilla, deserve a particular notice. Dr.
Prout has seen full doses of the carbonate of
iron, with Dover's powder, have the best effects.
Tonics, with catechu, kino, &c.,and the vegetable
bitters, as well as the mineral tonics, in conjunc-
tion with opium, have severally been employed,
particularly by Shee, Abrahamson, Roeber,
&c. Under tliis head I may notice the use of
astringent wine, as having been recommended by
Celsus, and, in modern times, by Willis and
Morton. Dr. Peacock advises a powder, con-
sisting of powdered nux vomica, gr. v.; preci-
pitated iron 3 ]. ; prepared chalk, 5 ]■ ', powdered
opium gr. j,; to be taken three times a day.
(Lancet, iS'o. 707. p. 91 1.)

30. C, Diaphoretics, have been very generally
recommended, and particularly by Roeber, Sto-
ELLER, Wener, RI'Cormick, and IMarsh, with
the view of restoring the suppressed functions of
the skin, and diminishing the determination to-
wards the kidneys. Amongst the various medi-
cines which have beenexhibitedwith this intention,
the putiis ipecacuanhcE comp. and opium with
antimonials deserve a particular notice. I have
prescribed these with full doses of camphor on
several occasions with much benefit. This last-
named substance has been much praised by Shee
and Richter, who recommended it to be ex-
hibited in large doses in mucilaginous emulsions.
Of this class of remedies, there is certainly none
more decidedly useful than the warm and vapour
baths. Salzburgher, Riiter, Werner, Richter,
Heineken, and Marsh justly place much reliance
on them. To these may, perhaps, be added the
sulphur baths; but I have had no experience of
them. 'I'he promotion of a free and even copious
perspiration by tiie constant use of woollen cloth-
ing next the skin, and active exercise, has been
noticed by several writers ; and forms a most im-
portant part of the regimen to which diabetic pa-
tients should be subjected.

31. D. Alvine evacuations. — a. Emetics have
been employed witli advantage in some cases by
Ettjiuli.er, RivERius, Brendel, Michaelis,

ROLLO, W'iNTRINCiHAM, WaTT, and RiCIITER,

particulaily early in the disease. It is chiefly at
this period, or in subjects whose constitutions still
retain some degree of vigour, that they are ad-
missible, b. Purgatives have received less attention
from writers on diabetes than they deserve. Trnka,
however, has passed very just encomiums on
fhera: and they have likewise received some
notice from Dr. Marsh and a few other recent
authors. I believe them to be very generally be-
neficial, not only in as far as their occasional
exhibition may remove morbid accumulations, and
obviate constipation, which is so frequently an at-
tendant on the disease, but also as regards a con-
tinued and decided use of tiiem, so as daily to
procure two or three copious evacuations. With
tliia view, full doses of rhubarb, or of the iuj'usion
»/ nentia, with compound infusion of gentian, or
of the phosphas soda-, should be exhibited daily.

There are few remedies that deserve a more
favourable notice in diabetes than rhubarb. It
received the warm approbation of Baglivi and
Lister, who recommended it in conjunction with
aromatics, and of Brocklesby, Morton, Buch-
WALD, and Harris. Dr. Baillie prescribed it
with laudanum. I have employed it frequently
as an aperient, both in powder and infusion ; and
combined it with vegetable tonics, aromatics, and
opium, with the intention of promoting the di-
gestive and assimilating powers. It is one of the
best medicines that can be used in this disease.
Frequent and full doses of magnesia have been
praised by Trotter, Hufeland, B. Phillips,
and R. Willis, not merely as an aperient, but
on account of its effects in counteracting the dis-
position of the digestive organs to form sugar.

32. E. — a. Sulphur and the alkaline siJphurets
have received a deservedly favourable notice from
Autenreitii, Redfearn, Bang, Rollo, and
MiCHAiiLis. The hepatised ammonia was par-
ticularly noticed by Dr. Rollo, with the view of
furnishing to the system, along with a liberal
animal diet, the elements which seemed to be
wanting to the chyle and to the urinary secretion.
The free use of sulphur, so as to produce an
aperient eflect, is often beneficial. I have seen
much advantage derived from it ; and the sulphu-
rets are often serviceable as adjuvants to the
general plan of treatment. Dr. Christie, men-
tions them with approbation in his interesting de-
tails of cases treated bj' him in Ceylon. — b. Can-
tharides, either in the form of powder or tincture,
exhibited alone or combined with camphor, have
received a favourable notice from Morgan, Wer-
ner, Herz, Stoeller, &c. W^olfe combined
them with ciiichona : but Brisbane, Busch, and
Frank derived no advantage from them.

33. F. Opium, either in substance or tincture,
alone, or combined with tonics and aromatics, or
with astringents or with diaphoretics, with cam-
phor, valerian, or with assafcetida, or even with the
sulpliurets, according to the varying features of
particular cases, is, perhaps, the most generally
applicable and beneficial remedy that has been
employed. But it should be given in large doses,
and its use persisted in, and so managed as not to
prevent a free and continued action on the bowels.
If the dosebe suflRciently large.it will seldom con-
stipate the bowels in this disease, or impede the
action of purgatives and aperients ; and it will
determine more sensibly to the skin, while it
will more decidedly diminish the urinary flux
than when prescribed in small doses. It is chiefly
to Archioenes, Sydenham, Buckwald, and
Warren, and afterwards to Guedeville, Heine-
ken, Money', IMarsh, Carter, and others, that
we are indebted for proofs of the great advantage
to be derived from this medicine in diabetes.

34. G. — a. Mercurial iintnction has been recom-
mended by ScoiT, Lubbock, and others. Brera
prescribed it at the same time with the internal
use of nitric acid; and Frank, with tonics: he
even advised it to be carried so far as to produce
salivation. When diabetes is complicated with
hepatic disease, this treatment will be requisite.
I have seen it employed with some advantage,
alternated with the nitro-liiidrochloric lotion ap-
plied on the hypochondria and loins, in a case of
this description. W hen biliary derangement exists,
the occasional exhibition of a full dose of calomel

■with rliubarb, or the compound extract of colo-
cynth at bed- time, and followed, in the morning,
by an active purgative medicine, will be found of
service. — b. Medicines that act as rf/ure/ics may be
supposed to be contra-indicated in diabetes. But
they are not necessarily injurious; for, if tliey
have a beneficial effect on the body generally, or
on the visceral disorders with which diabetes is as-
sociated, they may even be of benefit ; and if the
action of such medicines on the kidneys be ener-
getic, they may change the morbid action induced
in these organs by the disordered state of organic
nervous influence and of the circulating flui(i,and
in this way prove beneficial. Among the different
substances that have a diuretic tffectci)[chicinn may
be mentioned as having lately been sometimes pre-
scribed in this disease, but chiefly on account of
its sedative operation. It may be of some service
in promoting the biliary secretion, in increasing
the quantity ofurea and uric acid in the urine,
and in diminisiiing the irritability of the frame.
Its good effects, however, require confirmation,
and may probably be ensured by combining it
with ammonia or its preparations, or with camphor,

35. H. Nutrients in various forms have been
strenuously recommended by Home, Rollo, Du-
PUYTREN, Nicolas, Oswald, Frank, CiiitisTiE,
and many others. Dr. Rollo particularly in-
sisted upon the nearly exclusive use of animal
food, with the view of resisting the secretion of
saccharine matter, and furnishing the elements of
urea and the animal salts to the blood. There can
be no doubt that the greatest benefit has been
derived from this treatment. It should, however,
be admitted, that it often fails ; and that, when it
is too freely indulged in, it sometimes occasions a
diarrhoea, which exhausts or even carries oft' the
patient. With a knowledge of these occasional
effects. Dr. Prout recommends it with very
judicious restrictions, and to be taken with a
moderate proportion of farinaceous food ; and
Frank advises, in addition to it, the decoction of
Iceland moss, or of the althasa officinalis with
milk.

36. /. Besides the foregoing, various other re-
medies have been prescribed. The cupri ammo-
nio-sulphas (in doses of half a grain to a grain
twice or thrice a day), myrrh, and valerian, have
received the commendations of Frank and Rich-
TER. Assafa:tida has been favourably noticed by
Wolff; tartar emetic combined with valerian has
been directed by Richter. A combination of
assafoetida with myrrh and valerian has also been
very generally used by Continental pliysicians.
Dr. Watt has employed the volatile alkali ; and
it will certainly often prove an useful adjuvant,
combined with other medicines, particularly with
opium, or with tonics or diaphoretics; and be
serviceable in combating such nervous or sinking
symptoms, as sometimes occur in the course of
the disease. It may, moreover, counteract the
tendency to the formation of saccharine matter,
and promote the animalisation and assimilation of
the chyle, as well as tlie formation of urea. Even
urea itself has been recently tried as a remedy in
this disease by Segalas, but instead of changing
tiie mellitic urine, it was found to increase its
quantity. Hufeland, and some other physicians
in Germany, have prescribed recent ox-gall, in as
large doses as the stomacii will bear, and fre-
quently with the effect of causing the disappear-

DIABETES — Treatment. 515

ance of the sacch.arine state of the urine during its
use ; the disease, however, has generally returned
upon discontinuing the medicine.

37. A'. Blood- letting in diabetes has been
mentioned as far back as the Commentaries of
AuciiioENEs on Aetius; and it was noticed as
an occasional measure by Le Fevre and Rollo.
But it is to Dr. Watt, that we are indebted for
the introduction of this practice in a most decided
form. This physician advises full and oi'ten-
repeated blood-lettings, with the view of arresting
the inflammatory determination to the kidneys.
This plan has been adopted by Dr. Satterly
and others with manifest advantage, whilst it has
failed with some. Drs. Prout and Hufeland
consider it beneficial only in the early and acute
stage of the disease. Dr. Marsh offers a similar
opinion. And my own experience would lead
me to employ it, only when the disease is recent,
the strength of the patient not much exhausted,
and the pulse remains of good strength and
volume. When the patient feels much pain in
the loins, an additional indication is thereby
furnished for resorting to it. Sir David Barry
has advised frequent cupping on the loins in the
course of the disease, — a practice which is de-
serving of adoption in cases of the above descrip-
tion, or when much pain is complained of in that
situation. I have found advantage from the ap-
plication of a number of leeches on the epigas-
trium, and cupping on the hypochondria, both
in relieving the sen^e of pain and heat complained
of in the stomach, and in lessening the quantity
of the urine, and of the saccharine matter con-
tained in it. Depletion, as Dr. Watt first ob-
served, certainly improves the state of the blood,
and renders the weak and imperfect crassamentum
more firm.

38. L. Blisters and external applications of a
derivative and irritating nature have been recom-
mended by Ritter, Dfsaut.t, Van Swieten,
Whytt, and Reidlin, to be applied chiefly to
the loins and epigastrium. Frank and Weiz
advise repeated blistering of the sacrum. Seions,
issues, and moias have likewise been employed
in the latter situation ; but 'I believe without any
permanent benefit. The most eflficacious modes
of derivation are the vapour bath, warm alkaline
baths, and thick woollen clothing worn next the
skin. Topical applications of a tonic and an
astringent nature have also been directed to be
kept constantly applied to the loins by AViiytt,
Rlidlin, and Van Swieten. Of these, how-
ever, I have had no expeiience. 1 have, how-
ever, prescribed liniments to this situation, as well
as to the epigastrium, generally composed as
follows : —

No. 165. B I^ininienti Camphorae Comp, Olei Tere-
binth., Linimenti Saponis Cornp., aa 3 j.; Pulv. Opii Piiri
5j. ; Pulv. Capsici Anniii 3ss. ; 0!pi Limonis V\ xxx.
M. Fiat Linimentum, cura quo assidue illinantur rpgio
lumbalis et spina dorsi, mane nocteque.

I have found this application extremely useful
in the excessive discharge of albuminous urine,
which is not infrecjuently met with in young sub-
jects. I have likewise employed it witii other
means in the mellitic state of urine ; but it was
difficult to determine what share of the temporary
benefit derived was owing to it.

39. ii. The Treatment in u'hich the Author is
most disposed to confide. — It is not easy to fo:m
LI 2

516 DIABETES -

to ourselves precise and rational indications of
cure in this disease, particularly as opinions re-
specting its nature are not supported by a suffi-
cient number of accurately recorded facts ; nor are
those which have been observed so constantly
present, or so uniformly grouped, as to permit us
to draw indisputable pathological inferences, for
tlie basis of therapeutical indications. I shall
therefore state succinctly the method of cure,
which is sanctioned by my own observation, and
by experienced physicians. The remark which
has been made by Dr. Paur, Dr. Prout, and
others, tiiat this disease should be viewed in a
two-fold light — namely, 1st, as respects its sac-
charine state independently of the increase of its
quantity; and, 2d, as regards this state in con-
nection with an augmented secretion — should be
kept constantly in recollection ; and, although
the discharge of an increased quantity of urine, in
addition to its saccharine condition, generally in-
dicates either a more advanced or a more severe
state of disease, yet we should be aware that the
saccharine change is the more important of the
two ; and that it is much more easy to diminish
the quantity than to improve tlie quality of this
secretion. Dr. Prout justly remarks, tliat it is
exceedingly doubtful if there be any remedy that
exerts a specific action in improving the quality
of the urme — at least, there is none at present
known. The improvement can therefore be at-
tempted only by those agents that have a ten-
dency — • 1st, To remove the morbid affection of the
stomach; 2nd, To restore the general health and
assimilative energies of the frame; and 3rd, To
diminish the (juantitij of the secretion.

40. These ends are generally all that we can
reach ; and, by attaining them, we sometimes
advance still further, and thereby improve the
quality also of the discharge. There are, how-
ever, other subordinate objects, which, although
they might be accomplished with the fulfilment
of the chief ends now proposed, yet often require
an immediate regard ; and the more especially as
their attainment very frequently promotes the
chief intentions of treatment. These are, — a. To
remove a congested, loaded, or oppressed slate
of the vascular system, and reduce the quantity
of the circulating fluid more nearly to a level
with the amount of vital power and assimilative
function. — b. To promote and improve the secre-
tions employed in digestion, and excite the ex-
halations and secretions from the respiratory and
intestinal surfaces. — c. To remove the unper-
spirable and harsh state of the cutaneous suriace,
to increase perspiration ; and thereby to lessen
the determination to the kidneys. — d. To di-
minish the morbid sensibility and irritability of
the frame, with the other morbid phenomena
allied lo them. 'J"he means which we employ in
attaining l<otli the principal and the sul)ordinate
o!)jects which 1 have now stated, wdl, of course,
vary exceedingly, according to the particular
features of individual cases, and the constitutional
powers of the patient. The previous duration of
the di-^ca';e — the degree of activity it may pre-
B'.-nt — the age of the patient — the state of the
circulation — and the |)arlicular condition of the
urini", as resj)e<:ts Ijotli its density and (luantity,
Rhouid iiirlividually and collectively be considered
by the practitioner as circumstances calculated
greatly to modify the means of cure ; and should

- Treatment.

weigh so entirely with the judicious, as to lead
them to consider even the best practical sugges-
tions which can be offered as applicable merely
to some cases, and as requiring to be varied, and
rendered appropriate to others. It must be ob-
vious that we cannot endeavour to attain, seriatim,
the ends now proposed ; for a judicious and an
active treatment will often fulfil two or more of
them contemporaneously.

41. I have already noticed the opinions of
Dr. Watt and others (§ 37.) as to blood-letting.
In cases of recent occurrence, with an active
state of the circulation, and pain in the loins,
with much heat and pain in the epigastrium, or
where congestion or oppression of the vascular
system exists (§ 40. a), 1 consider general
blood-letting, repeated as often as the circum-
stances may require, as requisite to fulfil the
intention stated above (§ 40. «). The frequency
of, or even the propriety of repeating, the opera-
tion will depend much upon the appearances of
the blood drawn, and the effects produced by it.
If the crasis of the blood be weak — the coagulum
being loose, and dark — I have seen no benefit
derived from it until the vital energies have been
somewhat excited by appropriate means. If,
however, doubts respecting the propriety of its
repetition be entertained, cupping upon the loins,
or upon the hypochondria, or the application of
leeches on the epigastrium, according as the
sensations of the patient may direct, the practice
should be substituted, and carried to an extent,
as respects quantity and frequency of repetition,
on which the observation of the practitioner will
enable him to decide. In protracted cases, when
the disease occurs in old subjects, when the de-
bility is great, and the pulse quick, small, or
weak, general blood-letting is not productive of
benefit. If, even in these cases, much pain, ten-
derness, or fulness be coinplained of about the
epigastrium, local depletion, as now recommended,
may be employed in its vicinity. It will often
happen that blood-letting — especially general
blood-letting — will, at first, either be inadmissible,
or of little or no service; and yet it will subse-
quently prove of very great benefit, after the other
parts of the treatment have prepared the system
for it. '1 his fact should not be overlooked at any
period of the disease, even in the most unpromising
cases.

42. Immediately after depletion, a complete
evacuation of the bowels, either by a full dose of
castor oil and of spirits of turpentine, or by the
following pill, repeated according to circum-
stances, will generally be directed with advan-
tage : —

No. lf>G. R Extr. Colocynth. Co. 5ss.; Pulv. Ipcc.i-
cuaiiha.' gr. iij. ; .Saponis Castil. gr. viij. ; Olei Crotonis
TigliiTllij. M. Fiant Pilulae xrj. C.ipiat duas statim,
ct rcpctantur binse quarts quaque liora donee plend de-
jicorit alvus.

The bowels being freely evacuated by the above
means, assisted in more obstinate cases by ene-
mata, of which I believe those with from one to
two ounces of turpentine to be the most efficacious,
a full dose of o|)ium with camjjhor should be ex-
hibited, or of the jiulvis ijiecacuanlui; compositus,
or the Ibllowing : —

No. Ui7. IV Camiilior.T; rasa; gr. v. ; I'ulv. Ipecacuanha;
gr. j. ; I'ulv. Opii gr. ij. ; Pulv. Myrrlia; gr. vj. ; Mucil.ig.
Acacia', vel Conserv. Itosar., q. s. ut fiat Bolus, statim
siuiiendus.

After having taken this, the patient may liave re-
course either to a warm or to a vapour bath, have
the surface always well rubbed witli tlie lle-h-
brush on leaving it, and clotlie himself in a warm
dress, with flannel next the whole of the skin.
The opium, or the Dover's powder, or the bolus
above directed, and the warm bath, may be re-
peated at intervals, varying according to the cir-
cumstances of the case. Tlie effect of this treat-
ment is manifested in the state of the skin, and
urine, as well as in the feelings of the patient.
But, in cases characterised by much debility and
irritability, we must vary the means. Here the
sulphate or ammonio-tartrite of iron, or the sul-
pliate of zinc, or the sulphate of quinine, com-
bined witli opium and capsicum or camjjhor,
and exhibited either in the form of pill or of
draught, will often prove of advantage.

No. 1C8. B TnfusiRosar. Co. 3jss. ; Quininae Sulphatis
gr. ij. ; Zincl Sulphatis gr. ss. adj. ; Acidi Sulph. Aroni.
Ill XX. ; Tinct. Opii tllxx. — xxx. ; Tine. Aurantii Co.
3j. ; Tinct. Capsicinixx. M. Fiat Haustus, ter qua-
terve in die capiendus.

In cases of the same description, Dr. Prout re-
commends an electuary with the ferrl sesqui-
onidum, and opium, and alhiunen ovi. I have given
the sesquioxide of iron in the form of electuary,
with confection of senna, Ccc. (see F. 79. 86. 93.),
in order to preserve a freely open state of the
bowels. The combination of tonics and astrin-
gents, or even of astringents with aperients, is
sometimes useful. I have obtained advantage
from the following : —

No. 109. R Pulv. Cinchona?, Pulv. Rhei, aa .3 ss. ;
Wagnes. Carbon. 3 j. ; Mist. Camphorie 5jss. ; Confect.
Arom. gr. x. M. Fiat Haustus, bis in diesumendus. — J'el,

No. 170. R Pulv. Rhei, Pulv. I'va Ursi, aa 3jss. ;
Aquse Cinnamom. 5jss.; Confect. Aromat. gr. xij. M.
Fiat Haustus, bis terve quotidie sumendus.

The above may also be taken with a full dose of
laudanum, when the bowels have been sufficiently
acted upon, and the irritability of the system is
considerable. In order to counteract this symp-
tom, I have on some occasions had recour.-e to
the hydrociianic acid in doses of from one to three
minims, in a mucilaginous mixture, or employed
it in combination with iron or with zinc, in the
state of a cyanide of iron and cyanide of zinc.
The following was lately prescribed, and continued
for several days, with advantage : —

No. 171. R CamphorEe rasajet subactfe gr. xv. ; Oxydi
Zinci 3 ss. ; terc cum Mucilag. Acaciae vel Tragacanth.
Sss. ; Aquae Cinnamom. 3ivss. ; Acidi Hydrocyanici
lit XV. Misce. Fiat Mist., cujus capiat cochlear, j. vel
ij. larga, ter quotidie, prius agitata phiala.

43. Whilst tonics or astringents are employed,
either of the kind now noticed, or of any other
description, the bowels ouglit to be kept ojien, not
less than two or three satisfactory evacuations being
daily procured ; and this action should be main-
tained perseveringly for a long time, either by
purgatives given in the intervals between the ex-
hibition of the tonics ; or, what is preferable, in
conjunction with them, as in Form. 266., or as
follows : —

No. 172. R Infusi Gentianae Comp. 3j. ; Infusi .Sennae
Comp. 3ss. ; Tinct. Rheijij.; Spirit. Ammon. Arom.
5f,s. M. Fiat Haustus, bis terve quotidie suftiendus.

No. 17.3. B Decocti Cinchona-, Infusi Rhei, aa 3 vj. ;
Tinct. Cinnamom. 3jss. ; Ammonias Sesqui-Carl.on.
gr. vj. M. I'lat Haustus, bis terve quotidie sumendus.

As the difficulty of preserving an open state of the

DIABETES — Treatment. 51 7

bowels is great in' this disease, the (juantity of
purgative ingredients in the above medicines may
be increased, or otheis added, according to cir-
cumstances. I have seen great benefit derived
from inspissated ox-gall, in the form of pill, with
rhubarb and purified extract of aloes. These
pills may be taken at dinner, and repeated, if
necessary, at bed-time. Care should always be
taken never to employ saline medicines as purg-
ative-, excepting the phosphates in large doses,
which are sometimes of service. Even calomel
should be avoided, unless conjoined with cam-
phor and opium, or when we find it requisite to
act decidedly on the biliary secretions, and then a
single full dose of it may be given. If the biliary
organs require deob.'truent remedies, tlie hiidrar-
gyrtim cinn creta is the most suitable preparation
in this malady ; or the internal or external use of
the nitro-muriatic acids (§ 34.), or mercurial in-
unction. I have seen benefit derived from iodine,
ioduret of iron, and nu.r vomica or strychnia, in
several cases of diuresis, but I have had no expe-
rience of them in diabetes. Creasote, soon alter
its discovery in Gfrmany, was tried with benefit
in this disease ; and very soon afterwards it was
employed in a case which I saw with Dr. Roscoe.
Some advantage was derived from it in this and in
another case ; but the inspissated ox-gall, as pre-
scribed above, was equally beneficial with it.

44. In addition to the foregoing, and (Contem-
poraneously with the use of purgatives, diaphore-
tics, opiates, &c., external irritation, and deriva-
tion may be resorted to. For this purpose,
repealed vesication on the loins or epigastrium, or
the excitement of artificial eruptions on these parts
by croton oil rubbed upon them, seem to be the
preferable means. But, to be productive of any
service, the external irritation should be kept up
for a very considerable time, or frequently repeated.
If the above measures fail, wemust have recourse
to such of the other medicines as have been noticed
(§ 24 — 38.), as may seem most appropriate to the
person under treatment ; and we .should not be
content with trying the various remedies in suc-
cession ; but so associate, and contemporaneously
prescribe them, as to bring their combined action
to bear upon the morbid conditions which seem to
exist in particular cases.

45. Whilst these means are being employed,
the diet and regimen of the patient should be re-
gulated, and consist chiefly of animal food, with
a small proportion of farinaceous substances. He
should abstain from vegetables, particularly those
which are s\^ eet and acescent, and from fruits. Ani-
mal and farinaceous food are much more easily
digested and assimilated than the more bulky ve-
getables ; and, partly on this account, are more
suitable to the patient. For, although the de-
mand for food is urgent, owing to the call made
upon the digestive organs to supply the waste
arising from the nature of the discharge and to
the erethismal state of their mucous surface, yet
the digestive and assimilative energies of the
frame are defective, and insufficient for those
articles which require much change to be effecteil
in them during the process. Beside, animal food
furnishes fewer of the constituents of saccharine
matter. Jluch attention should also be paid to
tli-j quantity as well as the quality of both the
solid and fluid ingesta. Dr. Phout has very
judiciously remarked, that the constant and press-

L 1 3

518

ing desire for food generally induces the patient
to take by far loo mucli at one time, the conse-
quences of vvliich are not only unfavournble to
his recovery, but sometimes dangerous and even
fatal : and he refers the greater number of sud-
den deaths, vvliich is not an infrequent termination
of this disease, to errors either in the quality or
quantity of the food, or to both, the patient having
been frequently cut off after what is commonly
called a hearty meal. The diet, therefore, as to
its quantity and description, should be strictly re-
gulated by the physician, be chiefly of a solid
form, and not taken at longer intervals than four
or five, nor at shorter than three, hours. The pa-
tient ought also to abstain, to the utmost of his
power, from all drink for an hour or two after his
meal. Animal food ought not to be taken oftener
than twice in the day ; and beef-steaks or mutton
chops, under-done and plainly cooked, are per-
haps the preferable kind. The other meals may
consist of any of the farinaceous articles with milk,
or occasionally of eggs.

46. The drink also should receive particular
attention. Dr. Prout expresses himself favour-
able to the use of distilled water. Of this, how-
ever, I have had no experience. Lime water,
either alone or with milk, alum whey, and the
Bristol Hotwell and Bath waters, have been long
celebrated in this disease, and are certainly
amongst the most quenching drinks that can be
employed in it. 1 have prescribed the mineral
acids, and particularly the nitric and hydiochloric
acids, with seeming advantage. In a case which
lately occurred to me, I employed a weak solu-
tion of the boracic acid, and afterwards of the
biborate of soda, with much benefit. In another
case, however, this did not seem to agree, and in
that obvious advantage was derived from the use
of tar-water. In order that the patient may not
be induced to drink too largely, the beverages pre-
scribed should be taken in a tepid state, and his
resolution be fortified against the seduction of his
appetites. In addition to this diet and regimen, he
should remove to a dry and warm situation,
should constantly wear woollen next his skin, and
keep up a free cutaneous discharge by suitable
exercise. Even when he is convalescent, or ap-
parently recovered, this regimen ought not to be
abandoned; and the bowels should be constantly
kept open by the tonic aperients already recom-
mended, or by an electuary composed of sulphur,
magnesia, and confection of senna. Sulphur, in
full and frequent doses, is one of the best re-
medies we can resort to either in the disease or
during recovery, as it acts both on the bowels and
bkin. Errors in diet, or in the use of beverages,
and even a single irregularity as to fruit and
vegetables, will liazard a return of the disease.

47. iii. Treatment in the dark-ikinned varieties
of the species. — I have had occasion to see two
cases of this disease in negroes ; and Dr.CmusTiE
has given the particulars of ten or twelve cases
which he treated among the natives of Ceylon.
In all his cases, as well as in mine, the disease
was evidently owing to a very poor vegetable diet,
and a moist i^tate of tiie air. Dr. C.'s cases
terminated favourably, from the use of animal
food, the sulphurct of potassium, lime water, and
purgatives. 'J'he cases which occurred to me
were treated with tonics, purgatives, the warm
bath, and diaphoretics and narcotics : they derived

DIABETES — Tbeatment,

some benefit, but circumstances occurred which
prevented me from knowing the ultimate results.

BiBLioG. AND Refer. — Ga/f.'j, De Locis Affect. 1. vi.
cap. 3. ; De Crisibiis, 1. i. cap. xii Celsus, 1. iv. cap. 20.

— Archigenes, in A'etius's Tetrab. iii. serm. iii. cap. 1. —
Oribasms, Synops. 1. ix. cap. 3-5, 36. — Alexander Trnl-
lianus, 1. iii. cap. 41. — Baillou, Opera, vol. ii. p. 254.,
vol. iv. p. 244 — Zacuius Lusitanns, Prax. Admir. Amst.
1641, 1. ii. obs. 71. — Aniaius Lusitanus, cent. ii. cur. 94.,
et cent. v. cur. 33. — Willis, Pharmaceut. Rat. sect. iv. c. 3.
Si/dcn/ia>n, Epist. Resp. i. Const. Arm. 167-'>. ; Opera,
p. 'ASS. — Lisler, Exercit. de Diabete. .S;grot. 2, 3. 4. 7.—

Morton, Phthisiologia, 1. i. cap. 8. Amst. 1675 Bonet,

Sepulchretum, 1. iii. sect. xxvi. — Ruysch, Observat.
Anatoni. Chir. No. 13. — Baglivi, Opera, p. 717. — Mor-
gagni, De Sed.et Cans, epist. xli. art. 2. 15. — Blackmore,
On the Dropsy and Diabetes, 8vo. Lond. 1727. — Ricdiin,
Linear. Med. p. 948. — Chtselden, Anatomy, Svo. p. 130.

— I.c Fevre, Opera, 4to. 1737, p. 134. — Harris, Observ.
de Morbis aliquot Gravioribus, ob. 3, 4. — BuchwuUl, De
Diabct. Cur. cumprimis per Rhabarb. Ilafn. 1733. —
Mead, On Poisons, 8vo. Lond. 1743. — Kruzenslein,
Theoria Fluxus Diabetici. Halte, 1746. — Dover, Le-
gacy, &c. p. 33. — Stedman, in Edin. Med. Essays, vol. ii.
p. 4S — Oosterdi/k, Samml. Auserl. AbhaiuU. fiir Pract.
&c. b. i. p. 179 Brocklesby, in Med. Observ. and En-
quiries, vol. iii. art. 26 Dobson, in Ibid. vol. v. art. 27

Brisbane, Select Cases, Sec. 8vo. Lond. 1772. — Isenflar)im,
Versuch einiger Anmerkung. die Eingewcide, &'c. Erl.
1784. — Bnchetoni,mCom'ment. Bonon. t. ii. parsl. p. 218.

— Caii'ley, in I,ond. Med. Journ. vol. ix — M' Cormick,
Edin. Med. Comment, vol. ix. p. 349. — Cruickshanks,
On the Lacteals and Lymphatics, p. 69. — J. P. Frank,
De Curand. Hom. Morbis, t. v. p. 39. Man. 1792. ; et
Interpret. Clinic, vol. i. p. 347. — Baillic, Trans, of Soc.

for Improvement of Medical Knowledge, vol. ii. art. 5

Lalham, Facts and Opinions concerning Diabetes, 8vo.

Lond. 1811 iJfS«e</<, Journ. de Chirurgie, t. i. No. 3

Satterley, Med. Trans.'jct. vol. v. art. 1. — Warren, in
Ibid. vol. iv. p. 188. — SAee, in Duncan's Med. Annals,

vol. i. p. 343. —Jarrold, in Ibid. vol. vi. p. 390 Socm-

merring,I)e Morb. Vasor. Absorbentium,p. 157. — Fahner,
IJcjtr'age zur Pract. Arzneyk. b. i. art. 4. — Hollo, On
Diabetes Mellitus. Lond. 1797, 8vo. — Hertzog, in Hufe-

land's Jonrn. der Pract. Arzneyk. b. vii. st. 2. p. 155

A. G. Richter, Die Specielle Therapie, b. iv. ji. 443. —
Bardslcy, Medical Reports and Exper. &-c. 8vo. Lond.
\f,OT.—Trnka, De Diabete. Vindob. 8vo. 1778.— JVeber,

Observat. Med. fasc.i Flencix, Acta et Observat. Med.

p. I.'i3. — Marabelli, Mem. suite Differenze dell' Orina in
Diab. 8vo. Pavia, 1792 — Tommasini, Storia ragionata di
un Diab. 8vo. Parma, 1794. — Bang, in Acta Regia;

Soc. Med. Haun. vol. ii. p. 291 C. Darwin, in Med. and

Physical Journal, vol. xxvi. p. 4G.'i. — Gij-dlestone, On

Diabetes. Yarmouth, 1799 Red/earn, in Lond. Med.

and Phys. Journ. vol. i. p. 218. — Gilby, in Ibid. vol. iv.
p. 20.5. — Marcel, in Ibid. vol. ii. p. 207. — Lubbock, in Ibid.
vol. V. p. 56. — Sioeller, Beobachtungen, obs. 1. ; et in

HnfelaiuVs Journ. der Pract. Arzneyk. b. vi. p. 64

Richter, Med. and Chirurg. Bcmerkung. p. 76. — Home,
Clinical Experiments, p. 296. — Roeber, in Museum der
Heilk. b. iv. p. 296. — Watt, Cases of Diabetes, &c.
Glasgow, 1808. — Ritter, in Hufeland's Journ. der Pract.

Heilk. b. xx. st. 3. p. 145 Sclivtz, in Ibid. b. xii. st. 2.

p. \2».—Michaelis, in Ibid. b. xiv. st. 3. p. U.—Iittfeland,
in Ibid. b. xlvii. s. WT —Wolff, in Ibid. Jun. 1810. p, 120.

— Ciillen, Practice of Med., by Tliomson, vol. i. p. 313. ;
vol. ii. p. 491.. — Ferriar, Medical Histories and Reflections,
vol. iv. p. 46 Bhimcnbacli, Med. Biblioth. b. ii. p. 127.

— Monro sxiA Duncan, in Annals of Med. vol. viii. p. 388.

— Nicolas et Gueudevilk, Recherches et Experiences
Medicates suria Iliabete Sucrt'e, ou la Phthisnrie Sucree.
Paris, 1803. — Place, De vera Diabetes Causa in Defectu

Assimilationis quaercnda. Goet. 1784 Met%, Diabetis

Observatio, in Disput. Med. Pract. Ilaller, t. iv. —
Henry, Ann. of Philosophy, vol. 1. p. 27. ; et Trans,
of Med. and Chirurg. Soc. vol. ii. p. 119 — Wollastoti
and Marcet, Philos. Trans, vol. ci. 1811, p. 96. — Du.
puytrcn et Thenard, in Journ. de Mi'd. Contln. vol. xii.

p. 83 Clarke, in Edin. Med. and Surg. Journ. 1810. —

Boslock, Mem. of Med. Soc. of Lond. vol. vi. p. 237. ; et

Transac. of Med. and Chiriug. Society, vol. iii. p. 107

Money, in Ibid. vol. v. p. 236 Mynster, in Acta Regiae

Soc. Mcdic;u llafniensis, vol. v. IH18. — Kiimer, in Horn's
Archiv. \A\'.K—Aittetiricl/i, Physiol. ^813. — Dexeimeris,

in MCiiioircs do la Soc. Med. d'Emulation, t. ix. p. 211

Duncan, in Transact, of Med. and tJhirurg. Society of

Edin. vol. i. p. 474 Fraser, in Edin. Med. and Surg.

Journ. vol. i. p. 16 Alley, in Ibid. vol. iv. p. ,35 Chris-
tie, in Ibid. vol. vii. p. 285. — Renauldin, in Diet, des
Sciences Med. t. ix. p. 12,5. — Henry et Sonbeiran, in
Journ. des Progrt's des Scicn. Med. t. i. p. 2.50. — Hvfe-
land, in Ibid. vol. ii. 2nd series, p. 43. — Mars/i, Dublin
Hospital Reports, vol. iii. p. 480 — MM. Vauqnelin et Se-
ealas, in Magendie's Journ. de I'hysiologie, t. iv. p. 356.

DIAPHRAGM —

Paris, 1825. — W. Prout, Inquiry into the Nature and
Treatment of Diabetes, Calculus, &c. 2d edit. Lend.
1S25. — Rochoux, Diction, de Jled. vol. vi. — Hcineken,
in Lond. Med. Repos. vol. xix. p. 265 — Carter, in Ibid.
%'ol. XX. p. 31)0. —D. Barry, see Lancet, No. 238. p. 926.

if. Venables, On Diab., &c. 8vo. Lond. 182.5 — f'auque-

lin et Siigalas d'Etchrpare, in Archives (Jener. de Mede-
cine, t. vi. p. 625. — Lobstem, in Ibid. vol. xviii. p. 432. ;
et in Rupert. GCner. d'Anat. et Phys. vol, ii. p. 356 —
Skarkey, in Transac. of Irish College of Phys. vol. iv.
p. 379. — Bouiliaud, Diction, de Med. et Chir. Prat.

vol. vi. p. 249 M. Good, Study of Med. by Cooper,

vol. V. p. 494 Bcrndt. Encyclop. Worterb. de Med.

Wissensch. art. Diabetes Ambrosiani, in .\nnali Univer.

di Med. Apr. 1835. — Mai/land, in Lond. Med. Gaz.
vol.xvii. p. 900. — M'Gregor, in hond. .Med. Gaz. vol.xx.
May 13 and 20, 1837. — B. lf'i//is. Urinary Diseases and
their Treatment, 8vo. Loud. 1838, p. 196.

DIAGNOSIS. See Symptomatology.
DIAPHRAGM (from Sia4>pac-(raj, I separate). —

SvN. 'Tml^aifA.e., Aristotle. Aia<p(a.yfA.a., ifpEVEf.

SepUun transversiim, Lat. Der Zwergnmskel,

Ger. Diaphragme, Fr. Midriff', Eng.

1. When we consider the musculo-tendinous
structure, and varied connections of the dia-
phragm,— that it is situated between three serous
membranes, and attached to the vertebral column,
the ribs and their cartilages, — that it is traversed
by the most remarkable nerves and blood-vessels
of the body, and itself provided with important
vessels and nerves, that it is in more or less
direct contact with the lungs, the heart, the
liver, stomach, pancreas, kidneys, and spleen;
and intimately associated by its nerves, its ves-
sels, and its functions, not only with the mucous
surface of the respiratory organs, as well as with
these organs themselves, but also with the diges-
tive and large secreting viscera, — its importance
in a pathological point of view must be appa-
rent. The extent of its organic and functional
relations are such, that agents acting on either
the external or internal surfaces of the body
must necessarily influence its actions. It cannot,
therefore, be a matter of surprise to find it
frequently subject to disorder ; but I am at a
loss to conceive the reason for the very general
neglect witit which even its most serious diseases
have been treated. This can be owing only to
the circumstance of their being imperfectly
understood, or referred to some one of the
adjoining organs, and viewed as merely symp-
tomatic or secondary affections.

1. Inflammation of the Diaphragm. —
Syn. Diaplirogmitis (Hildenbrand, J. Frank,
&c.) ; Parapitrenitis, Paraphrosyriis (Rufus
Ephesius, et Auct. Vet.); Diuphragmite,
Paraphreiiesie, Fr. ; Zwergmuskell-Eiitz'un-
dung, Ger.

Classif. III. Class, I. Order (Author).

2. Defin. — Acute pain and constriction af the
lower part of the thorax, extending to the buck and
loins, increased upon respiration and raising the
body erect, with singultus, convulsive distortion of
the angles of the mouth, and very acute inflamma-
tory fever.

3. i. Seat. — Inflammation of only the mus-
culo-tendinous structure of the diaphragm is a very
rare disease, particularly in its primary form ; and
I believe is very seldom met with, excepting upon
the disappearance of rheumatism from some exter-
nal part, or after penetrating wounds and other
external injuries. As a consecutive or secondary
affection, and especially in conjunction with in-
flammation of one or more of its serous membranes,
it frequently occurs, although often either entirely

Inflammation OF. 519

overlooked, or mistaken for inflammation of some
one of the adjoining viscera. The advantages of
being able to distinguish it in practice are not di-
minisiied on this account ; and it often becomes of
great importance to ascertain its existence, whe-
ther as a primary or as a consecutive disease.

4. I believe that inflammation may originate in
the cellular tissue connecting the serous membranes
reflected over the diaphragm to its musculo-tendi-
nous structure, in which case the disease will ex-
tend chiefly to either one or both of those surfaces;
but tliat, in the more frequent states of diaphrag-
mitis, — particularly its consecutive form, — the
inflammation commences in one of the serous sur-
faces, and extends thence, through tlie medium of
the sub-serous cellular tissue, more or less to the
other structures of the organ.

5. ii. The Causes of diaphragmitis, particularly
in its consecutive forms, are generally those which
are productive of pleurisy, pneumonia, hepatitis,
or peritonitis. In addition to those, I may adduce
others, which have a more evident influence in
producing this disease, viz. punctured and other
wounds; external injuries and fractures of the
lower ribs ; concussions of the trunk, particularly
from missing steps on descending stairs, or from
falling upon the hips; immoderate laughter ; vio-
lent retchings ; continued crying and weeping ;
obstinate singultus ; currents of cold air, when the
body is perspiring ; the incautious use of cold
drinks, ices, &.c. ; the suppression of painful emo-
tions ; violent efforts of any description ; the re-
pression or metastasis of rheumatism ; the stop-
page of accustomed discharges ; and the drying up
of old eruptions or ulcers by external applications.
Instances of the occurrence of inflammation of the
diaphragm from the repression of rheumatism have
been recorded by Paterson ( Mem . of Med. Society
of London, vol. v. No. 32.) and Portal (Anat.
Med. t. ii. p. 444.) ; and from healing up old
sores, suppressing gout, &c., hy Aaskow Act , Reg.
Soc. Med. Hafn. t. i. p. 205.), Boisseau (Nosogra-
phie Organ, t. xi. p. 620.), Wendt, Selle, and
others. Hildenbrand considers the habit of
wearing tightly laced corsets a cause of the disease.
I doubt not that it is, at least, a predisposing cause.

6. iii. Symptoms, Co.mplications, &c. — A.
Either after rigors, chills, horripilations, &c., or
consequent upon disease of some one of the abdo-
minal or thoracic viscera, the patient experiences
violent, sharp, burning pam, tension, and cord-like
constriction, at the lower part of the thorax, parti-
cularly beneath the sternum and hypochondria,
and stretching to the loins, — increased and de-
scending lower during inspiration — diminished
and ascending during expiration, — augmented by
coughing, sneezing, fulness of stomach, and pres-
sure on the abdomen ; likewise by vomiting, by
the expulsion of the faeces or urine, and by bend-
ing the trunk of the body in any direction. The
breathing is short, frequent, anxious, small, and
performed entirely by the intercostal muscles, the
abdomen being nearly motionless. The hypochon-
dria fall inwards, or are retracted, and, with the
precordia, are sensible to pressure. There are
frequently painful and difficult deglutition, re-
ferrible to the lower part of the oesophagus and
cardia ; great anxiety, with occasional interrupted
sighs ; singultus, particularly towards the close of
the disease , involuntary retraction of the angles of
the mouth, or risus sardonicus ; delirium, which is

L14

520

DIAPHRAGM

sometimes furious ; spasms, or great feebleness of
the muscles of the abdomen and extremities ; irri-
table, porraceous vomiting ; leipothymia or sinking,
&c. The pulse is always frequent — at first
strong and hard, afterwards small, more quick,
•vviry, &c. The bowels are constipated and urine
in small quantity ; thirst, is at first urgent, after-
wards not felt ; and restlessness, particularly as the
disease advances, is extreme.

7. B. Comjjticated Forms. — a. The symptoms
vary considerably with the surface of the organ
chiefly affected, and according as inflammation of
an adjoining viscus may have preceded, accompa-
nied, or followed that of the diaphragm. When
inflammation implicates the diaphragmatic pleura,
or extends to the lungs, mediastinum, or pericar-
dium, we must expect to observe many of the
symptoms of those diseases ; particularly those
consisting of lesion of the function of respiration.
Percussion will give out a somewhat duller sound
than natural ; cough will be more or less com-
plained of, and be frequently attended with a wa-
tery mucous expectoration.

8. When the inferior surface of the diaphragm
is inflamed, the stomach and liver seldom escape
participation in the disease. In this case the pain
and sensibility of the hypochrondria are increased,
and the stomach is more severely disordered.
When the muscular or tendinous structures are
chiefly implicated, the complaint assumes its most
violent forms ; and, owing to the nerves of the or-
gan being then more seriously affected, the sym-
pathetic effects of the disease, as delirium, the sar-
donic spasm of the muscles of the countenance,
singultus, dysphagia, anxiety, retiaction of the hy-
pochondria, spasm of the abdominal muscles, &c.
are more constant and severe.

9. Uiaphragmitis is sometimes complicated
with, at other times consequent upon, acute rheu-
matism ; and I believe that it may be associated
both with inflammation of the convex and posterior
part of the liver, and with acute rheumatism, in
the same case and at the same time. I am at pre-
sent attending a patient, in whom there is every
reason to infer the existence of this very compli-
cated malady ; and am of opinion that similar asso-
ciations of the disease would have been more fre-
quently remarked in practice, if the severity of the
rheumatic pains, and of the remote symptoms
caused by inflammation of the diaphragm, had not
masked those more directly connected with the af-
fected organ, and thereby misled the practitioner.

10. There are several symptoms which have
been adduced by authors as pathognomonic of this
malady, but which are not uniformly observed :
thus Sroi.T., Aaskow, and IjOisseau have found
delirium frequently wanting altogether: and, in
several cases, in whicii I liave seen the disease
complicated with hepatitis and pleuritis, — particu-
larly the former, — neither delirium, nor liie cynic
spasm, was present. I agree, however, with J. P.
FnA VK ( De i'Airaiid. Morh. Horn. t. ii. p. 193.), in
considering these symptoms as being more fre-
quently met with in this disease, than in any other
aHecting tlie viscera of the large cavities, and par-
ticularly when the tendinous part of the organ is
affected.

11. (,'. Cnurse inid l\'ri)>iiiiilion. — The course
and progress of this disease are generally acute.
If it t(trniinate not in resolution within a few days,
it produces cither adhesion to the adjoining viscera,

Treatment of Inflammation of.

or disorganisation, followed rapidly by death.
When adhesions form, signs of chronic disease of
this and the adjoining viscera continue after the
subsidence of the acute symptoms ; but when dis-
organisation and gangrene supervene, the patient
experiences, after a very few days, a sense of suffo-
cation, sinking, with singultus, extreme frequency
and smallness of pulse, faintings, &c., speedily
followed by dissolution.

12. D. The morbid Appearances most fre-
quently found after diaphragmitis are, effusions of
coagulable lymph, or of sero-albuminous fluid, or
of both, on either of the surfaces of the organ, ge-
nerally with adhesions, more or less extensive, to
the adjoining viscera ; increased redness and vas-
cularity, or deepness of colour, of one or more of
the different structures composing the organ ; false
membranes upon its surfaces ; portions of it ulce-
rated, or of a dark colour, softened, and nearly
disorganised ; and, more rarely, sphacelated in
parts, infiltrated with pus, or containing one or
more distinct purulent collections.

13. iv. Prognosis. — Recovery from this ma-
lady should be considered as very doubtful, until
we have very unequivocal symptoms of resolution,
without any sign of the extension cf disease to the
organs situated on eitlier side of the diaphragm. —
o. The circumstance of diaphragmitis arising from
external injury, or the extension of inflammation
from the pleura and pericardium ; the early acces-
sion of urgent anxiety, followed by delirium ; sin-
gultus, and sobbing ; depressed, collapsed, and
anxious countenance, with spasms of the muscles
of the face ; irregularity, intermission, and small-
ness of pulse ; coldness of the extremities ; leipo-
thymia ; difticult deglutition ; frequent and irrita-
ble vomiting, and restlessness; absence of thirst;
convulsions ; convulsive, frequent, and laborious
respirations, &c. ; are very urifavourahle symptoms.
— b. The subsidence of the urgent symptoms ; an
improved state of the pulse, and appearance of the
countenance ; the occurrence of any of the critical
evacuations, or restoration of the suspended secre-
tions, or a sound and refreshing sleep ; a more
natural respiration, and the absence of serious
disease of the collatitious viscera; are the most

favourable circumstances.

14. vi. Treatment. — The intentions of cure
arc the same in this as in other acute inflammations.
The antiphlogistic treatment promises us the prin-
cipal aid ; but to be successful, it must be em-
ployed early in a decided manner. Full blood-
letting from the arm, the patient being in a semi-
recumbent posture, until a decided effect ensues —
until syncope approaches, but is not induced — as
recommended in another place (see Blood, §64.) ;
afterwards cupping on the loins and back, on each
side of the spine ; leeches applied near the anterior
insertion of the diaphragm; purgatives; refrige-
rating diaphoretics ; febrifuge diluents; external
fomentations and cataplasms : tepid baths ; purga-
tive, and subsequently emollient cnemata, with
complete stillness and silence ; should be employed
according to tiie exigencies of the case. The
practitioner ought not to be deceived by the pre-
sence of singultus, and the great depression of the
powers of life so frequently attendant on the dis-
ease ; and thus be led to the exhibition of antispas-
modics and stimulants, when opposite measures are
requisite. l\'or should he be mduced by the state
of the stomach, and of the matters discharged from

DIAPHRAGM— Organic Lesions — Spasmodic Actions of.

521

it, to exhibit emetics. When vomiting is present,
it sliould be allayed ; and, for this purpose, as well
as to prevent the formation of coagulable lympii
and adhesion between the surfaces of the organ and
the adjoining viscera, large doses of calomel and
opium — from ten to twenty grains of the former,
and from one to three of the latter, either witli or
without from one to three grains of cumpluu- —
should be exhibited, and repeated at intervals of
six or seven hours ; the first dose being given im-
mediately after the first blood-letting. The danger
of the disease requires prompt and powerful agents ;
and, after depletions, the combination of calomel,
opium, and camphor, is particularly serviceable.

15. Wlien the disease is associated with inflam-
mation in the adjoining viscera, the calou)el should
be carried so far as to affect the mouth ; and if the
pleura or pericardium be also diseased, antimonials
and diuretics ought to be added. If the convex
or posterior parts of the liver and peritoneum be
also inflamed, the use of mercurials are also re-
quired, and \vith nearly the same intentions, viz.
to prevent adhesions, and procure the absorption
of effused fluids. If the disease be associated with
rheumatism or ^'I'lif, then, after local depletions,
active mercurial cathartics, and derivatives applied
to the joints, colchicum, with large doses of soda
or potash, or with magnesia, aminonia, or camphor,
may be exhibited.

16. It often happens, that after the inflammation
in this organ and its collatitious viscera is sub-
dued, considerable irritability, evinced by the
occurrence of singultus upon taking substances
into the stomach, continues for some time. To
remove this, the use of gentle tonics, combined
with anodynes and antispasmodics, as the infu-
sion of calumba, with opium, carbonate of
soda, hyoscyamus, or camphor, is generally re-
quired, or of the Infusion of valerian, or of the
oxide of zinc, or the tris-nitrate of bismuth, or
musk, &c. Convalescence, and the regimen of the
patient are to be managed precisely as in other
inflammatory diseases.

17. II. Diaphragm, Obganic Lesions of. —
i. Perforation of the diaphragm is not an un-
common consequence of abscess of the liver,
pointing up towards the thorax. In the great
majority of such cases, adhesion of the adjoining
surfaces of the liver and diaphragm has preceded
the perforation ; and when this has been accom-
plished by the disorganising process following the
inflammation excited in the diaphragm, the con-
tents of the abscess pass either into tiie cavity of
the thorax, or adhesion of the inflamed diaphragm
to the lungs having also taken place, into the
lungs, whence it may be expectorated, and the
patient even recover. (See Livfr — Abscess of
the.) Instances have even occurred of the ab-
scess having thus traversed the diaphragm, and
opened into the pericardium.

18. Perforation of the diaphragm has likewise
taken place from abscess of the spleen, and from
ulcerations of the stomach, which had adhered to
the diaphragm. It has very seldom been ob-
served that the perforation of this organ has oc-
curred in an opposite direction, namely, from the
thorax downward*!. But Portal (Anat. J\Ied.)
met with a case in which an imposthume of the
lungs opened through the diaphragm, and burst
into the abdominal cavity. The diaphragm may
likewise be perforated in this direction by aneurism

of the aorta. Meckel also found K/cejvifio/i of the
diaphragm, apparently resulting from chronic in-
flammation, in the dissection of a maniacal patient.

19. ii. Rupture of the diaphragm sometimes
occurs from falls ; violent succussions of the
trunk ; vomiting, or severe retchings ; blows on
the abdomen, back, hypochondrium, or epigas-
trium ; suppressed efforts, and sudden muscular
exertions. M. Percy states, that a young female,
suppressing the pains of child-birth, uttered a
plaintive cry, had her mouth hideously distorted,
and shortly afterwards expired, giving birth to a
child. On dissection, the diaphragm was torn
obliquely in the fleshy part of the left side. Two
thirds of the stoinach, with a portion of the omen-
tum and colon, had passed through the rupture
into the thorax. On another occasion, M. Percy
found, after a fall, the ribs of the patient very
prominent ; the abdomen, at its upper part, sunk
inwards; and the countenance presenting the risus
sardonicus. He prognosticated a rupture of the
diaphragm which was found after death. (Percy,
Vict, des Scien. Mtd. t. ix, p. 214.) Rupture of
the diaphragm is not necessarily immediately fatal.
BoissEAu (Nosog. Organ, t.u. ^.623.) mentions
a case where a patient lived six months, and fol-
lowed his occupations, after the occuirence. A per-
son having taken an emetic, died soon afterwards
with convulsions, the cynic spasm of the muscles
of the face, &;c. On examination, the tendinous
part of the diaphragm was found torn near the part
where the intercostal nerve passes through it.

20. iii. Various INIorbid Productions have
been found more or less intimately connected
with the diaphragm, in persons who had expe-
rienced disorder of the respiratory function. These
have consisted of tumours of various descriptions,
encysted or unencysted ; cartilaginous or osseous

Jormations, and earthy concretions in its surfaces
(ScHREiBFR, Leveille, Voigtel) ; flcshy tu-
mours; and large_/i7;roi(scj/5fs containing hydatids
(Portal), or merely an aqueous or serous fluid.
It is not infrequently found partially displaced in
aneurism of the heart and aorta. Cases of this
description are recorded by Vetter and Blan-
card. It is also pressed high into the thorax by
enlarged or suppurated liver.

21. iv. Spasmodic Actions. — The diaphragm
contracts forcibly in crying, coughing, vomiting,
during the expulsion of the excretions, child-
birth, and tenesmus. It contracts slowly, but
forcibly, and is rapidly followed by relaxation, in
sighing. It contracts for a longer time, and is
relaxed more quickly in yawning. The contrac-
tion is more rapid, forcible, and interrupted by
closure of the glottis, in hiccup, sobbing, &c.;
and sneezing is owing to convulsive contraction of
the diaphragm, followed soon afterwards by con-
vulsive action of the expiratory muscles. In all
these, the other inspiratory muscles co-operate
more or less energetically.

22. The motion of the diaphragm is generally
more frequent, irregular, and unequal, than na-
tural in convulsive diseases, particularly when the
irritation is propagated to this part, or influences
the functions of theparvagum, by being extended
to the top of the spinal chord, &c. This is evinced
in epilepsy, hysteria, pertussis, &:c. The con-
tractions of the organ are still more disordered in
tetanus, they being nearly permanent about the
fatal close of the disease. Death is occasioned by

522

DIARRHCEA ~ Idiopathic.

this, rather than by any other circumstance ; the
permanent spasm of the diaphragm and other re-
spiratory muscles preventing the expulsion of the
inspired air, and consequently producing a variety
of asphyxy. (See art. Hiccup.)

2-i. V. Paralysis of the diaphragm is incom-
patible with the duration of life, and can occur
only during the last moments of existence. It may
be induced by the inhalation of noxious gases into
the lungs, and from virulent poisons, thus con-
stituting another form of asphyxy : and it is pro-
duced by injuries of the medulla oblongata, or in
its vicinity, or by whatever may interrupt the
functions, or injure the par vagum. I have met
with a case where it followed, at a remote period,
fracture by muscular action of the dentated cer-
vical vertebra, as verified on dissection by Profes-
sor R. QuAiN and myself.

BiBLiOG. AND Refer. — Galen, De Locis Affect. 1. v.

cap. 4 Bonet, Sepulch. Anat. 1. i. sec. 1. obs. 1 — Mor-

^(jgre!, Epist. vii. art. 14. — Roth, Diss.de Inflammat. Septi
transversi. Lips. 174S. — Schidxe, Diss, de Paraphieni-
tide. Hal. 1742. — Schneider, De Inflatn. Diaphragmatis.

Witteb. 1665 Meckel, in Mem. de I'Acad. de Berlin,

1764, p. »H.—Schroe(te>; De Inflam. Diaph. Goet. 1772.
Stall, Ratio Med. t. ii. p. 385. — De Haen, Ratio Med.
par. i. p. 84., par. ix. p. 17 — L. A. Ebeling, Diss. de. Iii-
flammatione Diaphragmitls. Goet. 1771 — G. M. Gatten-
hof. Spec. Sist. Paraphrenitidis Rationera et Curationem.
Held. 1791. — Isenflamm, Prakt. Aum. iiber die Mus-
keln. H62. — Aaskow, in Act. Hafn. vol. i. p. 205. —
Sandijort, Exercit. Acad. 1. ii. p. 88. — Portal, Anat.
Medical, t. iv. p. 233. — Hempel, De Diaph. Sano et Mor.
boso. Goet. 1808. —J. P. Frank, De Cur. Horn. Morb.

t. ii Roy, Traite sur le Rire. Paris, 1814 — Satvicx,

De Diaphragmitide. Wilna, 1819. — Ilildcnbrand, In-
stitutiones Medicae, t. iii. p. 267.— J. Frank, Praxeos Med.
I'rajccp. Univ. par. 2. vol. ii. sect. 2. p. 2. — Roi'sseau,
Nosographie Organique, t. ii. p. 617.— Voigtels, Pathol.
Anat. t.ii. p. 201.

DIARRHCEA. — Syn. (Aiaffota, from happio),
I flow through, J'la and pii»). Diarrheea Ca-
caloria, Rheuma Ga.stros, Galen. Rheumatis-
mus, Alexander of Tralles. Defluiio, CaBlius
Aurelius. Aivi Fiuxus, Ventris Projiuvhun,
Auct. Lat. Coins de Ventre, Devoyement, Ft.
Der Durchfall, Bauchjiuss, Dnrchlaiif, Germ.
Diarreo, Ital. A Purging, Looseness, &;c.
Classif. — 2. Class, Nervous Diseases; 3.
Order, Spasmodic Affections (Cullen).
1 . Class, Diseases of the Digestive Func-
tion ; 1 . Order, Affecting the Digestive
Canal (Good).

1. Defin. — Freqtient, loose orjluid alvine eva-
cuations, without tormina or tenesmus.

2. Although diarrhoea may occur as an inde-
pendent or unassociated complaint, yet may it
supervene as an occasional or even common symp-
tom, in several maladies. Dr. Cullen, whilst
he admitted diarrhoea as a specific disease, yet
viewed it as always symptomatic of other patho-
logical states. That it is so in most cases, cannot
be doubted ; but that it also is, in some instances,
an idiopathic disorder, in respect both of its priniaiy
manifestation, and of it independence of inflam-
matory action of the intestinal mucous surface, or
of disease of immediately related organs, is equally
certain; and fully demonstrated by its causes and
progress, — by the effects of treatment, and the
appearances observed in fatal cases.

3. I. SVMPTO.MS AND VAlilF.TlES OF Dl ARRnd. A .

— This disease is usually preceded by various
dyspeptic symptoms, sometimes by slight nausea,
frequently by uneasiness in different parts of the
abdomen, by flatulence, and by pain, particularly
before un evacuation takes place. In severe cases,

the abdomen is somewhat distended and tender to
the touch, and its temperature increased ; and
occasionally the stools are preceded by much pain
in the tract of the intestines, and accompanied
with vomiting, or with fainting, or leipothymia;
they are always without effort, but are rarely in-
voluntary. Each evacuation relieves for a time
the patient's uneasiness, which, however, soon
returns. The discharges are usually copious,
offensive, and feculent at first ; but they soon be-
come more scanty, watery, or mucous — often in
proportion to the frequency of the calls to evacua-
tion, after each of which the patient feels more
and more weakened. Their number varies from
three or four, to twenty or thirty in the twenty-
four hours, but they are not so often voided in the
night as in the day. At the commencement of
the attack, and in slight cases, the pulse is ge-
nerally not materially affected ; but when vomit-
ing or much griping pain is present, it is often
increased in frequency. At an advanced period
it is usually small, weak, and somewhat accele-
rated ; the countenance being pale, the body
somewhat emaciated, the strength diminished, and
the skin dry and very sensible of cold. The
tongue is often loaded from the commencement in
the middle and at the root, and sometimes is red
at the point and edges. The urine is generally
scanty throughout the complaint. The evacua-
tions vary remarkably as to the nature of the
matters composing them, their colour, consistence,
smell, and other appearances, not only in different
cases, but even in the same case, at different
periods. Nosologists have generally divided the
disease into varieties or species, founded on the
different states of the discharges. But this is not
a satisfactory basis of classification, as the appear-
ances of the evacuations do not depend upon de-
finite pathological conditions, although furnishing
important indications of the seat and state of
disease. The most coiDmon of these appearances
are, the feculent, which usually precedes the
others; the bilious ; the mucous ; the serous ; the
chylous ; or ivhite ; and the lienteric. But every
practitioner must have observed that not only will
these discharges present themselves during dif-
ferent periods of the disease, but that two or more
of them may co-exist; thus the evacuations are
not infrequently, at the same time bilious, mucous,
and serous ; or feculent, bilious, and mucous ; or
watery and bilious,

i. Idiopathic Diarrhea. — Classif. If.
Class, I. Order (^Author).

4. Defin. — Copious, feculent, and frequent
evacuations, sometimes preceded by griping, and
unattended by fever,

5. A. Diarrhoea of Irritation. — This form
of the disease comprises most of the cases denomi-
nated feculent by authors, and termed D. Sier-
corea by Saiivages, D. Crapuloiu, by Cullen,
and D.Fusa, by Good. — (a) It is usually caused
by any stimulating or irritating substance re-
ceived into the stomach ; by loo great a variety
or quantity of food or drink, or even by a small
quantity of that which is unwholesome, or which
may disagree with the patient's diathesis, or with
the exi.«ting state of tl)e digestive organs; by in-
digestible vegetables, particularly cucumbers,
melons, salads, Sec. ; by various acid fruits, par-
ticularly plums, pine-apples, &c. ; by accidities
generated in the prima via, and the quality of the

DIABRHCE A — Symptomatic.

523

nurse's milk ; and by dentition in infants. — (b)
The symptoms in this variety are frequently
nausea ; severe griping pains before eacii evacu-
ation ; foul, or loaded tongue; copious feculent
stools, afterwards becoming frothy, watery, or
mucous, and exhaling an offensive, or sour odour;
the pulse and temperature of the surface being but
little affected. — (r) This form generally ceases
spontaneously, owing to the evacuation of the
offending substances ; and the digestive functions
are soon afterwards restored, if its cause be sub-
sequently avoided. It may, however, excite
some of the other pathological states to which this
disease has been ascribed, and be thereby pro-
longed ; or it may terminate in organic change.

6. B, Diarrh(ca of ReUixation associated with
Irritation ( Diarrhteaa Cibis corrtiptis, Sennert)
' — (a) may be caused by whatever relaxes tiie
tone of the intestinal mucous surface, or of its
vessels, by its septic influence, whilst it excites
the peristaltic actions of tlie tube, as stale fish,
high game, or any animal food approaching to
putridity, over-ripe, or decayed fruit, stale vege-
tables, &c., and putrid, stagnant, marsh, or
running waters containing animal matters, or
exuviffi, or vegetable substances in a state of
decomposition, or of minute division or solution,
&c. — (^b.) The symptoms are, copious, feculent,
offensive, and, in some instances, involuntary mo-
tions, becoming scanty, watery, and frothy, and
preceded by borborygmi, or gurglings in the
abdomen — seldom by gripings or nausea ; a na-
tural or slightly foul, mucous, slimy, or clammy
tongue ; diminished temperature of the surface ;
and a soft, weak, or a natural, or but little accele-
I'ated pulse. — (c) This variety either ceases as
soon as the matters which occasioned it are ex-
pelled, or it assumes more severe characters.
When it has been produced by unwholesome
water, and particularly if this cause continues to
operate, it frequently passes into the 7nucous va-
riety, or into dysentery, or into a chronic state ;
and sometimes a low remittent form of fever
supervenes, terminating in disease of the mucous
follicles, and ulceration of the bowels, &c.

ii. Symptomatic Diarrhcea. — Classif. III.
Class, I. Order (Author).

7. Defin. — Frequent, and generally morbid,
alvine evacuations from disease of the bowels or col-
lalitioits viscera, often attended by fever.

8. A. Diarrhcea from acrid, or an increased
Secretion of. Bile (the D. Biliosa, of authors). —
(a) Bilious diarrhoea is a very common variety,
particularly during summer and autumn, and
amongst Europeans who have recently migrated
to warm or intertropical countries. It also fre-
quently occurs in persons who live intemperately,
in respect either of eating or drinking ; and in
those who are harassed by anxieties or the de-
pressing passions, especially if they be of the me-
lancholic temperament. It may be induced also
by violent fits of anger, or other intense emotions :
an aperient or purgative medicine may even ex-
cite it, if the biliary organs be loaded at the time
with morbid or acrid bile, and the liver be in an
excited state. It appears probable that irritation
of the duodenum, in the vicinity of the common
duct, may be propagated to the liver and pan-
creas, occasioning an increased secretion both of
bile and of pancreatic fluid ; and that, whilst such
irritation augments the vermicular action of the

upper part of the intestinal tube, thereby accele-
rating the passage of the chyme along it, the
quantity or quality of the secretions poured into
tiie duodenum excites the internal surface of the
bowels, increasing both their secreting and con-
tractile functions. — {b) 'i he evacuations in this
form of diarrhoea are at first feculen*, and com-
monly of a green or greenish yellow, or even
bright yellow colour : they afterwards become
more fluid and watery, vary in colour, and are
mixed with thin feculent matter. If the diarrhoea
continues, they frequently contain yellowish or
greenish yellow mucus, either in large thick
masses, or in thin, glairy, or gelatinous pieces,
which fall to the bottom of the pan, and admit of
being drawn into long filaments ; or they consist
chiefly of a serous fluid, coloured by the bile, and
presenting either a glairy mucus or albuminous
fiocculi, evidently owing to the irritation caused
by the acrid bile having been followed by in-
creased vascular action in the intestinal mucous
surface, and an excited state of its follicles. — (c)
In this case, bilious may pass into injiammatory
diarrhoea, in either of its forms, as constituting the
two following varieties ; or into dysentery.

9. B. Diarrhcea from Determination to, or in-
creased vascular Action in, the Intestinal Mucous
Coat — Injiammatory Diarrhwa (the D, Serosa, of
Sauvages,Good, &c. ; D. Aquosa, of Hoffmann).
— (a) This variety is caused by whatever occa-
sions a greater flux of blood to the intestinal
mucous surface, and a freer exhalation and secre-
tion than are natural, by obstructing these func-
tions on other surfaces : as the application of
cold, in any form, to the cutaneous or pulmonary
surface, or to both at once ; various mental emo-
tions, as anxiety, fright, surprise, &c. ; or even
the slightest agitation of mind in some consti-
tutions; cold acid beverages, or ices, taken when
the body is overheated or perspiring ; the sup-
pression of chronic eruptions, or copious or accus-
tomed perspirations or discharges : the disappear-
ance of abscesses, drying up of old sores, and
checked menstruation or lochial discharge. — (b)
The evacuations are vvatery or serous, mixed with
thin feculent matter, and exhibit every shade,
from a dark brownish, or. greenish brown, to a
pale, greyish, or whitish colour; and they con-
tain, in some cases, pieces of thick gelatinous
mucus, or a thin, glairy, and stringy mucus; in
others, whitish albuminous flocculi ; and, in a
few instances, large membranous or albuminous
shreds or flakes, moulded on the internal surface,
the intestine constituting the D. Tubutaris of Dr.
Good. The discharges in this variety are often
preceded by sickness or vomiting ; by severe
griping pains in the abdomen ; and are attended
by a dry, harsh skin ; increased temperature of
the trunk; a flatulent state of the bowels; a
small, frequent, constricted, but soft pulse; a
furred or loaded tongue, particularly towards the
root, with red edges and point; ancl scanty high-
coloured urine. The patient also often complains
of an aching, dull pain in the abdomen, some-
times increased by heavy pressure. — (c) Inflam-
matory action may not exist in every case of this
variety ; or it may not supervene until after simple
determination of blood to, or irritation of, the
mucous surface has continued for some time ; and,
even when present, it does not necessarily oc-
casion the diarrhoea. This variety occurring in

524

DIARRHCEA — Symptomatic.

infants constitutes what is usually called the
watery gripes (§ 15. )> &nd sometimes gives rise to
one or more intus-susceptions ; or it passes into
chronic diarrhoea, with disease of the mucous and
mesenteric glands ; or into slow remittent fever,
marasmus, and fatal exhaustion.

10. C. Diarrhiva from excited nr inflammatory
Action of the mucous Follicles {Catarrlnts lutes-
tinorum, of various authors; D. Catarrhalis, o(

BOERHAAVE ; D. MuCOSO, of CULLEX, GoOD, &C. ;

Ca^liaca Mucosa, Sauvages). — (a) This form
generally appears in the course of functional dis-
order of the digestive organs, particularly indiges-
tion, hypochondriasis, costiveness, and colicky
affections ; which may be viewed as predisposing
to it, by favouring the accumulation of mucous
sordes in the follicles and on the internal surface
of the bowels ; and is excited by t4re causes
already enumerated, especially those of the pre-
ceding variety (^ 9.). It occurs most frequently
in old persons, or in those who have suffered
from chronic disorders of the digestive organs ;
and in children, particularly during the period of
first dentition. — (6) The stools often consist en-
tirely of thin gelatinous mucus ; frequently, also,
of thick mucus, and a considerable quantity of
watery or serous fluid ; sometimes the mucus is
mixed with this fluid and thin feculent matter, or
is accompanied with small pellets of faeces ; and
occasionally it has the appearance of a semi-
transparent mucilage, passing into a muco-
puriform matter. Tl>e consistence of the motions
varies much ; and in some cases they are very
offensive, but in others without any odour.
In many instances they have a greenish or yel-
lowish green colour ; in others, an orange or
yellow tint: in a few cases, they are nearly
colourless, or white, and thin, constituting the U.
Alba of Hillary ; the Fluxiis Caliacus of some
writers: the Album Alvi Prof uvium of Piso ; the
D. Fituitosa of Sauvages ; the D. Cceliaca of Cul-
LEN ; the D. Chylosa, or l^ceta, of several
authors. These appearances are chiefly attribut-
able to the morbid action of the mucous follicles
in some part of the digestive tube, most probably
in the colon : to the presence or absence of the
biliary and pancreatic secretions ; and to the states
of these secretions. This, as well as the preced-
ing variety, may or may not be attended by fe-
brile symptoms, may assume the acute character,
and may pass into the chronic form, the mucus
discharges in this latter case often presenting a
light, whitish, or muco-puriform appearance, —
(c) When mucous diarrhoea continues for some
time, or becomes chronic, it occasions emaciation ;
a dry, harsh, or foul skin ; and, in children, gives
rise to marasmus, disease of the mesenteric glands,
&c. When it becomes c/u-idu'c, the stools sotne-
times assume a whitish, or mucilage-like, or grey-
isli appearance, evincing the absence of bile ; or
they pass into a muco-puriform state, occasionally
streaked with blood ; or they contain long whitisli
shreds, or threads; and consist either altogether
of these matters, particularly if the disease be
seated low in the large intestines, or of an ad-
mixture of thin feculent matter witii them, jiar-
ticuluily when the upper portions of the colon and
termination of the ilinm are affected. In some
cases of this forn), occurring during difficult den-
tition, or after the use of calomel or mercurials, or
upon the suppression of ptyalism, the stools have

consisted of a thin, ropy, mucus, of a translucent
hue, and have seemed to be chiefly augmented
pancreatic secretion. In children especially, when
mucous diarrhoea has assumed the chronic form,
the evacuations often present the chylons or milky
appearance just noticed, — the Chylous Diarriiaa
of Dewees and others. I'his state is attributed
by them to the presence of chyme, or imperfectly
eloborated chyle, which the lacteals refuse to ab-
sorb ; and to the absence of bile : to wl;ich
causes it is very probably partly owing, as well as
partly to the morbid secretions of the mucous sur-
faceand follicles. ^Vhateverappearance this variety
may assume, it is frequently followed by the next.

11. 1). Diarrhcea from Ulceration of the mucous
Follicles — (a) occurs either consecutively of the
two foregoing varieties, or in the course of several
febrile or chronic diseases ; in which cases, how-
ever, it is veryoften preceded by serous or mucous
evacuations, or by both. But ulceration may
take place without any such indication, and with-
out the bowels being much, or even at all,'j re-
laxed.— (6) The stools are usually muco-
puriform, streaked with blood ; sometimes con-
taining shreds or threads of albuminous matter ;
and mixed with thin, watery faeces, paiticularly
when the disease is seated in the small intestines or
caecum. When the large intestines are chiefly
affected, the muco-puriform discharges may con-
tain little or no feculent matters ; or these matters
may form distinct portions of the stools, or may con-
sist of detached pellets. In some instances, the stools
have been very dark, grumous, watery, and foetid ;
and, occasionally, merely thin, serous, or mucous,
or both, varying in colour, and more or less fecu-
lent and offensive ; and yet ulceration has never-
theless existed. In rarer cases, they have been
quite black, grumous, and melanoid ; or resem-
bling ink, probably from the admixture of blood
exuded in the small intestines, and changed by the
action of the secretions — whether healthy or
morbid. — (c) In this variety of diarrhoea, the
emaciation becomes extreme, and the skin as-
sumes a dry, harsh, foul, or lurid appearance.
The pulse, in its latter stages, is quick, small, and
weak. Aphtha? sometimes appear on the lips and
tongue ; and hectic fever, with exhaustion, prevails.

12. E.Diarrhaa icith the Discharge of unaltered
Ingesia ; Lientery ('AsiEvrspia, Gr. ; Lubricitas,
vel Levitas Intestinorum, Lat. ; D. Lienterica, of
Cullen ; the Lienteria of Sauvages and others)
— («) occurs more frequently in children, before
the period of the second dentition, than at later
epochs ; and it is generally the consequence or se-
quela of inflammatory irritation of the digestive
mucous surface, aud disease of the mesenteric
glands — of the advanced stages of these patho-
logical states. It i-most common during the first
dentition, particularly when the canine and molar
teeth are about to appear ; and, in this class of
patients, as well as in adults (in which latter it is
comparatively rare), it either follows dysentery,
or is a concomitant of the last stages, or chronic
states, of one of the preceding varieties, — com-
monly of the serous or mucous — than a primary
form of the disease. It is caused by the same re-
mote agents which induce these its primary con-
ditions ; and it evidently depends upon a similar
state of increased peri'-taltic action, and deficient
vital function of the stomach and duodenum, to
that which obtains in the intestines ; the food

DIARRHCEA

being thereby propelled onwards before it has
undergone the changes usually produced by these
organs, and discharged from the bowels but little
altered from the condition in which it passed into
the stoniarii. — (h) The appetite is usually vora-
cious in this variety, particularly in children, al-
though the emaciation and debility may be extreme.
The biliary secretion is also deficient or vitiated ;
and, in some cases, it appears nearly or altogether
wanting in the stools, owing rather to the weak or
imperfect action of the liver, than to obstruction.
— (f) It usually terminates in stupor, and death
from exhaustion ; although recovery sometimes
takesplace when itiseaily and judiciously treated.

13. II. Of certain Relations and Mani-
festations OF DiAURiicLA. — i. The Catues of
this disease have been noticed in the description
of its different varieties. — (a) Diarrhoea is most
frequent in childluwd, particularly during dentition
and in persons of a weak constitution and lax fibre ;
and in those addicted to spirituous liquors. 1 have
observed a tendency to it in some families —
sometimes in all the children of a family, one of
the parents being possessed of the same liability. —
(6) It is endemic in some places, evidently owing
either to their humid, close, and miasmal situ-
ation, or to an impure state of the water espe-
cially in large cities or towns ; or to the nature of
the food in common use. — (c) The epidemic
prevalence of diarrhoea has been noticed by
BAnTHOLiNus (Hist. Anat. cent. ii. his. 65.),
Sydenham {Opera, p. 160. 209.), and Leich-
NER (De Diarrh. quadam Epid. Erf. 1676.) ;
and, in some summers and autumns, its fre-
quency has been so great, within my own
experience, especially in children, as to justify
me in stating that it sometimes assumes this
form. — (</) It has also occasionally put on a
periodic character, particularly when it has arisen
from endemic causes, and been connected with a
masked or latent intermittent. It has appeared
monthly, in females whose menstrual disciiarges
have been suppressed, — and thus constituted a
substituted evacuation.

14. ii. Puerperal Diarrha;a may occur either
very soon, or a few days, after delivery. It is
occasioned by a neglected state of the bowels
previously — by the irritation of collected faeces,
or by the irruption of morbid secretions into the
intestines. When it proceeds from the former
cause, the evacuations are feculent, lumpy, ofl'en-
sive, and attended by some degree of tenesmus ;
when from the latter, it is often accompanied with
sickness, or vomiting, and sometimes with cramps
of the lower extremities; the stools being foetid,
bilious, dark green, or greenish yellow, with
whitish flakes floating in them. It may be con-
nected with suppression of the lochia or of the
milk ; but, in such cases, it is rather the cause
than the effect of the suppression. It commonly
originates in one of the states of disorder now
mentioned, or in both. \Vhen, however, such a
degree of irritation of the bowels is produced, as
will be followed by excited vascular action, sup-
pression of either the m.ilk or lochia, or both,
may follow with more or less febrile commotion.
Cases of this description usually do not super-
vene until a few days after parturition ; and are
attended by the phenomena of serous or inflam-
matory diarrhoea, with disordered biliary secre-
tions, offensive dark stools, with albuminous

Relations and Manifestations of.

525

whitish flakes or flocculi, quick pulse, and
symptomatic disorder of various functions, fa-
voured by the puerperal state. The more strongly
marked cases of this form of disease, pass into
and constitute wdiat has been termed Jnlestinal
Fever by Burns and others. (See Fevers of the
Puerperal Slate.} The slighter cases even not
infrequently terminate in chronic inflammation
of the intestinal mucous surface, with all the
symptoms of mucous diarrhoea, or of ulceration
of the follicles, or of dysentery.

15. iii. In Infants and Children, diarrhoea is
remarkably freciuent, especially from the com-
mencement of dentition — or the time of weaning, to
the third year of age ; and is, in respect both of its
phenomena and of its contingent efl^ects, a most
important disease. These states of it which are
identical with those generally observed in the
adult, have already been noticed, particularly the
serous, 7nacous, and lienteric. — a. The frst of
these, in the form of icatery gripes, may appear
previously to the period of dentition ; and then it
is connected with the state of the nurse's milk, or
too early or over feeding, which induces acidity
of the prima via ; with either inflammatory ex-
citement of, with augmented secretion from", the
mucous suiface, or increased and irregular
action of the muscular coat , or both. In either
case, the disease may be very acute — may run
on to unequivocal inflammatory action, and may
occasion introsusceptions, with scanty, dark,
watery, or mucous and bloody stools, terminating
in convulsions and death ; or it may be prolono-ed
into the chronic state, owing either to neglect, to
the continuance of the causes, or to injudicious
treatment. When it lapses into this state, the
evacuations become very offensive, watery, of a
dark green, brown, or curdly appearance ; are
preceded by severe griping ; and are voided sud-
denly and violently, frequently with much flatus
and straining. In these cases, there are also more
or less febrile symptoms ; and, in its advanced
stage, often a raw or aphthous state of the
mouth; the disease assuming the lienteric form,
or occasioning rapid exhaustion. In such cases,
moibid secretions, and knotty or curdly faeces,
frequently are retained aboilt the sigmoid flexure
of the colon; and fatal cases generally present
the termination of the ilium, the caecum, and
lower part of the colon, more or less chanoed in
structure: or exhibit, along the greater part of
the digestive canal, the appearances usually con-
sequent upon inflammatory action of the mucous
surface.

16. 0. Diarrhoea Is also very common in deli-
cate children, at the period of iceaning ; and, in
many cases, is connected also — although not
necessarily — with the irritation of difficult denti-
tion. It usually assumes a chronic form ; and is
most severe and most rapid in its progress in
infants who have been much too early or ab-
ruptly weaned, and improperly fed at the time,
or afterwards. '1 his form of diarrhoea was de-
scribed very minutely by Dr. Ciieyne, under the
term " Atrophia AbUictatorium," or " Weaning,
brash ;" and afterwards by CnuvEii.iiiEn, An-
dhai., and others, 'I'he evacuations are usually
greenish, watery, or slimy ; sometimes ash-
coloured and lienteric, and attended by griping
pains, often by retchings and vomiting, with
symptomatic fever. The appearance of the stools.

526 DIARRHOEA — Termination and Appearances on Dissection, etc., op

however, varies very remarkably ; but they

generally partake more of the serous, bilious, or
lienteric characters, than of any others ; thereby
indicating, what, indeed, is displayed on dissection,
namely, the inflammatory nature of the disease,
and its extension along the alimentary canal, and
even to the hver. It usually occurs during sum-
mer and autumn, particularly when the seasons
are moist and hot; and is seldom of shorter
duration than four or five weeks, or longer than
three or four months. It is evidently a milder
grade of the same pathological states which give
rise to the disease I have described under the
name of Choleric Fever of Infants : and, although
it is connected in its advanced stages with inflam-
matory action, yet it is very probable that the
inflammation is of an asthenic kind ; and that it
originates in irritation produced by acrid and
morbid secretions, and by imperfectly digested
and improper food, or by an unhealthy state of
the nurse's milk. It is attended by great ema-
ciation and debility, and frequently terminates in
fatal intus-susceptions, convulsions, or coma from
exhaustion, or serous effusion within the head, or
from both.

17. y. In rarer instances, a peculiar form of diar-
rhoea occurs after weaning, in which the stools
are not so very frequent or abundant, but they
are pulpy or semifluid, of a clayey colour, and
very offensive ; and accompanied with an abun-
dant secretion of pale, ammoniacal, albuminous,
and foetid urine, — both the stools and urine
emitting a nearly similar smell. The abdomen
is full and soft ; the skin generally cool ; the
mouth, lips, tongue, and fauces are red ; and the
debility great: emaciation rapidly follows; and,
in some cases, the bones yield from the absorption
of the phosphates, which are probably carried off
by the urine ; the disease partaking as much of the
characters of diuresis, or albuminous diabetes, as
of diarrhoea. A bilious form of diarrlicea may
also orcur as a symptom of incipient disease of the
membranes of, or effusion into, the ventricles; or
irritation about the origin of the nerves.

18. iv. The Dark Races of our species, parti-
cularly the negro, are much more liable to diar-
rhoea than the white ; and in them it usually
assumes a chronic state, and frequently the mu-
cous form. It also very commonly presents ast/ie-
nic characters, is often complicated with intestinal
worms, and is prone to pass into dysentery, or to
be followed by rapid depression of vital power.

19. III. AssociATiONSOFDiAnnHosA. — (a)This
affection may attend thecommencement of dangerous
maladies, particularly fever, dysentery, pestilential
cholera, hepatitis, meningitis, &r., owing to irri-
tation of tiie mucous coat of tiie intestines, to the
flow of morbid or acrid secretions into them, Sec.
the evacuations being feculent, bilious, mucous, or
serous. — (/;) Its occasional association with gout
has been noticed by Sydenham, Baci.ivi, Mus-
ORAVE (De Arthrit.Anom. cap. 4.), andLouENZ ;
and has given rise to the 1). Arthritica of Sau-
VAOES. In children, it is very often complicated
with bronchitis, especially during dentition. It
may constitute a serious, or even dangerous, com-
pliculinn in low remittent or continued fevers in

scarlatina, small-pox, measles, hepatitis, &c. ; .„ j,..., „,.,.„^ ..^ ..,, > ,..„., ,. „..,,j.^ ,„

and may proceed either fiom determination of wliicli hi; lost somucli 1)1()0(1 tli;it hcratlicclwith ailHculty.
vascular exdtement to the abdominal v.sccra^]^'^:::^^;\l::Xr::;l::l^^^^
particularly the mtestmes ; or from inflammation, ' some years altcrv.aids, liad not rcturncil.

ulceration, &c. of the mucous coat in some part
of the canal, especially after retrocession, or re-
pulsion of the eruption in tiie exanthemata ; the
stools being serous, dark-coloured, with whitish
flocculi or flakes, or mucous, and sometimes
bilious. It is also often associated, in its chronic
states, with mesenteric disease and woims. — (c) It
may be critical in several febrile and inflamma-
tory diseases; the discharges being bilious, homo-
geneous, &c. (See Crises, § 8.) — (d) It is
also frequently colliquative, or the result of ex-
haustion of the constitutional powers from pro-
tracted disorganising disease — as pulmonary
consumption, chronic abscesses, diseased joints,
hectic fever, and morbid states of the blood,
caused by the absorption into it of purulent or
other matters generated in any part of the body.
In such cases, it more directly depends upon dis-
ease affecting particularly the mucous follicles,
the tone or vital cohesion of the m.ucous surface
and vessels supplying it being diminished, and
the evacuations being mucous or muco-puriform,
or serous and grumous, or sero-puriform and
partly feculent. Colliquative diarrhoea is also
frequently dependent upon ulceration, apparently
commencing in the follicles, and often without
any evidence of antecedent inflammatory action,
at least of asthenic kind.

20. IV. Duration, Termination, and Ap-
pearances ON Dissection. — A, Diarrhoea, par-
ticularly in its idiopathic state, is generally of
short duration ; but bilious and mucous diarihcea
may be much longer protracted. I have seen the
former continue, in a warm climate, for several
months ; and, in this country, nearly as long,
sometimes with short remissions. The serous and
mucous varieties often assume an acute character,
in respect both of intensity and duration ; but
they frequently also, particularly the latter, de-
generate into the chronic form ; either retaining
their specific distinctions, or assuming those of
ulceration or lientery. When the disease has even
been cured, there generally remains during life
a liability to its return, particulai'ly when it has
passed into the chronic state, and has possessed
the mucous character. A slight diarrhoea may
continue the greater part of life, and at last pass
into dysentery.*

21. B. Diarrhoea may fei'«n"?(af<? — (a) in dy-
sentery, from an increased affection of the large
bowels, frequently connected with inflammatory
action or ulceration of their mucous surface and
follicles, and spasmodic action of the lower part
of the colon : — (b) or it may run into enteritis, or
even peritonitis, particularly when it commences
in the serous form, owing to the extension of in-
flammation from the internal to the more external

* Some years ago, I was consulted by a well-known and
eminent person, past tlic nii<l(lli^ age, of the san{,'ulne
tem])erament and pletlHirii- lialiit of body, and a rigid
water-drinker, who bad always liad diarrha-a — at least
tor twenty years. He was directed to be blooded ; and
the diarrhoea was moderated merely, without being
eheelied, when it became unusually troublesome, as apo-
plexy was dreaded, and as he was otherwise in excellent
iiealth. Soon afterwards, he went to South America,
where the diarrhoea passed into acute, and, afterwards,
chronic dysentery, which reduced him, from a full and
almost corpulent habit, to a state of extreme emaciation.
In this state he met with a dangerous a(!(idcir

coats of the intestines ; or to the perforation of
them by ulcers ; and it may end in abdominal
dropsy : — (c) or it may give rise to convulsions,
to intus-susceptions, particularly in children :
and — ((0 it may assume ihe chronic form, varying
in severity and duration, and occasioning mesen-
teric disease, emaciation, and exhaustion ; and it
may be prolonged even for years, with irregular
remissions and intermissions.

22. C. The Appearances on dissection can be
ascertained only in severe or chronic cases, or in
those who have died of its complicated states ; or
of some other disease on which diarrhoea had
supervened, or with which it was associated. In
some recent or slight cases, the mucous coat of the
intestines has been found quite pale and blood-
less ; and the follicles, only, more developed than
usual. In others, it has been somewhat softened,
or merely injected ; occasionally it has been con-
gested and discoloured, the injection or congestion
generally existing in patches or streaks, between
which it has been quite pale. In more chronic and
severe cases, it has likewise been pale, anasmic,
and softened ; in some, inflamed, congested, and
of every shade, from a rose tint, to a brownish or
purplish colour — commonly in streaks or patches.
In some instances, either without, or in addition
to, these and other appearances about to be no-
ticed, the mucous and submucous tissues have
been cedematous, thickened, and very much soft-
ened. Inspissated mucus, or even coagulable
lymph, and more frequently a thin, brownish or
greyish, or puriform mucus, have been found co-
vering the diseased surface. In some cases of
children, the intestines have become soft, white,
almost diaphanous, and easily torn ; and have
contained a purulent, custard-like matter. Their
calibre, in a few instances, has been greater than
usual; but mucli more frequently diminished, or
even much and irregularly contracted, particu-
larly in the part chiefly afl^ected. In some in-
stances, small pustules, containing purulent matter,
iiave been observed, apparently unconnected with
the follicles ; and, upon breaking, have left merely
a slight, superficial, and reddish ulceration, or
excoriated-like surface (Bright and myself).
Both the small and large intestines have occa-
sionally presented one or more intro-susceptions
— sometimes a number, especially in infants and
children ; and, in fatal cases, soon after weaning,
softening, with or without inflammatory appear-
ances, has often also existed in the stomacli and liver.
The intestines have been, in some instances, of a
darker hue than natural, externally, as well as in-
ternally ; either in large portions, or throughout,
and occasionally in thickly disseminated dots or
points. The mucous glands, particularly in severe
or chronic cases, and those belonging to the mu-
cous and lienteric varieties, have been very gene-
rally found either prominent, enlarged, inflamed,
or the seat of ulceration, or of a dark, or blackish
colour, by Brunner, Stahk, Lieutaud, Baxg,
Abercrombie, Bright, Andual, Annesley, and
myself. Fungoid ulcers in the situation of the
follicles, often with prominent and inflamed bases,
have likewise been observed by these writers.
Brunner (De Gland. Duodeni, &c.) noticed
their prominent and enlarged state in the duo-
denum ; and Stark (Klin. Bemerk, &;c. c.p.7.)
principally in the large bowels. I have often ob-
served them enlarged^ or otherwise diseased, in

DIARRHGEA — Diagnosis. 527

the former of these situations, in cases of the lien-
tery and atrophy of children ; but those of the
caecum of the termination of the ilium, and of the
colon, are more frequently afl^ected in this class of
patients. The mesenteric glands are often inflamed,
or enlarged, or indurated, particularly in young
subjects and in chronic and lienteric cases. The
gall-bladder sometimes contains greenish bile ;
and the liver is occasionally more vascular than
natural. The parts most commonly or most
severely diseased are the ilium, especially its
lowest third, and the caecum. The absence of
any appreciable lesion in some cases ; and the
slight nature of those observed in others, militate
against the doctrine of Broussais as to the uni-
versal dependance of diarrhoea on inflammation
of the intestinal mucous surface. He, however,
contends that the blood had retired, in such cases,
from the inflamed capillaries into tiie veins, at the
time of, or after, death ; thereby leaving no traces
of inflammation observable on dissection. This
change may occur in vessels that are simply ex-
cited, or after erethism merely of the mucous coat
(states most frequently attendant upon slight
diarrhoea) ; but not when inflammation has actu-
ally existed. (See Digestive Canal — Pa-
thology of.)

23. V. Diagnosis. — (a) DicLrrhoea is dis-
tinguished from dysentery by the tormina and
tenesmus; the scanty, mucous, and bloody eva-
cuations ; and the more early and marked febrile
symptoms of the latter. In it, the c:ills to stool
are almost incessant, and abortive, and the mo-
tions are nearly destitute of faeces, or sometimes
contain scybalaj. In the former, the griping pains,
even when most severe, never equal the tormina
of dysentery ; of which the distressing tenesmus,
the quick pulse, the increased frequency of the
calls to evacuation during the night, the presence
of strangury, are also pathognomonic. — (6) Di-
arrhoea differs from cholera, in the much less
seveiity of attack; by the absence of spasms
of the extremities : by the entire absence, or oc-
casional occurrence merely, of nausea or vomit-
ing; and by the milder character and less rapid
progress of the former. Bilious diarrhoea, how-
ever, is sometimes merely a slighter form of bilious
cholera ; the existence of spasms in the latter
constituting the chief difference, excepting as to
grade : and pestilential cholera very frequently
commences in some one of the common forms of
diarrhoea. — (c) Diarrhoea differs, in certain of
its varieties — especially the fourth, fifth, &c. — •
but little from inflammation of the internal surface
of the intestines, excepting as respects the activity
or acuteness of the affection, and the extent to
which the constitution sympathises with the local
disease. But although certain states of diarrhoea
are chiefly owing to inflammatory action, still this
action is attended by increased exhalation and
secretion from the mucous surface, whilst inflam-
mation, either limited in extent, or of a low grade,
may exist in this situation, and particularly in the
follicles, without the alvine evacuations being
either frequent or increased, and even in some
instances they may be constipated. It is chiefly
from the quickness of the pulse, and tiie evening
accessions or exacerbations of fever; from tiie
sensations of the patient on pressing and examin-
ing the abdomen; from the temperature and state
of the skin, particularly in this situation ; and

528 DIARRHOEA — Treatment of

from the wliltish, furred, or reddish appearances of
the tongue, and the state of the discharges ; that
the existence of inflammation of the mucous sur-
face or follicles of the intestines, in diarrhoea, or
independently of diarrhoea, can he inferred.

24. VI. The Prognosis— (a) of idioputhic dhr-
rhoea is generally favourable : it is usually slight,
and soon subsides after the removal of tiie ofl^ending
cause. There are, however, fevi' disorders that
will be more readily aggravated, or converted into
a more serious disease by injudicious treatment.
— (6) The symptomatic varieties of the complaint
are to be viewed entirely as respects the pathologi-
cal states which occasion them. The serous and
mucous forms, especially when they assume the
clirouic state, or occur in children after weaning,
should always be considered as serious affections,
and a cautious prognosis ought to be given. The
varieties referred to ulceration, and to the appear-
ance of undigested substances in the stools, are
very dangerous diseases, requiring the most ju-
dicious medical treatment and regimen ; and,
even with these advantages, the larger proportion
will terminate fatally. — (c) The complicated
states of diarrhoea, unless those attending the com-
mencement, or marking the crisis, of diseases, are
all more or less serious or unfavourable, especially
colliquative diarrhoea. The degree of danger they
portend is particularly noticed in the articles on
the maladies with which they are most com-
monly associated. In all the forms and states of
this complaint, the causes, the effects of previous
treatment, and the constitution, the habits, and
existing state of the patient, ought to be carefully
considered before we form an opinion of the ulti-
mate issue.

25. VII. TRnATMENT. i. OfloiOPATHIC DlAR-

RHCEA. — A. The Feculent form, or Diarrha-a of
Irritation, when recent, requires demulcents or
diluents merely, in order to facilitate the discharge
of acrid or accumulated matters. This having
been accomplished, disorder soon ceases. But
the irritating substances may be partly retained,
and keep up a prolonged, or remitting state of dis-
ease, with griping pains and scanty stools, which
may be partly feculent, mucous, or serous — the
latter predominating when the irritation is con-
siderable. In this case much discrimination is re-
qui-ite in selecting the aperient which is obviously
required ; for, if it be insufficient, the disorder will
be prolonged ; if it be too active, either super-
purgation or inflammation will be occasioned. In
such cases, a moderate dose of fresh castor oil ; or
the compound infusion of senna with manna,
tartrate of potash, and an aromatic, sometimes
with tincture of hyoscyamus ; or, when the sto-
mach is not irritable, rhubarb with magnesia, and
a grain of ipecacuanha, in aqua pimentaj, &c.,
will generally have the desired effect. In some
circumstances, five or six drops of the tinct. opii,
in the aperient draught, will both moderate its
operation, and render it more effectual. If hyper-
catharsis be occasioned by the pur;j;ative, a full
doseof laudanum, or from one to two drachinsof the
old paregoric elixir, with external warmth, &.c. will
soon calm the irritation. When the bowels have
been previously constijiated, and there is any ten-
sion, or hardness, or fullness of the abdomen ; or
when the stools are partly faical and partly mu-
cous, or dark-coloured, serous and muddy ; a mild
purgative, such as already advised, will be neccs-

Idiopathic and Symptomatic.

sary. The practitioner should take into consider-
ation the habits of the patient as to exercise and
modes of living, and every argument for or against
the existence of accumulated faeces in the bowels,
and be thereby guided in his practice. When he
observes sufficient indications to warrant the ex-
hibition of a purgative, the effects produced by it,
the persistence of the irritation, and the state of
the abdomen and of the evacuations, will influence
him as to the propriety of repeating it, or of pre-
scribing other medicines. If the first purgative
have not produced a satisfactory effect, if there be
no tenesmus, and if the stools are not very mucous,
it will generally be advisable to give a full dose of
calomel and of James's powder at bed-time, and
either of the purgative doses already noticed early
in the morning. VVhen this form of diarrhoea
appears to have arisen from acidity in the prima
via, particularly in children, with green, spinach-
like, or knotty or scybalous evacuations, a full dose
of calomel, or hydrarg. cum creta with magnesia,
or magnesia only in aniseed water, followed by
castor oil, will generally be effectual.

26. B. Diarrhoea from Relaxation, or from the
septic and irritating operation of the injurious in-
gesta, either solid or fluid, mentioned above (§ 6.),
— requires demulcents combined with aromatics,
particularly the confect. aromatica, capsicum, and
other hot spices. If the action produced by the
offending substances on the bowels have been suf-
ficient to have procured their complete discharge,
this may be all that is necessary. But if we
suspect, from the associated phenomena, that a
part of them has been retained, the treatment now
advised for the removal of fascal matters, should
be adopted, with the addition of the aromatics and
restoratives just mentioned, in quantity propor-
tionate to the urgency of the case. In cases of
diarrhoea arising from putrid matters, capsicum is
almost a specific, especially when it is occasioned
by fish : burnt brandy is also beneficial in these,
after the ofl^ending matters have been expelled.
When either of the foregoing varieties passes into
the c/iroHic state, the same treatment will be requi-
site that is recommended for the chronic mucous
form of the disease (§30, 31.).

27. ii. Or Symptomatic Diarrhcea. — A. The
Bilious variety should be treated with strict refer-
ence to the presence of griping pains, and the
colour of the stools. In this disorder, calomel
has been much loo indiscriminately prescribed.
In every case of it, the existence of pain or of
heat about the region of the liver, about the
shoulder blades, &c., or of fulness in the epi-
gastrium, should be ascertained ; and, if these
exist in any degree, the treatment should be com-
menced with blood-letting, or cupping, or leeches
on the prKcordia or hypochondiia. An excited
state of the substance of tiie liver may be present,
without any increased frecjuency of pulse or lieat
of skin ; therefoie the absence of fever should not
prevent the adoption of depletion, which may even
be repeated. Next in importance to depletion,
is the use of demulcents, lubricating infusions, or
diluents with nitre and carbonate of soda, and
small doses of antimony, or of camphor, particu-
larly if the papilla of the tongue be erect, and the
stools are not ofl^ensive, nor dark, or greenish co-
loured. If they be either, or both, and if the
tongue be foul, a full dose of blue pill, or hydrarg.
cum creta, may be given, and followed by castor

DIARRHCEA — Treatment of SEnors and Mucous. 529

oil, or any other purgative already mentioneci, or
by the medicines of tliis kind in the Appendix
(F. 96. 205. 430.). When the bile, from either its
acridity, or its quantity, occasions much irritation,
the rectum becomes often excited to spastic con-
striction, thereby preventing the discharge of fffical
and more consistent matters, and occasioning
tenesmus, or superinducing dysentery. In order
to prevent this, or to remedy it at its commence-
ment, the refrigerating demulcents just noticed
may be associated, or alternated, with cooling
laxatives, and the retention of the morbid secre-
tions in the colon guarded against, and their irri-
tating properties diminished by emollient ene-
mata. The too early exhibition of astringents or
opiates is often injurious in this variety; for,
although they may aftbrd relief for a few days,
and the patient may think himself cured, yet he
will soon afterwards complain of uneasiness in the
abdomen, and region of tlie liver, with fever, foul
or furred tongue, and all the symptoms of hepatic
disease, which may be soon followed by inflam-
mation of the substance of the liver, or dysentery.
When we suspect that the diarrhoea has been in-
duced or kept up by irritation in the duodenunij
the treatment above recommended is quite appro-
priate ; and the refrigerants already prescribed,
with -demulcents and a mild and low diet, should
be continued sufficiently long to take effect. Bil-
ious diarrhoea may accompany di//z'cu/t dentition;
and in this case, lancing the gums, and the treat-
ment advised in that article, siiould be adopted.

28. 73. Diarrhwa from Vasciilur Eicitemenl, or
Serous diarrhcea, should be treated with reference
to the cause which produced it. — (a) If it have
arisen from the irritation of morbid matters, and
if tiie symptoms indicate their partial retention,
laxatives or mild purgatives are requisite; but it
will not always be safe to exhibit them until
general or local depletions, especially leeches
aaplied to the anus, warm baths or fomentations,
and demulcents with refrigerants, have been
employed. Any of the mild purgatives recom-
mended above, or F. 790., may be afterwards
exhibited, and their action promoted by demul-
cent and aperient enemata. — {!>) When, however,
neither fiEcal nor other injurious matters are re-
tained, depletions should be accompanied witli,
and followed by, the internal exhibition of the
nitrate of potash, with carbonate of soda, and
tincture of hyoscyamus (F. 838.), or tinct. opii
comp. ( F. 729.), or the paregoric elixir, in de-
mulcent vehicles (F. 728. 866.) ; and if nausea
be not present, with vinum ipecacuanhas. —
(c) When this form of aflection arises from
checked perspiration, diaphoretics, diluents, the
warm bath, a warm bed, and mild, demulcent
or farinaceous diet in small quantity, will gene-
rally remove the disorder in a very short lime.
If it be attended by any heat of skin, or accelera-
tion of pulse, the liquor ammonia; acetatis,
nitrate of potass, and camphor julep (F. 865.
871.), will be of much service. — (d) If the
motions be frothy, or emit a sour smell, the
chalk mixture with ipecacuanha and opiate, or
» aromatic confection, will be requisite ; and if
griping pains with tenesmus be complained of,
the pulv. ipecacuanha; comp. with carb. of soda,
mucilage, oleum anisi, and aqua pimentas, may
be given ; or the old paregoric elixir (F. 728.) in
chalk mixture, and assisted by small emollient
Vol. I.

and anodyne clysters. — (e) These will generally
soon remove the complaint ; but when it has be-
come nwre chronic, or is very severe at the outset,
or is attended witii tenesmus, or seems inclined to
pass into dysentery, from eight to twelve leeches,
in addition to the previous depletion, should be
applied close to the anus, and repeated if necessary,
the medicines now recommended (</) being also
exhibited in a more decided manner.* In this
form of diarrhoea especially, little or no food
should be allowed, excepting the lighter farina-
ceous articles, as sago, arrow-root, rice-gruel,
tapioca, &c. When the complaint has subsided,
and the appetite become craving, or when much
irritation of the lower bowels exists, chicken,
veal, or mutton broth, may be taken; and the
same articles, after having been strained, may also
be exhibited in clysters.

29. C. DiarrhcEa from Disease of the Mucous
Follicles — Mucous Diarrha:a. — (a) Emetics
have been recommended in diarrhoea by Hippo-
crates, Celsus (lib. iv. cap. 19.), Pichonet,
Fontaine, Sydenham, Bang, and Yogel ; but it
is in this variety that they are most serviceable,
particularly in its more recent states. In it, also,
purgatives are required more than in any other.
Ipecacuanha is the most appropriate emetic, and
small doses of it will likewise be advantageously
conjoined with the purgatives or other medicines
prescribed. I have usually directed, if the dis-
order was not removed by two or three doses of
the more common purgatives, equal quantities of
the oleum ricini and ol. terebinthina; to be taken
on the surface of a suitable veliicle, each alternate
morning ; a dose of calomel or hydrarg. cum creta,
sometimes with Dover's powder, having been
given the preceding night, if tenesmus was not
complained of; and although tins practice has
been pursued by me in some hundred instances in
the Infirmarj' for Children, besides occasionally in
adults and in private practice, I have never been
disappointed in its effects. If, however, it does
not very soon remove the disorder, we should
suspect the existence of inflammatory action, and
have recourse to local depletions, particularly
from the anus ; to warm baths, fomentations, rube-
facient cataplasms or blisters, on the abdomen,
and to a repetition of the alteratives and refrigerants
already advised. After morbid or accumulated
matters have been removed, and the mucous

* This form of diarrhcea isVcry common in persons ad-
dicted to the use of spirituous liquors; and it is, in them,
frequently attended by vomiting, and severe infla;nmatory
symptoms refcrrible to the duodenum, and by chronic
disease of the biliary apparatus. A case of this descrip-
tion, in a married female of good circumstances, was seen
by me, in consultation with an able practitioner, whilst
this slieet was in the press. She had, in addition to the
above complication, long complained of difficult and very
scanty menstruation ; this evacuation being watery, and
of a greenish colour. Slie had been blooded locally, and
very judiciously treated. As the return of this discharge
was expected, and taking into account the previous treat-
ment, the following were prescribed; the biborate of
soda, chiefly on account of the scanty catamenia : —

No. 174. 1^ Hydrarg. cum Creta gr. iv. ; Pilul. Saponis
cum Opio gr. v. ; Syrupi ^Simp. q. s. Fiant Pilulae ij.
omni nocte capienda?.

No. 17.'j. B Soda? Bi-horati* 3j. ; Aqn.-E Famiculi
dulcis 3xj. ; Tinct. I>.avandul Comp. 3j. ; Tinct. Opii.
HI. vj. M. Fiat Haustus, quater in die sumendus.
The purging ceased ; the motions became feculent, and of
ahealthier colour ; the severe paroxysms of pain, and the
tenderness complained of in the region of the duodenum,
and ducts subsided ; and the catamenia became, after a
few doses of the biborate of soda, copious and more
natural.

Mm

530

jDlARRHCEA — Treatment of Lientebic.

follicles excited by these medicines to a more
healthy action, aromatics, cretaceous powders or
mixtures, and the pulvis ipecacuanhaj compositus,
or small doses of opium or the paregoric elixir,
may be prescribed. Care should be taken not
to exhibit astringents or opiates before morbid
secretions have been discharged, nor to allow the
bowels to become constipated, otherwise a chronic
state of the disease or dysentery may supervene.

30. (b) The chronic form of this variety usu-
ally arises either from a neglected or injudiciously
treated acute stage, or as a sequela of dysentery ;
it is also very common in children ; and often oc-
casions, as well as attends, obstructed mesenteric
glands. There is no ailment, particularly when
existing in children, that requires more discrimin-
ation that this. If, after an attentive enquiry
into the history and previous treatment of the
case, as well as into its existing state, we find the
abdomen hot, the skin dry and harsh, the tongue
red at its edges, or its papilla3 erect, and the
pulse excited but not weak, local depletions are
required, and should be followed by the tepid or
warm both, or by fomentations, and by moderate
doses of the purgatives last recommended. As
soon as the stools are improved by these means,
aromatics with opiates, or absorbents, or both
(F. 623. 633.), may be prescribed ; and warm
clothing, with light farinaceous food, allowed. If
these means be insufficient, a blister, or rube-
facients, iScc. applied over the abdomen, and the
hydrargyrum cum creta, with the pulvis ipecacu-
anhae comp. (F. 653.), and small doses of rhubarb
given night and morning, or even oftener, will be
of much service. I have frequently prescribed,with
the greatest benefit, in chronic cases both of this
and the preceding variety, the biborate of soda,
with honey, and the compound powder of traga-
canth and capsicum.

31. (c) Chronic mucous diarrhcea, vfhh whitish,
greyish, or mucilage-like stools, arising from the
absence of bile, the imperfect absorption of the
chyle, and the morbid state of the mucous secre-
tion, requires low diet, consisting entirely of fari-
naceous substances. At the same time, the hy-
drarg. cum creta ought to be exhibited twice or
thrice daily, with the carbonate of soda or potash,
and minute doses of opium. A tonic or stomachic
powder or mixture should also be prescribed, with
the warm bath, and frictions of the surface upon
coaling out of it. If these means fail, there is
probably disease of the mesenteric glands, — the
liquor potassffi may be given in beef-tea, the mild
mercurial continued every night, and the purgative
draught already directed (§ 29.) also be tried.
In some obstinate cases of this kind, I have resorted
to the chlorates of the fixed alkalies or of lime,
conjoined with the compound tragacanth powder
and aromatics (F. 283.), with great benefit. It
will generally be necessary in this state of the dis-
ease to rouse the digestive and assimilative func-
tions by tonics, and the action of the liver by mild
mercurials ; and to combine these remedies with
antacids, or with demulcents and aromatics, or
with balsams or the terebinthinates. The infusions
of calumba, or cascarilla, or cinchona, or cusparia,
with sesqui-carbonate of ammonia, and confectio
aromatica, may be first employed ; and afterwards
the balsams, or vegetable and mineral astringents.
In more obstinate cases, the warm salt-water bath,
or a tonic, stimulating, or gently rubefacient

plaster to the abdomen or loins, or both, may he
prescribed, and the trunk surrounded by a flannel
roller ; a Ught farinaceous diet being allowed.
The treatment now described is requisite equally
in children as in adults. This form of chronic
diarrhoea is most common in the former ; and
when it is connected with dentition, requires con-
stant attention to the state of the gums.

32. D. Diarrhcea from Ulceration requires very
nearly the same treatment that was recommended
for chronic mucous diarrhcea (§ 31.), of which
it is generally only a modification or conse-
quence. When the evacuations in this variety
are fluid, or muddy and fcEtid, and without tenes-
mus, the disease is most probably seated in the
small intestines ; and when arrested by opiates
and astringents, uneasiness at the stomach, with
nausea and sickness, are usually produced.
Besides the means noticed in the preceding
paragraph, the terebinthinates and balsams
may be given, with small doses of rhubarb,
magnesia, tragacanth, &c. The mistura cretae,
with tinct. camphorae comp, and mucilage; the
decoction of logwood, with laudanum; the hy-
drarg. cum creta, with pulv. ipecacuanhas comp.,
and either an aromatic'or an alisorbent ; thenitro-
bydro-chloric acid, with tinct, opii, in tonic infu-
sions ; a decoction of cusparia, with nitric' acid
and laudanum ; the infusion of catechu, with
aromatics ; sulphur, with sesqui-carbonate or bi-
borate of soda and opium; camphor, with nitrate
of potash, or chlorate of soda, and tragacanth ;
the chlorates, with demulcents or emollients ; the
nitrate of silver, with tonic extracts, &c, ; the
sulphates of copper, or of iron, or of zinc, or the
tris-nitrate of bismuth, either alone or witW opium ;
lime-water ; blisters and rubefacients ; demulcent,
emollient, and opiate clysters ; tepid salt-water
bathing, followed by frictions with rubefacient
liniments (F, 296. 305.), and tonic plasters, with
flannel rollers round the abdomen ; are the means
which are most to be depended upon, in this un-
favourable state of the disease. Animal food
generally increases the disorder, and farinaceous
articles of diet should be in moderate quantity, or
taken after short intervals.

33, E. Diarrhwa with indigested Matters in the
Stools. — The treatment in this variety should be
directed principally with the intention of pro-
moting the functions of the stomach and duo-
denum. These may, particularly in children,
and during the period of dentition, be disturbed
by inflammatory irritation of the mucous surface,
associated with increased action of the muscular
coats (§ 12.) ; whenever, therefore, this con-
dition is presumed, leeches should be applied
over the epigastric region, and be followed by a
sinapism, or a blister, with tissue paper interposed
between it and the skin, or by a rubefacient cata-
plasm or liniment. As the biliary functions are
usually torpid or otherwise morbid in this variety,
and the mesenteric glands often diseased, hy-
drarg. cum creta, with carbonate of potass, ought
to be given at bed-time. The digestive functions
will be most permanently promoted by the infu-
sion of cinchona, or catechu, or cascarilla, or
calumba, or of cusparia and rhubarb, with liquor
potassa?, or sesqui-carbonate of ammonia and
small doses of opium (see F. 413. 623. 788.
870.) ; or by chalybeate preparations, parti-
cularly the ammonia-tartrite of iron, with lau-

DIARRHQ'^A — Treatment of, in CiiiLDnEtf.

531

danum, or extract of syrup of poppy, or tincture
or extract of hop. The use of recent ox-gall,
as recommended by Horn (Arcltii'. War. 1810.
p. 335.), or F. 481., is appropriate in this and
the two preceding varieties, and will be very
beneficial when it can be exhibited. In addition
to these, and other internal and external remedies
already noticed, the tepid or salt-water bath or
semicupium, will also be productive of much ad-
vantage, particularly when followed by frictions
of the abdomen or spine with stimulating embro-
cations or liniments.

34. iii. — (fl) Diarrhcea in the Puevpeml State
(§ 14.), when it arises from accumulations of
faecal matters, and morbid secretions, requires
the use of gentle laxatives and mild purgatives,
assisted by emollient and aperient clysters, with
strictly regulated diet. After the offending mat-
ters are evacuated, opiates should be exhibited.
When bilious vomiting accompanies diarrhceaj^
or when the stools are bilious, demulcents, di-
luents and mild laxatives are requisite, until the
morbid secretions are evacuated ; but if spasms
v/ith much irritability of stomach be present,
opiates must be immediately exhibited, with
magnesia, and nitrate of potash, which will
generally remain upon the stomach ; but if these
be vomited, small opiate clysters or suppositories
should be administered. As long, however, as
the stools continue offensive, or otherwise mor-
bid, mild laxatives, and an occasional dose of
colomel or blue pill, should be prescribed. In
other respects the treatment is to be conducted
according to the principles already sketched. —
(/;) When, in addition to the accumulation of
morbid secretions, slight or chronic inflammation
of the mucous surface of the bowels, with serous
dark-coloured and offensive evacuations super-
vene, an emetic of ipecacuanha, if given suffi-
ciently early, will be of service. After its oper-
ation, or independently of it, three or four grains
of calomel, or five or six of hydrarg. cum creta,
■with a little magnesia, may be exhibited, and in a
few hours afterwards, either a dose of fresh castor
oil, or any other mild purgative. If griping be
present, an emollient and opiate enema should
be administered. If the lochia be suppressed,
the bi-borate of soda, in doses of from ten
grains to a scruple, may be given three or four
times daily, in emollient decoctions or infusions
(F. 209. 630. 867.), or the liquor ammoniffi ace-
tatis, with spirit, ammon. aromat. and camphor
mixture may be prescribed ; mild purgatives or
laxatives being repeated occasionally, until the
tongue becomes clean and the stools natural.
If the disease be not relieved by these means,
and if pain be felt in any part of the abdomen
upon well directed pressure, or if a sense of heat
or the symptoms of serous diarrhcea be present,
general or local bleeding, with the rest of the
treatment recommended in that variety (§ 28.),
should be put in practice. Having removed
morbid matters, or inflammatory irritation, where
either or both exist, demulcents, absorbents, gentle
restoratives, and tonic or astringent infusions, with
mild diet, may be prescribed.

35. iv. In Infants and Children, diarrhoea
assumes the bilious, serous, mucous, and lienteric
characters : the former two more frequently before
weaning, and in an acute form, or at a more ad-
vanced age in connection with irritation in the

brain ; the latter more usually after weaning, and
in the chronic states (§ 16.) — (a) In slight diar-
rhoea, with fluid feculent motions, small doses of
rhubarb with magnesia (F. 623. 633.), a grain or
two of hydrarg. cum creta at night, and the tepid
bath, are all that is required ; care being taken that
the bowels shall not become costive. If the dis-
order be occasioned by improper ingesta, or over-
feeding, or if it be attended by fever, an ipeca-
cuanha emetic should precede the above means,
which ought to be followed by a dose of castor
oil ; and a grain or two of calomel ought to be
given at bed-time, as advised by Dr. Clarke
{Mem. of Irish Acad. vol. vi.). When the
stools are slimy or serous, and ejected forcibly,
with tenderness on pressure, leeches and foment-
ations should be applied to the abdomen, and
small anodyne and emollient clysters thrown up.
If the evacuations emit a sour smell, and if they
be greenish, or curdled, or frothy, cretaceous sub-
stances and magnesia, or ammonia, with aro-
matics, and occasionally with opium or syrup of
poppies, ought to be exhibited ; after the more
urgent irritation is subdued, mild purgatives will
still be required, and should be repeated, when-
ever the evacuations are morbid. Great caution
is necessary in exhibiting opiates to infants, either
by the mouth, or in clysters, and they ought not
to be given when the symptoms indicate the
cetention of morbid matters in the bowels. In
order to evacuate these matters, the following may
be prescribed : —

No. 176. R Spirit. Ammon. Aromat. 3jss.; Olei Ri-
cini, Syrupi Rosa;, et Mannae Opt., aa 3 ss. ; Aquae Pimen-
tas et Aq. Com. aaSj. Fiat Eraulsio, de qua sumatur
Coch. unum minimum vel mediocre, pro re natd. Vel,

No. 177. R PotassiE Tartratis 3ij. ; Infusi Senn«
Comp. et Aq.. Foeniculi Dul. aa 3 j- ; Syrupi Sennffi3 ss. ;
Olei Anisi HI vj. Fiat Mist., cujus capiat Coch. unum
mediocre vel araplum pro dosi.

No. 178. R Hydrarg. cum Creta gr. xij. ; Sodse carbon,
exsic. 3 ss. ; Camphorfp rasa; gr. iij.; Pulv. Ipecacuanhae,
Pulv. Opii, aa gr. j. ; Pulv. Cinnamom. gr. xviij. ; Sac-
chari Albi 3j. ; Olei Anisi TU, iv. Tere probe simul, et
divide in Cartulas xij., quarum omni nocte, vel mane
nocteque, capiatur una.

36. When the diarrhcea proceeds from icean-
ing, either prematurely or at the proper time,
the treatment now advised, or that recommended
for the mucous variety' (§ 30, 31.), should
be employed. Dr. Cheyke directs small and
repeated doses of calomel ; but, unless morbid
matters are accumulated in the prima via, —
when it should be given in a full dose, and be
followed either by castor oil, or the mild purgatives
already prescribed, — the hydrarg. cum creta,
with magnesia and Dover's powder, or F.
923., is preferable. When the stools are slimy
or bloody, or squirted out forcibly, leeches should
be applied to the abdomen, and these medi-
cines be also given in small but frequent doses;
fomentations, demulcent clysters containing- olive
and castor oil, the tepid bath, and warm clothing,
being alj^o prescribed. If it assume the nciUc cha-
racter, or at the commencement of the attack, the
treatment prescribed in the article on the Cho-
leric Fever ofInfants (§ 1 1. 15.), of which it is
merely a modification, is in every respect appro-
priate. When it passes into the clironic form,
the means recommended with reference to chronic
mucous diarrhoea, or the ammonia-tartrite of
iron, with confectio aromatica and compound
tragacanth powder, should be employed ; the
hydrarg. cum creta and Dover's powder being
Mm 2

532

DIARRHCEA — Treatment of its Complications.

exhibited every niglit. The abdomen or spine
ought also to be rubbed night and morning with
either of the liniments (F. 296. 300. 311.),
upon coming out of the tepid or warm bath, and
be rolled in flannel. When the patient's strength
is not much reduced, and if there be fever, and
ofiensive evacuations, much benefit will result
from a dose of calomel, with a grain of James's
powder, at bed-time, and from one to two
drachms of castor oil, with half a drachm of
the spirits of turpentine, taken on the surface
of fennel water the following morning. Clysters
of beef-tea, or of strained mutton or veal broth,
well salted, may also be thrown up ; and the
chlorates of the alkalies or of lime, or lime water ;
the sulphate of iron in small doses, with the
sulphate of potash ; the liquor potassas, or the
sesqui-carbon. of ammonia, with infusion of cin-
chona, or of catechu, or F. 183. 363. 536. &c.,
may be prescribed. With a light nutritious
(chiefly farinaceous) diet, a sufficient quan-
tity of salt should be taken ; and if the vital
powers be much depicssed, warm spiced port
wine negus may be allowed in small quantities.
In the variety attended by copious, pale, albu-
minous urine, &c. (§ 17.), strong jellies and
soups, animal food, fresh eggs very lightly
boiled, the chlorates, with small doses of rhu-
barb, vegetable and mineral tonics and astrin-
gents, the preparations of iron, warm salt-water
batiis, and frictions with stimulating liniments,
are the most beneficial. If the bowels become
constipated, the mildest laxatives should be
prescribed. If the urine be much diminished in
the more common form of the disease after
weaning, the spiiit. ajtheiis nitrici ought to be
given ; and if drowsiness or coma supervene,
blisters may be applied behind the ears. These
last symptoms are more frequently the conse-
quence of exhaustion than of effusion, when
they occur late in the disease : or if effusion
take place, it is the result rather of the physical
state of tlie brain, a sei'ous fluid poured out from
the vessels filling the vacuum that would other-
wise have been left by the anaemic and atrophied
encephalon, and requires tonic and restorative
remedies. In such cases, more advantage will
accrue from measures calculated to support the
vital powers, to allay irritation in the prima via,
and to determine the circulation to the external
surface, than from those which depress the ener-
gies of life, although they may act beneficially
in other respects. It is necessary to watch care-
fully the state of the gums throughout tjiis
serious and olistinatc form of diarrhrca, and to
lance them whenever they indicate the propriety
of the operation. — ((/) Iftlie diarrhoea, either
in infants or older children, be symptomatic of
cerehtal con;j^es,l'wn, inittitioii, or iiijtaimnation
(§ 35.), leeclies beiiind the cars, calomel with
.James's powder, the scmicupium, cold effusions
oh, and cold applications to, the head, with cool-
ing diaphoretics, diuretics, and external deriva-
tives, are the chief remedies.

37. v. Diaiihaa in the Diirk Races requires
a much more general and liberal use ofaromatics,
absorbi:nts, and warm astringents, liian arc admis-
sible in the white variety of our species. In them,
capsicum and the other hot spices, witii cretaceous
powders and niixtuies, the preparations of ca-
tccliu, of kino, of iron, &cc. arc almost indispens-

able. When symptoms of retained faecal matters
are present, purgatives are requisite, but they
should be of a warm and tonic kind, or be com-
bined with substances of tliis description. Al-
though diarrhoea is only occasionally camplicated
with intestinal ivorms in Europeans, and then
chiefly in children, or in the inhabitants of low,
moist, warm, imperfectly ventilated and unhealthy
places, it "is very often thus associated in the
dark races, and at every age. This circumstance,
therefore, should suggest the employment of an-
thelmintics, especially those which are tonic and
astringent, as the decoction of the pomegranate
root, or the pink-root, or the male fein, in pre-
ference to other medicines, particularly when
these parasites are suspected to be present. In
this class of subjects, whether diarrhoea be thus
associated or simple, a suflficient quantity of salt
with aromatics should be allowed, and the pa-
tient's strength be kept up by suitable nourish-
ment, and by vegetable and mineral tonics.

38. vi. The Associations of diarrhoea (§ 19.)
require the greatest discrimination. — (n) When
it accompanies the invasion of fevers, it generally
proceeds from the irritation of retained excretions
and acrid secretions in the prima via. These
should be evacuated by an ipecacuanha emetic,
and by diluents and clemulcents, followed by a
full dose of calomel, and this latter by a mild
purgative and oleaginous enema. If signs of
vital depression exist, warm diaphoretics with
ammonia, and occasional doses of rhubarb with
magnesia, and the warm bath, should be after-
wards prescribed ; but if febrile excitement ac-
company the diarrhcea, saline refrigerants, and
the rest of the treatment recommended in the
serous variety', will be necessary. (See Fevers.)
— (ft) Wlien the disorder accompanies gout,
or occurs in the gouty habit, it should not
be checked. IMild purgatives may be first pre-
scribed in conjunction witli preparations of am-
monia, or one of the fixed alkalies; and when
morbid secretions and faecal matters are eva-
cuated, full doses of magnesia, or of potash or
soda with the spirit, colchici ammoniatus, and
afterwards mild tonics, will generally restore tlie
digestive functions — (c). ^V hen diarrhoea is com-
plicated with bronchitis (§ 19.), as often occurs
during dentition, local depletions, lancing the
gums, and calomel or hydrarg. cum creta, fol-
lowed by a mild purgative, and these by diapho-
retics, demulcents, emollients, the tepid or warm
bath or scmicupium, and attention to diet and
warm clothing, are the means to be chiefly de-
pended upon. In many of such cases, ipecacuanha
emetics, and in others, camphorated refrigerants,
will be productive of great benefit : the former
when the bronchi are much loaded, and the
stools are mucous and oftensive ; the latter when
there is much heat of skin, and serous or watery
evacuations. — (d) Diarrhoea complicated with
scarlatina, measles, or S7nall-po.r, must be treated
with strict reference to the state of vital power,
the appearance of the cruj)tion, and the clia-
ractcr of the evacuations. These important
complications are particularly noticed in the
articles on tiicse diseases ; but I may here re-
mark, that a sudden arrest of the evacuations
may be followed by eft'usion within the head, and
coma, whilst their unresti'ained continuance may
occasion exhaustion, or fatal disorganisation of

DTAUUHCRA — Notices of Remedies t^f.commended by AuTirons.

.533

the intestinal mucous coat. The treatment
should therefore be directed, in sucli cases, with
the intentions of diminishing inflammatory action
in this part by moderate local depletions, of
equalising the circulation and secretions by ex-
ternal derivatives and relaxants, and by diapho-
retics and diuretics, and of supporting the
powers of life, whenever they become depressed,
by diffusible and permanent stimulants. I may
state as the result -of experience, that, when this
complication follows an imperfect developemenl,
or retrocession, of the cutaneous eruption, even
moderate depletions are not well borne, unless
they be accompanied by warm diaphoretics and
diffusible stimulants ; and that, of the latter me-
dicines (which are very generally appropriate),
full doses of ammonia, or of camphor, or of
both, in some instances combined with nitrate
of potash, in others with alkaline carbonates or
magnesia, in most with demulcents and emollient
diluents, in several with laxatives, and in many
with aromatics, or tonics and antiseptics, have
proved the most beneficial. — (e)\Vhen a diarrhoea
that is not critical aca)/»/i(7)i(Vs or follows remittent,
ciintinued, or adynamic fevers, the evacuations
being watery, muddy, dark-coloured, or otherwise
morbid, the hydrarg. cum creta, with ipecacuanha,
cani|)hor, and cretaceous substances; or the tere-
binthinates and tlie balsams, with vegetable or
mineral astringents ; also tonics and antiseptics,
the nitric and hydro-chloric acids, or both, or rhu-
barb with magnesia ; the chlorates with demul-
cents; external derivatives with warm rubefacient
and stimulating liniments, &c., are the chief re-
medies, and the most likely to prevent the extensive
sloughy ulcerations that sometimes attend the
diarrhoea that supervenes either during, or subse-
quently to, these diseases.

39. Colliquative diarrhoea is sometimes not
easily controlled ; and even when most readily
repressed, the constitutional disturbance may be
thereby increased. It is most benefited by small
doses of the sulphates of copper and of zinc (F.577.
587.), by the mineral astringents generally, and
by the cretaceous and demulcent preparations,
combined with camphor, aromatics, and opiates,
or with tonic and astringent infusions and decoc-
tions, which, at the same time that they alleviate
the symptoms, also support the vital energies.
But the adoption and combination of these, or the
choice of other remedies already or about to be
noticed, should depend mainly upon the nature of
the primary disease, of which the diarrhoea is, in
this state, merely an advanced symptom.

40. Cautions, &c. — The critical manifestation
of diarrhoea should never be interfered with, un-
less it either proceed so far as to depress the vital
energies, or be attended by signs of inflammatory
disease of the mucous surface and follicles, in
which case the treatment recommended for the
varieties indicative of such disease and its conse-
quences should be prescribed. When diarrhoea
occurs in gouty or asthmatic persons, or in those
of a plethoric habit of body, or who have a ten-
dency to, or have suffered from, cerebral affections,
or hepatic disorders ; or in the leuco-phlegmatic
and hydropic diathesis ; it ought fo be treated with
much caution ; and should be only at first mode-
rated, if very severe, by mild purgatives or laxa-
tives ; by depletions, diaphoretics, and diuretics ;
by a regulated diet ; and by warm clothing.

according to the circumstances of the case, be-
cause the sudden arrest of the evacuations by
opiates and astringents may be attended by some
risk,

41, vii. Notices of pahticuear REJiEDirs
RrcoM. 11 ended by Authors, &c. — A. Bleeding
has been advised by Cotugnus (De Vena'sect. in
Diarrh. Rom. 1604.); by Ilonsnus (0pp. lii.
p. 68.) ; by Zacutus Lucitanus (Med. Pr.llist,
l.ii. p. 734.) ; in the bilious variety, and by
Sydenham. It is obviously requisite in the in-
flammatory states of the disease, whether acute or
chronic, and preferably by leeciies applied to the
abdomen, to the sacrum, or to the verge of the
anus, particularly when tenesmus is present.

42. B. Refrigerants are always beneficial in
the serous and mucous varieties, and when the
complaint is attended by increased heat or excited
circulation, and erect papillae of the tongue ; and
they may be combined with demulcents and
opiates (F. 36.821.838.886.) according to the
circumstances of the case. Of this class of medi-
cines the iiitrate of potash or of soda, camphor
(F. 431.), the muriate of ammonia (F. 352.431.),
borax (V. 209. 630. 867.), variously combined,
and the tepid bath, are the most appropriate. Reca-
MiER (Annuaire Med. Chirurg. vol. i. p. 113.)
recommends nitre with the oxyde of bismuth, and
opiated arornatics. Hufeland prefers the muriate
of ammonia (Stark, Archiv. b. i.st. 3. p. 93.) in
the inflammatory states, and when it accompanies
fever; and Zadig combines it with mucilaginous
substances (Jonrn. der Erfnd. st. xxi. p. 57.).

43. C, Laxatives and 7nild purgatives have al-
ready been sufficiently noticed. Those of an irri-
tating nature are not unfrequent causes of the
complaint, and ought never to be presciibed.
Even castor, olive, or almond oil, if they be in the
least acrid or rancid, will be productive of much
mischief, I have seen enteritis supervene on diar-
rhoea from this cause. In the chronic states of
the disease, sulphur, with cream of tartar and
sub-borate of soda in the form of electuary
(F. 790.), and conjoined with aromatics, is often
the best laxative that can be employed. It has
been preferred by Lance (JVJisce//. Verit. f. 29.)
and it possesses the advantage of relaxing the
skin.

44. D. Dwp/ioret;>s are of much benefit in all
the febrile states of the disorder, particularly the
serous variety, and are advantageously combined
with refrigerants. They have been adopted by
SyuENUAai, DiE-iiERBROECK (Obscrvat. et Curat.
No. 64.), Lentin (Bev^ri/ge, b.iv. p. 332.), Osi-
ANDER (Denku'iirdigheilen, h.u. p. 179.), &c.
The chief of this class are James's powder, ipe-
cacuanha, camphor, carbonate and acetate of
ammonia, spiritus a?ther!s nitrici (F. 394. 840.),
&c. Ipecacuanha, particularly when associated
with nitrate of potash, camphor, and opium, is one
of the most certain and efficient remedies we can
prescribe in all the acute forms of the disease ;
and it is also a very useful adjuvant of other
medicines (see F, 39. 495.642. 744.924.). It has
been very generally used, and particularly by
LiNN/Eus (Ama-n. Acad. Upsal. vol. viii. p. 246.),
Fotiiehgii.e (Med. Obscrvat. and Inqitir, vol. vi.
art. 18.), Baldinger, (K. Magazin. b'. xix.
p. 404.), Stark, Loeffler (Beptrdge, b. i.), and
Broussais (Loc.cit. in Bifc/i.), either in the com-
binations now noticed, or in those constituting the

]M m 3

534 DIARRHCEA — Notices of Remedies nEcoMMENCED ry Autiiohs.

tract of the former, byTnEussiNK, Oswald (Archiv .
der Pr. Heilk. f. Schlesien, h. ii. st. 4. art, i.),
Horn (Archiv. Nov. 1810, p. 258.), and Rum-
MEL ; the latter by Recamier and Graves (see
BibL), who gave the twelfth part of a grain of it
twice or thrice a day, with complete success, in an
obstinate case of white mucous diarrhoea. Dr.
RuMJiEL considers it particularly efficient in
removing this very obstinate form of the complaint,
when seated in the lower bowels.

49. I. Astringents are requisite in similar states
of combination as tonics, and in the same forms of
the disease. They are not admissible in the
bilious variety, or where faecal collections or acrid
matters are retained, or in the inflammatory states
of the complaint, until after depletions, refrigerants,
and diaphoretics have been employed ; but they
are seldom of use whilst the temperature of the
surface is increased, and the pulse accelerated,
although M, Rally's experiments indicate the
contrary. — a. Of the vegetable substances belong-
ing to this class, the most serviceable are catechu,
kino, the pomegranate bark or root, the cusparia, or
angustura bark, logwood, &c., and some mineral
substances. The preparations of catechu with
those of chalk and opiate confection, or F. 30.183.
788., are very generally employed, as well as
those of /i!?u) (F. 34. 536.). Some doubts exist
as to whether catechu or kino is most serviceable.
Dr. Pembertox preferred the latter ; and M,
Rally (Gazette dc Sa7itt, &c. 1829, and Med.
Guz. vol. v. p. 700.) found, from an extensive
trial of it, that it generally arrested chronic diar-
rhoea, without fever, in four or five days, when
taken to the extent of from twelve to twenty grains
daily ; and that even in diarrhoea with fever, and
tenderness of the abdomen on pressure, it was
equally successful. The bark of the root of the
pomegranate as well as its flowers, and the exterior
of the fruit, have been long employed in diarrhoea
in Eastern countries. They were much prescribed
by Mead, Strandberg, and Cullen. JMead
gave them in the form of decoction with cinnamon
and red roses. They are very beneficial when
the diarrhoea is complicated with worms. The
cusparia or angustura bark was much praised by
Lettsojm (Mem. of Med. Soc. of Land. vol. vi.
art. 15.) and Theussink ; and is an excellent
medicine, either in substance, tincture, or infusion
(see F. 201. 413.). The krameria or rhatani^
root, first employed in diarrhoea by the Spanish
physicians. Dr. Ruiz (Mtm. de VAcad. l^oy. de
Madrid, 1796, p. 364.) and Dr. Hurtado (Joimi.
de M^d. (l^c, t.xxxvii. p. 216.), has since been
used with advantage in this country (F. 734.).
The simarouba bark was recommended by Jussieu,
Cai'et, Fni/.E (Annalen, I. -p. 59.), and WERi.iior
( Observat. de Fehr. sect. iii. § 6.), but ciiiefly in the
diarrhoea attendant on fevers ; and the mahoganii
bark by IlrciiES (Med. Facts and Observ. vol. vi.
art. 10.). These may be prescribed in the form
of infusion with the arnica, the root of which has
been much used by Tueussink in this complaint.
The loguood is an excellent astringent, and, in the
form of decoction, a suitable vehicle for other re-
medies. The bistort, il\e uva itrsi (F. 217. 396.),
and tormentil, are also of much service, particu-
larly when associated with ipecacuanha. 'l"he
root of comfrey, the consolida major, is recom-
mended by Jli'iELAND (Journ. der Pr. Heilk.
1809.); and the lythrum salicaria, by Blom,

old and new Dover's powder. It may also be
given with the nitrate of soda and opium ; or with
the tormentil, zs formerly directed by me (.LoHrf.
Med. Repos. vol. xviii. p. 329.).

45. E. Demulcents and emollients are of service
in all the varieties of diarrhoea: those of an olea-
ginous kind, in the form of an emulsion, when a
laxative is required, as the castor, olive, or almond
oil, with ammonia, or the fixed alkalies, &c. ; and
those of a mucilaginous description,' when a con-
stipating effect is desired, as the compound powder
of tragacanth (F. 389.) or mucilage of acacia,
and decoction of Iceland moss (Lind. Herber,
in Horn, Archiv. Nov. 1810, p.289.) ; and they
may be combined with refrigerants, or opi-
ates, aromatics, absorbents, or astringents, — also
with sedatives, as the hydro-cyanic acid, the pre-
parations of morphine, or of hyoscyamus, or of hop,
or those of ipecacuanha, according to circum-
stances. (See the IZmulsions in the Appendix.).
They are often of great service when administered
in the form of small clysters, conjoined with
opium, as advised by Sydenham (0pp. p. 87.).
Hildenbrand (Hufeland, Jo!fr7i. der Pr. Heilk.
b. xiii. St. 1. p. 148.), and Hufeland (in Ibid.
b. xxvi. St. 3. p. 155.).

46. F. Absorbents are especially indicated when
the complaint is connected with acidity in the
prima via ; and the cretaceous, magnesian, and
ammoniacal substances, combined with opiates,
aromatics, and astringents. (F. 37. 347. 354.
384. 442. 648.), are the most serviceable when
relaxation of tlie mucous surface and debility
exist ; and the carbonates of the fixed alkalies,
associated with refrigerants (F. 838.), when in-
flammatory action is present in this surface.

47. G. Aro7natics (¥. 348. 363.) are particu-
larly requisite in asthenic cases, and if the patient
has been in the habit of using hot condiments and
spices with his meals ; or when the diarrhoea
arises from unwholesome water, from stale animal
food, and from endemic causes; in which cir-
cumstances, charcoal, in large doses, as recom-
mended by Dr. .Jackson, and some American
physicians, may also be given. Aromatics are
best combined with absorbents and vegetable
tonics or astringents.

48. H. Tonics, particularly calumba (F. 51.
869.), cascarilla (F. 870.), and cinchona (F.380,
381.), are often re(|uisite, especially in conjunc-
tion with the alkaline and other absorbents, and
with aromatics, opiates, &c. ; and in the idiopathic,
the asthenic, and chronic states of the disease. In
such cases, and thus combined, calumba has been
recommended by Percival (Essays, vol. ii. p. 3.),
Stark (Klin, and Anat. Bemerk. p.7.), Thomann
(Annalen. ad 1800, &c.), Frank (Acta Inst.
Clin. Viln. Ann.u. p. 79.), Fischer (in Hufe-
LAND, Journ. d. Pr. Heilk. h.xvi.sl.i. p. V23.),
and LicnTENSTEiN (Ibid. b. xix. st. i. p. 180.) ;
quassia, by I>ettsom ( Mem. of Med. Soc. of Loud.
vol.i. p. .) ; cascarilla, by Bang (Act. lieg.
<Soc. Med. Haun. vol. i. p. 241.) and others ; the
wilLrw bark (F.414.), by White (On the Broad-
leaved Willow Bark. Bath, 1798.) ; and the cin-
chona with opium, by Picquk (Journ. de Med.
t. xlij. p. 433.), and Schmidt (Horn, Archiv.
b. v. p. 236.), chiefly when the complaint assumes
a periodic form, or is connected with remittents
orintcrinittcnts. A'nx vomica and strychnia ]\a.vc
also been prescribed in atonic diarrhoea; the ex-

DIAHUHCE A— Notices of Remedies hecommended by Authors.
Bang (0pp. cit.), De Haen (Rat. Med. par

535

par. 195., p.iv. p. 250.), and Hehz (Briefe, st. i.
art. i.). Tliey are much employed in tlie north
of Europe.

50. b. The mineral astringents are very bene-
ficial in several of the forms of diarrhoea, par-
ticularly the chronic. Lime in various forms, —
in cretaceous powders and mixtures, chiefly as ab-
sorbents, and in the state o( chlorate (V. 283.)
or recent time%uater,as povverful astringents — are
very serviceable, especially when associated with
demulcents, mucilages, and aromatics. I have
used the chlorate of lime on many occasions with
advantage ; and lime water, with boiled milk, or
with the other medicines just referred to, is in
very general use. Alum, also, variously com-
bined, or in the form of alum whey, has been
praised by Adair (Edin. Med. Comment, vol. ix.
p. 21.) and Harrison (New Land. Med. Journ.
vol. ii.). It may likewise be given with other
astringents, 'or with aromatics and opiates. The
acetate of lead was prescribed by Dr. Archer
(JV. Y. Med. Eepos. vol. iii. No. 3.), with opium ;
but Horn (Archiv, h. vi. p. 144.) states that he
found it of no use. I have seen benefit derived
from it in the diarrhoea attending the advanced
stages of phthisis. The sulphate of copper has
been tried successfully by Dr. Elliotson, in
doses of from half a grain to two grains, given
twice or thrice a day, with opium ; and the am-
moniated copper has been prescribed by Bianciii.
CBkera, Comment. Medici. Dec. i. vol.ii. art. 2.).
The sulphate and oxide of ^inc are also useful,
especially when combined with rhubarb, or myrrh,
or the balsams, or terebinthinates fF. 578. 587.
666. 875.). The nitrate cf silver, triturated with
a tonic or astringent extract, and in small doses,
has been employed by me on various occasions
with advantage, particularly in the mucous variety,
and in very chronic cases. The mineral astrin-
gents are often the most efficacious in colliquative
diarrhoea.

51. K. Besides the above, there are other reme-
rf/es which may be noticed. These are, the fussi/no-o
(Percival, Essays, vol.ii. p. 224., and Friborg,
in Todes Biblioth. h. i. p. 118.); large doses of
almond oil, as an emollient and laxative (Vallis-
NERi, 0pp. iii. p. 278.) ; the infusion of the diosma
crenata (F. 231. 396.) ; the plantain in demul-
cent broths; nnnpe medlars (Forestus, 0pp. vol.
iii. p. 47.) ; tho root oi the geum urbanum (De
Miza, in Acta Reg. Soc. Med. Haun. vol. ii.
No, 4. p. 28., and IIanoe, in Thid. vol, iii. p.
369.) ; the Peruvian, Canadian, and other bal-
sams (F. 369.); the briony (Arnaud, in Journ.
de Med. t. Ixxvi. p. 257.) ; the decoction of elm-
bark (CoLLiNGwooD,in Edin. Med. Convnent. vol,
xvi. p. 58.) ; and camphor (Thomann, Annalen
ad 1800, p. 355.); which latter I have already
recommended, from a frequent experience of its
good efTects when judiciously prescribed. Sarsa-
parilla will also be found useful in chronic
states of the complaint, and may be associated
with the decoctions of elm-bark or of Iceland
moss, or with lime water or liquor potassas ; small
doses of hydrarg. cum creta, with Dover's powder,
being exhibited at bed-time. Bang advises sali-
vation in obstinate cases ; and in rare instances it
may be advisable to resort to it, Dr, A, Stout
(Phil. Med. Journ. Way, 1823.) states that he
cured a case of diarrhoea from suspended men-

struation by the ergot of rye, given in doses of six
grains three times a day.

52. L. The administration of most of the medi-
cines noticed in the course of this article, in the
form of clyster, will prove of much benefit,
whenever signs of disorder in the course of the
colon can be traced, or when the complaint has
been preceded by dysentery. In these, Horn
(Archiv.,h. vi. p, 139.) advises the infusion of
valerian to be administered in this way. An
infusion of ipecacuanha may likewise be thus
prescribed. When the diarrhcea assumes a
chronic form, warm or tepid salt-water bathing
or artificial irritations and eruptions induced on
the abdomen, and kept up for some time, will be
generally serviceable, VVhen this practice can-
not be adopted, either warm, tonic and deobstru-r
ent plasters should be placed on the abdomen or
loins, or a flannel belt or roller be worn around
the lower part of the trunk. I have found a large
plaster consisting of equal proportions of the
emplast. picis comp., the emplast. ammoniaci
cum hydrargyro, and the emplast. galban. comp,,
extremely useful, particularly when the complaint
has been connected with hepatic disease. These
means, in the most severe and obstinate cases, will
be much promoted by slow and frequent or con-
stant travelling, or sea voyaging.

53. M. The diet should be strictly regulated, not
only in the course of the disease, but also during
convalescence, and after recovery. Whilst the
complaint continues, especially in the acute
form, the food ought to be farinaceous, very mild,
and in small quantity. In the chronic states,
also, this injunction should be followed in many
cases ; the lighter kinds only of animal food, in
small quantity, being allowed when the patient's
strength requires it, JNIalt liquors, acid wines,
and acid or over-ripe fruit, or pastry, particularly
its crust, ought to be entirely relinquished. Good
or old port wine, however, or old sherry, will
frequently agree with the patient, and is often
even requisite. In cases requiring astringents
and tonics, not only may wine be allowed, but
also a substantial, but light, diet of well-seasoned
and simply dressed animal food. The diet,
during convalescence and recovery, ought never
to be continued on so restricted a scale as to
lower the patient's vital energies, without making
trial of the effects of that which is more nu-
tritious,

BiBLioG. AND Refer. — Galen, Local Affect, vi. 2 —
Aetius, Tetrab. i. serm. iv. c. 19., tet. ii. ser. i. c. 90. &c —
Alex. Trallianxs, 1. viii. sect. 7. — Ponccl, Ergo Fluxibus
Alvi Purgatio Venaescctione commodior. Paris, 1.571. —
Loncrus, De Fluxu Diar. et Lienterite, &c. Naumburgi
Observ. Lips. 1589. — Bassalis, Non ergo fluenti Alvo
Evacuantia. Paris, 1617. — Roljinck. Diss. Patholog.

No. XV. Jen. 1637 Lcw/mer, De Diar. quadam Epi-

demica. Erf. 1676, 4to. — Pichonei, Ergo Alvi diuturno

Fluori Vomitus. Paris, 1686 Fcrnethuys, An Omni Alvi

Fluxui Radix Brasiliensis V Paris, 1706 Fontaine, An

Alvi Diut. Fluori Vomitas. Paris, 1733. — .Brrg-ftw, De
Pr. Med. i. cap. 9. — Vesti, De Diarr. Lochiis Super-
veniente. Erf. \7Vi. — Morgagni, De Caus. Morb. &c.
ejiist. xxxi. et Ixv. cap. b.—A. Bergen, De Diar. Puerpe-

rarum. Fr. 1721 Cockburne, Cure of Looseness, &c.

8vo. 'Lond. 1721. — Piso, De Morbis ex Serosa Colluvie,
p. 68.' 234.— Weiss, De Daninis e Diar. Suppressa oriun-
dis. Alt. \7M.— A. deJussicu, 'Ergo Inveter. Alvi Fluxi-
bus Siniarouba, 4to. Paris, 1730 — Juncker, De Diar.
plurium Annorum. Hal. niti. — Capet, An in Inveter.
Alvi Fluxibus Simaruba? Par. \75S.Smivages, Class ix.
order ii. gen. 13. — Bayig, Act. Reg. Soc. Med. Haun.
vol. i. p. 100. ^43. ; et Selecta Diarii Nosocom. Regii
Hafn. vol.i. p. 47., vol.ii. p. 233,<< seq. — Zorf/^', in Ar-
chiv. der Pr. Hcilk. fiir Schlesicn, b. i. st. 1. art. 8 —
Z). Monro, Med. Transac. &c. vol. ii. p. 325. — C. Smith,
]Mm 4

536

Med. Coramunicat. &c. vol. ii. p. 210 Cullcn, Works,

by Thomson, vol. i. p. 312. 485., vol. ii. p. 485. —Saillie,
Med. Transac. &c. vol. v. p. 166. — Bateman, arts. Diar-
rhcca, 3.x\& Lientery , in Rees's, Cvclopeedia. — Dewar, On
the Diar. and Dys. of the Brit. Army in Egypt, 8vo.
Lend. 1803. — Pembcrton, On Diseases of tlie Alulom.
Viscera, 8vo. p. 148. — Bonte, in Journ. de Med. t. xxx.
p. 27. n%— Fischer, Vom Alter, p. 201. ; et in Hzifeland's
Journ. dor Pract. Heilk. b. xvi. st. 1. p. \01. — Broussais,
Hist, des Phlegmasies Chroniques, &c. vol. ii. cap. 3. —
Good, Studv of Med. vol. i. p. 270— Riinnnel, Der Fluxus
Cffiliacus, Oder die Milehriihr, &c. Hufeland, Journ. der
Vr. Heilk. June, lS26.—E//iutso7i, Transac. of Med.-Chi-
rurg. Soc. vol. xiii. p. 451. — Burns, Princip. of Midwif.
and Diseases of Women and Children, 6th edit. 8vo.
p. 775.— Graves, in Dub. Hosji. Reports, vol. iv. p. 46. —
JJcwces, On the Phys. and Med. Treatment of Children,

8vo. Lond. 1826, p. 414 /fi(-«j»/«-, Archives Gener.

de Med. t. xviii. p. 101. — C. F. Tache7-on, Recherches
Anat.-Patholog. sur la Med. Pratique, &c. 8vo. Paris,
1823, t. ii. p. 419. — Gardicn, Des Maladies des Enfans,

p. VM. — Andral, Clinique Medicale, t. i. p. 424 P. M.

Lathatn, Account of Dis. prevalent at the General Pe-
nitentiary, &c. 8vo. Lond. 1825. — W. P. Deivees, On
the Phys. and Med. Treatment of Children, 8vo. Lond.
1826, p. 398. — AbercroDthie, On the Diseases of the Stem.,
Intestinal Canal, and other Abdom. Viscera, 8vo. Edin.
1828, p. 206. —Bright, Medical Reports, itc. vol. i. p. 172.

— C. H. Roche, Diet, de Med. et Chir. Prat. t. vi. p. 287.

— Marley, On the Diseases of Children, 8vo. Lond.
1830, p. 65. — Anncsly, Researches on the Diseases of
India and Warm Climates, imp. 4to. vol.ii. p. 339 — (The
Author, in support of his own originality in some parti-
culars, pathological and therapeutical, refers to some
extended observations on diarrhcca in the Lond. Med.
Repository for October, 1822, p. 326.)

DIGESTIVE CANAL — ITS Lesions. — Syn.
Digestive Tube, Alimentary Canal, Prima
Via, Gastro-intestinal Canal or Tube. Canal
Gastro-intestinal, Fr.

Classif. — General Pathology; Morbid
Structures,

1. The several morbid changes to which the
digestive canal below the diaphragm is subject,
will be noticed here, in a general and con-
nected manner, its principal diseases being de-
scribed individually in separate articles. The
changes experienced by that part of the tube
which is placed above the diaphragm, are de-
tailed in the articles Fauces, (Esophagus, and
Pharynx.

2. Of certain appearaiices in the digestive tube,
that cannot be imputed to disease of any part of
it, but ivhich have often been mistaken for disease.
— The internal surface of the stomach or intes-
tines of a living animal, whose circulation is not
disturbed, is of a red tint, somewhat deeper
than that of the mucous membrane of the cheek
of a healthy person. During tlie period of di-
gestion the tint is much deeper, evidently owing
to increased flux of blood ; and its secretions and
exhalations are much increased. Tlie red tint of
health, however, disappears after death ; and the
digestive surface generally becomes uniformly
pale, or slightly rose-coloured in places, at the
period when jiost mortem examinations are usually
performed. There are, however, certain circum-
stances whicli modify its appearances upon dis-
section, totally independent of disease of any part
of the digestive canal. Some of these circum-
stances have operated shortly before death ; others
during the last moments only ; and several feither
sf)on, or a considerable time, -after the extinction
of life. • . . '.

3. (n) The causes which operate before death,
are 1st. The performance oT the digestive pro-'
cesses, the increased redness of the viljous surfiu;e
attending them generally continuing after the
cessation of life. 2d. 'I'he free return of the
venous blood from the gastro-intestinal tube, to

DIGESTIVE CANAL — Its Pathology.

the right cavities of the heart, causing, in the
first degree, . simple congestion of the venous
trunks ; in a higher degree, along or continuous
with this congestion, an injection of the small
vessels in streaks, stripes, patches, or points, with
opacity of the injected parts; and, in the highest
degree, a partial eflusion of blood into the sub-
mucous cellular tissue, forming ecchymoses, or
into the cavity of the part, colouring red the
matters contained therein. It is evident, not
only that the disease of remote or related organs
will thus affect the colour and state of injection
of the vessels of the digestive tube, according as
it may impede or facilitate the return of blood
from them; but that the kind, the mode, and
phenomena of dissolution will have the same
effect. • Thus, death by asphyxia generally pre-
sents a congested and deep-coloured tint of the
digestive inucous surface. 'Jhese facts, whicli
seem to have been not unknown to Mohcagni,
to have been proved by experiment by Boer-
haave, to have been observed in the cases of
strangulation examined by Dr. Yelloly, and
to have been demonstrated in cases of asphyxia,
and by experiment, by the French pathologists,
especially Billard, Andral, &c., are most im-
portant, and evidently indicate that disease has
been incorrectly imputed to the digestive canal,
when the appearances whence the inferences were
drawn, arose either from lesions of other organs,
or from the mode in which death was produced.

4. (b) The causes of redness and injection of
the digestive mucous surface operating after
death, are, 1st. The gravitation of the blood;
and, 2d. Its transudation through the parietes of
the vessels. The first of these begin to act im-
mediately after death, and whilst the blood is
still fluid, as shown by the researches and ex-
periments of ]MM. Trousseau and IIigot. The
injection and redness of the intestinal parietes
produced by gravitation, or injection from hypo-
stasis, generally acquires its highest degree at the
end of some hours from the extinction of life,
and ceases to increase as soon as the falling tem-
perature of the internal parts allows the blood to
coagulate. Hence, the longer the blood con-
tinues fluid, and the more abundant it is in tlie
vessels cf the digestive canal, the more marked
will be the injection of depending parts from^
hypostasis. The second of these post mortem
causes of redness takes place at a remoter period —
usually after twenty-four hours in summer, and
after thirty-six or forty hours in winter ; but the
period varies with the nature of tlie disease, and
the state of the blood at the time of dissolution.
This change commences first with red spots in the
course of the vessels, isolated, groupei,! together, or
running into one another, giving rise to coloured
streaks, and evidently proceeds from the exudation
of the blood through the vessels containing it. At a

later period, the redness is not limited to the course
and situation of vessels; but the whole surface
becomes more a'nd more uniformly tinged, until
it is equally red, approaching the appearance
existing iti the internal surface of the blood-ves-
sels under similar circumstances. The following
is a summary of the causes modifying the appear-
ance of the gastro-intestinal canal ; and which, in
some respects, and with some additions, is the same
as given by M, Andral.

5. 'i'he digestive mucous membrane is seldom

DIGESTIVE CANAL— Functional DisonDEns or.

537

of the same colour in the healthy state. It may
be — (a) perfectly ichite or whitinh, altliougli this
state does not imply that functional disorder did
net exist during life. — (h) It may present various
tints or degrees of colour, without ceasing- to be
sound, depending, 1. on the performance of the
digestive processes, sliortly before or at the time
of death ; 2. on the congestion to which internai
vascular parts are liable at tiie last agony or
moments of life ; 3. on mechanical obstacles to
the return of blood in the veins existing a longer
or shorter period before dissolution ; 4. on the
gravitation of the blood to depending parts ; 5. on
the exudation of blood tiirough tlie parietes of
the vessels ; 6. on the exudation of this fluid
through the capsule of the spleen ; 7 on the
gases existing in the canal at the time of death ;

8. on the developement of other gases at a
remoter period, when putrefaction commences;

9. on the combination of the colouring matter of
the bile present in the digestive tube, with parts
of its mucous surface ; and 10. on the medicinal
or other ingesta, which may ciiange its colour so
as to resemble the morbid state. Some of the
colours produced by these causes cannot be con-
founded with that resulting from inflammation ;
others very nearly resemble it, especially those
occasioned by the 1. 2. and 4. and certain va-
rieties of 3. and 5. Those states of the digestive
surface that most nearly resemble inflammation,
may in respect of it be denominated passive. J\I.
BiLi.ARD has given the following diagnosis be-
tween passive and active or iiijiammatory redness
of the villous or digestive mucous coat.

Inflammatory. Passive.

a. With or without maiii- a. The s^me.
fest thickening of the
membrane.

b. Indifferently in a de- b. Almost always in a de-
pending or elevated part. pending part.

c. Without general injec- c. Witli general injection
tion of the abdominal of the abdominal vessels.
vessels, and without any and with an obstacle to
obstacle to the course of the course of the blood ;
theblood; sometimes con- rarely being an isolated
sisting in only a slight lo- local injection, Imt fre-
cal injection. quently occupying a fold

of the intestine, or the
whole intestine.

d. With considerable ten- rf. A power of raising the
derness of the sub-mucous mucous membrane in
tissue, and a capability of shreds only, which is the
raising the mucous coat case in health.

in large patches.
c. With thickening and c. Without abundance or
abundance of the intes- thickening of^the intes-
tinal mucus ; and some- tinal mucus ; but some-
times with sanguineous times with sanguineous
exhalation. , •exudation.

6. This diagnosis refers merely to the differences
between redness from inflammatory irritation and
redness from passive congestion. I'he various
results of inflammation of the n^ucous membrane
are entirely left out of the question. This tissue
seldom experiences any change in densiti^ within
the period which usually elapses between death
and the examination. Therefore, soflening can
very seldom be justly considered a post mortem
change. In respect, however, of the stomach,
the case has been supposed to be otherwise, and
upon good grounds. The observations of J.
Hunter and Allan Burns on the human subject ;
of Carlisle, Cooper, and Wilson PniLir, on
rabbits ; of Adams, Bretonneau, andTnossEAu,
on dogs ; and of Spallanzani on fishes ; show
that the solvent action of the juices of the stomach
may be exerted upon itself, within twenty-four

hours from death, so as not only to soften its
villous coat, but to dissolve both it and the coats
exterior to it, until the organ is perforated or de-
stroyed in one or more places. The possibility of
this occurrence is shown by the experiments of
Stevens, Lovell, and others, demonstrating the
solvent power of these juices ; and that it actually
takes place, is established by the experiments of
Drs. Camerer and Carswell, as well as by the
sound health of the subjects of it at the time of
death, and the absence of inflammatory appear-
ances around thedestroyedpart, or inthe peritoneal
coat. The healthy state of the other tissues com-
posing the parietes of the digestive canal, and the
natural capacity and position of its different parts,
require no remark.

7. 1. Functional Disorders. — The disposition,
which has prevailed for many years, and which is
still so manifest in medical literature and practice,
to impute every morbid condition to inflammatory
action, and changes of structure, has been dis-
played more in this branch of pathology than in
any other. Since the appearance of the writings of
Marcus, and especially since the promulgation of
the doctrine of Broussais, all the states of
disorder referrible, directly, or sympathetically, to
the digestive organs, have been considered by
many to arise from inflammatory irritation and
action, or their consequences, in various grades
or states of activity ; and even those who have not
adopted the views of this very zealous writer, have
too generally overlooked the primary and con-
trolling influence of the vital endowment in the
origin and removal, not only of the diseases of the
alimentary canal, but of its related viscera, and, ,
indeed, of those of all otherorgans. The pathologist
who observes closely the action of the numerous
agents which either merely change the conditions
of life, as manifested in the sensitive and con-
tractile systems, or which produce alterations of
structure cognisable by the senses, and who notes
the manner in which primary impressions affect
related and even remote parts, must have often
remarked, that some connection subsists between
the nature of the agent, the particular system
acted upon, and the effect produced ; that the
more obvious and palpable, lesions are generally
remote and often only contingent results; and
that alterations apparently identical are often
associated with, even when they are not the con-
sequences of, very different states of sensibility
and contractility, as well as of the other manifest-
ations of vital power. It is necessary to our
enquiries into the morbid states of a pait, which,
with reference to the formative ancl vegetative
processes especially, is primarily and essentially
vital, and which, from its intimate connection witii
the organic system of nerves, powerfully influences,
whilst it is itself influenced by, the vital endow-
ment or appropriate influence of this system, —
of a part especially devoted to the preparation of
the materials for the reparation of the structures,
and the support and perpetuation of Hife, — to
view its changes of function and of structure ac-
cordingly, and with strict reference to the foregoing
considerations.

8. i. Changes in the Desire for- Food and Drink.'
— II the ahmentary canal be admitted to be, of
all parts of the economy, that in which identity
of lesion the least infers identity of symptoms,
the same admission should be extended to the

533

DIGESTIVE CANAL — Functional Disordeiis of.

causes whence its lesions arise. Morbid states of
hunger audtliirst have, with other disorders of the
digestive tube, been imputed either to inflammatory
irritation or action, or to organic changes. That
they proceed, in many cases, from those lesions,
must "be admitted; but that they uniformly or
necessarily thus originate, cannot be maintained.
— ((/) Anorexia, or loss of appetite, although a
very general attendant on all the organic changes
observed in the stomach, is not uniformly present;
for circumscribed lesions had been sometimes
found in this viscus, without tiiis symptom having
been observed. And, on the other hand, it often
exists entu-ely unconnected with any change of
texture. Both M, Louis and M. Andral have
found, in persons who had long evinced the
greatest aversion from every kind of food, the
stomach perfectly sound. Anorexia appears
frequently, independently of the evidence of post
mortem research, to depend upon a change in the
state of the nervous power, as shown by the
influence of moral emotions, and mental and
physical fatigue in producing it. Its occurrence
as a symptom of all acute or serious diseases of
related, as well as of remote organs, and of idio-
pathic and exanthematous fevers, is well known.
— (6) The frequent connection of bulimia with
irritation and organic diseases of the stomach, and
even of the bowels, is admitted ; but it is also
dependent upon a temporary activity in the nutri-
tive processes, as in convalescence from acute
diseases ; and is then referrible to the condition of
vital endowment, as manifested in the digestive
and reparative functions. — (c) Pica, whilst it also
often arises from chronic irritation of the stomach,
is as frequently a symptom of disorder in the
organic nervous system, and even of a morbid
state of the blood, and it sometimes depends upon
functional or organic change in some remote organ,
as the uterus or ovaria. (See Appetite, Mor-
bid ; and Chlorosis.) — (d) Thirst has also
been imputed to irritation or inflammatory
action ; but, although it is certainly a symptom of
this and other diseases of the stomach, and the
rest of the digestive tube, it likewise arises from
diminished exhalation and secretion in the pharynx
and fauces ; from the rapid discharge of the
aqueous parts of the blood by the surfaces or
kidneys ; and from the superabundance of sa-
line particles in the serum.

9. ii. Disorders of tIteFv notions of Chiimifaction ,
Chill ij'action, and Facation. — That the nume-
rous phenomena attendant upon indigestion, may,
and very often do, arise from various states of
irritation or structural change in the digestive
canal, particularly in its villous surface, is un-
([uestionable ; and I\L Bhoissais, although he
has pushed the doctrine extravagantly far, has
drawn attention to important and too frequently
neglected facts. I must, however, contend that
disorders of the digestive processes frequently
cannot be referred, after the most patient investi-
gation, to such sources; but must be imputed to
altered states of the vital or nervous power im-
parted to the viscera which perform these pro-
cesses ; and that those pathological states gene-
rally are more or less intimately associated with
debility and altered sensibility, or even wholly
consist of these states, affecting either the ali-
mentary canal and related organs, or thcoeconomy
throughout. (See Debility, $ 15.)

10. A. In respect of chymifaction, or digestion
in the stomacli, the aiiove positions cannot be dis-
puted. For disorders of this function often depend
upon causes which observation has proved inca-
pable of directly influencing the organisation, or of
acting otherwise than upon the sensibility or the
other manifestations of life displayed by this
viscus, or even by organs affecting it sympa-
thetically. The influence of moral emotions not
only upon chymifaction, but also upon chylifaction
and fajcation, is well known. JMoreover the
stomach has often presented after death no lesion to
account for the total deprivation of function long
experienced during life ; and even when organic
changes have been observed, they have not
always been such as usually arise from inflam-
matory irritation or action : for it should not be
forgotten, that structural lesions may also proceed
from sub-action, or from conditions of vital power,
and of vascular action, diminished as to grade,
and modified in kind from the healthy standard.
Indigestion may therefore arise — (a) from de-
pression or modification of the nervous influence ;
giving rise, 1st, to imperfect or disordered action
of the muscular coats of the stomach ; 2d, to a
diminished or modified secretion of the gastric
juices ; (fc) from a morbid state of the mucus
secreted by the follicular glands of the stomach,
either connected with, or independently of, irrita-
tion (^Embarras Gaslrique of the French) ; (c)
from inflammatory irritation and various organic
changes; and, (d) sympathetically, from functional
or structural disease of adjoining or remote organs.

11. B. The observations now offered apply
equally .to the function of chylifaction, which,
whilst it is often disturbed by inflammatory irri-
tation and organic changes, is as frequently dis-
ordered from modifications of the vital or the
organic nervous influence supplying the duo-
denum, the small intestines, and their related
organs, particularly the biliary and pancreatic
apparatus. When this influence is depressed,
exhausted, or in other respects modified, then im-
perfect and irregular action of the coats of the
duodenum and small intestines ; deficient, or in-
sufficiently elaborated, or otherwise morbid se-
cretions from their internal surface, and from the
liver and pancreas ; and alterations of sensibility,
as well as of tonic contractility, must be the result ;
whether organic change be superinduced or not ;
— such change most commonly being the remote
consequences of neglected and long continued
functional disorder, or of its repeated reproduction
by the numerous agents which occasion it. As
respects chylifaction, the result must be an
imperfectly formed chyle, which undergoes the
further process of assimilation either with difliculty
or insufficiently, occasioning various disturbances
or diseases, expressed chiefly in the secreting or
depurative viscera, as well as in the body gene-
rally. Also, when the vital influence is insuffi-
ciently exerted on the organs of chylifaction, the
materials on which they act more readily assume
those coinbinations to which their chemical aflS-
nities, assisted by warmth and moisture, dispose
them. But when their vital energy is duly ex-
erted, the secretions poured out by the glands and
surfaces, and intimately mixed with the ingcsta
from the commencement of mastication, arc so far
imbued with that influence which pervades the
oeconomy, and converts other substances into

DIGESTIVE CANAL — Functional Disorders of.

539

those structures, with which it is itself so inti-
mately associated, as to withstand purely chemical
affinities, or to change tliem into such as are
strictly vital. And as this controlling and self-
perpetuating power is more and more weakened,
so are the purely chemical forces more strongly
exerted, until various new combinations, either of
a gaseous or of an acid or acrid nature, are
formed, whereby the digestive tube is inordinately
distended, irritated, and, ultimately, permanently
changed in structure, capacity, and even in posi-
tion.

12. C. The processes of fivcutinn, although
obviously and most severely disturbed by in-
flammatory irritation and organic changes, are
also impeded or otherwise disordered without
any such lesions. A deficient exertion of the
vital endowment, through tiie medium of the
organic nerves supplying them, or alteration of
their sensibility, and the resulting modifications in
the tonic and insensible contractility of their mus-
cular coats, and in their exhaled and secreted
fluids, are even more frequently the causes of dis-
orders in the functions of defajcation than appre-
ciable organic change ; and even when this latter
becomes developed, in this part of the canal as
well as in others, it is still more frequently the
consequence of neglected and continued func-
tional disorder. (See Constipation.)

13. iii. Morbid States of Sensibility of the Di-
gestive Canal. — These states consist chiefly of
pain in various grades and modifications. Acute,
lancinating, dull, or heavy, gnawing, burning,
pungent, remittent, periodic, &c. ; and, whilst
they are often attendant upon, — particularly burn-
ing or gnawing pain, — rather than occasioned by,
organic lesions, especially of tlie external tunics
of the canal, they are still more fiequently unac-
companied by any appreciable change. Indeed,
the numerous alterations of texture found in the
gastro-intestinal mucous and sub-mucous tissues
are seldom attended by severe pain. M. Andral
very justly remarks that the mucous coat may be
acutely, or chronically diseased — may be in-
flamed, thickened, softened, or deeply ulcerated
— without any uneasy sensation, or, at most, with
griping pains on going to stool. The abdomen of
persons, whose intestines are ulcerated during
adynamic fevers, may be even pressed in all direc-
tions, without the sensibility being painfully ex-
cited, unless the ulcers extend in depth to tiie
peritoneal surface. On the other hand, the ali-
mentary canal is frequently the seat of the most
severe, or even excruciating pain, without its
texture being at all affected, as proved not only
by post mortem examinations, but also by its
causes, its sudden accession and departure, and
by the juvantia and laedentia.

14. ^. The stomach is the most prone of any
part of the digestive canal to experience changes
of sensibility, probably owing to the numerous
agents, chiefly ingesta — solid and fluid — hot
and cold — bland and relaxing — exciting or irri-
tating— depressing or inflaming — indigestible or
unwholesome — to whicli it is subjected during
life ; and often to all these, in hurtful variety and
inordinate quantity, producing opposite impres-
sions on, with extraordinary distension of, its
coats. Add to the above, the various passions
and emotions wiiich disturb the nervous and cir-
culating systems, and the reasons wherefore the

stomach manifests not only the simpler states of
indigestion, but also the severe and complicated
forms characterised by altered sensibility, dis-
ordered action of the muscular coats, and morbid
secretion — as cardialgia, flatulency, acid and
acrid eructations, pyrosis, rumination, bulimia,
gastrodynia, and cramp or spasm will be apparent.
These, although sometimes asst)ci«fe(/ with organic
change, rather than occasioned by it, are most
commonly referrible merely to modifications of
vital and nervous power and altered sensibility —
pathological states, however, which will often
superinduce organic changes when prolonged
or aggravated by injudicious treatment and diet.

15. B. The small and large intestines also ex-
perience very remarkable changes of sensibility,
often without any manifest lesion of structure,
but generally in connection with irregular action
of the muscular tunics, diminished secretion and
exhalation, and an increased production of flatus.
The difl'erent forms of colic — the flatulent, hys-
teric, lead, jMadrid, bilious, or the dry belly-ach,
&c. — are the most marked examples of this
state of functional disorder, which may, how-
ever, terminate in, or be complicated with, va-
rious alterations of texture, or of position and
capacity.

16. iv. Disorders of Secretion and Excretion.
— The secretions and excretions of the digestive
tube are disordered in various ways, and often
to a very considerable extent, without much
general disturbance being the result. — A. When
the nervous influence of the stomach, and occa-
sionally also of the duodenum, is suddenly im-
pressed or seriously disturbed, nansea and vomitiv,
witli increase of the secretions of these viscera,
are often, although not always, or even generally,
produced. Such disorder may depend on the
state of the stomach ; on disease of the small
intestines, especially of the duodenum ; on ob-
structions in some part of the canal ; on afl^ections
of distant organs, as the nervous centres, the kid-
neys, the uterus, &c. ; on intense impressions
made upon any part of the frame, or on severe
affections of the whole system. Even when
vomiting is occasioned by a morbid state of the
stomach itself, it is as often the result of an altered
condition of nervous influence, as of structural
change ; although in many cases both pathological
states co-exist. Tliis act may arise not only from
irritating or injurious substances taken into the
stomach, but also from similar matters absorbed or
introduced into the circulating current, and from
morbid secretions poured out from its own villous
surface, or regurgitated into it from the duodenum.
Ingesta of the most opposite kinds — whether
highly stimulating and irritating, or depressing
and septic, or simply relaxant — may occasion it ;
the stomach evincing in either case the disposition
to eject whatever is injurious to the frame; the
retching often continuing long after the noxious
matter is thrown ofl^, apparently in consequence of
the morbid impression made by it upon the nerves
supplying the organ, and through their channel
upon the vital manifestations of the body. Vomit-
ing from irritating or injurious matters in the circu-
lation, arises most probably as much from the efl^ect
produced by them on the vital endowment, es-
pecially as manifested in the organic nervous
system, as from their efl^ect upon llie stomach
tself through the medium of the blood circu-

540 DIGESTIVE CANAL

lating in it. Indeed, Majendie has shown, that
attempts at vomiting will follow from this cause,
even when the stomach has been removed from
the body. In delicate persons, the sight even
of certain substances, or the odour of others,
particularly if they at any time had overloaded,
or disagreed with the stomach, will produce
nausea and vomiting. The repeated retchings
supervening with the collapse consequent upon
excesses is probably favoured by the morbid and
accumulated secretions generated during the ex-
citement and the nausea following it. In this
case, the vomiting is attributable chiedy to the
exhaustion of tlie nervous influence of the organ,
and to tlie affection of the nervous centres ; a
moderate repetition of the stimulus, or of some
analogous excitant, removing the disorder. Sea-
sickncis is, however, the most conclusive illustra-
tion of the frequent origin of vomiting in modifica-
tions of the nervous influence. These facts, as
Well the effects of irritation of the uvula or pha-
rynx, and of inflammatory affections of the brain,
and other remote viscera, warrant tlie conclusion
that vomiting is chiefly a nervous affection ; and
that, althougli it is frequently attendant upon, it is
often also entirely independent of, change of struc-
ture, either of the stomach, or even of any other
part. (See Vomiting.)

17. B, Owing to the superabundance, or the
irritating nature of the secretions formed by the
intestinal villous surface, or to the quantity or
<|uality of the biliary and pancreatic secretions, or
to both pathological states conjoined, diarrhoea,
iientery, or dysenteri/, may take place, independ-
ently of organic lesions and even when such
lesions exist, it is generally to the co-existence
with them of increased or morbid secretions
proceeding from one or more of these sources,
that these diseases are to be imputed. Even
in cholera, in which the eruption of an in-
creased quantity of morbid secretions into the
duodenum occasions copious discharges from the
stomach and bowels, with cramps, &c., we are not
justified in concluding that any organic change is
present beyond simple irritation, of a temporary
kind, excited in the villous surface by the acrid
state of the secretions passing along it.

18. II. Lesions of the Tissues composing
THE Digestive Canae. — The difficulty of dis-
tinguishing between the slighter lesions of struc-
ture, and changes occurring shortly before and
after death, as well as states of the villous mem-
brane connected with the conformation and
diathesis of the individual, has already been
pointed out. More frequently, however, no such
difficulty exists, the change being of a kind that
will not admit of a doubt as to its nature. ]3ut
in judging of very many of tlicse more palpable
lesions, we shall fall into numerous errors, if their
more prominent appearances merely be considered,
without reference to their causes, and to the state
of vascular action which occasioned them, and to
the conditions of vital j)ower with which the
vascular action was associated. Tor various
changes of a remarkable description, closely re-
sembling each other, may arise from very different
states of vascular action and of vital power —
either from sthenic inffanimation, or increased
organic action of the tissue, or from sub-action or
diminished organic action, or from perverted
nutrition of the part. To ascertain the nature of ,

— Lesions of Cikculatiox.

the morbid process, therefore, wliicli gives rise to
very manifest lesions, from even the closest ex-
amination of these lesions themselves, is frequently
a matter of difficulty, and often of impossibility, I
in the present state of our knowledge ; and it is I
ciiiefly by connecting them, as far as we may be
enabled, with their causes, and with the conditions
of vital power and of vascular action, that we can
approach to accurate views of their nature. This
I have attempted to do more fully and appro-
priately in the article iNPLAjniATiox ; and have
only referred to these important and too much
neglected pathological states, when the nature of
the changes required that they should be briefly
noticed.

] 9. It should be understood that the several
lesions about to be noticed, may exist cither sepa-
rately, or variously associated the one vv-ith the
other ; in some cases, in the same part of the
canal, and holding the relation of cause and
effect; in others, in distinct or remote parts, and
without any such connection. As it will, how-
ever, be impossible to describe the changes ob-
served in this part, in their numerous states of
association, they will be considered separately,
but with reference to such of these states as are
most common. I shall, conformably with this
plan, notice — _/Jrs{, changes of vascularity ; second,
lesions of the tissues composing the canal ; third,
lesions of internal secretion, comprising adven-
titious productions; and, fourth, changes of ca-
pacity and position.

20. i. Changes of Vascularity, or Lesio)is of
Circulation. — A. Ancemia, or diminished vascu-
larity of the digestive canal is sometimes observed ;
extreme paleness, existing either throughout, or
in parts only. It is usually attended by more or
less attenuation of the gastro-intestinal parietes;
and is most frequently met with in subjects that
have died from the exhaustion of chronic diseases,
or after severe fevers. In these cases, ulcers are.
often found co-existent with it, that are as pale
and bloodless as the surrounding tissue. This
association of ana;mia with asthenic ulceration is
not infrequent in children who have suffered from
chronic diarrhoea and lientery, with or without
mesenteric disease, and who have died comatose.
Anaemia of the digestive canal is also observed in
cases of fatal haemorrhage from other organs.

21. li. Increased vase ularit If, not arising from
the causes stated above (§ 3, 4.), but from ex-
cited organic action, is of extremely frequent
occurrence. As it is generally confined to the
villous membrane, the canal externally will often
exhibit no appearance of it, or will even be un-
usually pale; for sometimes, when this membrane
is intensely red, the subjacent cellular tissue even,
and the rest of the tunics, arc quite devoid of co-
lour. It is owing to this circumstance chiefly,
that the existence of increased vascular action in
cases of liowel complaints has been, until recently,
so much overlooked amongst pathologists. I'his
connection of infianunatory injection of the vil-
lous coat with disorders of the digestive tube had
not, however, entirely escaped the observation of
Cmsson, Bageivi, Mouoagni, L. Bang, and C.
S.MYiii, and was afterwards placed in its true
light by I'lNEi,, Baiei.ie, Makcus, IIilden-
niiANO, AiiEiunoMiiiE, Latham, Andhai., Gln-
niiiN, IJii.EAUi), and others (see liefer.) ; whilst
JinoussAis and his followers made it the basis of a

DIGESTIVE CANAL — Lesions of its Tissues —Atrophy.

541

pathological doctrine, and stretched it beyond its
legitimate limits.

22. Increased vascularity may be seated
chiefly or separately in the villous membvaiie
itself, or In its villi, or in the Jhllicles either dis-
seminated through or aggregated in it, or it may
aftect two or all of these anatomical elements
simultaneously. — (a) Wiien tlie »«emfc)-n)ie itself
is injecteil or inflamed, the appearances are di-
versified ; but at fiist t lie light can still be par-
tially seen ilirough the coats, the vessels being
disposed in a finely arborescent form. Some-
what later, the opacity is complete ; the redness
being at the commencement in spots, stars,
patches, streaks, or bands ; and of a rose or
florid colour ; but afterwards more deep, and
dark or purplish ; and terminating eiliier insen-
sibly or abruptly. — (b) When the yi7/j are in-
flamed, the internal surface presents a number of
red points, which are often closely crowded
togetlier, rendering the membrane opaque. Upon
a close inspection, tiiese points are found to
consist of the villi ; their injection occasioning
the change of colour, which is either limited to
their summits, or is extended from tlience to tlieir
bases. In some instances, the injection is alto-
gether confined to the villi ; in others, the mem-
brane itself is also more or less affected. In
many cases, the villi are of a brownish, or even
blackish colour, particularly in persons that have
luid chronic diarrhoea. Active injection of the
villous membrane may thus exist in an acute or
chronic state, without any further change, for
periods of very variable duration. In some cases,
it will terminate in softening or ulceration in a
few days ; and in others, signs of irritation may
exist for a very long time, and still simple injection
without change of structure will only be found.
— (c) When xhe follicles are the seat of increased
vascularity, the injection is in the form of a
small circle or areola, consisting of interlaced
capillary vessels, with slight elevation of the
membrane of the part, owing to the injection of
these vessels and the tumefaction of the follicle.
Often a sm.aller red circle is placed within the
preceding, and situated, as ]\I. Andhal supposes,
in the margin of its orifice. Sometimes the
situations of the follicles present both these in-
flamed circles quite distinct ; at other times they
both increase, and at last meet each other. In
some cases, instead of these reddish circles,
brownish or blackish circles, similarly disposed
and elevated, are met with. In other instances,
where this disposition of the injected vessels is
observed, there is neither tumefaction within the
circle, nor depression in the central red point, to
indicate the existence of a follicle. Inflamma-
tion of the follicles of Brunneh and PKVEn has
recently attracted great attention, owing to the
writings of Bretonneau, Trousseau, and others
on the subject (see the Bib. and Refer.)

23. Increased vascularity of the digestive
canal is seated either (a) in the arterial and
other capillaries, (6) in both the capillaries and
venous trunks, or (c) in the larger vessels only.
The^rst of these is an undoubted evidence either
of irritation, or of incipient inflammatory action,
if no further lesion exi-t. The second may
belong either to these pathological states, or to
congestion, of a morbid kind existing during life,
or of a mechanical nature occurring after death.

The third may be the indication of pre-existing
inflammation, partially subdued, or of increased
determination of the circulation to Ihe part. It
is of importance to recollect, when judging
respecting the nature of increased vascularity
observed in the digestive tube, that, when it
arises from augmented organic action, it com-
mences in the capillaries and extends to the
larger vessels, — the former only being found
injected after death, in many instances ; whereas,
when it proceeds from passive congestion, it
begins in the large veins and extends to the
capillaries, — the former only sometimes continuing
injected after dissolution. When the vascularity
is active, it commences generally with a capillary
or reticular injection, which increases until an
uniform red tint takes place, and every trans-
parent interval disappears, owing to the crowded
state of the injected capillaries. As the vascular-
ity declines, it again assumes the reticular form,
and at last only some large vessels are observed
in an injected state.

24. Can the colouring of the part be an index
of a primarij chronic, or of a consecntively chronic,
state of inflammation, or of an acute inflamma-
tion which has supervened on the chronic? An
approximation only to the truth can be made in
answering these questions. JM. Andral sup-
poses that the brown, grey, and slate colours
especially belong to chronic irritation. But sub-
stances taken into the stomach, and proving
quickly fatal by the extensive and intense irri-
tation they occasion, or by their noxious impres-
sion on the nerves of organic life, or by both
modes of action, usually impart a brown, dark,
or purplish colour to the injected villous surface.
The inflammation also of this surface, in adynamic
fevers, is often of a very dark ochry or brown
colour ; and the asthenic forms of inflammatory
action, as well as many of those in which the blood
is contaminated or otherwise morbid, frequently
present similar hues. Also a red colour may
attend chronic as well as acute inflammatory
action, although much less frequently. The
above lesions of circulation are generally followed,
after a longer or shorter time, according to the
state of vital power, tlie condition of the circulat-
ing fluid, and intensity of action, by a change, to
a greater or less extent, in the vital cohesion, and
tonicity of the tissues composing the parietes of
the canal, giving rise to the alterations of texture
about to be described.

25. ii. Lesions of the Tissues composing the
Parietes' of the Canal. — A. Atrophy may aflPect
only one, or all the coats of the gastro-intestinal
parietes. — (a) Atrophy of the villous membrane
presents several grades : in a less degree, or at
its commencement, the villi are greatly diminished,
or nearly or altogether efliiced. In a more ad-
vanced grade, not only have the villi disappeared,
but the membrane itself is remarkably attenuated.
In some cases, the villi are obliterated in places,
and not in others. In the situation of cicatrised
ulcers they are always absent. Atrophy of the
villous membrane is met with chiefly in chronic
cases, similar to those in which anaimia has
been stated to occur ; and it is obviously in some
cases a post mortem change. It is often a con-
sequence of anaemia ; but it may accompany
ulceration, vascular injection, or other lesions of
the digestive canal. — (6) The muscular coat may

542

DIGESTIVE CANAL — H

also be atrophied, so that its fibres become much
less apparent, the fasciculi wasted and separated
by wider intervals, occupied by cellular tissue,
from which they can hardly be distinguished.
Atrophy of the muscular coat most frequently
co-exists with atrophy of the other tunics, but it
may also occur when they are hypertrophied,
especially when the sub-mucous cellular tissue is
much thickened. — (c) All tlie coats of the di-
gestive canal may be co-existently atrophied, the
parietes of the canal being then remarkably at-
tenuated, and appearing to consist merely of a
sero-cellular tissue, which is transparent and
colourless, and apparently without villi, follicles,
or blood-vessels (Andral, Louis, Billahd,
&c.). This change is only met with in any con-
siderable degree in parts of the tube; most fre-
quently in the splenic portion of the stomach, and
lowest third of the ilium.

26. B. Hiipertrophii, or thickening, of the
parietes of the alimentary canal may be confined
to a single tissue, or may simultaneously exist in
all the coats of which they are composed. This
change, when far advanced, or seated in the sub-
mucous tissue, and particularly when associated
with ulceration, has been often mistaken, until
recently, by British pathologists for scirrhus, and
by Continental writers for true cancer. Although
thus generally misconstrued, it appears to have
been better understood by Rudolph: (^Bemer-
kiingen, th. i. p. 35.) and Thilenius (Med. u,
Chir. Bemevk. i. p. 202.).

27. (a) Hifpevlrophy of the villous or 7nucous
membrane consists of an increase of its density as
well as of its thickness, and is thereby distin-
guished from the slight tumefaction produced by
inflammatory injection of its capillaries, and from
tumefaction and softening, with more or less
discolouration, occasioned by acute inflammation,
or intensely irritating ingesta. — a. When really
hypertrophied, the villous coat may be removed
in large shreds, which are harder as well as
thicker than natural. When thus altered, it
rarely retains its natural colour, but commonly
presents either various shades of redness, or a
slate-coloured, or a brownish, or blackish tint.
This lesion is most common in the stomach ; next
in the rectum, caicum, and colon ; and least so
in the small intestines. It may exist throughout
either of these viscera, or in parts or points
merely. When the membrane is thickened in
the whole or greater part of the viscus, it may be
either smooth, or unequal ; in the latter case it
usually presents a number of elevations separated
by depressions, giving it a mammillated or pa-
pillary appearance. When the hypertrophy is
only in isolated spots or points, it may pro-
ceed so far as to produce various elevations,
patches, projections, tumours, and polypous
growths, with or without narrow pedicles, and
which have often been mistaken for fungous or
malignant formations ; but which, when ])ro-
minent, are more appropriately termed vegeta-
tions or excrescences. They have been described
by J5auiiioi,inus, Van dek Wiei- (cent. i. obs.
56.), De IIakn (Rat. Med, vi. cap. 4.), Baueu,
Schaaiisciimid (Med.u. Chir, Nachrichlen, b. v.
obs. 10.), Sandikout (Ohserv. Atiat. Pathol. \. i.,
ei Mus. Anut. i. p. 255.), PonTAL (Anat. Med.
t. V. p. 243.), Baii.i.ii-. (Ser. of Eiig. &;c. fasc.
iv. pi. 6.), Stauk (Archiv. b. i. St. iv. n. 3.),

YPERTROPHY OF ITS TiSSUES.

Rebiere {Jonrn. de Mt'd. t. Ixiv. p. 619.),
Andral, and others. These excrescences may
either be of the usual consistence and colour of
the mucous coat, or they may be harder or softer.
They may also present every shade of colour ;
and be either nearly bloodless, or remarkably
vascular. In some cases, their capillary vessels
are so numerous or interlaced as to impart to them
an erectile appearance ; in others, their veins are
large and engorged so as to resemble the morbid
productionsdescribed hereafter(§48 — 51.). They
have bases of various extent ; in some eases large,
in others very narrow, or slender pedicles ; their
summits being either pointed or rounded, or broad,
resembling a mushroom. They are found in
every part of the gastro-intestinal surface ; in the
cardiac and pyloric orifices, or any part of the
stomach ; in the cascum, in the commencement
of the rectum, in the colon, and least frequently
in the duodenum and small intestines. About
the anal orifice, however, and inferior part of the
rectum, they are very common, and are there
often produced by the syphilitic virus. Their
number varies from one to twenty, or more.
M. Rullieu preserved a stomach which was
studded with about eighty, each of the size of a
filbert. They may exist simultaneously in differ-
ent portions of the digestive canal, as in the sto-
mach and Cfficum.

28. 0. These excrescences should not be con-
founded with hypertrophy occurring in some of
the villi with which the membrane is provided.
When much enlarged, the villi project further,
and are of a whiter colour, than the rest of the
surface ; and form small cylindrical vegetations,
which may be readily distinguished from excres-
cences of the mucous coat itself.

29. y. The villi, however, are much less fre-
quently hypertrophied than the follicles. When
the digestive canal of adults is studded with very
apparent or projecting follicles, we may con-
sider these bodies as diseased, although they
may not be really hypertrophied. When they
participate in the increased vascularity of the
inflamed mucous coat, they become tumid from
this circumstance, or from the morbid secretions
collected in them, but not truly enlarged.
When the aggregaied follicles are tumified, ele-
vated patches are thereby formed, giving rise to
the Dothinenteritis of ]M. Bretonneau. How-
ever, as M. Andral has remarked, when thus
tumefied from increased organic action, their nu-
trition is often thereby augmented, and they then
continue enlarged, or even increase in size, after
the morbid vascularity has disappeared, and are
then truly hypertrophied. When thus changed,
they consist chiefly of small, conical, hard,
whitish bodies, with central orifices. This lesion
is met with often in persons whose digestive
functions had not been disordered, as well as in
those who had experienced either acute, chronic,
or recurring diarrhoea. But hypertrophy of the
follicles may al-o arise without any signs of an-
tecedent increase of vascularity cither in them,
or in the villous membrane itself. When this
has been the case, the only disorder has been
either constant, or recurring diarrhoRa ; but as
often no ailment has been complained of. En-
larged follicles may have their orifices of the
natural size, or widened so as to be mistaken for
a small ulcer, or narrowed and even obliterated.

DIGESTIVE CANAL — HvPEHTROPHY of its Tissues:

543

When this latter occurs, the follicle becomes i
distended by its secretion, in some cases, to such
an extent as to form large globular tumours.
The parietes of the hypertrophied follicle may
also be transformed into a fibrous, or fibro-car- \
tilaginous, or even a cartilaginous tissue, thereby j
augmenting their thickness, — a change justly!
imputed by M. Gendrin to chronic inflammation, j
Hypertrophy of the follicles is most common in
the inferior part of the ilium, in the ca;cum, in the
rectum and colon, and in the duodenum, but is
rarely met with in the stomach. It is most fre-
quently a consequence of diarrhixa, dysentery, and
gastric fevers (which see) ; and may be mistaken
for tufts of enlarged white villi, and for small
white bodies; consisting of the rudiments of vatvulce.
conniventes. It is very common after the bowel
complaints of children, amongst whom, however,
the follicles are always more manifest than in
adults.

30. (ft) Hypertrophy of the sub-villoiis tissues
may be more or less general throughout one of
the principal divisions of the digestive canal, or it
may be circumscribed. It is not unusual to find,
after chronic diarrhoea or dysentery, thesu&-?nitcous
cellular tissue much more apparent than usual, or
even two or three lines in thickness, in the colon
or rectum, or both. It is then denser than natu-
ral, sometimes with more or less regularly arranged
fibres, or plates, of a pale or pearly white colour,
and without any evident blood-vessels. It is often
of a homogeneous semi-cartilaginous-like texture;
but wtien thus generally enlarged and indurated,
the hypertrophy is never so great as when it is
circumscribed. When it forms, in some part of
the canal, a tumour, elevating the mucous surface
by its thickness, it constitutes the change to which
the term scirrhus has been very generally applied,
and differs from the diffused hypertrophy only in
being circumscribed, and m.any times thicker. That
the tumour occasioned by the circumscribed hy-
pertrophy, whether existing in the cardia or pylo-
rus, is not the result of the production of a new
tissue, but arises from enlargement and induration
— owing to excessive irritation — chiefly of the
sub-mucous tissue, is manifest in the early states
of the lesion. Tliis may continue to be the only
change ; but often ulterior alterations take place,
and a new structure is developed ; the part becomes
vascular, is sometimes divided into lobes, and
morbid secretions are poured into its substance,
whereby it acquires the appearance of areolae and
cells containing these secretions ; the fibriles of
the cellular tissue between them becoming at the
same time more and more hardened and hypertro-
phied. Frequently the hypertrophy is not confined
to the sub-mucous tissue, but is extended to the
tissue connecting the muscular and peritoneal
coats; hardened, with fibres running between and
separating the fasciculi of the interposed muscular
coat, and thereby connecting both layers of hy-
pertrophied cellular substance. M. Andrai.
considers these fibres to consist of the cellular
tissue placed between the muscular fibres, also in
a state of hypertrophy ; the latter structure gradu-
ally disappearing before the progressive increase
and induration of the former. At last, all ap-
pearance of muscle is lost, and a mass either of
simply hypertrophied and indurated cellular tissue,
or of this substance further and consecutively al-
tered, chiefly by the deposition into it of morbid

secretions, is placed between tlic peritoneal and
mucous coats.

31. This lesion is generally the consequence of
inflammatory irritation long kept up or frequently
reproduced in the mucous meml)rane, which may
be sound, no change of it having existed, or that
which formerly existed having ceased. More fre-
quently, however, it is either injected, indurated,
softened, ulcerated, or entirely eroded in the hy-
pertrophied part. Hypertrophy of the sub-mucous
tissue is most frequent in the stomacli and large
intestines, particularly the rectum, where it may
be either difl^lsed or circumscribed ; and the least
so in the small intestines, in which it is commonly
circumscribed. It is rarely met with in infants.
MINI. BiLLARD and Andral have, however, ob-
served it in them ; and I have seen it in the colon
of children a few years of age, who had long been
aftectedwith chronic diarrhoea. It seldom is seen
in the stomach before thirty ; but it is common
in this viscus between the ages of thirty-five
and sixty-five, especially near the pylorus and
cardia.

32. (c) The muscular coat is sometimes hyper-
trophied, either alone, or along with the submu-
cous tissue. In the former case, the pyloric orifice
of the stomach is its chief seat (Cruveilhier, R.
Pnus, Louis, BouiLLAUD, Andral, &c.), and is
much increased in thickness from this circumstance.
In hypertrophy of the sub-mucous tissue, the mus-
cular coat, instead of disappearing before the in-
creasing bulk and induration of the cellular tissue
that surrounds and penetrates it, as most frequently
occurs, and as above described, is sometimes also
hypertrophied. In this case, when a section is
made of the diseased part, the hypertrophied mus-
cular coat may be traced, in the form of a bluisii
semitransparent layer, placed between two other
layers of a whitish colour, consisting of the sub-
mucous and sub-peritoneal cellular tissue also in a
state of hypertrophy. This central or muscular
layer is traversed by lines of tlie same colour
as the layers on each side of it ; the enlargement
and induration thus extending to the muscular
coat, and through its fibres, by means of their in-
terposed cellular tissue, to that connecting it with
the peritoneuni. This lesioli is most frequent in
the stomach, particularly near the pylorus, and
constitutes, as well as the preceding states (§ 27.)

— often with various alterations of secretion super-
added— what is usually called scirrhus. (See
Stomach — Diseases of.)

33. C. Hypertrophy, of the nerves and vessels.—
(a) The iierves supplying the gastro-intestinal
canal are very rarely enlarged. M. Andral has
never observed any such change in them. M. R.
Prus, however, found, in a case of circumscribed
hypertrophy of the sub-mucous tissue and muscu-
lar coat (^scirrhus) of a part of the body of the
stomach, the right cesophagajan branch of the
pneumo-gastric nerve increased to twice its bulk,
from the cardia to its disappearance in the tumour.
It should be recollected, that the state of the nerves
is seldom enquired after in ]>ost mortem inspections,
and that to ascertain the condition of the ganglial
nerves requires the most minute research, which
can seldom be devoted under such circumstances.

— (6) The blood-vessels of the gastro-intestinal
tube are very often large and dilated ; but this is
not hypertrophy. Their parietes are very rarely
thickened. M. Ancral found, in two cases of

544 DIGESTIVE CANAL —

chronic disease of the stomach, the parietes of the
veins thus changed, constituting tine hypertrophy.
FoRESTUs {Observ. 1. xviii. ; SchuL ad ObservAQ.)
and VoiGTEL (Handb. de>- Pathol. Anat. ii. p. 95.)
have noticed a varicose state of the veins of the
stomach ; a lesion which M. Andral has not met
in his numerous dissections. — (c) The li/rnphatic
vessels, and especially the glands of the digestive
canal, are very frequently hypertropliied, if the
increase of volume so often found in the lacteal or
mesenteric glands after irritation of the intestinal
mucous surface be considered as true hypertrophy.
But, in many instances, tlie enlargement is merely
the consequence of vascular injection, and serous
or sero-puriform infiltration of their tissue, without
any increase of nutrition — the very element of
hypertrophy. But after these pathological states
have subsided, an evident increase of the bulk and
density of these glands remains, whether the pri-
mary irritation continues, or has long previously
disappeared. When these glands are enlarged,
dense, and not very vascular, we may attribute
the change to increase of nutrition, according to
the state of our knowledge of what constitutes it.
But when evident signs of inflammation — as in-
creased vascular injection, redness, and tumefac-
tion — are observed, the change must be chiefly
imputed to increased organic action of the blood-
vessels; although this condition does not preclude
the co-existence of hypertrophy ; with which, in-
deed, increased vascular action, in some grade or
other, is very frequently, and even necessarily,
associated, and of which it is generally the cause.
However, in many cases of what maybe called
hypertrophy, or, otherwise, enlargement of the
lacteal or absorbent glands, instead of being more
vascular, they are pale, and even more bloodless
and colourless than natural, particularly after
chronic diarrhoea, lientery, and marasmus. The
glands through which the lymphatics of the
stomach pass are not so frequently enlarged as
those of the mesentery. Often, however, tiiose
along the curvatures of the stomach and around
the pylorus are much increased in size.

34. D. Sojteniiig of the digestive canal is one of
the most common changes observed ; and it may
be limited to one of the coats, or extended to two
or all of them. In this latter case the parietes of
the canal may be torn with the greatest ease. —
(a) Softening of the villmts coat is most frequently
met with : it occurs in every degree, and either
throughout or in parts of this membrane only, the
consistence of the other coats being undiminished.
This lesion is most common in the stomach, where
it has been most minutely studied. In its first
stage or grade, it can hardly be removed in shreds,
as it may be in the healthy state ; and it is readily
converted, by scraping, into a kind of pulp. As
the softening increases, the slightest touch reduces
it to a mucous-like pulp ; and at still further ad-
vanced periods, it is either no longer uniformly
spread over the gastric surface, or it is entirely
deficient in parts or throughout, leaving the sub-
villous tissue (|uile bare. This lesion may exist in
the whole of the stomach, or in parts of it only, —
most frequently in the splenic portion. It is often
attended by marked dilatation of the veins running
between the coats, evincing the antecedent exist-
ence of increased vascular action in (;ases where
other appearances of it may have vanished. In

Softening of its Tissues.

some cases of children, the softening exists only in
a number of small round patches of a red colour ;
and in others, it is in lines, streaks, or irregular
bands. It is probable that the small softened
spots which have been also noticed by iM.Lestikr
may become ulcers from the extension of the lesion
to the subjacent tissues. The colour of tiie soft-
ened villous coat may be greyish or natural, or
white with a bluish tinge, or a dead milky white, or
red, brown, brick red, and more rarely purple.
Softening, with some one or more of tliese shades
of colour in different parts of the canal, is met
with as a consequence of various acute and chronic
maladies seated either in the digestive organs, or
in remote viscera, especially chronic diseases of
the lungs. White softening in the lower part
of the small intestine and colon is one of the
most common lesions observed after chronic diar-
rhoea.

35. (6) Softening of all the coats of the diges-
tive canal may take place to a remarkable extent,
particularly in the stomach and bowel complaints
of children, and in the gastric and adynamic fe-
vers of adults. It has been described by Jaeger,
Zei.ler, F. Rhades, Fleischmann, Laisne,
Cruveilhier, Haviland, Wiesemann, Gaird-
NER, and other writers referred to in the Biblio-
graphy. In some cases, the parietes of the sto-
mach may be torn with the utmost ease, all the
tunics and interposed cellular tissue having be-
come friable and semi-dissolved ; resembling, in
extreme cases, a kind of jelly, without any tiace
of organisation, and hence denominated by M.
Cruveilhier " gelatiniforin softening." In some
of these cases, the gastro-intestinal parietes are
modified only in respect of consistence, and have
the outward appearance of being sound, until
more closely examined. With this loss of vital
cohesion, the colour of the part may be either na-
tural, or remarkably pale, or red, and without re-
ference to the acuteness or chronicity of the dis-
ease. The splenic portion of the stomach is most
liable to general softening of the coats ; but it also
occurs in the small intestines, and the cajcum and
colon. M. Anural states, that he met with red-
dish softening of the coats of the stomach in a child
who had taken sulphuret of potash before death.
I believe that this substance, as well as the caustic
alkalies, will readily occasion this cliange, if exhi-
bited in too large doses, or continued too long.
As to softening of the gastro-intestinal parietes
ever being a post mortem change, this pathologist
remarks, that it may be established as a genera!
principle, that any softening observed on opening
the body at the usual period after death should not
be considered as the result of putrefaction. But
it may be, when observed in the stomach, the re-
sult of tJie action of the gastric juices, as shown
by J. Hunter and others referred to. It is,
moreover, extremely probable that the acrid and
morbid secretions of the diseased gastro-intestinal
mucous surface may so far act upon any part
of it as to soften and to erode it during the
latter hours of existence, and the time that
elapsed after dissolution. These inferences have
received support from experiment and pa-
thological observations (§ 6.). Dr. Cajieheh,
of Stuttgaid, made, in 1018, a number of exam-
inations with a view to the solution of this
(question ; and found that, in all the animals

DIGESTIVE CANAL — Ulcehation of its Tissues.

545

which had been killed while in good health, the
great extremity of the stomach was softened, and
if a sufficient time had elapsed, its parietes were
dissolved or even perforated ; no signs of putre-
faction being observed. Whilst, on the contrary,
in a dog already evincing putrefaction, no trace
of softening existed in the stomach. This phy-
sician also found that the fluid collected in the
stomach of two children who had died of gela-
tiniform softening of this viscus, introduced into
the stomach of a man just dead, produced, at the
end of twelve hours, solution of the coats of the
part wit!) which it had come in contact ; that a
portion of the same fluid had no effect upon the
stomach of a living rabbit ; but as soon as the
animal was dead, or when the pneumogastric and
trisplanchnic nerves were divided on each side,
this fluid had an immediate action on the coats
of the stomach. Hence it must be concluded
that softening of this viscus is not unfrequently a
post mortem change. It ought to be remarked,
that softening of any part of the digestive canal
has been too generally imputed to inflammatory
irritation, owing to the frequency of its occur-
rence in febrile and inflammatory diseases, and
from the action of acrid poisons. But the ex-
treme cases of it that I have had an opportunity
of observing, have been in the choleric fever and
diarrhcta of infants occurring after weaning, and
in children who have died from aqueous effusion on
the brain. In most of these it was unattended by
vascular injection ; the softened parts themselves,
and those surrounding them, being either softened
merely, or also attenuated or even eroded and
perforated, and quite pale, excepting in the course
of a few large vessels. I have likewise observed it,
but in a different and more general form, in the
adynamic and deliquescent states of remittent and
continued fevers*, and in two cases of puerperal
disease ; the softened parts being more or less
discoloured, and sometimes ulcerated, but not per-
forated. From the condition of vital manifestation
in the cases in which I have remarked this chano-e,
it may be inferred that it results chiefly from a
loss of the organic nervous power, and of the vital
cohesion of the tissues previously to death, but is
increased by this event, and by the action of the
morbid fluids and secretions upon them.

36. F. Ulceration of the gastro-intestinal pa-
rietes is a frequent and important lesion, and has
long attracted much attention in practice. — a. It
seems to have been first noticed by Avic'enna
(^Canon. 1. iii. fen. 16. tr. 1. cap. 2.), who often
makes mention of excoriations and ulceration as
a cause of vomiting and diarrhoea ; and it has
been described by Bonet {Sepulch. l.iii. sect. xi.
obs. 2, 3, et passim.), Gmelin, Friend. Haller,
Field, Penada, Baillie, Frank, Phost, An-
DRAL, and others (see Bibliog. and Refer.). It
is met with in the parts of the canal in the fol-
lowing order in respect of frequency: — The in-
ferior third of the ilium, the ca;cum, the colon,
the rectum, the upper two thirds of the ilium,
the stomach, the jejunum, and the duodenum.
In either of these situations it is a consequence —
(a) Of softening of the villous coat, without any

• I should state, in support of my own originality as to
this change in fevers, that it was noticed in a paper read
by me to the London Medical Society in 1819, and pub-
lished in the Quarterly Journal of Foreign Medicine for
Jan. 1821.

Vol. I.

evident injection, the ulcer being formed in the
centre of the softened part; — (6) Of small in-
flamed spots of the villous membrane, which is
quite sound in the intervals between them ; — (c)
Of a general injection or inflammation of this
membrane, the intervals being more or less red ;
— (d) Of the sloughing of circumscribed parts of
the villous, and sometimes of the sub-villous, and
even of the muscular tissues ; — (e) Of a change
in the mucous follicles, either the isolated, or
Peyer's glands, or of both, — generally preceded
by obstruction and enlargement of them. These
glands first form conical knobs, and are either
few or numerous, greyish or reddish, and with or
without areola; ( § 22. c). Subsequently, a slight
depression appears on their summits, owing to
enlargement of their orifices, or to an incipient
ulcer : this depression gradually becomes more
considerable; the tumid glands thus resembling,
particularly in their inflamed state, and when
they contain a small quantity of puriform matter,
the dimpled pustules of small-pox. They were
formerly considered identical with these pus-
tules, particularly when found, as is occasionally
the case, in tliat disease ; and they have been
described as such by Fernel (De Abd. Rer.
Causis, 1. ii. cap. 12.), Baillou {Epid. et Ephem.
1. ii. p. 207.), HoRSTius (Instit. Med. Disp. 3.),
A.PAHEH.xiv.cap.i.), Peyer (Observ, Anut.W.),
Mead (De Variul. &ic. Lond. 1747, p. 323.),
Bartholin (cap. iii. obs. 29.), P. Fabricius
{Observ. circa Const. Epidem. Ann. 1750, § 18.).
Pustular ulcers have been particularly noticed
in chronic dysentery, by Sir J. Pringle, Sir G.
Baker {Epid. Dysent. of 1762), Sir G. Blane,
and Dr. D. JMonro ; the last of whom describes
the black colour of their bottoms in that disease.
These pustular or pimple-like excrescences are
often destroyed from the apices to the bases,
leaving circular and deep ulcers in their places,
that sometimes extend or run into one another
wlien the aggregated follicles are afl^ected, and
thereby produce large, irregular,ulcerated patches.
Ulceration originating in the follicles may pro-
ceed either from inflammatory action, or from
obstruction of their outlets, and their consequent
distension and irritation by their natural secretion,
which had become acrid from the retention, or
by the accumulation of a morbid or tuberculous-
like matter, which imparts to them the appear-
ance of white granules; this change being suc-
ceeded by ulceration, often without any apparent
increase of vascularity. — (f) Ulceration may
also arise from disease of the sub-villous tissue,
instead of commencing in the villous coat itself,
as in all the preceding states. In this case the
sub-villous tissue is the seat of various morbid
secretions — as of tuberculous matter — which
irritate the villous coat, inflame it, and at last
ulcerate it ; or which, by interrupting the con-
nection of a portion of this coat with the parts
beneath, cause it to sphacelate, leaving an ulcer-
like excavation in its place.

37. /). Ulceration of the digestive tube is — or
rather is an attendant upon — 'either an acute, or
a chronic disease — more commonly the latter.
It is very rarely acute in the stomach, but is
more frequently so in the small and large intes-
tines. The number of ulcers is various — from
one to some hundreds. They are generally only
few, or even single, when they occur in the sto-
N n

646

mach ; and very numerous, crowded together,
and confluent, in the ilium and large intestines;
in which latter, however, they are sometimes met
with singly, or few in number, and isolated.
Their form is usually round or oval ; but they
are also sometimes linear and irregular. They
are most frequently seated on one side of the
canal, but they may occupy its circumference.
Their margins are either white, pale, red, or of deep
brown; the portion of villous membrane forming
them, being either of natural thickness and con-
sistence ; or softer, harder, thinner, or thicker.
In some cases the surrounding sub-vdlous tissue
is thickened and indurated. Their bottoms con-
sist of different tissues, according to the depths
to which they may have penetrated. In some
instances they are so slight as to appear like abra-
sions or excoriations ; and in these the mucous
coat still remains at their bottoms, the villi only
having been destroyed. More commonly, how-
ever, the villous coat is penetrated ; the sub-
villous tissue, which is usually either grey, red,
brown, or blackish, soft and fungous, or hard
and scirrhous, forming the bottom of the ulcer.
In other cases, neither the surrounding villous
membrane, nor the cellular tissue below it, is
further altered than as regards the solution of
continuity, and sometimes diminution of con-
sistency, "the bottoms and margins of the ulcers
being white, pale, without inflammatory appear-
ances, and occasionally remarkably softened.
These alterations are common in the stomach
and bowels of children who have suffered dis-
eases of these organs, or of the brain, after wean-
ing ; and in adults who have died of pulmonary
maladies, or of bowel complaints after fevers.
Dr. J. Gairdner considers that they are not
true ulcers, but erosions of portions of the coats
which were previously diseased, by the juices of
the organs after death. I have seen many of
these cases, chiefly in children, and believe that
the principal part of the change must have taken
place previously to dissolution, which had most
probably rendered the surrounding tissues less
vascular, and further diminished their already
weak cohesion, long before the period at which
these changes usually supervene (§ 35.).

38. As the ulcers deepen, the sub-mucous and
the muscular tissues are successively penetrated,
and in some cases without any appearance of vas-
cularity in either the bottoms or the margins of
the ulcers, or in the intervals between them ;
these latter cases generally occur in the dis-
eases already alluded to, and in cases of great
asthenic or vital depression, sometimes associated
with anaemia or a cachectic habit of body ; the
ulcers often assuming a truly phagedenic cha-
racter. When the peritoneal coat is reached, it is
either thickened, by a development of the cellular
tissue connecting it with the muscular coat ; or it
is inflamed, the vascular injection being evident,
and sometimes attended by an effusion of lymph,
on its free surface, giving rise to partial ad-
hesions between it and the opposite parts. In
other cases, particularly in the asthenic ulcers
now noticed, the peritoneum at their botton)s is
thin, transparent, and pale ; no coagulable lymph
being thrown out upon its free surface, owing to
the weak and cachectic state of the frame. A
single small ulcer may penetrate deeply, and
perforate the intestine; whilst a similar result

DIGESTIVE CANAL —■ Perforations of.

may not arise, although the ulcerations are both
numerous and large.

39. The coats in the intervals between the
ulcers, as well as the parts immediately sur-
rounding them, may be of natural colour, con-
sistence, and thickness ; or more or less either
softened, injected, tumefied, thickened, or hyper-
trophied, and variously coloured. The inter-
vening villous surface is often of healthy colour,
but softened, and studded with enlarged follicles ;
and although it is more frequently slightly in-
jected, yet, in some cases, the opposite condition
already noticed obtains

The sub-villous tissue is
often more or less thickened and indurated where
the ulcer penetrates the villous coat, the ulcer ap-
pearing in the centre of a thickened or hypertro-
phied mass. The cicatrisation of ulcers has been
observed by Baldinger (JV. Magaziii, b. ii.
p. 347.), Male, Abercbombie, Andral, Trol-
LiET, Billard (see Bibt. and Refer,}, and others.
A large cicatrised ulcer was found in the stomach
of ]M. Beclard, who had long experienced dis-
order of this organ. Andrai, refers to several
cases, in two of which the mucous membrane was
evidently reproduced. The changes that take place
on the peritoneal surface, when it becomes the
bottom of the ulcer, as well as when it is perforated,
have a marked reference to the state of vital power :
under usual circumstances, and in a sthenic state
of the system, the adhesions already noticed take
place ; but in an asthenic habit of body, coagu-
lable lymph is not produced, or not in such a
state as to form adhesions ; and often merely an
aqueous or turbid fluid is exhaled, sometimes
long before the ulcers have penetrated far through
the parietes of the canal. Thus ascites may
supervene in any of the stages of ulceration, as
observed by Prost (Med. Eclair par I'Ouver.
des Corps, t. ii. p. 52.) and others.

40. G. Perforations of the digestive canal
have recently attracted much attention ; but
they had not passed disregarded in former times.
Among the numerous writers of the 16th, 17th,
and 18th centuries, who have noticed this lesion,
a very great proportion, having observed it asso-
ciated with intestinal worms, imputed the per-
forations to them, — an inference not confirmed
by more accurate modern research ; the worms
having merely passed through the openings they
found ready made. Instances, however, of this
lesion unassociated with the entozoa have been
recorded by Morgagni (Epist. xxxi. art. 2.) ;
Monro, Vetter (Aphorismen, S^c. b. i. p. 193.),
Bang, Hunter, Gerard, Portal, Breschet,
Laennec (Joiirn. de Mid. Cont. vol.iv. p. 557.),
Percy (Ibid. vol. iii. p. 510.), Leboux (Ibid.
vol. XV, p. 239.), Penaoa, Jaeger (Hufeland
u. Himly. Journ. d. Pr. Heilh. May, 1811.),
GisTREN (7/)((/. July, 1811.), Marcus (Ep/ieme-
riden der Heilk. b. i. heft, ii.), Cloquet (Nouv.
Journ. de Mid. t. i.), Louis (Archives GcnSr.6^c.
t. i. p. 17.), Legai.lois (Ibid. vol. vi. p. 68.),
Chaussier, RuLLiEii, Ehermaier, Gairdner,
Abercromhie, Armstrong, &c. (see Refer, in
liibtiog.). This lesion may arise in vaiious ways :
(a) It may be partly or altogether a post mortem
change, and attended by softening and thinning
of the surrounding tissues; (h) or it may be
caused by an eroding ulceration of the tunics,
without injection, but either with softening and
thinning, or with thickening and induration , of

DIGESTIVE CANAL — Perforations of.

547

the margins ; (c) or by a circumscribed slough
involving all the gastro-intestinal tunics ; (d) or
by an ulcer that has penetrated all the coats;
(e) or by rupture of a previously softened or
otherwise diseased portion of the parietes.

41. (a) Perforation from the action of the
gastric juice is always in the depending part of
the stomach; its size is large and irregular,
its margins are fringed and thin ; and the sur-
rounding tissues are pulpy or gelatinous and
transparent, having a semi-dissolved appearance,
and a pale, whitish, yellowisii colour, sometimes
streaked with brown or black lines from the
action of the acid juices on the blood remaining
in the capillaries. — (6) Eroding ulcerations of
the stomach, such as have been described above
(§ 35 — 37.), and which are with difficulty dis-
tinguished from the post inortem effects of the
gastric juice, may end in perforations, having
pale, thin, and soft edges, especially in children.
Dr. CosTE records two instances of such per-
forations in the stomachs of adults, caused by
the bi-chloride of mercury and spirits, long and
largely employed. — (r) A portion of the canal
very rarely sloughs so as to involve all the coats,
and to give rise to perforation when the slough
is thrown off, excepting in cases of poisoning by
acids, and of strangulated hernia. — (d) Ulcera-
tinii is the common cause of perforation, and is
most frequently, in such cases, seated in the
solitary or aggregated glands of Brunner and
Peyer. — a. It n)ay occur suddenly, and peri-
tonitis supervene, the patient having previously ap-
peared in good health. Such instances are recorded
by Male, Rogers, C. Smith, Craimpton, Tra-
vERs, Laennec, Andral, the author, and Houri-
enne (Journ, de Med. t. xxxvi. p. 464.), as
having occurred in the stomach ; and by Neu-
mann and HuFELAND (Jourii. der Pract. Heilk.
h. ix. p. 170.), the perforation having taken
place in the duodenum and jejunum. — S. Per-
foration is more frequent in the course of, or
during convalescence from, the gastric and
enteric form of continued fever, particularly in
the epidemic or rather endemic forms of it, similar
to those described by M. Bretonneau under
the name of Dothinenterites, and previously by
Roederer and Wagler by that of mucous
fevers. But it may occur in all fevers of an
adynamic form, the surrounding portions of in-
testine being of a dark or dirty brown, or ochry
colour, softened, and often ulceiated in numerous
places, or studded vi'ith minute ulcers of the ag-
gregated glands. This change has been well
described by Bright, Chambers and Hewett.
(See Fevers — Diseased Appearances in.) — y. It
is also met with after chronic complaints of the
stomach or bowels, which are sometimes attended
by much pain or retchings, as in the cases re-
corded by J. Moore, M. Workman, Elliotson,
and Heim (Horn's ,4;-c/i(L'. Jan. 1822.), but more
frequently by little acute sufiTering, until after per-
foration, followed by peritonitis, has taken place. —
$■. It also supervenes during chronic disease of
the lungs, owing either to simple ulceration of the
glands, or to softening of tubercular matter de-
posited between the gastro-intestinal coats, and
consequent ulceration, as in the case recorded by
M. Legallois (see Refer.) : perforation from
this latter cause sometimes, however, occurs in-
dependently of pulmonary disease, particularly in

children. — (e) Perforation from rupture of an
ulcerated, cancerous, thinned, softened, or other-
wise diseased part of the canal, is most frequently
observed in the stomach, and in the colon or
caecum ; and is sometimes favoured by stricture,
thickening, &c. of the portion below it ; the
rupture usually arising from the over-distension
of the diseased part of the canal, from external
violence or pressure, and from straining at stool
or vomiting. Most of the cases of rupture of
the stomach and bowels recorded have been con-
sequent upon some one of the changes already
described, as may be seen in the cases recorded
by MoRGAONi (Epist. liv. art. 15.), Andry
{Hist, de la Soc. Roy. de Med. 1776, p. 2.57.),
Lieutaud, Acrel (A^5c/iHff/. ^6/(. b. ix. n.3.).
Portal, Richter (Chir. Bihlio. b. xii. p. 403.),
SoEMMERRiNG ( N ol cs S^'c .) , Sandifort (Observ.
Anat. Path, l.iv.), Zeviani (Mem. di Matem. e.
Fisica della Soc. Ital. Veron. t. v. 1790.),
Hufelanu (Joiirn. d. Pr. Heilk. b. v. p. 819.),
BouiLLAUD (Arch. Gen. de Mtd. vol.i. p. 534.),
Marjolin (in Ibid, vol.ii.), Annesley, Cramp-
ton, Eli.iotson, Lisle, F. Davis (in the duo-
denum), Abercrombie, W. Cooke, and others.
— (_/■) Ruptures of the stomach and duodenum,
without, as well as with, vomitings, but without
any organic change or violence sufficient to ac-
count for the occurrence, have been observed
by DupuY, Lallemand, Chevalier, and B.
Brown ; but, probably, softening or atrophy, or
thinning of the coats also existed, although not
mentioned.- Perforations of the digestive canal
are most frequent in the stomach, especially
in the splenic portion. In other parts of this
canal they seldom occur, except at the bottom
of ulcers ; whilst in the stomach they are more
commonly produced by the other causes above
enumerated. They may, however, exist simul-
taneously in different parts of the intestinal tube ;
and may occur at every age. Cruveilhier,
Wiesemann, Gairdner, and Billard have ob-
served them in young children. I have seen them
as early as two and three months in infants de-
prived of their nurse's milk; but they are rarely
met with until after weaning. (See art. Stomach.)
42. When perforation has taken place, various
consequences ensue, according to its situation,
and the disease and circumstances in which it
has occurred. — (a) The contents of the viscus
generally escape through the opening into the
peritoneal cavity, and produce acute peritonitis,
soon terminating fatally. But this is not a con-
stant result ; for the perforation may give rise to
chronic peritonitis, under which the patient may
continue to linger for several months. I have
seen this in two instances — one in an adult, and
another in a child. ]\I. Andrai, notices a case
in which lumln-ici escaped into the peritoneal
cavity through the opening, and occasioned
merely an obscure lingering irritation. — (b) 'J"he
perforation may communicate with the cellular
tissue outside of the peritoneum, as when the
caecum and rectum are penetrated, and give rise
to abscesses and fistulas. I have referred to
cases of this description, one of which occurred
in my own practice, in the article on the Cecum.
— (c) In other cases, the gastro-intestinal con-
tents do not pass into the abdominal cavity,
owing to the circumstance of the peritoneum
having, previously to its perforation, become in-
N n 2

548

DIGESTIVE CANAL — Morbid SEcnExioNs in.

flamed, so as to throw out coagulable lymph
on its surface, which excites inflammatory irri-
tation in that part of it directly opposite, and
thereby forms adhesions between them, and shuts
the opening. When this occurs, other conse-
quences ensue. — a.. Tire adhesion may take place
to some part of the peritoneum reflected over
the abdominal parietes, and the ulceration, by
penetrating it, may also occasion abscess or
fistula between the peritoneum and the walls of the
abdomen. Osianuer (Denkw'urdigkeiten , b.i.
p. 99.) has recorded a case of this description;
and Nebei,, Lieutaud, Vetter, Godot, Jac-
QuiNELLE, and B. GoocH, instance others, in
which the inflammation and matter thus formed
advanced externally and opened in the left hy-
pochondrium, a fistulous communication- being
thus established between the stomach or any
other part of the digestive tube and the external
surface. In this way artijicial anus or Jistula i)t
ano, commonly arises, when some part of the
mtestinal canal is perforated. — j3. Owing to
adhesion having taken place between the surface
of some viscus and the penetrated peritoneal
coat of the canal, the former either stops up
the opening, preventing the escape of the gastro-
intestinal contents into the abdominal cavity, or
becomes itself penetrated by the ulcerative pro-
cess extended thither. Meckel (Epist. ad Hal-
LER. Scrip, vol.iii.) found the opening in the
stomach closed by the omentum accreted over it.
Zeviani, CiiAussiER {Bull. de I'Ecole de Med.
de Paris, 1808, p. 41.), and Leroux (Journ. de
Med. Cont. vol.xv. p. 239.), observed it covered
by the spleen, into which the ulceration had par-
tially penetrated. Keppelhout (^Sect. Cadav.
Path. L. B. 1805, p. 19.) met with a similar
connection with the liver. M. Andral saw an
ulcer in the ascending colon, the bottom of which
was formed by the substance of the kidney ;
and M. Rayer, a perforation of the duodenum
stopped by the liver. Perforations of the sto-
mach may be closed not only by the liver and
spleen, but also by the diaphragm and transverse
colon, and even may be likewise carried through
either of them. M. Andj'.al records cases in
which the perforation passed through the sto-
mach and diaphragm into the thorax, and also
into the substance of the lungs, the serous sur-
faces of each having previously adhered : and a
communication had thereby been established be-
tween the cavity of the stomach, and either that
of the pleura, or that of the bronchi. When the
viscus which becomes accreted to the surface of
the perforated portion of the canal has itself a
cavity, then a .communication generally takes
place between them ; thus Camper (^Mem. sur le
Prii, &;c. t. v. n. 9.) met with an opening
into the bladder. Indeed, communications thus
formed with either the bladder, uterus, or va-
gina, are not very rare. A case occurred lo
M. CiiOMF.L (M. Andrai.'s Aiiat. Path. vol. ii.
p. 136.), in which the duodenum communicated
with the colon, through the gall-bladder, which
adhered to both ; and cases are not very un-
common, in which perforations and accretions
of the serous surfaces of several parts of the
digestive canal take place, and openings are
thereby directly formed between them. 1 have
seen communications thus existing in the same
case between opposite parts of the small intes-

tines in two places, and of the small and large
intestines in three places. In another instance
there existed no less than four or five such com-
munications, each of which was of course a
double perforation. These changes have been
observed by me in four cases in children ; and
in all, the perforations were associated with
chronic peritonitis. Dr. G. Gregory (Trans,
of Med.-Chirurg. Soc. vol. xi. p. 258.) has re-
corded a similar lesion ; and an instance, in which
it occurred in an aged person, is given in the third
volume of the Bulletins of the Faculty of Medi-
cine of Paris. Dr. Abehcrombie found an ul-
cerated passage existing between the stomach
and colon, feculent vomiting having preceded
death; Mr. A. Bellot detected several per-
forations, forming openings between the small
and large intestines, and into the abdominal pa-
rietes of an adult female ; and M. C. Broussais
observed carcinomatous ulceration and perforation
of the stomach, opening into the vena porta.

43. In all these, excepting the second perfora-
tion, by which a communication is established be-
tween contiguous portions of the canal, as in the
cases now alluded to, the opening takes place
from within outwards. But the perforation may be
produced in an opposite direction, as where ab-
scesses of the liver burst into the stomach or
colon. ]M. Cayol {Journ. de Med. by Corvisart,
&c. vol. xiv.) mentions a case in which an
abscess in the kidney burst into the ascending
colon. Abscesses, perforating, and opening into,
the rectum, that had formed, in one case be-
tween it and the uterus, and in another between
it and the sacrum, during convalescence from
fever, have occurred in the practice of the author.
44. iii. Morbid Secretions in the Diges-
tive Tube. — These may form on the free surface
of the villous coat, or in the substance of the
parietes of the canal. — A. The secretions and
Jluids found on the internal surface of the villous
coat are — 1st, the natural secretions altered
from the healthy state ; and, 2d, those which
are altogether adventitious and foreign to this
situation. — (o) The mucous secretion and the
aqueous and gaseous exhalations may be increased
in quantity, and otherwise modified. — a.. The
mucus covering the villous surface is often
greatly increased in quantity, and modified in
consistency, either throughout the tube, or in
portions of it only ; this membrane itself being
commonly of a bright red, and more or less
injected ; or of its natural colour, or sometimes
even paler than usual. — 13. The aqueous exhala-
tion is also occasionally increased on the villous
coat, and the vessels more or less congested, par-
ticularly the veins. The existence of increased
aqueous exhalation, connected most probably
with determination of the circulating fluid, is
evidently the chief pathological state in cholera
and serous diarrhoea. But vascular congestion
is not always found upon dissection in those cases,
especially if the person have died of some other
disease, of which serous diarrhoea was a con-
tingent symptom. In these the parietes of the
intestines arc generally attenuated and pale, and
contain more or less of a serous, yellowish, or
colourless fluid. — y. The gaseous Jluids, of
which the digestive canal usually contains more
or less in health, are often greatly increased,
and are sometimes a very inqwrtant symp-

DIGESTIVE CANAL — Morbid SEcnETiONs ix.

549

torn, although not constantly or generally con-
nected with any one pathological state. In-
creased exhalation of the intestinal gases is,
however, a very frequent, although not a con-
stant, result of inflammatory irritation of the
villous membrane, or of disease of Peyer's
glands; but it may also proceed from extreme
debility, manifested especially in the organic
nervous system, and by the bloodless state of the
digestive canal found after death. Hysteiia,
hypochondriasis, asthma, flatulent and lead colic,
rabidity, and other aflfections, are cliaracterised
by great accumulations of air in the intestines,
without any sign of vascular irritation of the
villous surface. These gaseous collections are
generally greatest in the large intestines ; but they
also take place in the stomach and small intes-
tines, particularly in the latter, as observed in the
last stages of typhoid fevejs, and of various other
acute diseases. The meteorismus of fever has
been imputed by BnocssAis to disease, especially
ulceration of the intestines ; but, although the
connection is frequent, it is by no means general,
and, even when observed, both pathological states
are merely associated effects of the same anterior
change, viz. diminished vital power, expressed
particularly in the organic nervous system and
viscera influenced by it. The formation of air
in the digestive canal has been chiefly attributed,
in the article on Colic, to exhalation from the
villous surface. The flatus may also arise partly
from the chemical reaction of the diversified and
heterogeneous substances taken into the stomach,
as they are acted upon by the secretions and are
propelled along the canal, and a portion of air is
commonly swallowed with the ingesta.

45. (6) TheJJuids and secretions foreign to the
digestive canal in health, but which are some-
times found in it, are, blood, pus, coagulable
lymph, melanotic matter, tubercular matter, con-
crete or fluid fatty matter, a thick albuminous
substance, calculous concretions, and worms. —
a. Blood is occasionally found in the stomach and
intestines, both in a fluid and coagulated state,
and in very variable quantity. The causes of
its effusion on the free surface of the villous
coat are — 1st, Atony of the extreme vessels,
and diminished vital cohesion of the coat ; — 2d,
A mechanical obstacle to the return of the blood,
particularly in the vena portae ; — 3d, Inflamma-
tion or irritation of the villous membrane in
various states of intensity and morbid association,
supervening either spontaneously, or caused by
irritating ingesta ; —4th, A morbid or dissolved
state of the blood itself, most frequently, how-
ever, associated with the 1st state, as in scurvy,
the black vomit of yellow fever, and purpura
haemorrhagica ; — 5th, The erosion of the coats
of a blood-vessel in the seat of an ulcer ; — 6th,
Disease of the coats of a blood-vessel, independ-
ently of any lesion of the villous coat; — and
7th, from having been swallowed, as in cases of
excessive hasmoptysis, haemorrhage from the
fauces, &c. When the sanguineous effusion
proceeds from the third source, it may be either
very slight, the mucus covering the villous sur-
face being merely tinged with it, or very con-
siderable, according to the various concomitant
circumstances under which it may take place.
Its _^'t/i and si.i (A sources are the most rare, but
not so rare as M. Andral supposes, the sixth

being entirely overlooked by him. M. Prost,
Dr. Abercrojibie, and others, have detailed in-
stances of the former ; and a case of the latter,
from atheromatous deposit in the coats of an
arterial vessel disposing it to rupture, very recently
occurred in my own practice. {See Hemorrhage
— from the Digestive Canal.)

46. (3. Puriform matter is but rarely met
with on the villous surface, instead of the mucus
usually secreted by it, in any appreciable quan-
tity. It is much more commonly found in the
follicles, either in an inflamed state of this coat,
or independently of any marked injection of its
vessels. When the follicles contain this fluid,
they generally present the appearances already
described (§ 22. c, 36. e.), especially the conoidal
and pustular state, the puriform matter escaping on
incising them. — y. Dr. Monro describes a brown
fluid like cocoa, which he has seen in some in-
stances voided in large quantity during life
from the stomach. In a fatal case, this viscus
was very large, and half filled with this fluid, its
coats and adjoining viscera being sound. — J-.
Coagulable lymph, in various grades of density,
and in the form of false membranes, is also
sometimes found on the gastro-intestinal villous
surface ; but not so often as in the mouth,
pharynx, and oesophagus. I have observed it
most frequently in the form of whitish flocculent
or thin membranous-like patches and shreds,
covering the inflamed or partially injected sur-
face, in fatal cases of scarlet fever, with gastro-
intestinal symptoms. In sub-acute inflammatory
affections of the digestive organs, either with or
without diarrhoea or dysentery, as in the cases
described by Baillie, Powell, Good, Annes-
LEY, Lelut, Billard, &c., the false membrane
is occasionally so complete as to form a tube of
various dimensions, which, when evacuated with
the stools, has been mistaken for a sphacelated
portion of intestine, or for its mucous coat. Dr.
GoDMAN found it covering the whole villous sur-
face of the stomach ; and Mr. Howship remarked
a similar production in a child that had acci-
dentally swallowed boiling water. M. Andral
thinks that it may sometimes proceed from a
morbid secretion of the mucous folliees; but, as
in the other situations in which it is seen, it evi-
dently arises from inflammatory action of the
villous or mucous coat itself, the exhalant vessels
of which, in the inflamed state, throw out co-
agulable lymph instead of their usual watery or
serous exhalation ; these vessels also sometimes
secreting puriform matter, in a modified form of
disease. — 6. The gastro-intestinal mucous coat
sometimes exudes a black matter, the melanosis of
modern writers. This substance exists either in
a fluid form, on the free surface of the mem-
brane, or combined with its tissue, or in both
forms in the same or different parts of the canal.
When merely deposited on the free surface of
this coat, it can generally be washed off; the
matter composing it staining linen. But when
It is infiltrated or combined with this tunic, it
cannot be removed by ablution, and it does not
stain linen. It is most apparent at the bottom
of the lacunae in the duodenum, or in the sum-
mits of the villi, or in the margins of the orifices
of Peyer's glands, or in the bottoms of small
ulcers. — ij, Tuberculons ma»er is sometimes found
in the follicles, the intestines being studded with
N n 3

550 DIGESTIVE CANAL — Complicated Productions in.

n number of small white bodies, seldom exceed-
ing the bulk of a pea. The substance they
contain is concrete, whitish, and friable. JM.
Andral remarks that these tumours are merely
the follicles altered in their nutrition and secre-
tion ; the afi'ection being a genuine acne of the
mucous membrane. — n. Fatty matter is very
rarely met with in the intestinal canal ; but seve-
ral cases are recorded in which it has been passed
in a fluid and concrete state during the advanced
stages of chronic diseases. — &. A thick albumin-
ous matter is generally found covering the villous
surface of the small and large intestines of those
who die early in the Pestilential Cholera. (See
art. Pestilence.) Of Calculous Concretions
and Worms in the digestive canal, a detailed
account is given in their respective articles.

47. -B. Morbid productions in the tissues com-
posing the ■parietes of the digestive canal. — a.
Blood is sometimes effused in the sub-mucous
cellular tissue to an extent varying from a line
to some inches, often without any change in the
mucous membrane, and generally from the same
causes as have produced its effusion within the
canal (§45.). — b. Serous injiltration, or oedema,
of the cellular tissue connecting the different
tunics and muscular fasciculi with each other, is
sometimes observed in various degrees, the thick-
ness of the parietes being thereby proportionately
increased. The fluid occasionally raises up the
villous surface in the form of blisters or small
vesicles. (Edema is most frequent in the large
intestines, the villous membrane being remark-
ably pale, or more or less injected and variouslj'
coloured, or softer than natural, or even more
consistent, or ulcerated, either independently of
disease of its follicles, or in the seat of Peyer's
glands, and with enlargement of them. The
cellular tissue itself, the seat of serous infiltration,
may be unaltered or softened, or hypertro-
phied, thickened, and indurated. In the latter
case, it is, in some places, dry, and grates under
the scalpel, without yielding any fluid; and in
others, there are considerable deposits of serum,
or of a gelatinous fluid of various consistency,
constituting one of the more frequent states of
what is usually called scirrlius, as met with in
the pylorus or cardia of the stomach, or in the
rectum. OEdema, in the different forms now
enumerated, is often the chief lesion observed
after chronic diarrhoea and dysentery, and pro-
longed affections of the stomach. 'The exhala-
tion of serum may also occur within serous
envelopes or cysts, developed between the villous
and muscular coats, and varying from the size of
a pea to that of an egg. — c. Gaseous exhalation
may take place between the coats of the diges-
tive tuhe soon after death, from incipient decom-
position ; but a case observed by M-.T. Ci.oquet
{Bullet, de la Faculte de Med. vol. vii. p. 267.)
shows that it may also supervene during life. —
d. The secretion of fat has been observed in
one instance byM.ANDRAt. in the sub-mucous
cellular tissue, the coats of the small intestine,
in which it formed a small tumour, being quite
aoMnd. — e. Purulent matter is seldom found in
the substance of the gastro-inteslinal tissues, and
then only in small (juantity in the sub-r.iucous
and connectingcelluliir substance — forming either
one or more collections, which are generally
encysted, but also infiltrated in this tissue.

These small abscesses should not be confounded
with the pastular-like tumours, containing pus,
formed by inflamed follicles. They do not ap-
pear to give rise to any peculiar symptom. — /'.
Tubercular matter is secreted more frequently
than pus in the gastro-intestinal parietes, particu-
larly in the lower part of the small intestine,
and generally in the cellular tissue connecting
the coats. It forms small whitish tumours,
owing to the colour and form of the deposition
being perceptible through the elevated villous or
peritoneal membrane, varying from the size of a
millet seed to that of a pea. They may be very
few or numerous — usually the latter in persons
who have had tubercles in the lungs, particularly
at the margins and bottoms of ulcers. They may
exist long without giving rise to any symptom
referrible to the digestive organs, until the mu-
cous membrane becomes affected, when diar-
rhoea— generally chronic and intermittent — is the
usual result. The membrane over and around
these tubercles may be unaltered, or injected and
inflamed, variously coloured, softened, ulcerated,
&c. The softening and breaking down of the
tubercular matter, and the attendant ulceration,
may also terminate in perforation, as in the case
published by M. Legallois. — g. Melanoid
matter is occasionally deposited in the cellular
tissue connecting the coats either in a diffused
or disseminated state, or in isolated spots, forming
small projecting tumours. — h. Osseous matter
is very rarely deposited in any part of the gastro-
intestinal canal. De IIaen (Rat. Med. vol. iv.
cap. i.), however, met with it in the stomach ;
and Short (Edin. Med. Essays, vol.iv. p. 353.),
in the colon and rectum.

48. iv. Complicated Productions generally

THE ADVANCED StAGES OF MoRBID NuTRITION

AND Secretion conjoined. — The morbid form-
ations now to be mentioned, are chiefly the ad-
vanced stages of two or more of the morbid
changes already described ; and, as might be in-
ferred a priori, so nearly approximate to each
other in their external characters, as well as in
their anatomical and chemical elements, as often
to render it a matter of difiiculty to distinguish
between them, unless in an arbitrary manner.
From this gradual approximation of the appear-
ances of organic lesions to one another has arisen
thediflicultyofdescribing and arranging them ; and
from attempts at both having been made without
being aware of this circumstance, or adverting
to it sufficiently, or from endeavouring to es-
tablish, in respect of morbid changes, that which
has been successfully performed in regard of the
living productions of nature, and of which the
former does not, but the latter does admit, —
fiom describing as unvarying species what are
constantly changing vaiieties, — has arisen much
confusion and misconception.

49. A. Local or partial hypertrophy of the
villous membrane, forming the excrescences al-
ready noticed (§ 27.), seems to be an early stage
of several changes, which have been variously
denominated, according to the appearances they
have presented, and which have evidently arisen
from alterations of their nutrition, and interstitial
secretion, probably occasioned, as well as modified,
by local irritation, constitutional vice,. tempera-
ment, diathesis, age, and vital endowment. — (n)
The simplest of these productions seem to be the

DIGESTIVE CANAL — Complicated Productions in.

polypous or JJeshy mass, which may assume either a
pyriform, oval, or spheroidal form ; with a broad
or narrow base, and an opaque, dark red or pur-
pHsh colour, and various grades of consistency,
and of vascularity chiefly as respects its venous
circulation. It has been found in the stomach by
MoRGAGNi, JMoNRO, Granville, and otiiers ; and
in the intestines by Rjiodius, Portal, Monro,
&c. ; and has been seen as large as the closed hand.
After repeated irritation it may either throw out
much blood, or may experience a sloughing or
destructive form of ulceration. — (b) Oilier modi-
fications of polypous tumours present a lo-
bulated, irregular, or fissured surface, with a
more decidedly J'loigous appearance and spongy
structure than the foregoing, particularly in tlie
old and debilitated. They are commonly dark-
coloured, abound more with varicose-like veins,
are less homogeneous internally, are more cellu-
lar, spongy, and vascular, and contain a dark
serous or sanious fluid in their areolre or minute
cavities. They also bleed more frequently and
profusely than the preceding, and discharge a
foetid and sanious matter ; and, when they
ulcerate, assume the form of a soft fungous mass.
They have been mistaken (ov fungus hamatodes,
but, although they very closely resemble the
baEmatoid form of it, tliey differ from it in oc-
curring primarily in the digestive canal, and not
simultaneously in other parts, in being more
spongy than it, and in containing little or no
albuminous or brain-like substance. — (c) A
third modification of these polypous produc-
tions has been described by Dr. Monro under
the name of milt-like tumour. It approaciies
in appearance that variety of fungus licema-
todes which has been denominated encephaloid,
from its brain-like structure. The milt-like form-
ation resembles in colour and consistence the
milt of some fishes, extends to a large size,
and is very slow ia its growth. It is exter-
nally of a pale red colour, with an irregular
surface, emits an ofl'ensive foetor, and is covered
by a fine membrane, in which a number of in-
jected vessels are ramified. It has a homoge-
neous structure, consisting chiefly of a whitish
albuminous secretion deposited in the texture,
or under the epithelium, of the villous membrane ;
and is imperfectly organised. It is partly mis-
cible with water, and is somewhat hardened by
spirits ; the surface to which it is attached, and
the adjoining parts, being discoloured, vascular,
abounding with large engorged veins, and, when
it is removed, presenting a villous, honey-comb
appearance, besmeared with drops of blood from
the torn vessels. The neighbouring lymphatic
glands generally participate in the disease, and
are filled with a similar matter. This struc-
ture difl^ers from the true fungus hamatodes in
being found only on the digestive mucous sur-
faces ; the latter, in every situation. It is also
not so firm and elastic, nor so dark-coloured and
purplish, nor of so unequal a consistence in
difl^erent parts as that di-icase. IMoreover, it is
not liable to fungous ulceration, as the latter is;
and while it occurs only in advanced life, the
true hKmatoid or encephaloid disease is most com-
mon in early and middle age. It is met wiih most
frequently in the stomach, and several cases of it
are detailed in Dr. Monro's instructive work.
50. B. The various states in which simple

551

tself in

scirrhus or scirrho-carcinoma presents
the digestive canal have been here ascribed
chiefly to hypertrophy of the sub-villous cellular
tissue ; and to the modifications of nutrition and
secretion superinduced in it by long continued
irritation, morbid diathesis, advancing age, and
depressed vital power. In the simple states of
scirrhus, the hypertrophy of the tissues to which
it has been chiefly attributed (§ 30.) may be
distinctly traced ; the thickening and induration
of the sub-villous cellular tissue amounting in
many instances to a fibro-cartilaginous change.
But in further advanced stages, or in states of
the disease which are diflerent from the com-
mencement, a more complex lesion evidently
obtains; two or more, and ultimately even all,
the anatomical elements of the part bemg involved
in this change. Scirrho-cancer is jnost frequent
in the pyloric extremity of the stomach, the
cardia, the rectum, the sigmoid flexure of the
colon ; but it may occur in other parts of the
stomach and small or large bowels; and has been
described by JMorgagm, Baillie, Pinel, How-
ship, JMonro, Chardel, Armstrong, Paletta,
Louis, Bavle, R. Prus, Cruveilhier, and
Craigie. It appears commonly to commence
in the sub-villous tissue ; the mucous follicles,
the villous tissue itself, the muscular coat, the
blood-vessels, the lymphatics, the nerves, and
lastly the serous coat, evincing sensible evidence
of change. But, although the former of these
are the first to manifest altered structure, there is
every reason to infer that the morbid condition
originates in the organic nerves of the part, their
functions only being at first affected ; and that
lesions of circulation, secretion, and nutrition,
more or less gradually result, and ultimately the
organic changes which are found implicating the
above anatomical elements. — (a) The scirrhims
and simpler state of this change consists of a
greyish white structure, sometimes inclining to
yellow, interposed between the internal surface
and the serous coat of the part, frequently with
lighter coloured and denser fibres — in some
cases approaching to the fibro-cartilaginous tex-
ture— running through it, and generally in a
transverse direction to the' axis of the canal.
This change may be confined to the connecting
cellular tissue (§ 30.), or be coeval with a simi-
lar change in, or progressively implicate, the
mucous follicles, and tiie villous or muscular
coats. Along with the circumscribed thickening
and induration of the part, a contraction of its
canal generally takes place ; the villous coat or
the mucous follicles of the more prominent places
become ulcerated ; and, either consecutively or
simultaneously, the interior of the morbid struc-
ture is partially softened and disorganised. Sub-
sequently to this, a phagedenic, and, in some
cases, a fungous form of ulceration rapidly pro-
ceeds; death, however, frequently anticipates this
change. In rare instances, this structure is much
more soft, larilaceous or pasty, and indented by
erosions; and is chiefly met with in the rectum.
I have, however, seen it once in tiie pylorus.—
(h) In another variety, the scirrho-cancerous
structure consists of circumscribed and irregular
or nodulated masses; and, in the opinion of
INIoNRo and Craigie, commences in the mucous
follicles. Its internal structure varies, but gene-
rally consists of a hard fibrous-like structure or
N n 4

552

DIGESTIVE CANAL — Changes of Capacity and Situation.

bands traversing a soft or pulpy substance, fre-
quently containing a gelatinous or ichorous fluid
in minute cavities. (See Cancek.) At a more
advanced stage it becomes softer, often in sepa-
rate parts, and at last ulcerates, leaving cavities
with hardened, scirrhous, and ulcerating sides.
It is most frequently found obstructing the ori-
fices of the stomach. —(c) Scirrho-cancer of the
digestive canal is not always limited, but some-
times extends to the adjoining parts ; and it may
attack distinct portions, or even other viscera,
either simultaneously or consecutively. Gene-
rally the peritoneal coat is the last to be affected,
and, when implicated, it resembles coarse parch-
ment. The ruga; of the internal surface are
generally thickened and indurated, or eroded
and ulcerated in the centre, or studded with
small hard tubercles. There are often fungous
growths in the advanced stages, proceeding from
the ulcerated surface, which has ragged, unequal,
and retorted edges ; the disease being then in an
open or carcinomatous state. In some instances
the adhesion precedes the ulcerative process ;
and thus life continues, though all the coats are
destroyed, and the malady is extended to the
adjoining parts. When adhesion has not taken
place, the ulceration communicates with the
cavity of the peritoneum. If the malady be situ-
ated so as to interrupt the passage through the
canal, the parts above it generally become very
much enlarged, at first thickened, but afterwards
thinned, and ultimately either ulcerated, per-
forated, or ruptured. The thickness and hard-
ness of the diseased part vary much. When it
is seated in the cardia or the pylorus, it may
extend to the diaphragm or duodenum respect-
ively, and so on as to other parts. The lymphatic
glands in the vicinity are usually enlarged and
scirrhous. The progress of the malady is generally
very slow ; but in other cases it is more rapid.

51. C. Medullary Saixoma — H<zmatoid, or
encephaloid disease — may originate in any of the
elementary tissues of the digestive canal. It also
presents modifications, according as the encepha-
loid, or medullary, or the vascular structure pre-
dominates. But it differs from the fungous and
scirrho-cancerous maladies, in its more obvious
connection from the commencement in constitu-
tional vice, in the greater rapidity of its progress,
in its belonging to early age, and in its simulta-
neous or consecutive occurrence in different and
\inconnected parts. Its colour varies remarkably :
it being generally much lighter when the medul-
lary or albuminous substance is greatest, and
passing through every shade to a violet or purple,
as it becomes more vascular, and consists more of
convoluted and injected capillaries ; and varicose-
like and congested veins. It generally consists
at first of a soft elastic and distinct tumour, with-
out fluctuation, but occasionally of unequal firm-
ness in different parts. In its progress it bursts,
and a soft dark or purplish fungus, which bleeds
profusely, rises from itu centre, and rapidly in-
creases. When divided, separate portions of it
exhibit different colours and consistence, — some
being as soft as brain, others as iiard as the
boiled white of egg, and others like cartilage, —
and cavities of various sizes and forms, containing
a bloody fluid. It experiences a fungous ulcer-
ation, and, as it extends, implicates or converts
into its own form the tissues surrounding it. It

occurs more frequently in the stomach than in
other parts of the canal ; and when it obstructs
the orifices of this viscus, occasions the further
changes noticed with reference to the preceding
lesion. (See H;ilmato-encephaloid Disease.)

52. V. Changes of Capacity and Situation.
— A, Increased capacity of the alimentary canal
is usually partial only — in one of its compart-
ments; and is often associated with, and, indeed,
occasioned by, narrowing or constriction of a part
immediately below it. General increase of capa-
city has, however, been observed in some cases
of bulimia. The stomach and large bowels are
most frequently thus altered ; either of which may
become so much enlarged as to occupy the greater
part of the abdomen. Cases of this description
have been observed by Plater, Morgagni,
Hasenolhul, HAMBEnoER, Frank, Anderson,
Stoerck, Sandifort, myself, and others ; and
are usually attended by thickening, induration
and constriction, or scirrho-carcinoma of the
pylorus, when the stomach is dilated ; and of the
rectum, when the colon is thus changed. M.
Andral found the duodenum as large as the
stomach in a case where the commencement of
the ilium was contracted. When a portion of the
canal becomes constricted or obliterated, either
from simple thickening, induration and ulceration,
or from scirrhous or carcinomatous disease, the part
above may be not only dilated and sacculated,
but also attenuated or even ulcerated, or it may
ultimately burst from the consequent faeculent and
flatulent distension. Cases of this description
have been recorded by Girdlestone, Burbell,
Annesley, and others. Instances of great dila-
tation of a part of the canal, without contraction
of a part below it, are rare. M. Andral, how-
ever, found the stomach excessively dilated in
two cases, without any obstruction of the pylorus.

53. B. Diminished capacity also is generally a
partial change, and seldom observed throughout
the canal, excepting in a slight degree, after long
fasting or death from starvation, or after an ex-
cessive or prolonged use of acids and astringents.
The stomach has been found as narrow as an in-
testine after poisoning by acids, and sometimes
after irritating substances ; and the intestines con-
tracted throughout from the same cause, and the
protracted use of acids and powerful astringents.
In cases of artificial anus, the portions of intestine
below it, no longer receiving the matters trans-
milted along the canal, contract remarkably, their
cavity being filled with mucus. Obliteration of
the cavity of some part of the digestive tube may
take place either partially or completely — 1st,
from intrinsic causes ; and, 2d,{rom extrinsic causes,
or changes external to it, but which alter or de-
stroy the permeability of its canal. The intrinsic
causes UTe — (a) hypertrophy, with induration of
one or more of the tissues forming its parietes ;
(b) excresences or polypous growth on its internal
surface ; (c) concretions, either calculous or
fffical, or a ball of worms; (d) constriction of
the muscular coat in a circumscribed part. In
tiiis last form of constriction, which is not infre-
quently observed in fatal cases of dysentery, and
of whicii several delineations are given by Mr.
Annesley in the work referred to, the adjoining
portions of intestine are commonly distended by
air ; the internal surface of the constricted part
being generally either injected, or ulcerated, or

DIGESTIVE CANAL — Guanoes op Capacity and Situation.

553

otherwise altered in structure. The contraction
observed about the middle of the stomach, uncon-
nected with any change of the tissues, by Wepfer,
MoRGAGNi, De Haen, E. Home, Monro, Nac-
QUART, and others, has been ascribed to spasmodic
constriction ; whilst some conceive that it exists
very generally during congestion. Soemmerring
imputes it to the pressure of the stays, as it has
been noticed chiefly in females. The four speci-
mens figured by Meckel all occurred in this sex
{Tah. Anat. Path. fasc. iii. tab. 20.). The most
common intrinsic cause of permanent contraction
or diminished capacity of a considerable part of
the digestive canal is that first assigned, — hyper-
trophy, with induration, of some one or more of its
coats, either with or without ulceration. Numerous
cases illustrating this are on record. Dr. Drake
found the stomach diminished to one tiiird of its
capacity, its coats being thickened threefold
througiiout; and instances of thickening, indura-
tion, ulceration and contraction of large tracts of
the intestinal canal — most frequently of the large
bowels — have been recorded by Hill, Green-
how, Burrell, Holmes, Carter, Bouillaud,
HowsHip, Monro, and many of the writers referred
to. Besides these, other instances of the various
forms of intrinsic constriction, or contraction
from organic ciiange occurring in the stomach,
and in the small as well as the large intestines,
are adduced by Bartholin, Bonet, Walther,
Haller, Portal, Michaelis, Mollinelli,
Loesecke,']Mollison, and several others, in places
referred to in the Bibliography.

54. C. Intimately connected with muscular or
spasmodic constriction of some part of the canal
is the occurrence of introsusception ; the con-
tracted portion passing witiiin the adjoining dilated
part. A large proportion of introsusceptions takes
place at the moment of dissolution, particularly
in children, as justly remarked by Camper,
Monro, J. Davies, and others; at least, no
symptom referrible to it had occurred during
life. The usual results of this change both of
capacity and position are strangulation of the re-
tained portion of intestine, and obstruction or ob-
literation of the canal; with the symptomsof Colic
and Ileus (§ 39, 40.), and internal strangulation.
In all introsusceptions, the villous coat is inner-
,most ; next, the two serous surfaces are in contact ;
and more externally still, the two villous surfaces
are also in contact. This arrangement, as M.
Dance (In Repert. d'Anut. et Path. ^c. t. i. p.
441.) has shown, should be recollected, as it ex-
plains how, in consequence of the constriction
and inflammation of the introsuscepted portion,
its serous surfaces, which are in close contact,
adhere ; and, owing to its consequent strangulation
and sphacelation, the whole of it is sometimes
detached and passed by stool, without any of the
intestinal contents escaping into the peritoneum.
Instances of this kind have occurred, and several
are recorded in the works referred to. Introsus-
ceptions are most frequent in the small intestines,
several sometimes occurring in the same case.
They may also take place in this situation to a
small extent without any bad effect. A large
portion — even the greater part of the small in-
testines— is in some instances invaginated in the
CEECum and colon ; and, in rarer instances, the
caecum itself, either with or without portions of
the ilium and colon, may be introsuscepted into

the sigmoid flexure of the last (Hevinus, Monro,
Andral, Dance, and myself).

55. The extent to which the intestinal canal
may be thus invaginated is extremely various —
from a few lines to many feet. The introsus-
cepted portion may even protrude more or less
through the anus. Instances of this kind are re-
corded by the writers now mentioned, and by
many others. When the invaginated part
sphacelates, sloughs are thrown off, leaving
perforations, through which the intestinal con-
tents may pass into the peritoneum. But when,
owing to the circumstance just explained, this
part is separated, perfect adhesion of the parietes
of the intestine at the point of separation taking
place, the canal sufl^ers no interruption of its con-
tinuity. In this case, the invaginated part is
passed by stool. Hevinus met with an instance
in which twenty-three inches of the colon, and
another in which twenty-eight inches of the ilium,
were evacuated. Cruveilhier and Andral saw
twenty and thirty inches of small intestine, with a
portion of mesentery, thus passed. Cases in which
an opportunity occurred of examining the intes-
tinal canal at a remote period from the separation
of the invaginated part, are recorded by Hevinus
and Dumeril. In that by M. Dumeril, six
inches of the jejunum and ilium had been de-
tached. Upon examination after death, the two
extremities of the intestines were perfectly united,
their edges having been bevelled and exactly fitted
to each other. They had contracted adhesions to
the peritoneum at their junction, but the canal
was not sensibly diminished even at the cicatri.x.

56. D. The extrinsic causes of obliteration or
strangulation of the digestive canal are numerous,
and have been referred by M. Andiial to an
irregular disposition, either of the peritoneum or
of the intestinal canal itself. — 1st, These depend-
ing upon the peritoneum are — a. Perforation
of the mesentery; — ^. Perforation of the omen-
tum ; — y. Strips of the omentum adhering to the
abdominal parietes, and entangling a coil of in-
testine; — J. Fraena extending like arches from a
portion of intestine to some other organ, as from
the uterus or ligamenta lata of the rectum (Es-
quirol) — or from a portion of intestine to the
abdominal parietes — or from the omentum to a
part of the abdomen • — or from one of the abdo-
minal viscera to another ; — E. The mesentery or
omentum, involving a coil of intestine, when
folded or rolled together. — 2d. The causes of
strangulation seated in the tube itself are — a. The
compression of one portion of intestine by another,
as a portion of the transverse colon situated between
the vertebral column and the duodenum (M.
GENDRiN,in Arcli. de Med. b. viii. p. 494.) ; — 0,
The escape of an introsuscepted portion of intes-
tine through a perforation or rupture in the con-
taining part, the introsuscepted portion beino'
strangulated by the margin of the perforation"
(M. M. Solon, in Bullet, de la Soc. Med. d'Emu-
lation, 1822.) ; — y. Twisting of the appendix of
the caecum around a portion of the ilium, com-
monly owing to the unusual length of this part ;

J. Adhesions of the extremity of the appendix,
so as to form an arch or ring, in which a portion
of intestine may become entangled ; — e. The
twisting of a diverticulum around either the part
from which it is produced, or a coil of intestine •
— ?. Adhesions of the extremity of a diverticulum,

554 DIGESTIVE CANAL — Congenital Lesions of Dimension and Situation.

which may compress a portion of intestine over
which it passes, or that portion to which it is at-
tached. All these causes may, however, exist
without giving rise to internal straiigulatipn. But
they more frequently produce it either slowly or
suddenly. In the former instance, symptoms in-
dicating a greater or less obstacle to the passage of
the intestinal contents are generally complained
of for weeks, months, or even years, before the
signs of strangulation appear. In the latter case,
no premonitory symptoms are observed.

57. E. The situation of parts of' the digestive
canal may be changed in several ways, which are
referrible to two principal classes : — 1 st. Alterations
of situation in respect of different parts of the
tube, and of the related viscera, — or internal dis-
placements; — 2d. Protrusions through some part
of the abdominal parietes, — or external displace-
ments, (a) Internal displacements arise from — a.
obstruction; B. alterations of its calibre ; and, y.
the impulsion or dragging of adjoining parts. The
stomach is not infrequently partially displaced
from some one of these causes, especially its py-
loric extremity, and generally in consequence of
scirrhous thickening and induration, or tumours
developed in it or its vicinity. 1 have seen the
scirrhous pylorus form a tumour below the um-
bilicus,— a circumstance which might have led
to an incorrect diagnosis, if it had not been known
occasionally to occur. This viscus may also be
displaced by the dragging of the omentum in a
large hernia, the pyloric extremity descending
equally low from this cause, as in a case re-
corded by Dr. R, Lowis. The situation of the
small intestines, c<rcum and colon, is also fre-
quently changed from the causes now stated.
Alterations of this description in the two latter of
these have been noticed in their respective articles.
The second or external class of displacements be-
long to the province of the surgeon, the medical
relations of the subject falling more appropriately
under the articles Dyspncea, in which diaphragm-
atic hernia is noticed, and Peritoneum, where
the diseases of the serous coat of the digestive tube
are considered.

58. vi. Congenital Lesions of Dimension and
Situation. — The gastro-intestinal canal has never
been found wholly wanting, even in monstrous
productions. Of the diflerent parts which con-
stitute it, that proved to be tlie first formed is never
deficient. This is the extension of the vesieula
umbilicalis into the intestinal canal, which, how-
ever, may be arrested in its formation before one
or other extremity of tiie tube has been produced,
thereby occasioning deficiency of a portion of
eitiier.or the impertoiation of their outlets. With
the various congenital faults of configuration, di-
mension, and situation, it is unnecessary to occupy
my limits. A few only of the most important may
be noticed.

59. A. The dimeiuions of the digestive canal
may be lessened or increased, either throughout,
or in parts only. — (a) The stomach has been found
so small as not to exceed the diameter of tlie
small intestine. The convolutions of the small
intestines have been observed less numerous or
nearly wanting, and tlie length of the canal from
the cardiac orifice to the anus hiirdly ecjualling
tliat of tlie individual. The cacmn has souietimes
been so small as not to form a cul-de-sac, or it has
been, as well as the appendix, altogether defi-

cient, the ilium opening directly into the colon. — ■
(b) Increased dimensions of some part of the di-
gestive canal are more common than the preced-
ing. In infants and children, the stomach has
been found of a remarkable size; and in some, the
duodenum has been as large as the stomach. The
caecum, or its appendix, has also been very large.
BnuGNONi and Meckel {Tab. Anat. Pathol.
fasc. iii. p. 23.) have adduced instances of two
colons springing from a single caecum, and reunit-
ing at the rectum, in the case of the former ; but
terminating in cul-de-sacs, floating freely in the
abdomen, in that of the latter. One part of the
canal has been found greatly increased in size,
whilst the other is diminished. M.Cabrol found
the stomach of a person so large as to fill the
greater part of the abdominal cavity, and the
small and great intestines together little longer
than three feet. — (c) Appendices or diverticula
are sometimes attached, like the fingers of a glove,
to the side of the canal. M. Andhal states them
to be most frequent on the jejunum and ilium,
and Meckel on the lowest third of the ilium ; but
they have been found on the duodenum and on
the rectum (Morgagni). — Their cavities are
continuou* with that of the intestine, and they ter-
minate in a cul-de-sac, which either floats loosely
in the peritoneal cavity, or adheres to some ad-
joining part. Their length varies from a few lines
to three or four inches. They may either fall
short of, equal, or surpass, the diameter of the
intestine whence they spring ; and they form every
angle with it. They vary in number from one,
which is most common, to five or six in the same
portion of intestine. Their terminations are
rounded or pointed, and they sometimes present
a series of cHlatations and contractions. Meckel
saw one inserted into the navel, forming a kind of
umbilico-intestinal canal. From this and other
circumstances — particularly their being com-
monly found single, and on the lowest third of the
ilium — he infers that true diverticula are the re-
mains of the original intestine formed by the ve-
sieula umbilicalis; and contends that, when they
occur in any other situation, or when more than
one exists in the same case, they are false, and
consist merely of hernia of the villous through the
muscular coat, or of some other change ( Ueher die'
Divertikel, in Reil's Archiv. &c. b. ix. h. 3., et
Tab. Anat. Path. fasc. iii. pi. 21.). They seem
to dispose the adjoining portion of intestine to or-
ganic change, as well as to alterations of capacity,,
as in the cases recorded by Dr. Francis and others.

60. B. The situation of the digestive tube, or
of parts of it, is variously changed, either by ori-
ginal conformation, or by accident or disease.
The congenital abnormal positions of the viscera
are so numerous, and of so little importance in a
practical point of view, that I shall not touch on
them. 'J he reader will find them described in
the works of Meckel and Andhal referred to in
this article. Jmperforations of the canal cortie
not within the scope of the work.

61. As the same alterations of structure occur
in all the parts constituting the digestive canal,
although in difterent degrees of frecjuency, I have
described them in a connected manner, in order
to prevent the repetition that could not be avoided
if tiiey had been comprised in the articles on the
Intestines, Stomach, &c. ]5ut in these, and
some other articles, 1 have detailded the symptorut

DIGESTIVE CANAL — Bidliography and Rr.FEnENCES to its Lesions.

555

of those alterations, and the treatment they re-
quire, because the same lesions, seated in different
parts of the canal, are attended by different phe-
nomena, and claim modified means of cure ;
reference being made to the changes here de-
scribed. Therefore, the diseases of the diges-
tive canal should be also studied in the following
articles, which contain most of what is known
respecting them : — C.tcuM, Colic and Ileus,
Colon, Concretions, Constipation, DiAannoEA,
Duodenum, Dysentery, Fevers, Indigestion,
Intestines, Oesophagus, Peritoneum, Pha-
rynx, Rectum, Stomach, Worms, &c.

BiBLioG. AND Refer. — i. General Treatises. —
Waldsc/imid/, DeVentric. ct Intest. Morbis. Marl), 1G84.—
Kraus, De IiUest. eorumque Morbis. Jeiia>, 1GS4. — Git's,
son, De Ventric. et Intestiiiis, tr. ii. — J. M. Hii/T/natin, Dis.
quisitio Corii Hum. Anat. Pathol. &c. 4to. Alld. 1713. —
iSauer, in Halter's Bibliotli. Med. Pract. iii. p. 461. — Peyer,
Exercitat. de Gland. Inte.-it. par. ii. p. 80. — Adolphi, De
Tunica Intest. Villosa foco Morb. &c. JenjB, 1721. ; et De
Colo Intest. Mult. Morb. Nido,&c. Leips. 1718. — //«/-
ler, Morbi aliqui Ventric. in Cadav. Observati. Goet.

1749 Lieutaiid, Hist. Anat. Mijd. I. i. observ.400., et

passim. — Slimzer, De Morb. Intest. cSrc. Tub. 1767. —
£. Sandi/ort, Observ. Anat. Path. 4 vols. 4to. ; L. B. 1777,
8vo. — C F. J.udiuig, Prima; Line;E Anat. Pathol. 8vo.
Leips. 1785. — J'icq d'Azi/r, Anat. Path, in Encyd. Me-
thodique, 4to. Paris, 1789. — M. Bail/if, The Morb.
Anat. of the Hum. Body, 5th ed. Lond. 1818. — A. R.
Vetter, Aphorismen aus der Pathol. Anat. &c. Wien.

1803 Prost, Med. Eclairee par I'Observat. et I'Ouvert.

des Corps, 2 tomes. Paris, 1804. — Kade, in lieil's Ar-
chiv. iv. p. 382. — J. Cruveilliicr, Sur I'Anat. Patholog.
&c. 2 vols. 8vo. Paris, 1816. ; et Med. Eclairee par I'Anat.
et Phys. Path. cap. i. Paris, 1821; et Anat. Path, du
Corps Hum. 1. i. — xv. Paris, 1727-33. — Bruussais, Hist.
des Phlegmasies Chroniques, &c. t. ii. cap. 1. et seq. —
Jiev. in J. Ju/inson's Med.-Chirurg. Kev. vol. ii. p. 1. —
J. Abercronibie, in Ed. Med. and Surg. Journ. No. 84. ; et
Dis. of Stomach and Abd. Viscera, 8vo. Edin. 1828. —
Tacheron, Kecherches Anat. Pathol. &c. 3 t. 8vo.
Paris, 1823. — Andml, Recherches sur I'.Anat. Pathol, du
Canal Digestif, &c. in Nouv. Journ. de Med. t. xv. p. 193. ;
et Lond. Med. Repos. vol. xix. p. 248. et seq. ; et Anat.
Pathol, 8vo. vol. ii. par i. ef seq. — J. B. Palletta, Exer-
eit. Pathol. &c. 4to. Med. 1820-7. — ."V^n^ in Diet, des
Sciences Med. t. xxxviii. p. 152. — X Bic/iat, Anat. Pa-
thol, ed. par Boisseau, 8vo. Paris, 1825 — A. N. Gen.
drill. Hist. Anat. des Inflammat. vol. i. p. 493. 659. 691.

— HiUin, Nouv. Biblioth. Med. t. ix. p. 4. 328. — fow/'i-
loiid. Ibid. vol. v. p. 169. — Billard, De la Mamb.
Muquese Gastro-lntest. dans I'Etat Patholog. &c. 8vo.
Paris, 1S25. — Bourdon, in Rev. Med. t. ii. 1S24, p. 209.—
J. Anneslejf and Author, in Researches, &c. Dis. of Warm
Climates, vol. ii. p. 39, et seq. — Craigie, Elements of
Gen. and Pathol. Anat. 8vo. 1828, p. 684. — J. Armstrong,

Morb. Anat. of the Bowels, Liver, and Stomach, 1. i iiL

Lond. 1828. — .4. Monro, Morbid Anat. of the Gullet,
Stomach, and Intestines, 2d. 8vo. Edin. 1S30.

ii. Lesions of Functio.n and Circulation. — A. Of
Function. Biedlin, Lin. Med. 1700, p. 173. — De BUchner,
Diss, de Spasmo Intest. Erf 1741. ; et De Consensu Pri-
mar. Via.'. &c. Hai.-e, 1764. — Schnetler, De Ardore Ven-
triculi, &c. Arg. 1786. — Dannenberg, De Asthenia Ven-
triculi et Intest &c. Jens, 1801. — JViesner, De Spasmo
Ventriculi. \'it. 1802. — Burdin, in Mem. de la Soc.
Med. d'Emulation, t. ii. p. 86. — Cheyne, Dub. Hosp. Rep.
vol. iv. p. 252. — Macfarlane, in Glasg. Med. Journ. vol. ii.
p. 170.

B. Of Circulation. — Blnsius, Observat, Med. Rar.
par. i. n. 21. —Hoffmann, Op. t. vi. p. 223. — Stoll, Uat.
Med. par. viii. p. 129. — Kaempf, Abhandl. die Krank.
heit.d. Unterlebs. &c. passi?n. — Bang, in Act. Reg. Soc.
Med. Hafn. vol i. p. 110., ct vol. ii. p. 279. — Bleuland,
Descrip. Vascul. in Intest. Tenuium Tunicis, &c. Traj.
ad Rh. 1797, p. 14. — Mic/iaelis, Med. Bibliothek, b. i. st. 3.
p. 271 . C Wit/ioui pain or other sign.) — Yelloly, in Trans.

of Med.-Chirurg. Soc. vol. iv. p. 228 Trousseau, De la

Dothinentdrite, &c. in Archives de JNIcd. t. x. p. 67. 169.

— A. Grimaud, in Journ. Compl. du Diet, des Sc. Med.
July, \S2'd.—Schmidtmann, Observ. Med. t. ii. p. 98—181.

— Goldmann, in Archiv. Gen. de Med. t. i. p. 278. —
M. A. C. I.andini, in Rev. M^d. t ii. 1826, p. 189. 398.
{Of mucous foliicles.) — I.eitret, Archives Gen.de Med.
t. xvii. p. 453. (Mur. follicles.)

iii. Atropuv, Hvpertropkv, and Induration. —
ScAun^, Chylologia, p. 560. (Atrophy.) — i^uwrf, Sepulch.
1. ii. s. vii. ob. 56. (Atrophy.) — Sclienk, Observ. 1. iii.
obs. 92. (Atrophy.) — Pohl, De Callositate Vent, ex Potus
Spir. Abusu. Lips. 1771. — fetter, Aphorismen, i. p. 172
—191. (Scirrhus to be seated in the cellular tissue.) — Le-

velling, De Pyloro Carcinomatoso. Ing. 1777. — Shcrwin,
in Mora, of Med. Soc. of Lond. vol. ii. p. 27. — Thilenius,
Med. und Chirurg. Bemerk. i. p. 202 — Budolphi, Be.
merkungen, th. i. p. 35 — Portal, Mem. sur Plus. Malad.

vol. iii. p. 1. — Baitiie, Series of Eng. fas. iii. tab. 6, 7

Cloquet, in Bullet, de la Soc. de M^d. 1810, No. 7. p. 106. _
Fournier, in Sedillot's Journ. de Med. May, 1812 — Dar-
luc, Journ. de Med. t. xi. p. 499. — Smyth, in Med. Com-
munic. &c. vol. i. No. 29 — Sims, in Ibid. No. 28 — Har-
rison, in Mem. of Med. Soc. of Lond. t. v. n. 16. — Halter,
Opusc. Path. obs. 26. [From abuse of acids.) — Beit, Ar-
chiv. f. d. Phys. b. iv. p. 381. — i/or;i, Archiv. f d. Pract.

Med. b. iii. p. 67 Girdlestone, in Med. and Phys. Journ.

vol. xl. p. 13 J. Holmes, in Ibid. vol. xxviii. p. 170

ly. G. Burrell, in Ibid, vol, xxx. p. 515 F. Ckardel, Des

Degenerat. Scirrheuses de TEstomac. Paris, 1808; et in
Quart. Journ. of For. Med. &c. vol. ii — Drake, in Edin.
Med. and Surg. Journ. vol. ii. p. 417. — N. Hill, in Ibid,
vol, xii. p.275. — Greenhoiu,\n Ibid, vol.xvil p. 375. — Louis,
Mem. et Rech. &c. 8vo. p. 120.; et Archives Gt'nerales,
&c. t. iv. p. 536. — Bouillaud, in Rev. Med. Mars, 1827 —
H. Prus, Recherches Nouv. sur Cancer de I'Estomac, &c.
8vo. Paris, 1828.
iv. Softening, Ulceration, Erosion, Perforation,

&c Bonet, Sepulchr. 1. iii. sect. xi. obs. 2, 3, 4, &c. —

Morgagni, .Sed. et Caus. Morb. ep. xxxv. art. 15. — Du-
verney, Mem. de I'Acad. des Scien. 1704. p. 27. — Haasius,
De Tunicas Villosae Renovatione, &c. Altd. 1735. —
Friend, Comment, de Febribus, p. 142. — Hamberger,in
Halter's Coll. Diss. Pract. vol. iii. n. 98.' — R. Lowis, Edin.
Med. Essays, vol. i. p. 291. — I'an Swieten, Comment. &c.
ad ^^955. — D. Monro, Essays Phys. and Lit. vol. iii.
p. 516. — Gmelin, Ulc. Intest. Casus, &c. Tub. 1759. —
Lieutaiid, Hist, Anat. Med. L ii. obs. 719. — Geqffroy,
Hist, de la Soc. R. de Med. ad 1780, 1781, p. \m.—Bang,

Act. Reg. Soc. Med. Hafn. t. i. p. 280 Fearon, Mem. of

Med. Soc. of Lond. vol. ii. n. 38. — Field, in Ibid. vol. vi.
p. 1'.,'3. — Burrouis, in Med. Facts and Observ. vol. v.
n. 17. ; et in Trans, of Irish Acad. vol. iv. n. 12. (Fistula
open, extern.) — Luchtmnns, Diss. Med.-Chir. Miscel.
Ultr. 1783. — HalUr, Opusc. Pathol, obs. 28. — Cruick-
shanks, Anat. of Absorl). Vessels, &c. p. 113. — fan der
Kolk, Observat. varii Argument. &c. Gron. 1793. — Go-
dot, in Journ. de Bled. t. xl. p. 145. — Jacquinelle, in Ibid,
t. xc. p. 209. — Haile, in Ibid. Contin. iv. p. 103.— - AVic/,
De Ulcer, in Ventr. Penet. &c. Ileid. 1782. — Stoll, Rat.
Med. i. p. 266., ii. p. 409, vii. p. 164. — J. Hunter, Philos.
Trans, vol. Ixii. p. 444."; et Observ. on Animal CEco-
nomy, 2d edit. p. 226. — B. Gooch, Med. and Surg. Ob-
serv. &c. ; et in Edin. Med. Comment, vol. it p. 373

C. Smyth, Med. Commuuicat. vol. vii. p. 467. — Ada7tts„On

Morbid Poisons, &c. 2d ed. p. 30 Ludwig, De Lum-

bricis Intest. Perforant. Lips. 1792. — J. P. Frank, Acta
Institut. Clin. Viln. ann. ii. p. 7. ; et De Cur. Horn.

Morb. 1. vi. par. i. p. 131 M' Lagan, in Ed. Med. Com.

ment. vol. ii. p. 78. — Penada, Saggio d^Osservazioni, t. i.
— Keppelhout, Sect. Cadav. Pathol. 1805, p. 19. — ^. Ge-
rard, Des Perfor. Spontanees de I'Estomac, &c. 8vo.
Paris, 1803. — J. Moore, in Med. and Phys. Journ. vol. iii.
p. 511. — ^. Bellot, in Ibid. vol. xxii. p. 392.— JK. Cooke,

Ibid. vol. xxx. p. 337 G. E. Male, in Ibid. vol. xiii.

p. 164. — Chaussier, Halle, et Leroitx, in Bullet. del'Erole
de Med. de Paris, 1808, p. 41. — .4. Burns, in Edin. Med.
and Surg. Journ. vol. vi. p. 137.' — Heiin, in Horn's Ar-
chiv. Jan. 1812, p.\2. — Hanius, in Ibid. 1812, p. 162.—
F. Davis, in Lond. Med. Rev. vol. v. p. 258. — Jaeger, in
Hufeland u. Himly's Journ. d. Pract. Heilk. May, 1811.;
et in Lond. Med. Repos. voL x. p. 416. — Gistren, in
Hufeland u. Hiriily's Journ. A. Pr. Heilk. July, 1811.—

Michaelis, in Ibid. Feb. 1812, p. 45 Marcus, in Ephe-

merid. d. Heilk. b. i. st. 2. — Lallemand, Otwerv. Path.
&c. 8vo. Paris, 1818, 4to. — StUtx, in Hufeland's Journ.
d. Pr. Heilk. b. xxiv. p.H3. — Schenk, in Ibid. b. xxvii.
p. W.—Zeller, De Nat. Morbi Ventric. Infant. Perforan-

tis. Tub. 1818 Breschet, in Journ. rie Med, Contin.

t. xi. — F. Rhodes, in Horn's Archiv. Sep. et Oct. 1822,
p. 238. — Laisne, Consid. Med. Leg. sur les Erosions et
Perfor. de I'Estomac, 8vo. p. 163. — C. Broussais, Bullet.

de la Soc. Philomath. Sept. 1823, p. 156 Haoiland, in

CambridgelPhilosoph. Trans, vol. i. p. 287 J. Gnirdner,

Cases of Erosions and Perforations of Aliment. Can. &c.
Trans, of Edin. Med.-Chir. Soc. vol. i. p. 311. [An able
memoir.) — P. C. A. Louis, Jlem. et Recherches Anat.
Path. &c. 8vo. Paris, 1826, p. 1. 136 ; et in Archives de
Med. t. i. p. 17., et t. v. p. 5. ; et Lond. Meil. Repos.
vol. xxii. p. 154. — Legallois, in Archives de Med. vol. vi.
p. 68, — Troillet, in Ibid, t. ix. p. 5. — Ebermaier, in Ibid.
t. xviii. p. i9.1. — Rullier, in Ibid. t. ii. p. 380. — L.isle, in
Ibid. t. XX. p. 433. — Chaussier, in Nouv. Journ. de Med.
t. iv. p. 295. — Hewett, in Med. and Phys. Journ. vol. Ivi.
p. 97." — Chambers, in Ibid. p. 354. ; and in Lx)nd. Med.
Gazette, vol. ii. p. 513. — Bright, Medical Reports,
vol. i. 4to. p. 178 — W. E. Horner, in Amer. Journ. of
Med. Scien. Feb. 1829, — Laennec, \n Rev. M^dicale, t. i.
18l'4, p. 379. — Caniiet, in Ibid. t. iv. 1825, p. 527. ; et in
Archives do Med. t. xviii. p. 427. — Sestii, ionrn. Heb-
domad, de Med. t. i. p. 216. — Pilschajl, Edin, Med. and

556

Surg. Journ. vol. xxvi. p. 451. — Glasgow Med. Journ.

vol. ii.p. 341 Hediard, Journ. des Progres cles Scieii.

Med. t. xvi. p. 250 E. Blasius, in Rust's Magazin f. d.

Gesamm. Heilk. &c. vol. xxvii. ; et Journ. Hebd. de
Med. t. iii. p. 69. {Gelatiniform softening.)— Cioquet, Nouv.
Journ. de Med. t. i. ; et Lond. Med. Repos. vol. x. p. 332.

— Billard, Nouv. Biblioth. Med. t. i. 1826, p. i'i.— niese-
mann, Lond. Med. Repos. vol. xxv. p. 168. — Dupny, in
Ibid. vol. xxvii. y>- 315. — Rogers, in Ibid. vol. xxviii.
p. 249. —B. Brown, in Ibid. vol. xvii. p. 108. — Carter, in
Ibid. vol. xxi. p. 371. — M. Workman, in Ibid. vol. xix.
p. 208.— Co«/c, in Ibid. vol. xx. p. 2V2.—Crampton, Trans,
of Irish Col. of Phys. vol. i. part i. ; and in Trans, of Med.
and Chirurg. Soc. vol. viii. p. 228: — C/ievalier, in Ibid,
vol. V. p. 93.— Elliotson, in Ibid. vol. xiii. p. 26.— Travers,
in Ibid. vol. viii. — Abercrombie, in Edin. Med. and Surg.
Journ. vol. xxi. \).6.— Laennec, R^v. MM. Mars, 1824.

— Carswell, in Edin. Med. and Surg. Journ. vol. xxxiv.
p. 283. {An excellent memoir.)

V. Morbid Secretions and Productions. — Riverius,

Observ. cent, i Fubricius Hildayius, cent. ii. obs. 64. —

Morgagni, Epist. xxxv. art. 25. — Blasius, Obs. Med. Rar.
p. vi. ob. 3. — Sand, Deraro Ventric. Abscessu. Reg. 1701.

— Sten%cl, De Stcatomatibus, &c. Viteb. 1723. — Hasen-
oehrl. Hist. Febr. Petech. p. 67. — Niesky, De Humor.
Intest. Ten. Path. Consideratis. Halae, 1766. — ,Sproegel,
De Morb. Humorum in Intest. Hal. 1766. — Holier,
Opusc. Pathol, obs. 27. — De Haen, Rat. Med. p. vi.
cap. 4. ^ 10. — Watson, in Med. Conimunicat. &c. vol. ii.
— Oberteuffer, Mus. d. Heilk. b. i. No. 16. — Osiander,
Denkwiirdigheiten, i. p. 403 — M. Baillte, in Transact, of
Coll. of Phys. Lond. vol. v. p. 166. — R. Powell, in Ibid,
vol. vi. p. 106. — Martinet, Journ. de Med. t. xxviii.
p. %i4. — Godman, Philad. Journ. of Med. May, 1825.—
Seymour, Trans, of Med.-Chir. Soc. vol. xiv. p. 222. —
Lherminier, in Ed. Med. and Surg. Journ. vol. xxvi.
£14. — Bourgeois, in Archives de Med. t. xi. p. 137. —
Annesley, Sketches of Dis. of India, chap, on Dissect,
in Cholera, 2d ed. 1S29. — Also the works of Chardel,
Vetter, Monro, Louis, R. Prus, Cruveilhier, Artnstrong,
Herat, and Abercrombie, already referred to.

vi. Changes 01' Capacity and Position. — Bartholin,
Hist. Anat. cent. iv. n. 40. — Bonet, Sepulchret. 1. iii.

sect. 14. — Plater, Observ. 1. ii. p. 439., et I. iii. p. 656

Kerkring, Spiceleg. Anat. obs. 50. — Schacher, De Morbis
a Situ intest. Praeternat. &c. Lips. 1721. — Morgagni,
Epist. xxxix. art. 15., liv. art. 1.5. — Walther, De Intest.
Angustia, &c. Lips. 1731. — Hamberger, Observ. Clinic.
Jen. 1754, p. 10. — Meckel, in Mem. de I'Acad. de Berlin,
1758, p. 68. — Felix, De Intestin. Intus-susceptione. Lug.
Bat. 1769. — Lalouette, Hist, de la Soc. R. de M^d. ann.

1776, p. 267 Loesecke, Observ. Anat. &c. p. 29—37. —

Huxliam, in Philos. Trans. No. 382. — Van Doeveren,
Specimen. Observat. &-c. p. 76. {Diverticula.) — Troesckel,

De Morb. ex alieno Situ Part. Abd. &c. Franc. 1754

Base, De Diverticulis Intestin. Lips. 1779. — Lieutaud,
Hist. Anat. Med. obs. 27. — Hasenoehrl, Hist. Morb.
Epidem. p. 60. — Bang, Diarium, ii. p. 367. ; et in Act. Reg.

Soc. Med. Hafn. vol. i. p. 243 Callisen, in Ibid. vol. i. —

Stoerck, Annus Med. i. p. 126, et ii. p. 268. — iJoM, Diss.
Path. Intest. Coli, p. 14 De Haen, Rat. Med. par. x. \ i.

— Mollinelli, in Comment. Bonon. t. ii. p. 1. — Sandi-
fort, Observ. Anat. Path. 1. i. c. 10., et 1. iii. cap. 3. p. 59.,

1. iv. cap. 2. p. 28. — Schneider, Clin. Geschichte, b. v. p. 86.
— Anderson, in Ed. Med. Comment, vol. ii. p. 302 Hal-
ter, Opusc. Path. obs. 27 Mursinna, N. Journ. f d.

Chirurg. b. i. p. 241.— J. P. Frank, De Cur. Horn. Morb.

1. v. par. ii. p. 391., et 1. vi. par. i. p. 53 Letlsom, in

Philos. Trans, vol. Ixxvi. p. 305 — Rahn, Diss. Pass. Ili-
ac£E Path. Halae, 1791. — Lee, in Lond. Med. Rev.
June, 1801. — Francis, in Med. and Phys. Journ. vol. xxxv.
p. 436. — Portal, Anat. Mod. t. v. p. 180. 208. — Treuner,
in Stark's N. Archiv. &c. b. i. p. 241., b. ii. p. 91. — Mezler,
in Hufeland's Journ. d. Pr. Heilk. July, 1811, p. 24. —
Andral, Journ. de Physiol. AoQt, 1822. — J. Davies,
Lond. Med. Repos. vol. xxii. p. 469. — Micha'elis, in Ibid.
Feb. 1812, p. .39. — J. F. Meckel, Beitr. b. i. h. I.; et
Ccmp. Anat. Path. t. i. p. 553. — Mo/lison, in Trans, of
Med. -Chirurg. Soc. of Edin. vol. ii. p. 249. — Rostan, Ar-
chiv. Gen. de Med. t. xix. p. 332.

DISEASE — THE Causation and Doctrine of.

— Ci.AssiF. General Pathology; JEtiology

and Pulhpgeny.

1. I. Piti.LiMiNARV Remarks. — It is of great
importance to llie tyro in medicine to acquire
general principles, derived from a careful and
comprehensive investigation of disease; that may
guide him in the jiractioal course lie has to pur-
sue. Nor is it of less moment to the experienced
to find inferences and doctrines calculated to
serve aa the basis of therapeutical indications
deduced for him even from those phenomena

DISEASE — Causation and Doctrine of.

which have become familiar from frequent obser-
vation, or have appeared trivial when viewed in
an imperfect or false light. It is by an intimate
acquaintance with morbid actions, in respect of
their origin, of their conditions at the time of ob-
servation, and of their tendencies, and by a know-
ledge of principles derived therefrom, that we
are chiefly enabled to direct our course through
those numerous difficulties which beset us in the
practical discharge of our duties, when we are
insufficiently aided by published authorities, or
imperfectly guided by the results of personal
observation. Even the most experienced will
often find examples of disease in some one or
other of the numerous combinations or succes-
sions it is constantly assuming, of which memory
will not furnish sufficient examples, by the re-
sults of which he may be guided ; and will fre-
quently have to recur to those principles, both
doctrinal and practical, which he had learnt from
his predecessors, or had acquired for himself by
analysing and recombining the numerous mani-
festations of morbid action which have been
presented to his view. In endeavouring to sup-
ply what is not to be obtained in our medical
literature — to satisfy a want which I know has
been very generally felt — I have only to regret
that my limits will preclude those details, which
many might require, and will confine me chiefly
to succinct statements, where vivid illustrations
might be necessary, and therefore looked for.
But some advantage will be derived from ex-
hibiting an outline of the subject, in a methodic
manner, filled up in its more essential parts
with such touches and shades as may be neces-
sary to truth of representation, and treated in
separate articles where it assumes a practical
interest. The origin of disease, and the nu-
merous circumstances, which, existing either
intrinsically or extrinsically in respect of the
frame, modify disease in its progress, are amongst
the most important topics to which the mind
of the scientific practitioner can be directed ; in-
asmuch as upon a due recognition of these, in
their individual or joint operation, will depend
the justness of our indications of cure, the ap-
propriate employment of remedies, and conse-
quently the success of our practice, and our own
eminence.

2. i. The intimate Relation of the Subject to
the Doctrine of Life. — In all speaulations re-
specting the causes, the nature, and the removal
of diseased actions, the body ought to be con-
sidered in relation — 1st, to its organisation
and mechanism ; and, 2d, to the influence by
which that mechanism is actuated : we should
view it as presenting an assemblage of numerous
and beautifully contrived parts, all displaying a
wonderful and harmonious combination of phe-
nomena, — the most perfect and the highest pre-
sented to us in the physical world. Some of the
finest illustrations of mechanical adaptation and
power, and of those principles of action to which
the researches of the natural philosopher have
been directed, are manifested in the human body.
But these manifestations are subject to a finer and
yet a more powerful principle than any which
govern tlic operations of inanimate matter. The
whole organised creation, especially the higher
animals, and man in particular, display functions
which inanimate substances cannot produce ; and

DISEASE — Causation and Doctrine or.

557

although physical actions are observed in their
most admirable conditions in the animal body,
they are entirely subject to higher functions, to
which the term vital, from their nature and
object, has been applied. It is one of the chief
characteristics of life that it is allied to matter,
delicately and peculiarly combined, and differ-
ently constituted from inanimate matter, which
is kept in a state of cohesion by means of the
attraction subsisting between its particles, and
which state its chemical affinities dispose it to
preserve. Life allied with matter produces com-
binations entirely different from those, which the
chemical affinities of the elementary particles dis-
pose them to assume, and preserves these combina-
tions in opposition to their physical tendencies as
long as it continues thus associated. Life, then, as
I have already contended, is a. superior power ; and
this superiority is instantly shown by the readiness
with which the elementary particles of that mat-
ter with which it is so intimately connected enter
into different combinations and forms as soon as
this principle is withdrawn. One, therefore, of
the chief, although apparently one of the lowest
and most generally diffused manifestations of life,
is to preserve the textures, or the matter with
which it is associated, in a state suitable to the
performance of the various functions of the ani-
mal. But it also executes higher offices. By
a series of beautiful processes, it changes sub-
stances foreign to the constitution of the animal
to which it is allied, and at last assimilates them
into the organised structures which it animates.
Thus nutrition and growth are produced, and the
decay of the organised body is prevented.

3. Life, in its intimate alliance with the struc-
tures of the body, gives rise to various manifest-
ations, according to the peculiar organisation of
each ; these structures being the instruments of its
influence, and the organs by which vital operations
are performed. Thus the muscular fibre, endowed
with life, displays contractile properties ; the ner-
vous fibriles manifest sensibility ; the liver and kid-
neys perform their secreting functions ; and so on as
respects the various parts composing a perfect ani-
mal. The healthy f mictions of life form the study
of the piiysiologist, whilst the description of the
organs performing them belongs to the anatomist.
It is with the derangements of both functions and
organs that the pathologist and practitioner are
chiefly concerned. The knowledge of structure
and healthy function is, however, the basis on which
both the one and the other raise a superstructure
of great public benefit. The duly instructed
pathologist is enabled to comprehend the beauti-
ful combination of physical principles evinced
by the human body ; and to understand how
they are directed by, and made subservient to,
life, whether in perpetuating its healthy duration,
or in guarding it against agents threatening any
of the functions and organs which it endows,
or in removing derangements when actually pro-
duced. It is from an enlightened recognition of
the operation of external agents on vital func-
tions, of the relation subsisting between causes
and their effects, and of the succession of mor-
bid phenomena consequent on primary changes,
either vital or organic, that the scientific practi-
tioner is enabled to devise suitable plans [and
appropriate means of restoration to the healthy
state. But, when contemplating the functions of

the livmg body, whether in health or in disease,
he should not restrict his considerations either to
the physical, or to the vital, ])henomena which
any particular organ or structure presents. He
should recollect that the physical phenomena are
under the direction of the vital power ; and that
this power, although influenced by mechanical
or physical operations, is equally energetic in
controlling these operations, as they are, in
their turn, of controlling it. The pathologist
must be aware that the study of the living
frame in health, and more especially in dis-
ease, is the investigation of the numerous ma-
nifestations of life through the various organs
and structures with which it is wonderfully
and inexplicably associated. Of life itself we
know nothing but through those manifestations,
and thus it is through them only we can en-
quire respecting its conditions. Although we can-
not demonstrate the intimate nature of vitality,
and cannot show the peculiar ties which bind it
to organisation, we can prove, by an accurate
enquiry into the numerous phenomena exhibited
by living bodies, and by the manner in which ex-
ternal agents modify these phenomena, as well as
by the derangements evinced by particular organs
and structures, that the connection is intimate,
and that causes operating upon the one generally
affect the other. This powerful influence of life
over the functions of the organs with which
animals are endowed, and the manner in which
causes modify the conditions of this principle,
whether acting immediately upon it, or through
the medium of the organisation with which it
is allied, are amongst the most important topics
which interest the medical practitioner.

4. The conditions of life, as manifested in the
functions either of a single organ, or of the
frame generally, are liable to change, from in-
trinsic and extrinsic causes ; and the resulting
alterations modify the structures with which this
principle is so intimately and mysteriously re-
lated. On the other hand, the states of the
animal organs and textures are readily affected
by agents acting directly upon their organisation ;
and these states of structure modify its vital
manifestations, and, through them, the vital en-
dowment of the body generally. From this
mutual dependence — this reciprocative influence
— it will appear that, as life can only be
contemplated through the medium of an or-
ganised body, so the derangements of such a
body cannot be accurately investigated, and the
conditions of life — its manifestations in ap-
propriate systems and organs — be left out of
consideration.

5. ii. Health and Disease defined, — Whilst the
energy of the vital endowment is uninjured, and
its manifestations in the various systems are in
due harmony throughout, and with the state of
the structures with which it is associated, all the
operations of the body are duly and steadily
performed. This is the condition which may be
termed health. But as soon as the energies of
the vital principle become depressed, excited,
exhausted, or otherwise altered, either through-
out the body, or in any of the systems or organs
by which it is manifested, and when change
from the natural condition is primarily produced
in any of the structures with which it is asso-
ciated, disease supervenes. This aberration from

558

DISEASE — Causation of — Etiology.

the natural condition of the vital energies en-
dowing the whole, or parts of the frame, or
alteration of the textures which these energies
actuate, is produced by causes acting sometimes
singly, occasionally in combination, and fre-
quently in succession. To point out the nature
and modes of operation of those causes upon the
living body, as far as their natures and effects are
known, is the object here proposed.

6. A knowledge of the causes inducing those
changes; the nature of the changes produced,
as respects either the vital manifestations, or the
structural alterations ; the signs or phenomena
by which morbid conditions of vital function or
of structure are recognised ; are the chief topics
which interest the pathologist ; whilst the means
of removing those disorders, of averting death,
and of alleviating tlie sufferings which they oc-
casion, when cure is beyond the reach of our
science, are the ends which he proposes to him-
self as the reward of his investigations. In order
that all that is advanced respecting the various
kinds and states of disease may be more clearly
understood, I 'propose to give, in this, and some
articles that will be referred to, a sketch of patho-
logical principles ; so that, by pursuing the plan
pointed out in the preface, the knowledge which the
tyro ortiie inexperienced reader will have acquired
from this part of his systematic course of study,
will become serviceable to him in the acquisition
of that which should be afterwards brought be-
fore iiim. By considering what is simplest and
most elementary, and proceeding onwards to what
is more complicated and difficult, the mind will
be gradually enabled to understand the abstract
subjects which will come before it ; the know-
ledge successively acquired introducing it to an
acquaintance with what will follow. Before
treating of the principal states or alterations from
the healthy condition of the frame, which con-
stitute the disease, I shall point out, Jirst^ the
causes which act upon the living body most fre-
quently in an injurious manner; secondlii, the
morbid conditions themselves which these causes
induce ; and, thirdly, en([uire (in a distinct ar-
ticle) into the symptoms by which the nature of
these conditions are recognised. Hence, disease
will appear as a series of changes resulting from
causes, between which and their effects there is
a most intimate, although not always an obvious,
relation.

7. II. Causation of Disease, or Etiology;
from aiTia, cause, and Xoyo^, a discourse.

Causes act primarily on the vital endowment.
— I have already stated, that although the va-
rious textures and organs of the body display
the finest combinations of mechanism, and tlie
most beautiful principles of action presented by
tiie physical world, yet they are entirely under
the dominion of life, by which only they are ac-
tuated, and on which they entirely depend for the
functions they j)resent. It is not upon the tex-
tures or organs themselves that the causes of dis-
ease generally make their first impression ; and
even when they are brought in immediate relation
to a particular organ or structure of the body,
we liave no evidence to furnish that they derange
these parts by primarily affecting the machinery
of which they are composed ; but, on the con-
trary, from the gradual manner in which de-
rangemeul is produced, from the nature and

effects of the disorder which follows, and nume-
rous other considerations, it may be inferred that
they make their first impression upon the vital
endowment of the organ, disordering the func-
tions which it performs under the dominion of
life ; and the functional disorder either leads on
to the production of further disease, or indirectly
to a return to the healthy condition. No doubt,
some causes affect at once the organisation of
the part, such as many chemical, physical, and
mechanical agents ; but the majority modify the
vital manifestations of the frame, either in one
organ or structure, or in several simultaneously ;
and by impeding or modifying, deranging or
altogether changing these manifestations, thereby
induces effects, which become themselves causes
of further disease, until life itself is terminated,
or a healthy condition of function re-established.
Of the justness of this inference satisfactory
evidence will be furnished in the sequel. (See
§ 63., et seq.)

8. The causes of disease have been variously
arranged and named by pathologists. For the
better understanding the subject, and writers on
disease, the different arrangements and distinctions
which this subject has received may be briefly
alluded to. Causes have been denominated ex-
ternal or extrinsic, and internal or intrinsic,
according as they operate upon the body from
without or within. They have also been called
principal and accessory or concurrent ; disease
proceeding chiefly from the former with the as-
sistance of the latter. They have also been
named positive and negative, from the manner in
which they act upon the body ; and by some they
have been divided into physical, chemical and
physiological, according to their nature. The
division, however, which has been most generally
adopted is into remote and proximate or imme-
diate, according to their relation to the disease oc-
casioned by them : the remote being the first in the
chain of causation, the proximate or immediate
those early changes which they eflPect in the ceco-
nomy, and which constitute the primary condition
of the disease, or, in other words, the patholo-
gical states arising directly from the operation of
the remote agents. The remote causes have
been divided mXo predisposing&nAexciting or occa-
sional causes ; the predisposing being those which
influence the conditions of the living functions
so as to favour the operation of those occasional
or exciting causes whence disease more directly
springs. To these two classes I would add a
third, viz. determining or consecutive causes,
which, being posterior to the others in point of
time, determine or call into action the exciting
causes, or rather come in aid of, and follow up,
the impression made by the latter; and which,
without such aid, might have been insuflBcient to
produce actual disease, or would have induced it
only in a slight degree.

9. It must be obvious that all causes, as well
as the effiects they produce, must have an in-
timate relation to the condition of the living
frame ; and that those which may be quite in-
efficient on one person will be powerfully active
on another; or which are without efl^ect on an
individual at one season, will be very influential
at another, owing to the state of vital energy at
the time, to the concurrence of other causes, or
to exposura soon afterwards to such as will de-

DISEASE — Predisposition to — -iEtiolocy

termine, or otherwise aid, those which preceded
it, and which, although the principal or exciting
causes, were insufficient, until thus reinforced,
fully to produce the disease. Owing, also, to
the condition of the frame, no effect will some-
times follow one, two, or even three exciting
causes ; and until a greater number are brought
into operation, no mischief will often result. The
effects produced by various animal and vegetable
exhalations on different individuals, or upon the
same person at distinct periods, under different
states of mind and predisposition ; and by tlie
action of numerous concurrent, accessory, and
determining causes; fully illustrate this position.
It is chiefly owing to a want of knowledge of the
doctrine of causation, that so much error and
difference of opinion prevail respecting infectious
and non-infectious diseases. On the other hand,
persons may be so very easily affected, that
causes of the slightest nature, and such as are
determining or accessory in the majority of
cases, are principal in respect of them ; and in-
fluences which are usually predisposing are often,
in such persons, the exciting causes of disease.
Also those wliiclj are remote in their operation on
some constitutions, are direct or immediate in
respect of others. Examples of this are found
in the diseases of the lungs, liver, stomach, and
bowels. In considering the agents which afl^ect
either the functions, or the organisation, I shall
first notice those which generally predispose the
system to disease ; next those which excite dis-
ease in a direct or immediate manner; afterwards
such as are specific, or produce determinate
results ; the effects of their operation on the
living frame being obvious, and often admitting
of being foreseen ; and lastly those circumstances
which sometimes determine, reinforce, or call into
action, exciting or specific agents.

10. i. Of the predisposing Causes of Dis-
ease.— These may be classed — 1st, into such as
are proper or peculiar to individuals, and the cir-
cumstances in which they are placed; 2d, into
such as are not proper or peculiar to individuals,
but which may affect various persons, and even
numbers of persons, but individually and occa-
sionally ; and, 3d, into such as are general, and
affect more or less all who are exposed to them.
— A. Those which are peculiar to the indicidual,
and to the circumstance in which he is placed,
and which may be called the individual predis-
posing causes, are — 1st, original conformation
and hereditary predisposition, age, sex ; tempera-
ments, original and acquired ; habit and consti-
tution ; trades, professions, and circumstances of
life, &c. ; and, 2d, the various external and inter-
nal agents, and circumstances modifying the state
of the functions, — as previous functional disorder,
and convalescence from disease ; and the preg-
nant and puerperal states.

11. a. firigiiial conformation and hereditary
predisposition.- — ■ It is generally observed, that the
constitutions, temperaments, and diathesis of the
offspring closely resemble the parent; and that
whatever disposition to disorder, whether of func-
tion or of structure, the latter may have pos-
sessed, is liable to evince itself in the former.
From this circumstance having been very gene-
rally remarked in respect of certain maladies,
they have been termed hereditary. But it must
not be supposed that cliildreu are actually born

559
with the diseases of their parents. This is but
seldom remarked ; although, in rare instances, I
have observed the commencement of tubercles in
the lungs of a new-born infant by a consumptive
mother ; and small-pox and syphilis are some-
times communicated to the foetus in utero, occa-
sioning in some instances its premature birth,
and even its death, either previously to or about
tiie natural termination of utero-gestation. Hy-
drocephalus, cataract, and various imperfections
of the organ of hearing, and, indeed, of other
organs of sense, are not infrequently congenital,
or examples of disease from original conform-
ation ; but, in such cases, it is rare that the
parent is similarly affected at the time, although
the hereditary predisposition, as about to be ex-
plained, exists nevertheless ; and, as respects the
first of these, a tendency merely to the disease
could have existed at an early age in the parents.
It should be kept in recollection, therefore, that
the foetus in utero may be affected by several
cachectic, inflammatory, or even febrile diseases,
communicated by the parents, or supervenincr
accidentally : but, of those which are thus com-
municated, even the majority are not, properly
speaking, hereditary ; and those which are acci-
dental do not depend upon the constitution of
the parents, or the ailments experienced bv the
mother during the period of gestation. Con-
genital diseases a.Te consequently divisible into —
1st, Those which occur in the foetus, without
any participation on the part of the parents, —
as imperfect developement of organs, inflam-
mations, effusions of fluid in various parts, &c. ;
2d, Diseases in which the foetus participates with
the mother, owing to their contaminating influ-
ence, or their extension throughout her organis-
ation, — as syphilis, small-pox, fevers, &c. ; 3dly,
Those that affect the foetus from a constitutional
liability in one or both parents, — as hydroce-
phalus, cataract, tubercles, &c.

12. Most commonly, however, the child is born
free from disease ; but, inheriting the constitution
and diathesis of the parent, has that condition
of function and organisation which renders it
more susceptible of impressions produced by the
exciting causes of certain maladies. Examples
of this may be contemplated daily in respect of
diseases of the lungs and brain ; the constitution
and functions of tb.ese viscera disposing them or
rendering them more prone to experience those
derangements by which the parent or parents
had been affected. In some instances this pre-
disposition may be more strongly marked in the
child than in the parent ; and in other cases the
predisposition may be extremely slight, and only
brought to light by the operation of the more
energetic agents.

13. The predisposition of the offspring gene-
rally evinces itself more strongly at certain ages
than at others, according to the kind of morbid
constitution or predisposition which it may in-
herit, the causes to which it is exposed, and the
nature of the malady which results. Thus, the
disposition to hydrocephalus, convulsions, idiotcy,
rickets, scrofuh, cataract, &c., is most apparent
soon after birth, and at early epochs of life ; to
epilepsy, hemorrhage, and pulmonary consumption,
about the age of puberty, or previously, or soon
after; to gout, asthma, and angina pectoris, in
adult and mature age ; to insanity, apoplexy, and

560

DISEASE — Predisposition to — Etiology.

paralysis, during the mature or advanced stages
of life ; and to various nervous disorders, at more
irregular periods. But these diseases do not
necessarily supervene, although one or both pa-
rents have been affected by them ; and several
usually appear in alternate generations. Some
occur more uniformly than others. When the
predisposition to them is derived from only one
parent, they very frequently never make their
appearance, unless as the effect of very active ex-
citing agents. But even when the predisposition
is derived from both parents, and when it may be
considered as being thereby heightened, exciting
causes are generally required to develope the
disorder.

14. b.Age. — Each of the different epochs of
existence is more liable to certain diseases than
to others. During the earlier periods, there is
generally a predisposition to particular disorders,
even when no hereditary taint exists. This is partly
owino- — (a) to the changes going on in the frame ;
(6) to the state of vital manifestation; and (c),
to irritations in the alimentary canal. Amongst
the changes proceeding in the frame, that either
readily suffer derangement or lead to it, the most
important are the processes of ossification and
developement of the contents of the cranium.
These processes are more or less under the do-
minion of the vital influence ; and they are more
or less disturbed as this influence is affected,
in respect either of the system generally, or of
particular organs. Hence, rickets, hydrocephalus,
inflammations of the brain or its membranes,
readily occur. The quantity of blood sent to
the brain in early life is another predisposing
cause of cerebral affections ; and the readiness
with vrhich the functions and even the circula-
tion of the brain are disturbed by impressions from
without or by irritations from within, becomes,
especially when assisted by other causes, a fre-
quent source of disease. (See Age, § 10. ; and
Dentition.)

15. After the first dentition, and during growth,
the powers of life are energetic, as shown by the
reaction of the vital functions upon the depress-
ing causes of disease ; and are eminently conserv-
ative, particularly in resisting hurtful agents.
The predisposition is chiefly to inflammatory ail-
ments and acute attacks of fever, especially in
those who breathe a wholesome air and are suf-
ficiently nourished. But the susceptibility to
impressions, both moral and physical, is energetic;
and irritations, from whatever cause, are gene-
rally followed by augmented vascular action,
with which the whole frame, owing to the sus-
ceptibility of tiie nervous systems, promptly sym-
pathises. Hence febrile attacks, eruptive fevers,
inflammations, cerebral affections, disorders of
the air passages, of the alimentary canal, and
lymphatic glands, usually appear. At this period,
also, all specific causes readily fake effect, par-
ticularly of those diseases which are incidental to
childhood ; their full operation, however, destroy-
ing the susceptibility to be again affected by
them. About the time of puberty and ndn-
lescerice various complaints first show themselves,
especially some that are inflammatory, and to
which there is an hereditary tendency, — as pul-
monary consumption, haimorrhage from the lungs,
epistaxis, plethora ; and as soon as the body has
ceased to grow in height, or the vessels to ex-

tend themselves in the direction of their axis,
those disorders are still more readily produced by
exciting causes. In manhood and mature age, the
susceptibility to impressions gradually diminishes,
and generally continues to decrease as age .ad-
vances. During the former of these periods,
hypochondriasis, melancholy, insanity, ha»mor-
rhoidal affections, asthma, rheumatisms, and the
majority of organic diseases, with the exception
of such as are scrofulous, commonly make their
appearance. Towards the decline of lije, gout,
softening of the brain, apoplexy, paralysis, scir-
rhus, cancer, changes in the coats of the blood-
vessels, diseases of the organs of sense, affections
of the urinary passages, &c. usually supervene.
(See Age, and Climacteric Decay.)

16. c. Sex. — There are a great many dis-
eases to which both seres are equally liable.
Fevers, inflammations, organic diseases, and many
others, attack both. But it has been observed,
during the prevalence of epidemics, and in un-
healthy countries, that the female sex suffers
much less than the male. This, no doubt, arises
from the more regular habits of females, and their
less exposure to the determining or concurring
causes ; something may also, perhaps, be attributed
to their periodical discharges, which tend to dimi-
nish plethora and to purify the circulating fluid —
circumstances calculated to impart a partial ex-
emption from several diseases, particularly those
which are epidemic and endemic, although they
may dispose to others. But the conformation
and temperament of females, the sympathy exist-
ing between their generative organs and the state
of the circulation in the brain, the marked sus-
ceptibility of their nervous system, and great mo-
bility of their muscular organs, dispose them —
especially thosein cities and populous towns — to
diseases usually denominated nervous. The natural
vicissitudes, also, of female life are accompanied
with a tendency to particular maladies, especially
the periods at which the menstrual discharge com-
mences and ceases ; at the former of which,
nervous and cachectic complaints — at the latter,
diseases of the organs of generation, or of those
closely allied to them in function or situation —
very frequently appear; — chorea, chlorosis, irre-
gular convulsions, hysteric or painful affections,
difficult, suppressed, or irregular catamenia, oc-
curring about the former epoch ; and chronic
inflammations, scirrhus, cancer, and other organic
lesions of the womb, disease of the breast, and
disorders of the colon or rectum, about the latter
period.

n.d. Tewperament and diathesis. — The san-
guine and irritable temperaments dispose to ple-
thora, inflammations, haemorrhages, pneumonia,
and to inflammatory fevers. The bilious tem-
perament most readily experiences biliary de-
rangements, bilious fevers, affections of the
stomach and bowels, hypochondriasis, mental
disorder, chronic cutaneous eruptions, and various
organic derangements of the abdominal viscera.
Persons of the lymphatic or phlegmatic temper-
aments are predisposed to catarrhal attacks, slow
fevers, chronic discharges, dropsies, scrofulous
and scorbutic affections, diseases of the joints
and glands, and to tuberculous and other chro-
nic diseases. In persons thus constituted, the
powers of life are languid, the preservative in-
fluence and vital resistance feeble, and reaction

DISEASE — Predisposition to — Etiology. 661

manifestations of mind, frequently take place ic
consequence of the predisposition to them gener-
ated in the system by the excessive indulgence of
this appetite. It also leads to other maladies, by
lowering the vital energies of the frame, and

upon noxious causes or agents seldom developed
or energetic. The nervous temperament disposes
chiefly to convulsive diseases, especially to hy-
steria in the female sex ; to mania and insanity,
or other derangements of the mental manifest-
ations, as hypochondriasis, melancholia, &c. ; to : thereby" rendering them more assailable by the

nervous and typlioid fevers, &c. This tempera-
ment often modifies the progress of various acute
diseases, and imposes upon them a nervous cha-
racter. When the temperaments are 7itiied, an
accordant predisposition may often be remarked ;
as, in the sanguiiieo-bilinus, a disposition to bilious
inflammatory fevers, to hepatitis, to inflammations
of the alimentary canal, of the brain, and of the
serous surfaces, &c., is often manifested.

18. e. Of constitution dind habit of body , ilTna.y
be remarked, that a robust constitution generally
successfully opposes tRe impressions of many ex-
citing causes ; but when once a morbid impression
is produced, disease assumes a more active or
acute character, and is attended with higher vas-
cular action, the powers of life and reaction being
great. On the other hand, weak constitutions,
and those of a scrofulous taint, are more disposed
to disorder, more readily affected by its causes
upon the first impression ; and disease in them
assumes a more chronic and low form. When
persons thus constituted have become habituated
to the impression of certain morbid agents, they
frequently cease to be affected by them in the
usual manner ; as observed in respect of marsh
or terrestrial emanations, which seldom give
rise to regular attacks of fever in such subjects,
but induce organic disease, and sinking of the
powers of life.

19. f. Habits of life and profession are amongst
the most influential predisposing causes of disease.
Whatever profession or occupation requires an
active exertion of the powers of the mind, and
continuation of that exertion to the neglect of
sufficient relaxation and exercise, occasions de-
termination of blood to the head, and favours
tlie production of inflammation of the brain or
of its membranes; especially if such persons live
fully or luxuriously ; and, if fever attack them,
the head, the liver, and stomach, become severely
and dangerously affected ; and, unless the disease
be actively treated at its commencement, death
may supervene in consequence of serous effusion
from the membranes, or of softening of the texture
of the brain, rupture of its vessels, or of organic
change in the liver, or digestive canal. Those
who take active exercise in the open air are gene-
rally more disposed to inflammatory attacks of an
acute character, to pneumonia, and to rheumatism,
than to other complaints ; although in them the
predisposition to disease is much less than in other
persons. Those who indulge the appetites beyond
what the economy requires, — especially the desire
for food, and for vinous and spiiituous liquors, —
are liable to disorders of the stomach, liver, and
intestinal canal ; and, if attacked by fevers, these
organs generally are the most seriously affected :
such indulgences also dispose to plethora, apo

common exciting causes of disease.

20. g. The circumstances of life in which per-
sons are placed have a marked influence in favour-
ing or counteracting the operation of exciting
causes. It has been determined, by exact ob-
servations and calculations, that those who enjoy
easy or comforiable circumstances are much less
subject to disease than tlie poor, the insufficiently
clothed, and ill-fed. This arises not only from the
former class being less exposed to its exciting
causes, but also from the good effects of sufficient
nourishment in supporting the energies of life,
and thereby warding off the impressions of inju-
rious agents and influences. Much, also, is owing
to personal and domestic cleanliness, to proper
clothing, and to living in airy apartments in
healthy localities. Yet, while full living thus
wards off many diseases, especially those arising
from debility, as low or adynamic fevers, scorbutic
disorders, scrofula, dysentery, and various others,
it disposes to gout, dyspeptic and nervous affec-
tions, particularly to apoplexy and paralysis. (See
Arts and Employments.)

21. h. Debility, previous disorder and con-
valescence from other diseases, often favour the
operation of exciting causes; particularly when
the powers of life are much depressed or ex-
hausted. In respect of the predisposition occa-
sioned by already existing disorder, some doubt
may be entertained by those who may have
adopted the hastily formed and incorrect dogma
that two disorders cannot co-exist in the economy.
This may be true in respect of certain febrile
diseases, especially those of a specific or exan-
thematous kind : but in nearly all beside, so very
numerous are the exceptions, that the principle
becomes quite untenable ; and, in many cases,
even an opposite doctrine may be enforced, par-
ticularly in respect of bilious and nervous dis-
orders. Thus, when the functions of the stomach
are weakened, or those of the liver obstructed,
various afl^ections of difl!erent organs related to
these, either in function or anatomical connection,
are apt to supervene, more especially febrile dis-
eases, disorders of the bowels, brain, and lungs.
The exhaustion of the powers of life partially
continuing during convalescence, also disposes the
fiame to the invasion of the exciting causes. On
this account convalescence ought always to be
watched by the ordinary medical attendant,
who, if not allowed to continue his aid for this
purpose, should state his reasons for proffering
it; and, if it should be declined, the patient will
then have himself only to blame. (See Debi-
lity, &c.)

22. i. Amongst the other individual predis-
posing causes of disease, I may mention the preg-
nant and puerperal stales. These states favour, in

plexy, paralysis, gout, dropsy ; and in many cases a very marked manner, the occurrence of several

directly excite those maladies. Inordinate sexual
intercourse is also a frequent predisposing cause of
many diseases, and often immediately induces
disorder. Pulmonary disease, affections of the
heart, epilepsy, mania, and the other disordered
Vol. I.

maladies, which, owing to this connection, have
been denominated puerperal, &c. Although these
diseases arise chiefly from the predisposition created
by the conditions of the female organs and con-
stitution during these states, yet a great difference
O 0

662

DISEASE — Predisposition to — Etiology.

exists between Uiem as to tlieii necessary depend- '
ence upon these conditions ; for, whilst tliesestates
predispose to the invasion of exciting causes deve-
loping disease in other circumstances, the maladies
that result may be either such as are peculiar to
them, as adynamic puerperal fever, &c. ; or such
as are not necessarily dependent upon, although
remarkably favoured by, them, as inflammations
of the uterus and peritoneum, uterine hemorrhage,
convulsions, mania, dec. During the puerperal
state, also, although the predisposition to fevers,
inflammations, consumption, various nervous af-
fections, rheumatism, &c., is less strong than it is
to the preceding diseases, yet it is greater at this
period than at any other.

23. B. Amongst those predisposing causes
which are not peculiar to the individual, but which
affect persons individually and occasional ty, cer-
tain states of the mind deserve the first place. —
(d) When the mental energies are depressed by
grief, anxiety, disappointment, fear, &c., the
powers of life are less able to oppose the debi-
litating causes of disease which invade them from
without, and of wliich nature all the exciting
causes of fevers, particularly those which are spe-
cific or contagious and miasmal, generally partake
in a most marked manner. On the other hand,
when the mind is elevated by success, by hope,
by confidence, and the other exciting passions, the
depressing causes make little or no impression
upon the constitution ; and individuals thus cir-
cumstanced almost always escape from diseases
■which readily invade the fearful, the dejected, and
the disappointed. There is, perhaps, no circum-
stance winch more certainly disposes the system
to the operation of the exciting causes of fever,
than the fear of being attacked by it ; whilst no-
thing fortifies the constitution more surely than a
full confidence that the causes of disease will not
take effect.

24. (6) Next in importance to mental depres-
sions, is whatever lowers the vital energies, or ex-
hausts and debilitates the body. Under this head,
low diet, fatigue, previous illness, excessive
secretions and discharges, want of sleep, and
venereal excesses may be classed. (See art. De-
bility.)

25. (c) Dress, even, has a very evident in-
fluence in creating a predisposition to disease.
Too little clothing, particularly in females, favours
the occurrence of difficult and suppressed men-
struation, pulmonary disease, and disorders of the
bowels. It was remarked, during the French
revolution, when it was the fashion to dress
classically, — which was almost a state of semi-
nudity, and more appropriate to the warmer cli-
mates of Athens and Rome than to those of the
north of France and this country, — that pul-
monary diseases, rheumatism, suppressed men-
struation, bowel complaints, catarrhs; and amongst
the children, who were exposed with naked busts
and thin clothing, croup, and other diseases of
the air-passages and lungs, were uncommonly
prevalent. On the other hand, too warm clothing
IS a source of disease, sometimes even of the same
diseases which originate in exposure to cold ;
and often renders the frame more susceptible of
impressions of cold, especially of cold air taken
into the lungs. The remarks now offered may be
applied to overheated sitting and sleeping apart-
menti, and to warm soft b^ds and bed clothing.

These relax and weaken the frame, dispose to
disorders of the kidneys, urinary and sexual
organs, and render the system much more sus-
ceptible of injurious impressions from without. A
predisposition is thus produced, not only to ca-
tarrhs, inflammations, affections of the lungs, and
rheumatism, but to irregularity in the menstrual
discharge. It has been remarked, that the females
in Holland, who generally use very warm clothing,
warm apartments, and warm beds, are very sub-
ject to excessive menstruation and fluor albus.
Females, also, become disposed to various diseases,
particularly those affecting the pulmonary organs
and heart, from wearing very tight-laced and un-
yielding corsets. Indeed, those dressed in this
manner can scarcely call the intercostal muscles
into action, and can breathe only by means of the
diaphragm. The mechanism of respiration being
thus impeded, the requisite changes are not fully
produced upon the circulating fluid ; and conges-
tion supervenes in the lungs, right side of the
heart, and parts situated below the seat of pressure.
This cause is especially injurious to females during
growth and pregnancy ; for the chest should be
fully and freely expanded, especially at these
periods, in order that the circulation through the
lungs and heart may be unimpeded ; and that the
blood should experience those changes without
interruption, that are required for the develope-
ment of the body and of the foetus. The func-
tions, not only of the lungs and heart, but of the
liver, stomach, and bowels, are materially inter-
rupted, and even these organs themselves are
removed from their natural positions in respect of
each other, by this cause. This is more remark-
ably the case as regards the colon, which, by the
squeezingtogether of the hypochondria and lateral
regions of the abdomen, is thrown into unnaturaal
duplicatures ; the passage of the faecal matter
along it being thereby impeded, and habitual cos-
tiveness, with all its consequences, produced.

26. (d) Amongst the most frequent predisposing
causes to disease, is intemperance in food and drink.
Too much and too great a variety, particularly
of animal food, high seasoned dishes and soups,
rich sauces, the too liberal use of vinous, spirituous,
or other exciting liquors, overload over-distend,
and over excite the stomach ; dispose it, the liver,
and bowels to inflammations and functional and
organic disease ; directly induce plethora ; and
when this state is produced, inflammatory com-
plaints in early life, and gout, apoplexy, paralysis,
&c. at a more mature age, frequently follow. On
the other hand, an unwholesome, poor, innutritious
diet, or food of a fluid or watery consistence, pre->
disposes to diseases of debility, by diminishing the
powers of life, particularly in the digestive organs,
and lessening the vital resistance to depressing
causes. Typhoid or adynamic fevers, dysentery,
cutaneous complaints, verminous diseases, tuber-
cles, scrofula, scurvy, scorbutic dysentery, enlarge-
ments and afl^ections of the joints, are common
under such circumstances.

27. (e) Excessive secretions and evacuations,
although in some instances a disease of themselves,
frequently predispose to further disease. The
abuse of remedies which have an cvacuant oper-
ation, excessive perspiration, fluor albus, too long
suckling, and venereal excesses, weaken the
powers of life, and expose them to the invasion of
exciting causes.

DISEASE — PnEDisrosiTiON to — ^Etiology.

563'-

28. (f) Indolence and too great exertion, both
predispose to and occasion disease ; whilst mo-
derate exercise, especially in the open air, increases
the energies of the frame, fatigue generally
favours the impression of causes wliich produce
acute afTections, as fevers and inflammations ;
whilst indolence and sedentary occupations dis-
pose to chronic maladies, as congestions of the
liver and abdominal organs, to corpulency, apo-
plexy, ha?morrhoidal affections, and derangements
characterised by diminished tone of the nervous
and vascular systems.

29. (g) Sleep. — The laint of this restorer of
the vital energies favours the invasion of fevers,
inflammations of the brain, and disordered mani-
festations of mind ; whilst too much sleep, and the
horizontal posture too long retained, or too fre-
quently assumed, predispose to apoplexy, paraly-
sis, softening of the brain, inflammation of the
cerebrum or of its coverings, and affections of tlie
kidneys. Many, also, of the causes of acute dis-
eases make their impression during sleep, when
the body is relaxed, and thereby exposed to their
invasion. On tlie oilier hand, earlj' rising pro-
motes both mental and corporeal energy. It has
been remarked by the actuaries of Life Insurance
Companies, that early rising is, of all habits, the
most conducive to longevity ; all long livers being
early risers.

30. (h) Due regulation of the temper, the
passioTis, and desires, and a proper conduct of the
imagination, are also necessary to resist exciting
causes. Indulgence of temper and passion not
only predispose to disease, but also frequently di-
rectly excite it, particularly in nervous, irritable,
and sanguine temperaments. Diseases of the
heart, brain, liver, stomach, and bowels, often ori-
ginate in these sources. Uncontrolled passions of
every description occasion numerous functional
and structural changes, seated chiefly in the
viscera of the large cavities. Moderation in eating
and drinking, in sleep, in the indulgence of those
appetites, feelings, passions, and desires which have
been implanted in our natures by a wise Provi-
dence for our advantage, gratification, social im-
provement, and happiness ; an equable state of
the mind, with confidence in our powers ; and
the pleasant excitement accompanying a well-
regulated course of application to business or
study ; are the best means of resisting the impres-
sions of injurious agents.

31. C. General predisposing Catises. — Of these,
the most universal in their operation are certain
constitutions of the atmosphere. Besides the
variations in the temperature and dryness of the
air, its electrical conditions also vary extremely ;
but as yet we are not possessed of sufficient data
to enable us to state with precision how far these
conditions may predispose to, or directly excite,
disease, or what particular change in our bodies
result from certain electrical states of the atmo-
sphere. But that the electrical conditions, to-
gether with a more or less humid state of the air,
are connected, in the relation of cause and effect,
with the prevalence of disease, is extremely pro-
l)able, although not satisfactorily demonstrated.
Those conditions which predispose to disease are
— 1st, temperature ; 2il, humidity; 3d, these two
states conjoined ; and, 4th, electrical conditions
of this fluid. Two very important subjects, very
intimately allied to these, and which act both as

predisposing, exciting, and specific causes, viz.
ENDEMIC and EPrDEMic influences, are considered
in separate articles.

32. (a) Temperature has a considerable influ-
ence in generating a predisposition to certain
diseases. Thus, in low states of atmospheric tem-
perature the functions of respiration are fully and
actively performed, especially as respects the
blood ; and the diseases observed in such circum-
stances are of an inflammatory nature, are seated
chiefly in the respiratory organs, and are charac-
terised, unless when the reduction of temperature
is remarkably great, or the air very moist, by
reaction of the powers of life on the causes which
excite them. Very ivarm states of the air impede
the clianges which the blood undergoes in the
lungs; and, by thereby furnishing abundant ma-
terials for the formation of bile, occasion an in-
creased secretion of this fluid. Hence bilious
diseases are most prevalent during high atmo-
spheric temperature. This ettect upon the blood
is still more marked, if warmth be conjoined with
moisture (§ 34). Under those circumstances,
bilious fevers, hepatic diseases, dysentery, diar-
rhoea, and cholera prevail.

33. (b) Moisture. — In dry states of the air,
changes are fully effected on the blood by respira-
tion ; its wateiy portionsare more freely carried off
from the exhaling surfaces ; its purity is increased,
its congestion and excessive fulness prevented ; and
consequently, the vital energies are promoted ;
and the depressing causes of disease, as infectious
animal etiluvia, and terrestrial exhalations, make
much less impression on the system. Disorders
occurring in this state of air assume chiefly a phlo-
gistic or sthenic character, and affect most fre-
quently the organs of respiration and the nervous
system. A very 7noisl state of atmosphere causes
opposite effects. It fails of producing to the full
extent the requisite changes in the blood, and of
carrying off the fluids exhaled from the surfaces,
especially of the lungs ; thereby rendering the
powers of life more languid, and the system con-
sequently more open to the invasion of the ex-
citmg causes. Less moisture, also, being exhaled,
the elements of biliary secretion, and the watery
portion of the blood become redundant in the
vascular system. Hence an abundant secretion
of bile, fevei's, affections of the liver, and deter-
mination of fluids to the intestinal canal &c. are
promoted. (See art. Climate.)

34. (c) Temperature and moisture conjoined.—
That warm and humid states of air are individu-
ally active as predisponents of disorder, has been
shown ; but it is when they are conjoined, that
they are especially injurious. A warm and humid
atmosphere dissolves and accumulates tlie specific
causes, such as animal and vegetable effluvia;
assists their operation ; and favours a rapid trans-
fer of electricity from the earth's surface, and the
ciiange in the condition and the accumulation of
it in the air resulting therefrom. It has been shown
by the experiments of Prout, Fvfee, Allen, and
Pepys, in an artificially increased temperature,
and by those I made in an intertropical atmo-
sphere, that heat remarkably diminishes the changes
effected by respiration on the blood ; and these
changes are further diminished by warmth asso-
ciated with moisture, which, moreover, promotes
the passage of positive electricity from the body.
And as the researches of Rittlr show that the

O o2

564

electricity of the positive pole beiglitens, whilst
that of the negative depresses, the actions of life,
the ultimate effect of humid atn)0spheric warmtli,
as respects both the state of the circulating fluid
and the locomotive electricity of the body, will be
to lower the whole circle of vital manifestations,
and to dispose to, or even to induce, diseases of a
low character — to occasion adynamic, continued,
and remittent fevers, or agues of a pernicious and
congestive kind, or dysentery, cholera, chronic
asthma, diarrhoea, and affections of the liver and
spleen. A moist and warm air may, therefore,
be stated to be doubly injurious, inasmuch as it is
of itself an extremely active predisposing and ex-
citing cause, and as it is tlie means of dissolving
vegetable and animal miasms, — of marsh, infec-
tious, and pestiferous emanations, — and the ve-
hicle or medium in which they act injuriously on
the frame.

35. (d) A moderately cold and a dry air in-
creases the respiratory actions, and the energies
of the system; proving what is commonly called
a bracing atmosphere. Diseases usually assume
an acute, sthenic, or phlogistic form ; and the
respiratory organs are liable to suffer. — la cold
and moist states of air, rheumatism, gout, nerv-
ous affections, scrofula, and glandular diseases,
intermittent and adynamic fevers, erysipelas,
dropsies, anasarca, and chronic disorders and
congestions, often prevail, especially in low, ill-
ventilated, and marshy places. The positive
electricity being rapidly carried off by induction
from the body, a salutary stimulus, and one which
experiments have siiown to be productive of in-
creased activity of all the animal functions, may
be supposed to be lost. But when the air is very
dry, the transit of electricity from the surface of
the earth and from the body is impeded ; this
fluid accumulating until a moister state of air
diminishes its quantity, and changes the re-
lation subsisting between the electrical condition
of the frame and that of the atmospheie. In very
dry and warm states of air diseases less frequently
prevail than when it is both warm and moist; and
are more frequently characterised by increased
vascular action. Inflammatory fevers, inflamma-
tions of the brain, liver, and stomach, are then
most prevalent.

36. (e) Sol-lunar injivence. — Considerable
importance has been attached to the influence of
the sun and moon in creating a morbid predis-
position. Close observation of the relation sub-
sisting between the prevalence of fever and dysen-
tery, and the full and change of the moon, has
apparently established some degree of connection
between them in warm climates, particularly in
the eastern hemisphere ; but the manner of ex-
plaining this circumstance has been by no means
satisfactory. Some impute it to a direct lunar
influence; and adduce in support of their opinion
the fact, that dead animal matter, when ex-
posed to the moon's rays, more speedily suffers
decomposition than when protected from them.
Others, who favour sol-lu^ar influence, argue that
it proceeds from the height of the tides, at full
and change of the moon, occasioning the rivers
on the coasts to inundate their banks, and to de-
posit vegeto-animal matter, which is rapidly
decomposed, when the water retires and leaves
the low ground exposed to the sun's influence.
But if the relation subsisting between the preva- I

DISEASE — PnEDisrosiTioN to — ^Etiology.

lence of disease, and the

moon's changes we*"^
owing to this circumstance, it could hold only in
respect of parts situated in the low alluvial coun-
tries on the coast, and not in districts inland and
much elevated above the level of the sea. This,
however, is not the case ; for observation has shown
the influence, whatever it may be, to be as power-
ful in high and inland countries as in districts on the
sea-shore.

37. (/') Light and sunshine. — That the power
of the sun's directed and refracted rays, in the pro-
duction and removal of disease, is by no means
inconsiderable, is proved by their influence on the
vegetable and animal kingdoms ; and by the effects
which ensue in the economy when they are en-
tirely excluded. These effects have been described
in the articles on the Blood (§ 47. J, and De-
bility (§ 6. c). The vital depression, attended
by increased sensibility, mobility, and suscepti-
bility to impressions, and the anaemia and gene-
ral cachexy, which ultimately result from the
protracted exclusion of light, are sufficient proofs
of the beneficial inffuence of the sun's rays
upon the frame. But additional and more direct
evidence is furnished in the ' greater activity of
the vital functions in spring ; and in the genial
excitement of the frame of the aged and debili-
tated, and indeed of both the minds and the bodies
of all, by sunshine ; light, as ordained and regu-
lated by nature, being a salutary stimulus, and
necessary to the energetic and healthy performance
of all the functions. The exciting and depressing
effects of the excess and absence of light respect-
ively prove its influence over all the organic and
mental manifestations, and consequently its power
in predisposing to, and even exciting, disease —
the intense or continued action of light inordinately
exciting the nervous and vascular systems, and
producing disorders of this kind ; its abstraction
weakening all the mental and bodily functions,
and favouring the occurrence of diseases of de-
bility. It is obvious from this, that light, especially
sunshine — and even its abstraction — may be
made subservient to the removal of disease, either
in its individual capacity, or in association with
a pure, dry, and temperate, or warm air, assisted
by suitable exercise, and change of locality ;
and that the partial abstraction of one or both
of these requisites to the due or energetic per-
formance of the functions, must be ultimately
followed by disease, however remote the effect,
or numerous the intermediate links in the chain
of causation.

38, ii. The exciting Causes. — These have
been called occasional by some writers, and direct
by others, determining by several, and principal
by a few writers. I shall divide this class of
causes into — (a) those which are occasional in
their operation ; and (b) those which are specific,
or whose influence is followed by specific and de-
terminate results. The causes already described,
dispose the body to the action of those about to
be noticed ; either by impeding, modifying, or
interrupting some one or more of the vital func-
tions, or by changing the constitution or organ-
isation of the tissues or organs which are the
instruments of the functions under the dominion
of life. But the predisposing causes may, either
by their activity, or by their acting in combination
or in close succession, of themselves, produce dis-
ease, without the aid of any of those which are

DIS EASE — Exciting Causes of — ^Etiology.

665'

usually termed exciting ; the predisposing being,
in such cases, the true and only exciting, causes.
Thus the indulgence of the appetites, fiitigue, the
depressing passions, moist states of the air, &:c. —
either alone, or associated with age, or constitu-
tion, or habit of body, &c. — are often the only
causes to which disease can be traced. On tlie
other hand, the exciting causes frequently produce
their effects without the previous operation, as far
as we have the means of knowing, of tlie predis-
posing causes ; and many of them merely predis-
pose the system to the action of others following
in close succession.

39. 1st. The occasional exciting causes act either
• — (a) upon the vital functions, or the manifest-
ations of life in the various organs and structures;
or (b) upon the organisation of the part to which
they are applied.

40. A. Of the causes which primarily injluence
the functions. — These will be considered in rela-
tion to the organs on which they immediately and
chiefly act: — 1st, Those which are applied to,
and disorder or obstruct the functions of the ex-
ternal parts of the body ; 2d, Those which make
their morbid impression upon the respiratory or-
gans ; 3d, Those vvhich act simultaneously upon
both the cutaneous and pulmonary surfaces ; 4th,
Those which act primarily upon the digestive
organs ; 5th, Those which affect the organs of
sense; 6th, and lastly. Those which excite the
feelings, passions, and moral emotions, and
thereby modify the manifestations of mind, or the
functions and organisation of the body.

41. (n) The causes luhich injuriouslij affect the
external parts oj the frame, either disorder the
perspiratory and eliminating functions of the cuta-
neous surface, or modify the sensibility, or obstruct
the actions, of external parts. — a. The perspir-
atory offices of the skin are disordered by the
diversified modes in which its temperature is af-
fected, i/eat increases the organic actions of this
surface — by exciting the nervous influence, ex-
panding and relaxing the capillaries and exhalino-
pores, and, indeed, all the integumentary tissues,
by determining thither an augmented circulation,
and thereby increasing the vital turgescence and
excretory functions, — and cold diminishes or en-
tirely arrests all these actions (as shown in the art.
Cold); the excessive increase or diminution of
the cutaneous functions in a part or in the whole
of tlie surface, by disordering the balance between
those performed throughout the frame, exciting
diseases which assume varied forms and grades,
according to the predisposition of different organs,
the state of the system, and the causes which may
co-operate with the change of temperature.
Whilst insolation and unusual rvarmth in any form
— as warm baths, vapour baths, currents of heated
air, frictions, &c. — are powerful agents in the
production or in the removal of disease, accordino-
to the circumstances in which they are employed,
considerable or prolonged cold is equally eflicient
in both capacities. But it is more owing to the
vicissitudes of temperature — to their rapid alter-
nations— than to any excessive grade of eitiier,
that the supervention of disorder is to be imputed.
The sudden suppression of a copious perspiration ;
the partial exposure, also, of certain parts, and
the superfluous coverings of others ; or the action
of currents of cold air upon one part, and of radiant
heat on another, as when seated near large fires;

and wearing unnecessary coverings on the head
whilst the circulation is determined to it by posi-
tion ; are also no mean agents in the production
of rheumatic and nervous afl'ectioiis, and inflam-
mations, by deranging both the perspiratory func-
tions, and the sensibility of the parts thus oppo-
sitely acted upon. The influence of too much
clothing around the hips and thighs of females,
and of too soft and warm beds and couches, in
favouring uterine and vaginal discharges, and
hemorrhoids ; and of too little clothing on the
same parts, in obstructing the catamenia ; is ge-
nerally admitted. The want of personal and
domestic cleanliness, by allowing the accumulation
of sordes upon the cutaneous surface, and the
continued irritation of hurtful matters which may
have come in contact with it, is a frequent cause
of disorder of both its functions and its sensibility,
and a common origin of many of the eruptions to
which it is liable.

42. 0. Obstructions to the free actions of volun-
tarii parts are often occasioned by the kind or
fashion of the coverings which protect them ; and,
not infrequently, injurious pressure of parts is
superadded. Very thick and unyielding shoes pre-
vent the developement of the muscles of the lower
limbs, particularly the gastrocnemii, weaken the
ankle joints, and occasion a shuffling gait. Strait,
confined clothes, on young and growing persons,
cinctures of any part, and too close or straitly
braced breeches, sometimes produce diseases of
the organs of generation, varicose state of the
veins, varicocele, flexures of the spine ; and wast-
ings, painful affections and organic changes of
the testes. All impediments to free motion and
the exercise of our organs are more or less in-
jurious.

43. (b) The respiratory surfaces are afl^ected by
several of the causes which act upon the cutane-
ous surface. The operation of a warm and moist,
or of a cold and humid, air on the lungs, and
through them, upon the whole frame, has already
been pointed out. (See § 32 — 35., and art. Cold.)
The specific gravity, also, of the atmosphere has
some influence in disease ; the diminution of it
occasionally producing hsemorrhages from mu-
cous surfaces. Exertions of -voice or speech, long-
and loud speaking, running against the wind, and
foreign substances floating in the air (as shown in
the article on Arts and Employments) are com-
mon causes of bronchial and pulmonary affections.
The pollen or the odour of vegetables, grass, and
flowers, the effluvium of new hay, &c., sometimes
give rise to severe attacks of asthma, or that form
of it which has recently been termed hay fever.
The animal effluvia floating in the warm, moist
and often stagnant air of assemblies, theatres,
camps, ships, hospitals, and crowded gaols, inde-
pendently of the admixture of any of the specific
miasms hereafter to be noticed, change the condi-
tion of the organic nervous influence, disorder the
secreting functions, contaminate the circulating
fluid, and, in this manner, produce efl^ects which
are injurious in proportion to their concentration
or intensity — generally low or adynamic fevers.
Chemical fumes sometimes excite bronchitis ; and
various simple or compound gases, the air of
mines, the exhalations of privies and sewers, and
even of new-painted rooms, are productive of
syncope, asphyxy, or even apoplexy, convulsions
and paralysis. In such cases, the diminution of
O o 3

566 DISEASE — Exciting Causes 0

oxygen in the respired air, or the impression made
by the foreign fumes or gases upon the nerves of
the respiratory organs, or both conjoined, impede,
obstruct, or arrest the changes produced upon the
blood in the lungs, and ultimately terminate in
death, preceded by one or more of the above af-
fections.

44. (c) Several of the exciting causes act upon
both the external and respiratori) surfaces ; espe-
cially vicissitudes of season, of temperature, and
of dryness of the atmosphere, suddenly passing
from a cold to a warm air, prevailing winds
(see Climate, § 11, 12.), the night or morning
air ; and numerous circumstances connected with
the habitation or locality — especially the exist-
ence of the endemic sources of disease in its
vicinity — ventilation, temperature, and dryness.
The influence of north-east winds in reproducing
attacks of ague and rheumatism ; of the night and
morning air in causing disorders of the mucous
surfaces and of low, damp, ill-ventilated, and
crowded habitations, in giving rise to fevers ; is
■well known.

45. (d) On the digestive surfaces and organs. —
a. Mode of operation. — The numerous and diver-
sified substances which are either commonly, oc-
casionally, or accidentally received into these
organs, produce their effects in different ways.
Those which are injurious from their specific tend-
ency, or from excess, as numerous poisonous and
medicinal substances, and those which disagree,
from idiosyncrasy, mode of preparation, or injudi-
cious admixture with others, as various articles of
food, drink, and condiment ; act in some one of
the following modes : — 1st, By irritating the vil-
lous surface, or alteiing its organic actions from
the standard of health. 2d, By exciting, depress-
ing, or otherwise modifying the nervous power of
these organs ; the morbid impression being propa-
gated, in a greater or less degree, to other related
organs. 3d, By both these piodes of action con-
joined. 4th, By the absorption of these substances
into the circulating fluids, and by their exciting,
depressing, or changing the vital actions, through
this channel ; the manifestations of life in the or-
ganic nervous system, or in the blood itself, or in
the cerebro-spinal system, or in secreting and ex-
creting organs, being individually or conjointly
afTected in one or other of these ways. And, 5th,
both by their primary morbid impression on the
digestive villous surface and nerves, and their
consecutive influence, as stated in the 1st, 2d, and
3d heads; and by their absorption and action, in
the manner now assigned.* (See, also, art.
Poisons.)

46. /?. Food and drink. — The full discussion
of these topics would comprise the subject of
Dietetics ; upon which, however, the scope of
this work will not allow me to enter further than
very briefly in connection with the causation of
disease. Tliey have already received some atten-
tion in relation to climate and season (see Cli-
mate, § 26.); and to the habits of individuals
as to their use ($ 19.). It must be obvious that

* Tho above classification is in arcorrlanco witli tliat
publishod by me in tlie l.umhm Mcdiriil l!rpiisilon/ for
May, 1H22, p. 380. ; and was tljc lirst, lliat was hascil'upon
tlieab«or|)tionot'sul)stanccs into (lie circiilatKjn.aiid upon
ttieir relative action on tlic organic niTvous and ccrcbro-
niiinal ByBteiiu.

F — Dietetics — Etiology.

any article of diet will occasionally be found
difficult of digestion, or even injurious, in certain
latent and open states of disorder. When ob-
structions of any of the viscera, or accumulations
of secretions in the biliary organs or in the piima
via, already exist, owing to weak action or torpor
of any of these parts, very slight aberrations from
an accustomed diet, or substances not usually
hurtful, may occasion very serious disease. It is
also evident that the privation of food and drink ;
excesses in either, or in both; and, in this cli-
mate, loo large a proportion, or the exclusive
use, of either animal or vegetable diet ; will be
productive of correlative ill effects. The exces-
sive use of animal food, particularly pork, gives
rise to plethora, scrofula, and gout ; and the want
of vegetables, herbs, and fruits, in sufficient pro-
portion to the salted provisions consumed, or an
innutritions diet, is productive of scurvy, purpura
hemorrhagica, of an intermediate disorder, which
may he called land scurvy, and chronic diarrhoea
and dysentery. Both flesh and fish are some-
times productive of disorder, owing to their being
diseased at the time of being killed, to their be-
coming tainted subsequently, and to unwhole-
some ways of preserving them. A poisonous pro-
duct is occasionally evolved in smoked and dried
meats; and shell-fish, chiefly from being imper-
fectly boiled, and long kept by the retailers, is
often extremely injurious. The plan very gene-
rally adopted by the fishmongers of London, of
preserving fish — especially turbot, salmon, and,
indeed, all tiie fish that is not sold before even-
ing — by means of ice ; a large proportion being
frozen, thawed, and frozen and thawed again, as
alternately exposed in the day on their stalls,
and lodged in the evening and night in the ice-
pits, until the cohesion of the fibres is lost, and
the flavour dissipated ; is most prejudicial to
iiealth, particularly during summer and autumn;
and is one of the most frequent causes, in Lon-
don, of disorders of the stomach and bowels,
although overlooked by writers on this class of
diseases. Nor does the evil end here ; for all
the salmon that becomes tainted from this mode
of keeping, is either pickled or smoke-dried, and
sold for that prepared in these modes from the
fresh state. Independently, however, of these
circumstances, all kinds of fish — some more
frequently than others — may occasionally dis-
agree, particularly with certain idiosyncrasies,
and with weak digestive organs ; as lobsters,
mussels, &c. Some kinds are even poisonous,
especially in warm climates; and others produce
disorder fiom being out of season, as salmon,
trout, &c. The injurious action of fish is ex-
erted chiefly upon the stomacli and bowels; ge-
nerally in the form of cholera, attended by
extreme vital depression ; and sometimes by an
eruption on the skin. That the poisonous ele-
ments are partially absorbed into, and act partly
through, the circulation, may be inferred from
tlieir efl'ects, and from their peculiar odour being
afterwards detected in the cutaneous secretions.
The means of preventing and counteracting the
ill efl'ects of fish are stated in the article Poisons.
Vcgetalilcs, even, will also disorder the digestive
organs if (hey be allowed to run to seed, or grow
too far, or if kept too long after they liave been
removed from the soil.

'17. y. Cookery and condinioils. — Animal sub-

DISEASE — Exciting Causes of — Dietetics

stances become indigestible by being either too
much or too little cooked ; and vegeUible sub-
stances, chietly, by being too little. Fried and
baked meats are less digestible than roasted and
broiled. Stewed dishes, meats prepared a second
time, and very highly seasoned articles, are all
prejudicial. Fish often disagrees with the sto-
mach, from the manner of cooking, and the
sauces taken with it ; and, of these, butter is one
of the worst ingredients. Vinegar, lemon-juice,
and salt are the most wholesome condiments ;
and, if the fish be rich and fat, Cayenne or
black spice may be added, — these being amongst
the best antidotes to any ill effects it may pro-
duce. The livers of fish are generally productive
of disorders in weak digestive organs ; for, during
boiling, all the oil — which is extremely whole-
some, and even medicinal, and which mi^ht
advantageously enter into the composition of the
sauce instead of butter — is extracted, and,
swimming on the surface of the water in which
the fish is boiled, is thrown away with it ; the part
remaining being that only which is generally, but
improperly, used. Coiic/ime«ts,excepting by those
who have been long habituated to them, are
hurtful, unless taken in very small, or at least
moderate, quantity. Salt, vinegar, and lemon-
juice are the most wholesome under all cir-
cumstances. The fact, that salt is necessary to
health at all periods of existence, is not easily
reconciled with the equally well-established fact,
that the protracted use of salted provisions is a
principal cause of scurvy, scorbutic dysentery,
external sores, ulcers, as well as an evident pre-
disposing cause of fevers, inflammations, &c. But
it may be presumed that the combination of salt
with the animal fibre decomposes it or modifies
its effects upon the living system. Besides, sailed
meat, particularly when it has been long pre-
served, becomes less nutritious, and more difficult
of digestion ; the ill effects being equally attri-
butable to the deficiency of vegetables, frequently
conjoined with bad water, and the depressing
passions.

48. ?•. Baked pastes, and pies, tarts, S^c, and
■the boiled dough of puddings, are difficult of
digestion, especially the former ; and should never
be taken by dyspeptics. Fruit, when in season,
is much more wholesome. But if it be used
either previously to being fully ripe, or when it
has become over-ripe or stale, and particularly if
■it be uncooked, disorders of the stomach and
bowels are frequently produced by it. New cheese
is very injurious when partaken of largely ; and
nuts, cucumbers, and melons are always indi-
gestible, however ripe they may be. A variety of
fruits, immediately after a full meal, is also pro-
ductive of disorder; the most wholesome being
ripe oranges, grapes, strawberries, &c. All pre-
served and stimulating articles of dessert merely
load the stomach, occasion thirst, and lead to the
ingestion of a greater quantity of fluid, and of
■wine, than is consistent with easy digestion, and
with the regular performance of the functions.

49. E. Dritik and beverages are also common
sources of disease, either from being of improper
kind, or used in excessive quantity. Tiie most
wholesome wines are port and sherry, after hav-
ing been six or eight years in bottle, and the
finest and highest flavoured French and Rhenish

■/T^TIOLOGY.

567

wines. The constant use, however, of even the
best port and sherry occasions vascular plethora,
and its consequent ills, unless very active exer-
cise be taken. Delicate persons should dilute
them with an equal, or one half the quantity of
water. Champagne often excites gout : I have
observed two or three glasses of it bring on an
attack the following day. Malt liquors, although
both tonic and nourishing, owing to the hop and
extract of malt contained in them, occasion dis-
ease wiien constantly used, from these very cir-
cumstances ; a plethoric state of the system,
obesity, and various contingent diseases, being
the result. The most wholesome of this kind of
beverage is brisk small beer. Cider and perry
are sometimes productive of colicky affections,
gastrodynia, indigestion, and diarrhoea, especially
if they be taken while the body is perspiring, or
in very hot weather. Spruce beer is much more
wholesome. Spirituous liquors, particularly those
in common use, are most injurious to the frame;
and, in the lower classes, are the most frequent
causes of, first, functional, and afterwards organic,
diseasesof the stomach, liver, bowels, and brain,
as well as of some other viscera, and of insanity.
Cojf'ee and tea, atthough, upon the whole, whole-
some beverages, may be, in some constitutions
and states of the system, productive of disorder.
A strong infusion of cojf'ee, taken soon after the
principal meal, promotes digestion, and counter-
acts whatever ill effects the cold and poor wines
used on the Continent might otherwise produce.
But it is sometimes injurious, from its stimulant
properties, in cases of cerebral irritation, or ex-
citement; and, when taken late in the evening,
prevents sleep. The infusions of black or green
tea are gently tonic and narcotic ; the latter act-
ing more energetically upon the cerebro-spinal
system than the former. Green tea usually ex-
cites the nervous power ; and, like coffee, in-
creases the activity of the cerebral functions.
But, when morbid, vascular, or nervous excite-
ment exists, it generally proves an excellent tonic
and sedative ; procuring sleep, and diminishing
both nervous and vascular disorder. In cases of
asthenic vascular action, attended by coma or
lethargy, I have found it A most valuable re-
storative of both vital and cerebral power. In
addition to the above, the use of hard or un-
wholesome water, and either a high or a very low
temperature of the ingesta, are often productive
of disease.

50. ^. The effects of accidental or designed in-
gestion if poisonous substances, as well as the
means of counteracting and removing them, are
considered at another place; and, althouo-h in-
judicious ^ises of remedial means are but too fre-
quently causes of disease, and of its aggravation,
especially the inappropriate use of mercurial pre-
parations, of emetics and irritating purgatives, of
vascular depletions ; of stimulating and heatmo-
substances, exhibited with the view of restormc^
nervous power, or of promoting expectoration,
instead of allaying increased vascular action,
and of secret remedies of every description ; the
nature of the subject precludes further allusion
to it at this place. The influence of morbid
secretions poured into the digestive tube, and the
effects of arresting accustomed or salutary eva-
cuations, as increased discharges from the ute-
O 0 4

568

DISEASE — Exciting Causes of — Etiology,

rine organs, haimorrhoids, &c., or vicarious
secretions, without having opened aa artificial
outlet, or produced artificial irritation and dis-
charge, in extending, perpetuating, and aggra-
vating disease, rather than originating it — for
morbid states of secretion imply existing disorder
— are sufficiently obvious.

51. (e) The causes which act on the organs of
sense consist chiefly of the abstraction of the
natural stimuli or impressions, and the appli-
cation of tliem in unusually intense forms; the
mental phenomena excited through the medium
of the senses not falling under this head. —
a. Sight may be weakened by prolonged dark-
ness, and consequent inaction of the organ ; but
it is much more commonly injured by the un-
usual impression of liglit, which may so intensely
excite and exhaust its sensibility as to destroy its
functions. The rays of the sun, and lightning,
have produced this effect almost instantaneously ;
and the light reflected from snow in northern
countries, and from the sands of the arid districts
of intertropical climates, has frequently occasioned
it in a slower but not less effectual manner. Per-
sons employed in glass-works, forges, founderies,
&c., who frequently subject their eyes to an in-
tense light and radiant heat ; and those who are
occupied on small, very near, or minute objects ;
are often affected by amaurosis, cataract, and
other chronic disorders of the organ. When the
sensibility of the eyes is increased by protracted
darkness, the admission of even a moderate light
often becomes painful and injurious, if it take
place suddenly. Of the various colours reflected
by tlie rays of light, white and red are most
fatiguing to the sight. — B, Hearing is injured by
very loud noises, or detonations, near to the
organ : and persons of weak or nervous constitu-
tions may even lose this sense by such causes ;
or experience convulsive seizures, syncope, vio-
lent palpitations, or disorder of the digestive and
circulating organs. Loud noises are extremely
injurious in all cases of cerebral and vascular
excitement; and in cases of external injury, as
well as of internal inflammation. ]\I. Percv
states, that he observed the wounded often very
sensibly affected by the report of cannon during
sieges and battles. — y. The sense of touch, and
the sensibiiitii of external parts, are acted on by
many of the causes already noticed ; but often in
an imperceptible manner. Numerous external
irritants ; extremes of temperature, either of the
air, or artificially excited, as extensive vesications
and burns ; violent or protracted excitement of
the senses of sight and hearing ; or irritations or
injuries of nerves; frequently affect sympatheti-
cally the wliole frame ; and even occasion con-
vulsions, spasms, inflammation of the brain and
spinal chord, or of their membranes; and, when
extremely intense in relation to the vital resist-
ance of the sufferer, great depression, and even
fatal sinking, of the ])Owers of life. — J". The
sense of smell may be impaired by over-excite-
ment ; or by causes acting in this, or in any
other way. It is also partly through this sense
that various agents invade the system, espe-
cially those of a depressing kind, as infectious
effluvia. (See art. Infection.) Odours some-
times, also, produce syncope, nausea, vomiting,
and nervous affections through this medium.- — -s.
The sense of taste is the least frequently the channel

through which exciting causes act : the impression,
however, made upon the palate by certain articles
are sometimes productive of severe disorder of the
digestive organs ; and, in the case of the more
active narcotics, &c., of dangerous disease of the
nervous system.

52. In the foregoing review, those causes which
act eiternaily upon, or through the medium of, the
organs of sense have been noticed. But there
are numerous changes, which are intrinsic, or take
place in the organic, nervous, and circulating
systems, as well as in the brain and secreting
viscera, and which affect these organs in a very
remarkable manner. These, however, are rather
secondary or pathological causes — or the effects
of agents acting primarily upon those or other
parts of the frame, which effects become contin-
gent or necessary causes of disorders of the or-
gans of sense — from altering their condition, or
the state of parts necessary to the perfect per-
formance of their functions. Thus the senses
may be disordered, or altogether abolished by
disease of the brain, or of their nerves, or by af-
fections of the digestive and assimilating viscera.
This influence of disease of one viscus or system,
upon those anatomically or physiologically re-
lated to it, also subsists more or less evidently
throughout the frame ; the primary affection
giving rise to a variety of sympathetic and se-
condary disorders, according to the progress it
has made, to the circumstances that have influ-
enced it in its course, and the predisposition of the
individual (§ 21.).

53. (f) On the sentiments and passions.— The
circulation of the brain, the action of the heart,
and the functions of the digestive and generative
organs, are frequently disturbed by causes affect-
ing the manifestations of mind. — a. Excessive
mental employment ; long protracted attention,
especially to one subject ; over-exertion of indivi-
dual powers, without the requisite repose, and
the relaxation resulting from an agreeable diver-
sity of pursuit ; the distraction also occasioned
by a number of pressing or abstract topics ; can
seldom be very long persisted in, without ex-
hausting the mental energies, exciting or other-
wise disturbing the circulation through the brain,
and ultimately inducing either acute or chronic
cerebral disease, as phrenitis, delirium, insanity,
apoplexy, paralysis, epilepsy, &c. ; especially
if other circumstances concur to excite or over-
load the vascular system, and determine the cir-
culation to the head, or if the requisite nightly
repose be abi-idged or interrupted. — 0. Certain
trains of feelings, and particular desires or pas-
sions, as religious sentiments, affection, love,
hatred, revenge, avarice, pride, vanity, &c.,
may all be cari-ied to that pitch, by being con-
stantly and exclusively entertained, as insensibly
to pass into monomania, or other forms of insa-
nity ; or to occasion ecstasy, catalepsy, convul-
sions, or some one of the diseases mentioned
above (a). — y- Various circumstances occa-
sioning solicitude, anxiety, distress of mind,
sadness, fear, shame, penitence, disappointments
and losses of all kinds, the indulgence of grief,
and anxious or constant longings alter objects of
desire or of afi"ection, may not only disorder the
mental manifestations in a partial or general
manner, but also disturb the functions of the
heart, as wcl) as those of digestion and assinii-

DISEASE — Specific Causes of — jEtiologv.

569

lation. All the depressing emotions of mind have
an especial effect upon the circulation, upon the
nutrition of the frame, and indeed upon all the
functions dependent upon the organic nervous
system ; and favour chronic and asthenic diseases
of the heart, particularly passive dilatation and
enlargement of its cavities, indigestion, and con-
stipation; also chlorosis, pulmonary consump-
tion, hysteria, and tubercles, early in life ; and
hypochondriasis, melancholia, chronic diseases
of the liver, spleen, and pancreas, and cancerous
or other malignant diseases, at mature or advanced
ages. — J. Surprise, fright, terror, anger, and
indignation, are not infrequently productive of
apoplexy, paralysis, epilepsy, convulsions, syn-
cope, violent palpitations, painful or acute af-
fections of the lieart, disorders of the stomach,
liver, aud bowels, hysteria, abortions, derange-
ment of the uterine functions, and of the mani-
festations of mind. — £. Great mental excite-
ment, unlooked-for success, the sudden accession
of fortune, extreme joy, and all the pleasurable
emotions carried to excess, are not infrequent
causes of insanity, of phrenitis, epileptic convul-
sions, hysteria, and catalepsy. — ^. An impro-
per conduct, and an insufKcient control, not only
of the sentiments and emotions, but also of the
imagination, are amongst the most common
causes of disorder in the manifestations of mind,
as well as of the other maladies enumerated
above (a, (3). — >i. Inordinate indulgence of the
sexual appetite occasions epilepsy, loss of me-
mory, and mental and corporeal debility, impo-
tency, diseases of the testes, prostate gland, and
urinary bladder, and affections of the heart and
lungs in males ; and in females, inflammation
of the ovaria and uterus, Huor albus, hysteria,
chlorosis, melancholy, irregular convulsions,
organic or scirrhous changes in the uterus, dis-
eases of the ovaria, and sterility, &c. (See art.
Age, §24.) — Sr. Persons who have been habi-
tuated to excessive sexual indulgence, and
become altogether continent, are liable to noc-
turnal emissions, to impotency, convulsive and
other nervous diseases, and to disordered mental
manifestations. — <. Numerous acts of volition
injudiciously attempted or directed may be pro-
ductive of the most dangerous injuries and disease ;
as violent muscular efforts, of sprains, aneurisms,
ha;morrhages, inflammation and caries of the
vertebrae, or inflammation of the intervertebral
substances. Positions with the head low, or on
the back, and especially such as are uneasy or
unnatural, too long retained, or too frequently
assumed, give rise to cerebral disorder and curv-
atures of the spine ; and encumbered, obstructed,
or too rapid and protracted movements, produce
injurious acceleration of the circulation, exljaus-
tion, with other ill effects.

54. B. The cliemical and mechanical causes
of disease require little notice here ; the former
of these having received attention in the articles
on Asphyxy, and Poisons; and the latter on that
of AnTS AND Employments, as Causes of Disease.
— (a) Chemical agentsareinixinons — - 1st, by their
influence on the functions of the part with which
they come in contact, their effects varying with
their individual properties ; 2d, by the change
they produce in the structure itself, either in
combining wltli it, or otherwise changing its
constitution, so as to render it incapable of its

healthy offices ; and, 3d, by totally destroying the
nervous and vital influence, and intimate organis-
ation of the part. — (ft) Of mechanical causes and
positions impeding, upon physical principles, the
flux or reflux of the circulation and secreted fluids,
continued pressure of various grades, and unna-
tural ligatures of parts, are the most common, and
act slowly, and often insensibly and unremit-
tingly. Shocks or concussions of a part or of
the whole of the body, or other kinds of external
violence, not only occasion the division, fracture,
dislocation, bruise, and comminution of external
parts, but also the rupture, laceration, hasmor-
rhage, displacement, vital depression, or extinction
of function of internal viscera, as of the urinary
bladder, liver, spleen, stomach, and bowels, brain,
spinal chord, &c.

55. iii. The Specific Causes of Disease. — Of
the causes which may be thus termed, emanations
from the soil are, perhaps, the most common. — A,
The miasmata arising fiom stagnant water, par-
tially covering the soil, or covered by vegetating
substances ; from vegetable matter in a state of
decomposition ; from moist absorbent soils exposed
to the sun's rays; from the muddy and foul bot-
toms of lakes, marshes, and lagoons, or the marshy
banks of rivers and canals ; and from low grounds
which have been partially inundated by the ocean
or by rivers ; are productive of agues, enlarge-
ments of the spleen, of the liver, and even of all
the glands, of rheumatism, catarrh, &c., in cold
or temperate climates ; and in addition to these,
of remittents, bilious and gastric fevers, dysentery,
cholera, diarrhoea, and hepatitis, in warm climates
and seasons, according to the predisposition of the
patient, and the circumstances which have aided
the action of the efficient cause on the system.

56. B. When dead animal matters or exuviae
mix with vegetable substances, and putrefy along
with them, in a warm and moist air, the efflu-
vium assumes a more noxious form, especially if
the air stagnates in the vicinity of its source ;
and it becomes more certainly productive of dis-
ease than that which proceeds from the decom-
position of vegetable matter only ; the effects
produced by it being often of a more adynamic
or malignant character. In warm countries, the
localities enumerated above abound with dead
animal bodies, and the exuvia3 of immense swarms
of insects; and hence may be inferred the reason
wherefore terrestrial emanations in these climates
give rise to more severe forms of intermittent and
remittent fevers, depress more remarkably the
vital powers, derange more the vascular system,
and more sensibly affect the blood and the secre-
tions, than the miasmata exhaled from similar
places in northern latitudes. The water of low,
inoist, and marshy places is also productive of
various maladies, particularly of dysentery, chro-
nic diarrhoea, diseases of the spleen, Guinea-
worm, 6iC. These causes and effects, with what
is at present known of their operation, are more
fully discussed in the arts. Endemic Influence,
and Fevers.

57. C. Emanations from animal matter only,
the air being in other respects uncontaminated, or
frequently renewed, are seldom productive of any
serious maladies. But when they burst forth
suddenly, in a close and moist air, the effects are
sometimes most pernicious. It has been recorded,
that fevers of a very malignant kind have attacked

570

DISEASE — Specific Causes of — ^Etiology.

persons who have opened a grave and exposed the
body whilst undergoing decomposition, the efflu-
vium having instantly produced a sensible influ-
ence upon the frame. The effects of air accumu-
lated in sewers, privies, &c., are shown in the
article on Asphyxy.

58. I'he particular elastic fluids which are
evolved from the foregoing sources have not been
satisfactorily demonstrated by analysis. They
seem, however, to consist of an admixture of va-
rious gases, in very variable proportions, parti-
cularly sulphuretted hydrogen gas, and sulphuro-
carburetted hydrogen, with azote, and aqueous
vapour, holding the more subtile particles of de-
composed animal and vegetable matters in solution ;
which particles most probably make the most in-
jurious impressions on the frame, and are the
actual causes of the consequent disease.

59. -D. The various exhalations and secretions
formed in the course of disease are most common
and important causes. These consist either en-
tirely of insensible emanations from the bodies of
persons affected by the exanthematous and speci-
fic fevers, &c. (infectious) ; or altogether of a
consistent and palpable fluid formed on the mor-
bid surface of the diseased body or part, as the
itch, lues venerea, &c. {contagious). Many
of the maladies which spring from specific causes,
propagate themselves, both by impalpable or in-
visible emanations from the body floating in the
surrounding air, and by the contact of a consist-
ent fluid or virus formed in the diseased part,
with a part of an unaffected body rendered ca-
pable of being affected by it. Such is the case
with small-pox and plague (both infectious and
contagious). Rlaladies which are produced by
the contact of a consistent fluid secreted by a
diseased part, may be propagated artificially, or
by inoculation, although not in every instance
where it is attempted. Those, however, which
do not form upon some part of the chief seat of
disease a consistent secretion, capable of being
artificially inserted in a healthy body, may never-
theless be conveyed from one person to another,
by bringing substances capable of absorbing and
retaining for a time the emanations given out
from the diseased body, as frequently demon-
strated by typhus and scarlet fevers, &c. ; and
all those whicli are propagated by contact, or by
a palpable fluid, also, may be disseminated in
a similar way. The substances thus imbibing
and conveying the invisible or infectious emana-
tions, as well as the palpable and contagious virus
or consistent secretions, have been called fomites
— if a single substance has been the vehicle,
fames. Of all the various materials which may
thus become the medium of transmitting infectious
diseases, animal productions, particularly woollen
and hairy substances — manufactured or unmanu-
factured— iurs and feathers, bedding and body-
clothes, have the greatest disposition to imbibe
the morbid effluvium, and to retain it the longest.
It seems as if animal emanations were attracted
and retained most strongly by substances belong-
ing to the same kingdom. Js'ext to these, cotton,
flax, linen, and otiier substances of a soft and
porous texture, are most likely to convey morbid
effluvia. In respect of the diseases which are
really infectious or contjjgious, or which proceed
merely from terrestrial emanations, great differ-
ence of opinion exists, and has long existed.

IMany fallacies connected with the use of the
terms in dispute, much misapprehension and ig-
norance, great prejudice, and unbecoming acri-
mony, have characterised the controversies which
have arisen on this subject. The topics, how-
ever, connected with it, both essentially and col-
laterally, are fully discussed in the articles on
Fevers — Caxises cf ; and Infection ; — and in
those on the diseases, respecting the nature of
which difterence of opinion has existed.

60. E, Mode of action of specific causes. —
On this subject, a very general remark merely
may be hazarded at this place. Those specific
causes which are suspended in the atmosphere
or dissolved in the moisture it contains, and in-
haled into the respiratory passages, seem to make
their first impression on the nerves supplying
those parts ; the organic nervous system being
chiefly affected. That this is the case in respect
of maish miasmata, and other terrestrial emana-
tions, is indicated by the periodicity — the intervals,
the recurrences or paroxysms, the exacerbations,
and the terminations, of the various diseases re-
ferrible to these sources. If the circulating fluid
were eai'ly and chiefly affected by them, as some
believe, morbid action would take place more
rapidly, and assume a more malignant and conti-
nued form ; for, as soon as the blood becomes af-
fected, complete remissions are never detected ;
whereas all affections of the nervous system, es-
pecially those of a functional kind, are charac-
terised by remissions and exacerbations ; or by
intermissions and regular paroxysms. In ad-
vanced stages, even, of those maladies, particu-
larly after the various secreting and depurative
functions have been disordered, the circulating
fluid probably becomes changed, although not
in a very remarkable manner ; the chief morbid
condition, however, still existing in the organic
nervous system. Wlien the miasms floating in
the air consist principally or altogether of animal
emanations — proceeding either from animal matter
in astate of decomposition, orfrom persons affected
by adynamic or specific forms of disease — not
only may the first impression be made upon the
oi'ganic nervous system, but the blood itself may
also be early contaminated, although not at first
in a sensible manner ; for it is not unreasonable
to infer, that the fluid emanations from the bodies
of the diseased, and dissolved or floating in the
respired air, may pass into the blood along with
those constituents of the air which partially enter
it, and in this way induce a similar disease of the
whole frame, owing to the universal diffusion of
this fluid, and the very intimate connection sub-
sisting between it and the organic nervous sys-
tem, even before the changes effected in it have
become manifest to our imperfect senses.

61.iv.TllE DETER HI IMNG OR CONSECUTIVE C A USES

OF Diseases require little observation, further than
that the practitioner should not overlook the cir-
cumstance, that the exciting causes, whether
common or specific, will frequently fail of being
followed by any marked effect, when the system
is in due healtii at the time of exposui'e to them,
and is not subjected for some time afterwards to
various additional influences or agents, particu-
larly such as pi'oduce a depressing or debilitating
impression. Thus, a person who has been exposed
to emanations from fiie subjects of typhus fever, or
from marshy grounds, &c., may experience no ail-

DISEASE — General Doctrine of — Pathogeny.

571

ment, until a change of weather — from dry to
moist, &c. — or depressing menial impressions,
or cold and fatigue, or venereal excesses, or in
short, any debilitating influence, occur to aid its
operation and deteimine its action ; and if no such
consecutive causes aid the principle or specific
cause, iu a few days from the exposure to it, dis-
ease will often not appear. I have frequently
seen this exemplified in a very striking manner :
one instance on a large scale will be sufficient.
Between twenty and tliirty persons were exposed
all night, without cover, to the air of one of the
most fatal sources of miasmata furnished by a
warm climate, during the unhealthy season, but
were soon afterwards removed to sea — far from
any further exposure to this specific cause. They
continued well for six or seven days, when about
half their number experienced great fatigue. All
these were nearly simultaneously — on the fol-
lowing day — seized with remittent fever ; whilst
those who had not been subjected to this conse-
cutive cause, with the exception of two, who were
not attacked till several days subsequently, en-
tirely escaped, although all had been equally
exposed to the specific cause of that form of fever.
Further illustrations from my experience in dif-
ferent climates, and of various diseases might be
adduced ; but the simple statement of the above
fact is suflficient. The practical importance of it,
however, should not be overlooked ; for it shows
— what I have frequently believed has been suc-
cessfully practised — namely, that a person who
has been subjected to the impression of a specific
or any other exciting cause, may escape its effects,
if he immediately fortify the system against it,
and avoid exposure, for some time subsequently,
^to all other injurious agents, especially those
which lower the vital energies of the frame. Per-
sons even who expeiience the sensations more
immediately caused by exciting agents of a spe-
cific kind, as infectious emanations, will oftfen
escape by observing this precaution, and having
recourse to a restorative regimen, with the usual
means of promoting all the secreting and excreting
functions of the frame, as shown in the art.
Fever — Prophi^lactic Means.

62. It is unnecessary to enumerate the causes
which most commonly come in aid of the exciting
agents of disease. They comprise nearly all those
already adduced as predisposing the system to,
as well as occasionally exciting, morbid action ;
particularly such as depress vital power, by their
specific properties and immediate impression ; the
abstraction of requisite or accustomed stimuli, as
of warmth, food, ike. ; whatever impedes the
functions of respiration, digestion, assimilation,
and excretion ; all weakening discharges ; de-
pressing aflfections of mind, particularly fear of
being affected by the cause to which the person
was exposed ; and all circumstances in any way
deranging the accustomed tenor of the mind, and
habits ol life.

63. III. General Doctrine of Disease, or
Pathogeny (from Trafioj, disease, and yindoj, I
gender, or produce). — An examination of the
systems of medicine proposed since the revival of
learning in Europe, or even of those advanced in
modern times, would occupy more of my limits
than I could devote to the subject. I shall,
therefore, proceed at once to the developement
of those general views of disease, which observ.

ation and reflection have suggested to me, and
convinced me to be of importance, not only in
estimating aright the exact state of the more com-
mon specific maladies, but in forming safe opinions
respecting those more anomalous or complicated
affections, which frequently present themselves to
the practitioner.

64. I have already contended ( § 7.), that,
with few exceptions, which have been particular-
ised, the causes of disease Jirst modify the mani-
festations of life in some one or more of the sys-
tems and organs with which it is allied ; or, in
other words, first disorder the functions with
which they have a direct relation ; and that, after
a period of longer or shorter duration, the disorder
of function becomes a cause of further disorder in
related or associated organs, and ultimately, if
circumstances obtain hereafter to be noticed, of
change of structure either in the primary seat of
disorder, or in that consecutively affected. From
this, and what has been already stated, it will ap-
pear that a great proportion — nay, all — of those
disorders of internal parts which have been
viewed as intriiisic predisposing and exciting
causes of disease, are, in truth, pathological
conditions, or existing states of disease, induced
by _^some one or more of the causes specified
above, and ready to produce further disease, or to
lead on to a salutary change, according as the ex-
isting state of vital power or resistance, and the
influences or agents acting on it, may determine
the procession of phenomena, or incline the ba-
lance. These primary or early changes, or morbid
conditions, may very aptly be termed secondary or
pathological causes, when they give rise to ulterior
change either of function or strifl'ture ; but they
are so diversified, that but little notice can be taken
of them here, beyond what is necessary to the con-
sideration of general principles ; their different
forms being more intimately viewed in the articles
on specific diseases. It may, however, be remarked
that they often exist in latent, or almost imper-
ceptible, states, and predispose the frame to the
invasion of causes to which it otherwise might have
been exposed with impunity.

65. 'I'he great fault of all systems of patiiology,
down even to the most recent has been their con-
fined or narrow principles, and consequently their
inadequacy to the explanation of all the states
of morbid action constantly occurring. Buovvn
and his followers admitted but two modifications
of the vital manifestations from the normal state,
viz. depression and excitement, whilst he substi-
tuted an inappropriate and single term as a sign
for those manifestations, which are as obviously
and frequently changed in kind as in degree. Dr.
Parry referred the ciiief states of disease to the
vascular system and to changes in its states of
action, without sufficient reference to the nervous
system, as controlling and even causing these
changes, especially to the organic nervous system,
with which the vascular is so intimately con-
nected ; whilst his contemporaries, who con-
sidered that disease originates in the nervous, and
affects the vascular, system consecutively,
viewed the cerebro-spinal axis, and its various
prolongations in the form of nerves of sens-
ation and volition, as the parts primarily im-
pressed. Considering, however, as stated in the
article on Debility ( § 13.), that the intimate
association of the organic nervous system with

572

DISEASE — General Doctrine of — Pathogeny.

the vascular system throughout the frame, and
particularly in vital, secreting and assimilating
viscera, fulfils important objects, — that these
systems are the chief factors of life in the various
structures and organs, which, however, modify
its manifestations, giving rise thereby to specific
manifestations of this endowment, according to
the nature of their superadded organisation, so
that the liver secretes bile and not urine, the
pancreas its peculiar secretion and no other, the
kidneys, urine, &c. — I believe that the causes of
disease commonly act directly upon one or both
of these systems, most frequently on the former;
and generally on their numerous ramifications in
one or more of those organs or surfaces, witii
which the exciting and other causes are more
immediately related, and with which they are
brought in connection from their nature and pro-
perties. Thus, those causes which are apphed
to the respiratory surfaces primarily affect the
organic nerves distributed to them, and the blood-
vessels of the lungs, and in some cases the blood
itself; and those which are received into the di-
gestive organs, make their impression on the
nerves, supplying them, thereby modifying their
vita! manifestations, as well as the functions of re-
lated or associated viscera, according to the pro-
perties of the individual agents. Having pointed
out the intimate relation of the exciting and other
causes to the organs on which they chiefly act, and
having here and at preceding places noticed the
particular system on which they seem to exert their
primary impression, it becomes requisite next to
enquire into the nature of that impression, or early
disorder, and afterwards to consider the changes
which consecutively accrue, and the means which
nature employs to arrest their progress or to give
them a salutary tendency.

66. i. Of the principal States of Morbid
AcTioM. — In considering the earliest aberrations
from the healthy state following the impression
of morbid agents without especial reference
to the system or organs on which they directly
act, we are particularly struck with their very
diversified nature ; and, upon an intimate view
of the numerous shades of difference, often
evanescent or inappreciable, between effects ap-
parently similar, we necessarily arrive at the
conclusion, that, however multiplied tlie various
grades of action or vital manifestation may be,
some other differences than such as are purely
dynamic exist ; and that the changes may also
be of an anomalims or Cachectic kind, — that the
vital manifestations in the various organs may
not merely present simple changes of degree,

but also COMPLICATED ALTERATIONS OF KIND,

that vital action may not only be depressed and
excited, but also changed in other respects, or
vitiated, as well as at the sa;ne time either de-
pressed or excited. Sufficient proof of the
above positions will immediately suggest itself
to the practitioner, when he considers tiie dif-
ferent states of action that may be even artifi-
ciiilly produced by the ingestion of different
stimuli, the grades of whose action may be very
nearly tiie same; or when he views the very nu-
m(!rous modifications in degree, form, and kind,
which ciiiier vital depression or excitement as-
sumes, in affections even of the same system or
organ, lie will, moreover, recollect that nu-
merous maladies have come before him, in which

the least distinctive characters were those result-
ing merely from grades of action ; that the most
prominent features, whether pathognomonic or
diagnostic, had no reference to degree, but to
form or kind ; and that many of these were of
the utmost importance in the recognition of the
actual pathological condition, and as bases for
therapeutical indications, however difficult it
might be to describe or explain them, or to
convey such an idea of them as he had himself
formed, and successfully applied to practice. In-
deed, every one must have remarked, that nume-
rous phenomena, either cognisable to the senses
of the observer, or merely connected with the
sensations of the patient, indicate rather a change
in the condition of life, a vitiation of its properties
and manifestations, than any grade either of
its depression or excitement. If we take the
common symptom of pain, as remarked by Dr.
Pring, we have no evidence that it is more inti-
mately allied to increased, than to diminished, vital
action. In imputing it to altered sensibility,
we in fact imply that the alteration is not altogether
one of grade merely; indeed, a careful examin-
ation of related phenomena will show that the
most intense states of pain are more commonly
connected with lowered, than with exalted action.
As respects, therefore, numerous changes in
particular functions and organs, as well as in the
whole body and its general manifestations, it may
be inferred, that the condition or properties of
life, and consequently of vital action, may be
altered very variously, otherwise than in de-
gree ; and that, as intermediate grades of action
or vital manifestation are innumerable, and
admit only of an arbitrary estimation, so are
the modifications or alterations of it, in kind or
condition, equally diversified — merely the more
prominent features admitting of recognition by
our imperfect powers of sense and intellection.

67. 1st. Of THE Dynamic States of Vital
Manifestation. — Grades of action must neces-
sarily be infinite, between the lowest consistent
with life, and the highest to which excitement can
be carried without passing instantly into complete
exhaustion. They have been very generally-
divided into two classes or divisions, namely,
those helotc, and those above, the medium grade
of health ; the former having the generic ap-
pellations of debility, asthenia, adynamia, and
frequently of exhaustion when occurring conse-
cutively, applied to them ; the latter that of
excitement, hypersthenia, sthenic or increased
action and often of reaction when secondary or
indirect.

68. A. Debility, in its various conditions, —
primary, secondary, and complicated; as well as
its special manifestations and effects in the dif-
ferent systems, tissues, and organs ; was fully
discussed in an article devoted to the subject;
where also its pathological relations — its associ-
ations, consequences and terminations, with its
practical bearings, were considered at length. I
therefore, proceed to give a succinct account of
that state of vital action or manifestation which
seems to mount above the standard of health ;
and which presents various modifications, and
produces diversified effects, not only according
to its cause, and the system or viscus primarily
affected, but also as it may appear primarily or
consecutively.

DISEASE — General Doctrine of — Pathogeny^

573

69. JB. Of excitement and reaction. — No
circumstance has tended more to prevent tlie ac-
quisition of sound principles in pathology than
the terms introduced by Brown and iiis fol-
lowers, and the meaning attached to them. In-
deed, it was a matter of no small difficulty to
arrive at a precise idea of what meaning they
did convey ; for a single word was in itself an
hypotliesis ; and " eicitahiliti/" — accumulated,
exhausted, &.c. — " sensihililti," "susceptibility"
&c. were made to perform more than actually
falls to their lot. As, however, these terms are
frequently employed in medicine, and cannot
now be conveniently discarded, it will be as well
to state the idea that should be attached to
them. Sensibility is the faculty of receiving im-
pressions, and of being conscious of them. Ex-
citahilitij, the power of being excited by stimuli
or irritants, whether consciousness attend the
act or not ; consciousness generally follow-
ing their application to organs of sensation and
volition, or of animal life ; but not when applied
to those of involuntary motion, or of vegetative
life, unless tlie excitation be carried to a great
height. Susceptibility is the power not only of
receiving impressions, but of being affected by
them, whether the agents be physical or moral,
and whatever may be their mode of operation ;
consciousness either attending or not attending
the act, according to the nature of the agent,
and the organ it affects. Here it will he per-
ceived, that sensibility implies a certain faculty ;
excitability the power of acting only in one direc-
tion ; and susceptibility of being affected in
every way, according to the nature of the cause ;
and that the meanings are the same, whether
these terms be applied to a single organ or to the
whole frame ; they representing intimately allied
manifestations of life in organised parts. The
states, moreover, which these terms represent,
are variously modified in different persons, ac-
cording to temperament and constitution ; but
they are still more remarkably altered by the
causes enumerated above, as well as by the suc-
cessive changes characterising diseases ; and
hence they become important signs of the condi-
tion of vital power, and of the progress of func-
tional and organic change. When existing in a
very manifest or extreme degree, they are of
themselves important pathological states, and in
this respect they deserve notice.

70. Sensibility, excitability, and susceptibility,
are great or especially prominent in delicate,
debilitated, nervous, and irritable persons, and are
morbidly increased by whatever lowers the ge-
neral amount of vital power, if the functions of
the brain be not impeded, or by excited action
in any part of the cerebro-spinal axis not at-
tended by pressure. They are much less lively
in the robust, lymphatic, and phlegmatic constitu-
tions ; and are more or lessdiminished in congestive
diseases, particularly those of the brain ; in many
cases of vital exhaustion, when the blood be-
comes contaminated ; or when pressure takes
place in any part of the cerebro-spinal centres
or prolongations. They are likewise temporarily
or permanently impaired by the intense, frequent,
or continued impression or action of the same im-
pressions ; and are restored or heightened by
the abstraction of those which are of a lively or
intense kind. Although excitability is easily and

quickly roused in the delicate and nervous frame,
and in states of simple debility, as specified
above, yet it is more rapidly exhausted or alto-
gether extinguished ; whilst, on the other hand,
it is much less readily brought into action in the
robust ; but when once roused, it is either more
energetic or longer sustained than in the debili-
tated. In these states of disease, which I have
denominated secondary and complicated debility,
and especially when the cerebro-spinal centres
are congested or pressed upon, or when the cir-
culating fluid becomes contaminated, the excit-
ability is either much diminished or altogether
lost, — chieHy, however, as respects voluntary
organs, when the nervous system of animal life
is affected ; involuntary parts still admitting of
excitation, although not so readily as in health.
Susceptibility, even more remarkably than the
two other powers, is increased by debility and
novelty of impression, and diminished by a robust
and due manifestation of vital power ; by a repe-
tition of the same effect, whether it be stimulant
or depriment, unless each succeeding application
of the same agent be made before that of its an-
tecedent had altogether ceased ; as evinced by
both the causes of disease and the operation of
stimulating and narcotic remedies. The com-
plete manner in which the susceptibility to be
affected by certain causes of disease is destroyed
by their full and adequate action, is shown by seve-
ral of the specific agents.

71, Excitement may be of two kinds, accord-
ing to the manner of its occurrence : it may di-
rectly follow the impression of the exciting or
irritating cause, in which case it is primary or
direct ; or it may follow as a more or less remote
effect of agents which lower the action 'either of
a part or of the frame throughout, when it con-
stitutes what is called secondary, or reaction, as in
the case of the vascular excitement following the
application of severe cold to a part, or the whole,
of the external suiface. It is necessary to dis-
tinguish between these two grand conditions or
manifestations of excitement ; for the secondary,
or that following indirectly the impression of
lowering or sedative agents, may be variously
modified throughout by the nature of the primary
impression, and its mode of action. Hence one
cause for the distinction here made. There are,
besides, numerous other modifications of excite-
ment, whether primary or secondary, referrible to
the nature of the agent, and the parts of the
body on which they have directly acted. The
excitement caused by mental emotions is different
in its progress, duration, and consequences, from
that following the ingestion of spirituous or other
stimuli ; and this latter, and indeed both, are
different from the increased action following
sympathetically the irritation of some organ or
viscus. In the first, the cerebro-nervous and
vascular systems are simply excited, the excite-
ment terminating in slight exhaustion, unless
some part has been injured during its conti-
nuance. In the second, these systems are more
than simply excited. A more manifest febrile
state continues for some time subsequently, with
concomitant lesion of the digestive functions or
viscera, owing to the passage of a portion of the
morbid agent into the circulation, and to the
more immediate lesion experienced by tlie parts
on which it made its primary impression. In

DISEASE — General Doctrine of — Pathogeny.

the third, the excitement is more especially ex-
pressed in the organic nervous and vascular
systems — the chief factors of life — owing to
its extension to the whole of these systems, from
the part in vifhich it originated, and still exists :
hence its duration depends upon the primary
lesion, and there is, in addition to the general or
sympathetic excitement, disordered function of
the part primarily aftected, as well as of those
more intimately allied to it. Even from what has
now been stated will appear the importance, in
pathological and tlierapeutical points of view, of
instituting a comprehensive analysis of those states
of vital action to which the term excitement has
been applied, and which bears a very wide and
often indefinite signification.

72. (a) Primary or direct excitement is one
of the most frequent effects produced by the
agents which surround the body. It may pro-
ceed from such only as are external to the frame,
and to the part which it excites, or from such as
are internal or intrinsic. Its phenomena and con-
sequences vary as it arises from causes acting
chiefly upon the organic nervous and vascular
•systems, and their immediately related organs —
upon the organs and functions of organic life —
and affecting them principally ; or from such as
act primarily upon the cerebro-spinal system, and
organs of animal life, as those of sensation, re-
flection, volition, contractility, &c. But the
modifications which spring from other sources,
especially from the properties of the agent, the
intensity of its operation, and the number of
parts aifected by it, are too numerous for a super-
ficial view, even if the knowledge requisite to
the attempt were attained. I must therefore
content myself with noticing merely a few of
the more prominent features of this condition
of life.

73. a. Excitement of the si/s(ems and organs of
vegetative life gives rise to various changes and
phenomena, according to the nature of the im-
pression, and its intensity. — Gentle excitation
of the digestive canal increases the tone or in-
sensible contractility not only of it, but also of
all the circulating system, of the hollow viscera,
and of fibrous or muscular parts. If the stimulus
be considerably greater, either the same effect
is produced, or the excitement is concentrated in
the digestive viscera, and proportionately with-
drawn from other parts. If the excitement be
still greater, and be of a kind that irritates the
villous surface, the secretions of this surface are
augmented, and the muscular coats of the canal
roused to more or less energetic action, followed
by the excretion of their contents.

74. Excitement of the vascnlar system is ge-
nerally a conse(iueuce of stimuli applied to the
fligestivesurface, of irritation of any kind affecting
the tissues, of local inflammation, of stimulating
substances conveyed into the current of the cir-
culation, of muscular exertion, and of the lively
mental emotions, directly increasing the heart's
action. 'J"he grade, duration, and effects of ex-
citement originating in this system, vary with the
cause and the state of the body at the time. Its
gentlest, and, at the same time, most permanent,
form is caused by the action of a pure, dry, and
temperate atmosphere on the blood circulating in
the lungs ; whilst the most tumultuous and the
most Injurious, as respects its cflccls on the heart

and blood-vessels, on the blood itself, and on the
functions of vital organs, is that produced by in-
ordinate or continued muscular exertion ; and by
the absorption of various stimulating and irri-
tating substances into the blood. Violent exer-
cise affects the crasis of the circulating fluid
(see Blood, § 134.), causes its irruption through
tiie capillary canals of soft and yielding tissues,
as the mucous surfaces and the parenchyma of
the viscera, induces inflammation of the heart and
arteries, and excites similar disease in predisposed
organs. Irritating or exciting substances con-
veyed into the blood, inflame the internal surface
of the heart and arteries, alter the condition of
this fluid, occasion various acute and chronic dis-
eases of the vessels (see arts. Arteries, Heart,
and Veins), and often severely affect the functions
of secreting and excreting viscera, inordinately
exciting or inflaming those depurative organs
which carry them out of the system.

75. The portal circulation, and the liver, lo
which it is distributed, may be especially ex-
cited, owing to the quantity of stimulating,
morbid, effete, or foreign matters carried into,
or generated in, the blood which is returned from
the digestive canal and other abdominal viscera.
These may not only inflame the portal vessels,
but also the substance of the liver; or, when the
materials and elements of these vessels are of a
less irritating kind, may give rise to morbidly in-
creased secretion of bile, or to various organic
changes and adventitious formations in this viscus.

76. The absorbent system is seldom or never
co-existently excited with the arterial system'
Indeed, inordinately increased vascular action is
generally attended by a proportionate inactivity
of the absorbents — both lymphatic and lacteal.
Whilst it is frequently observable that a weak
action of the arterial is accompanied with great
activity of the absorbent system. It would seem
as if (liminished organic action, or that state re-
sulting from an insufficient exertion of the organic
nervous influence on the arterial and capillaiy
systems — the chief source of nutrition, struc-
tural cohesion, and other vital manifestations —
leaves, in consequence of the animal molecules
being then held together by a weaker attraction
than in an opposite state of this influence, a greater
proportion of efl'ete materials, by which the absorb-
ent vessels are excited to increased action.

77. Excitement of involuntary muscular
parts is characterised by spasmodic contraction
of either a permanent or alternating clonic
kind — or rather of the various intermediate
states between sthenic and asthenic, as marking
the extremes — and is generally occasioned by
irritants of the surface covering the hollow mus-
cles, and more rarely by direct excitation of the
nerves supplying them, and by morbid states of
the blood, affecting either them or the nerves
supplying them. Tlic asthenic or clonic form of
spasm is most commonly associated with exhausted
vital power, or an impure state of the circulat-
ing and secreted fluids, the excitability of these
striictures being more easily acted upon in weak
than in robust frames ; and hence, when in action,
is more rarely conjoined with excitation than
with debility of other organs. It would seem
that, in most spasmodic disorders, the excitation
necessary to this state of action consists in the
concentration of an undue proportion of vital

DISEASE— General Doctrine of — Pathogeny.

575

power in the nerves supplying the affected muscles,
and in the muscles themselves, and a proportion-
ate abstraction of it from other parts ; and that
when the excitability of an unaffected structure or
viscus is energetically roused, the pre-existing
morbid excitement will be derived from, or subside
in, tlie parts in whicli it was seated.

78. The excitement of secreting viscera and
glands presents various modifications and grades,
according to the cause which induced it, and the
elementary system especially affected. If the
organic nerves supplying them be chiefly excited,
the special functions tliey perform will be aug-
mented— their secretions will be abundant. In
this case the excitement will be more particularly
limited to the organs whose excitability has been
acted upon ; the morbid condition consisting
chiefly of a concentration of vital manifestation or
action in them and derivation of it from other
viscera, thus occasioning one of the forms of
Dkbility specified in that article (§8, 9.), the
increased secretion generally preventing the oc-
currence of febrile commotion or acute sympa-
thetic disorder, unless it be carried very far. But
when the excitement is seated principally in the
blood-vessels, and assumes the form of inflamma-
tion, the specific function of the secreting surface
or organ will be variously altered ; tlie fluid
elaborated, in this case, by a secreting surface,
being either increased or quite changed from the
natural state, or both, according to the degree and
form of the excited vascular action vvith which
it is affected ; and that secreted by glandular
structures being also either much altered, dimi-
nished, or entirely suppressed, as in cases of in-
flammation of the kidneys, salivary glands, &c. ;
this form of excitement not giving rise to the state
of vital concentration observed in respect of the
former, but frequently to general or sympathetic
febrile commotion. Excitement of secreting vis-
cera, then, assumes two forms, viz. that affecting
chiefly the organic nerves — -the excitement of
irritation, which is always attended by augmented
secretion, and increased determination of the cir-
culation to the part thus aflected, but not neces-
sarily by true inflammation, although this may
follow ; and that affecting the arteries and capil-
laries— the excitement of infammation, which is
accompanied with altered secretion, always in kind
and frequently in quantity, — the quantity being
often increased in mucous surfaces, and remark-
ably diminished from glandular organs.

79. The excitement of the generative organs
may proceed from the accumulation and irri-
tation of their proper secretions, from mental
emotions, and from the excitation of adjoining
and related parts, as when the rectum or urinary
bladder is stimulated. It is, more especially at
its commencement, a purely nervous change ;
the nerves of organic life which chiefly supply
these organs being excited, either through the
medium of the brain and sensorium, or in a
direct manner, and as above stated. There is no
part of the economy which furnishes so evident
a proof as this does of the influence of the organic
nerves upon the local or general circulation ;
their excitation being here shown to be followed,
unless the susceptibility and excitability be en-
tirely exhausted, by increased determination, vas-
cular action, and vital expansion of the tissues ;
irritation of this class of nerves evidently deter-

mining also in other parts of the body, particularly
in mucous glandular and cellular structures, as
well as in these organs, increased flux of blood,
and occasioning the turgidity or vital expansion
of the vascular canals running between the ex-
tremities of the arteries and the radicles of the
veins. The influence of sexual excitement upon
all the other functions, especially at the period
of puberty, and subsequently ; its sympathetic
action on the rest of the nervous system giving
rise to various disorders, particularly to the
numerous forms of hysteria, anomalous convul-
sions, epilepsy, catalepsy, &c. ; and its more
direct operation in producing menorrhagia, fluor
albus, inflammatory and organic changes of the
ovaria and uterus, besides other disorders in both
sexes, more especially referrible to premature,
too frequently repeated, or too excessive stimula-
tion, and consequent exhaustion of the excitability
of those organs; are circumstances familiar to the
practitioner.

80. S. Excitement of the organs of animal life
may arise from intrinsic or organic changes, as
from the condition of the organic nerves and ves-
sels distributed to them, or of the blood itself; or
from causes affecting the instruments of sensation,
the general sensibility of the frame, or any of
the mental manifestations ; or from those which
excite to mental or physical exertion. Intrinsic
changes may occur in the organic nerves and
vessels, influencing the circulation through the
brain, without any very obvious cause ; and these
may be such as will excite not only this part, but
all others depending upon it for their functions.
It is more than probable, that with the brain, as
with other viscera, the excitation may be seated
chiefly in the organic nerves distributed to it, and
hence assume more of an irritative state, or of an
exaltation of function, without any particular
lesion, as when it is simply excited by vinous or
spirituous liquors: or the excitement may extend
to, and principally aflect the blood-vessels ; giving
rise, according to its degree, to certain states of
inflammatory action, and to general febrile com-
motion, with more or less lesion of function. It
is almost unnecessary to observe that either of
those forms of excitement, -related as now ex-
plained, or both of them coetaneously, may ori-
ginate in the exercise of those faculties, of which
this organ is the instrument under the endowment
of life. It often falls to the physician to trace
the progress of excitement in relation to the brain,
from the lively exercise of function characterising
talent and genius, into exaltations, approaching
to morbid, of one or more of the mental manifest-
ations ; and next, into inflammatory action or
mania ; and lastly, into a state indicating mental
collapse, or structural change. The influence,
particularly in susceptible persons, of lively or of
violent impressions upon the instruments of sens-
ation, in exciting the nervous centres, with which
these instruments are in constant communication,
is shown, not only by the effects of loud noises,
and of a strong light, but also by violent or painful
stimulation of any portion of the sentient system
distributed throughout the frame. The sympa-
thetic operation of external injuries, of extensive
burns or scalds, of long-sustained or suppressed
pain and sufferings, in exciting an irritative state
of the cerebro-spinal axis and its membranes, in
increasing their vascularity, and even in giving

176

DISEASE — General Doctrine of — Pathogeny.

rise to effusion, with the related phenomena of
delirium, tremefaciens, mania, general febrile
action, or convulsions, is not the less true or im-
portant, from its being overlooked, and the exact
seat and nature of the consecutive suffering, as
well as the more immediate cause of death, being
misunderstood.

81. Excitement- of the voluntary muscles and
locomotive organs takes place either from voli-
tion, or from causes acting in opposition to it.
Exercise promotes the synovial secretions, and
the developement of the muscular structures and
of their energies. But long-continued exertion
increases the flux of blood to the related parts of
the cerebro-spinal axis, and to the muscles them-
selves. The morbid excitement, however, of vo-
luntary muscles, which removes them out of the
control of the will, has never been satisfactorily
explained. Their more asthenic, or clonic anormal
actions, wliich have been usually denominated
convulsions, have been frequently traced to obvious
lesion in the brain ; but they have likewise been
as truly referred to causes seated in the prima via,
irritating the organic nerves, and, through them,
the voluntary nerves. The almost universal state
of sthenic spasm, called tetanus, has been ascribed
to inflammatory excitement of the arachnoid and
other membranes of the spinal chord, from the
circumstance of its having been detected in several
cases, and by myself in two instances. But this
change is as probably a consequence of the mus-
cular excitation, as the cause of it. How, then,
does this state of muscular action originate ? The
answer is not easy. But when we consider the
connection — anatomically and physiologically —
subsisting between the muscular, the voluntary
nervous, and the organic nervous, systems, the
reasons wherefore irritants acting on either of the
latter will affect the former, or those affecting
the muscles themselves, or even their tendons,
will, in certain circumstances, through the me-
dium of the nervous systems, excite general mus-
cular contractions of a permanent or recurring
kind, will not appear so far beyond our compre-
hension. If we connect the causes of these af-
fections with the earlier phenomena, we shall
generally find, even when the exciting agent has
acted on an external part, that the organic or
sympathetic nerves have been thereby irritated ;
and that, owing to tiieir influence on the volun-
tary nerves, a state of spastic action is kept up
in the voluntary muscles, or recurs in them at
intervals, the brain itself being affected only in
those cases which present lesions of its func-
tions. This opinion, published by me in 1821,
subsequent experience — pathological and the-
rapeutical— has confirmed, particularly in respect
of those cases in which the brain is free from
disease. (See arts. Convulsions, Tetanus.)
It follows, therefore, as corollaries from the
foregoing, that whatever irritates the voluntary
nervous system, or makes an extraordinary demand
upon its influence, or any of its functions, will
excite it, in that part e-pecially upon which the
particular influence or function called into oper-
ation depends, or with which the part principally
acted on is in communication ; and will determine
to it an increased floiv of blood, which may, in
certain circumstances, go on to inflammation or
structural change ; and that irritation propagated
to the voluntary nerves will so express itself

upon the muscles they supply as to give rise
to various states of spastic action, according as
it originates in the sympathetic nerves, or in
the brain, or is connected with other changes,
functional or structural. Thus, mental exertion
excites and determines the circulation to the head ;
muscular exertion to the spinal chord ; and local
irritation occasionally gives rise, through the
medium of the organic and voluntary nervous
systems, to spasmodic action of the muscles of
volition, of either a remittent, intermittent, or
continued form.

82. (b) Secondary or indirect excitement, or re-
action, is that state of increased function or func-
tions following the impression of causes of a de-
pressing or sedative kind : as when the powers
of life, having been for an indefinite time more
or less lowered by cold, by terrestrial emanations,
or by the effluvium from the sick, react upon the
state of depression, and give rise to various
phenomena characterised by excitement, which
thus becomes one of the terminations of direct
Debility (see that article). Great diversity of
opinion has existed as to the way in which the
economy reacts upon injurious and depressing
agents. The vis medicatri.i naturx, vital resist-
ance, the conservative powers of life, with other
terms, have been substituted as explanations of
what admits not of explanation, either by names,
however expressive they may be, or by any other
means. We can merely express what appears
to be a law of nature, and describe certain re-
sulting phenomena. We believe that the organ-
isation is built up and kept together by the aid
and intimate alliance of life, and that this prin-
ciple or endowment may be modified by changes
in the structures, the instruments of its functions,

— that, in short, so intimate is the union of life
with all the organs and tissues, that it is con-
stantly influencing them, according to its varying
states, and being itself influenced by them, as
they become changed, both in respect of its local
alliances and its general condition. And all
that we can know respecting vital resistance and
reaction must resolve itself into the general in-
ferences, viz. 1st, That the innate powers of the
vital principle, and the intimacy of its union with
its material instruments, are such that it opposes,
by means of these alliances — by its manifest-
ations throughout the organisation, and by their
mutual dependence and reciprocative influence

— and by the manner in which it is influenced
or modified by changes in its allied organs, — im-
pressions of an injurious nature, the intensity of
which is not so great as immediately to dissolve
its connection with the structures, or at once to
overwhelm its energies ; and that, whilst it there-
by resists the further progress of change, it at the
same time restores that which has been induced ;
these phenomena constituting what has been
called vital resistance : 2d, That when the morbid
impression is energetic, a succession of changes
generally follow in some part of the economy,
owing to the circumstances now adduced, calcu-
lated to remove the primary impression, and its
more immediate effects, to recover the last ba-
lance of vital action, and to restore the impeded
or interrupted functions, — to these changes the
terms reaction and secondary excitement have been
applied ; which, however, may be variously mo-
dified, in form as well as in degree and duration :

DISEASE — General Doctrine of — Pathogeny.

577

3d, That when the impressioti and its immediate
effects are very intense, relatively to the state of
the person's constitution, tlie vital endowment
may be thereby rendered incapable of resistance,
or of developing any reaction ; and, when this is
the case, it sinks more or less rapidly, before tlie
cause that effected it ; sometimes, however, mak-
ing certain feeble and abortive eflbrts at restor-
ation, until, between its depressed state and the
cousenuent changes on the tissues, its further
manifestations and material alliance altogetlier
cease.

83. If we endeavour to trace the succession
of morbid phenomena characterising the simpler
states of reaction, viz. those whicli take place
from cold or from marsh miasmata, some idea
of the way in which they are brought about may
be formed. The impression made by cold upon
the nervous, and, through it, upon the vascular
systems, is evidently depressing, and vital action
is diminished in the parts to wliich it is applied.
V'ascular determination, consequently, takes place
to other, more especially to internal, parts; which
are thereby excited, and their vessels enabled to
react upon the greater quantity of blood sent to
them. The consequence of this, in secreting
organs and surfaces whose vital energy is not im-
paired, is an increase of their proper functions, as
an augmented flow of urine, or free discharges
from the bowels ; but, during a state of predis-
position to vascular lesion in any of the parts
experiencing the increased determination, inflam-
matory action will be the result; and disorder
will be extended thence to the whole frame,
through the medium of the organic nervous and
vascular systems, with especial affection of the in-
ternal organ primarily disordered. In other cases,
a less simple process may take place ; and the im-
pression of cold not only may impede the exhaling
and secreting functions of the surface or or^an
on which it directly acted, but, through the me-
dium of the organic nervous system, may also
interrupt the action of other secreting organs;
and thus give rise to increased plethora, attended
by the retention of elements in the circulation,
which the healthy performance of the functions
would have eliminated from it. The necessary
consequences of these states will be reaction
upon the distending and exciting contents of the
vascular system ; during the continuance of which,
those organs which are most predisposed to dis-
ease, particularly to inflammation, will suffer
especially. AVhen miasmata act upon the sys-
tem, it may be inferred, from the more immediate
effects, that the nervous system of organic life is
thereby especially impressed, and its influence
diminished ; the vital actions more immediately
depending upon it impaired, and the secreting
and excreting functions impeded. As those
changes are often gradually induced, a consider-
able period of latent or of slight ailment may
exist ; until at last they reach their acme, and
the organic nervous energy is unequal to the
active continuance of the circulation. AVhen
this point is reached, animal heat is imperfectly
evolved ; and the usual changes on the blood,
as well as the proper functions of the viscera, are
insufficiently performed. The necessary results
are congestions of the large veins and yieldin

rarely proceeds so f;xr as to overwhelm th(\ power
of vital resistance, but more commonly ends in the
developement of reaction. This is brought about
by the greater fulness of the vascular system, and
the more exciting properties of the blood, arising
out of impeded secretion and cicretion, and re-
tention of exciting elements 'in the circulation,
assisted by the influence of the rigors attending
the cold stage in accelerating the circulation
through the veins.

84. From what has been already advanced, it
will appear evident that the nature of the primury
action, or impression made upon the system by
the depressing cause, will not only determine the
character of the more immediate phenomena,
but will also modify the stale of reaction into
which these may pass ; and even the kind or type
of action will not terminate with the develope-
ment of this form of excitement, but will gene-
rally continue long afterwards. This is remark-
ably exemplified by the morbid impression made
by malaria, which will apparently act in the
manner now stated, until the hot stage of the dis-
ease, or that of reaction, is produced by it ; and,
although this subsides, and is followed by free se-
cretion, still the morbid impression is not thereby
removed, or its type changed, but continues, in
the organic nervous system, to exert its influence
upon all the vital actions, and to reproduce the
same series of morbid changes, until either it is ex-
hausted by their recurrence, or some internal
organ undergoes structural change, and the dis-
ease thereby becomes complicated, or in some
respects modified. Such is the case especially
when it is left to nature. That the morbid im-
pression is made chiefly on the nervous system, is
shown by the periodicity of action, by the cir-
cumstance of the successive changes and free
evacuations terminating the paroxysm not bring-
ing the disease to a close, and by the most effi-
cacious means of cure being those which most
energetically excite that system. That the im-
pression is made upon the organic nervous, and
not upon the cerebro-spinal, system, is shown by
the more especial afiection of those functions and
organs which the former actuates, and the general
absence of any considerable lesion, even of the
functions of the latter.

85. C. The intensitxj and duration nf excitement,
whether primury nr secondary, vary remarkably,
according to the cause, the constitution and habit
of the patient, the circumstances in which he is
placed, tlie agents or influences which continue
still to act, and the states of the individual viscera,
and of the circulating and secreted fluids. As re-
spects intensity of excitement, it may be inferred
that, where susceptibility and excitability are both
great, intensity of excitement will also be great,
but only relatively to the state of vital power ; and
that it will so much the sooner, and the more
completely, exhaust itself. But, where neither is
considerable, action will be moderate, and reac-
tion will more slowly and less perfectly supervene,
AVhere, however, tlie excitability is great, and the
susceptibility not remarkably so, as in many ro-
bust states of health, excitement may not be so
quickly or so readily induced, but it will be more
energetic and of longer duration. Thus we per-
ceive that, in delicate, irritable, or nervous con-

structures, and all the phenomena of the cold stitutions, excitement is easily produced, and soon
stage of intermittent or remittent fever ; which | arrives at its termination ; whilst the reverse ob-

^ oL. I. r n

578

DISEASE — Gexeral Doctrine of — Pathogeny,

tains in the robust. In the phlegmatic, lymphatic,
and cachectic constitution, it is excited less per-
fectly and with greater difficulty, and often as-
sumes a modified form, particularly as respects
its terminations. When excitement arises directly
from a cause that is constantly present, as when
an irritating body is lodged in the intestines, or
in any of the tissues, it generally is continued,
sometimes remittent, and of long duration ; but
when it occurs indirectly, or from a depressing
cause, it may be either imperfect, or of short
duration, the consequent exhaustion being great.
This is evinced by diseases arising from malaria ;
reaction being less perfect, and vital depression
with its effects more remarkable, when the cause
continues to operate, owing to the residence of
the patient in the locality wliich generates it. Ex-
citement is, moreover, modified by states of the
air — humidity lowering it, and a dry, pure
air developing it — by mental emotions, by the
condition of the circulating fluid as respects
purity, and by previous health and habits. How
these will influence the occurrence and course
either of primary excitement or of reaction, is
evident. The state of the vascular system as to
fulness has also a great influence upon both :
pleUiora favours local excitement and determin-
ation ; whilst, when very great, it prevents the
free developement of reaction, and disposes to
dangerous internal congestions in circumstances
that would have otherwise induced a free and
salutary reaction. The condition of the secretions,
also, has a marked influence in the production
and duration of increased vital action. The
accumulation cf morbid secretions in the prima
via or in the biliary apparatus may either im-
pede the occurrence, or shorten the duration, of
excitement ; or may determine it more especially
to these parts. The state of the circulating fluid
itself, particularly in respect of purity, will mainly
influence this manifestation of vital power. If it
contain stimulating elements in excess, reaction
will be rapidly and strongly developed. But if
materials of an opposite kind be carried into or
developed in it, neither primary nor secondary
excitement may at all appear ; the conditions
of life throughout the structures being thereby
depressed and modified, and the living solids ulti-
mately rendered unfit for the performance of their
functions.

86. I). The consequences and terminations of
excitement, primary or secondary. — (a) The con-
sequences of excitement are — 1st, Various morbid
productions or plastic formations, capable of or-
ganisation in certain situations, particularly when
the vascular system has been affected in a sub-
acute form ; as the formation of coagulable lymph,
and album.inous exudations in the form of false
membranes, &:c. ; — 2d, The exudation of sangui-
neous, or sero-sanguineous, or muco-albuminous
fluids ; as in cases of acute irritation of mucous
surfaces ; — 3d, The production of various changes
in the structures (see Inflammation), and ad-
ventitious formations.' — {!>) The ter7ninations of
excitement are varied according to the system or
tissue principally affected, the nature of the cause,
and the concurrent circtmistances. It has been
stated as a general axiom, that excitement ter-
minates in eiiiausfiim, the degree of which is pro-
portionate to the height to which the former had
been carried. I'ut there ai'e numerous exceptions

to this, especialy as respects reaction ; which
may be very slight, and yet the exhaustion may
be extreme. The nature of the chief cause,
numerous influences connected with the consti-
tution of the patient, the surrounding media, and
the mental affections, will modify the results. —
a. Excitement, in any of its forms, may gra-
dually subside into a slight and chronic grade, in
which it may give rise to certain changes in the
nutrition or secretions of the tissues affected ; to
morbid depositions, and effusions in shut cavities
or the parenchyma of organs ; or to increased
secretions from mucous and glandular parts. —
0. It may also pass more rapidly into exhaustion,
expressed more especially either in one of the
nervous systems, or in the capillary and vascular
system, or in the absorbent system, according as
one or other of these had been principally dis-
eased. (As to the efl^ects of exhaustion on the
different functions, organs, and structures, see the
article on Debility, § 10 — 25.)

87. 2d. Of perveuted States of A'^ital
Power. — Having considered the simpler changes
of the conditions of life, as manifested in the func-
tions and characterising disease, those which are
more complicated are next to be discussed ; and
it remains to be shown, that the conditions and ma-
terial alliances of life may not only be changed iti
degree, but also in kind — the change in kind
being, in some cases, unconnected with either
excess or defect of action ; and, in others, asso-
ciated with the one or the other ; but more fre-
quently with depression, or an irregular distribu-
tion of the vital energies, and concentration of
them towards particular parts. The conditions of
life present three states or stages of change in kind,
without any reference to degrees of action : —
1st, Modifications in function, or vital manifest-
ation, the proper offices of the part being vitiated,
but the structure not being sensibly changed.
2d, JNlodifications of function, in connection with
change in the constitution of the part; the natu-
ral tissues having been metamorphosed by an
alteration of their nutrition or secretions, and by
adventitious formations. 3d, Modifications in
function and organisation in several parts, or in
the whole of the frame ; generally attended by a
vitiation of the circulating fluids.

88. A. The conditions of life may he modified
in kind, without any visible alteration of structure.
This state is often the commencement of the
others now particularised ; but it also frequently
proceeds no further, or one form of it may merely
pass into another, or terminate in health. Its
slighter grades are more especially seated in the
moving powers ; the organic and cerebro-spinal
nervous influences, and the vital properties of con-
tractile parts, being chiefly affected ; presenting
accordingly, a great variety of morbid phenomena,
not strictly referrible to either excitement oi- de-
bility, but consisting chiefly of alterations of the
sensibility of tliese systems; of pain and anxiety
in their numerous forms; of cerebral affections,
and disordered mental manifestations ; of lesions
of the contractile and locomotive organs ; of modi-
fications of the sensible and insensible contractility
of parts, of their susceptibility and excitability ;
and of many changes in the state of the secre-
tions and excretions, independently of those that
relate to quantity. In its more exquisite and
widely diffused forms, this state proceeds from

DISEASE — Gekeral Docthine of — Pathogeny.

57^

several of those causes which I have termed
specific ; as malaria, animal and infectious ef-
fluvia, endemic and epidemic influences, tiie
rabid virus, various poisons received into the
stomach, lungs, or circulation, &c. These, as
well as the causes which produce tiie foregoing
morbid conditions, evidently modify the nature of
the vital functions, without any change of struc-
ture or of the circulating fluids to account for the
efl'ect ; and, when organic lesions do occur, they are
consecutive, and sometimes accidental, alterations,
which, in their turn, occasion a further change in
tiie life of the part, or of the system generally.

89, B. The manifestations, us well as the struc-
tural alliances, of life may he vitiated in a part of
tiie body, from causes which determine to it a
greater share of vital power ; or which act fre-
quently or permanently upon its excitability, and
occasion an irregular distribution of life through-
out the economy ; or which abstract from it any
portion of its nervous or vital-influence ; or mo-
dify the condition of this influence by their primary
impression or continued action, particularly in
constitutions predisposed to some hereditary vice,
or imperfectly organised, or debilitated. A similar
result may also follow unwholesome or innutri-
tious food ; tlie too frequent or excessive discharge
of recrementitious fluids, as the seminal and pro-
static ; the absorption of an imperfectly prepared
chyle, or of morbid secretions ; or products gene-
rated in the body ; repeated excitation of an organ,
or continued irritation of a particular part, ending
in change of stiucture, &c. When tiie vital actions
of a part are depressed, or modified in any man-
ner, or from whatever cause, and the change
continues, owing to the vital endowment beino-
insuflficient to overcome it by local or general
reaction, and thereby to restore the healthy
condition — the powers of vital resistance and
restoration being incapable of removing the
morbid impression, — a succession of alterations
may supervene : the depressed or otherwise mo-
dified life of the part will impede or diminish its
circulation, or occasion its congestion ; thereby
facilitating changes in its fluids, or giving rise to
alterations of its secreting and nutritive processes ;
and, ultimately, to various organic lesions of a
chronic or malignant kind. Also, when the
organic nerves and vessels of a part experience a
continued or often repeated excitation of too
slight a grade to extend far, or to affect related
and sympathising organs, but sufficient to modify
either its secreting or its nutritive actions, or both,
its elementary tissues at last become more and
more altered, adventitious formations are deve-
loped, and the continued change in the conditions
of life in the part at last gives rise to a complete
metamorphosis of structure. The life of the dis-
eased part, having thus formed to itself new
alliances and instruments of altered manifest-
ations, is thereby, in its turn, fuither acted upon,
xintil the vital endowment is modified throughout
the body ; the local alteration of structure expe-
riencing, from this circumstance, a remarkable
increase : and hence the properties of life, and of
its structural alliances, act and react upon each
other, until they become very sensibly vitiated,
first, in the part primarily diseased, and ultimately
in the whole frame. Such appear to be the origin
and progress of various changes of structures
of a local, specific, and adventitious kind — tu-

bercular, scrofulous, scirrhous, fungous, carcino-
matous, &c.

90. C. The functions of life and the organisation
arc often vitiated, independently nf grades of aciion,
either in several parts, or in the whole frame. —
Alterations of this nature are frequently the most
advanced stales of the foregoing ; commencing,
as I have now stated, in modified vital manifest-
ation of a part, or of the whole body ; and irre-
gular determinations of it, which superinduce
alterations of secretion and nutrition, give rise to
changes of the elementary tissues,, and the form-
ation of others which are adventitious, and ter-
minate in the slate now imder consideration, with
sensible ;dterations in the circulating and secreted
fluids. But this general morbid condition may
also occur more rapidly from causes producing a
very powerful and quickly diffused impression on
the organic nervous system, and affecting the
circulating fluids; as several of the poisons, espe-
cially the animal poisons, infectious maladies of a
pestilential or malignant kind, epidemic diseases,
exanthematous fevers, &c. In all these, the
grades of vital depression, or of excitement, —
although most important circumstances, and each
of them forming grand pathological conditions,
when diverging considerably towards either ex-
treme,— are mucli less distinctive features of the
nature of the malady — are not so pathognomonic—
as differences of kind, which form the only true
specific conditions by which we are enabled to
distinguish one species from another ; as typhus
fever from plague, yellow fever from small-pox,
scarlet fever from measles, &c. In these, as well
as in several other maladies, grades of action
merely, or the depression or the excitement of
particular functions, or the irregular distribution
of vital power throughout the frame, are far less
attributes of their nature, than are perversions of
their properties. The conditions of life in these
are altered more especially in kind, than in degree ;
this alteration in kind constituting the true morbid
state. Hence one principal reason wherefore a
lowering treatment is much less eflicacious in
changing the morbid aciion, than remedies which
elevate the vital manift stations, and enable them
to oppose progressive deteriorations in their con-
ditions, and in the constitution of their allied
structures. The delirium, and the morbid and
apparently high vascular action, in many of such
diseases, are often no reason wherefore remedies
which excite the vital energies, and change their
morbid actions, should not be employed. Every
practitioner who has ventured beyond mere rou-
tine, or the track pointed out by the numerous
authors who have written to obtain that expe-
rience of which their writings should have been
the results, must have observed the beneficial
operation of ammonia, camphor, cinchona, qui-
nine, &c. in many cases of the above maladies ;
and even in states of action where it became a
question whether or not an opposite practice
should be employed.

91. D. Of vitiation of the conditions of life, and
oj their allied Jiuids and structures, conjoined with
depremon or excitement. — (a) The association of
depression with vitiation of the conditions of life,
and with change of the fluids and solids, obtains in
the last stages of the maladies already instanced,
particularly in those called mahgnant ; whether
originating locally or con>titutionally and ad-
P p2

580

DISEASE — Altehations of

vancing slowly to the condition now being con-
sidered, as carcinomatous and their allied diseases ;
or taking place in a more rapid and violent form,
as malignant or adynamic fevers, tiie effects of
animal poisons, &c. It would seem that all de-
teriorations of the conditions of life are either
consequences of, or otherwise related to, depression
of them. If we trace tiie progress of those ma-
ladies in which the change in kind is the most
conspicuous, we shall find that vital depression is a
characteristic of the impression of their exciting
causes, even although these causes may also irri-
tate tlie vascular system, or impart irritating pro-
perties to the circulating fluids ; for extreme
depression of the manifestations of life — of its
conservative and restorative properties especially
— is frequently conjoined with an apparently
high, and, as respects rapidity of action, extreme
vascular excitement. When great depression is
the attendant upon vital and structural deterio-
rations, the sensible properties of the circulating
fluid and of the tissues — the crasis of the one,
and the vital cohesion of the other — experience
rapidly progressive changes, until the bond of
union between life and structure is dissolved :
alterations of a very conspicuous kind taking
place in various parts of the body some time
before death. (See article Debilitv, § 11. 26.)
92. (h) The excitement which is sometimes
associated with an alteration of the conditions
and material alliances of life is essentially morbid,
antl is different from that which attends an other-
wise unchanged or non-deteriorated state of the
vital powers. Tin's morbid excitement is gene-
rally expressed in particular systems and organs ;
the vital actions of the rest of the frame being
proportionately lowered ; but, whether it affect
chielly the nervous or the vascular systems, or
take place primarily or consecutively, it soon ter-
minates in profound exhaustion, and in a more
or less complete vitiation of the conditions and
alliances of life. This is illustrated by the ad-
vanced states of adynamic and epidemic fevers,
by plague, &c. in an extreme degree ; and by
the worst forms of erysipelas and eruptive fevei's
in a less conspicuous manner. The excitement
thus associated with other vital and material al-
terations, may proceed directly from its efficient
cause, which may excite or irritate, whilst it
otherwise affects, the organic nervous and vas-
cular systems; or it may take place indirectly, or
consecutively on depression, and be more or less
a state of reaction, developed by clianges in the
circulating fluids, arising either from the absorption
of irritating materials, or the uninterrupted elimi-
nation of hurtful elements. But in either case a
j)rogressive deterioration is observed ; the morbid
conditions of life affect the secreting and excreting
lunction-;, and consecutively vitiate the circulat-
ing fluids, and even the living solids : and the
irritating or vitiated state of the former excites
the vascular system ; and thus alterations of the
one reciprocally increase those of the others,
either until the alliance of life with the structures
can no longer be preserved, or until, in con-
sequence of the exhaustion of the vascular action,
which had been excited by the changes in tlie
circulating fluid, and of tiie efl'ects of this fluid on
the secreting and excreting organs, the balance of
vital excitement is inclined in their favour, a new
action takes place, their functions arc resumed,

Exhalation and SEcnEtiox.

morbid matters are thereby eliminated from the
system, and health is ultimately restored; the
change being either ushered in by critical plieno-
mena, or promoted by remedies, the operations of
which are merely an artificial or substituted crisis.
(See art. Crisis.)

93. IV. Disease of the Fluids and Solids,

ORIGINATING IN ALTERED CONDITIONS OF LlFE,
AND GENERALLY IN THOSE ALREADY DISCUSSED.

— iMorbid exhalation, secretion, and nutrition
may be viewed as stages of the same organic
action ; exhalation passing into secretion, and
secretion into nutrition. Thus we perceive the
natural exhalations, during disease, assume the
characters of a secreted or elaborated fluid,
and certain morbid secretions become more or
less organised. I shall therefore notice — 1st,
The simpler changes of exhalation and secretion ;
2d, Simple iTiodifications of nutrition; 3d, Pre-
ternatural exhalation and secretion, comprising
the transformations and misplacements of these
fluids ; 4tii, Preternatural or metamorphosed nutri-
tion; 6th, Adventitious formations, or productions,
foreign to the economy — consisting of secretions

— (a) insusceptible, and (/>) susceptible, of or-
ganisation ; and, 6th, Of destruction of parts.

94. i. The sijii>ler Alterations of Ex-
halation AND Secretion. — I have considered
in distinct articles, on account of their great im-
portance, morbid states of the Blood, and Con-
gestions of this fluid. I shall here briefly notice
changes in the exhalations and secretions. — /i.The
exhalations into shut cavities, or in the areolae of the
cellular tissue, may be increased from the follow-
ing changes : — 1st, From deficient tone, refen ible
either to the exhaling vessels and pores, or to im-
perfect vital cohesion of the tissues, or to both :
2d, From deficient action of the absorbents, de-
pending on diininished vital power, or on ob-
structions in their course : 3d, From increased
determination of blood in the vessels distributed
to these parts; 4lh, From inflammatory action
terminating in, or being followed by, effusion : 5th,
From obstructed and retarded cn-culation of the
venous blood returning from these places, par-
ticularly in the liver, in the heart, lungs, &c. ;
the conse([uent nervous and capillary distension
favouring augmented exhalation : 6th, From
increased vascular or ratlier serous pletiiora, owino-
to the obstruction of some emunctory, — as ana-
sarca, from the sudden arrest of the cutaneous and
pulmonary exhalations ; and this, as well as other
forms of dropsy, from inflammatory or structural
disease of the kidneys: 7th, From the sudikii.
arrest of an accustomed discharge from the pul-
monary or digestive mucous surfaces, the morbid
exhalation being determined to the contiguous
serous surfaces ; and 8th, From two or more of
the foregoing states conjoined. (Sec art. Dropsy.)

95. B. Altentlions (if the secretions depend —
1st, upon the state of the organic nervous in-
fluence ; 2(lly, upon vascular action ; and, 3dly,
upon the condition of the blood itself — upon the
chief factors of ors^anic action and life; and they
are thus indications of the manifestations of
this principle. They may be — a. more or less
dimiiiislied, — as from causes whic'h lower the
organic nervous influence, or retard the cir-
culation ; 0. or more or less increased, chiefly from
agents which alter the distribution or determin-
ation of organic influence, and consequently of

DISEASE — Alterations of ExirALATiON and Skcretion,

581

the circulation and vascular action, either by ex-
citing- the secreting structures themselves, and
their intimately allied parts, or by depressing,
impeding, or obstructing the functions of distant
and especially of other secreting organs, and from
a superabundance in the blood of the elements of
which the increased secretion is formed ; y. or
more or less altered from the healthy state, inde-
pendently of diminution or increase of quantity,
— as when the conditions of life are modified
otherwise tlian in grade, and when tiie circulating
fluid is vitiated, either generally, or merely in
respect of the greater abundance of some one
element; J. or both diminished in quantity and
altered in quality, owing chiefly to lowered as
well as modified vital power, to changes in the
blood, and to morbid vascular action or inflam-
mation of the secreting organ ; £. or lastly, they
may be both increased and vitiated, either from
a morbid distribution, and alteration of vital in-
fluence and action owing to the impression of
causes on remote but related organs, or from irri-
tation or excitement of the nervous influence of
the secreting structure itself, by agents acting
either exteriorly to the vessels, or interiorly
through the medium of the blood. Thus, various
substances received into the digestive canal will
increase and alter the secretions of its mucous
surface ; and the accumulation of the elements of
bile in the blood, with other eftete matters, will
excite the liver, and give rise to an abundant as
well as acrid or otherwise morbid bile. Such
seem to be the chief pathological states on which
morbid secretions depend.

96. From what has been stated, it will be evi-
dent that, although alterations of the secretions
are often dependent upon vascular action in its
various states, from augmented determination to
inflammation and its results, and upon conditions
of the blood, organic nervous influence has also a
marked eflfect in generating them, and even in
originating the vascular disturbances to which
they have been most generally assigned by authors.
And although the secretions are constantly and
conspicuously disordered in fevers and inflam-
mations, yet they are also often remarkably
altered in other diseases ; and, in some, even con-
stitute the most prominent change from the
healthy state. In fevers and inflammations, the
secretions are more acutely aflected, but are
more disposed to a spontaneous and salutary
change, than in chronic disorders. In those ma-
ladies in which their alterations form the chief
pathological state, their natural conditions are
very slowly restored ; and, even when the restora-
tion is effected, their derangement is apt to
recur from the slightest causes. This is exem-
plified in diarrhcea, diabetes, and several other
chronic diseases.

97. (a) The recremeiitilious, as the salivary,
pancreatic, and gastric secretions ; or the partly
recrementitious and excrementitious, as the biliary
and intestinal secretions ; are more or less altered
in most diseases, and from a diversity of causes.
Agents, whose operations may be sufficient to
excite the organic nerves, but not to produce
inflammatory action ; or whose properties are
calculated to afTect the influence of these nerves,
rather than the action of the capillary vessels ;
may give rise to an increase or otiier change of
the secretions in -preference to inflammation.

Thus, aromatics and stimulants will excite the
flow of the gastric juices, but will not occasion-
inflammation unless taken in very large quan-
tities ; various substances will increase the in-
testinal secretions, but not inflame the vUlous
surface ; and mercury, in small or moderate
doses, will remarkably augment the salivary fluid,
but, in excessive doses, will inflame the glands
and diminish the secretion. The effects of sti-
mulants upon parts related or contiguous to those
to which they are applied, also show the influence
of the nerves on the secretions, — as the action of
certain odours and savours on the salivary and
gastric secretions, and of various purgatives on the
biliary fluid. Even mental emotions affect the
secretions through the medium of. the related or-
ganic nerves supplying secreting structures ; and
this eft'ect is not limited to the recrementitious
fluids, but is also extended to those which are en-
tirely excrementitious, as the urine, the sweat,
iS:c. The influence of mental anxiety in pro-
ducing both diuresis and enuresis, and of hysteria
in occasioning the former, is well known. Defi-
ciency of the recrementitious fluids causes
dyspeptic, hypochondriacal, and other diseases of
the digestive organs ; impedes or otherwise modifies
sanguifaction and nutrition ; and favours the pro-
duction of nervous aftections. JMorbid states of
the biliary secretion are amongst the most im-
portant in pathology. Impure air, want of
exercise, increased temperature, rich or full living,
stimulating liquors, &c., change both the quantity
and the quality of this fluid ; rendering it either
more copious, or of a deeper colour, and of a
more acrid quality, than in the healthy state.
Its more languid circulation through the ducts,
or its undue retention in the gall-bladder, owing
either to indolent habits, or to exhausted powers
of digestion and assimilation, favours the absorp-
tion of its more aqueous parts, increases its con-
sistence, disposes certain of its constituents to
crystallise or to concrete into calculi, and gives
rise to various chronic disorders of the liver and
of its related viscera. Obstructions to its passage
or discharge, and various other circumstances,
favouring its absorption on the one hand ; and
torpor of the liver, or suspended action of this
viscus preventing its secretion on the other, and
causing the accumulation of its constituents in the
circulation ; are important pathological conditions,
and constitute no mean part of several acute and
chronic maladies, besides those in which the biliary
fluid is more especially disordered. (See Concre-
tions— Biliarii; Jaundice, and Liver.)

98. (6) The secretions which are elaborated by
the intestinal mucous surface are often remarkably
changed, both in quantity and kind. Diarrhoea,
dysentery, and cholera, present extreme increase
and alteration, not merely of these, but frequently
also of those poured into the digestive canal
from the coUatitious viscera, originating in the
pathological states adduced above (§ 95.) ; and
illustrate the action of morbid secretions upon
the surfaces with which they may come in con-
tact. ^\'hen these secretions are produced in
large quantity and altered quality, whether from
a modified and excited condition of the vital
actions, or from both, or from these conjoined
with an impure state of the blood, the eflFects fol-
lowing their passage over the villous surface are
often very severe, and even disorganising. Thus
Pp3

582

DISEASE — Alterations of

an altered state of the salivary fluid inflames
and ulcerates the moulh, tongue, and gums ; and
the irruption of a large quantity of acrid bile
irritates the duodenum, excites severe vomitings
and purgings, sometimes with spasms of the vo-
luntary muscles owing to the irritation of the
visceral nerves acting upon the related spinal
nerves, and, in more chronic cases when morbid
secretion is prolonged, even excoriates the intes-
tinal surface. A similar efl^ect very probably is
occasioned by the intestinal fluids themselves, as
shown in diisentery. But the injurious opera-
tion of the fluids poured into the digestive canal
does not arise only from their morbid increase.
Diminished secretion, if it be attended by the
accumulation and retention of the fluid in the
secreting viscera, and of the mucus on the
villous surface, may prove equally detrimental,
but more insidiously and slowly. INIorbid in-
crease of these fluids is usually an acute, and
diminution of them a chronic, disorder. The
latter is generally accompanied with alterations
in their properties, especially if they are long re-
tained. When the retention and alteration take
place in respect of the mucus contained in either
the solitary or aggregated follicles, dangerous or
even fatal ulcerations, or other organic changes,
may be the results. Their accumulations on the
intestinal surface favour the production of worms,
indigestion, constipation, colic, &c. The manner
in which one secretion may be greatly increased,
whilst the rest are suppressed, is remarkably il-
lustrated in pestilential cholera. In this malady
it would seem as if the efficient cause suppressed
the vital manifestations of all other organs, de-
termined the remaining vital influence and cir-
culation to the digestive canal, and occasioned an
uncommon increase and alteration of its exha-
lations ; the serous portion of the blood being in
great part evacuated in this situation, leaving a
portion of its albumen lining the intestinal surface
in the form of a muco-albuminous and tenacious
exudation.

99. (c) The excrement itiovs secretions are also
altered by the pathological states already speci-
fied (§ 95.), The changes of these, as well as
of the foregoing fluids, are important agents in
continuing or aggravating disease, and furnish
some of the chief indications of its nature, pro-
gress, and terminations. — As the office of the
organs which secrete this class of fluids is to
expel those elements which are efl^ete, and would
be injurious to the frame if retained in the blood,
it must necessarily follow, that any interruption to
this function, andespecially a complete obstruction
or suppression of it, must be highly injurious,
'i'he dropsical effusions in various cavities follow-
ing interruption to the action of the kidneys, and
the more acute eftects of entire suppression of
their functions, fully illustrate this. As a large
quantity of ingested matters is carried into the
blood, either directly from the stomach, or along
with the chyle, and discharged from it by the
emunctorics, it is evident, not only that the kind
of ingcsta will afl^ect very remarkably the pro-
perties of the excretions, but that obstruction
or even interruption of any one of them will be
followed by serious eftects, unless some other
organ perform an additional office, vicarious of
that which is suppressed ; and even in this case,
diseaje will generally ultimately arise.

Exhalation and Secretion.

100. a. The menstrual evucuation, and even the
lochia, may be considered as excrementitious se-
cretions, interruption or morbid increase of them
being followed by similar consequences to those
arising out of suppressed perspiration. That
the menstrual discharge has essentially a depura-
tory eflfect upon the blood, is shown by the alter-
ations which it undergoes from morbid states of
the circulation ; thus, I have seen copious cata-
menia, the fluid being remarkably offensive, irri-
tating, and otherwise sensibly altered from the
natural state, form the crisis of erisipelas, and
fevers; and a copious, offensive, and excoriating
lochia evidently the means of preventing the
accession of those adynamic and malignant dis-
eases which often affect puerperal females, owing
to the respiration of the impure air generated by
several females confined in one lying-in apart-
ment. The catamenia, moreover, is diminished,
increased, vitiated, or changed into a serous or
mucous secretion — into fluor albus — by the same
agents and pathological conditions (§ 95.) as aflfect
the other excretions.

101. S- JMorbid states of the perspiration, in-
dependently of its increase or decrease, are not
infrequent attendants on both acute and chronic
maladies. They may even accompany appa-
rently sound health, particularly when the bowels
are habitually constipated ; this evacuation being
sometimes so offensive, or both copious and offen-
sive, as to render the person thus affected a
nuisance to those near him. In this case, the
skin evidentiy performs an office vicarious of the
diminution of the intestinal secretions. The per-
spiration is generally promoted by excited vital
action of the cutaneous surface ; in which case it
is fluid and warm. But it may also be much
augmented by a very opposite condition of vital
power, as by syncope, the skin being cold and
clammy ; or by the extreme vascular depression,
occasioned bj- excessive fear. In these cases, the
lost tone of the integuments, and of the ex-
creting pores, allows the escape of a portion of
the fluids contained in the superficial vessels.
This change also occurs in many instances of
extreme vital depression, and shortly before death
in many diseases. It is a pathognomonic symptom
of pestilential cholera, in which it is most re-
markable; the cold, wet, livid, and shrunk
surface, being the result not only of the suppressed
vital powers, but also of the circulation of venous
blood.

102. y. The urinary, of all the excretions, is
the least frequently suppressed ; the consequences
of such a state being, if not soon removed, the
most dangerous, or rapidly fatal. Whilst this
excretion is very much influenced by the quantity
and nature of the ingesta, and by the temperature
and humidity of the air, it is also variously altered
by disorders of digestion, sanguifaction, and cir-
culation ; but more particularly by the conditions
of the blood itself, by changes in the nervous in-
fluence, and by injuries to the spinal cord. On
the other hand, interruptions of the urinary dis-
charge afi'ect the quantity and quality of the
circulating fluid, disorder the nervous systems,
ultimately increase the exhalations and the other
secretions, and change the constitution of the
soft solids. The other j)athological rehitions of
diseased urine are fully explained in the articles
Diabetes and Urine.

DISEASE — PnETEnNATuRAL Exhalation and Secretion

103. ii. Simple Modifications of Nutrition
may affect the whole frame, or a particular tissue
or part, or merely a circumscribed portion of a
single structure. The entire absence of parts or
deviations in the distribution and arrangement of
the elementary molecules and tissues, producing
tiie various kinds of 77ionstrosities, will be left out
of consideration, they .being of less practical in-
terest. Those changes which are most important
may be resolved into tiie following : — 1st, Alter-
ations of bulk ; 2d, Modifications of density and
cohesion, either of which may lead to various com-
plicated lesions. Hiipertrophy , or augmented
nutrition, perhaps never affects all the tissues
simultaneously ; and although generally a disease,
sometimes of dangerous import, yet, wiien seated in
the muscles of voluntary motion, it cannot be con-
sidered in any respect as a morbid change. It may
be conjoined with softening or with uiduration.
with increase or diminution of density and vital
cohesion. Atrophy, or impeded nutrition, may
also be associated with similar lesions. Any one
of these four alterations, or either hypertrophy or
atrophy conjoined with softening or with indur-
ation, may commence in one, or at most two, of
the elementary tissues, and extend to those most
intimately connected with it. In these modifica-
tions of nutrition — producing variations in size
and density — it is understood that the ti.^sues
still retain their distinctive characters. (See
Atrophy, Hypertrophy, Induration, Soften-
ing, and Ulceration.)

104. iii. Of preternatural Exhalation and
Secretion. — A. Transformation of the Natural
Exhalations and Secretions. — (a) The exhalations
o{ serous surfaces, or shut cavities, may be altered
according to the state of organic action in the sur-
face producing them. — a. Exhausted vital action
and cohesion will be followed, according to its
grade, by the effusion of an aqueous, serous, or
sero-sanguineous fluid, the relaxed state of the
capillary pores and serous tissue allowing, instead
of asimple halitus, the escape of the watery parts
of the blood, sometimes with a portion of its albu-
minous constituents, and even of its red particles ;
and under certain circumstances, as of obstructed
return of blood from, and congestion of, adjoining
parts, and dycrasia of this fluid, — states not in-
frequently consequent upon exhausted vital powers

— the effusion of a portion of blood itself.
— S. When depression of vital power and dimin-
ished cohesion of the serous surface are associated
with increased action of the vascular system and
contamination of the circulating fluid, as in several
adynamic fevers, the exhalations are not merely
increased, they are also turbid and of various
shades of colour, from a dirty grey to a dark brown

— y. When organic action is morbidly increased
in serous surfaces, the exhalation is clianged into
a sero-albuminous matter, which is at first fluid or
semi-fluid, but which afterwards assumes modi-
fied states, according to the grade of constitutional
power and morbid action, and tiie particular cha-
racters such action presents, — whether that of

583

tain a turbid serum in the opener spaces. If the
inflammation be of a diffused kind, the effusion
will be more copious, and fluid, varying from a
turbid serum to a dirty deep-coloured, or floc-
culent, or sero-purulent, or albumino-purifonu
matter, without any adhesion of the opposite
inflamed surface ; and thus the morbid exhalation
will be altered in all acute cases, as tiie in-
flammation, owing to the degree of vital power,
has partaken more or less of the sthenic or asthenic
state. If the inflammation be of a chronic kind,
the eff'usion will often be more dense and cohe-
rent, or even become organised ; and, when the
albuminous exudations consequent upon acute
phlogosis have given rise to adhesions, or passed
into a ciironic state, tliey fre([uently become
transformed into cellular bands, with or without
a turbid or flocculent serum contained in the
unadherent spaces.

105. (h) 'I'he exhalations and secretions from
mucous surfaces are also remarkably changed by
the states of vital power, of structural cohesion,
and of organic action. — a. When vital energy,
and cohesion are much diminished (§ 91. 95.) the
watery exhalation from these surfaces may be in-
creased, and transformed to a serous, or sero-
sanguineous, or bloody discharge; particularly
in some malignant and cachectic maladies. If
the tone of the extreme vessels be lost, vital ac-
tion being at the same time depressed, the san-
guineous exhalation will be what has usually been
termed passive, and the crasis of the blood —
both that effused and that circulating in the body
— will be either lost or dt-ficient. But if vas-
cular action be increased, the capillary vessels
and pores being either expanded or relaxed, or
the cohesion of the mucous tissue greatly impaired,
the haemorrhage will assume more of the active
characters, and the coagulation of the efl'used
blood be more or less perfect. Between these
grades of action, however, — the terms active and
prtMue expressing the opposite extremes, — there
will be every intermediate degree ; much of the
appearances of the exhaled blood being those
of its condition, or depending upon its con-
dition previously to its discharge. (See H.e-
morkhage.)

106. /3. Not only may the purely exhaled
fluid be thus altered, but both it and the more

strictly secreted fluid, as the mucous, may be
disordered either consecutively or coetaneously.
This change is usually a consequence either of
local determination and irritation, or of inflamma-
tion of a slight or specific kind. In such cases
these fluids are thin, strous, ropy, glairy, albumin-
ous, muco-albuminous, or puriform, frequently
in succession, and secreted in large quantity.
'Ihus, when the respiratory mucous surface is
irritated by catarrh, its natural secretion, which
is scarcely evident in healthy becomes succes-
sively transformed into these states; and a similar
effect follows irritation of the digestive surface.
In acute and sub-acute inflammations of this
tissue, its exhalations and secretions are altered.

pure phlogosis or sthenic inflammation, or that of I either to a muco-puriform matter, streaked with

diffusive phlogosis or asthenic inflammation, or
of the intermediate forms. If the organic action
consist chiefly of the former, in an acute, or sub-
acute state, tiie effused matter will be more or less
albuminous, concrete, and spread over the in-
fiained surface in variable quantity, and will con-

blood, or to a puroalbuminous fluid, or to an
albuminous exudation, which concretes in the
form of a false membrane in the surface that pro-
duced it. These modifications of the morbid pro-
ductions are referrible to the degree in which
either the exhaling or proper vessels of the sur-
Pp 4

584

DISEASE ^PnETEPNATURAL Exhalation and Sechetion.

face, or tlie iraicous follicles, are respectively af- ipemliar principles, have been secreted in unna-

fected, and to the grade of vascular action.

107. (c) Tiie exhalation' usually poured into
the areola: of the cellular tissue may be similarly
transformed, and the various alterations may re-
spectively depend upon the states of vital power,
of vascular action, of structural cohesion, and of
the crasis of the blood, particularised above, — a
watery, serous, sero-sanguineous, a purely san-
guineous, sero-albuminous, or a puriform fluid
being poured out in this tissue, either where it
connects more external or superficial parts, or
forms the parenchyma of the viscera. In such
cases, the transformed exhalation is either diffused
or circumscribed, according to the state of action,
and the consequent nature of the transformation.
Thus, great depression or exhaustion of vital
power and cohesion is connected with the diffused
infiltration of a serous, or sero-sanguineous, or
even a bloody fluid, and, if this state be attended
by increased vascular action, with the infiltration
of a puriform, or sero-puriform, or even an ichor-
ous matter. But when vascular action is increased,
and partakes of the phlogistic or sthenic characters,
a puriform matter is formed, and is always circum-
scribed (see arts. AnscESS and Cei.lui.ah Tissue).
Tiic dift'used or imperfectly circumscribed depo-
sition of a puriform fluid, which sometimes occurs
in the cellular tissue, and the cavities of joints,
consecutively upon inflammation or suppuration
in the veins or in remote parts, during states of
vital depression, have been explained in tlie aiti-
clcs now referred to, particularly the former
(§29.).

108. B. Of the Exlialations and Secretions
uliich are adventitious to the situation, — or mis-
jdaced Sccretio)ts. — (a) Fatty matter has, in
rare instances been found in unnatural localities;
as in the blood, in the urinary bladder, and in the
intestinal canal, either in its cavity, or forming
small tumours in the connecting cellular tissue
of the parietes. — (h) A yellow mutter has fre-
rjuently been observed colouring the various
tissues and the secreted and excreted fluids, occa-
sioning jaundice; and, although generally
referred to the colouring matter of bile, has
only recently been proved by chemical analysis
to consist of that substance. This change is
often connected with biliary obstruction or dis-
order, but in many cases no such connection
exists, as far as can be ascertained during life
or after death. In such instances we must infer
— and the inference is borne out by tlie very
sudden manner in which the change takes place,
and by other circumstances — that other organs
and tissues than tlie liver may acquire the
power, under certain circumstances of forming
or separating the colouring, and probably other
principles of the bile from tlic blood. 1 have
been olten convinced by practical observation,
that more than one of the principles of the bile
have passed off with the perspiration, in persons
whose biliary organs were torpid, and in those
affected by chronic cutaneous ilisorders connected
with hepatic obstruction, even although the colour
of the skin remained unchanged. — (c) Choles-
terine, another principle of the bile, has also
been found in various secretions and structures;
and therefore it must likewise be infericd, that it
also may be sonietimcs separated from the blood
by the tissues. — (^d) 'i'he urine, and certain of its

tural situations. Facts of this description were
often related by the older writers ; and the more
precise researches of modem times have deter-
mined the circumstance, as respects the presence
of some of its principles in the supplementary
secretions, which were formerly considered a
metastasis of the urine: thus, uric acid has been
detected in the sweat, and in gouty concre-
tions, &c.

109. In respect of the causes of the misplace-
ment of the secretions, it may be concluded that,
as the elements of all the secretions exist in the
blood, they may be occasionally separated from
it by other organs or tissues, than by those which
are the usual instruments of such separation and
combination into the state of perfect secretions,
particularly when the organs thus appropriated
are diseased to the extent of impeding their func-
tions. In such instances, however, the accumu-
lation of the elements in the blood does not excite
other organs to the elaboration of a secretion
similar to the natural one ; but merely to the
elimination of the particular element or elements
that may be in excess, in a sepaiatc form or dif-
ferent state of union to that which it naturally
presents. Thus, when the urine is suppressed, it is
only urea, or uric acid, that is found in the sup-
plemental evacuations ; or when the bile is ob-
structed, it is not elaborated bile, but certain of its
principles, especially its colouring matter, that
tinges the secretions; and, in aggravated cases,
the structures, or when the milk is suppressed,
it is not milk that is found in oilier situations,
than in the breasts, but cascum, &c. In
the cases of obstruction of the urine and bile, the
respective organs being unable, either from pa-
lalysed nervous influence, or inflammation or
structural change, to perform their depuratory
functions, the aqueous and eft'ete elements which
consequently accumulate in the blood are either
separated by the tissues, or pass oft' through other
channels, but in different staler of combination,
the appropriated instruments of the function being
incapable of elaborating them into the natural
secretions. In cases, however, where this unna-
tural separation of elements occurs without evi-
dent interruption of the functions of the organ
destined to excrete them, we must necessarily
infer an exubciant formation of the elements in
question in the blood, and a consequent elimina-
tion of them through additional channels. It is
not uncommon to observe jaundice associated with
a natural or copious secretion of bile, and even
with a greatly augmented evacuation of this
fluid ; we must, therefore, conclude that the co-
louring elements are formed so abundantly in the
circulation, as not to be sufficiently excreted from
it even by the increased action of the liver; and,
consequently, that they are accumulated to the
extent of being separated by the difterent struc-
tures. It may further be conceded, that the
elements may be combined into more or less
perfect secretions in the organs destined to excrete
them ; but that, before they are discharged from
them, or excreted from the system, tlioy may be
occasionally taken into the blood, and separated
from it by other structures, and through difl'ercnt
ways.

110. iv. RIet/Njioiu'Iiosed on TnANsionjiED
JN'uriurioN — or that change which consists of the

DISEASE — METAMonniosED ou xnANSFonMED Nutrition.

585

transition of one tissue into another — is of a less
simple kind than that noticed above (§ 103.) — a..
]M. Andkal has shown that the same principle of
developement which obtains in the foetus, extends
also to the morbid transformations of the natural
tissues ; and that as the cellular is the matrix of
the other textures, so it may, from disease, be
changed into most of the other simple structures.
There are, iiowever, certain facts connected with
such alterations deserving notice:— 1st. Cellular
tissue, in being changed into some otlier, no further
affects the proper texture of the organ, whieh it
either invests or of which it forms the parenchyma,
than in causing its atrophy in some cases. — 2d.
Cellular tissue cannot be transformed into the
nervous, unless in situations where the latter pre-
viously existed : thus, nerves that are divided, and
of which a portion is removed, aye first connected
by cellular tissue, and subsequently by the ex-
tension of medullary substance from each divided
extremity. ^-3d. Other tissues, whose continuity
has been resolved, have the breach repaired, in
the first instance, by means of the production
of coagulable lymph, which passes into the state
of cellular tissue ; this latter being frequently af-
terwards transformed into a texture analogous to
that which was divided ; thus, divided muscles are
reunited by a fibrous tissue ; and so on, as respects
bone, cartilage, &c. — 4th. The nature of the trans-
formation of cellular tissue is sometimes regulated
by the functions of the part : thus, when sub-
jected to friction, it becomes a serous membrane ;
when exposed to external agents, it becomes
tegumentary, &c. — 5th. Other tissues, besides
the cellular, may be transformed, but the alter-
ations are similar to the natural changes they
experience in the processes of foetal growth ; car-
tilage being converted into bone, the mucous tis-
sue into the cutaneous ; or a reverse course may
be followed, in respect both of these textures and
of tlie muscular tissue, which can be changed
only to the fibrous. Hence the metamorphoses
of cartilaginous, osseous, fibrous, muscular,
cutaneous, and mucous structures are much more
restricted than those of the cellular. — Gth. All
tissues, when remarkably atrophied, present evi-
dence of degeneration towards their primitive or
rudimentary state, viz. to cellular tissue.

111. B. The causes of the mutation of one tissue
into another are not easily ascertained. Some
have ascribed it to inflammation or irritation.
l>y ascribing it to modified nutrition, we merely
express an obvious fact, the cause of which is
thereby not more nearly approached. It certainly
is not occasioned by inflammation, although se-
veral of th.e transformations may be accidental or
contingent consequences of that condition, espe-
cially in its slighter grades; for, however we
may irritate, or determine blood to a part, we
shall not transform it, unless under circumstances
identical with those that are concerned in the
production of those alterations. The series of
analogous changes that take place in the fcetus is
not connected either with irritation, or with in-
flammation, or with opposite states of organic
action. Wc can, therefore, impute (he meta-
morphosis only to modifications in the conditions
and manifestations of lit"e influencing the nutri-
tion of the organ or part ; for we know that in-
crease of function, or of vital manifestation, will
often occasion a transformatioa of nutrition in a

certain direction — will change cellular tissue to
a higher grade of structure, as "in the develope-
ment of the organs of the foetus ; whilst the
diminution or privation of function — that is, of its
due vital endowment, — will transform the organ
which performed it into a more rudimentary tissue :
thus, a part becomes atrophied from being unex- ■
ercised, an unemployed muscle is reduced to a
pale fibrous structure, and an impervious artery
or duct to cellular tissue. In briefly noticing the
specific metamorphoses of tissue, I shall com-
mence with the simplest, and generally the
earliest change, in the ascending scale of trans-
formation.

112. (a) The cellular tissue having always
existed as the matrix of the compound structures
and organs, it is obvious, when, owing to sus-
pended or abolished function, the superadded
organisation devoted to such function is lost, that
the cellular tissue will then remain as the pri-
mitive structural base. This is shown by the
evidence already adduced. The coagulable
lymph exuded during inflammation of serous
surfaces may become organised into cellular, and
even into serous tissue, and be the matrix of
certain other changes (§ 140.).

113. (/>) ThestniKs tissue, and the cellular, are
often tr.insformed one into tlie other. Cellular
substance may have serous cysts developed in it,
in almost any part of the body, either from
friction or pressure; or from the lodgement of a
foreign body, or the existence of a coagulum, &c.
But, independently of these causes, it may have
cysts of various dimensions formed in it, either
where it invests the different organs, or enters
into their internal structure ; the parenchymatous
organs sometimes being either partly or altogether
transformed into a serous sac, or having these
productions attached to them. AVhen thus de-
veloped, they have been attributed to irritation
by some, to a diminution of the natural action by
others, and to perverted action by several patholo-
gists. There can be no doubt of the last being
the case, whether other states of action may
accompany it or not.

114. a. Serous cysts \RTy from the size of a mil-
let-seed to that of a child's head ; they exist either
singly or in clusters, have their external surface
in contact with the organ in which they are pro-
duced, and are either intimately connected with
the cellular tissue surrounding them, or entirely
without any organised connection. lied vessels
are seldom seen passing into them. The struc-
tures immediately surrounding them may retain
their natural appearance ; or may lose it for a
time and regain it ; or may be shrunk and con-
densed : or be altogether atrophied, and expand-
ed over the cyst, as in the liver, brain, lungs ;
or be merely congested, or moreover be softened,
indurated, or surrounded by pus, or by tuber-
cular matter, or by blood. In this last case,
the cysts themselves are sometimes broken down,
or partially destroyed. The investing cellular
tissue may also become fibrous, cartilaginous,
osseous, or even calcareous ; and additional
layers thus may be superimposed on the original
cyst. The internal surface of the cysts may be
smooth, or may present changes altogether similar

I to those which serous membranes experience
I from disease; it may be uneven, rugose, granu-
1 lated, covered by specks of concrete albumen, or

586

DISEASE — Metamorphosed or transformed Nutrition.

lined by false membranes, with or without cellu-
lar bands or partitions running across the cavity.

115. (3. These cysts usually contain a limpid
fluid, but other substances have been sometimes
found in them, viz. 1st, a serous fluid tinged
with the colouring matter of blood ; 2d, blood,
with its fibrinous coagulum ; 3d, fluid, or semi-
fluid substances, of a dark, colour, probably con-
sisting of altered blood ; 4th, a flocculent serum ;
5th, a mucous fluid ; 6th, a fatty substance ;
7th, ciiolesterine ; 8th, the difl^erent varieties of
pus ; 9th, tubercular matter resembling that
found in the lymphatic glands of scrofulous
persons; 10th, a solid elastic substance, probably
consisting of altered albumen; 11th, several
species of entooza. Occasionally two or more
of these substances are found in different com-
partments of the same cyst; and without any
appearances in its parietes to account for the
circumstance ; thus furnishing an additional
proof that the state of the secretion does not
always arise from any appreciable modification
of structure. As to whether these cysts are
formed before or after the matters found in them,
it may be stated tiiat, in respect of those contain-
ing the first three kinds of fluids, and possibly of
some others, there can be no doubt of the efl^used
fluid having caused the formation of the cyst en-
veloping it ; but as to those tiiat contain difl^erent
productions in separate parts of the cells, it must
be inferred that the matter is secreted by the pa-
rietes or part of the cyst in which it is found.

116. (c) Mucous membrane may he produced
from the transformation of the cellular tissue —
1st, in the place of the old mucous membrane,
which had been ulcerated or otherwise destroyed ;
2d, in abscesses without external outlet ; and
3d, in abscesses having some external outlet, and
old fistulous passages. In the progress of this
change, the cellular tissue becomes successively
smooth, vascular, and raised to the same plane as
the continuous surface. It then admits of being
detached in shreds from the subjacent tissues ;
and, in the alimentary canal, ultimately becomes
studded with villi. But in abscesses and fistulas
villi are not formed ; and neither there, nor in
the digestive canal, does the transformed mucous
surface contain mucous follicles. IMeckel and
Andrai, record some cases, in which tlie internal
surfaces of cysts containing a viscid fluid could
scarcely be distinguished from mucous mem-
brane. I have seen this appearance in the
ovarium, where it has been principally met with.
The free surface of the false membranes formed
on serous surfaces has, in one or two instances,
where there existed an external opening, been con-
verted into a mucous-like tissue.

117. ((/) The ciUniieiiHs te:iture is generally
incompletely reproduced after being destroyed ;
the newly-formed part being composed of a cel-
lulo-fibrous layer, without the vascular tissue in
which the colouring matter is deposited. Owing
to this circumstance, cicatrices in the black
races are usually white. But there are excep-
tions ; the vascular layer being occasionally de-
veloped at a later period, and the newly formed
texture assimilated to the surrounding surface.
When mucous membrane becomes constantly
exposed to the air, it generally assumes more and
more of the characlers of the cutaneous structure,
but the transformation is by no means complete.

118. (e) Fibrous productions are also evidently
formed at the expense of the cellular tissue, the
change from the latter admitting of being traced
through its various gradations. They are gene-
rally composed of delicate filaments, sometimes
parallel to each other, at others matted together
or interlaced, and occasionally coiled, convo-
luted or rolled up ; and usually containing cellu-
lar tissue between the fibres. These productions
may exist as bands, distinct patches, and as
rounded or irregular bodies. They may be either
pale, or slightly vascular, or exceedingly so ;
and be disposed in the shape of chords; or in
that of membranes surrounding or covering other
parts or adventitious formations ; or in the form of
tumours.

119. a. Fibrous tunwurs vary as follows : — 1st,
They are homogeneous throughout, and consist
almost entirely of condensed fibres ; 2d, They are
lobulated, having cellular tissue interposed be-
tween the lobules, in which the fibrous structure
is more or less distinct and variously disposed, as
stated above ; and, 3d, They are, according to
M. Andral, granulated, the granules being dis-
posed in lobules, connected by cellular sub-
stance. Fibrous transformations often undergo
further changes, portions of them becoming car-
tilaginous, or even osseous. But, instead of these
changes, they sometimes experience acute or
chronic inflammation, which may disorganise
either the fibrous structure or its connecting tissue,
giving rise to infiltrations of pus, or of blood, or
depositions of fibrine, the purely fibrous tumour
thereby undergoing a complete metamorphosis.

120. (3. To what cause is the fibrous transform-
ation to be imputed 1 This can be answered
only by adducing the circumstances under which
it has been observed to occur. — 1st. Fibrous
growths sometimes appear in an apparently
healthy state of the organ in which they are
found, and are so completely isolated, a few
delicate cellular and vascular connections ex-
cepted, as to admit of being removed without
afl^ecting the adjoining structure. — 2d. The pro-
per tissue of the organs has occasionally disap-
peared as the cellular tissue has become trans-
formed into the fibrous state. — 3d. The organs
in which they are developed are sometimes the
seat of inflammatory action, but it cannot be deter-
mined whether inflammation is the cause or the
effect of the transformation. From these facts it
may be inferred, that no conclusion, as to the im-
mediate cimse ofthe production of fibrous growths,
can be offered with confidence ; but that they
may probably arise from altered organic nervous
influence of the part modifying the state of vascu-
lar action and nutrition.

121. (e) Cartilaginmis transformations are often
found under the same circumstances as the fibrous.
They are met with in the following situations : —
1st. In the cellular tissue interposed between organs,
or connecting different textures, — as in that sub-
jacent to serous membranes -usually in the form
of grains, laige spots, or irregular depositions or
incrustations ; and either unattended by any oilier
lesion, or accompanying changes in the serous
mcmbiane under which they are produced, or in
the substance of the viscus ; these changes being
of the most diversified kinds in the dilForent cases,
'i'hcy may also occur in the cellular tissue sur-
rounding morbid secretions and productions,

DISEASE — METAMOni'HOSED OR TRANSFORMED NUTRITION.

587

either as masses, or as membranes ; and of them-
selves, or with tlie serous or the fibrous transfurm-
ations, or with both, may form the cysts or en-
velopes of tliese secretions. — 2d. In tite structure
oj' parendiymati'us organs, the cartilaginous pro-
ductions are formed, like the fibrous tissue, at
the expense of the cellular. I'hey may be de-
posited in masses, or in the form of envelopes of
various morbid secretions. Whilst cartilage is
most frequently formed beneath serous mem-
branes, these membranes themselves never ex-
perience this ciiange. It is rarely produced in
the cellular tissue under the mucous or villous
coats; and very rarely in these coats themselves,
and ^then only consequently upon repeated or
prolonged irritation. The osseous tissue may
also be transformed into cartilage. But in re-
spect of the change of muscle, and of parenchy-
matous viscera — as the liver, spleen, kidneys,
&c. — into cartilage, it is more probable that the
developement of this substance in the cellular
tissue merely causes the disappearance of the
proper structure in the part thus altered. There
is, however, little doubt of a portion of brain
being sometimes changed into cartilage. — 3rd. In
cavities lined by serous or synoviat membranes,
cartilages have been found, either entirely loose,
or attached by a membranous prolongation or
pedicle to some part of the parietes. They vary
from the smallest size to that of a bean, and are
of different forms. They are generally homo-
geneous and elastic, and sometimes they contain
osseous points in their interior. They have been
found in the peritoneal cavity, by Lafnnec and
Andral ; within the serous membrane of the
brain ; within the tunica vaginalis testis; in nearly
all the articulations, but most frequently in the
knee and shoulder joints ; and even loose in the
interior of serous cysts, by Andral. As to their
formation, this pathologist thinks, " that they de-
rive their origin from their fluid exhaled in serous
and synovial cavities;" whilst Beclard and
Laennec suppose that they are originally formed
on the external surface of the membranes lining
these cavities, and that they gradually protrude
before them the portion of membrane covering
them, thereby giving rise to the pedicles by which
they are sometimes attached to the sides of the
cavities. Morbid cartilaginous formations vary
from a fibro-cartilaginous or mixed state, to one
purely cartilaginous, in which the internal struc-
ture is perfectly homogeneous; they also vary in
firmness. They occur in the following situations
in some one of these states : — 1st, In false articu-
lations ; 2d, At the extremities of bones of which
a portion had been long previously amputated ;
3d, In the situation of ligaments belonging to an-
chylosed joints; 4th, In cicatrices; 5th, In com-
pound tumours of the uterus, ovaries, and thy-
roid ; 6th, In the fo:in of incrustations or patches
in the parietes of arteries; 7th, In the cysts and
envelopes of morbid formations ; 8th, In certain
parenchymatous organs; 9th, In the interior of
articulations; and 10th, In serous cavities, both
natural and morbid.

122. (_/') Ossiform formations differ in form,
and somewhat in constitution, from the natural
osseous tissue ; and are generally confined to the
cellular, the fibrous, and cartilaginous tissues.
— a. The cellular substance is not susceptible of
this change in all parts of the body ; for ossific

deposits have not been found in the sub-mucous
although frequently in the sub-serous, cellular
tissue ; the serous membrane apparently still
covering the osseous fonuations, and giving them
a smooth pale surface. This change has been
found in the sub-serous tissue in every part of the
frame ; and it generally begins with slight thicken-
ing, and the infiltration of a turbid fluid ; morbid
nutrition, very evidently in this instance, and, in-
deed, in most other cases, as I have above con-
tended, commencing in vitiated secretion. The
connecting cellular tissue between the coats of
arteries, especially that below its serous coat, is
still more frequently ossified than the foregoing.
Also the cellular substance surrounding fistulous
openings, foreign substances, and adventitious
secretions or productions, often become incrusted
by plates, or grains, or complete layers of osseous
matter. Thus tubercles, hydatids, &c. are some-
times contained in osseous envelopes.

123. /3. Ossification of Jibrous and cartilaginous
textures is a part of the process of developement in
foetal and early life ; and the process goes on
through life, although generally in an impercepti-
ble manner, until old age advances, when it ex-
tends more rapidly, and seizes on additional parts
of these textures ; the fibrous tissue of the arterial
system, and the cartilages of the ribs, larynx,
trachea, &c., being then often converted into bone.
But when parts not liable to this change in old age
are aflfected by it, or when those disposed to it are
prematurely transformed, the circumstance is re-
ferrible to disease. The experiments of JMM.
CnuvEii.HiEH and Rayeu show that a certain
degree of inflammatory action or vascular in-
jection of fibrous, fibro-cartilaginous, or carti-
laginous tissues precedes the osseous deposit ; and
hence the reason that fractures or injuries are
often followed by ossification of the adjacent
parts of these textures ; and that siinple irritation
of a slight but continued form has given origin to
this alteration. But, in many instances, no cause
or appearance of inflammatory irritation could be
traced to the ossified part ; as when the coats of
arteries, the dura mater, the capsule of the spleen,
&c. are thus affected.

124. y. The form, texture,- and constitution of
ossiform formations vary much, both from one
another and from the natural structure. As to

form, they are — 1st, Granular, and either isolated
or in groups, their number being extremely vari-
ous, and sometimes remarkably great ; their size
extends from a minute point to that of a pea;
they are rounded, with either a smooth or a rough
surface. — 2d, Lamclliform or membraniform ^
developed in the adherent surface of serous mem-
branes, or in the pariete? of cysts, &c. — of vari-
ous sizes, and sometimes of several inches in dia-
meter, and consisting of thin irregular plates. —
3d, Amorphous, — generally found either alone,
or in conjunction with other morbid productions
in the parenchymatous organs ; they consist
more of a phosphato-calcareous deposition,
than of an ossiform formation. Their texture
is — 1st, Ho)nogeneous, and without fibres or any
division into compact and spongy parts; 2nd,
Obscurely fibrous or radiated, and more nearly
resembling the natural flat bones. The con-
stitution of natural bones is generally uniform ;
but that of the ossiform productions varies re-
markably in respect both of their earthy or saline

588 DISEASE — Adventitious

constituent?, and of the animal matters they con-
tain. In some instances, the calcareous salts are
found with little or no admixture of animal
matter.

125. V. Secretions and PnoDUCxiONS ad-
ventitious TO THE Economy. — The morbid
productions about to be considered present an
infinite variety of appearances, in respect of con-
sistence, colour, form, &c., occur under the most
opposite circumstances, and are connected ^yitll
the most diversified phenomena at their origin
and during their progress. They have all a tend-
ency either to increase by the juxtaposition of
new particles; or to grow by the assimilation or
intus-susception of matters transmitted to, and
circulating in, their own vessels. But, in either
case, they undergo various alterations, arising out
of their own intrinsic properties, or of the sur-
rounding parts, or of the state of the constitutional
powers and vascular action. Such of them as
are unorganised are liable to changes chiefly from
the conditions of the system, and of the parts in
whicii they are seated. These changes are of a
more limited extent than are experienced by those
\vhich are capable of performing certain inde-
pendent actions ; and are generally confined to
the removal by absorption of the more fluid parts
when they are soft, and of the eflTusion of a fluid
matter when they are hard and irritating to the
parts containing them. Productions, however,
whicli become organised, exercise functions of
their own : they have become the instruments,
under the influence of a derived vitality, of per-
forming and secreting nutritive functions peculiar
to them ; and they thereby not only perpetuate
and extend the morbid condition in which they
originated, but also superadd others, either of a
local or constitutional kind, or both.

126. a. The local c/w/i^q-es connected with adven-
titious productions are various : — 1st, The parts
in which they are developed may be natural, or
merely compressed by theii bulk. — 2d. The sur-
rounding parts may be inflamed, injected, or con-
gested, and variously coloured. — 3d. They may
be either indurated or softened, at the same time
that they are pale or injected. — 4th. They may
be hypertrophied, or remarkably atrophied in
other instances ; but most frequently the latter ;
the presence, and probably the pressure, of the ad-
ventitious formation diminishing their nutritive
action. — 5tli. 'I'hey may exhale or secrete a fluid
or puriform matter, which may dissolve the inor-
ganised productions, or soften them, and dispose
them to undergo further changes. The states
now enumerated of the surrounding parts, or cer-
tain of them only, may take place in succession ;
and may follow one another with various degrees
of rapidity.

127. S. The phenomena which attend their
commencement are very diversified ; but the
powers of life more frequently evince various
grades of depression, and even of perversion, than
tliosc of excitement. In many instances, however,
such changes are very slight or scarcely percep-
tible ; but they generally become very manifest
in the progress; of the morbid production ; the func-
tions of organic life — circulation, secretion, nu-
trition, excretion, &c. — experiencing more or less
disorder. When ailecting internal viscera, this
disturbance n)ay exist long without the nature of
the lesion being more than suspected. J5ut the

Secretions and Productions.

symptoms, local as well as constitutional, will
vary not only with the seat, but with the changes
constantly supervening in the productions them-
selves, and in the structure surrounding them.

128. y. The immediate causes of adventitious
productions must necessarily vary vvitli their na-
ture. In most of them, the constitutional powers
are in fault; and, in some, the cause is chiefly
local. Some pathologists have referred them to
debility; others, to increased organic action or ir-
ritation ; and several, to the perversion of the
functions of secretion and nutrition. The first and
last opinions conjoined will, perhaps, the most
nearly approach the truth ; for it must be admitted
that the perversion of these functions often origi-
nates in, or is associated with, debility. Those
secretions, however, which proceed from sthenic
or phlogistic vascular action, as healthy pus, coa-
gulable lymph, &c., do not fall within this descrip-
tion. With those exceptions, therefore, they may
be imputed to that condition of life to which 1 have
already attributed them viz., to depressed as well
as perverted manifestations of vital power (§ 91.).
The circumstances, extrinsic and intiinsic, in
respect of the frame, under which they appear, —
the agency of cold, moist, and impure air, of
deficient and unwholesome food, and of the de-
pressing passions, in producing them, — furnish
strong evidence of the accuracy of this inference.
Even as respects those changes which most fre-
quently commence with signs of local irritation
or vascular excitement or congestion, the general
conditions of life, and, consequently, the whole
economy, are more or less in fault ; and are es-
pecially concerned in producing the local change
of which irritation, or any other form of local
agent, is merely the efficient cause.

129. J. The terms which have been assigned to
the various productions falling under this head,
have been sufficiently arbitrary ; and a greater
desire has been evinced to discover new species,
and to impose on them new names, than to view
them as they are actually presented to our ob-
servation, and without reference to the descrip-
tions and opinions of their nature — too often
erroneous, and improperly mixed up — that have
been given of them. Nor have the arrangemenis
of them that have been attempted been less arbi-
trary. Certain of them iiave been named, from
their form, as tubercle ; others, from their colour,
as melanosis; and some of them, from their re-
semblance to healthy structures, as medullary,
mammary, encephaloid substances : and they
have been variously arranged ; as, into such as
are products of secretion without organisation, or
of nutrition with signs of organisation. It must
be evident, however, that the difference is chiefly
that of terms ; for nutrition is only a modification
of secretion. They have also been divided into
the enciisted and the non-cnc>istcd ; into the local
and the conslilutional ; and into the inet t , or not
necessarily noxious, aiul the malignant, or con-
taminating. These distinctions, although very
important, are not uniformly preserved ; for the
same substance may be cither encysted, or non-
encysted or infiltrated ; and the alteration, which
is merely local in some cases, may be constitu-
tional in others, or become so; and that which
may long or always remain inert in some instances,
may sometimes be malignant and contaminating
from the commencement. Besides, they may

DISEASE — Adventitious Secretions and Productions

oris^inate either in changes in the nutrition of the
natural tissues, the adventitious secretion being
a consequent lesion ; or in the production of new
substances, alterations of nutrition being later
lesions ; or even the secretions, as well as the na-
tural tissues in which they are elaborated, may
undergo subsequent transformations. So extremely
diversified are the causes which induce these
diseases; the states of vital manifestation and of
vascular action by which they are attended at
their origin and in their progress ; and so re-
markably are they modified in their course by ex-
ternal agents and intrinsic states of action ; and,
moreover, so insensibly tlo they pass into one
another, and so frequently and variously are tiiey
complicated ; that any arrangement must neces-
sarily be arbitrary, and a choice of difficulties.
Reference, however, to the varying characters of
the adventitious formations having been had in
the articles upon specific morbid structures, and
upon the varying alterations which the principal
tissues and organs present, I sliiill here only lake
a general view of them, in the following order : —
1st, Secretions adventitious to the frame, and
devoid of organisation : 2d, Adventitious secre-
tions associated with morbid nutrition ; or those
that are apparently organised, but which depend
upon the adjoining tissues for their vitality : and,
3d, Those which become organised, and possess an
independent life.

130. A, iSecrct'ioiis adcentitious to the frame,
and incapable of organisation or vitalily. — These
substances present no trace of fibres, laminae,
canals, or areola,' ; they are of various degrees of
consistency ; and certain of them change either
from a fluid to a solid state, or from the latter to the
former. They consist chiefly of albumen, gela-
tine, and the usual salts found in the serum of the
blood. The substances that fall under this de-
scription are : — ]. Pus; 2. Tubercle; 3. Fatty
matter ; 4. Glue-like matter, or the colloid mat-
ter of Laennec ; 5. ^Melanosis, or black matter ;
and, 6. Saline ingredients. These may exist
either singly, or variously associated.

131. (a) Fus. — -This term has been applied
to a morbid secretion, whose physical properties
vary considerably. That form of it which is
usually secreted in a state of the constitution not
remarkably depressed or vitiated, is a homogeneous
creain-like fluid, of a yellowish white colour, faint
smell, and slightly sweetish taste. But it often
departs far from this state ; and even that which
is secreted from the same surface, may be very
remarkably changed in a very short period, gene-
rally'owing to modifications of vital power and
vascular action. Sometimes it very closely re-
sembles a thick cream ; at others a mixture of
curds and whey ; and at others a turbid serum, or
a grumous sanies, or the dregs of wine. Occa-
sionally it seems disposed to become solid, and to
assume the appearance of tubercle. At one time
it is quite inodorous, at another very foetid. Its
colour also changes from white to yellow, from
green to red ; or this order is reversed. In some
instances, it is yellowish green, or yellowish
brown, and other related shades. The following
are its varieties, according to its physical proper-
ties : — 1. Creamy, homogeneous, or laudable pus ;
2. Curd-like pus; 3. Serous pus, or sero-puriform
matter ; 4. Aluciform pus, or glairy puriform
matter, or puriform mucus ; 5. Bloody pus ; and.

589

6. Concrete or lardaceous pus. These alterations
are , chiefly attributable to the texture in which it
is secreted, to the degree of local irritation or ac-
tion, to the period it has been retained, to the
general state of vital energy and vascular action,
to the condition of the circulating fluid, and to
the diatiiesis and constitution of the patient. But
these varieties often run into one another, showing
that any arrangement of the physical appearances
of this secretion must necessarily be arbitrary.
In the scrofulous diathesis, however, it often pre-
sents certain distinctive characters, and inclines
nearer to the curd-like variety, or seems more
disposed to become solid, from the absorption of
its serous portion, when it has been some time shut
up. But the most specific differences that exist
in pus are not to be ascertained by chemical re-
search, nor external appearances. Two portions
of this fluid, identical in every respect, will pro-
duce very dissimilar effects : when introduced
beneath the cuticle, one will occasion merely a
slight irritation ; the other a most dangerous con-
stitutional malady, capable of disseminating itself
througii thousands.

132. Pus has been found in every tissue, struc-
ture, and organ of the body, and in all the vessels,
and in the blood itself, both imperfectly mixed,
and in the centre of clots. It may exist in the
tissues and parenchymatous organs, either col-
lected in the form of abscesses, or disseminated
and infiltrated through their structure. When
formed in muscular, nervous, and even in some
other structures, it is in reality furnished by the
connecting cellular tissue, which is the chief seat
of the inflammatory action producing it. In a
great majority of cases, its presence, either in dis-
tinct collections, or in a state of infiltration, is ac-
companied with signs of irritation or inflammatory
action ; but instances occur, in which it is attended
by no such appearances. The opinion, that it
could be formed only where there is ulceration,
has been siiown to be unfounded : for it may be
secreted on the surfaces of membranes, without
any breach of continuity ; or collected in the
parenchyma of the organs, without any appear-
ance of inflammation ; or infiltrated between the
fibres and in the areolae of the tissues, without
any loss of substance. It 'is met with in the
second and last of these forms in the consecutive
states o( siippuralion, or when puriform or sanious
matters have passed into the circulation, from
distant parts, or from disease of the veins, &c.
When the production of pus has been preceded by
any degree of vascular irritat'on, the surrounding
tissues present — 1st, various grades of injection ;
2d, various shades of colouration ; 3d, different
degrees of softening; 4th, solutions of continuity,
which may either have preceded or followed the
purulent secretion ; 5tli, the disappearance of the
proper structure of the part, and its degeneration
into cellular tissue, in the areolai of which the pus
is infiltrated. (For the various distinctive cha-
racters of pus, the pathologii al states which gene-
rate it, the symptoms that precede and accompany
its formation, and the means of protecting the
frame against its contamination, see the articles
Abscess, § 7. etseq.; Inflam.matio.v, and Sup-
puration.)

133. (6) Tufcerc/e especially illustrates several
of the pathological inferences stated above rela-
tive to the constitutional conditions favourinor

590

DISEASE — Adventitious Secretions and Pboductions.

the occurrence of many adventitious productions
(§ 128.). The history of these formations in the
lower animals, and the depressing causes so fre-
quently connected with their appearance in the
human subject, would lead me to infer — 1st,
That the conditions of life throughout the frame,
in tubercular disease, are not merely weakened,
but also otherwise modified or perverted, either
from original conformation, or from acquired
diathesis : 2d, That this state of vital manifest-
ation often obtains in connection with tubercles,
without any symptom during life, or appearance
after death, that can warrant the conclusion that
they originate in inflammatory action : 3d, That
they sometimes form under circumstances that
would lead to the inference that inflammatory
irritation is an energetic, although not a neces-
sary, cause of their appearance : 4th, But that
local irritation, or that local or general inflam-
matory action, can no more account for their
formation, than for the production of any other
adventitious secretion, without the concurrence of
those conditions of life alluded to above (1st);
and that, whilst irritation or vascular action does
not necessarily excite tubercles, they may occur
without the least evidence of irritation : and, 5th,
The general conclusion seems to be that the con-
ditions of life modify or pervert the functions of
secretion in those parts of the frame in which
they are developed, and this perversion is often
attended by vascular injection. (As to their
SYMPTOMS, NATURE, and TREATMENT, scc the arti-
cle Tubercles.)

1.34. (c) Glue-like, or gelatiniform matter, or
colloid substance. — Whilst pus and tubercle are
chiefly composed of albumen, with varying pro-
portions of water and salts, this secretion consists
principally of gelatine. It is sometimes colour-
less, but it also occasionally presents shades from
a yellow to a pale rose tint. It is without any
trace of organisation. It is either infiltrated in the
areolffi of the tissues, thereby altering very much
their appearances ; or it is collected in one or
more masses, which slightly condense the sur-
rounding structure. When infiltrated into the
cellular tissue, it generally indurates this tissue,
and constitutes a variety of scirrhus. M. Andrai.
states, that whether the induration is a true hyper-
trophy of the cellular fibie, or merely the lesult
of mechanical condensation, the jelly-like sub-
stance is always traversed and divided into com-
partments, by numerous white, hard, resisting
plates, which seem to secrete it. Sometimes these
plates pass into the fibrous or cartilaginous state ;
and red vessels have been observed ramifying on
their surface, but have never been traced into
this peculiar substance. It has also been found
in tumours composed either merely of cellular
tissue in a state of hypertrophy and induration,
or of a variety of morbid products. It is often
contained in serous cysts, which appear to have
secreted it. When existing in this last form.
It constitutes the tumours or cysts called me-
licerous, from the semblance of their contents
to honey. It may thus be secreted in the dif-
ferent tissues in either an infiltrated or an en-
cysted form.

13.5. (rt) Fully substinices may be secreted in
iliflTereiit parts of the system in two forms : 1st,
that which is similar in every respect to the fat
of the body ; and, 2d, that which is in some

[ respect or other different from it. The first variety
has been noticed under the head of transformed
secretions ; the second differs in appearance from
the natural fat. Cysts of various sizes contain,
either alone, or with several other organised
substances — as bone, hair, fibrous structure, &c.

— a matter resembling suet. These cysts are
found in several parts of the body, but most fre-
quently in the ovaries. '1 he parenchymatous
organs may have their proper tissue atrophied
and replaced by a [fatty matter, forming the fatty
degeneration of modern authors.

136. (e) Melanoid and other colouring matters
have been secreted in almost every part of the body.
(For its nature and pathological relations, see the
article Melanosis.) The golden yellow tinge,
sometimes observed in spots, or generally diffused,
in foetal bodies and new-born infants, constituting
a variety of what has usually been called jaundice
of this class of patients, has been ascribed to a pe-
culiar secretion, called c(rro»os/s ( Hippo;, yellow) by
Professor Lobstein ; but it is probably nothing
more than a modification of the colouring principle
of the bile secreted under citcumstances described
above (§ 108.).

137. ( /■) The saline substances usually exist-
ing in all the fluids of the body are sometimes
secreted in uncommon superabundance in various
parts. But besides these, others, not generally
found in the fluids are secreted ; and are found,
1st, in the reservoirs and excretory ducts, through
which the secretions, in which they have been
formed, pass out of the system, as in cases of
salivary and urinary calculi ; 2d, in the cellular
tissue and parenchymatous organs, either alone,
or combined with other morbid productions ; and,
3d, replacing other morbid secretions — tubercles
being sometimes succeeded by calcareous con-
cretions, &c.

\38. B. Morbid secretion associated with morbid
nutrition, or secretions susceptible of organisation,

— This class of productions, in addition to a
small proportion of the constituents of unor-
ganised secretions, contain a large C[uantity of
fibrine. M. Anural supposes that a small por-
tion of this substance, either coagulated in the
blood-vessels, or extravasated into or upon the
tissues, is the original source whence the or-
ganised productions are formed ; the fibrinous
deposit presenting the appearance of a whitish
or reddish mass, of variable consistence, and hav-
ing a tendency to become organised, although at
first possessing neither organisation nor vitality.
But I believe that all fibrinous exudations have
a certain degree of derived vitality, disposing
them to organisation, particularly when they con-
tinue in contact with the part that produced
them. M. Andral considers thiit a portion
of fibrine may, when coagulated, indicate its
vitality without presenting any blood-vessels or
any determinate texture ; in which state it may
be compared to a zoophyte, which performs a
certain grade of vital function, although destitute
of a circulating system: and that the fibrinous
mass, when imj)regnated with life, becomes the
seat of various organic actions ; has a tendency to
assume the form of some one of the simple
or compound animal textures; performs the
functions of secretion ; and exhibits the same
morbid phenomena, when irritated, as the natural
tissues do under similar circumstances. He fur-

DISEASE — Adventitious Secretions and Productions.

591

ther supposes that several tumours, the origin of
which has hitherto been mistaken, may be traced
to the soUdification of fibrine in the blood-vessels
of the part ; and adduces cases, from the minute
dissection of which, he infers, that many of the
adventitious productions usually called cajicerous,
sarcomatous, encephaloid, and nieditlluni, are en-
tirely formed in this manner ; the minute vessels
— arterial, capillary, and venous — being filled
with solid fibrine deprived of its colouring matter.
It appears, however, mucli better established,
that the latter especially of these productions
are formed chiefly of coagulated or altered fibrine,
thrown out of tlie blood-vessels owing to their
perverted action, and either collected in masses,
into which blood-vessels are produced, or infil-
trated into the tissue of the part, the vascularity
of which is increased along with the alterations
that supervene in the adventitious formation and
its containing structure.

139. It may be stated of organisable products
generally, — 1st, that they seem chiefly to proceed
from the secretion or formation, by the morbid
state of the vessels, — frequently depending upon
a morbid condition of the frame, — of a certain
substance very nearly resembling coagulated
fibrine deprived of its colouring matter ; 2d, that
this substance, from participating to a certain ex-
tent in the vitality of the structures in which it is
lodged, and from the state of organic action in
the parts which formed it, has circulating actions
and vessels extended to it, and thereby becomes
organised, and capable of performing a certain
grade of function ; 3d, that it is at the same
time transformed into tissues, either similar to
the natural textures, or entirely different from
them, but equally organised and endowed with
life. I shall next notice in a very general man-
ner — ■ 1st, Organisable products arising from
sthenic inflammatory action, and not necessarily
depending upon a perverted or morbid state of
the constitutional powers ; and, 2d, Those adven-
titious productions, which not only originate in
some constitutional vice, but which also increase
both the local lesion and the vitiation of the cir-
culating fluids and living solids.

140. 1st. Achentitious structures consequent
tipon sthenic uiftamniatortt action. — (o) Organ-
isable matter, of a fibrinous or fibro-albuminous
nature, is frequently formed on serous surfaces,
and is generally termed, in its unorganised state,
coagulahle lymph ; and in its organised form,/aZse
membranes, cellular adhesions, &c., from its dis-
position to assume the appearance of serous and
cellular tissues. That these adhesions or pro-
ductions may be absorbed, and almost or altoge-
ther disappear, if the constitutional energies
continue impaired, is established by the observ-
ations of M^Nl. RiBES, DurUYTREN, ViLLERME,

and Andr.u., as well as by my own experience.
And I believe, moreover, that they may become
more fully developed, and assume progressive
alterations, when the vital powers are reduced or
perverted, (As to the manner in which they are
formed, and their progressive changes, see the
articles Inflammation and ^Membrane.) — (fc)
Tlie fibrinous exudation sometimes formed on
the internal surface of the blood-vessels, and
obstructing them, and ultimately causing their
obliteration, is in most respects similar to that
produced ou serous surfaces ; the chief difference

is in its influence in attracting the fibrine of the
blood, and in the consequent results. (See
Arteries and Veins.) — (c) A coagulable mat-
ter, more albuminous than that formed on the
surface of serous membranes, is sometimes se-
creted by mucous surfaces. I believe that it is
merely a modification of the transformed exhala-
tion noticed above (§ 106.), and proceeding from
inflammatory action aflecting chiefly the exhaling
vessels of the mucous tissue, and transforming
the fluid usually given out by these vessels to
a fibro-albuminous state; the morbid exhalation
concreting in the form of a false membrane upon
the inflamed surface, owing to the evaporation or
absorption of its watery parts, — Its organisation
has been a matter of dispute with French and
German pathologists. M. Guersent states that
he has seen vessels ramifying in the false mem-
branes of croup, and anastomosing with those of
the mucous surface. (See Croip, §36.; Inflam-
mation, and Membrane.) — (rf) The internal
sarface of serous cpsts may become inflamed and
form coagulable lymph, and thereby give rise to
further results; — 1. merely to false membranes
lining their cavities ; 2. to lymph agglutinating
their opposite surfaces, and gradually causing the
obliteration of their cavities. This latter change
often occurs in the cysts formed around coagu-
lated blood, particularly when extravasated in
the parenchyma of organs. — (e) The adhesion
of divided structures takes place in consequence
of the eflrision of coagulable lymph, which be-
comes organised, and passes from a cellular to a
fibrous state, and ultimately becomes identified
with the tissues it unites.

141. 2d. Adventitious productions depending,
■upon constitutional vice, as well as upon perverted
organic action in their seat, may be divided into
two species — the cansecutive and the primary —
the former commencing in carcinoma, the latter
appearing at once in the true cerebriform or
hcemato-cerebriform states. The former is the"
connecting link between carcinoma, or hard
cancer, and the cerebriform disease. They both
have certain points of resemblance, — secretion
and nutrition being perverted in both ; adventi-
tious productions, and subsequent destruction of
the affected tissues taking place in both ; and
both being attended by a perversion of the con-
ditions of life, and an increasing contamination
of the circulating fluids and living sohds. Their
chief points of dissimilarity are referrible espe-
cially to the manner in which the former ori-
ginates. It occurs, like the transformations in
which it begins, in certain parts or tissues in
preference to others, and only at mature or ad-
vanced epochs of life ; commonly commencing
locally, and but rarely simultaneously in different
parts of the same tissue, or in different structures
and organs, however frequently affecting both
the one and the other successively. — Tlie latter,
or primary, is met with chiefly at the early epochs
of life ; it attacks any texture or viscus, either
siniultaneously or successively, and at once
appears as a soft, tumefied, spongy, pulpy, or
cerebriform structure, or in some one of its modi-
fications {§ 142.).

142. The consecutive species only sometimes
occurs in the advanced course of scirrho-cancer,
which usually commences in certain of the states
of morbid nutrition and secretion noticed above.

DISEASE — Adventitious Secretions and PnoDucTioNs.

especially In hypertrophy or condensation of the
cellular and allied tissues, with a perverted se-
cretion, and deposition of a firm, grey, semi-trans-
parent substance in its areolse, and without any
specific boundary between it and the healthy
structure, in some cases ; or with a more distinct
demarcation, and a regular or lobular formation,
in others ; or with the secretion of a purely
gelatinous substance in minute masses, or in the
areola; of the tissue (f 134.) ; or, lastly, with a
uniform infiltration of a more albuminous and
lighter coloured matter in the texture of the part,
i^ivinff rise, respectively, to the diflferent varieties
of scirrhous. I3ut these hard, grey, or gelatini-
form, or lardaceous alterations, are generally
softened, liquefied, ulcerated, or even partially
destroyed, and have thereby passed into the car-
cinomatous state, before the adventitious produc-
tion makes its appearance in any of the forms
about to be noticed. Thus, scirrhus passes into
carcinoma, or open cancer ; and this latter, in
rarer instances, into some one of the varieties
which the cerebriform malady presents.

143. The ])i-tmarv species is very varied as to
its colour, figure, size, and consistence. Some
belonging to it have a homogeneous structure,
resembling coagulated fibrine deprived of its
colouring matter, and are of diflferent degrees of
liardness, occasionally approaching to cartilage,
and sometimes being almost semi-fluid, or resem-
bling putrified brain. Others of these produc-
tions are composed of substances which are
variously constituted ; their structure being fila-
mentous, or areolar, or cellular, or both cellular
and lobular, generally witii numerous canals or
cavities containing different kinds of fluids. In
all, there is an admixture of solids and fluids in
various proportions; the latter being either
colourless, resembling serum, or more or less
coloured, or altogether fluid blood. This struc-
ture may be so arranged, as to constitute either
of the varieties of sarcoma, especially the vuim-
mari^ and meduUarii of Abhrni-thv ; or it may,
owing to its softness, the delicate nature of its
vessels, the tendency to ha;morrhagic infiltration,
the rapidity of its protrusion through its ulcerated
coverings, and to the occasional bleeding from
its surface, form the true fungus ha:matodes of
several modern writers. When it assumes this
last appearance, it is more or less coloured,
either in parts, or throughout, from the admix-
ture of fluid or coagulated blood, collected into
small circumscribed masses, or infiltrated into
portions of its tissue. (See H^mato-cerebui-
FORM Disease.)

144. It may be remarked generally, respecting
all the forms of organic change cliaracterised
by the deposit of either an unorgunisable or or-
ganisable substance, that the specific matters
entering into their composition have been de-
tected in the lymphatics, in the glands, and in
the veins proceeding from the diseased part.
I'us, tubercular matter, melanoid matter, cerebri-
form matter, &c. have all been found in tliese
situations; the consecutive appearances of the
disease in other parts being thereby explained,
even alliiough — in respect of certain of these
maladies especially — it may also occur in more
tiian one part, coetaneously, owing to the dia-
thesis, or general condition of vital manifestation ;
and previously to the absorption of any portion

of the morbid deposition, and to its consequent
softening or destruction.

145. C. In respect of those productions iLihich
are not only organised, but iiliicli possess an inde-
pendent Life, and which constitute the Enlozou,
1 shall add but little to what I have stated else-
where. They are found in all animals, either in
the cavities, or in the parenchyma of organs :
each of them having its special habitation — the
fusciola heputica in tile liver, the fliaria in the

cellular tissue, the strongylus in the urinary pas-
sages, and the ascuris tundiricoides in the intes-
tines. 'I'hey may be divided into three orders ;
the vesicular, the flat, and the cylindrical. Their
organisation varies from a parenchymatous mass,
or a cyst containing a limpid fluid, but without
appendices, to that provided with one or more
appendices, or with an evidently organised head ;
from this stale, to a regularly formed structure,
consisting of muscular fibres and an alimentary
canal ; and, ultimately, thence to a fully de-
veloped animal, possessed of sexual organs and
the rudiments of nervous and circulating systems.
LiNNyEus arranged the entosoa into the intestinal
and the visceral. Rudolpiii divided them into
fee classes, according to their form. Cuvieu
classed them into two orders; the ■parenchymu-
teux, or those without any alimentary canal,
and the cavitaires, or those possessing a digestive
cavity. This last arrangement vvill be followed ;
inasmuch as in the article Hydatids will be
noticed all those comprised in the parenchyma-
teitx of CuviEU, and under Worms those belong-
ing to the cavitaires.

146. As to the origin of the entozoa, much
difiference of opinion has existed, chiefly among,
German, French, and Italian writers. In respect
of the first of the classes, viz. hydatids, little doubt
can exist ; but in respect of those that lodge in
the intestinal canal, the case is otherwise. The
subject, however, is sufficiently discussed in the
articles referred to. But there is one important
fact, which holds good in respect of the gene-
ration not only of hydatids and worms, but also of
all adventitious productions and depositions ; and
which should not be lost sight of in devising
means for their prevention and permanent re-
moval ; viz., that whatever depresses the mani-
festations of life throughout the frame — more
especially tliose of healihy secretion and nutri-
tion— will both favour their developement, and
their increase or extension. Tiiese morbid form-
ations may even be produced at will, by whatever
lowers the vital energies; — by cold, moisture,
unwholesome air and food ; by a watery vege-
table, or impoverished diet; by the depressing
passions ; by exclusion of light or sunshine, &:c. ;
— and not only may they occur singly under
these circumstances, but tiiey may also be coni-
plicateil with various other maladies, of a consti-
tuti(mal or local kind, the nature of which may
be thereby so far modified as to require a diflferent
treatment from what would be requiied in or-
dinary cases. Thus, complications of fever or
of visceral inflammations vvith intestinal worms,
are often the ultimate efli'ects of long-neglected
states of debility, and require less lowering mea-
sures than under other or usual circumstances, as
well as differently appropriated remedies. Are
we to suppose that, whilst the human reconomy
is under the influence of the depressing causes

DISEASE — Connection- between

noticed above, the organic molecules are thereby
prevented from being so perfectly assimilated, or
so highly animalised, and indeed vitalised, as in
health ; and that, tlie vital attraction requisite to
due nutrition being weakly or insufficiently ex-
erted, they proceed to arrange themselves accord-
ing to the grade of vitality they possess, into much
interior beings in the scale of creation 1

147. vi. Of Destruction of organised Pahts.
— This may take place in three ways : — 1st. By
interstitial absorption, by means of which the part
is first atrophied, and afterwards altogether re-
moved;— 2d. By superficial absorption, or ulcera-
tion, which may be consequent on inflammation,
or may proceed from the pressure of adjoining
parts, and from loss of vital cohesion in circum-
scribed portions of membranes or superficial tis-
sues:— 3d. By mortificatimi, owing to intense
grades of inflammation, either absolutely or rela-
tively to the state of local or general vital energy,
— to a destruction of the nervous influence of the
part, — to interruption of the circulation from dis-
ease of the vessels, — to pressure impeding both
nervous power and vascular action, — and to
generally depressed vital power, associated fre-
quently witii a morbid condition of tlie blood, and
sometimes with diseased blood-vessels, or with ex-
ternal pressure : hence the readiness of the occur-
rence of any of the forms of mortification in old
age, during dynamic and exanthematous fevers,
from erysipelas, from deficient or unwholesome
food, and from syphilis or mercurial cachexy ; —
and 4th. By the softening and swelling arising
from the greatly diminished or lost vital cohesion
of cellular and adipose parts, and their infiltration
with a serous fluid (comprising tlie Noma, or
watery cancer, of authors) giving rise to a form of
disorganisation diflerent from the foregoing, that
often passes rapidly into a stale of jelly-like solu-
tion and gangrenous erosion, particularly in the
lips, cheeks, and genitals of children. A similar
destruction sometimes also takes place in the sto-
mach ; and the true softening of the brain, in
its extreme states, seems to be of the same nature.
This species of disorganisation is intermediate
between ulceration and gangrene. (See Atro-
phy, Cellular Tissue, Gangrene, Softening,
and Ulceration.)

148. V. Connection of Morbid Actions
and of Organic Lesions with States of the
Blood. — Depressed and perverted states of vital
power have heen siiown to be often connected
with a deficiency, or vitiated state of the circulat-
ing fluid, in ciironic and cachectic diseases, and
with excrementitious plethora, or the accumula-
tion of the constituents of the various secretions in
the blood in the early and advanced stages of
fevers. (See Blood, and Debilitv.) Primary
excitement, in either its local or general forms, is
often caused, or at least favoured, by vascular
plethora ; and reaction, or secondary excitement,
with local determinations or inflammatory action,
is frequently produced by this condition, existing
either absolutely or relatively, or associated with
the accumulation in the blood of the constituents
of the secretions and excretions, owing to the
interruption of these functions, as in the stage of
reaction in fevers (§ 85.).

149. The connection of the lesions of secretion
witii the states of the circulation is one of the
most important topics in pathology, and has

Vol. I.

Alterations of Fluids and Solids. 593

therefore been noticed in this ( § 95. et seq.) and
other articles. The superabundance and trans-
formations of one or two of the natural secretions
are sometimes owing to the alteration, interrup-
tion, or suppression of others, — to the derange-
ment of the balance of healthy action, and to the
consequent plethora or vitiation of the circulating
mass. Thus, morbid states of the cutaneous or
of the intestinal secretions are often caused by
inactive function of the kidneys or liver; and
alterations of the urine, or of the bile, are fre-
quently produced by suppression of the perspir-
ation, or of the secretions from mucous surfaces.
iMorbid increase of the exhalations, particularly
those poured into serous cavities, or into the
areola; of cellular parts, is, in many instances,
connected with general plethora, as well as with
local congestions, and deficient excretion ; whilst
the transition of congestions into inflammations,
and the transformation of these exhalations into
a fibrinous, or filjro-albumiuous substance, by
sthenic inflammatory action, are promoted by the
abundance of this constituent in the blood, and
the general exuberance of this fluid. When the
recrementitious secretions are imperfectly elabo-
rated owing to depressed vital power, the func-
tions of chylifaction, sanguifaction, nutrition, and
depuration are also impeded ; the usual results
being insufficient excretion, an impure state of
the blood, and ultimately slow irritative fever,
marasmus, anaemia, and other chronic diseases.
In such cases the morbid phenomena proceed in a
circle, or rather act and react upon each other,
either until vascular excitement is produced by
the state of the circulating fluid, and the secreting
and excreting functions are thereby restored, as
shown in the article Crisis (§ 15.), or until
some organic changes supervenes. If we attempt
to trace the procession of morbid actions, we shall
often find that depre.-sed vital power affects the
secretions subservient to sanguifaction ; these
modify the quality, and ultimately the quantity
of the blood; the altered condition of this fluid
disorders the vascular actions and depurating func-
tions, whilst it further ileranges the nutritious
secretions; and thus the evil continues to increase
until the living solids become changed, and in-
capable of performing their prescribed actions.

150. In connection with the various le.uons of
nutrition whicli have been brought into view, the
blood can seldom long retain its healthy state.
But the change is evidently, in the first instance,
that of quality rather than of quantity, although
it is very difficult to show in what respect the
quality is modified. Excessive excretion and
discharge will often, however, sensibly diminish
the quantity of this fluid before any other change
either in it or in the functions of nutrition becomes
apparent. Local alterations of secretion and nu-
trition conjoined, whether originating in the
organic nervous influence of the part, or in the
quality of the blood circulating through it, ulti-
mately change both the one and the other, and
generally in a way that cannot be mistaken. In
many instances the alteration of the blood is evi-
dently owing to the absorption of the molecules
which had been deposited, secreted, or combined
in the morbid structure, and removed in the usual
course of that transition of the solids into fluids,
which obtains in the living economy, equally
with the transition of fluids into solids. Animal
Qq

594 DISEASE — Procession

organisation is the complement of a process of
combination and decomposition, — of attraction
from, and dissolution into, the blood, of the con-
stituents of the various tissues composing it ; and
if, in the former part of the process, the elements
form heterogeneous productions, the dissolution of
these productions, and commixture of their mole-
cules in the blood, must necessarily vitiate both
it and the structures through which it circu-
lates. Accordingly we find, even in fevers, that
the rapid absorption of a large portion of the
molecules of the similar or primitive tissues alters
the circulating fluid often in a very evident man-
ner; diminishes the density, cohesion, and bulk
of many of the soft solids; and changes, at the
same time, the colour, and other sensible proper-
ties, of both fluids and solids, to a remarkable
extent. But as this resolution of a portion of the
constituents of the textures into the fluid state, in
fevers, generally takes place without any pre-
existing adventitious formation or malignant pro-
duction, the absorbed materials admit of removal
by the emunctories without permanently contam-
inating the frame, or being deposited in various
tissues or organs, and thereby increasing and ex-
tending the mischief.

151. In case of chronic alterations of secretion
and 7iiitrition, giving rise to various adventitious
productions, whether local, constitutional, or
malignant, the dissolution of the molecules that
must necessarily take place (conformably with
the law of organisation stated above (§ 150.),
if they be organised ; and owing to the irritation
of the surrounding tissues, and consequent secre-
tion of a fluid matter which dissolves them, and
prepares them for absorption, if they be concrete
and unorganised,) and the passage of these mole-
cules into the blood, will first vitiate it, and next
diminish its quantity ; at the same time that such
of the molecules as are not quickly discharged
by the emunctories from the circulation, will be
deposited in other parts of the frame, forming
consecutive productions of a similar nature. The
consequences, therefore, of various local alter-
etions of secretion and nutrition — as of pus,
tubercle, carcinoma, &c. — will be, — 1st, As
respects the absorhetit system — (a) the presence
of a portion of the molecules of these productions
in the absorbents proceeding from the parts in
which they are formed; (b) irritation of these
vessels, excited by the morbid molecules, espe-
cially where they ramify and reunite in the
glands ; (c) the accumulation of the moibid mat-
ter in the absorbents, or its deposition in the glands
themselves : 2d, As regards the blood and vascular
system — (a) the passage of the morbid molecules
into this fluid, either directly by the veins, or more
circuitously by the absorbents, or by both chan-
nels; (fe) the contamination of this fluid ; (c) con-
sequent irritation or inflammation of the blood-
vessels ; (ti) an imperfectly assimilated or deficient
quantity of blood, owing to disorder of the recre-
mentitious secretions, and of the functions of chy-
lil'action and sanguifaction : and, 3d, As respects
the soft solids — (a) the deposition of the moibid
molecules in the areola; of the cellular tissue, or
the infiltration of tlieni into parenchymatous organs;
(6) their secretion on the surface of serous mem-
branes, or shut cavities, as those of the joints or
bursa; ; (c) their excretion on the mucous and
cutaneous surfaces, with inflammation, softening,

OF MoHBTD Phenomena.

ulceration, &c. of these surfaces, or of their folli-
cles; (d) their excretion by glandular organs,
either with or without inflammation and disor-
ganisation of those organs.

152. VI. Of THE PiiocESsioN OF Morbid Phe-
nomena.— i. The Stages of Diseases have been
variously divided by pathologists. Some writers
admit only three periods, viz. the increase, the acm6,
and the decline ; whilst others enumerate five, six,
or even seven. Tiie three stages now mentioned
are sufficient to distinguish the principal changes
of disease generally ; but in respect of febrile
diseases*, they may be subdivided with advantage.
A. T\\Q first or incremental stage consists of — (a)
the precursory period, or the time that elapses from
the impression of the exciting cause until the dis-
ease forms, or manifests itself in an evident man-
ner. The characteristics ofthis period are generally
languor, a diminution of the usual physical and
mental energy, a weak or slow pulse, or irregular
accelerations of pulse, slight chills, alternating
with flushings, or heat of skin ; change in the coun-
tenance ; and weakened power of the digestive,
secreting, and excreting functions. In many in-
stances little or no complaint is made; or, at
most only a slight malaise, or indefinite feeling
of indisposition indicative of depression of the
vital energies. This period is of very variable
duration — from a few hours to two or three
weeks — and is the same with the "stadium op-
portunitalis" of Hildenbrand, the " latent period"
of Dr. Marsh, and the period of " incubation"
of the French pathologists. — (ft) The formative
period, or that of manifest invasion, comprises
the time from which the commencement of the dis-
ease is usually reckoned, and critical evacuations
expected. It is frequently attended by convul-
sions in young children ; by syncope in females ;
and by chills, rigors, sickness, or vomiting,
pain, &c., in all classes of patients. These
symptoms are generally accompanied by others,
having a more especial reference to the nature
of the disease which they usher in : as by aching
pains in the head, loins, and limbs, in fevers ;
by acute pain, and difficulty of breathing, in
pleuritis ; by vomiting, constipation, and pains
about the umbilicus, in enteritis, &c. ; and seldom
continue longer than some hours. — (c) The pe-
riod of developed excitement or of reaction, or —
if this pathological condition is not prominent —
of aggravation of the chief symptoms : in which
the pulse becomes quicker, fuller, and harder than
in the former periods ; the functions of digestion,
assimilation, secretion, and excretion more or less
impeded ; the animal temperature and thirst
commonly increased ; and the tongue coated,
&c. This period may continue only a few
hours; or be prolonged to as many days, or
even weeks, in sub-acute or local diseases. The
whole duration of this stage is extremely various ;
but is usually much shorter in febrile than in
local and organic diseases. — B. The second stage,
or the acme, consists — (a) of the period of
stationary reaction, in which the symptoms,
having reached their height, remain in this state

* This division of the periods of fevers, and an abstract
of my opinions of their pathology, tal^en from my Lec-
tures delivered from IH'24 to lN'2!), whs published in the
jMndon MMiftil Hcposilury for Se))t. 1H'J7, I). 238. I state
this, as similar views have beeu promulgated by others
subsequently to this last date.

DISEASE — Type or Form of.

595

for an indefinite time — varying from a few hours
to several days, weeks, or, in local maladies, even
to some months — presenting slight modifications
and vacillations, tending either to a favourable
or unfavourable termination. — (6) Of the period
of crisis, in which new phenomena appear, indi-
cating either a salutary or fatal issue. The whole
duration of this stage is, in febrile diseases, gene-
rally shorter than tbat of the first ; but there are
numerous exceptions to this rule. — C. The third
stage, or that of decline, consists — (a) of the
period of decrement, or exhaustion in which the
symptoms subside more or less rapidly, and the
vital organs begin to resume their functions, in
favourable cases ; or the energies of life to sink,
in those of an opposite tendency. — {b) Of the
period of convalescence, in which the remaining
traces and consequences of the malady disappear,
and the vital and animal functions regain their
healthy condition and balance.

153. There may be some doubts of the pro-
priety of adopting certain of the above sub-
divisions, as they are chiefly applicable to febrile
diseases ; but they likewise obtain in some other
maladies. In those in which they are less re-
markable — namely, in organic diseases — any
division into stages can seldom be adopted with
advantage, or be made otherwise than in an ar-
bitrary manner. In these maladies, and, indeed,
in some others, the second or formative period of
the first stage may not be manifest ; nor the second,
or critical period of the second stage ; and many
may question the propriety of ma.k\ng convalescence
a period of the disease. But I believe, that,
during the restoration of the various functions,
there still remain certain pathological states or
degrees of disorder, requiring the attention of the
practitioner ; and, in many instances, a marked
tendency to relapse upon exposure to the exciting
causes of the malady. For pathological reasons,
therefore, as well as on account of the future
health of the patient, convalescence should be
always treated as a period of disease.

154. ii. Grades of Action. — The terms active
and passive have been much employed in pa-
thology, and often without regard to precision.
They should have reference only to the kind of
vital action characterising disease, and not to
its duration ; with which, however, they have
been too frequently confounded. Thus the term
active has been often employed synonymously
witli acute, and passive with chronic. But,
altliough an active disease is generally acute,
it is not so always or necessarily, and may even
be of a chronic duration ; whilst the most pas-
sive maladies, as respects the grade of vital
action, may be most acute with reference to their
continuance. It should never be overlooked,
in our appreciation of pathological conditions,
that medical terms are only conventional or ar-
bitrary signs, employed, often too indefinitely,
to convey our ideas of certain ever-varying con-
ditions of vital manifestation and organic change ;
and that, in using the words active and passive,
we should restrict them entirely to the expression
of grades of vital action, and view them as pos-
sessing an arbitrary as well as a relative import,
inasmuch as there is every intermediate degree
between the most active and the most passive
states of disease.

155. iii. Of the Type or Form of Disease, —

The type is the order of succession observed to
obtain among certain morbid phenomena ; and
admits of modification from various causes, with-
out the intrinsic nature of the phenomena being
essentially aftected. It has commonly been
divided into the periodic and the continued ; the
former being subdivided into several specific
forms. — A. Of the periodic type, a7jd the periodi-
city of morbid actions. — The intermissions or re-
missions of morbid phenomena, and their return
or exacerbations after regular or nearly regular
periods, constitute their periodicity ; and are
characteristic features of a number of diseases.
These features, are, however, more or less modi-
fied and marked in certain maladies than in others,
in respect botli to the paroxysms or accessions of
morbid action, and to the intervals which separate
them ; and hence periodic maladies admit of various
modes of arrangement, of which, however, that
into the febrile and non-febrile (pyrexial and apy-
re.rial) seems to be the preferable. The former
are characterised by the regular stages of febrile
action which the paroxysm presents in most in-
stances, and the definite duration of the intervals
or remissions : the latter are remarkable for the
suddenness of attack, and their evident dependence
upon, and affection of, the nervous system ; as
well as for the less regularity of their intervals.
Of the various modifications, which these two
classes of disease present, sufHcient notice has
been taken in the articles on Fevers, and on the
nervous disorders which possess this feature,
especially Asthma, Epilepsy, Hysteria, and
Neuralgic Affections.

156. The cause of the periodicity of many
diseases has never been satisfactorily assigned.
Some have imputed it to the daily alternation of
the erect and supine postures ; others to the action
of light, or, in other words; to solar influence.
There is a certain tendency to periodicity in almost
all diseases, in which the nervous functions are
more or less aflfected, and even in convalescence:
the remissions being often scarcely perceptible,
and the exacerbations generally assuming the
tertian type. The periodicity of morbid actions
cannot be explained otherwise than by referring it
to a law of the animal economy ; and, as those
maladies, in which the nervous systems are pri-
marily and chiefly affected, are most remarkably
periodic, we may infer that it is especially de-
pendent on these systems. This law obtains to a
certain extent in health, as respects the perform-
ance of many of the vital functions ; its existence
in disease, in a more evident or modified form,
should not therefore be a matter of surprise, par-
ticularly when the functions of those systems on
which it is more immediately dependent- are
principally affected. It is most distinct^ and the
intervals most complete, in maladies consisting
especially of disturbance of the organic and ce-
rebro-spinal functions, and in those in which the
excretions are not much impeded, and the blood
consequently not materially altered from the
healthy state, or where the other causes to which
the continued type is attributed (§ 157.) do not
exist.

157. B. T/ie co)((i»M(erf fi/pe consists of an unin-
terrupted succession of the morbid phenomena,
from the irruption of the disease to its termination.
Some maladies present a nearly regular intensity
during their course, and have therefore been called
Qci 2

596

DISEASE — DaRATioN of Morbid Actions — 'Terminations.

by the older writers " murhicontineiites." Others
evince slight morning remissions, with exacerba-
tions in the afternoon or towards evening : others,
in addition to these, experience some degree of
exasperation on certain, most frequently on alter-
nate, days ; and others, as some kinds of fever, as-
sume at first a remittent form, but soon become con-
tinued, and at last again slightly remittent during
convalescence. Even the more strictly continued
febrile diseases evince a remitting or periodic type,
in some degree, during decline or early conva-
lescence. It would seem that a marked tendency
to periodicity exists in all diseases, and that the
continued type is imposed — (a) by a high degree
of inflammatory action ; (h) by impeded or inter-
rupted secretion and excretion, and consequent
alteration of the quality and quantity of the circu-
lating fluid. Thence it may be inferred, tiiat the
type will be the more evidently continued, the
greater the pathological states to v.'hich I liave
chiefly imputed it ; and that, as in respect of other
medical terms, continued or periodic are usually
employed in an arbitrary manner, — the one type
passing into the other, the regularly periodic and
the continued forming the extremes of the scale,
between which there is every grade, ascending
from the former, or regularly intermittent, through
the less perfect and the remittent, until the con-
tinued is reached.

158. iv. Of the Duration of Morbid Actions, —
The period intervening between the actual irrup-
tion and the termination of disease is of very
various length. Hasmorrhnges sometimes continue
only a few minutes, cholera a few hours, whilst
asthma, rheumatism, and gout, may remain the
greater part of life. Some maladies, originating
in infection, have a specific duration, as small-
pox, measles, typhus, ice. If we calculate from
tiie time when the exciting cause made its im-
pression, many diseases, whose length often
appears definite, will present a much less uniform
character. Thus, in plague and other pestilen-
tial maladies, the effluvium from the sick has
sensibly affected the healthy, and terminated ex-
istence in a few hours from its impression, wliiist
other persons have not been seized by the fully
formed malady until many days after exposure
to its cause. Marsh miasmata have, in some
instances, not produced ague until several weeks
after their impression was made on the frame ; and
the rabid virus has sometimes not occasioned its
dreadful eflects until many months after its inocu-
lation. If we comprise the time that elapses from
the first manifestation of functional disorder, to
its termination from fatal organic lesion, the dur-
ation of numerous diseases will not infrequently
form no mean portion of the usually allotted period
of existence. Some maladies of a slight and febrile
kind, depending upon disturbance of the stomach
or bowels, occasionally subside in a few hours, or
in a day or two, and from this circumstance have
been called ephemeral.

l.'JO. A. The terms acute and chronic arc very
arbitrarily employed to designate the duration of
morbid actions ; and, owing to the circumstances
of their being often used as general but loose
characterislics of disease, they have been mis-
taken by the inexperienced as indicating the
existence of two forms, between which there is
none intermediate. 'l"o this misconception me-
dical writings have contributed, chiefly by de-

scribing merely these two conditions as simple
and unvarying forms, instead of considering them
as arbitrary signs employed to indicate the more
extreme states, in respect of duration, between
which there may exist every intermediate degree.
IMany employ these terms, to express not only
the duration of morbid action, but also its grade
or intensity. Of this little need be complained,
if the meaning attached to the words be pre-
viously assigned. Numerous writers, impressed
with the vague manner in which these appella-
tions have been used, have endeavoured to give
them a greater degree of precision by adjoining
qualifying epithets to them. — -(a) Diseases have
been generally viewed as acute, when the)' are
not prolonged beyond forty days ; some writers
subdividing those thus characterised, into the
" most acute," when they terminate in three or
four days, — into the " veni acute," "when they do
not continue longer than seven days, — into the
" si/nply acute," when they endure for fourteen
days, — and into the "sub-acute," when they
reach forty days. — (/;) Rlaladies which are pro-
longed beyond the last term have been usually
designated chronic; but they hardly admit of a
similar subdivision to the above, their duration
being indefinitely prolonged. The subdivision
of them into functional and organic, if the dis-
tinction could be made during life, would be of
practical importance ; but, although it might be
made in diseases of some organs, it cannot so
readilj' in respect of others : besides, most chronic
ailments are first functional, and so gradually and
imperceptibly run into organic change, that no
line of demarcation can be drawn between the
two states.

160. VII. Of the Tehminations of Disease. —
Morbid actions end ultimately in two ways : 1st,
In health ; 2d, Deatii. But before terminating
in either, they may assume other forms, or alto-
gether distinct characters; giving rise to what
may be called the succession, the transition or
conversion, and the metastasis of disease. — A,
The return to health consists in the restoration of
all the functions. It takes place in ways pecu-
liar to the nature of the malady, and conse-
quently in very diversified modes. — (a) In local
diseases, and in those simple pathological states
consisting of debility, excitement, exhaustion, &:c.,
the terminations in health are the most direct.
Nervous affections and haemorrhages commonly
end by the mere cessation of the phenomena of
which they consist ; and a similar occurrence
obtains in respect of simple congestions and
various functional complaints, as jaundice, dis-
orders of the stomach and bowels, &c. In the
restoration, however, of inflammations to the
healthj' state, the changes are more numerous,
the various phenomena of which this lesion is
composed either disappearing in succession and
gradually, that is, in resolution ; or giving rise to
other alterations of a more or less serious or dis-
organising kind; and these to new secretions and
states of nutrition, as purulent collections, ulcer-
ation, sphacelation, and ultimately to the pro-
ductions of coagulable lymph, granulations, and
cicatrisation. — (b) In j'ehrile and constitutional
maladies, the return to health is generally the
result of a series of changes in tiie economy,
however rapidly it may take place ; and is usu-
ally characterised, Jirst, by the subsidence or

DISEASE — ITS Relatioks, S

exhaustion of the morbid state constituting the
chief pathological condition, and, second, Ijy the
restoration of the secreting and excreting func-
tions, the interruption of which constituted one
of the chief features of disease. (See Crisis.) —
((•) In organic lesions, the restoration of the
health is less frequently efl'ected, either by nature
or by art, than in the preceding classes of disease,
and is usually the result of modifications of the
secretions and nutrition of the part different from
those in which the organic alterations originated.
Consequently the return to the natural structure
is generally slowly, and often only partially, ac-
coniplislied, — is always aided by a due mani-
festation of the vital energies and performance of
the secreting and excreting functions, — and is
frequently favoured by irritation of, and deriva-
tion to, some remote tissue or viscus, occurring
spontaneously, or excited by art.

101. In all diseases, the restoration to health is as
much owing to the vital energy, as to subsidence of
the particular morbid actions wliich constitute them.
Thus, acute or sub-acute inflammations occasion
various changes of structure ; yet the mere disap-
pearance of the inflammation does not constitute
the return to health. The organic lesions still
continue ; but these are ultimately removed in the
course of that constant process of attraction from,
and dissolution into, the blood, of the special
molecules of the tissues. Secretion and nutrition
have been shown to be not the mere deposition of
organic particles, but a constant circulation of
tiiese particles from the blood into vaiious fluid
and solid forms, and back again into the blood,
after having retained these forms for a longer or
shorter period ; and, as the organic molecules are
identified with the various structures, in virtue of
the vital influence and attraction which actuate
these structures, it follows that the more this in-
fluence is exerted, the more will nutrition be per-
fected, and any aberration from the healthy form
avoided and restored. C!onsequently, in the course
of this process, the natural type of formation will be
preserved, and any morbid production be removed.
— (n) Va"ious phenomena (^critical cluuiges) of a
very marked character indicate the terminalion of
acute diseases in health ; and have received, from
their importance, the attention of physicians.
(See Crisis.) — (b) As the functions become
re-established, and the pathognomonic symptoms
subside, and at last disappear, so the decline of dis-
ease passes into convalescence, in which, at first,
more or less of the phenomena constituting the
disorder, and of debility, not merely of the organ
chiefly affected, but also of the rest of the frame,
still remain ; the functional or the organic lesion
gradually disappearing as the manifestations of
life throughout the system become more and more
developed, orattain their healthy state and balance.
(See DiBir.iTV, § 43.)

162. B, The termination in death takes place in
vaiious ways, l;oth in acute and chronic diseases.
It may occur in thu former more or less suddenly
— (n) from rapid sinking of the vital powers, as in
adynamic fevers ; (/;) or from fatal haimorrhage be-
fore exhaustion has reached its utmost, as in some
diseases of the lungs and digestive canal ; (c) or
from pressure on, or interrupted circulation
through, the brain, accompanied with convulsions,
or coma, or with both, as in various diseases of
this organ; (rf) or from profound or prolonged

UCCESSIONS, AND COMPLICATIONS.

597

syncope and sudden cessation of the heart's ac-
tion, as upon (juickly assuming or retaining the
erect posture in states of exhaustion ; (e) or lastly,
froxnasphijxy, as pointed out in that article. Death
may also occur much more slowly in acute mala-
dies, owing to the gradual sinking and abolition of
the vital manifestations; giving rise to the collapsed
countenance, the frequent, weak, and unequal
pulse and respiration ; the loss of animal heat, and
cold clammy perspirations, the resolution of the
sphincters, and insensibility, t!ie cadaverous smell,
&c. observed some hours previously to, and usher-
ing in, dissolution. In some chronic maladies,
death often occurs suddenly, as inorganic diseases
of the heart, large blood-vessels and lungs, owing
to cfliision into the pericardium, interruption of
the heart's contractions, to rupture of its cavities
or valves, to bursting of aneurisms or profuse
hajmorrhages, to suffocation from effusion into the
bronchi, or into the pleural cavities, &;c. More
frequently, however, death takes place slowly in
this class of maladies ; and is chiefly owing to the
exhaustion of the vital energies, or to the disorgan-
isation of some important part, and the interruption
of a vital function, disordering and ultimately
obstructing others ; as when fluid is slowly effused
in any of the large cavities.

163. Vlll. Of THE IIelations, Successions,
AND Complications of Disease. — A. The rela-
tions of disease are not easily explained in many
instances; in others, however, they are more ob-
vious. It cannot be shown wherefore a state of
erethism, or inflammatory irritation of the diges-
tive mucous surface, should frequently co-exist
with acute or chronic eruptions on the skin
otherwise than by supposing that the state of the
circulating fluid is such as to excite or irritate
the vascular reticulations of both the skin and
villous membrane ; and, although this fluid may
be in excessive quantity in the majority of such
cases, yet quantity merely will not account for the
phenomena, without calling into aid an alteration
of quality ; which, while it excites the digestive
mucous surface, also inflames the cutaneous ves-
sels, during the depurating process they exert
upon the blood. But the state of this fluid will
not explain all the relations of .complicated mor-
bid actions. The reciprocative influence of the
organic nervous and cerebro-spinal systems, and
of the former and the vascular systems, must be
considered as the earliest and chief sources of
inorbid associations. When the dependence of
vascular action, and of the secreting and excreting
functions on the organic nerves, — of the conditions
of the circulating fluid on the states of these
fiinclions,- — and of the cerebro-spinal manifest-
ations on both the organic nervous and vascular
systems — on the strictly orjianic actions, — is duly
considered, the relation and succession of several
morbid conditions will appear as necessary re-
sults of this union. A\'lien we perceive the pro-
cesses of digestion, secretion, and defecation imper-
fectly performed — processes essentially dependent
upon the organic nervous influence — should
we be surprised to observe further disorders super-
vene ; and are we not rather to expect morbid
phenomena to present themselves, referrible
to the vascular system, to the circulating fluid,
to the nutritive functions, and to the purely
animal manifestations'! When important elimi-
nating processes are either impeded or increased
Qq 3

598

DISEASE — ITS Relations, Successions, and Complications.

to such a degree as to constitute disorder, ought not
other states of disease to be looked for t When
the urinary secretion is interrupted, excrementi-
tious vascular plethora, followed by a morbid
increase of the exhalations, dropsy, congestion
or effusion on the brain, convulsions, coma, &c.
will necessarily follow. When this excretion is
morbidly increased, the other secretions will be
diminished, and assimilation and nutrition im-
peded. AVhen the menstrual discharge is de-
layed or suppressed from torpor of the generative
organs, an important depurating function is not
performed, the co-existent debility of all the or-
ganic actions is thereby increased, the cerebro-
spinal functions are weakened ; ultimately assi-
milation and nutrition are reduced to the lowest
grade, and anaemia and marasmus supervene.
But when this discharge is copious and frequent,
owing to increased action or excitement of these
organs, the blood is purged of its impurities, all
the organic functions assume a proportionate
activity, and the cerebro-spinal system evinces
augmented susceptibility and excitability : sangui-
faction and frequently nutrition proceed rapidly ;
and vascular plethora, with a tendency to local
determinations, to inflammations, to hysteria, to
convulsions, 6\:c., is the consequence, particularly
upon any interruption of the discharge.

164. -B. Also, when morbidly increased secre-
tions have become habitual, other and more im-
portantdiseases may succeed any interruption liiey
experience. An habitual diarrhoea, when sup-
pressed, may be followed by peritonitis or as-
cites ; an old bronchorrhcEa, or chronic bronchitis,
may, when arrested, be succeeded by hydrotho-
rax ; leucorrhcea, or menorrhagia, if injudiciously
treated, may pass into inflammation of the womb,
or of the peritoneum, and even into ascites. In
these the succession of morbid actions admit of
ready explanations; for these morbid secretionsor
discharges being generally the result of local de-
termination and plethora, their interruption or
suppression merely changes their direction from
a surface, whence they were evacuated, and
where they, consequently, were comparatively
innocuous, either to the substance or to the sur-
face of the organ or part aftected, where their
retention and accumulation occasion dangerous or
fatal eflfects.

1G5. C. Whilst the mutual dependence — the
reciprocative influence — of the different systems
and functions of the frame, explains the relations
and successions of diseases, it also accounts for
their complications, and for the comparative in-
frequency in practice of those simple or specific
forms or states of morbid action described by
nosologists. Indeed, when we reflect on the in-
timate manner in which the various parts of our
frame are anatomically related and functionally
dependent, we should rather be surprised to find
disease so simple as it often is, and be prepared
to observe not only associated lesions of structure
and disorders of functions, but also the one va-
riously complicated with the other. There are
numerous circumstances which favour the com-
plication of disease. Amongst these the follow-
ing are the most important: — 1st, Constitution
anil diathesis, — as the scrofulous, the rheumatic,
the gouty, the plethoric, and the debilitated ; —
2d, The nature of the predisposing and exciting
causes, viz. those v^hich act upon the organis-

ation generally, as impure air, unwholesome food,
&c. ; — 3d. The state of the secretions and excre-
tions, particularly the vitiation or interruption of
them ; — 4th, Vascular plethora, anaemia, and a
morbid state of the blood; — 5th. The disposition
of membranous or continuous parts to experience
an extension of morbid action, particularly when
vital resistance is weak, and the excretions un-
natural or interrupted ; — 6th. The influence of
irritation of a part upon remote organs, through
the medium of either the organic or cerebro-spinal
nervous systems; — and, 7th. Injudicious treat-
ment. It would be inconsistent with my limits,
were it possible, even to enumerate the compli-
cations which result from these and other causes ;
but there are certain illustrations required to show
the truly practical importance of this branch of
pathology.

166. (a) Tubercular productions in the vis-
cera, or in the membranes, often co-exist with
disease of the absorbent vessels and glands.
Rheumatism and gout not merely modify the
character of other diseases, but may seize on a
number of parts successively, and even on several
simultaneously, whilst they are very often asso-
ciated with a torpid state of the liver and bowels,
and disorder of the stomach and urinary organs.
A plethoric state of the vascular system, whether
absolute or relative, associates congestions of in-
ternal viscera with various disorders of secretion
and excretion ; with affections of the nervous
system, and of the female generative organs, and
sometimes with eruptions on the skin. Debility
disposes to the extension of inflainmatory action
to continuous or contiguous parts, and associates
disorders of the digestive and assimilating viscera
with those of the nervous system and sexual or-
gans ; and thus examplesof the succession andcom-
plication of disease from diathesis and constitution
(§ 165, 1st.) are constantly appearing in practice,

167. (6) Extremes of temperature, and hu-
midity, and impure air, often seriously affect
more than one organ. A warm and impure air
frequently produces, either successively or simul-
taneously, not only functional but also struc-
tural disease of the liver, spleen, and bowels, as
well as fevers in which these viscera and the
stomach are principally affected. Unwholesome
food contaminates the chyle, the circulating and
secreted fluids, and ultimately occasions co-
existent disease of several viscera, — the complica-
tion of causation (§ 165, 2d.).

168. (c) A vitiated, copious, or interrupted
state of one or more secretions not only affects tiie
organs which produce them, and the viscera to
whose functions they are either directly or indi-
rectly subservient, but also vicariously influences
other secretions, and changes their quantity or
(juality. A copious flow of acrid bile may com-
plicate disease of the liver with inflammation of
the mucous surface of both the stomach and the
intestines, particularly of the latter; and func-
tional disorders, or inflammations, or structural
change of the kidneys, may so alter the conditions
of the urine and blood as to associate with them
either renal and vesical calculi, or inflammation
and structural disease of the urinary bladder, or
dropsy of one or more of the siiut cavities, and
of the cellular tissue. Also, interrupted discharge
of the secretions, particularly of those that are
excrementitious, from disease of their outlets, not

DISEASE — Metastasis of.

infrequently occasions consecutive changes in
the organs which elaborate or retain them. Ob-
structions to the due evacuations of the urine,
from obstacles existing either in the uretiira or
about the neck of the bladder, or in the ureters,
superinduce alterations of the kidneys, or of the
bladder itself; and disease of the biliary ducts
commonly associates with it lesions of botii the
gall-bladder and liver, and of the digestive canal ;
furnishing examples of siiperiiiduced complica-
tions (§ 165, 3d.).

169. (f/) Changes in the quantity and quality
of the circulating fluid, especially when carried
far from the healthy state, although usually the
consequences of disorder of one or more of the
secreting and assimilating viscera, yet become
the cause* of co-existent disease of several organs
and structures, modifying their interstitial secre-
tions, their nutrition, and their vital cohesion and
manifestations ; the whole organisation generally
presenting more or less of change. These com-
plicated effects may assume varied forms, and
implicate particular organs in a more remarkable
manner than the others, according as either ple-
thora or anajmia may be associated with the accu-
mulation of excrementitious matters in the blood,
or as the quantity and nature of these matters
may vary — thereby causing diversified humoral
complications (§ 165, 4th.).

170. (e) — a. \Vhen we advert to the circumstance
of disease, essentially the same having different
symptoms, and producing varied effects, merely
in consequence of a slight difference in its seat,
one reason for the frequency of what should be
called rather the extension or succession of disease,
than its complication, will be apparent. Thus,
when inflammation of the fauces extends down the
trachea and bronchi, there may be either a suc-
cession of disease, if the inflammation disappears
from the former seat as it extends to the latter ;
or a complication, if it exist at the same time in
all ; and yet the nature of the morbid action is
essentially the same, as long as the vital energies
remain unaltered. When inflammation extends
along the digestive mucous surface, or to distinct
parts of it only, a similar succession or compli-
cation, but without difference of the nature of the
disease, also obtains. These are instances of the
succession or complication of continuity. — S. But
disease may extend from one tissue to another,
instead of being thus limited to the same, as in
the above instances ; — it may originate in a mem-
branous surface, and involve the substance or
parenchyma of an organ, and ultimately even its
opposite and differently organised surface, and
either disappear from the former upon affecting
the latter, or implicate them all simultaneously,
thereby giving rise to a succession or compli-
cation of morbid actions, without altering their
characters, although materially changing their
symptoms. Thus, bronchitis may pass into pneu-
monia, and this latter into pleuritis, or they may
all co-exist ; and inflammation of a part of the
digestive mucous surface may be extended to the
cellular tissue connecting the coats of the aliment-
ary tube, and thence to the peritoneum ; and so on
in respect of other organs, which, equally with
these, not infrequently furnish examples of the suc-
cession OTComplication of contiguity (§ 165, 5th).

171. (f) Irritation and other disorders of an
organ or part not infrequently associate with them

509

a morbid condition of remote as well as adjoining
parts. AVorms in the intestinal canal often induce
either febrile or convulsive afl'ections. Congestion
inflammatory irritation, erethism, or merely func-
tional excitement of the female organs, may occa-
sion epilepsy, irregular or anomalous forms of
convulsions, hysteria, altered sensibility of the
nerves — referred by some writers to irritation of
the spinal chord — vitiated appetite, and disordered
manifestations of mind. Injury of a tendon or
nerve may produce tetanus ; and the accumu-
lation of fajcal matters in the large bowels may
excite, and be complicated with, various disorders
of the stomach, inflammation and ulceration of
the fauces and pharynx, febrile disturbance,
hemorrhoids, numerous nervous ailments, and
disorders of the uterus. These may be termed the
sympathetic associjttions or complications of disease.

171. (g) That injudicious treatment often com-
plicates disease, may not be so readily admitted as
the circumstances now adverted to. But I can
state, as the result of observation, that lowering
measures carried too far will occasionally favour
the extension of disordered action and structural
change, either by continuity or contiguity (^ 170.),
or by promoting the function of absorption, and the
passage of morbid matters into the blood (§ 169.) ;
and that stimulating remedies used too freely will,
either by their operation on secreting organs and
surfaces, or by irritating the parts to which they
are applied, sometimes superinduce inflammatory
action in addition to the disease which they were
intended to remove. Thus, arsenic exhibited too
freely, in order to cure agues, has produced in-
flammation of the internal surface of the heart and
arteries ; and bark of quinine, given freely before
morbid secretions and faecal matters have been
carried off by purgatives, has superinduced hepa-
titis or dysentery, or both, upon the intermittent
disease for which it was prescribed. Stimulants
and tonics taken in some forms of dyspepsia, as
complicated functional or structural disease of the
stomach, liver, and bowels; and astringents im-
prudently employed, have excited inflammation in
the organ whence the discharge, for which they
were exhibited, proceeded, as well as disease in
some related organ.

172. IX. Of the Metastasis of Disease. —
Metastasis {fj.sTaa-raa-i;, a change, migration, from
/UE9ijTi/W(, I change, or transfer) of disease has
been often improperly confounded with the terms
Metaptosis, Epigencsis, Diadoxis, and Metaschema-
tismus, which have had different meaninos at-
tached to them. Metaptosis has usually been
used to mean a change in the nature or state of a
disease, without a change in its seat ; — Epi<renesis
the superinduction of another, upon an antecedent
disease ; the anterior affection not being amelio-
rated by the occurrence ; — Diadoxis, the succession
of a less, to a more, important malady ; — Metas-
c/ieniHd'snms, the transformation of disease simply •
— and Metastasis, the displacement or disappear-
ance of disease from one part of the frame, and its
seizure of another of more vital importance. It
will be percei\ed, that the phenomena, which these
terms have been employed to express, have been
already noticed, excepting those which fall under
the last. When rheumatism or gout disappears
from a joint and attacks the head, heart, or sto-
mach ; or when erysipelas, or any febrile or
chronic eruption, forsakes the surface and is fol-

Qq 4

600

DISEASE— Metastasis of.

lowedbyangina, or pneumonia, or internal abscess,
or inflammation of the alimentary canal, or peri-
tonitis; there is a metastasis, or change of the seat,
of the disease.

173. A. Tliere are certain topics connected with
this subject, which liave been much discussed,
viz. Whether the disappearance of disease from
its original seat is the consequence, or the cause,
of its seizure of another part : and through what
channel does the transfer take place. The abettors
of the humoral pathology explained the occur-
rence of metastasis, by considering that a transfer
of the mato-ies morbi, or morbid matter, takes place
from one part to another, tiirough the vascular
system ; and that the consecutive disease is gene-
rally the consequence of the disappearance of
the antecedent. The supporters of solidism, whe-
ther with reference to nervous influence or to
the doctrine of excitability, supposed that disorder
manifests itself in the new seat owing to its sup-
pression in the old, — the cerebro-spinal nervous
system being the medium of dii^placement ; wliilst
they admitted — particularly the disciples of
Bkown — that its irruption in tlie former fre-
quently subdues it in the latter, owing to the ex-
citability being more intensely acted upon in the
one than in the other. A greater desire, Iiowever,
has been displayed by either class of theorists, to
conform facts to their views, than to investigate
the matter in a legitimate manner. In order to
draw accurate inferences, it is necessary to inter-
rogate Nature herself, by an intimate observation
of the phenomena to which the term mestastatic
has been applied ; and, wlien the practical im-
portance of this subject is considered, tlie results
will repay the investigation. A few facts which
have fallen lindcrmy observation will serve to elu-
cidate the subject. — 1. A medical friend had gout
in the lower extremities, for which he took a large
dose of colchicum before the morbid secretions iiad
been evacuated. He almost instantly had a violent
attack of the disease in the stomach, with simul-
taneous disappearance of it from the original seat.
The free use of stimuli caused it to relinquish the
stomach, and to reappear in the extremities. In
this case, the transfer from one place to the other
was instantaneous ; tlie medium being evidently
the nervous system. — 2. Another patient, had upon
suppression of gout from the lower extremities, an
attack of simple apoplexy, for wliich he was bled
and purged. When 1 saw him, lie was still coma-
tose. 1 he head, however, was cool. I directed
mustard cataplasms to the feet, and camphor and
ammonia internally. The gout suddenly reap-
peared in the feet, and at the very same instant he
awakened as from a profound sleep, evincing not
the least cerebral disturbance, organic or func-
tional.— 3. A middle-aged and not robust man had
most severe rheumatism in the thighs and legs, for
which he took a large dose of croton oil, which
produced iiypocatharsis, and the complete ces-
sation of the pains of the limbs, Jhllowed by the
niost distressing agony referrible to the heart, with
palpitations, &c. He was actively treated, but
ho died in a day or two. Withtiie exception of a
somewhat increased vascularity of the substance
of the heart, no disease could be detected in any
part of the body. — 4. A female, ;d>out 30, sanguine
and ])lethoric, had rheumatism of the lower ex-
tremities, which she attcuiptcd to remove by a
quack embrocation. 'J'hc disorder disappeared

from the extremities, but she was instantly seized
by most acute pains and tenderness in the re-
gion of the uterus and ovaria, the latter being
greatly enlarged, so as to form small tumours.
Similar cases to the above have been observed by
me, and show that rheumatic and gouty diseases,
when suppressed in one part, or suddenly subdued
by lowering remedies or evacuations, will often
be manifested in some vital organ, and be removed
from it, in such a way as can be explained only
by nervous agency : and, when tlie conformation
of the parts consecutively affected are considered,
and the pronenessof the disease thus superinduced
to assume an inflammatory and congestive state,
retaining at the same time the gouty or rheumatic
character, is taken into account, it is reasonable
to suppose that the organic nerves are the chief
channel of transfer, and seat of the affection ;
their intimate anatomical connection with the
blood-vessels explaining the morbid state of vas-
cular action with which the transferred disease is
so frequently accompanied.

174. B. lint there are metastases of a somewhat
difl^erent kind from the above ; but which, equally
with these, present morbidly excited action ; the
difference consisting chiefly in the extreme degree
in which sensibility is altered in those already no-
ticed. In the exanthemata, and even in the
course of several chronic eruptions, the cutaneous
affection suddenly disappears, and dangerous
disease is developed in an internal organ. In
some cases the superinduced malady is merely
the localisation or determination of the morbid
action to a single organ, the external afl'ection
disappearing in consequence — a result not infre-
quently of depression of the powers of life, or of
irritants acting upon the part thus secondarily
diseased, or of both causes conjoined. In other
instances, particularly in chronic eruptions and
discharges, the internal or consecutive malady is
the consequence of the suppression of the external
disorder. In order to form an opinion relative to
the nature of metastasis in exanthematous diseases,
it is necessary to attend to the following circum-
stances: — 1st. That they are frequently caused
by the neglect of sufficient evacuations early in
the disease, by a cachectic habit of body and con-
stitutional vice, by breathing a foul air, and by
injudicious regimen; — 2d. That whatever sud-
denly lowers the nervous energies, or weakens vital
resistance to hurtful agents, or perturbatcs the
frame, will often cause a metastasis of the disease ;
— 3d. That the metastasis may be either complete,
the external eruption disappearing entirely ; or
incomplete, the eruption still partially remaining.
In these diseases the morbidly excited vascular
action of the skin evacuates a peculiar matter,
which is capable of propagating the disease, and
which is either carried off' chiefly in the in-;ensible
perspiration, as in measles and scarlatina, or in
the more consistent matter of the eruj)tion, or in
both, as in small-pox. When, therefore the
morbid vascular action and its attendant evacu-
ation are either prevented from appearing in, or
suppressed, Irom the cutaneous surface, it may be
reasonably inferred that they will be diterniined
to some internal viscus, giving rise to inflammation
of, and serous effusion from, mucous or serous
surfaces; and congestions, infiltrations, inflam-
mation or hepatisution of parenchymatous organs.
Thus in scarlatina, measles, small-pox, erysipelas,

DISEASE — Circumstances

&c., the suppression of the eruption not infre-
quently producesonc or more of the above efl'ects,
and constitutes the chief diseased appearances in
fatal cases.

175. C. There is another form of metastasis, that
consists chiefly of morbid secretion ; and altliough
vascular action is concerned in producing the
matter found in tlie secondary seat of di-case,
still the transfer from the original seat evidently
takes place through the channel of the circulation.
We not infrequently observe purulent or ichorous
matter, which has been formed in one part, re-
moved from thence, and infiltrated, or secreted
and accumulated, in another part ; occasioning
consecutive abscesses (see Abscess), or some
other structural change, in a parenchymatous
organ, or puriform effusion into natural cavities.
In these cases, the passage into, and presence
of morbid matter in, the blood, excite increased
vascular action in some part by means of which
it is either evacuated from tiie system, if the
morbidly excited part be an emunctory ; or infil-
trated and collected, if it be a parencliymatous
organ ; or effused and retained, if it be a serous
orsynovial cavity. Thus, collections of puriform
matters have been found in the liver, in the
joints, in the lungs, in the brains. Sec. after small-
pox, erysipelas, fevers, inflammations of veins, or
of remote or external parts, and after fractures ;
and olten without any antecedent disease of the
viscera thus consecutively disorganised, or disorder
referrible to them, proportionate to the extent of
disorganisation observed on dissection of fatal cases.

176. D. From the foregoing I conclude, 1st. That
metastases may be divided into — (a) those mani-
festing fully expressed disordered action, in which
the sensibility is more or less excited ; and (h) those
consisting of latent disorganisation, and produced
chiefly through the medium of the circulating
fluid: or into — (a) tho'^e which affect the sub-
stance of an organ ; and (S) those which take

^place to an excreting surface or viscus — as the
skin, the intestinal mucous surface, the kidneys,
and the salivary glands — and which frequently
terminate favourably by evacuation from the cir-
culation of noxious matters that were the chief
cause of the metastasis. — 2d. 'i'hat they are
brought about — (a) by means of the organic
nervous system, as in gout and rheumatism; —
(/)) by the influence of this system of nerves upon
the blood-vessels and capillaries, determining to
various surfaces or structures a preponderating
degree of morbid action and its results, according
to the operation of numerous intrinsic and ex-
trinsic causes, as in exanthematous metastases ; —
(c) by the absorption of hurtful matters into the
circulating current, wheie they excite, internally
as respects the capillaries, the increased or morbid
action of some secreting surface or emunctory, or
occasion the disorganisation of some predisposed
parenchymatous organ.

177. X. The Circumstances modifying the
FoniM, Complications, Duration, and Termi-
nations OF Disease, are as numerous as the
causes, — predisposing, exciting, and determining,
— in which it originates. The constitution ard
diathesis of the patient; a cachectic or vitiated
habit of body; the continued operation, during
the course of the disease, of the causes which in-
duced it; the depressing passions; impure or
stagnant air ; all sudden mental and physical per-

MODIFYINO THE FORM, ETC. OF. 601

I turbations ; extremes of temperature ; injudicious
I treatment and regimen ; the use of medicines
I which either suddenly or intensely excite, or de-
press, the vital or nervous energies, and weaken
the restorative powers ; neglect of evacuations,
and of the state of the secretions and excretions ;
the iiiiiiia diligenlia of the practitioner, or im-
proper interference with the salutary processes of
nature, and with critical evacuations and changes ;
the too early recurrence to a full or stimulating
diet, or exposure during convalescence to any of
the causes specified above ; will not only modify
the states and duration of disease, but also occa-
sion the succession of one disease into another,
render morbid action more or less coinj)licated,
transfer it from one structure or organ to another,
and occasion relapses of greater or less severity.
(See Physic — Practical Principles of ; and
Symptomatology.)

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— Franck, De Pcriodicarum Aflectionum Ordinandis

DROPSY — Pathology of.

603

Familiis. Pav. 1791 Ballhorn, Diss. Quorundarum

Phaenomenorum Period. Causs probabilcs. Goet. 1792.

— Bhctorides, De Morbis Periodis, &-c. Eriaiig. ISO'J.

V. Successions, Complications, and BIetastasis op

Disease Bag/ivi, Do Febra Motricc et Morbosa, &c.

Opp. p. 367. — Sla/il, De Morbis Consequentibiis. Ualte,
1710. ; et De Metascheraatismis Morborura. Hal. 1707. ;
et De Morb. Complicatione. Halse, 1715. — F. Hoffmann,
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— J'alcr, De Morb. ("omplicatis et Intricatis. Witeb.

1728 Zannutti, De Morb. Complicatis. Wien. 1719.—

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les Metastases. Montp. 1800 Thomann, Annalen ad

1800.— J. D. Brandis, Versuch iiber die Metastasen, 8vo.
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p. 75.

DROPSY. — SvN. "r^foii., Th. (L'Ja^p, water,
and oiv/-, aspect, appearance.) Hydrops, Lat.
Hydropisie, Fr. I)ie Wassersucht, Die Hy-
dropsie, Germ. Idropisin, Ital.

Classif. — 3. Class, Cachectic Diseases; 2.

Order, Intumescences {Cullen). 6. Class,

Diseases of the Excremental Function ; 2.

Order, Affecting Internal Surfaces (Goorf).

IV. Class; I., II., and III. Orders

(Author).

1. NosoL. Defin. The accumulation of watery
fluid in the natural cavities, or in the cellular areolte,
or in both, causing distension, impeded Ju7ictions
of the affected and adjoining parts, frequently with
fluctuation, softness, i5fc.

Pathol. Defin. A collection of fluid arising
either from increased exhalation or from diminished
absorption , each of lohich conditions depend upon
antecedent states of disease.

2. After having taken a general view of the
nature and treatment of dropsical effusion — of
Dropsy in its generic acceptation, — I shall pro-
ceed to consider its specific forms. By thus view-
ing, in a connected manner, the various species of
dropsy, which have been improperly separated the
one from the other, much unnecessary repetition
will be avoided, and several advantages obtained.

3. 1. Pathology of Dropsy. — i. Brief Histori-
cal View of Opinions. — Different views of dropsical
diseases may be found in several parts of the
writings ascribed to Hippocrates. There can
be no doubt, however, of the connection between
them and a state of active vascular disorder, as
well as of obstructions of the liver and spleen,
having been known to him, Erasistratus is
said to have referred tiiese maladies chiefly to
engorgements of the liver ; and Asclepiadls to
have viewed them as being either acute or chronic.
Aret.«us gave merely a lively description of tlie
history of dropsies : but Galen, in the uncon-
nected observations on these maladies scattered
through his writings, stated some just views of
their nature. He pointed out the seat of the
ascitic effusion ; contended, in opposition to

Erasistratus, that dropsies often depend upon
other causes, and upon disease of other viscera,
beside hepatic obstruction ; and that they fre-
quently proceed from a morbid state of the blood.
C«Lius AuRELiANus assigned, as their causes,
lesions not only of the liver, but of the spleen, of
the womb, and of the large and small intestines.
Aetius made some reference to a cachectic habit
of body in relation to them ; and Alexander of
Tralles noticed, but in a superficial manner, their
connection with diseases of the lungs, and with
antecedent fevers and inflammations.

4. Amongst the Arabian writers, little respecting
dropsy beyond vvhat is contained in the works of
their predecessors is to be found, Avicenna, how-
ever, attributed it to the liver and to the kidneys ;
and stated that the latter, owing to the coldness or
warmth of their temperature, or to obstruction or
induration of their structure, fail to attract or sepa-
rate the watery fluids. Mesue gave a similar view
to the foregoing, and both agreed in stating that
the liver does not concoct pure, but a watery and
phlegmatic, blood. When we reflect that the
lights of modern science have sliown that the liver
is both indirectly and directly concerned in sangui-
faction, that the crasis and vital constitution of
the blood is really affected in many states of
dropsy, and that the kidneys are often very de-
monstratively diseased, and in a way that may be
expressed in general terms nearly similar to those
used by Avicenna, we must conclude, that some
of the pathological opinions of the ancients are
not so despicable as many of the moderns sup-
pose; and that, even in recent, as well as in
bygone, times, there have been more absurd
theories than sound views of morbid actions, and
a greater disposition to generalise from a few im-
perfectly ascertained states of disease, than to
take into account numerous concurtent circum-
stances and morbid associations.

5. Since the revival of learning, but little was
added to the knowledge of dropsies, until the
writings of Willis appeared. This very eminent
physician first called in the state of the vessels to
the explanation of these diseases ; and argued that,
whilst the vascular extremities are either too re-
laxed or too constricted, causing thereby an
increased effusion and diminished absorption
respectively, the blood itself is often altered,
and its circulation impeded by scirrhous tumours,
tubercles, and obstructions in any of the abdomi-
nal viscera. Ettmuller and Lister adopted
the views of Willis. The experiments of tying
the veins, first performed by Lower, confirmed
the opinion promulgated, but not carried its due
length by Willis, that interruption of the venous
circulation is a chief cause of dropsical effusions.
F. Hoffmann repeated the experiments of Loaver,
and, as well as Boeriiaave and Van Swieten, ad-
mitted the importance of venous obstruction in the
pathology of dropsies. Morgagni says, " Qua-
cunque causa diutius potest sanguinis aut lymphae
cursum morari, aut humoris quo cavae corporis
madent, aut secretionem augere, aut exitum
deinde imminuere morbo huic potest originem
prffibere." Ludwig first directed attention to an
atonic state of the vessels as a principal source of
those maladies, and his contemporary INIilman
assigned as their chief causes a laxity of the fibres,
exhausted power arising from copious evacuations,
and acute diseases passed into the chronic state.

604

and an obstacle to the return of the blood through
the veins. The views of Haller were nearly
those of LuDwicand Miljian ; but he considered
not only that the mechanical obstruction, but
also that that grade of debility of the veins, which
would retard their circulation, would occasion
dropsies. The opinions of D.RIoMto and Cul-
LEN coincided with tlie foregoing ; the former
considering, and indeed proving by experiment,
that the notion entertained at the time he wrote, as
to rupture of the lymphatics being a cause of tlie
effusion, was not well founded.

6. When lymphatic absorption became gene-
rally insisted upon, owing to the writings of
Hunter, Hewson, and otliers, an additional
cause of these maladies was acknowledged, and,
as might have been expected, the part assigned
to these vessels was greater than they perform.
VoGEL applied the doctrine of atony to them ;
and most of his contemporaries entertained a simi-
lar view. Soemmering, Wedel, Assilini, and
Mascagni, |nearly altogether deprived the veins
of their share in the production of aqueous effu-
sion, and assigned its source almost entirely to
the lymphatics. These writers, with many of
their predecessors, still conceived that the rupture
of these latter vessels sometimes caused it, and
adduced cases in which this lesion was detected
on dissection. Mascagni considered that, besides
other alterations, the absorbents are either ob-
structed in their glands, or dilated to such an
extent as to prevent their valves from opposing the
reflux of the fluids absorbed by them. The un-
tenable hypothesis of a retrograde action of these
vessels was advanced by Mezler and Darwin,
but found no support.

7. The division of dropsies into active and pas-
sive, or acute and clu'onic, may be traced to
Riviere, or Riverius, who denominated them
hot and cold. 15oe«iiaave, Backer, 1'issot,
Stoll, and later writers, have given greater pre-
cision to this division, by denominating the former
plethoric, active, sthenic, and inflammatory, ac-
cording to the state of the circulation, and of vital
action. It was, however, chiefly Tissox, Sioll,
and J. P. Frank, who drew attention to active
plethoric, or acute dropsy ; and Grapengiesser,
the pupil of Frank, Blackall, Fauchier, Poil-
Roux, Breschet, AuERCROMiiiE, and Ayre, have
further illustrated this doctrine. G rapenciesser,
with much justice, observes, " Omnis, enim, in-
flammatio modica si organon secernens occupat,
functionem ejus auget." Geromini, a recent
Italian writer, carried the inflammatory origin of
dropsy as far as a medical sectarian might have
been expected to have done, and discarded venous
obstruction from any share in the production of
this lesion. 'J'he facts, however, which have been
adduced by Dr. D. Davis, M. Bouillaud, M.
Velpeau, and Dr. R. Lee, demonstrate the
important part obstruction of the veins performs
in the causation of at least partial dropsies ; and
the interesting researches of Dr. Bright, followed
up by Dr. Cmristison and Dr. 1. Grecjorv, dis-
close the great share the kidneys have in occa-
sioning this class of diseases. As to the existing
state of our knowledge of their pathology, fuller
details will ap])ear in the sequel.

8. ii. Of 'iHE Causes or Dropsies. — It is
evident that the chief causes of these diseases are
the pre-exbting lesions which will be hereafter

DROPSY — Causes of.

described. But there are others, more remote in

their operation, which deserve to be succinctly
noticed. — A. Remote causes. — a. The predis-
posing causes are chiefly a cold and moist
climate, or a warm and moist temperature when
conjoined with an impure air ; the lymphatic,
phlegmatic, and bilious temperaments ; a soft, re-
laxed, and plethoric habit of body ; the scrofu-
lous diathesis (Heister) ; the syphilitic taint
(PiDEniT and Hufeland); and advanced age.
'i"he infrequency of these maladies in warm and
dry climates, — as Egypt, Syrin, Arabia, and
JMubia, — has been remarked by several writers. —
b. The exciting causes are, — 1st, External, or
physical agents, which occasion ciiiefly the more
idiopathic and active forms of dropsy ; and, 2d,
Antecedent diseases. — a. Of the former, the most
influential is cold conjoined with moisture, par-
ticularly if acting upon a person in a state of
perspiration. Tlie influence of a humid atmo-
sphere may be imputed to the circumstance of
its impeding the pulmonary and cutaneous trans-
pirations, and occasioning the accumulation in
the va.scular system of the watery parts of the
blood, or a recrementitious plethora, if the kidneys
perform not a proportionately increased function ;
and this effect is promoted if cold be superadded.
When a moist air is loaded with miasmata, the
injurious effects are still further heightened, as
internal congestions and obstructions of the liver
and spleen are thereby produced ; humidity and
cold trequently giving rise to acute, and warm
moisture with malaria to passive, dropsies, or those
depending chiefly on visceral obstruction. The
operation of humidity in causing these diseases
was explained by Erastus, Van Swieten, and
De IIaen, on the supposition that a portion of
the moisture was absorbed from the air into the
circulation. Unwholesome food and a poor and
watery diet, although justly considered as a
cause by Bonet, Fothergill, and others, can
act only by debilitating the frame, and inducing
a state of general cachexy, or disease of some
viscus terminating in effusion. Van Helsiont
and Pezold conceived that the use of poik is
productive of dropsies ; and I believe that there
is some truth in the opinion. That this diet
favours the generation of the scrofulous and gouty
diathesis, is certainly a result of my observation.
Drinking cold fluids, particularly when the body
is perspiring and fatigued, not infrequently causes
the active states of these diseases ; and all kinds
of ingurgitation, especially drunkenness, arc per-
haps the most common agents, in as far as they
seldom fail of producing those visceral lesions
on which watery effusion so often depends.
Violent fits of passion were considered by Lu-
Doi.FF and De jMeza, indolence by Tissor, se-
dentary occupations by Ramazzini, and general
debility by Wainf.wriout, De IJaen, D.
JMoNRo, and Ludwig, as occasional sources of
dropsies. The influence of anxiety and the de-
pressing mental emotions, in favouring their oc-
currence, if not in directly exciting them, cannot
be doubted. Pregnancy and abortions ; severe
injuries, succussions and concussions of the trunk
(Bonet, De IIaen, &c.), diflicult dentition, may
also excite some one of these maladies. The com-
plication of ascites with' pregnancy has been
observed by every practitioner, 'i'he sudden sup-
pression of cutaneous eruptions and accustomed

DROPSY — Appearances on Dissection,

605

discharges is one of the most common causes of
dropsical effusions, particularly when other con-
current circumstances are present. Lentin,
Hautesieck, Backer, Riedlin,Thilenius,VVil-
LiCH, Schmidtmann, and Frank, insist much
upon the repulsion of the acute exanthemata and
erysipelas ; and Gmehn, Hui eland, and Osian-
der, upon that of the itch, herpes, lepra, and por-
rigo. I have often seen acute liy(lroce[)haIus
appear after tlie use of externul remedies in the
cure of porrigo, to the neglect of internal measures.
Morcagni, Piso, Guyon, Fischer, Michaelis,
and others, instance the occurrence of acute drop-
sies after the suppression of gout and rheumatism ;
C.ELius AuREi.iANi's, Rhodius, FoRESTi's, and
SciiMOEGER, after the disappearance of haemor-
rhoids; and jMorgagni, Hoffmann, Ab Hfer,
Oberteuffer, Demiani, Brisbane, Frank, and
Facchier, alter the suppression of the menses
and the lochia. The sudden arrest of an habitual
diarrhoea and of chronic dysentery has been
observed by IIippocrates, Riedlin, Frize, and
Stole, to produce effusion, particularly in
the peritoneal cavity and general dropsy has
been observed by BAXiTHOLiNjfjisTER, De IIaen,
PoMARD, and Lentix, to result from suppression
of urine. That aqueous effusion should follow
excessive depletions and hjemorrhages, has been
doubted by some of those who consider it as a
consequence of plethora or increased action :
but Forestus, Blankard, Hoffmann, Hal-
LER, De Haen, D. Monro, Gordon, Hel-
wiG, and others, have inet with such occur-
rences.

9. 0. The diseases upon which dropsy most
commonly supervenes, are chiefly fevers, and vis-
ceral inflammations and obstructions. Quotidian
and quartan intermittents, and bilious remittents,
when purgatives have been neglected, or when
bark and stimulants have been too freely ex-
hibited, to the neglect of requisite evacuations,
are often followed by dropsy. Tiiojiann states,
that he has seen it consequent upon sanguineous
evacuations carried too far in these maladies.
The occurrence of effusion as a termination of
inflammations, particularly of serous membranes,
and from diseases of the heart, lungs, liver, and
spleen, has been generally admitted in modern
times. The frequency and the characters of dropsy
after scarlet fever have attracted the notice of
most writers on these diseases, particularly of
Withering, Frank, Ploucquet, and Hufeland.
Its occasional supervention during phthisis, bron-
chitis, chronic catarrh, and hooping-cough, must
have been familiar to every physician of expe-
rience. An aqueous, or aqueo-sanguineous effu-
sion into the serous cavities was a common cir-
cumstance in the scurvies which forineriy proved
so destructive to fleets and armies. I'he con-
nection of dropsies with chronic and obscure
diseases of the kidneys, imperfectly noticed by
Aetius, Avicenna, Messue, Lentin, and Tiling,
and fully established by the researches of Dr.
Bright, is of the utmost practical importance. The
occasional dependence of these maladies upon
lesions of the uterus and alterations of the organs
already mentioned, as well as upon others, will be
more particularly noticed hereafter.

10. lii. Appearances observed on Dissection,
— A. In the cavities and parts the seat of the effu-
sion, — (a) The serous membranes are frequently

found thickened and opaque, sometimes softened,
and occasionally harder than natural. In many
cases, evidence of antecedent inflammatory ac-
tion, as coagulable lymph, and cellular bands, or
tlie remains of cold adhesions, exist in the pleurse
or peritoneum. Bonet observed the latter mem-
brane inflamed and covered by a mucus-like
matter ; De Haen and Barron, granulated or
tuberculated ; Tacheron and Ayre thickened,
opaque, and white ; and Stoerck and others,
indurated, and in parts cartilaginous. Similar
changes are detected in the pleura;. Both mem-
branes are often blanched and thickened when
the effusion has been of long duration. The cel-
lular tissue in anasarca is sometimes merely infil-
trated, and its areola; distended by the watery
fluid. Portal states, that it is frequently thick-
ened, the cells dilated or lacerated, and the inter-
muscular tissue indurated and almost cartilagin-
ous. When the infiltration and distention become
great, the denser structure of the cutis vera is
sometimes penetrated, owing to the separation of
its fibres (Bichat) ; and the epidermis is either
raised into blisters, — some of which have been
seen unusually large by Morgagni, — or lacerated,
the fluid partially, or nearly altogether escapino-
through the apertures. Occasionally the cel°
lular tissue is much softened and plastic after
the liquid is removed ; or it is very white or
blanched, its appearance suggesting the idea of
maceration.

11. (b) The characters of the effused fluid have
been remarkably overlooked. They vary ex-
tremely, but they generally have some reference
to the state of vascular action in the seat of effu-
sion. When this has been considerable, the
fluid is more or less whey-like and turbid ; or it
contains pieces of albuminous matter, or flocculi,
or fragments of a filamentous lymph ; and the
serous sui faces are often slightly covered in parts
with a reticulated lymph, or a muco-albuminous
substance. In cases where the effusion has been
chiefly owing to an altered state of the blood and
diminished vital collision of the tissues, the ac-
cumulated fluid is frequently dark-coloured,
turbid, of a dirty or sanguineous appearance.
These conditions are principaUy found in dropsy
of the pleura;, pericardium, and peritoneum.
When the disease occurs slowly, and is chiefly
owing to debility, original conformation, or im-
peded circulation, the fluid is usually more limpid ;
and it is frequently remarkably so, being also
nearly devoid of animal matter, as in chronic hy-
drocephalus and spina bifida. In some in-
stances, and particularly in ascites or ovarian
dropsy, the fluid collected after repeated tapping
often assumes very diversified appearances. It
has been remarked of a yellowish, greenish
yellow, or greenish colour; or brownish, or even
nearly black, by Morgagni, Littre, and others.
It has likewise presented puriform, viscid, Gela-
tinous, milky, or chylous characters, according
to Willis, Morton, Becker, Coste, and Pro-
ciiAsKA. It has, moreover, been found possessed
of a foetid or penetrating odour by some authors
now mentioned, and by myself. I'he milky, or
chylous fluid is ascribed by several pathologists
to rupture of a lymphatic vessel. The puriform
and viscid or jelly-like effusion is most probably
caused by sub-acute or tchronic inflammation
The yellowish or greenish yellow tint is some-

606

DROPSY — Appearances on Dissection.

times owing to concomitant jaundice, or disease
of the liver occasioning the accumulation of the
colouring constituents of bile in the fluids ; and
the green, brown, or black colour probably arises
from the presence of a portion of the colouring
matter of the blood, Tlie offensive odour, as
well, perhaps, as some of the above alterations,
may be the consequence of the admission of air
into the cavity after tapping, and of the super-
vention of inflammatory action upon this opera-
tion, or of the long retention in a high tempera-
ture of a fluid containing a large proportion of
animal matter, or of both circumstances con-
joined. The liquid effused into the ovaria is
generally possessed of very different characters
from those presented by the fluid found in the
pleurae or peritoneum ; and that of chronic hy-
drocephalus and spina bifida is commonly differ-
ent from all others, — the liquid found in the ova-
rium, and in the brain, presenting, respectively,
the opposite extremes of fluidity, or rather of
animal matter. As the properties of the fluids are
different not only in the several seats of the effu-
sion, but also according to the slates of vital action
accompanying it, but little importance can be at-
tached to the results of chemical analysis, unless
they be derived from an extensive and diver-
sified series of cases. These obtained by Dr.
Marcet, are not materially different from those
furnished by Bostock, Bauruel, and Berzelius,
who found that all the specimens of fluid contain
nearly the same saline ingredients as the serum of
the blood ; and that the chief difference consists
in the quantity of animal matter, chiefly albumen
and incoagulable mucus (the osmazome of Ber-
zelius and Barruel) they furnish. The follow-
ing table is given by ]-)r, INIarcet : —

In 1000 grains of nuid.

Fluid of Spina bifida

Hydrocephalus -

Ascites

Ovarian dropsy -

1— Hydrothorax

^— — — Hydrops pericardii

Hydrocele -

Blister

Serum of Blood

Specific

gravity.

1007 0
1006-7
1015-0
1020-2
1012-1
1014-3
1024-3
1024-1
1029-5

grains.
11-4
9-2
33- .5

26-6
33-0

80-0

2-2
1-12
25-1

18-8
25-5

71-5

8-4
8-0
7-8
7-5
8-5
8-1
9-2

12. B, The lesions of the viscera which are con-
nected with the production of dropsies, comprise
almost every variety of which these viscera are sus-
ceptible. The heart, its valves and membranes ;
the blood-vessels, particularly, the veins and
lymphatics ; have presented, in different cases and
states of the disease.nearly every alteration describ-
ed in tlie articles on the morbid anatomy of those
parts. To these I must refer ; but here may add,
that the absorbent vessels have been found varicose
and otherwise diseased, and the glands in the
vicinity of the blood-vessels indurated and en-
larged, by MoROAGNi, Morton, Soemmkrino,
Haase, Assai.ini, Bull at, Mascac.m, and Hodg-
so.v. The frequency of inflammatory appear-
ances in the inner membrane of the aileries, and
the presence of ossific deposits in them and in the
aorta, have been remarked by Hoffmann, Frank,
Badlr, and myself. Tiie respiratory organs, the
liver, gull-bladder and spleen, present in different
cases all the appearances described in the articles

observed, that those changes and morbid pro-
ductions which interrupt the circulation through
the ramifications of the vena ports, as remarked
by Dr. Bright ; also the nutmeg-like state of its
substance, obstruction of the branches of the
hepatic duct by inspissated bile and cholesterine
and calculi in the gall-bladder ; are the most
common lesions.

13. The next important changes are detected
in the kidneys. jVIorgagni gives a case from
PiccoLHOMiNi, in which one of them being lace-
rated from the presence of calculi, the urine
flowed into the abdomen. Kibe, {Schwed. Ab-
handl. b. xiv. p. 47.) found them scirrhous ; and
Hufeland met with numerous hydatids contained
in cysts formed in their substance. Instances,
however, were few, in which disease of the kid-
neys was mentioned by authors in connection
with dropsy, and, when noticed, it was in a very
vague and unsatisfactory manner, until Dr.
Bright furnished numerous proofs of the fre-
quency of lesions of structure in these organs,
and described their various forms, and relations to
dropsical effusions. The^'rsf form which he par-
ticularises, seems to consist of wasting of the
structure, and diminished vascularity and firm-
ness, of the kidneys, which are of a yellow mottled
appearance externally ; their internal structure
being also yellow, slightly tinged with grey, and
the tubular portions of a lighter colour than
natural They contain no morbid deposit. This
change is connected with a cachectic habit of
body and debility ; the urine being only slightly
coagulable. The second form is that in which the
whole cortical part is converted into a granulated
texture, with a morbid interstitial deposit of an
opaque white substance ; giving, in its earliest
stages, when the tunic is taken oflT, an increase
of the natural fine mottled appearance of the
organ ; subsequently with innumerable specks
strewed over its surface, and distributed through-
out its whole cortical substance, and with defi-
ciency of its firmness. At a later period, the
granulated texture shows itself externally, occa-
sioning irregular projections of the surface, the
organ being generally somewhat enlarged. In
the third form of disease, the kidney is quite rough
and scabrous, and its surface ri.ses in numerous
projections, not larger than a pin's head, of a
yellow, red, and purplish colour. Its shape is
often inclined to the lobulated ; it is nearly of a
semi-cartilaginous hardness, and it gives great re-
sistance to the knife. The tubular portions are
drawn near to the surface, every part of the organ
appearing contracted, and less interstitial deposit
being present than in the foregoing variety. Dr.
Bright connects these two varieties with coagu-
lable urine; and thinks tliat, as the one appears
to pass insensibly into the other, they are com-
monly grades, or stages of the same change.
Besides these, there are other lesions of the kidney,
found in dropsies : as preternatural softness ; ob-
struction of the tubular structure, by a white
deposit resembling small concretions; scrofulous
matter infiltrated or deposited in the cortical sub-
stance, and in the interstices between the tubuli
and, indeed, most of the lesions described in the
article Kidneys. It is very justly remarked by
Dr. J. Grigouy, that disease of these organs is
chiefly found in those dropsical patients who are

on these viscera. As respects the liver it may be | of a strumous diathesis, or who are addicted to

DROPSY — Pathological

spirituous liquors. The uterus and ovaria often
present numerous lesions of structure, but none
that are especially connected with dropsy, except-
ing those accumulations of fluid whicli sometimes
take place in the latter organs, and which can
scarcely be considered as a species of this disease.
Various morbid appearances are also found in the
omentum and mesentery, particularly in Ascitis.
(See Dropsy of the Abdomen.')

14. iv. Of the chief Pathological States
OCCASIONING Dropsies. — I'he lesions, to which
dropsical effusion has been imputed in modern
times, have been too generally those alterations of
structure either preceduig or attending it. But
although these are manifestly important agents in
its causation, yet they are not the only agents,
for we very frequently find them in their most
fully developed forms without any effusion. Of
the numerous remote and pathological causes
enumerated above, there is none, which will
singly produce dropsy. And, perhaps, in no
other disease is a greater concourse of causes re-
quisite to its appearance, than in this. In recent
times, the changes of structure have been investi-
gated, somewhat to the neglect of vital condi-
tions or manifestations ; and the former has been
too generally looked upon, in respect of the
diseases now under consideration, as proximate
causes, instead of being viewed as concomitant
lesions resulting from anterior changes implicating
the functions of life, in one or more of the systems
and organs of the frame. The association, how-
ever, of these lesions should not be overlooked ;
and the share which each may have in augment-
ing or perpetuating the other ought to be kept in
view, but with a philosophic reference to anterior
conditions.

15. Up to the end of the last century, dropsies
were considered as essentially depending upon
obstructions or debility ; although some among
the ancients, particularly Hippocrates, admitted
the propriety of bleeding in some cases. Stoll,
Strak, Brambilla, Schmidtmann, J. P. Frank,
and Grapengiesser, at the epoch now alluded
to, inculcated the frequent inflammatory origin
of these diseases. Wells, Blackall, Aber-
CROMBIE, Stoker, and Ayre followed in the same
track; and, excepting a slight disposition to carry
this doctrine too far, contributed to the advance-
ment of this branch of medical knowledge. At
present it is generally admitted that dropsy may
arise from sur-action, or sub-action, — from gene-
ral or local plethora, as well as from obstructed
circulation — from deficient excretion, and from
excessive evacuations rendering the blood thin or
watery. The numerous changes detected in con-
nection with aqueous effusion, and allowed to
favour both it and the accumulation of the fluid,
may be resolved into a single proposition, viz.
increased exhalation and diminished absorption,
which comprises all the views promulgated on the
subject, the matter chiefly in dispute being as to
which of these changes is the accumulation of
fluid cliiefly owing. It has been attempted to
settle the point by experiment and post mortem re-
search. But a matter purely of function — lesions
so dependent on vital action and structural cohe-
sion as eflPusion most undoubtedly is in many cases,
however associated, or otherwise dependent upon
organic change — cannot admit of a satisfactory
elucidation in this manner alone.

States which occasion it. 607

16. Those who favour the doctrine of increased
exhalation argue, that this change usually follows
excited action, or irritation of serous surfaces, or
relaxation of the exhaling pores, or this latter
state associated with increased action of the
larger vessels ; that the appearances of the fluid
and the constitutional symptoms indicate the ex-
istence of excited action ; and that absorption is
not diminished, is shown by the increasing emaci-
ation attending the effusion, and by the fact of
this function being generally augmented with the
progress of debility. The believers in diminished
absorption contend that, when the agents of this
function — either lymphatics or veins — are ob-
structed, an accumulation of serum takes place in
the parts beyond the obstruction ; that when
plethora, general or local, exists, absorption is
diminished, as shown by the experiments of JNIa-
CENDiE and FoDERA ; and that, as vascular fulness
and action are removed, this function becomes
restored to its natural activity. That the balance
of function — of exhalation — and absorption — is
broken, is very obvious ; but the question is, to
which is the fault chiefly attributable'! It is evi-
dent that exhalation preponderates over absorp-
tion, in all cases where vital action or vascular
plethora is increased ; and that, on the other
hand, diminished absorption chiefly obtains where
the venous or lymphatic circulation is either im-
peded or obstructed. These propositions are
proved by experiment, and confirmed by repeated
observation and numerous pathological facts. So
that, instead of contending as to which of these
functions is chiefly disordered, it would have been
more correct to admit that either may be more or
less affected in different cases and forms of the dis-
ease, according to the states of vital energy and
the nature of concomitant organic change. Con-
formably, therefore, with these facts, rejecting all
exclusive doctrines, and following nature as
closely as I am enabled to interpret her actions,
I believe that dropsy may arise as now stated, as
more precisely expressed in the article Disease
{§ 94.), and as will be more particularly described
in connection with lesions of vital manifestation
and of structure.

17. In considering the pathological states oc-
casioning dropsy, the conditions of vital action
appear equally important with structural change,
the more especially as the effusion, even where
the latter is the most obvious, depends as much
upon the former as upon it ; alterations of vital
manifestation giving rise to both the change of
structure and the effusion, whether or not the effu-
sion be a concomitant or a consecutive result.
This consideration has so forcibly influenced the
ablest writers, as to induce them to arrange the
forms of this disease with strict reference to it.
Thus they have been divided into the acute and
chronic, the sthenic and asthenic, the tonic and
atonic, the active and passive, the infianimatory
and non-injlammatory or lencophlegmatic, and into
the idiopathic and symptomatic, or the primary or
secondary — as they proceed directly from their
external causes, or from some visceral disease.
These forms are met with in all the seats of
dropsy, but in different degrees of frequency.
The acute, sthenic, or active state — the effu-
sion consequent upon increased determination
and excited action — occurs most frequently in the
ovaria and brain, and next in the pleuree, pericar-

608

DROPSY — Primary or Idiopathic.

dium, cellular tissue, and peritoneum. Although
these states are nearly allied to, they are not
identical with, the inflammatory variety of dropsy,
which is also most common in the former of these
situations. Idiopathic or primary dropsy very
generally assumes these states, being connected
either with plethora, with increased determination,
or with inflammatory action, the augmented ex-
halations supervening to, and promoting the reso-
lution of, its acute or early stages. This connec-
tion will, therefore, be kept in view in the follow-
ing remarks.

18.^. Primary or IdUrpathic Dropsy. — (a)
Acute dropsy, or e [fusion from increased action (the
Sthenic, Tonic, Acute, Active, and Injiammatory,
of aut hors ; tiie Augmented Secretion of Irritation
of DupuYTREN andBREscHLT; the Hydrophleg-
j)iasi<E of JNI. Rayer ; a form of Hypercrinia or
augmented secretion by M. Andral). Tissot,
Geromini, and Bouillaud consider this form of
disease to be intermediate between healtliy ex-
halation and inflammatory action ; and Dr.PARRY,
that it is the result of increased momentum or de-
termination of the circulating fluid to the seat of
effusion. That it often originates in vascular excite-
ment of the part chiefly affected, and is frequently
connected with general, relative, or excremen-
titious plethora have been fully demonstrated. But
the vascular excitement, and especially the injec-
tion of the capillaries usually accompanying it, is
often dissipated, either partially or altogether, soon
after the effusion it occasions has become con-
siderable ; and but little remains of the vascular
action, which may have approached the inflam-
matory state at the commencement, or of its usual
results, but the unabsorbed fluid. — As soon as the
vital tonicity of the exhaling vessels or pores be-
comes even partially exhausted, or the vital cohe-
sion of the serous or cellular tissues diminished,
even the natural momentum of the circulation in
the larger vessels will be sufficient to produce or
keep up a morbid increase of the exhalation.

19. a. The exciting causes of acute dropsy are
suppression of the perspiration, and of any of the
natural secretions and discharges, repulsion of the
exanthemata and acute eruptions, and the usual
causes of inflammatory diseases. It is often con-
sequent upon scarlatina, and the puerperal states ;
or connected with inflammations, particularly of
the viscera invested by serous membranes ; and
with sub-acute inflammation or active congestion
of the central parts of the brain, the substance of
the lungs, the pleura;, the pericardium, the uterus,
and tiie ovaria. It occurs most frequently in the
young and comparatively robust ; and is either an
idiopathic disease, as I have here chiefly considered
it, or a termination of a morbid state nearly
allied to inflammation, or a consecutive or symp-
tomatic malady, as when it is preceded or at-
tended by lesions of some adjoining or remote
viscus, in which form it will be considered in
the sequel.

20. /?. Progress. — Although acute dropsy ge-
nerally appears suddenly and increases rapidly,
yet various symptoms of disorder precede those
dependent upon the efl^usion. The preliminary
disturbance is often indefinite ; but a sense of un-
easiness, soreness, or slight pains of the parts in the
vicinity of, or inclosed by, the cavity about to be the
Peat of the effusion, with disturbance of their func-
tions ; more or less derangement of the natural

secretions and excretions ; increased hardness, or
fulness, or frequency of pulse ; irregular chilli-
ness or febrile phenomena, and a feeling of general
indisposition ; often precede, in various grades of
severity, and for a longer or shorter time, the pa-
thognomonic symptoms of effusion. When these
first appear, the pulse is usually hard, full, and
accelerated, and the skin hot and dry. There
are also restlessness, pains in the back and limbs ;
tenderness of the surface of the body, particularly
over the chief seat of disease ; loaded or white
tongue, thirst; constipated bowels ; scanty, thick,
high-coloured urine ; and, if the effusion takes
place in the thorax, dyspnoea, cough, and other
symptoms of that form of the disease, generally
precede rather than accompany it. The febrile
symptoms often partially subside in a few days
as the eflfusion increases, whilst the symptoms
caused by the accumulation become more and
more urgent. The urine, in this form of dropsy,
generally furnishes, by heat and acids, more or less
of a coagulated albumen ; — a fact first insisted
upon by Dr. Wells and Dr. Blackall, and im-
puted by Dr. Bright to disease of the kidneys.
There is no doubt of this being a frequent pheno-
menon, both in acute dropsy, where there is no
evident lesion of these organs, and in other forms
of the disease, where they are extensively altered.
I have, however, occasionally observed it where
there was neither dropsy, nor any disorder of these
emunctories ; but it is probably more frequently
connected with these disorders than otherwise.

21. (b) Sub-acute dropsy. — -The preceding
may be viewed as the most acute or inflammatory
form. Yet there are states of the disease interme-
diate between it and that next to be noticed. —
a. Those which approach the nearest to the
sthenic or acute arise from similar causes, are often
preceded by the same indefinite symptoms, and
manifest themselves more or less suddenly, but
advance less rapidly, than it. Sub-acute dropsy
most commonly occurs in the cavities of the chest
and pericardium, or in the cellular substance;
and is not infrequently complicated with bron-
chitis, or with inflammation and hepatisation of
the lungs. It sometimes follows scarlet fever, or
even measles. I met with two cases of it after
severe attacks of the influenza of 1833. — 0 Those
states of it which approach the asthenic or passive
form (5^ 22.) are most frequently seated in the pe-
ritoneal cavity, or in the cellular tissue, or in both;
are sometimes connected with the puerperal states,
or with chronicbronchitis ; and are seldom preceded
or attended by any fever, increase of temperature,
or tenderness of surface : but all the secretions and
excretions are more or less impeded, and some of
them are entirely interrupted. The urine is only
occasionally, or slightly coagulable, and chiefly
in those cases which approach closest to the
acute — y. The sub-acute form of dropsy, espe-
cially, may arise from whatever will determine or
solicit a greater flow of blood than natural to
serous surfaces ; particularly if the tonicity of the
exhaling pores, and vital cohesion of the tissue,
are insufficient to oppose the momentum of the
circulation.

22. (c) Asthenic or passive dropsy is much more
rarely a primary or idiopathic disease than symp-
tomatic of, or dependent upon, the pathological
states about to be described. In its primary
form, it may be attributed chiefly to relaxation of

the exhaling pores, and of the serous and cellular
tissues, and to increased tenuity, or allcuitions of
the blood existing independently of any consider-
able structural change. It is sometinies caused
by excessive sanguineous evacuations, or exhaust-
ing discharges ; by the suppression of secrelions ;
and by a deficient, watery, vegetable, or un-
wholesome diet. The dropsy tiiat sometimes
prevails among the poor in times of scarcity is
generally of this kind. It is usually cluiracteri^ed
by a weak, unequal, small, and frequent pulse ;
paleness of the lips, tongue, and gums; fl;iccidity
of the muscles ; anhelation on slight exertion ;
feebleness of the joints; swellings of the lower
limbs, or anasarca attending or preceding the
effusion into the cavities of the trunk ; an un-
healthy appearance of the cutaneous surface ;
and absence of those symptoms which indicate
the existence of visceial obstruction or dis-
organisation. I'lie urine does not coagulate by
heat or acids. This form of dropsy is usually
chronic, and is, in adults, most commonly seated
in the abdomen, or in the cellular tissue, or in
both ; sometinies appearing in these situations,

DROPSY — Secondary ok Consecutive. 60ft

is of an active nature, hemoptysis, pneumonia,,
or pleuro-pneumonia, or congestion, takes place
in the lungs in the course of the dropsy, and
favours or increases the thoracic effusion. When
ihe cardiac disease consists chiefly of passive
dilatation and thinning of the cavities, the effusioa
is usually also of a passive kind, or attended by
vascular and general asthenia, a lowering treat-
ment accelerating a fatal issue. Occasionally the
anasarca disappears, or is diminished, for some
time before death; hut the symptoms of the in-
ternal accumulation of fluid become more urgent.
When obstruction in the valves of the left side
of the heart exists, congestion of the lungs, with
sudden increase of the effusion into the pleura,
not unfre(iuently occurs, and terminates life by
asphyxy. The mine, in this state of the disease,
is often without any albuminous coagulum, or
with very little : but it may, or may not, exist
even in the same case, at different stages of its
course. This form of dropsy is very frequently
benefited by treatment, or tor a time apparently
removed ; but it as often recurs, until the pro-
ess of tlie primary lesion, and the exhausted

particularly the former, after parturition, when it vital energies, at last favour an increased, a more
may assume a less asthenic form than that now i general, or more sudden effusion, often associated
described. It occurs most frequently in females, with pulmonary congestion, and life is thereby
and is occasionally associated with hysteria. I quickly terminated. When the excreting func-
have seen it supervene on chlorosis. In infants tions are impeded, the effused fluids may, from
it usually takes place in the head, and proceeds i effete or irritating matters being secreted along
from constitutional disposition or congenital vice. " '' '' ' ' ' ' ' ■' ''

23. B. Secimdary or Cnnseciitive Dropsies —
Siimploiuatic Dropsies — Chroiiic or Passive Drop-
sies— are of most frequent occurrence. They are
sometimes preceded by inflammatory action ; are
seldom, hov;ever, attended by acute, but often by
sub-acute or chronic inflammation, or by active

with them, act injuriously upon the surface or
ti^sue with which they are in contact ; and, in
this manner, much of the appearance of initation
or of structural change, observed either in its
course or after death, may be superinduced.

25, (h) Disease of the blood-vessels und lympha-
tics is often productive of dropsies ; but in many

congestion. I'hey are usually of long duration, ' instances its seat and nature cannot be determined

and frequently the effects of complicated organic
change, although generally more immediately de-
pendent upon some specific lesion.

24. (a) Dropsii from disease of the heart is
always preceded, for a long or indefinite period,
by symptoms of disease of this organ. When
effusion commences, early evidence of it is pre-
sented in the countenance, particularly in the
morning, in the eyelids j and next in the feet and
ancles, in the evening ; or in the hands and fore-
arm, particularly the left. These partial anasar-
cous swellings usually continue a considerable
time before signs of the accumulation of water in
the chest are manifested, and still longer before
any effusion takes place in the abdomen. In
some cases, indeed, no fluid is found in this latter
situation. The pulse is fretiuenlly, but not
always, much afiected long before any anasarca
is observed. AVhen water collects in the face,
hands, or arms, after protracted ill-health, and
without pulmonary sym|)toins, disease of the
heart may be inferred, notwithstanding the re-
regularity of the pulse : but auscultation will
detect its nature. Generally, as the effusion
increases in these parts, so symptoms of its
commencement in the chest or pericardium,
most frequently in both, make their appearance.
The patient at first requires his head and
shoulders more elevated tlian usual in bed ; and
at last he cannot lie down, the effusion increas-
ing in the cellular tissue, and extending to
several or to all the shut cavities. In some

during the life of the patient, and frequently with
dilHculty afterwards. — a. The actions of the
arteries and capillaries are more or less affected
— are obviously increased in acute, and dimi-
nished in passive, dropsies; — but the change is
one of function rather than of structure. There
are, however, few eases of the chronic or passive
forms of the disease met with in advanced age,
where the arterial S3'stem is 'entirely devoid of
structural lesion. But when we consider the
frequency of alterations in this system in old age,
it becomes a question, whether it be connected
with effusion, otherwise than as both may be
coincident results of anterior disorders. Some
French pathologists, however, believe that the
simple retardation of the circulation, occasioned
by structural change in the arteries, favours effu-
sion into the cellular tissue and serous cavities.

26. $. In respect of disease of the veins, it may
be inferred a priori, and pathological facts have
confirmed the infeience, that obstructions of them
will occasion dropsical effusions, unless a collate-
ral circulation be establi-hed sufficient to prevent
extreme congestion of the vessels below the part
where the impediment exists. 'I'his position,
acknowledged since its demonstration by Lowkr,
has been frequently illustrated by the details
of c;«es. Raikem found, in two instances,
anasarca of the lower limbs, fibrinous concre-
tions obstructing the vena cava and internal
iliac veins. Moegagm observed a similar state
of the extremities from a tumour which pressed

cases, particularly when the disease of the heart ] upon these vessels; and attributes, in some cases,
Vol. I. 11 r

610

DROPSY — Secondary ou Conslcutive.

dropsy within the head to pressure upon the superior
vena cava. HALLERStates, that compression oi the
jugular veins has produced dropsy of the ventricles
and membranes of the brain. Laennec found obli-
teration of tlie vena cava in a case of ascites atid
anasarca. I have seen, in two cases, enormous dis-
tention of the thigh and leg, from the pressure of a
psoas abscess upon the iliac vein ; and analogous
facts are recorded by Hougson, D. Davis, Bouil-
i.AUD, Vei.peau, Meckel, and Lee. Organic
change about the right side of tiie heart, or tumours
pressing upon tiie thoracic portion of the vena cava,
will obviously produce a similar, but more general
effect. And 1 believe, with several pathologists,
that congestion or engorgement of the large veins,
from deficient vital power, particularly if it conti-
nue for any lime, will, independently of mecha-
nical obstruction, be sufficient to occasion both
increased effusion and accumulation of fluid ;
owing — 1st, to impeded circulation, consequent
dilatation of the smaller vessels, ande-'Cape through
the pores of a part of their more fluid contents ;
and, 2d, to diminished absorption ; which M. Ma-
jENDiE has shown, by experiment, to exist in parts
whose blood-vessels are inordinately congested.
If we allow, with this physiologist, and with se-
veral otiiers, who have furnished evidence in
recent times, that the veins exert an absorbing
function, either directly by their radicles, or by
lymphatic vessels opening into them, we must
necessarily admit that any obstruction, vital or
structural, of the venous circulation, will be fol-
lowed by an accumulation of fluid in parts beyond
the seat of obstruction.

27. y. Diseases of the lymphatics, both func-
tional and organic, have been viewed, as stated
above, as causes of dropsies. It is obvious that
little beyond the evidence of analogy can be ad-
vanced in favour of impaired function of these
vessels : but when we consider that many of
them open into veins, without passing through
glands, we may admit that they will experience
the same modifications of function as those vessels
with which they are thus intimately connected.
And when we reflect on the various circum.stances
calculated to retard or to entirely obstruct the
circulation in the lymphatics passing through
glands, and conveying their fluids into their prin-
cipal trunks, the admission of impaired function,
in some cases, cannot be unreasonable. Of this
species of lesion, it is obvious that post mortem
research can furnish no positive proof: but of
structural change direct evidence may be ad-
vanced, althougli the difficulty of obtaining it,
even in cases where it may exist, will necessaiily
diminish tiie amount. It has been considered by
-several of the authors mentioned above {§ 26.),
that rupture of the lymphatics; by JMoiigaoni,
AssAi.INI, BicHAT, SoEiMMEuniNG, 6cc. tluit a vari-
cose state of these vessels; by Sciikiih and Sa-
viAKD, that concretions formed in their ])rincipal
trunks; by IIaase, Boveh, IIunteu, Cuuick-

SIIANKS, SoEMMEKItlNG, JMaSCAGM, &i.C., that

compression of either them or their glands; by
most of the authorities now named, that obstruc-
tion, destruction, or extirpation of these glands ;
and, lastly, by some of then), that inflammation of
the lymphatics, may severally be followed by
dropsical accumulations. On the other hand,
cases have been adduced by ftloirroN, D. Monho,
Cui.T.KN, A. Cooi'iii, BitiiAT, and J>aennec, in
which the principal lymphatic trunks were ob-

structed without any collections of fluid having
been formed. — D. Monro and M. Dupuytrex
lied the thoracic duct in the lower animals, but
dropsy was not the consequence ; whilst Mr.
CiiESTON found it obliterated in a case of anasarca.
I therefore infer, that alterations of these vessels
either may, or may not, be the principal patholo-
gical cause of the accumulation of fluid ; that, in
respect of these species of lesions, as well as of
others, additional changes are frequently requisite
to the production of effusion ; and that, in many
instances where disease of these vessels has been
found in connection with dropsy, it has been rather
a coincident effect of functional or structural
change, or of both, in some vital organ, than the
chief source of the collection of fluid. From
what has now been stated, it may be concluded,
that opinions as to the exclusive operation of any
one set of vessels in producing symptomatic drop-
sies are altogether erroneous, and that either of
them may be concerned in the result, more espe-
cially the veins.

28. The Jiuid collected in dropsy from ob-
struction in the circulation differs from the serum
of the blood chiefly in containing much less al-
bumen. It is usually limpid, inodorous, either
colourless or of a citron tint ; and, in some
instances, when the obstruction has occurred
suddenly, it is slightly coloured by the escape of
a few of the colouring particles of the blood. The
parts containing it are commonly free from any
material change, excepting in the more chronic
cases ; and it often collects in very considerable
quantity, before much disorder referrible to the
accumulation is complained of. The symptoms
will necessarily vary with the seat and rapidity
of tlie collection, and the parts primarily or con-
secutively affected. The diagnosis of effusions
depending upon disease of the circulating vessels
is very difficult in all cases, and nearly impossible
in many. When it occurs in the strumous dia-
thesis, or early in life, or is connected with, or
consequent upon, swellings of the lymphatic
glands, lesions of the lymphatic system may rea-
sonably be inferred ; and when it commences as a
local oedema, or is limited to a single limb, or
continues in the lower extremities without any
signs of disorder referrible to the large cavities,
the obstruction of a considerable venous trunk
may be inferred. If it appear very slowly in
the lower extremities, and increase very gradually,
and be attended by a slow, or unequal, or irregu-
lar pulse, great coldness of the limbs, with or
v^■ithout discolouration or sores of the legs, parti-
cularly in aged or gouty persons, the arterial
system will very generally present structural
change, as ossific deposits in some part of its course.
29. ((•) Drops}/ cotmectedu-ith disease oj the lungs.
— Either hydrothorax or anasarca, or both, may
occur in consecjuence of jiulmonary affection,
or merely as coincident efl'ects of the same causes ;
and in many instances effusion may take place in
the pericaulium, in addition to the other forms of
dropsy. The acute states of anasarca are not
infrequently connected with inflammation, con-
gestion, or liepatisation of the substance of the
lungs, or with acute bronchitis, particularly after
exjiosiire to cold and moisture, or after scarlatina
or measles. In many of these cases tlie pulmonary
affection is somewhat obscure, the symptoms
being imperfectly developed ; and, unless auscul-
tation be used, is liable to be overlooked or mis-

DUOPSY' — SECONDAny on Consecutive.

611

taken. Dropsy from chronic bronchitis generally
supervenes, and proceeds nuich nure slowly than
that which is connected wilii the acute diseases
now mentioned, but it usually appears in the same
manner; the face, particularly the eyes, and upper
extremities, first becoming ccdemalous, and subse-
quently the ancles. When any aggravation of the
bronchial affection occurs, or if the inHammation
extends to the substance ot the lungs, the dropsical
effusion often increases rapidly. After repeated
exasperations of the pulmonary disease, with occa-
sional amelioration during summer, in the more
prolonged cases, the anasarca becomes more and
more general, and at last effusion takes place into
the pleurae, the pericardium, the cellular substance
of the lungs ; less frequently into the peritoneum ;
and in some instances into the ventricles, or be-
tween the membranes of the brain ; and the patient
is more or less suddenly cut off.

30. As fluid is effused into the pleura3, cr cel-
lular parenchyma of th.e lungs, difficulty of lying
down, and dyspnoea, come on and increase ; and
as it collects in the pericardium, irregularity of
the pulse, palpitations, anxiety, oedema of the
countenance, fulness of the jugular veins, &c.
supervene. If it accumulate on the brain, stupor,
coma, paralysis, or apoplexy, takes place. Dropsy
occurring in the latter stages of tubercular con-
sumption or chronic pleurisy is generally confined
to the lower extremities. It sometimes, however,
extends more generally, and occasionally more or
less fluid is effused into the cavities of the chest*

31. (d) Dropsy from disease of the liver and
spleen. — The ancients imputed dropsy more to the
liver than to any other part ; and during the fif-
teenth and sixteenth centuries, this organ was
generally considered as being always its cause.
VVarmbold, Pezold, Vater, Bianchi, and
others, however, showed that it was sometimes
free from alteration, even in ascites ; and more
recent and precise research has proved that it is
often not materially changed ; and that, in many
cases of dropsy, where it has presented certain
alterations, disease was likewise found in other
viscera, to which the effusion might be referred
with greater justice than to the hepatic lesion. But
collections of fluid are very fretjuently formed in
the la^t stages of most chronic diseases of the liver,
especially in those which impede or obstruct the
circulation of the vena porta. As to the nature
of the lesion, very imperfect, or hardly any know-
ledge can be obtained during life, or even previ-
ously to the effusion, unless as to the existence of
enlargement, and sometimes of abscess, which may
generally be ascertained by careful examination
and percussion.

32. When, however, the dropsy has been pre-
ceded, for a long period, by dyspeptic symptoms,
particularly by flatulence, uneasiness in the sto-
mach after a meal ; by pain or tenderness in the
right hypochondrium, below the right shoulder-
blade, or at the top of the shoulder ; by short, dry
cough, and the usual signs of chronic disease of
the liver, more particularly by the projection of
the edge of the organ below the cartilages of the
false ribs ; by jaundice ; light or clay-coloured
stools ; scanty red or high-coloured urine, de-
positing the lithic acid sediment ; and by slight
evening fever; the accumulation may be imputed
to the liver, the disease of which, and its attend-
ant symptoms, being frequently of very long

duration before any collection forms. The dropsy
usually appears first in the ancles, towards night ;
or in the abdomen, occasioning slight fulness ;
or nearly at the same time in both. The urine
is then more scanty ; and sometimes becomes
dark, muddy, turbid, or thick. The skin is often
harsh or dry, the bowels constipated, and thirst
increased. The progress of the accumulation
varies considerably. Occasionally the anasarca
of the lower extremities and the ascites increase
equally and gradually. In some instances, the
former proceeds much more slowly than the
hitter J and, in others, the acites arrives at its
utmost extent without much oedema of even the
ancles. In many cases there is great vacillation
in the course of each ; the one increasing and
the other diminishing, or either or both expe-
riencing a sudden aggravation, and rapidly reach-
ing the acme. Sometimes the collection in tlie
abdomen advances rapidly, and arrives at the
utmost in a very few days, without any attendant
anasarca ; the bowels being obstinately consti-
pated, and the urine nearly suppressed. In these
cases, the patient generally complains of nmch
pain and soreness, and frequently of tenderness, of
the abdominal parietes — probably owing partly
to the rapid distention ; and possibly, also, to the
action on the peritoneum, of the irritating proper-
ties of the collected fluid, arising out of the circum-
stance of its containing much of the injurious
constituents that are usually removed from the
system in the excretions which are so completely
suppressed. In dropsy from diseased liver, there
is seldom any effusion into the serous cavities of
the chest or head. But as ascites reaches the
utmost, dyspnoea becomes urgent, owing to the
diaphragm being carried high up into the thorax ;
and during the last few days of existence, slight
or low delirium appears, at first during the night ;
the pulse and breatliing becoming rapid and weak,
and the general weakness extreme, sometimes
with distressing nausea or retchings, and the
patient sinks.

33. When dropsy depends upon disease of the
spleen, evident enlargement of it generally pre-
cedes the accumulation of water, which, as when
it arises from disease of the liver, usually forms
in the abdomen, and in the lower extremities.
In some cases, particularly in those who have
resided in warm countries, or in miasmatous lo-
calities in temperate countries, the enlargement
of the spleen is associated with chronic alterations
of the liver ; and the consequent dropsy is but
little under the control of medicine. But when
the lesion of the spleen is its chief or only source,
it may be reinoved by treatment, along with the
disease in which it originated. When dropsy
comes on after repeated attacks of ague, and re-
sidence in an insalubrious climate, enlargement
of the spleen is often influential in its production,
or co-operates with other lesions in causing it.
In these cases, change of air is one of the best
means of removing it.

34. (e) Dropsi) from disease of the kidneijs. —
It may be stated of lesions of these organs, as
well as of others found in dropsies, that they are
often the principal pathological causes of the ef-
fusion, but that they frequently also exist without
this effect resulting from them. There can be
no doubt that every change of structure, to which
the kidneys are liable, may be more or less cod-

11 r 2

612

DROPSY — Secondary or Consecutive.

cerned in tlie production of effusion, especially
those which impeJe or interrupt their functions.
Of this latter kind seem to be the principal of
those so well described by Dr. Bright (§ 13.).
Dropsy may arise either trom disease of the kid-
neys alone — which seldom occurs, and in which
case it usually commences with anasarca, at
first affecting chiefly the lower extremities —
or from lesions of tliese organs associated with
those of the heart, or of the lungs, or liver. In
such complicated cases, the disease of the kidneys
may be either primary or consecutive ; perhaps,
more frequently, the latter. — a. When it is
consecutive, tiie dropsy commences, as already
described, in alterations of either the circulating
or respiratory systems ; the accession of the aftec-
tion of the kidneys being often distinctly indicated
by pains in the loins, sickness, vomiting, occa-
sionally purging, and coagulable urine. In some
instances, however, renal disease may exist with-
out these symptoms being prominent ; and co-
agulable urine may be present without the kidneys
being particularly implicated. — B. When the
renal afl:ection is the primary alteration, the
dropsy commences as anasarca ; but rapidly ex-
tends to the cavities of the pleuree and pericar-
dium, of the peritoneum, and not infrequently of
the arachnoid. In most of these cases, the symp-
toms are more acute, and the progress of the dis-
ease more rapid, than in any of the other forms of
symptomatic dropsy . This seems attributable to
the disease of the kidneys being such as pre-
vents them from removing all, or even a large
proportion, of the injurious elements constantly
requiring elimination from the blood ; to the con-
sequent secretion of a portion of them in the ac-
cumulated fluid ; and to tiieir imparting irritating
properties to it; whereby it induces inflammatory
action in the serous surfaces containing it, with
rapid aggravation of all the phenomena, and
occasionally a concentration of the malady in
one or more of its usual seats. Thus, it is not
uncommon to perceive symptoms of pleuritis or
pericarditis, or even of peritonitis, to accompany,
or even to precede, the more advanced periods of
the effusion into the respective cavities ; and, as
the disease is increased in one or more of these,
to observe the disappearance of the fluid from the
extremities. In some instances, where the collec-
tion has formed rapidly in the cavities of the
chest, either preceded or attended by acute
symptoms referrible to this situation and its con-
tained organs, not only the anasarca, but also
the ascites, where one or both have previously
existed, has partially or nearly altogether disap-
peared, the rapid eflTiision into tiiese situations
soon terminating existence. In other instances
of this form of dropsy, eflfusion on the brain is
superadded to these, and tlie patient dies comatose.
Dr. BuKMiT and Dr. Gregory remark, tiiat tiiere
is great proneness to salivation from small doses
of mercury in dropsy from <liseased kidneys.

35. (J) Dro/isi/ from disease of the uterus and
ovaria may arise either from the pressure they
produce, when enlarged, or containing tumours,
on the veins and lymphatic glands and vessels ; or
from the extension of disease from them to their
peritoneal covering. I met with a case, in which
ascites was conseiiucnt upon chronic inflamma-
tion of the uterus the peritoneum covering tiie
fundus having hccoiiie consecutively affected ;
and a nearly similar instance, in wliich the efiu-

sion into the peritoneum was owing to the sup-
pression of leucorrhoea by astringent injections.
In this latter case, I inferred that the discharge
proceeded from inflammatory irritation of the in-
ternal surface of the womb, or of the os uteri, and
that the treatment had suppressed the morbid
action in these situations, and determined it to
the fundus and peritoneal surface ; whence it had
extended further, and produced effusion into the
abdominal cavity. But little anasarca was
present in these cases, and that was confined
chiefly to the feet and ancles. Ascites may pro-
bably likewise follow chronic inflammation of the
ovaria, owing to a similar extension of the irri-
tative vascular action to the peritoneum. Ex-
cessive ha3morrl)age from the uterus, and abortions,
may also produce dropsy, as stated above (§ 8.).
Those diseases which have been generally de-
scribed as ovarian and uterine dropsies, are
purposely excluded from the present view of
the subject.

36. Of the Urine in Dropsies. — Owing to the
attention that has been paid to this topic in mo-
dern times, and particularly since the investi-
gations of Wells, Blackall, Prout, and
Bright, the state of this secretion has become
an important source of information as to the pa-
thological conditions giving rise to dropsical col-
lections ; although, when viewed alone, much
less dependence can be placed upon it. Dr.
Wells found that the urine was more or less
coagulable in the dropsies consequent upon scar-
latina, and even from the exhibition of mercury,
and that this symptom was most frequent in
anasarca, it having been remarked in twenty-four
cases out of thirty-seven. Dr. Christison and
Dr. I. Gregory also remarked it most commonly
in this form of dropsy ; and my experience ac-
cords with theirs. ' I have seldom seen it in
ascites. Dr. Blackall considered it as an at-
tendant upon the acute form of the malady ; and
Dr. Prout, as an indication of irritation. Dr.
Bright's cases prove its connection with the
more advanced states of the changes of the kid-
neys he has described, independently of the
existence of acute or sthenic vascular action.
Several physicians have remarked this state of the
urine in other diseases, unconnected with lesions
of the kidneys ; but admit its frequency in such
circumstances, as well as in acute dropsies. I
have often observed it in acute diseases of chil-
dren, where no alteration of the kidneys existed;
and I believe it is not uncommon after the ex-
anthemata. The above writers have also no-
ticed a less specific gravity of albuminous than
of healthy urine. As to tiie dark brown colour
which this urine fret|uently presents in dropsy,
the inference of Dr. Bright, that it arises from
the red globules of tiie blood, seems to be correct.
The presence of albumen may be ascertained,
eitiier liy boiling, or by the nitric or hydro-chloric
acids, ai:()hol, the ferro-prussiate of potash, or
bichloride of mercury. The last re-a'j< nt is, upon
the whole, tiie best. 'J'lie opinion of Dr. Phout,
as to the value of albuminous urine as a symp-
tom, will be adopted witii advantage ; namely,
that we ought always to be aware of its pre-
sence, as, tiiken along with the others, it may be
occasionally useful in directing our judgment of
the nature of the disaese ; but that, in the i)rc.
sent state of our knowledge, it does not indicate
any particular remedy or mode of treatment.

DROrSY TllEATMENT OF Pri.iiary.

37. V. Progxosis. — The prognosis in dropsies
will necessarily depend on their form and origin ;
on the extent and complication of tiie structural
changes occasioning them, the state of vital ma-
nifestations, and the habits and age of the patient.
— (a) y]cit/e and sub-acute dropsies are generally
much less dangerous than the symptomatic, par-
ticularly when occurring in young persons and in
tolerably sound constitutions ; but concomitant
circumstances, more especially their association
with pulmonary disease, and the nature and ex-
tent of that disease, will greatly modify the opinion
to be formed of the immediate or ultimate result.
The form of dropsy which occurs after scarlatina
or measles is much more curable than any other.
Asthenic dropsy, from excessive evacuations or
biemorrhages unconnected with structural change,
or that from insufficient or unwholesome diet,
generally admits of cure.

38. (J).) Consecutive or symptomatic dropsies
seldom are permanently removed. Those arising
from organic change of the heart may be remedied
for a time, but they generally recur again and
again; judicious treatment frequently prolonging
life, nevertheless, for several years. When the
effusion proceeds from disease of the lungs, the
prognosis will be formed with strict reference to
it; and on the whole, will be less favourable than
in the foregoing. The same remark applies to
dropsy from changes in the vessds. Accumula-
tions of fluid from organic lesions of the liver are
but little under the control of medicine, and
generally terminate fatally sooner or later. Oc-
casionally, however, exceptions occur ; and much
relief is often obtained for a considerable time.
When the malady depends chiefly on enlargement
of the spleen, a more favourable result has fre-
quently been obtained. Dropsy from disease of
the uterus and ovaria seldom terminates favourably.
And it would appear that effusions from structural
lesions of the kidneys are the most rapidly and
certainly fatal.

39. II. Treatment. — It will be obvious to
every experienced practitioner, that the distinc-
tions made above are merely the more prominent
features by which the malady may be recognised,
where the acquaintance with it is imperfect ; but
that there are numerous other shades of character
which deserve to be known, and by whicli he will
be in some measure guided in practice, that
scarcely admit of description. Of this kind more
especially are those ever varying states of vital
power, and grades of vascular action, which de-
mand certain indications of cure, or difl'erent
modifications of treatment, as imperatively as any
well-ascertained alterations of structure. There
are, perhaps, few diseases that require in the
treatment a stricter reference to the conditions of
vital power, in connection with changes of its
organic alliances, than those now being considered.
To ascertain these conditions, and to act strictly
in accordance witii them in dropsies, even as re-
spects those slighter modifications that can neither
be illustrated by examples, nor be made subjects
of precept, will tend more to successful practice,
than any other object of investigation.

40. i. Of Primary or Idiopathic Dropsies.
— A. Treatment nf the Acute. — The first object
of investigation will be the state of the disease in
relation to its remote and proximate causes, and
of the constitutional powers of the patient, com-

G13

prising every appreciable change in the vital
functions, and in the appearance of the soft solids,
as indicating modihcations not merely in the
grade, but also in the kind, of action. By the
inferences derived from this source, the practi-
tioner will be guided in the appropriation of the
means of cure, and in tlio alterations he may
conceive necessary of the measures about to
be described. — In this form of the disease, espe-
cially if it be associated with congestion or inflam-
mation of the lungs, if the constitutional powers
be unbroken, and if it have appeared suddenly or
advanced rapidly, a full bloodletting will be re-
quisite, and may even be repealed. In most
cases, however, local bleeding by cupping will
be preferable to a repetition of the venisection ;
and in more doubtful cases, the local depletion, if
decidtdly employed, will be sufficient. If cupping
be prescribed, it should be performed on the part
opposite to the seat of soreness or pain, or at a
distance from it, paiticularly when the lungs or
pleurae are affected. Contemporaneously neaily
with depletion, medicine should be taken to act
upon the secretions, and equalise the circulation;
and, for this purpose, there is, perhaps, nothing
superior, in the first instance, to calomel, in a full
dose, combined with James's powder, or with a
moderate dose of caiujduir, or with both. In some
cases, and particularly in persons who have been
addicted to drinking, the calomel will be advan-
tageously conjoined with opium. In this class of
subjects, general bloodletting must be employed
with caution. After one or two doses of calomel,
in either of these states of combination, a purgative
draught should be exhibited and repeated, and its
operation promoted by a terebinthinate enema.
(F. 149. 151.). Having removed plethora and
reduced the increased action, the good effects of
counter-irritation will be more readily obtained.
The ointment of the potassio-tartrate of antimony
(F. 749.), or the pea issue, are upon the whole to
be preferred ; but they should be employed on the
side opposite to that where uneasiness is com-
plained of, or at some distance from the most af-
fected part. Whatever external irritant may be
adopted should be long persisted in. In the course
of treatment, calomel, or blue pill, with either
James's powder or the ;jo;ai.sii)-((T)f cafe of antimony,
should be repeated from time to time, until in-
creased action disappear ; or be regularly continued,
particularly if the pleuras or pericardium be
affected, until the specific mercurial effects
become manifest ; when deobstruent and saline
purgatives may be prescribed, and their effects
promoted by the occasional exhibition of the
enema already recommended. The more cooling
diuretics only should be given at short intervals,
in order to promote the functions of the kidneys.
These will be advantageously associated with
diaphoretics. For the former purpose, the bi-tar-
trate of potash with biborate of soda, the acetate of
potass, and the nitrate of potash alone, or with nitric
aether, may be used ; and for the latter, the
camphor julep with liq. ammonia; acetatis, with
vinum antimonii potassio-tartraiis, or acetum col-
chici, and small doses of opium. In this form of
dropsy, 1 believe that all heating diuretics, as
squills, juniper, seneka-root, horseradish, with their
combinations and preparations, are, more or less in-
jurious, unless vascular action has lapsed into a
state different from the sthenic form with v\hich it
Jlr 3

G14 DROPSY— Treatment of Puimaey.

commenced. With this impression, I have usually
preferred those that are the most sedative and
refrigerating, especially foxglove, colchicum, the
wine of tobacco in small doses, and the spiritus
astheris nitrici, as long as any evidence of increased
action remains.

41. B. Of Sub-acute Dropsu. — Those intermedi-
ate states of the disease, between the acute and the
passive — between the sthenic and asthenic forms
— will necessarily require means appropriate to
the grade of action tiiey may evince. In the
more acute cases, local depletions, and the rest of
the treatment described above, will be most effica-
cious. In these, the judicious exhibition of deri-
vatives and purgatives, followed by diaphoretics
and diuretics, constitute the chief means of cure;
and, when this state of the disease occurs after
scarlatina or measles, or in connection with
bronchitis, digitalis, the preparations of antimony
with opium, and the warm or tepid bath, in addi-
tion to these medicines, and followed by change
of air, will prove of essential benefit. In the
more sthenic cases of the sub-acute, as well as in
the acute, disease, when it arises from suppression
of the perspiration, or of the exanthemata, the
warm or tepid bath, or medicated baths, consist-
ing of emollient decoctions, &c., or containing
the sulphuret of potassium, or the carbonate of
soda or of potash, will be serviceable, when em-
ployed after sufficient sanguineous and alvine
evacuations. In the less active states of the
disease arising from the same causes, particularly
from suppressed eruptions, the application, and,
occasionally, the repetition, of a large blister, or
of mustard poultices, or of warm terebinthinate
epithems, at a distance from the sent of effusion,
or of irritative action, where the existence of this
latter is inferred, will frequently be productive of
benefit. In those cases which approach the pas-
sive or asthenic character, or in such of the above
which may lapse into it, owing to neglect of
treatment, or to a too active treatment relatively
to the nature of the case, or to constitutional fault,
the means that will be advised for the form of the
disease which is thus characterised (§ 42.) should
be employed. It will sometimes occur, especially
in the intermediate or more doubtful cases, and
even also in the acute, that the more antiphlogistic
means will be productive of little or no benefit,
or will even appear to aggravate the symptoms,
although their exhibition seemed clearly indicated.
I have generally observed that the practitioner
has been misled by the great frequency of the
pulse, which he has mistaken for a sign of in-
creased or sub-acute action, instead of viewing
it, when it is at the same time soft, small, and
easily compressed, and when it is connected with
other signs of depression of vital power, as evi-
dence of great weakness conjoined with increased
irritability of the va-cular system. In such cir-
cumstances, I have found gentle tonics and astrin-
gents, with deobstiuenl laxutives, or with alkaline
Hub-carbonates; and the moderately stimulating
diuretics, more especially the bahdiiiic and tete-
binthinate preparations, with camphorated npiules,
&:c. ; and, if the pulse be languid, w'nh frictions
actively, long, or fref[uently emjjloyed ; prove
very beneficial. Sub-acute or acute drojjsie-,
ap])earing after the suppression of the ha-nior-
ihoiJal discharge, require, after moderate blood-
letting, the active exhibition of hpdragonuc. pnr-
gniiies; and the same states of disease connected

with suppressed menstruation are most benefited
by a nearly similar treatment, with the addition
of the bi-lwrate of soda, continued regularly for
some time. In some cases of the less sthenic
state of sub-acute dropsy, the internal and ex-
ternal use of tlie nitro-hydro-chloric acids ; or a
well-regulated course of Bathwaters, with frequent
changes of air ; and in others, the artificial waters,
of Carlsbad, Ems, or Marienbad ; and where the
bowels require frequent assistance, the Seidschutz
waters; have proved very serviceble.

42. C. Treatment of Asthenic or passive Drop'
sies. — In cases where the debility is general,
at tiie same time that vascular action is either
languid or weak — notwithstanding that the pulse
is frequent — and the vital cohesion of the cellular
and serous tissues is diminished, tonics with the
mineral acids, especially the infusion of cinchona
or the sulphate of quinine, should be prescribed.
Where a cachectic habit of body is manifest,
quinine will probably occasion heat and feverisli-
ness. In such cases, it will be necessary to
associate the vegetable tonics with deobstruents
and laxatives ; to exhibit the blue pill or Plum-
-MEii's pill, in small and frequent doses, with
taraxacum, or the compound decoction of sarsa-
parilla, the mezereon having been left out. In
many of those doubtful cases of this form of the
disease, where it is difficult to determine whether
it is primary, or associated with obscure lesion in
the secreting substance of the liver or kidneys,
some advantage will be derived from minute doses
of the bichloridum hiidrurgyri, in large quantities,
of the decoction of sarsaparilla, or of any of the
species of the smilax. 1 have likewise, in such
circumstances, found great service from iodine, par-
ticularly the iodide of potassium and the ioduretted
solution of the iodide, in smaller and much more
frequent doses than are usually directed.

43. When this form of dropsy has arisen from
excessive losses of blood, or has supervened on
chlorosis, the chalybeate preparations, with cha-
lybeate mineral waters, or the artificial Pyr-
mont and Spa waters, will be of the utmost
service. But care should be taken to ascertain
the non-existence of visceral ob'^truction before
they are resorted to, and to preserve the bowels
freely open during their use. W hen passive
dropsy occurs after delivery or abortion, bitter
infusions, and vegetable tonics, the decoction of
cinchona with mineral acids, occasional purga-
tives, and the terebinthinate enema, with frictions
of the surface and bandages, will be requisite;
and, if it be accompanied with hysterical symp-
toms, the preparations of juniper, spirit, ."ctheris
nitrici, or other a?therial preparations, with tinct.
camphoia; conip., or small doses of opium, will
be of much service. In these cases, tlie combin-
ation of diuretics with bitter or tonic infusions, and
small doses of the tinctura camphoraj Thebaica
(F. 7()({.), or the tinct. opii camph. (F. 728.) will
generally be advantageous.

44. ii. TnEATMENT OF Consecutive or Symp-
lOMATic DnopsiES. — It is obvious that the
intentions of cure in this class of dropsies should
have strict reference to the nature of the organic
lesions concerned in the production of cfl'usion,
and to tlie state of vital energy and structural
cohesion ; and that they should comprise the
following objects. — 1st. To remove these lesions,
and if this cannot be accomplished, to retard their
increase, ais the chief means of iliiniiiishing the

DROPSY — Treatment of Consf.cutive on Symptomatic.

615

effusion ; — 2il. To promote the absorption of the
fluid accumulated; — and, 3d. To support the
constitutional powers; as being necessary both to
the due operation of remedies, and to the exertion
of that vital resistance which guards the structures
against the impre>sion of hurtful agents, whether
generated within the system, and acting intnn-
sically, or invading them from without.

45. A. Of dropsy consequent on disease of the
heart. — It will be important to ascertain, as cor-
rectly as the rational and ausculatory signs will
enable us, the nature and seatoftlie cardiac lesion,
in connection with the seat of effusion, and its
characters in respect of activity. If obstruction
to the circulation be seated in the left side of the
heart, there will very probably be associated with
the effusion, congestion of the substance of the
lungs, which will aggravate the hydropic symp-
toms, and render depletion the more necessary.
Also, if the cardiac disease consist, eitlier alto-
gether, or in part, of active enlargement of the
parietes of the cavities, the dropsy will present
a sthenic character, and require antiphlogistic
remedies; but if the lesions be chiefly passive, —
if there be dilatation with thinning or softening
of the parietes of the heart, — the constitutional
symptoms will possess analogous features, and the
disease require an opposite — a tonic, treatment.
It will be evident from these facts merely, that,
in ss'mptomatic, as well as in idiopathic, dropsy,
and even in that connected with impeded circu-
lation through the heart, the strictest reference
should be had to the state of vital power and
vascular action, as the principal basis of our
intentions of cure.

46. If a state of sthenic action exist, local
depletion — preferably by cupping; hydragogue
cathartics, as eUiterium and the croion oil, repeated
from time to time ; or even these independently
of depletion ; and subsequently the \mi of diuretics,
or these at an earlier period where the active and
repeated exhibition rf purgatives are not well
borne ; will frequently remove the accumulation
of fluid. In this state of the disease, digitalis is
the most efficacious diuretic, especially after local
depletions and purgatives, in the more sthenic
cases. Debility rather indicates, than contra-
indicates, the propriety of resorting to it. The
infusion is the most certain preparation of this
medicine. Half an ounce of it two or three times
a day, as usually directed, is a much larger dose
than that recommenfled of its other preparations ;
hence the reason of its activity, its diuretic ope-
ration being heightened by the addition of small
doses of opium. If a tensive pain in the forehead,
with disturbance of the cerebral functions, come
on early after its exhibition, it will rarely be of
service, or it may even be injurious, as remarked
by Dr. Blackali,, and it, therefore, should be
immediately relinquished. AVhen there is much
debility, it should also be discontinued upon the
first appearance of an increase of the urine. But
even great debility is no reason against the use
of this medicine, as Dr. Witheuing has shown ;
only the more caution is required in its exhi-
bition. In such cases I have usually combined
it beneficially with camphor, a small quantity
of opium, or with cinchona (F. 8.59.), and
otlier vegetable tonics and cordials, or with
F. 708. or 728. Colchicuin is sometimes of
service when this form of 'dropsy assumes a

sthenic character, or appears in tiie rheumatic or
gouty diathesis; but it requires much caution.
It is most sate, and at the same time most service-
able, when combined with camphor or ammonia,
or with the alkaline carbonates, and infusion of
cinchona.

47. When the cardiac disease and its conse-
quent effusion are of a passive kind, and especially
if the constitutional powers are much reduced, a
tonic treatment, in conjunction with stimulating
diuretics, is retjuisite. The remedies of this de-
scription, already recommended (§ 43.), — the in
fusion of quassia, with the tincture of the sesqui-
i chloride of iron, and tincture of digitalis; the
j compound infusion of angelica (F. 219.); the
J decoction of broom (ops ( F. 75.), with the com-
pound spirit of juniper ; the compound decoction
of tara.vacuni (F. 77.), with tincture of calumba
or the potassio-tartrate of iron ; and either Formulas
570. 781. 859., or the following, will often be
prescribed with benefit : —

No. 179. R Potassa; Carbon. 3.i. ; Tinct. Ciimamom.
Co. 5j.; Spirit, ^i^ther. Nit. 3j ; Iiifusi Gcntianae Comp.
3j. {vel. Ilecocti Scoparii Coinp. 5j.) ; Aqus Anelhi 3iij.
M. Fiat Haustus ter quotidie suinendus.

No. 180. R PotassK Acetatis 3 ss. — 3ij.; Tinct. Di-
gitalis ^^\ viij. ; Tinct. Opii 111 v. ; Spirit. Junip. Comp.
5j. ; Infusi Quas.'iia; 3 ix.; Aqua; Pimenta; 3 iij- M. Fiat
Haustus ter quatervein die siimcndus.

No. 181. R Camplioras subactas, Guaiaci Resinse, aa
3j.; Pulv. Scilla; et Pulv. Digitalis aa gr. XV. ; Opii Puri
gr. v. ; Olei Juiiiperi lllxxij.; Mucilag. Acacia; q. s.
M. Contunde simul, et distribue massam in Pilulas
aquales xlviii., quaruni capi;it binas ter in die.

No. 18i. R I'inct. Digitalis HI x— xv. ; Liquor Am-
moni,-e Acetatis 3 ij. ; Infusi Cinchona et Mist. Cam-
plioriE aa 3 vj ; Tinct. Camphoric Comp. 5j.; et Spirit.
Anisi3ss. M. Fiat. Haustus bis quotidie suraendus.

43. B. Dropsy from disease of the absorbing
systems — veins and lymphatics. — The difiiculty of
determining when the effusion is owing to these
causes has been stated above, with such signs as
sometimes indicate its existence (§ 25. et seq.). In
the more limited states of anasarca, and even in
ascites, bandages and frictions, assiduously em-
ployed, with the internal exiiibition of the iodide
of potassium, or of the other preparations of iodine
to be found in the Appendix (F. 234. 723.),
have proved exceedingly beneficial in some cases
in my practice. The decoction of broom tops with
liquor potassae, or this latter In the compound
decoction of sarsaparilla ; equal quantities of the
bi-borate of soda and bi-tartrate of potass in the
decoctum cijdonim, or decoctuni guaiaci comp. ;
the diuretic drinks, in the Appendiv (F. 588. et
seq.) ; and frictions with deobstruent liniments
(F. 295. 297. 311.), will occasionally be of much
service. The carbonate of soda, or nitrate of
potash, or both, exhibited in tonic infusions, to
which small doses of digitalis are added ; and the
infusion of berberis, or the compound decoction of
taraxacum (F. 76, 77.), with carbonate of potash
or of soda ; or the same alkaline carbonates with
the infusion or mixture of the diosma crennta
(F. 231. 396.) ; may likewise be employed, with
a prospect of advantage, from their deobstruent
operation. In all cases of this kind, jreiule exer-
cise in the open air; the use of the artificial waters
of jMarienbad, and Eger, or of Seltzer or Seid-
schutz ; and strict attention to a moderate, di-
gestible, and cooling diet ; will prove of essential
benefit.

49. C. Dropsij coniiecled uilh p)ilmonarij dis-
eases.— 1'he treatment in this complication should
mainly depend upon the character of the vascular
Rr 4

616

DROPSY — Treatment of CoNSECU'ri\'£.

action, and vital power, and tlie nature of the
existing pulmonary lesion. If active congestion
or inflammatory action be present in the substance
of the lungs, or in the pleuiae, general or local
depletions, or both ; the internal use of antimonial
preparations with diuretics ; and external deri-
vation, as pointed out above (§ 40, 41.) ; constitute
the principal means. The same treatment is re-
quired, with the addition of purgatives, if the
effusion be associated with acute or sub-acute
bronchitis. In these states of the disease the heat-
ing diuretics, as squills, ammoniacum, senega, &C.,
ought not to be exhibited. The bitarlrate of
■potash vi\\.\i bihorate of soda or with digitalis; or
any of the neutral salts, with liquor ammonim
acetatis, the spiritus EEtlieris nitrici, or tlie acetic
cither; or the preparations of cn/f/ncHHi with the
alkaline carbonates, or with camphor or ammonia ;
are the most appropriate. In the chronic and
asthenic states of pulmonary disease connected with
a similar condition of the system, a tonic treatment
is indispensable ; and the warmer diuretics
(F. 552. 570. 893.) will generally be employed
with benefit, more particularly the balsamic and
terebinthinate preparations (F.22. 169. 485. 487.
571. 681. 827.), and ammoniacum, with the tinct.
camphora; comp. (F. 708.), or the tinct. opii
camphorata (F. 728.), or the preparations of
squills with any of the neutral salts, given in the
light bitter, or tonic, or diuretic infusions. (See
BiiONCHlTis — Treatment of Chronic, &;c.)

50. D. Treatment of dropsi) from disease of the
lirer and spleen. — (o) This form of dropsy is very
commonly connected with general debility, and
with a cachectic state of the frame. In some cases,
the colour, consistence, and vital cohesion of the
soft solids, are more or less changed, particularly the
cellular, serous, and mucous tissues. These cir-
cumstances should not be overlooked in framing
plans of treatment. Cases of this complication
are comparatively rare, that require general or
even local depletion. However, when symptoms
of inflammation of the liver are present, general
and local depletions — the latter at least' — should
not be omitted. ]\[ercuriuls should also be em-
ployed, especially when the surface of this organ
is the part chiefly inflamed; and occasionally
externally by friction, as well as internally ;
counter-irritation being kept up at the same time.
But it is doubtful whether or not these pre-
parations are beneficial in the chronic lesions
of the substance of the liver. I have generally
abstained from prescribing them in such cases,
excepting the bichloride, in minute doses in
the compound decoction of sarsaparilla, or in
the preparations of cinchona. More service will
accrue from the nitro-hydrochloric acid balli, or
from sponging the surface of the hypochondria,
night and morning, with a warm lotion contain-
ing these acids, or from the internal use of them.
Tlie chlorate nf soda may also be taken with ad-
vantage ; but 1 believe that greater benefit will be
derived from the iodide of pulassiuin, or tha olUor
preparations of iodine, given in minute doses, and
continued for a due ])eriod, than from any other
medicine. Either the infusion of calumba or of
quassia, or the infusion of pine lo])s; or the de-
coction of genista, or of taraxacum, witii the
alkaline carbonates, or with the liquor ammonia;
acetaiis, and spiritus a'theris nitrici; and the
bi-lartrate of poiash with iji-borate of soda, and
squills, taken in the form of electuaiy, with the

inspissated juice of the samburus nigra, will be
more appropriate when the liver is organically
changed than in the other forms of the disease.
'J"he preparations oi colchicum and tobarco, parti-
cularly the tinctura tabaci composita (F. 742.),
may also be given in this complication, but with
caution. They have seemed to me most benefi-
cial when associated with large doses of the alka-
line carbonates, and taken in tonic infusions or
decoctions; as those' remedies which depress the
vital powers too low are seldom productive of
benefit in cases of this description. (See Dropsy
— of the Abdomen."),

51. (6) A nearly sitnilar treatment will be
necessary when the sple/n is enlarged, to that now
recommended in cases of organic change of the
liver. I believe, however, that tonics of an active
kind, particularly cinchona, quinine, the prepa-
rations of iron, and the arsenical solution, either
conjoined, or alternated with purgatives or diure-
tics, are much more necessary in this complication
than in that last discussed. All the cases 1 have
seen connected with enlargement of the spleen
were consecutive of protracted agues ; and in
these, after exhibiting one or two full doses of
calomel with camphor, and fully evacuating the
bowels by means of the compound infusions of
gentian and senna (F. 266.), the above tonics,
prescribed as now mentioned, and assisted by
frictions over the region of the spleen, were pro-
ductive of great benefit. In the case of a patient
from one of the most marshy parts of Essex, with
tills complication, the preparations of iodine were
essentially efficacious. In this state of the disease,
but little or no permanent benefit will be derived
as long as the patient continues to reside in a
miasmatous locality. In it, also, more than any
other form, will advantage accrue from moderate
exercise, change of air, sea-voyaging, and the use
of the Carlsbad or Ems mineral waters, — which,
with those of Marienbad, Eger, and Seidschutz,
are often of service when the efi'usion arises from
hepatic obstruction.

52, E. Treatment of dropsy from disease of the
kidneys. — AUenUon has been so recently drawn
to this complication, by the writings of Dr.
Bright, that sufl^cient experience of the means of
treating it has not been yet acquired, I have had
an opportunity of treating only three cases, in which
these organs were found diseased after death, since
tlie publication of Dr, Brigiit's work. They
were persons of broken-down constitutions, by
drinking. In one of them the accumulation
steadily increased, notwithstanding cupping over
the loins, counter-irritation in this situation sub-
sequently, friction with stimulating liniments, and
various internal remedies, were employed. In
the others, these means were of temporary benefit.
The bitartrate of potash with jalap, and squills
with opium or hyoscyamus, are mentioned by this
pathologist as having been the most serviceable
in the cases which occurred in his practice. I
believe that, in a very great majority of instances
where effusion proceeds from this cause, the irri-
tating nature of the fluid poured out superinduces
inflammation of the membranes and cellular
tissue containing it, and thereby aggravates the
disease, and accelerates a fatal issue. That the
fluid is possessed of these properties may be
vi(!vved as a postulatum ; but if it i)e considered
that, when the functions of the kidneys are inler-
lupted, excrementitious or -serous plethora (see

DROPSY — Remarks on Medicines recommended in.

617

Blood, § 19.) will be the result ; and that the
watery parts of the blood, which are ertused from
this cause, must necessarily contain a consider-
able quantity of the injurious matters usually
eliminated by tiiese organs ; the irritating quality
of the accumulating fluid here contended for will
be admitted. In the cases seen by me, consecu-
tive inflammatory action appeared in the seats of
effusion; and a similar occurrence took place in
most of those detailed by Dr. Bright. When
this complication is attended by debility or diar-
rhoea, the propriety of employing tonics, with
diuretics and opiates, as cinchona or quinine with
the mineral acids or squills, cannot be doubted ;
and, when the bowels are constipated, or when
diarrhoea is not present, free alvine evacuations
by purgatives combined with bitter tonics, which
increase their operation, will be productive of
benefit. 1 believe that there are few cases of
this form of dropsy that may not admit of the
judicious exhibition of strengthening medicines,
when a free action is exerted on the bowels ; that
the diarrhoea and tormina which sometimes accom-
pany it, are seldom attended by copious evacua-
tions, but require that they should be procured by
medicine; that the bulsams and terehinthinules,
either conjoined with these, or trusted to chiefly
alone, or with small doses of opium, will prove
more beneficial than other diuretics ; and that a
lowering or antiphlogistic treatment has been too
generally adopted, as well in cases of this descrip-
tion, asin otherswhere coagulable urine is observed,
owing to the mistaken notion that this symptom
always indicates inflammatory or sthenic action.*
53. F. The treatment of dropsy from disease
of the uterus or oimria will depend upon the
state of vital power and vascular action. Al-
though very generally evincing an inflammatory
character, and connected with suppression of tlie
sexual discharges, yet it is often associated with
depressed vital or constitutional power, at least in
those instances which have come before me.
When, however, it supervenes on chlorosis, it is
altogether a disease of debility. In the former
.class of cases, local depletions, cooling aperients
and diuretics with gentle tonics ; the nitrate of
potash and carbonate of soda, with tlie spiritus
aether's nitrici and hyoscyamus in the infusion of
cinchona, or of calumba, or of juniper berries ;
the bi-tartrate of potash with bi-borate of soda;
the expressed juice of the sambucus nigra and
syrup of squills ; and frictions with oleaginous or te-
rebinthinated liniments (F. 297. 311.); may be
severally employed ; but the treatment should
mainly depend upon the presumed state of the pri-
mary disease, of the consecutive effusion, and state
of vital power. The object, in this form of the
disease especially, should be to remove the pri-
mary lesion ; for when this is accomplished, the
cflused fluid will soon be absorbed. When the
disease follows chlorosis, the preparations of iron,
the mistura ferri composita, the sesqui-oxide of iron
with electuary of senna and oxymel of squil's;
the preparations of juniper with cinchona, &lc.,

* A very obstinate case of anasarca, with coagulable
urine, in which I had prescribed various remedies with-
out, or with little, benefit, was entirely cured by the
following in a few days : — R. Potassfe Bitart. 5 j^^s. ; Soda;
Bilioratis 5 ss. ; Pulv. Jalapa; ,3 ij. ; Syrupi Zingiberis
3 ij. M. Fiat Kkcluarium cujus capiat cochleare unura
minimum, bis terve quotidit.

with change of air; horse-exercise, the chalybeate
mineral waters, and warm clothing, will generally
be efficacious. I had recently a case of this de-
scription under treatment, both whilst, it was
simple chlorosis, and when water had collected in
the abdomen and lower extremities. I was sur-
prised at its resisting- the free use of chalybeate
and other tonics; when I found that the patient
had entertained a dislike to salt, and to food which
contained it, and had long avoided it. The cause
of the general and extreme cachexia was now evi-
dent : the use of salt was enforced ; the chlorate of
potash was also prescribed alternately with the pre-
parations of iron, and recovery soon took place.

54. ii. Nonets of the JMedicinis recom-
mended IN Uropsies by Authors, with Prac-
TiCAi, Remarks. — Having, in the foregoing sec-
tions, stated chiefly the results of my own expe-
rience, I now proceed to notice, under distinct
heads, the means advised by respectable and
oiiginal authorities for the treatment of this class
of diseases. The remedies recommended in the
cure of dropsies have usually been directed with
the following intentions: — 1st. To remote the
state of vascular action, and vital power giving
rise to efusion — (a) by refrigerants, comprising
vascular depletion and other antiphlogistic reme-
dies ; (6) by sedatives ; (c) by external irritation ;
((/') by tonics and astringents ; and (e) by a com-
bination of two or more of these; — 2d. To remove
obstruction to the circulation, and to promote the
at,sorj)tion and discharge of the accumulated fuid
— (") ^y deobstruents, frictions, and bandages ;

(b) by purgatives and hydragogue cathartics ;

(c) by diuretics ; (d) by emetics; (e) by sudo-
rifics ; and (/) by various combinations of
them ; — and, 3d. To evacuate the fluid by
surgical aid — (a) by blisters and scarifications;
(b) by acupuncturation ; (c) by paracentesis.
Of these last means notice will be taken when the
specific slates of dropsy in which they have been
employed come under consideration.

55. 1st. To retnove the State of Vascular Action
and Vital Power giving rise to Ejf'usinn. — A. By
refrigerants, &ic. — (a) Vascular depletion, general
or local, or both, has been advised in the acute
states of the disease from Hippocrates up to the
present day ; and has been more particularly in-
sisted on by Mesue, Bonet, Aascheim, Schulze,
Bruele, Juncker, Stole, Tissot, Rush, Ober-

TEUFFER, GrAPENGIESSER, BlACK ALL, AbERCROM-

BiE, Graham, Venables, and Ayre. The
propriety of repeating it has been shown by
J. P. Frank, Dr. Grahasi, and some later
writers ; although the number of cases that can
admit of the repetition of general bloodletting
will be comparatively small, and those only in
the young or unbroken constitution. — (6) A'iti-e
has been very generally prescribed, not merely as
a refrigerant, liut as a diuretic. Rush attached
some importance to it after venaesection, directing
it with spare diet ; and Rosier and Obkrteuffer,
with squills. — (c) The hydro-chlorate of ammonia,
in doses of ten grains to a scruple, has been given
by me in some cases consequent upon ague with
benefit ; and is appropriate not only to acute and
sub-acute cases, but also to the more passive
states of the disease, particularly when taken in
tonic or warm diuretic infusions, and conjoined
with amrnoniacum. — (d) Low diet has been es-
pecially noticed by 'I'lssox and Rush.

618

DROPSY — Remarks on Mebicines tiecommended in.

56. B. By sedatives. — (a) Antimonials may
be more appropriately considered as sedatives than
as diaphoretics, inasmuch as their operation in
the latter capacity arises from their sedative influ-
ence on vascular action. James's poitder and tar-
tar emetic are the preparations of this class most to
be depended upon, and are sometimes useful in
the acute and sub-acute forms of the disease, con-
joined with calomel, or with cream of tartar.
They have been prescribed in such cases by Van
Hel:mont, Sydenham, jMynsiciit, and Riciiter.
With squills and saline diuretics, they have been
employed by Brisbane and Willich. — -(/;) Tiie
diuretic operation of tobacco is evidently owing
chiefly to its sedative influence on the circulation.
This active substance is indicated in the more
acute states of the disease, but it may also be ex-
hibited with tonics and stimulating diuretics,
where the debility is more manifest. It has been
recommended in the form of powder, infusion,
wine, or tincture, by Magninus, Bartholin,
Fowler, Neander, Garnett, and Baldinger.
Dr. Fowler advises the infusion in gradually
increased doses; Garden, its ashes with rhubarb
and sulphate of iron ; and some Continental
writers with camphor in the form of tincture (see
F. 742.), which may be added to other medicines.
The ashes of tobacco are very frequently men-
tioned by the writers of the last century, but their
operation can depend only on the quantity of
vegetable alkali they furnish. — (c) Several of the
solanaceous order of plants, besides tobacco, have
been employed in dropsies, both as the principal
means confided in, and in order to assist, by their
sedative and diuretic operation, other medicines
possessed of less equivocal diuretic properties.
The belladonna, the phijaalis alkekengi, the solanum
dulcamara , the s. somniferum, and the s. nigrum,
have been employed by SToisRK, Baldinger,
Stark, and others, with this intention. The
hifoscyamus has also been very frequently pre-
scribed, with the view of diminishing irritation and
promoting the action of other medicines ; but it
is inferior to — (d) opium, in this respect, the good
effects of which in dropsies have been particularly
noticed by Willis, Arnemann, Brocklesby,
RiTTER, Baker, and Masov. Its influence in
determining and heightening the effects of diuretics
has been shown by IjEntin and Paris. Doem-
UNG always added it to squills; and Leake, to
this medicine and cream of tartar. — (e) The
lactuca virosa has also been recommended to
fulfil the same indications with the above by
Collin, Durandk, and Riciiter, particularly in
conjunction with digitalis — two grains of the
extract of the former, with half a grain of the dried
leaves of the latter, finely triturated with white
sugar, and taken three or four times a day. The
foregoing sedatives, as well as the colcliicum ( $ 80. ),
will be found very useful adjuncts, and indeed not
infrequently the chief means that should be re-
sorted to when the disease is attended witii much
pain, or with spasms or cramps.

57. C. Bfi external irritation. — It is but
rarely that external irritants give issue to a quan-
tity of serum suflicient to unload very consider-
ably the vascular system : but in the acute, and
especially in the sub-acute, states of the disease,
after depictions, a judicious use of them is often
productive of benefit, by tiansferring the irritation,
sometimes occasioning the internal effusion, to

external parts. They are applicable chiefly to
dropsies of the thoracic cavities, depending upon
pulmonary disease, to those consequent on scar-
latina, and to ascites. The means by which
counter-irritation should be effected is an im-
portant consideration. In the states and species
of the malady now alluded to, the ointment of the
pofassio-tartrate of antimonii, or issues, may be pre-
ferred ; or blisters may be applied in the more
asthenic and rapidly progressive cases. When
the effusion seems owing to obstruction of the
liver, blisters, several times repeated, over the
right hypochondrium, and below the right shoul-
der-blades, or rubefacient plasters in the same
situation, are sometimes of much service. When
the kidneys are apparently affected, they may be
applied over the loins, alter cupping in that situ-
ation ; or the tartarised antimonial ointment may
be used. In the more sthenic cases, or when
the urine is very thick and scanty, it will be
preferable to apply fine tissue paper between the
skin and the blister, or to dip the plaster in boil-
ing water before applying it, in order to prevent
the absorption of the irritating principle of the
flies. In some cases, scraped horseradish, or the
inner bark of the mezereon, will prove excellent
counter-irritants ; or mustard poultices may be
used for this purpose. I have, in several cases,
however, seen more benefit arise from the appli-
cation of a cloth moistened with either of Formula;
296. 300. 311. in the Appendix, or with spirit of
turpentine, over the seat of disease, than from any
of the foregoing. The inflammatory irritation they
occasion is never followed by unpleasant results,
as in the case of blisters, which, in the old and
debilitated especially, sometimes produce danger-
ous effects if not carefully watched.

58. D. By tonics and astringents. — These
medicines are often necessary in some of their
various combinations, even in cases where it is
necessary to resort to vascular depletion, and not
infrequently after this practice has been em-
ployed. Much, however, will depend upon the
selection of these medicines, and the mode of
exhibiting them, appropriately to the pathological
states of the case. The observations already
ofl^ered will assist the practitioner, with a due
exercise of his own discretion, in this important
matter. Tonics and astringents are indispensable
in all. the passive or asthenic states of the disease,
associated either with diuretics or with purgatives ;
and in many of the sub-acute and even acute
forms, after the antiphlogistic treatment has been
prescribed, particularly when conjoined with ca-
thartics. They are especially indicated where
the eflTusion seems to depend chiefly upon an
atonic state of the extreme vessels, and deficient
vital cohesion o*" the cellular and serous tissues,
with flaccidity of the soft solids generally. In cases
of this description they have been directed by most
writers, and even by J. P. Frank and Riciiter,
by whom the inflammatory and sthenic states of
effusion have been so ably investigated.

59, (a') Of the particular tonics that may be
enqjloyed, the preparations of cinchona and sal-
phale of i/uinine are the most generally appli-
cable. They have been especially noticed by
Lentin, Df. IIaen, Brougiiton, and Ring. The
infusion or decoction of hark is an excellent
vehicle for the alkaline and saline diuretics, as
well us for several purgatives, the action of which

DROPSY — Remarks on Medicines recommexded ix.

61^

It tends to promote. Lettsom gave cinchona
with squills ; Lyson, witli serpentnria, either in
tincture or infusion; J. P. Fhank, with juniper ;
Horn, with the balsams or turpentines ; and
YoGEL, with the neutral salts, or carbonates of
the alkalies. Where the sthenic diathesis may
seem to contra-indicate its use, the infusion will
be advantageously associated with the nitrate of
potash and carbonate of soda, and with appro-
priate diuretic tinctures or spirits. It may also
be given with the mineral acids and Ethers,
especially the hydrochloric or sulphuric. The
suljiluite of quinine may also be taken in the com-
pound infusion of roses, or of orange peel, in con-
junction with the sulphates of magnesia, or of
potash, or of soda, and any diuretic spirit or tinc-
ture.— (6) 'V\\e injusions of caltunha, of qnassiii,
and of gentian, have been exhibited in similar
states of the disease, and combined with the same
substances, as cinchona.

60. ((■) The preparations of iron have been as
generally prescribed in dropsies as those of cin-
chona ; and, as in respect of them, with the object
of imparting tone to the minute vessels, and
thereby of diminishing effusion, and of preventing
its recurrence after the fluid has been directly
removed. This class of tonics was much em-
ployed by Dover, Btackmore, Bergius, Tissot,
Grieve, Frank, and Rush. The combination
of chalybeates with purgatives is advised by Ried-
LiN and Thomann. Dover recommended an
electuary consisting of the sulphuret of iron,
scammony, and crude mercury ; of which Dr.
Blackall has made lavourable mention. Fou-
QiTET directed it with sulphur. The ferri potassio-
tarlras and the tincture of the sesqiii-cliloride are
the preferable preparations ; but the sulphate or
sesqui-oxide may likewise be used. An electuary
containing the tartarised iron, the confection of
senna, the inspissated juice of tiie sambucus nigra,
and the syrup of squills, will often prove ser-
viceable in asthenic states of the disease. —
(rf) The absinthium, in the form either of in-
fusion, wine, or powder, was formerly much ern-
ployed ; and was praised by Celsus, Boxet,
Hartjiann, and many others, particularly when
given in conjunction with juniper, or other diu-
retics. It has now undeservedly fallen into dis-
use.— (e) Of the stimulating tonics, phosphorus
has been prescribed, in minute doses, and usually
dissolved in oil or a;ther, by Loebel, Gaultier
de Ci.aubry, and others: it has likewise been
used externally in oleaginous liniments. — (f)
Insolation, or exposure to the sun's rays, has been
recommended by Celsus and Portal.

61. (g) Several of the astringent tonics have
been directed in various combinations. The sul-
phuric acid was recommended by Mondschien,
Haller, TissOT, Bang, and Hartmanx ; and
was frequently given with the infusion of the bark
or of the flowers of the sambucus nigra, or the in-
fusion of quassia, or of cinchona. The hydro-
chloric acid was also exhibited in similar states of
combination by Riverius and Digbv. The nitric
acid, either alone, or v\'ith the muriatic in eciual
proportions, has been very commonly employed,
both internally and externally, by practitioners in
the East Indies, in cases depending upon hepatic
disease (^ 50.). — (h) The sulphate of copper, in
do-^es of half a grain each, with opium, has been
praised by Wright. — (i) In adelition to these,

the centaurium minus and the imtia campana
have been noticed by Gni:i,ixG and others, who
have prescribed them in the form of wine or beer ;
and the prinos verticitlatus, by Barton. — (A-)
The mineral waters of Pi/rmont, Spa, Bath, and
Tunhridge, have been severally directed in cases
for which tonics are appropriate. Dr. Percival
recommended the natural and artificial waters
which contain fixed air. Sciienck, Quarix,
(iii.tiiRisT, J. P. Frank, and several other writers,
mention in favourable terms change of air and
sea-voyaging. — (/) JNIost of the ancients, with
Fuller, Rush, and some others of the moderns,
have insisted on the good eft'ects of active ex-
ercise in the open air. AVhen the patient is able
to adopt this advice, there can be no doubt of its
great efficacy.

62. D. By a comhiiiaiion of iiuo or more of the
foregoing plans of cure-. — I have already re-
marked that depletions are not infrequently re-
quisite to a moderate extent, in order to remove
relative or excrementitious plethora, even al-
though vascular action may not be increased ;
and there is often a necessity for the exhibition of
tonics at the same time, generally with purgatives
or diuretics. The propriety, however, of asso-
ciating sedatives with the various antiphlogistic
measures noticed above, and counter-irritation
with both, in the inflammatory or acute states of
the disease, is still more manifest. The com-
bination, also, of some one of the sedatives with
the tonics or astringents, whether tliese latter be
given alone, or conjoined with one or more diu-
retics or deobstruents, is generally found useful,
not merely in promoting their operation, but also
in relieving the more uneasy sensations which
i'requently occur during the progress of the dis-
ease.

63. 2d. To remove Obstructions to the Circula-
tion, and to promote the Absorption and IJischarge
of the accumulated Fluid. — This indication com-
prises three objects, — the removal of obstruction,
the promotion of absorption, and the augment-
ation of the urinary discharge. These, however,
are so intimately connected, that the attainment
of the first is generally followed by the second
and tliird. — A. Bij deobstruents, and the use of

Jriclions and bandages. — These means are ob-
viously appropriate to cases of dropsy depend-
ing chiefly on congestion of the large veins, or
to obstruction either of them or of the lympha-
tic system (§ 48.). Many of the remedies which
are supposed to act upon the kidneys, operate in
some respects by removing obstructions to the
venous and lymphatic circulation, and increasing
the action of the absorbents. Those substances
which have been very commonly termed deob-
struents, pass into the blood by the veins or
lymphatics, where they either modify its con-
dition, or excite the extreme ve-sels when they
are congested, thereby accelerating the circu-
lation through them and the veins, and remov-
ing the state that favours increased exhalation. —
(a) Mercurial preparations are amongst the most
common medicines employed as deobstruents.
But they are not always applicable ; for when
the dropsy is connected with organic change in
the substance of the liver, they should be given
with circumspection. When the obstruction
exists chiefly in the venous and lymphatic systems,
or depends upon disease of the heart; or when

620 DROPSY — Remarks

the effusion is caused by increased action in the
serous membranes; they are valuable medicines.
The scrofulous diathesis and weak vital energy
are not always satisfactory reasons against tlieir
use, altliuugh these states of system require a
peculiar mode of exhibiting and combining them.
In acute cases, calomel, with antimony or cam-
phor and opium, is the preferable medicine. In
this and similar states of preparation, it has been
employed by Lysons, Langguth, Hamilton,
BECKtn, and" others. Where active disease exists
in the pleura;, pericardium, peritoneum, or sur-
face of the liver, this is the best mode of exhibit-
ing mercurials; but where there is much debilitii,
this medicine should be given in small doses with
soap, and guaiacum, as advised by RitPExnAu-
SEN ; or in the form of Plummer's pill, with
soap and taraxacum. In an atonic or asthenic
state of vital action, as well as in the scrofulous
diathesis, small doses of blue pill, similarly com-
bined ; or of tiie bichloride dissolved in the com-
pound decoction of sarsapariJla, or tincture of
cinchona, with diuretics ; will be found both safe
and beneficial medicines. JMercurials have been
directed to be pushed to salivation by many
authors; and in cases where the disease is con-
nected with inflammatory action in the serous
membranes, and when vascular depletion has
been previously instituted and carried sufficiently
far, tlie practice is beneficial. It is likewise
applicable when there is evidence of inflammation
of the surface of the liver, as indicated by pain,
soreness, and tenderness of its region, See. In
the more chronic and asthenic states of disease,
mercurials have been directed to be given with
squills, by Fischer and other writers; and with
tonics, by Wright.

64. (b) Iodine, variously combined, has proved,
in several cases of dropsy in which I have em-
ployed it, a most valuable deobstruent and diu-
retic. It is not applicable to the cases arising
from disease of the serous membranes, and heart;
but when the effusion proceeds from obstruction
in the liver, or in the spleen, or in the veins and
absorbents (§ 26, 27 . 3 1 . ), it seems to me more to be
depended upon than any other medicine. I have pre-
scribed it in tlie form o( tincture, iodide of potassium,
ioduretted solution of' the iodide, and of ioduret of
mercurii, both internally and externally, according
to the circumstances of the case ; and have more
frei|uently preferred the second and third of these
preparations ; but when the debility is great, the
tincture is, perhaps, more to be depended upon
than the others. — (c) 'J'he fixed alkalies and their
carbonates have had much repute in dropsies, and
were very commonly employed by Sydenham,
QuARiN, J. P. Frank, and most recent writers.
Although generally used as diuretics, tliey act
ciiiefly as deobstruenis, particularly when com-
bined witii taraxacum, small doses of antimony,
or of mercury. In cases of debility, tliey are ex-
tremely useful with the tonic or warm diuretic in-
fusions or decoctions, — as the infusion of cinchona,
of juniper beiries or pine tops ; and they may be
also associated with the nitrate of potash and
diuretic spirits or tinctures. Or they may be
prescribed with myrrh, or guaiacum, or sulphur,
or ammoniacum, or s(|uills, or camboge, or the
extract of black hellebore, according to the pecu-
liarities of the case. - (</) 'Jhe hi borate of soda
in a veiy useful adjunct to other deobstruents,

ox Medicines recobimexded in".

and to diuretics (see F. 57. 397. 599.). I believe
that its deobstruent action is greater than that
of the alkaline carbonates. — (e) Ammoniacum
has also been exhibited, chiefly on account of
its deobstruent operation, and is indicated in
the atonic states of the disease, and in the com-
plications with" organic change in the liver,
spleen, or kidneys ; and in cases of venous, ab-
sorbent, or glandular congestion or obstruction.
In these it may be conjoined with alkalies, ex-
tract of taraxacum and squills (see F. 552.
893,894.) FoRDYCE gave it with antimony and
nitre, — a form in which it may be safely pre-
scribed in the acute and sub-acute cases, after
vascular depletion and purgatives ; and Richter,
with the hydro-chlorate of ammonia and squills.
— (J) 5'i(//;/n(?-, when judiciously associated with
other deobstruents and aperients, or with diu-
retics, possesses no mean deobstruent properties,
more particularly when given with cream of tar-
tar, as Hufeland advises; or with this sub-
stance, the sambucus nigra, and the biborate of
soda; or with the nitrate of potash, and squills;
or with the balsams, as directed by Monds-

CHEIN.

65. Cg) The external deobstruents consist of
certain of the substances already noticed, kept
constantly applied over the chest, or the loins, or
hypochondria, in the form of plaster; or assi-
duously rubbed into the same places, in the
form of liniment or ointment. The Appendix will
furnish, under these heads respectively, several
preparations, consisting chiefly of ammoniacum
(F. 109. 117. 891.), the preparations of iodine
(F. 302. 768. 775.), of the terebinthinates
(F. 120. 296, 297.), of mercury (F. 511. 761.),
of camphor (F. 115. 306. 758.), and of the sul-
phurets (F. 309. 776.), witii other substances;
calculated to promote their operation, and allay
internal pain and vascular irritation. Besides
those now indicated, will be found arranged along
with them, several preparations which may also
be used according to circumstances. — (/i) Fric-
tions are of more benefit in dropsies, particularly
in tiiose which depend upon obstruction and
atony of the vessels and tissues, than is usually
imagined ; and were commonly employed by
Stoeuck, Stolt,, Rush, Wright, and others.
They will be advantageously used with the lini-
menis or ointments already noticed, but in weaker
forms. Frictions with the weak mercurial ointment
were advised by ]3RouGirrox, Frank, and
Knight; the addition of camphor to this lini-
ment, as recommended by Lentin, or the lini-
mentum hydrargyri reduced by the addition of
olive oil, or of the linimentum saponis com-
positum, will be found superior to the mercurial
ointment alone. Frictions with olive oil were
much confideil in by Stole, Oliver, Chambek-

LAINE, LaNOI', GaUDANE, lU'SH, and W RIGHT,

particularly in ascites and anasarca ; and are cer-
tainly often beneficial in favouring a free tran-
spiration from the surface, and do not merit the
disuse into which they have fallen. — (i) The
good effects of bandaging, not merely in anasarca,
but also in ascites, were insisted on by Rush ;
atid have lately been shown, in the latter form of
the disease, by some French practitioners.

66, B. Bji purgative and hydragogite cathar-
tics.— Purgatives are very generally applicable
in dropsies. — (a) on account either of tlieir ecco-

DROPSY — Remahks on Medicines foe — DiufiETics.

621

protic action, or of tlieir deohstruent opcr;ition I
when uninterruptedly continued, or of their iiiHu-
ence in deriving from tlie seat or effusion, in
draining tiie fluid parts of the blood from tiiat
circulating in the intestinal tube, in thereby les-
sening excrementitious or cerous plethora and
favouring the absorption of the effused fluid.
They constitute a most important part of the
treatment of every form and state of the disease,
according to the selection of them and the manner
of combining them. Thus, calomel and antimo-
nials, subsequently to bloodletting, are most ap-
propriate to the inflammatory, the pulmonary, and
cardiac complications ; the hydragogue cathartics
in ascites and anasarca ; and the milder purg-
atives associated with tonics and diuretics in the
atonic or passive forms. The advantages to be
derived from conjoining the saline purgatives
with bitter infusions and with diuretics, even in
the acute states of the disease, after the anti-

No. 1st. R Extr. Hellebori Nigri, Myrrh.-e, aa 3 ss. ;
Pulv. Cardui Benedict. .5jss. Contunde secundum artem
ill massain a^qualera. Cai>iat gr. ij. ad vj. ter quaterve
quotiiiie.

69. J. The sambitcus nigra and s. elmius — the
common and dwarf elder — were praised by Fokes-
Tus, Sydenham, Schroeder, Fouquet, Brock-
LESEY, QuARiN, CiiESNEAU, and Lange. The
inner bark is cathartic, and the flowers both purga-
tive and diuretic. The infusion, inspissated juice,
and powder, may be used. It has been almost
entirely neglected by recent writers, but I have
prescribed it with much benefit. — ?. The rham-
nus catharticus was likewise employed by Syden-
ham, and is still used in the form of syrup.
Camhoge is often very efficacious when triturated
with bitartrate or sulphate of jiotash. Hoffman.v
prescribed it in an alkaline solution ; IvicuTEn,
dissolved in oil ; and Ackermann, finely levigated
with white sugar or cream of tartar. — Jalap,
either its powder or its extract, has been very

phlogistic treatment has been directed, should not generally used. Grieve gave it with nitre, and
be overlooked (^59.) The combination of pur-
gatives and cathartics with tonics and diuretics,
was adopted by Scribonius Largus, Forestts, great reliance on the bitartrate of potash. I

Van SwiEiEN with turbith mineral

70. £. Dr. HoRNE and Dr. Ferriar placed

RiEDLiN, Sydenham, Thilenius, Baciier.Win
CLER, RiTTER, Grieve, and most recent writers :
the chief difference being as to the choice of
substances, and the appropriation of them to the
various states and forms of dropsy. — (/;) The
dechsirueni effect of purgatives is most certainly
obtained from moderate doses of j«/«7) with cream
of tartar ; or from the extract of black Jtellebore, with
myrrh, ammoniacum, and soap; orfrom Plummer's
pill, wiih caniboge, soap, and taraxacum, given
in moderate doses daily, and long persi-ted in.

67. {c) A hijdragogue operation is produced
chiefly by elaterium, croton oil, camboge, the inner
bark ol the common or dwarf elder, the rham-
nus catharticus, hellebore, and the neutral salts.
— a. Elaterium is often productive of benefit.
It was much employed by Sydenham and Demi-
ANi, and is still ve-y generally prescribed. It is
given with soap or any tonic extract, in doses of
half a grain every hour, until copious watery
evacuations are procured. The following pills
will be found the most certain in their operations : —
No. 183. R Extr. Elaterii gr. vj.; Potassa> Sulphatis
gr. XX. ; terebenesimul,dein contunde cum Pulv. Kadicis
Zingiberis 3 j. ; SaponisDuri gr. xvj.,et forma in massam
cum Olei Anisill] vj. vel q. s. Divide in Pilulas xxiv.,
quarum capiat unam, duas, vel tres, omni liora.

68. B. Croton oil is one of the most certain hydra-
gogue cathartics that can be employed. It may
be given with soap and compound extract of colo-
cynth (F.543.), or with the aloes and myrrh
pill, in doses of about half a drop every two or
three hours, until it operates copiously. Dr. Nui-
MO and Dr. Good prefer the alcoholic solution
of this oil, but of that I have had no experience;
I have found the mode in which I have directed
it answer my expectations. — y. The extract of
black hellebore has been much used in all drop-
sical cases. This plant was very commonly
employed by the ancients, and by Avicenna,
RiEDLiN, MoNDSHEiN, Van Swieten, and
QuARiN. The extract as prepared (F. 156.),
and combined, by Backer, is, upon the whole,
the best mode of exhibiting it. It should be
fresh, and its effects carefully watched. If it

have employed it more than any other medicine
in the acute forms of the disease, after the exhi-
bition of mercurials, sometimes in very large
doses, in the form of electuary, and variously
associated. In these, as well as in other states
of the disease, it often proves more efficacious
than its purgative or diuretic operation imlicates.
Either alone, or with the biborate of soda, it
often succeeds in removing obstructions from the
liver, and accumulations of bile from the hepatic
ducts, after other medicines had been directed
with this intention to no purpose. It may be
given in as large doses as Dr. Thomson and Dr.
Good have stated (?vj. and 5J.); but two or three
drachms twice or thrice in the day, and persisted
in for several days, is preferable. It is apt to be
nauseated by the patient ; in which case the elec-
tuary should be prepared with syrup of ginger,
to which the oleum anisi, and a little tincture or
powder of capsicum, may be added in addition
to the other substances with which it may be
requisite to conjoin it. In .some cases, sulphur
will be added to it with advantage ; in others,
guaiacum, ammoniacum, or squills; and in some
the inspissated juice of the sambucus nigra, and
extract of taraxacum. Its association with sul~
phitr was much confided in by Piderit; with
biborate of soda by Grant, Quarin, and most
Continental writers; with cawbnge, intimately tri-
turated together, by Sala and others ; with squills
by Bang ; and with ;a/(//), by Demiam. Of other
purgatives it is unnecessary to take any particular
notice. The neutral salts, particularly the sul-
phates, are often of great benefit, both as laxatives
and as diuretics, when prescribed wilh other pre-
parations possessed of the latter properties. The
iris forenlina, i. pseuilacorus, i. vulgaris, i. versi-
color, and i. fatidissima, have severally been em-
ployed as hydragogue cathartics in dropsies, in
the form of the expressed j nice, or powder, infusion
and decoction of the roots, and have received the
commendations of Plater, Eller, Duverney,
and SpiNDLER.

71. C, Bif diuretics. — This class of medicines

produce restlessness and anxiety, it ought to be i is, perhaps, more than any other, empirically pre

relinquished. The following is Bacher's recipe
for the pills known by his name : —

cribed in dropsies, owing chiefly to the imperfect
state of our knowledge of, and in some measure

622 DROPSY — Remarks on

lo waat of attention to, the mode of their oper-
ation. From researches into this subject, in which
I was engaged during the years 1819, 1820, and
1821, — part of the results of wliich, particularly
in respect of diuretics*, was published in the
Medical and FhysicaL Journal, for July and
August, 1821, p. 112—115. — it was there shown,
that these substances act — i. Upon the digest-
ive canal, and on the nerves nf organic life, ex-
citing or otherwise modifying, according to the
nature of their impremnn, the functions of these
viscera, und hy sympaLhii the functions of those
intimatelu related to them : — ii. By absorption, and
by their action on the lymphatic, capillary, and
venous systems, both during and subsequently to
their passage into the blood, — a. in exciting the
extreme vessels, or restoring their tone, and
thereby promoting their circulating functions ;
h. in exciting the absorbent system, and gradu-
ally removing impediments in the way of the
lymphatic and venous circulation, or in pro-
ducing a deobstruent operation ; c. in develop-
ing constitutional power, increasing the vital
cohesion of the soft solids, and enabling them
to yield the requisite support to the capillaries
and to the exhaling vessels and pores : — iii. By
their action on the kidiieqs, and other secreting
and excreting viscera, through the medium of the
circulating Jiuid, — a. in directly stimulating the
kidneys, by one or more of tlieir constituents,
during their presence in the blood and elimination
with the urine, and in exciting them to excrete
the watery parts of the blood ; b. in thereby
diminishing the quantity of the watery parts of
the blood, and promoting the absorption of fluid
from the cavities or tissues in which it super-
abounds. It will be seen from the above, that
substances which have had a diuretic action
ascribed to them, operate — 1st, in a more or
less indirect manner, whether their influence
be mainly exerted upon the prima via, or upon
the circulating systems ^nd viscera by means of
absorption ; and, 2d, in a direct manner, during
their circulation through the kidneys, and elimi-
nation from tiie blood by their agency. Con-
formably with these views, I proceed to notice the
use of this class of medicines in dropsies.

72. 1st. Indirect diuretics. — (u) Titose which
act chiefly upon the digestive canal. Under tiiis
head may be comprised most of the tonic and
.stimulating medicines already noticed, and which,
by increasing tiie organic nervous energy, and
promoting the digestive and assimilating func-
tions, also assist the circulating and eliminat-
ing actions, particularly ,in the indirect manner
already noticed.— (6) These effects are both ac-
celerated and heightened by associating these
medicines with substances ichich, being absorbed
into the circulation, e.icite the extreme vessels, re-
store their tone, and promote a healthy circulation
through them. Of the-e last, some mention has
been already made under the head of deobstrtienls

* 'flic former of tliesp memoirs contained the first at-
tem))t that had lieen made to determine tlie precise way
in which diuretics operate, and to arrange their effects.
In that article, as well as in tlie/,o/)(foH McUiJnl Ilcjiu-
silury tor May, 1822, p. .380, ,>H1., will be tbund the ar.
rangement of the action of diuretics given above, drawn
in a more precise and dct.iiled manner than my limits
will here allow me. 1 state this, because similar arranxe-
ments have been put foith at much later i)eriods than the
last of tric'se, but without tcfcience to the original sources
now rcfurrcd to.

Medicines for — Diuretics.

{§ 63 — 66.). Mercurials, when used as diuretics,
operate chiefly in this manner, unless carried to
tile extent of injuring the constitutional powers,
and of hazarding the production of their peculiar
cachexia. Foxglove seems to act chiefly in this
way, as well as in lowering the frequency and
strength of the heart's action, thereby diminish-
ing effusion, and determining the balance of action
in favour of the absorbing vessels. Its efltcts
are promoted by combining it with substances
which, being received into the circulation, act in
a similar manner with it, or in one of tiie modes
mentioned in the second order of the above classi-
fication (§71.); more particularly with the blue
pill, or minute doses of the bichloride of mercury ;
with the nitric or nitro-hydro-chloric acids, in
broken-down constitutions, or where mercury
has been already employed ; with the spiritus
ajtheris nitrici, or liquor ammoniaj acetatis ; with
the bitartrate of potash and biborateof soda,or wiih
colchicuin and the tinctura camphoras composita
(F. 195. 395. 400.599. 627. 859.). The diu-
retic operation of digitalis is most certain after
depletions and alvine evacuations in the more
acute states of dropsy, in the atonic forms of the
disease, and in the com]dicalions with legions of
the heart and lungs. The preparations of this
plant necessarily depend for their etHcacy upon
the period at which they are gathered, and the
manner of drying them. As soon as the leaves
or powder lose the green colour, they also lose
their active properties. Digitalis was much re-
commended by SciIIEMANN, WiTIIEUiNG, DaR-

wiN, I.Warren, Dick, Odier, IIeusinger, and
many others ; and it still retains its reputation,
particularly in hydrothorax. Ferriar prescribed
it with cream of tartar ; Langenbeck, with opium ;
and Beddoes, Ackeusiann, Knaus, and Leit-
soM, with calomel and opium. The addition of
small doses of this last promotes its operation,
and partially counteracts any unpleasant efi'ect
it may produce, — a fact wh'ch I have heard
confirmed by the extensive and discriminating
experience of Sir II. Halford. 'I'he tinctura
opii composita (F. 729.) is perhaps the most
eligible preparation for this purpose. The de-
coctum senegce has also a diuretic efl^ect, and
evidently from its influence on the capillary cir-
culation. It was used by Mili.man ; but is
applicable chiefly to the atonic states of the
disease. Oberteuffer conjoined it with cream
of tartar, which is, I believe, the best way of
giving it. Squills and ammoniacum (§ 78.) seam
to act, partly at least, in the present mode ; but,
of the former, more particular notice will be taken
in the sequel.

73. (c) Diuretics which excite the ahsorbing
vessels, and remove impediments to the lymphatic
and venous circulation, are manifestly few in num-
ber. It is probable that several of those already
noticed, and usually termed deobstruents, operate
partly in this manner; but we liavc no satisfac-
tory proofs that they do so act, as to any of them,
excepting the preparations of iodine, o( which men-
tion has already been made (§ 64.). 'i'hesc evi-
dently excite the absorbing vessels, and produce
a diuretic action in this way, particularly when
given in full doses. The carbonates of the
alkalies, the pure fixed alkalies, ammoniacum,
mercurials, &c., may probably also act partly in
the same manner.

DROPSY — Remarks on Medicints for — Diuittrics

623

74. ((/) Tliere are various substances which
exert a diuretic operation througii the niediutn
of the circulation, bi^ deielopi)ig coiistilutimuit
power, increasing the vital coliesion of the sojt
solids, and thereby restraining morbid exhalation
or effusion. In this manner, all the tonic and
astringent mineral salts may indirectly increase
the secretion of urine, as well as the mineral and
some of the vegetable acids. Lentin, Tissot,
AViNTiuNGiiAM, and others, prescribed the mine-
ral acids; Reusner directed the sulphuric acid,
with infusion of the bark or flowers of the sani-
bucus nigra: and Bang, the tartaric acid with
squills. Citric acid and lime juice have been
found efficacious in the complication of dropsy
with scurvy; and I have seen benefit derived
from ])iirol igneous acid. Sulphate of iron, and
sulphate of quinine with sulphuric acid, will also
prove of service in the asthenic states of the dis-
ease, by operating in this manner. Eut these
are, upon the whole, inferior to the ferri potassio-
tartras, which, whilst it increases the tonicity
of the extreme vessels and soft solids, produces
a very manifest diuretic action.

75. 2d. Direct diuretics. — Substances ichich
stimulate the kidneys through the 7nedium of the cir-
culating Jiuid are the only direct diuretics. Some
of these may be administered by the stomach ;
olliers by the cutaneous surface ; particularly after
the cuticle has been removed — according to the
endermic method. I'ut there are very few of them
which act in this way solely ; nearly all of them
producing more or less effect upon the organic
nervous system, on the vascular systems, and on
the vital cohesion of the tissues, during their pre-
sence in the blood. It will be found that such of
them as excite the kidneys most remarkably are
eliminated from the blood by these organs, and it
may be therefore presumed that their influence is
principally or specifically exerted upon them. It
will be manifest, that substances which increase
the proper function of the kidneys will produce
the double effect above stated (^ iii. a. h.), of
excreting the watery parts of the blood, of dimi-
nishing excrementitious plethora, and thereby
increasing the absorption of fluid from the situ-
ations where it superabounds. I have long since
shown (L(»ui. Med. and Phys. Journ. for July,
1821.) that certain diuretics, and these the most
active, are conveyed into the circulation, and to
the kidneys, unchanged ; and Dr. Paris has con-
tended that various other diuretics are decom-
posed or digested, and operate by means of certain
of their active constituents. This seems very

the kidneys, in the asthenic states ; lower inflam-
matory action, and prevent the consecutive eflusion
in the acute forms of the disease. 'I'he oil, tlie
active principle, may be taken as prescribed in the
Appendix (F. 149. lt)9. 681.), may be exhibited
in clvsters, and employeil externally in the form
of liniment or epithem. Its smell may be covered
by the cajeput or lemon oils, which also are direct
diuretics ; and the unpleasant eructations it occa-
sions, in great measure prevented by giving it with
magnesia, or by taking this substance immediately
after it. In the asthenic states of dropsy, ]\Ionu-
sciiEiN and Riland combined it with sulphur,
in the form of balsamum sulpliuris (F. 22.).
The former of these writers also recommended
the infusion of pine tops (F. 51.), which is an
excellent diuretic vehicle for the saline sub-
stances and spirituous tinctures belonging to this
class of remedies (F. 827.). — ^. The various
balsams (F. 485 — 487. 570.) are especially indi-
cated in the more passive states of dropsy, and
when the kidneyssetm to be diseased. The Peru-
vian balsam was much praised by De Haen ; but
copaiba is equally efficacious. 1 hese, as well
as the terebinthinates, may be given in the form
of pill with magnesia, or with the alkalies. —
■y. The preparations of juniper berries also act
directly upon the kidneys, by means of their
essential oil. They are most appropriate in the
sub-acute and asthenic cases, and are excellent
adjuncts to other diuretics (F. 194.). The infu-
sion (F. 235, 236.) is a suitable vehicle for various
substances appertaining to this class (F. 397.399.).
RivEiiius prescribed it with small doses of sul-
phuric acid ; Bang, with cincliona ; and Percival,
with camphor. — J. Cajuput oil, oil of aniseed, and
others of the essential oils, possess diuretic pro-
perties, and may be used both internally and
externally, as adjuvants of other substances be-
longing to this class of medicines, especially in
the more asthenic states of the disease. The
oil of aniseed is very serviceable in effusion con-
nected with asthma, bronchitis, or lesions of the
lungs, and with affections of the heart ; and is a
useful adjunct to colchicum, digitalis, camphor, &c.
77. (b) The alkalies and thejr salts are diuretic
in small or moderate doses, and are appropriate to
most cases of the disease. Liquor potassie has
been already noticed as serviceable in con-
junction with other deobstruents and diuretics
(§ 64.). It evidently neutralises the acid in
the stomach, and is absorbed into the circulation.
The carbonates and carbonates of both potash and
;oda are more generally useful, especially in the

probable as to some, but does not admit of proof complication with lesions of the liver, kidneys.

in respect of many of them. That the balsams,
juniper benies, and cubebs, excite tlie kidneys
by means chiefly of their essential oil, is very
evident ; but that colchicum and squills are
diuretic, owing to the separation of veratria and
scillitina, is merely a matter of opinion.

76. (a) a. Oil of turpentine, and substances
containing it, as the Canadian, the Chian, the
Venetian, and the common turpentines, are the
most energetic and direct diuretics ; and, in the
endless forms of combining and exhibiting them,
admit, in the hands of the practitioner who is
acquainted with their properties and effects, of
very general application : as they excite the
tonicity of the extreme vessels and soil solids,
during their presence in the circulation ; stimulate

and uterus, and when judiciously combined.
They are also absorbed, and are decomposed by
theacid (thehvdrochloric, as shownby Dr. Prout)
of the stomach. But as the quantity of this acid
which the stomach contains at any time is but
small, the change can be effected only on a por-
tion of the salt, if it be given in full doses. A
similar change is most probably produced upon
some of the vegetable acid salts in the stomach by
the same agent, as Dr. Paris has contended. The
citrates or tartrates are useful and pleasant. They
may be taken in bitter or diuretic infusions, whilst
the fixed air is being disengagetl by the action of
the acid on the bicarbonates. '1 he most certain,
however, is the cream of tartar, in doses that act
not energetically on the bowels. When pre-

624

DROPSY — Remarks on Medicines for — Diuretics.

scribed in order to obtain its purgative effect
(§ 70.), it frequently also excites the kidneys;
and, with biborate of soda it is sufficiently soluble
to be given in the form of draught or mixture, with
diuretic infusions. It is also advautageously
conjoined with the ferri potassio-tartras and other
tonics in the asthenic statues of the disease ; and
is most serviceable in ascites and anasarca. For-
mulfE 57. 397. 588. 590. 599. 628. are the best
modes of exhibiting it as a diuretic. Acetate of
pntassa and acetate of animonia may also be ex-
hibited with tonic or bitter infusions ( F. 196.
386.), and with either tiie decoction, spirit, or
infusion of tiie various diuretics about to be no-
ticed (F. 194. 358. 395. 400.). The decoction
and the extract of taraxacum are excellent ad-
juvants of all the foregoing salts, as well as of
the carbonates. Tiiey have been much praised
by BoNET, Bang, and J. P. Fuank, for their de-
obstruent and diuretic operation (F. 390 — 392.).
Nitrate of potash has already been noticed among
antiphlogistic remedies (^ 55.). It is readily
absorbed into the circulation ; and during its pre-
sence in the blood and elimination by the kidneys,
it excites tiie capillary vessels, and stimulates
these organs. It is indicated in all the acute
states of the disease ; and in these, after de-
pletions, as well as in the atonic forms, it may be
given in tonic infusions and decoctions, witii
diuretic tinctures or spirits (F. 399. 401. 406.
588. 591. 599.). All the neutral salts, par-
ticularly the s»//)/iutes, and the bisulphate of potash,
are absorbed, and excite the kidneys and extreme
vessels, when taken in small doses, or much
diluted. They are indicated chiefly in the acute
or sub-acute varieties of dropsy, and in their
complication with organic change in the liver.
They admit of the same forms of exhibition as
those more particularly mentioned, and are assisted
in their operation by the same adjuncts.

78. (c-) The action of the foregoing on the kid-
neys is well ascertained ; but there are several other
substances which are as energetic as they, but
whose mode of operation is not so well under-
stood. That the diuretics now about to be no-
ticed excite the kidneys by means either of one or
more of their constituent principles, seems very
probable; but they also act in a similar manner
upon the tissues to which they are immediately
applied ; and, when taken in small or moderate
doses, so as to be absorbed into the circulation,
they manifestly stimulate the capillary vessels, or
impart more or less tone to them. Hence they
are most beneficial in the atonic forms of the
disease ; or in th'e sthenic and plethoric states,
after evacuations. Of this class of diuretics,
squill is the most generally used. Frize, Stoli,,
and Zlviam, advise it to be prescribed with cau-
tion. It is commonly given with calomel and blue
pill, in doses of a grain, gradually increased to
five or six ; or with the neutral salts, in the form
of vinegar, tincture, or oxymel. Culi.kn pre-
scribed it with the bichloride of mercury ; Lang-
iiAus, Home, Langk, and Muoughton, wiih
nitre, rhubarb, cream of tartar, iS:c. ; Tissor, with
camphor ; Wii.licii, with taitar emetic ; 15i;u-
•jUANo, willi the -Ethiops mineral ; and Kneiiki,
and Lkakh, with opium. When it irritates the
stomach or bowels, in conjunction with mer-
curials or saline substances, the adilition of opium
is reriuisite, if the propriety of continuing the

combination be still manifest ; but, under such cir-
cumstances, it is seldom productive of benefit ; and ,
in cases where vascular plethora or sthenic action
is present, it is more injurious than beneficial.
The preparations of it in the British JMiarma-
copceias are the best modes of exhibiting it; and
these may be combined as directed in the Ap-
pendix (F. 196. 399. 533. 552. 627. 781. 893.).
This substance is indicated principally in the atonic
states of effusion, when the urine is high-coloured
and scanty (Blackali.), and it acts more ener-
getically upon the extreme vessels than on the
kidneys.

79. Genista, or spartium scopariuni, the com-
mon broom, in the form of decoction, has been
prescribed by most writers on dropsies (F. 95.) ;
as well as the sarsaparilla, various species of the
smilax evidently possessing diuretic properties.
Gratiola officinalis, or hedge hiissop, in the form
of inspissated juice or decoction, was recom-
mended by DuvERNEY and Stoerck in dropsy
consequent upon scarlatina, both as a purge and
as a diuretic, in small doses. The pyrola umbel-
lata has b en employed by Rudolph and Somer-
VII, LE. The former combined it with tartar
emetic and (ipium. Dr. Somerville, Dr. Beati y,
and Dr. Bigelow have adduced strong evidence in
favour of its diuretic operation. The decoction
is the most active form of exhibiting it. It seems
most elficacious in the hepatic complications of
dropsy. In addition to these, the infusions of
the ballota lanata and of the b. suaveolens have
been prescribed by Reiimann ; the decoction of
the petroselinum, or parsley, by Riciiter ; the
inspissated juice of the rhapliaiiusrhaphanistrum,
by Gruling and others; the expressed juice or
infusion of charefolium, or 7nusk chervil, with
nitre ; the clieuopodium anthelminticum and c.
ainbrosioides, by Lentin ; the cichoriuni verru-
carium and chondrilla juncea (species of sitccori/),
by Spindler. Several species of saponaria, the
angelica archangelica, the leiisticum, or lovage,
the siiim berida, sassafras, sweet-fennel, asparagus,
and various other plants, have been recommended
by authors, in the form either of infusion, decoc-
tion, or of the expressed juice.

80. Colchicuni was much used by Stojjiick,
Boeiimer, Erhmann, De Meza, and Obek-
TEUFFER, as a diuretic. It possesses much of
this property, when it does not irritate the sto-
mach or bowels. Hautesierk justly considers
it inferior to squills. In the acute states of
dropsy, it is best given with mercurials in pow-
der ; but, in asthenic cases, it is most advantage-
ously conjoined with the warmer diuretics, with
tonic infusions, or with preparations containing
camphor or ammonia (see F. 194. 395.), or with
large doses of the alkaline carbonates, particu-
larly in the gouty or rheumatic diathesis. Stoerck
combined it with the infusion of rhubarb ;
and Oberteuffer, with cream of tartar, juniper,
and guaiacum. The diuretic action of rinibavb
is deserving of notice. When given either in
small doses, or in infusion as a vehicle for
other substances of this nature, — as the saline
diuretics and the preparations of squills, of juni-
per, or of colchicum, — it is a useful medicine in
dropsies. It was employed in this way by Weul-
noF, Fordyoe, Bang, and Rush. The diosina
crenata also acts upon the kidneys. Its infu-
sion may be used in similar cascj and states of

DROPSY — REiiAnKs ox

combination to those in which rhubarb is np-
propriale (see F. '231. 396.). The marclKditia
heinisphericii, or liverwort, has been rcceuily
employed with much benefit by Dr. Shoutt, in
cases where other remedies liad been employed
wiiiioul advantage. He has, however, found but
little service from its internal use, and has
employed it chiefly externally as a poultice. For
tills puipose it is first boiled, afterwards beat into
a pulp, and mixed with as much linseed meal
as will bring it to the consistence of a poultice,
which is spread upon flannel, and applied warm
over the seat of the effusion, repeating the poultice
every twelve hours, until the accumulation of
water is removed. It produces " copious perspir-
ation, and at the same time acts powerfully on
the kidneys." The sinking sensation it sometimes
occasions is relieved by the spirilus letheris
niirici. The effects of this application are stated
to be increased by allowing the patient warm
and nourishing diluents, and beef tea, Sec. Dr.
Shortt believes that this application will be
found to succeed in many cases where the kid-
neys are affected. The bark of the root of ci-
chorea ruce»itisu cniquifolia has been lately em-
ployed by JNl. Lemasson. This bark furnishes
a crystullisable principle, of a bitter and astrin-
gent taste, soluble in water and alcohol, in which
the virtues of the plant reside. A decoction of
two drachms of the bark in eight ounces of water
is divided into two doses, which are taken with
an interval of two hours. This generally affects
the kidneys, and the action continues for some
days. As soon as its action begins to diminish,
tilt same doses are repeated. It is suitable only
to the asthenic states of the disease.

81. Cantharides have been recommended in
dropsies, on account of their diuretic action, by
HippocuATis, Galen, Dioscorides, and others
among the ancients ; and by linisDANE, Farr,
and several modern writers. Hoffmann, Wehl-
noFF, and Hcfeland, gave them with cream of |
tartar, the tartaric acid, or nitrate of potash,
and with camphor; and Tulpius in the form of
tincture with spiritus aitheris nitrici, cardamoms,
&c. They should be exhibited with great cau-
tion, and only in the most asthenic forms of the
disease. Dr. Groenevei.t, a licentiate of the
College of Physicians, was committed to Newgate
in 1693, by the president and censors, on the
plea of mala praxis for prescribing them in diseases
of the urinary organs, although numerous autho-
rities in support of the practice could have been
adduced. Cantharides act upon the kidneys, and
upon the capillary system, cliiefly from the ab-
sorption of their active principle, which has been
termed cantharii'en.

82. The rft/(er»- also act upon the kidneys, es-
pecially the spiritus atheris nitrici, and spiritus
atheris sulphurici. They are useful chiefly as
adjuvants of other diuretics. The sweet spirit of
nitre is, however, an active diuretic when judici-
ously combined, or when given while the patient
can take exercise in the open air (see F. 169.
195, 196. 397.). It may be remarked gene-
rally respecting the use of diuretics, that the ad-
dition of small doses of opium, or of the tinctura
opii comp. (F. 728.) as advised by Hufeland
and Paris ; and of out-door exercise, as di-
rected by TissoT ; will much augment their ope-
ration. Rlany of the Continental writers ad-

VOL. I.

Medicines recommended in.

625

vise them to be taken in malt liquors — a vehicle
which certainly promotes their action, and is not
inappropriate in the asthenic forms of the disease.
It -is in these forms principally that J3r. Rush
conceived that any advantage was derived from
this class of medicines; and Deckers, Frize,
]\Iursinna, and jMagennis, seem to have been of
nearly the same opinion, they having recom-
mended them to be given with tonics.

83. D. Emetics have been employed by several
authors, particularly by Sydenham, Lillie,
J. P. Frank, and Percival, chiefly after other
medicines had failed ; and some advantage has
been said to have accrued from them. Squills
are the emetic most commonly employed, which
probably are partially absorbed, and act also as
a diuietic. Several writers have mentioned in-
stances of the disappearance of dropsy after
spontaneous vomiting ; and have looked upon
this circumstance as an indication for exhibiting
emetics. They are scarcely ever used in modern
practice, and probably the cases are few in which
they are indicated. I have seen, however, in-
stances wherein obstinate vomiting supervened
apparently upon the medicines which had been
exhibited as diuretics, particularly digitalis, squills,
and colchicuni ; but the good effect that appeared
in these cases was attributable to the preceding
course of medicine, and to the accumulated eft'ecis
of these substances upon the system.

84. E. Diaphoretics and sudorijics have been re-
commended by most writers. But in the majority
of casts, particularly in the acute and plethoric,
there is great difficulty in producing perspiration ;
the means which are employed, unless they be
of a contra-stimulant or relaxing nature, tending
rather to excite the vascularsystem, and to increase
the morbid exhalation, than to relax the surface,
and produce diaphoresis. Tlie potassio-tartraie of
antiinonii, Dover's powder, and s]nritustrtheris nitrici,
are, perhaps, the best sudoriflcs that can be em-
ployed; but the former should be given, in the
acute cases, so as to occasion some degiee of
nausea ; and the last named, in asthenic cases.
Dover's powder vvas much confided in by INIudge,
and guaicicum by Chajiberlaine and Bruck-
MANN. As to the propriety of resorting to warm
bathing, in order to induce perspiration, much dif-
ference of opinion has existed. Tepid baths were
recommended by Stoll and Frank, in the acute
states of the disease, and vapour baths by Darbey
and others.

85. F. MiJiera/ leaders, if judiciously directed and
brought in aid of medicine, are often productive of
much benefit. Zacutus Lusitanus recommends
the internal use of. sea water ; and there can be no
doubt that it will prove beneficial if persisted in,
particularly in the sub-acute and atonic states of
the disease. In the more asthenic forms of dropsy,
the Bath waters, the mineral waters of Carlsbad,
Ems, Marienbud, and Vichi/, and those of !ieltzer,
are often serviceable. In cases depending chiefly
upon obstruction, and where an aperient action is
desired, the waters of Harrogate Moffat, and
Leamington* may be tried.

* Dr. Loudon, of Leamington, favoured the author
with the results of an extensive series of experiments
made to ascertain the composition of these waters, 'ihere
are eleven springs of mineral water, seven of wliich are
purely saline, tlirce sulphureous, and one chalybeate.
The saline contains '098 cubic inches of oxyyen, Tb',') of
azote, 3 156 of carbonic acid, 3l"4J5 grains of sulphate of
Ss

626

DROPSY — Remarks on Medicines recommended in.

86. G. The combination of two or more of the
jilans now mentioned is often necessary. But
this must depend entirely upon the nature of the
case in respect of vital energy, and of visceral
complication. Certain, however, of the above
classes of measures are incompatible one with the
other; as purgatives with diaphoretics, and ca-
thartics with diuretics. But a moderate purgative
action will often not materially prevent the opera-
tion of medicines on either the skin or kidneys ;
and some purgatives will even act sensibly upon
both the bowels and urinary organs, particularly
cream of tartar. Deobstruenls, emetics, and ex-
ternal applications, often aid the operation of both
diaphoretics and diuretics. Various substances,
especially those of vegetable origin, are even more
diuretic when applied in the form of poultice, or
fomentation, or liniment, to the cutaneous surface,
than when taken into the stomach, probably owing
to the alteration or digestion they undergo in the
alimentary canal, by which they partially lose
their activity. Several of the older writers insisted
much upon the external use of medicines in this
disease, evidently from having witnessed instances
of the success of the practice.

87. Diet. — Jn respect of diet, little need be
added. It should entirely depend upon the form
of the disease — be spare and cooling in the acute
cases, and light and nourishing in the chronic or
asthenic ; and directed with reference to the vis-
ceral complication. Tiie patient should not be
restricted from drink. Under the head " Potus,"
in the Appendix, will be found formula; for several
beverages, which may be reduced, modified, or
rendered agreeable, as circumstances may requite
such changes. Weak Hollands or gin-punch, or
cyder, perry, or soda water, may also be allowed,
according to the habits of the patient. Spruce
beer is, perhaps, the best.

BiBLioG. AND Refer. — Hippocrates, Aphorism. 3—7 ;
Ui^i youa-m, i. ii. ; et Opera, passim — Aretieus, Chronic.
]. ii. ch. t. — Galcn, Loc. Atl'ect. 1. v. 7. ; et Symp. Caus.
1. iii. 8. — Cxliiis Aurclianus, Morb. Chroi). 1. iii. cap. 8.

— Scribonius I.argi/s, De Coinp. Medicament, tbl. Paris,
J528, sect. 126. e'ditio princeps. — Mesne, Sen. sect. i.
cap. 13. — Avicenna, Ca.i\on. iii. fen. xiv. tr. iv. cap. iv. —
Fernelius, Consil. xxxii. et seq. — Forestus, 1. xix.

obs. 14— 39. — P/a<fr, Observ. 1. iii. p. G55 Ballonius,

Op. vol. i. 192. —Bartholin, Epist. p. 290., iii. p. 132. 327.

— Schenck, 1. iii. sect. ii. obs. 112. ctseq I(V//M,Phar-

macop. Kation. par. ii.sect. ii. S.5. — Horstius, Opera, ii.
p. 19y. 271. — Actuarius, 1. iv. cap. 7. — Bourgeois, Krgo
pra!caven(lo Hydr. Vcnajscctio. Paris, 1628. — Magninus,
Be Tabacco. Ticin. 4lo. 1G4S. — Pcrreau, Ergo Hydropi
Elaterium. Paris, 16,o8. — Hiverius, Praxis, p. 67 Sy-
denham, Opera, p. 199. 618. — Zacntus hnsitanus, Prax.
Hist. 1. viii. observ. b'Z. — Lower, in Philosoph. Trans.
No. 29. —J. Groenevelt, De Tiuo Cantharidum in Med.
Usu interno, 12mo. Lond. Iti98. — /I'o/ic/, Sepulclnet.
1. iii. aect. 21. et sect. 37. ; et Med. Sept. 705. ; et Poly-
althes ; de Ilydrope, iv. ca]). M. .— Morton, Phthisiologia,

1. i. cap. 10. ]). Ul Glisson. Ue Kach. H.— M. Lister,

Exercitatioties de llvdr. Eond. WM . — Riertlin, Lin.
Med. 1700. p. 307. — Ei/scliiis, Ue Ebrietate assidua Hyd.
Causa. Erf, \~{M. — Piso, (Jbservat. No. W&. — ls'eanrter,
Tabacologia, p. If;?. — Slalil, De Hydrope. Hala;. 1701.

Sloane, Voyage to Jamaica and Madeira. I,ond. fol.

1707. — J. If. .Vonf/ic//(7H, Die Wasscrsucht nach ihrem
Ursprung, &c. Hamb. 8vo. 1812. — Fuller, Meilicina
Gymnastica, 8vo. Eond. 1711- — i'«w«c//, in Mem. of

Boda, 14-534 of chloride of sodium, 17.'''70 of chloride of
calcium, and 260.'>0 grains of cliloride of magnesium, in
the Imperial pint. The suljjhureous wells, liesides these
ingredients, contain 3 620 inches of siilpluiretled hydro-
gen. The chalybeate differs in no way from tiie saline,
but in containing 8'.080 grains of bisilic.ile of iron. 'J'hey
are all, therefore, jiurgativc waters. The dose is a pint
daily or every oilier day ; and a course of six weeli

generally ' ■ ■• ■• •• ■■ ■ ' i i,_,.

also, have
watem

Acad, of Scien. Paris, 1701. 181., et 1703, 181.— Bag.
livi, De Pr. Morb. 1. i. c. 9. — Littre. Mem. Acad. Scien.
Paris, 1703, p.m. ; et Ibid. 1707, p. 667. ; et An Hydrope
Venjesectio i* Paris, 1714. — Erastus, Disput. vol. iv.
p. i>m. — Blankarcl, Collect. Med. Phys. cent. v. n. 25.—
Schroeder, Pharmacopceia, 1. iv. p. (;4. — M. Tiling, Ne-
phrologia. Fr, 1719, 12. — I'atcr, Hepar in Hyd.Saepiui
insons, &c. Witteb. 1720. — Bianchi, Hist. Hepatis,
pur. ii. cap. 5. — Blackmore, On the Dropsy, &c. Lond.
8vo. 1727. — Morgagni, De Caus. Morb. epist. xxiv.

art. 18., epist. xxxviii F. Hajfrniiun, Opera, Supp. ii. 2.

—Hclivig, Observat. 83. — Dover's Legacy, p. 32. — Schulze,
De Venaesectioiie in Hydropicis. Halte, 17^6. — Gilehrist,
Use of Sea Voyages, &c. p.88, — Griilin^^, cent. i. obs. 85.,
cent. ii. obs. 56., cent. iv. obs. 73. — Oliver, Philos.Trans-

act. vol. xlix. par. i, p. 46 Laurence, De Hydrope,

12ino. Lond. 1756. — Hitler, De Purgantibus Validis et

Opio. in Hydr. Vien. 1754 Tissot, De Variolis, Apo-

plexia, et Hydrope in Sandifort's Thesaurus, &c. vol. ii.

— A. Stocrclc, De RaJ. Colehici Autum. 8vo. Vindob.

1763.; et Ann. 'Bled. i. p. 82 BUchner, De Diveisa

Hydr. Medendi Methodo. Halse, 1766. — Juncker, De

Aq. Hydr. Vacuatione prudenti, &c. Halae, 1768

Quarin, Animadversiones, Cip. 8. p. 191, ct passim. —
I). Monro, Essay en the Dropsy and its ditterent Species.
Lond. YiQb. — De Haen, Rat. Med. iv. p. 77. et seq.,
V. p. 38. et seq.,vi.\}. 61. et seq. — Macl^enzie, Med. Ob-
serv. and Inquir. vol. ii. p. 287. — Ba/ier, Trans, of
Coll. of Phys. vol. ii. p. 235. — Stoerek, Ann. Med. i.

p. 121.,' ii. p. 177 Lentin, Memorab. m. Beobach. 97.

100, &c. 15eobach.der Epid. p. 93., etUeytriige, iic. p. 115.

— Vallisncri, Opp. vol. iii. p. 269.— Z). Lysuns, Essays on
Fevers, Dropsies, and on the EHt;cts of Calomel, &c. 8vo.
Bath, 1772. — liibe, Schwed. Abhandl. b. xiv. p. 47. —
Bergius, in Ibid. b. xxiii. p. 121 — Fotiquet, Kecueil, &c.
p. 80. et 293. — Gardane, Gazette de Sante, p. 254—279.

— Brocklesby, Econ. and Med. Observ. p. 278. — Odier,
Man. de Med. Prat. p. 214 — H. Wilkes, Essay on the
Drofisy, 8vo. Lond. 1781. — I'an Sivieien, ad \ 1240. —
Hautcsierck, Recueil, vol. ii. p. 308. oiiO.—Piderit, Pract.
Aiinalen, st. i. p. 9l.— lVerlho/, Opera, vol. iii. p. 699. —
Lange, Miscell. Verit. vol. i. p. 6/ — Ehrmann, DeCol-
chico Autumnale. Basil, 1772 — Backer, Exposit. des
diff. Movens usites dans le Traitein. des Hydr. Paris,

1771. — Fuller, Pharmacop. Exterap. p. 212 Lieuta.ltl,

Hist. Anat. 1. i., et I. ii. var. ^ — Baeher, Recherches sur
les Maladies Chroniques, paiticul. sur les Hyd. &c. 8<,o.
Paris, \116.—Bang, in Act. Reg. Soc. Haun. vol. i. p. 25?.,
ct vol. ii. p. 64. — Burrowes, in Trans, of Irish Aciiit,
vol. iv. No. 83. — Frank in Comment. Soc. Scien. Go( t.
vol. vii. p.64. — De Mexn, in Collect. Soc. Med. Hafn.
vol. i. No. 7.; et Act. Reg. Soc. Haun. ii. p. 266 — Lillic,
in Ibid. vol. i. p. 294. — Aaskow, in Ibid. vol. i — Hewsoyi,
Experimental Inquiries, &c. v. ; Edin.Med.Comm. vol.ii:.

p. 42. Furdt/ce, Fragmenta Chiriirg. et Medica, 8v( .

Lond. 1784. — Portal, Anat. Medicale, vol. iv. p. 118 —
Bader, Observ. 44. — Home, Clinical. Exp. Observ. and
Inq. 8vo. Edin. 1781. — F.Miiman, De Natura Hydropis
ejusque Curatione. IjOnd. 1779. 8vo. — lMtha)ii,\'\n\oA
Trans. 1779. 54. — ll'ithering. On Foxglove and its Me-
dical Uses, with Remarks on Dropsies, &c. bvo. Bii-
mingh. 1785. — Berends, De Reined, .'^ntihydr. maxime
celebrat. Laude el Auctoritate. Fran. 1804. — Boehmei ,

De Secura Hydr. Curandi Uatione. Halie, 1779 Greit-

lich. Cur. Hydr. Nova Methodus, 8vo. Fran. 1781. —
Murray, Hydr. Curt. &c. Ujis. 1785. — Garden, in Duti-
can's Med. Comment, vol. iii. p. 330. — Musgrave, in Ibid,
vol. iv. p. 387., vol. v. p. 194. 415 — Ring, in Uiid, vol. viii.
p. 83. — Grieve, in Ibid. vol. ix. p. 286 — Darb,y, in Ibid,
vol. ix. p. 315. — Broughton, in Ibid. vol. ix. ii. 368., et
vol. xix. p. 79.— X)?cA, in Ibid. vol. x. p. WL—Bennct, in

Ibid. vol. xli. p. 15 T. Hamilton,m Ibid. vol. xii. p. 370.

(Advises cyder.) — Latvson, in Ibid. vol. xiii. p. 299. —
Garnet, in Ibid. vol. xvi. p. 271. — iViAop^ic, in Ibid.

vol. xviii. p. 138. — Elliot, in Ibid. vol. xvii. p. 46

Gordon, in Ibid. vol. xviii. p. 75. — Langgulh, De Mer-
curio dulci jiotenti^simo Hydr. domitore. Vit. 1780. —
Hiclilcr, Med. ami Chirurg. Bemerkuiig. p. 278 — Ciotti,
in Giornale di IMcdiciiia, 1782. — Colin, De Lactuca Virosa,
8vo. Vien. 1780. ; and Lond. Med. Journ. vol. i. p. 2tJ3.

Wright, Lond. Med. Journ. vol. i. p. 266. ; et Ibid. vol. x.

)). 149. — Camper, Mem. Sue. Koy. de Mi'd.t. vii. 46. —
Mason, Med. Observ. and Inquir. vol. vi. p. 19. — E. Dar
win, Med. Trans, of Coll. of Phys. vol. iii. p. 255. 448. —
Mudge, in Ibid. vol. ii.— i'. Knight, in Ibid. vol. iii.]).,'>fi '.

G. Pearson, in Ibid. vol. iii. p. 316. — Stall, Rat. Med.

vol. i. p. 295., vol. ii. p. 158.378., vol. iii. p. 5. 132.377.300.,
vol. vii. p. 340. ; et Pra-lect. i. 52. — 7'h. Fotuler, Mcii.
Rep. of the Effects of Tobacco in the Cure of Dropsies.
&c. 8vo. Lond. 1785. — C. Darwin, Lond. Med. Journ,
vol. vi. p. B5.— J. Warren, in Ibid, vol.vi. p. 145. — Cook, in
Ibid. vol. vii. p. 5i.—Hatl,u\ Ibid. vol. vii. p. \hl. -Stark,
Observ. Clinic. — Sckwenkcrs, Uebcr Wassersucht, von
Sclimalz, Svo. Dresd. 1787.- Mexler, Vim der Wasser-

directed. Sin.'li portions of iodine and brome, i sucbt, Bvo. Ului. mi. -Bush, Med. Observ .^nd Inq.

been discovered by Professor DAUUiiNY in these vol. ii. p. 161 .-Brisbane, Select Cases, &c. p. ]3—Si»i,

. I in Phila. Med. Museum, vol. i. p. 316 — J. P. Iraitk, Dp

DROPSY OF THE ABDOMEN— Causes of. 627

viscera, with which it is connected, and of the
absorbent glands it incloses, the numerous sources
of disorder to which these organs are exposed,
the great number and weakness of the veins,
which transmit their blood to the portal vessels,
and the absence of valves from them, in some
measure account for the fre'iuent accumulatiou
of fluid in this cavity. Ascites may arise from
any of the causes enumerated above (§ 8, 9.),
and at any age. Cajiper, Lee, and others, have
seen it in new-born infants ; but it is most common
in women and aged persons. I have observed it in
children at all ages. It occurs more frequently
in married than in unmarried females and girls,
and is often the consequence of the distension and
pressure attending pregnancy, of difficult, orinstru-
mental labours, and of suppression of the puerpe-
ral secretions, or of the perspiration or catamenia,
or of the disappearance of this last evacuation. It
arppears in both sexes from the usual causes of in-
flammatory diseases, and the morbific agents to
which the abdominal organs are liable, particularly
the ingestion of cold fluids when the body is per-
spiring, the use of spirituous liquors, cold, and
moisture, and both, or moisture merely, conjoined
with marsh effluvia, a poor, watery, or unwhole-
some diet, or errors in diet, the drastic operation
of purgatives, external injuries of the abdomen,
and the suppression of accustomed secretions and
discharges.

90. {b) Pre-eiisteiit disease, particularly diar-
rhoea or dysentery, and sudden interruptions of

tiei't.'isn, p.Sol.—LangenOec/;, in Goet.°Anz. ibl'Z, j these discharges; intestinal worms; organic le-
sions of the liver and spleen, especially obstruc-
tions of their venous circulation ; inflammation
of the vena porta, and obliteration of one or more
of its principal branches ; the suppression of
chronic eruptions, or of the exanthemata, — -as
scarlet fever, erysipelas, &c. — or the premature
disappearance of the cutaneous aft'ection in this
latter class of disorders ; acute or sub-acute pe-
ritonitis; organic change of the structure of the
kidneys; the rupture of cysts into the abdomen ;
uterine or ovarian disease (§35.); intermittent
or remittent fevers ; excessive evacuation and
haemorrhages; are occasionally productive of
effusion in this situation.

91. ii. Pathological States. — Ascites is,
1st, III respect of its structural relations — (a)
idiopathic, or primary ; {b) consecutive, or
metastatic; and (c) symptomatic, or compli-
cated;— 2(1, As regards the state of vital energu
and vascular action; (a) acute, or sthenic;
(6) sub-acute ; and (c) chronic, passive, or
asthenic.

92. A. The idiopatliic form constitutes but a
small proportion of the number of cases of ascites
met with in practice. Lepois and Morgagni
have adduced several instances in which it ap-
peared soon after drinking large quantities of cold
water; and many more may be found in the
works of other authors. — (a) I'he acute, or active,
or even the injiammatory state, is that in which
idiopathic ascites is most frequently observed.
It usually occurs either in the young, the robust,
or the well fed, and presents all the symptoms of
the phlogistic diathesis: — the pulse is hard,
thirst increased, the urine scanty ; the skin is
warm, hot, or coloured, and resists more or less
the pressure of the finger. It commonly pro-
ceeds directly from, the external agents men

Ss 2

Curand. Horn. Morb. I. iii. p. 75. ; ct 1. vi. par. i. p. 322. ;
et Act. Iiistitut. Clinic. Vilnen. An. ii. p. 4.'. — Demiani,
in Bii/Jiiiger's Syllog. Op. vol.iv. — IVillicli, m Baidinger's
N. Mag. b. viii. p. '249 Rttdotp/i, m Ibui. b. viii. p. iio5.

— l.fttso7n, in Mem. of Mt'd. of Lond. vol. i., et vol. ii.
p. H5. — Farr, in Ibid. vol. ii. p. 132. — Wins/iip, in Ibid,
vol. ii. p. 3C8. — Chamberlaine, in Ibid vol. iii. p. 561. 571.

— Jl'rig/il, m Ibia. vol. iii. p. 563. — Walker, in Ibid. vol. v.
ji. +49. — UrUckinann, in Baidinger's N. Magaz. b. vii.
p. 'JD. — Baliliiiger, in Journ. x.t. p. 38. — IV. Luxmore,
Address to Hydropic Patients. Lond. 179i>. — Osiander,
BeobaclU. lli.—Gra/Jciigif!.srr, De Hyd. Pletliorico, Kvo.
Goet. 1795.— G^^//»■/.■, in IJii,iai?i'i Ann. of .Med. for 17!«,
p. 482.— fV«e, Annalen, b i. p. 9i.—Fcrriar, Med. Hist,
vol. ii. No. 3. ; and on tlie Med. Properties of llie Digitalis
Purp. Munich. 1799. — Percival, Kssays, &c. vol. i.
p. ~j3., vol. ii. p. l.)6. — Hunt, Btitiiige znr Med. Klinik.
b. ii. p. 211. — Buf/tirier, De Hyd. ejus Causis et Curat.
\'iteb. 1799. — Bueckmuiiit, De Hyd. et Vasorum Lymphat.
Irritabilitate. Erl. ISUU. — Thuiiiann, Annalen, ad 18UU,
p. :t57. — Soemmering, De Morbis Vas. Absorbentium,
p. 125. — E. Pluucquet, Sistens Hydr. cum Scarlatina co-
iiicid. Exempla. Tub. 1801. — Arncmann, Annalen des
Clin. Instit. heft. \.— Duciniing, in Hum's Archiv. b. iii.
p. 4,X — Bieschet, .Surles Hydropisies Actives, 4to. Paris,
1812, rev. in Corvisart's JouVn. de Med. Nov. 1812, p. oUU.

— II'. Hiimiltuii, On the Digitahs Purp. in Drojisy, Con.
suni))tion, &c. Svo. Lond. 1^07. — Schmtdtmann, in
Hiifiln lid's Journ. d. Pr. Arzneyli. b. iii. p. 522. — .duller,

in luid. vol. iv. p. 473. — Scha-Jfer, in Ibid. b. vi.p. 245

Hiifehuid, in Ibid. b. iv. p. 6UU., et b. v. p. 650. — Ober-
teiijer, m Ibid. b. v. p. 615. — Selig, in Ibid. b. iii. p. 291.

i'isclier. in Ibid. b. iv. p. 637 dmradi, in Hufeland's

Journ. d. Pr. Heilk, b. xxi. st. 1. p. 37. — Becker, in Ibid,
b. xxi. St. 1. p. 22. — liiijclaiid, m Ibid. b. xxii. st. iv.
p. 'Ja Bcdducs, ill Med. l-"acts and Observat. vol. v. n. 2.

— Sludtleu'urth, On Dropsy, &c., 8vo. Liverp. 1808.;
and Ellin. ML-d. Journ. vol. v. p. 217. — Erdmann,V>e
Hydropis N'atura, et Curati me. Viteb. 18i 8. — Zeviani,
in Mem. della Societa Italiana, vol. ix. n. 8. — Gaidtier
de Claubry, in Journ. Gen. de MM. t. xvi. p. 6. — D. A.
O. BiclUt-r, Die Spetielle Therapie, b. iii. p. 8. — Bale-
man, art. Drupsy, in Hces's Cycloptedia. — Briickmann,
in Horns Archiv. July, 1811, p. 70. — Hensinger, in Ibid

p. 191. — Horn, in Archiv. fiir Pract. Med. b. v, p. 119.
o62. — Loebel, in Hum's Archiv. Jul. 1820, p. 178. —
Fauchier, in Bulletin de la Facult. de Med. a Paris, No. 3.

1812 Wells, Trans, of Soc. for Imp. uf Med. and Chi..

rurg. Knowledge, vol. iii. p. 194. — Blackall, On Dropsies,
8vo. Lond. 1813, rev. in Edin. Jled. Journ. vol.ix. p. 334.

ihcrcrombie, in Edin. Med. Journ. vol. xiv. p. 163.—,

Hunter, in Ibid. vol. xiv. p. 619. — Marcel, in Trans, of
Med.-Chlrurg. Soc. vol. ii. p. 342. — SomerviUe, in Ibid,
vol. V. p. 40. — Bostock, in Ibid. vol. x. p. 77. — Dempster,
in Edin. Med. Journ. vol. xvi. p. 64. — I^ewins, in Ibid,
vol. xvi. p. 359. — Graliam, in Ibid. vol. xviii. p. 225. —
R Cliriatison, in ILid. >.o. 101. p. 2(i4. — J. C. Gregory, in
Ibid. No. !09. et 110. p. 54.— T. Sliort, in Ibid. No. 114.
p. 129. — Re/iman, in Nouv. Journ. de Med.t. v. p. 114. —
Taclieron, Recherches Anat. Patliologiques, t. iii. p. 190.

— Fercwal, in Dublin Hosp. Rep. vol. i. p. £93. — F. G.
Geromini, Sulla Generi e Cura dell' Idrope, 8vo. Crem.
1816 — Stoker, Pathol. Observ. on Dropsy. Dub. 1823.

— Crn?nptun,'m Trans, of Coll. of Pbys. of Dublin, vol. ii.
p. l;",o. — Laennec, .■Vrchives Gener. de Med. t. vi. p. 619.
(Ubliteration of vena cava.) — Portal, Sur la Nature et le
Traitement de I'Hydropisie, 2 vols. Par. 1824. — E. Bla-
siiis, in Journ. dcs Progres. des Scien. Medicales, t. xii.

p. 102. Itard, in Diet, des Scien. Medicales, t. xxii.

p. 375. _ P. Uai/er, in Diet, de Med. t. xi. p. 420. —
J. Buuillaud,Vkt. de Med. et Chirurg. Prat. t. x. p. 174.

Lemasson, in Journ. Hebdom. de Med. Oct. 1831. —

Mondat, des Hydropisies et de leur Cure, 8vo. Paris.

1S18. G. Gregory, A Lecture on Dropsy, 8vo. Lond.

1819. J. Ai/re, On the Nat. and Treatment of several

Forms of Dropsy, 8vo. London, 1825. — B. f enables.
Clinic. Rep. on L)ropsies, Svo. Lond 1821. — M. Good,
Study of Med. vol. v. p. 367. — Bright, Medical Reports,
&c. vol. i. p. 78. 4to. Lond. 1827. — Hodgkin, in Med.
Gazette, Jan. 1832. — Osborne, On Dropsies, &c. Svo.
Dublin, 1835.

HI. Dropsy OF THE Abdomen. — Syn. "As-xito?
(from ao-Ko-, a leather bottle); Ascites, Auct.
var ; Hydroccclia, Hydrops Abdominis, Hy-
dro-abdomen, Dropsy of the Peritoneal Cavity ;
Die Bauchwassersuclit, Germ. ; Ascite, Hydro-
pisie Ascite, Fr.; Idropisia Ascite, Ital.

88. Defin. Heavy, tense, and fuchiating
su-elting of the whole abdomen, arising from a collec-
tion of uateriijluid in the cavity of the peritoneum.

89. i. Causes, &c. (a) The great extent of the
peritoneum, the number and importance of the

628

DROPSY OF THE ABDOMEN — Pathology of.

tioned above, or from the suppression of an
accustomed discharge, or of some eruption ; and
often advances rapidly, with symptoms of in-
flammatory or excited action in the peritoneum,
— with pain, tenderness, and sometimes tension of
the abdomen ; a quick, small, hard, or wiry pulse,
and suppression or diminution of all the se-
cretions and excretions. Either consecutively
on, or concomitantly with, these symptoms, ful-
ness of the abdomen is observed, which usually
augments rapidly. At first the increase is most
remarkable in tiie lower part of the abdomen and
iliac regions when the patient is sitting up, and
the liver is not enlarged ; but it is always diffused
when the patient is in the supine posture, and
without any limitation or tumour. Upon exa-
mining the abdomen by percussion, a somewhat
dull sound is emitted, and the examination occa-
sions pain. The surface of this cavity is gene-
rally dry or harsh, warmer than natural, and
more tender to the touch ; and fluctuation is
very easily perceived by placing one hand, or
the index finger, upon the anterior part of either
iliac region whilst the patient is erect or sitting
rip, and striking gently, at a little distance, with
one of the fingers of the other hand. Accord-
ing to M. Tarral, a slight effusion will be
detected, and the nature of the disease made
evident by this means, long before it reaches the
height that can be recognised in the usual way
(See Abdomen, § 16.). As the accumulation
augments, all the abdominal functions are more
and more disturbed ; and at last respiration be-
comes difficult, from the pressure of the water
upon the liver and stomach, and the impeded
descent of the diaphragm ; and the patient is
unable to lie down. The abdomen is now large
and prominent in its upper regions, and pushes,
particularly in young subjects, the ribs and car-
tilages upwards. Irritability of stomach, anxiety,
restlessness, want of sleep, great quickness of
pulse, sometimes delirium, and ultimately coma
and death, supervene, if temporary or more pro-
longed relief be not obtained from treatment.

93. (/;) 'J'he sub-acute form of ascites is milder
in its character and slower in progress than the
foregoing; and, as well as the acute, is not an
infrequent sequela of scarlet fever, and more
rarely of measles ; but is, in such cases, always
attended by more or less anasarca. When it
thus occurs, it usually appears gradually, and
commences from seven to fourteen days from the
disappearance of tiie eruption, commonly with
a recurrence of the febrile symptoms, quickness
of pulse, dryness of skin, thirst ; loaded, white,
or furred tongue ; and diminution or interruption
of the secretions. All the phenomena increase
more gradually, however, than in the acute; and
are more readily controlled by treatment. In
both these forms of ascites, the urine is scanty,
often pale, and always contains more or less
albumen. The face is generally cedematous in
the morning, and the ancles in the evening. In
other cases of the sub-acute variety, the eifusion
takes place upon the disappearance of some
acute disease, either attended by free discharges,
or treated by copious depleticms ; frequently with
febrile symptoms, and alwjiys with interruption
or diminution of the natural seci-etions, the fluid
parts of the blood being discharged by the in-
creased determination to the peritoneum. In

both the acute and sub-acute idiopathic for7ns of
ascites, the accumulation of fluid arises from
increased exhalation — liypcfcriiiea of the perito-
neum, according to the phraseology of Rl. An-
DRAL — the result either of morbidly excited
vascular action, or of increased determination of
blood, conjoined with a relaxed or weakened
state of the exhaling vessels and pores.

94. (c) The astlienic, or yassiie, state of idio-
pathic ascites is the most rare. It occurs chiefly
after profuse haemorrhages and evacuations ; in
chloroiic females, or shortly before puberty ;
in ill-fed persons, living in cold, low, or damp
localities ; and in those wlio are excluded from
the solar light, or are under the influence of the
depressing passions, and are employed in seden-
tary occupations. It usually commences with,
or is preceded by, oedema of the ancles, feet, and'
legs. It proceeds very slowly ; and is attended
by general debility ; cold extreinities ; a pale and
sickly countenance ; a cold or cool skin ; a weak,
small, quick, or fluttering pulse ; pale or loaded
tongue ; diminished or vitiated appetite ; various
dyspeptic symptoms; and by chlorosis or hysteria
in females, amongst whom this variety is most fre-
quent. The urinary secretion is more co])ious, and
the bowels more irregular, and more readily acted
on by purgatives, in this than in the other forms.
Whilst lowering measures benefit the two pre-
ceding, they aggravate this variety of the dis-
ease (see § 102.).

95. B. Consecutive, or metastatic ascites, oc-
curs in either of the acute or sub-acute states
described above ; more frequently the latter
(§93.), when there has been no suppression of
the disease on which it is consequent : but when
any of the febrile exanthemata have been pre-
maturely driven from the surface ; or when the
patient has been exposed to cold or moisture, or
both, during convalescence; or if it have super-
vened upon erysipelas, rheumatism, or gout ; the
acute or sthenic condition is most common. It
is much less acute, if it have supervened upon
inflammation of some parenchyniatous or adjoin-
ing organ; or if it accompany pregnancy. In
other respects the characters and progress of the
disease are the same as those stated in respect of
the idiopathic varieties.

96. C'. The siimptomatic, or complicated, states
of ascites are the most common ; and, like the
primary or idiopathic, present every grade of
activity and acuteness. 13ut whilst, in tlie latter,
the acute and sub-acute are most fre(iuent, in the
symptomatic, the asthenic state predominates ;
although an irritative form of inflammation is
sometimes observed to occur in the course of the
disease, often, probably, owing to the irritating
properties of the effused fluid, as shown above
(§ 34.). Complicated ascites presents many of the
organic lesions that occasion symptomatic dropsy
(§ 12.) ; most commonly structural changes in the
liver, or vena porta ; in the spleen ; in the mesen-
tery and its glands ; in the kidneys; in the uterine
organs ; and in the veins and lymphatics. The
dropsical collection appears alter a longer or
siiorter period of disease referrible to these organs ;
commences imperceptibly, and proceeds slowly ;
and generally without febrile symptoms until
towards the fatal close of the disease. Ere-
(juently oedema begins in the feet, and extends
upwards to the knees, thighs, scrotum, or hips,

DROPSY OF THE ABDOMEN — Diagnosis of.

629

and as high as the iliac regions and loins. ]5ut
ascites often reaches its acir.e without any ana-
sarca or oedema. As ihe accumulation increases
and rises up into the epigastric region, the symp-
toms become inore urgent, — the respiration more
quick, short, and difficult ; tiie pulse more rapid ;
the functions of the stoaiach more disordered ;
the alvine evacuations longer retained ; tiie urine
more scanty, higher coloured, and more turbid
— often brown and foetid ; the skin drier ; and the
face and otiier parts which are not oedematous,
more emaciated. In this form of the disease, the
veins of the abdominal parietes often enlarge and
become very apparent ; a symptom whicii M.
Revnfaud found dependent in several cases,
upon obstruction or obliteration of the vena porta ;
the sub-cutaneous veins of the abflomcn having
been enormously dilated. When the effusion arises
from disease of the substance of the liver, it is not
infrequently associated with some degree of jaun-
dice. With great distension of the abdomen, dis-
tressing borborygmi occur, and aggravate the
symptoms. The anxiety, debility, restlessness,
and inability to sleep increase ; and in some in-
stances, hydrothorax or anasarca, or both, either
with or without a diminution of the abdominal
accumulation, supervene in this stage of the
malady. The fatal close of the disease is generally
ushered in by somnolence, or by delirium followed
by somnolency; by urgent thirst and dryness of
the mouth and throat ; by vomitings or retchings ;
by leipothymia ; small, freq>ient, and irregular or
fluttering pulse. The duration of this form of
ascites is extremely various : it may continue for
years, or it may run its course in a few days. In
this latter case, either the kidneys are very
seriously diseased, or the circulation through the
vena porta is obstructed. The complication of
ascites with pregnancy will be considered in the
sequel.

97. iii. Appearances in Fatai, Cases. —
(a) The eff'iised tiuid varies greatly in quantity
and appearances. It is usually of a pale citron
or yellowish tint; sometimes greenish, or even
brown. When it has arisen from obstruction in
some adjoining viscus, as in the passive st;ites, it
is generally limpid and nearly transparent; but
when it has proceeded from disease of the peri-
toneum, as in the acute forms, or from sub-acute
inflammation, it is turbid, whey-like, contains
albuminous flocculi, or pieces of filamentous
lymph, or even thin or partial adhesions. In
some cases the fluid exhales a foetid or urinous
odour, and it is occasionally of a brown, or nearly
blackish hue. from the exhalation of some of the
colouring particles of the blood. — (b) The peri-
toneiim presents, in different case=, all the changes
already described ( § 10.). Sometimeij it is covered
by a thin, albuminous, or inuco-albuminous coat-
ing, or is adherent in parts. In other cases it is
softened, thickened, blanched, and as if macerated ;
and in some granulated, or tuburculated ( Biciiat,
Ijaruon, Andhal). The omentum has occasion-
ally nearly disappeared (iMorgacnx, Pezold, De
Haen, &c.) ; or it is pushed up towards the sto-
mach (OiiANDER, myself, and others) ; or adherent
in parts to the intestines, or to the abdominal pari-
etes (IliBE, Andual, &c.); or suppurated, thick-
ened, and indurated (SroiiRCK, Osiander, &c.).
It has likewise containeil steatomatous or other
tumours. The mesente7'i/ is sometimes also diseased.

Its glands are very frequently enlarged ; and
tumours of various kinds have been found in it
by Tui.pius.IIaroer, J. P. Frank, Yon Berger,
Alix, Andral, myself, and others. The pancreas
has been seen enlarged and scirrhous, but it is
not often altered in structure. 'Jlie liver is most
generally diseased. The vena porta has been
found obstructed by coagulable lymph, the pro-
duct of inflammatory action, and even altoijether
obliterated , by Ixeynia-jd ; or pressed upon by tu-
mours, or its circulation impeded or interrupted by
atrophy, or by enlargement, or by induration of
the substance of the organ ; or by scirrhous, gra-
nular, or tuburcular degenerations of its structure
(see Liver). The gall-bladder and hepatic ducts
have been found containing biliary concretions, by
MonGAGNi, Hoffmann, SxoiiRCK, MARTEAu,and
others ; and in some instances distended by a
black and thick b.le ; or containing a small quan-
tity of pale mucous bile, by the same authors
as well as by Ridt.ev, Pezold, Duverney,
YoNGE, and several recent writers. The kidneys
have also been often seen diseased, as described
above (§ 1.'^.) ; and the spleen is very frequently
enlarged, indurated, and otherwise changed(SELLE,
ScHMiJCKER, Horn, Grottaneli.i, and myself),
a^ described in that article, especially in the ab-
dominal dropsies that occur in low, moist, warm,
and miasmatous localities.

98. iv. Diagnosis. — A. Ascites may be mis-
taken for tympanites, for the various kinds of en-
cysted dropsy, and for pregnancy. — (a) Tym-
panites is readily recognised by the clear resonance
furnished on percussion ; by the absence of fluctu-
ation, and of oedema of the lower extremities ; and
by the history of the case. — (b) Ovarian dropsi/
is generally preceded by pain, tenderness, and
tumefaction, or distinct tumour in the regions of
the ovaria ; and the enlargement proceeds from
one or both these parts. It is never general or
uniform in its earlier stages, as in ascites ; and
fluctuation is usually very obscure, and to be de-
tected only in the situation of the tumours, the
circumscribed form of which may be determined
until a very advanced period of the disease. In-
stances, however, occur, in \yhich the ovarian
tumour induces effusion into the peritonea! cavity :
in this case, the exact nature of the disease can be
ascertained only from a knowledge of the pheno-
mena attending its early stages, or of those con-
sequent upon tapping ; the letting out of the ascetic
fluid generally allowing the ovarian disease to be
readily detected. The same remarks apply to
dropsy of the Fallopian tubes, which are attended
with nearly the same phenomena as the ovarian
disease. — (c) lu hydrometra, or dropsy of the
uterus, fluctuation is with difliculty ascertained;
and cannot he detected in the iliac regions, by the
means described above (§ 92.) ; besides, the form
of the uterus may be defined upon a careful ex-
amin:ition ; the progress of the aft'ection is usually
much slower than in ascites, and there is much
less disturbance of the general health. There
are, moreover, entire obstruction of the catamenia,
and a sense of heavy pressure on the rectum,
bladder, and adjoining parts. — {d) Cysts con'
tainiiig a watery fluid, and of great size, ar
sometimes attached to the liver or to the spleen?
giving rise to appearances in their advanced
states closely resembling ascites. But Hiey al-
ways present a circumscribed tumour upon ac-
Ss 3

630

DROPSY OF THE ABDOMEN

-TnEATMENT

curate examination, the swelling commencing on
one side, generally in the upper regions ot the
abdomen, whilst ascites begins, when the patient
is up, in the lower, and is equally diffused when
he is supine. — Ot" encijited dropsies, generally, it
may be remarked, that a heavy weight, sometimes
with dragging pain, is commonly felt, when the
patient turns in bed, particularly to the opposite
side to that to which tlie cyst is attached ; and
that he usually lies on the latter side. When
only one large cyst, containing a watery fluiil,
exists, the diagnosis is sometimes very difficult,
unless the history of the case is known, particularly
in respect of the last stages of some kinds of
ovarian dropsy. In rare instances, several cysts
are attached to different parts of the same viscus,
or even to different organs, or to the abdominal
parietes. But very much more frequently, the
dropsical ovarium, or ovaria, is very irregular and
lobular, owing to its division into several distinct
cysts. In all such cases, the abdomen, upon an
accurate manual examination, will feel more or
less irregular and unequal, and the nature of
the disease be nearly manifest. M. Pioiuiv states
that a duller sound is emitted upon percussion in
encysted dropsies than in ascites; and that the
parts around the cyst furnish the same sound as in
health. The progress also of encysted dropsies is
always slow, and their duration frequently very
long. They are commonly unattended by much
constitutional disturbance until they reach a very
great height, so as to press injuriously upon the
stomach, and to impede the functions of respira-
tion, when hectic fever is often developed ; the
secretions and excretions, and even the quantity of
the urine, not being much diminished or disordered
until then (see Dropsy — Enciisted). — (e) Preg-
nancy is distinguished from ascites by the state of
the OS ((teri upon examination, by the progress of
the enlargement, and the defined form of the
uterus, when the patient is supine, and the ab-
dominal muscles relaxed ; by her unbroken health
and clear complexion, — the countenance of drop-
sical persons being pale, sickly, and cachectic ;
by the enlargement and firmness of the breasts,
and the deep colour of the areola;, — these
organs being soft and flaccid in ascites. (See

PHEGNANCY.)

99. B. It is not enough that we should satisfy
ourselves as to the exact situation of the effused
fluid, but we should determine us correctly as pos-
sible the pathological coiidilioii givitig origin to it.
In order to do this, we should enrieavour to con-
nect it with its exciting causes, and to enquire into
the external agencies concerned in its appearance,
and the conditions of the various secreting and
excreting organs. The manner of its accession,
the rapidity of its early progress, the sensations of
the patient previously to this event, and the
several phenomena furnished by an accurate
manual examination, as well as a rational con-
sideration of all the natural functions, in connec-
tion with external signs, must be our main guides
in coming to a conclusion relative to the alteration
or alterations, functional and organic, upon which
it chiefly depends. The rapid increase of the
swelling after exposure to cold or any of tiie usual
causes of inflammatory disorder, or alter the sup-
pression of discharges or of eruptions ; a sense of
tension or pain in any of its regions ; increased
sensibility upon examination by percussion, or in

any other way, especially in the hypochondria,
in the loins and uterine region, demand par-
ticular attention ; and the urine should be daily
examined, and its coagulability noted. Tiie
size of tlie abdomen should also be observed
daily, and the decrease and increase marked by a
tape measure.

100. V. Prognosis. — The prognosis in ascites
must necessarily depend upon its form and com-
plications, upon the habit of body, and constitu-
tional powers of the patient, and the effects of
remedies. A much more favourable opinion of
the result may be formed when the disease is
primary, occurs in young and previously healthy
persons, or follows scarlet fever or measles, than
when it proceeds from organic change either in
the liver, kidneys, ovaria, or other abdominal
viscera. In cases of this latter description, very
few recover permanently. Swelling of the hands ;
emaciation of the arms ; frequent cough ; very
scanty, fcetid, and thick urine; colicky pains ; the
presence of jaundice ; and the occurrence of hic-
cup, vomitmgs, or diarrhoea ; are very dangerous
symptoms. The appearance of aphtliEe, of con-
vulsions, of livid blotches on the extremities, par-
ticularly on the hands and forearms, are commonly
fatal signs, as justly insisted on by Hippocrates,
FoRESTus, Frank, and others. Somnolency,
great irritability of stomach, a pulse above 120 or
intermittent and small, and delirium, are not less
unfavourable (see §37.). The characters of the
fluid let out by tapping also indicate the result. If
it be thick, fcetid, brown, glutinous, or albuminous,
no permanent advantage will be derived from the
operation.

101. vi. Treatment, — But little in addition to
what I have already stated may be said of the
treatment of ascites. — 4. Its acute or sub-acute
idiopathic states require vascular depletions, gene-
ral or local, or both, and the rest of the antiphlo-
gistic regimen, to an extent which the pulse and
sym.ptoms, and circumstances of the case, will
indicate. In ascites occurring in children after the
exanthemata, local depletions will be sufficient,
but if leeches be applied, their punctures should
be carefully watched ; for there is often great dif-
ficulty in arresting the haemorrhage from them
after these diseases. IMercurials and antimonials,
at first so as to act upon the bowels, and subse-
quently as alteratives, or with opium, and pushed
as far as to affect the mouth ; external irritants
and derivatives ; deobstruent diuretics, and digi-
talis— this last particularly in the ascites conse-
quent on scarlet fever ; diaphoretics, and warm or
vapour baths, followed by oleaginous frictions of
the skin, in order to restore its perspiratory func-
tions ; and lastly, gentle tonics conjoined with
purgatives, oi; with diuretics, and assisted by warm
iodine, or medicated baths, will frequently succeed
in removing disorder, if early employed, and if a
vital organ have not experienced serous structural
change. Upon the whole, these forms of ascites
should be treated as described at length in a pre-
ceding chaj)ter (§ 40.).

\02. /i. The asthenic form of primary ascites
(§ 94.) is most readily removed by the tincture,
or other preparations, of iodine ; by the ferrum
tartari/atum with cream of tartar ; by the com-
bination of purgatives with tonics, as Bacheu's
pills ; or of Ionics with diuretics ; by warm salt-
water bathing ; warm medicated baths, particularly

DROPSY OF THE ABDOMEN— Tiieatment or.

C31

those with iodine or aromatic herbs ; and frictions
of the surface with stimuhiting liniments. The
gentler vegetable tonics should be first employed,
and subsequently chalybeates and the more active
tonics, as bark, gentian, ike. ; and these may be
conjoined with acids, particularly the sulphuric
with spiritus fetheris sulphurici, or the nitre-
muriatic with spiritus ajtiieris nitrici, and other
diuretics ; and alternated or associated with the
rest of tlie treatment recommended above (§ 42.).
In this, and other forms of asiiienic ascites,
J. P. Frank advises the exhibition of full doses
of :''pium, — a practice from which 1 have seen
niucli benefit obtained after morbid secretions had
been evacuated by purgatives as now prescribed.
I have, however, usually combined tiie opium

bitartrale of potash, with an equal quantity of
biborate of soda and sulphur, have succeeded in
restoring the suppressed evacuation, as well as in
removing the disease.

104. D. I'he siiniptomatic, or complicated,
form of ascites must be treated according to the
principles laid down (§ 44. et seq.), and with
strict reference to the original lesion or malady,
as far as that can be ascertained. The remedies,
perhaps, the most to be depended upon, are
purgatives, alteratives, and diuretics ; — calomel,
elaterium, croton oil, camboge, jalap, &c., va-
riously combined ; the nitro-hydrochloric acids, in-
ternally with the compound decoction of sarsa-
parilla, and externally in tiie form of bath or
lotion ; saline substances, with taraxacum ; the

with diuretics and tonics. Dr. Graves, whilst he j preparations of iodine in small but frequent doses,
„,!,., ...l; . -,-Tv • :__ i_ 1 niucii diluted, long persisted in, and associated

with narcotics, particularly opium, or lactuca-
rium, or conium ; cream of tartar or acetate of
potash, variously combined, especially with
squills ; and, subsequently, the decoction of
broom tops (F. 75.), or of pine tops (F. 51.), or
the decoctum cydonia; compositum (F. 57.), or
the decoct, inula? comp. (F. 67.), or the infusum
berberis (F. 225.), with one or more diuretic
medicines. Cream of tartar was found most
suc(ressful by Dr. Home ; and, if given in suf-
ficiently large doses, conjoined with substances
suitable to the complications of the case, and
continued sufficiently long, is the most certain
remedy that can be prescribed. I have usually
exhibited it, in this state of the disease, in doses
of from two drachms to half an ounce, in the
form of electuary, with an aromatic powder and
diuretic medicine. In this form it generally
acts freely on the bowels, and sometimes, also,
increases the flow of urine. Terebinthinate in-
jections, and oleaginous frictions, as already di-
rected ( j 65.), are also useful adjuvants. In some
states of ascites, advantage may be derived from
the internal exhibition of cantharides. J. P,
Frank has seen cases where it has effected a
cure ; yet he considers it the most uncertain
medicine that can be prescribed. Graduated
Compression of the abdomen, by means of the
belt recommended for ascites h'y the first JNIunro,
has been employed successfully by Professor
SpERANZA and M. Godelle; and, when it can
be borne, may prove serviceable in some asthenic
and chronic states of the disease. Riverius
recommends poultices of the bruised charlock,
the raphanus raphanistrum, to be placed over
the loins or upon the abdomen, and to be fre-
quently renewed. Bran poultices are also in com-
mon use. The warm medicated baths, already no-
ticed, are calculated to be of service, when assisted
and caused it to be persisted in for seven or eight weeks, I by sudorifcs. But these last cannot be depended
wlien good effects began to appear. This medicine was I upon unless they be combined with opium. Hence

continuedfornveorsixmonths at the end of which time I the occasional good effects of Dover's powder
the catamenia had become regular, and the eiTusion had - • ■ • o*^, r '

In some cases, an increased proportion of the ipe

adopts this part of Frank's practice, recommends,
in addition, the free use of animal food, which is
doubtless requisite in many instances, particularly
when the effusion has arisen chiefly from a poor
or thin diet, and other depressing causes.

103. C. The metastatic form of ascites requires
a similar treatment to that directed for the acute
and sub-acute states (§ 40, 41.), together with
means to restore the primary affection. Counter-
irritation of an active kind, and long persisted in,
as well as appropriate to the nature of tiie disease
on which it has supervened, will often prove
beneficial. The repeated application of moxas
has been for ages commonly resorted to in ascites
in the eastern countries of Asia, and has more
recently been found useful by some Continental
physicians. Several moxas are usually directed
to be placed around the umbilicus, or over the
hypochondria, or upon the loins, according as
the functions of the liver or kidneys appear to be
most obstructed. Sulphureous, vapour, iodine,
and other medicated baths, seem calculated to
prove beneficial in this, more than any other form
of the disease. In this variety, also, the bichlo-
ridum hydrargyri may be taken in the com-
pound decoction of sarsaparilla, with colchicum
or squills ; or the ioduret of mercury may be
cautiously exhibited, in small doses, with digitalis
and extract of conium. When the disease has
followed the suppression of the catamenia, the
preparations of iodine*, much diluted, or the

* I was consulted, some years ago, respecting a case of
ascites consequent upon profuse and frequent menstru-
ation. This discharge had been suppressed by exposure to
cold; and, soon afterwards, symptoms of inflammation of
the serous covering of the liver, with effusion, were ob-
served. These were combated by local depletions, wliich
were repeated ; by external irritants, by mercurials, and.
subsequently, by cream of tartar with liborate of soda and
diuretics, and other means in various forms of combin-
ation ; but without any permanent benefit. I directed at
last a weak solution of "the iodideof potassium witli iodine

regular
entirely disappeared. I was more recently consulted as
to a similar case, in the care of Mr. Gbabham, of Roch-
lord ; which had, likewise, been preceded by profuse
catamenia, suppression of this discharge foUrwjd by pul-
monary diseise, and extension of tenderness and fulness
from the thorax, over the region of the liver and abdo-
iiien ; with effusion of fluid into the abdominal cavity.
Tlie pulmonary affection and the more acute symptoms
'Mbsidcd under the very judicious practice of this gentle-
man ; but the means successively aiioptcd in consultation
failed of removing thedrop.sical collection, and of arrest-
ing the progressive em.iciation. There was also, in this
'_ase, scrofulous disease of one
bones of the left hand. This was left to itself, in hopes

cacuanha will be useful. 1 have seen benefit de-
rived from the following, when the stomach was

that the discharge from it would have had a salutary
eflect ou the principal scat of disease. In summer, f832,
this young lady came to London, where various remedies
were prescribed, without relief. I then put her upon a
course of iodine ; and, directing her to persist in its use,
advised her return to the country. I have since under-
stood that, during the use of this medicine, the effusion
ise, scr'ofuTous disease of one or two of the metacarpal i disappeared, and the catamenia returned ; that she re-

" " " " " ■ ■"■ ' ■ " - • . covered her looks, and is now married.

S s 4

632

DROPSY OF THE ABDOMEN — Trfatment or.

when this membrane is punctured or otliervvise

not iiritable, or when its contingent effect of
causing; vomiting would not be injurious : —

No. 185. RPulv. Ipecacuanha; gr.ij. ad iij.; Camphora;
Subactser.j.; Pulv. Opii Puri gr. j. ; Potassa; Nitratis
et Pulv. Radio. Glycyrrh.aagr. X. M. Fiat Pulvis quovis
in vehiculo idoneo sumendus; vel sit bolus cum Conserva
Rosa;,et bis terve in die capiendus.

105. I'iiracentesis is the last means to which
recourse should be iiad. I took occasion, many
years ao^o, in tlie Londnn Medical lieposiwry, to
differ from' those who advise either an early or an
indiscriminate recourse to this operation, and for
reasons about to be stated. It has, however, had
many advocates, from the earliest period of the
ait and probably originated in the benefit, in
some cases, dtvived from the spontaneous rupture
of the umbilicus and discharge of the fluid. The
empiiical manner in which it was resorted to duiing
the fifteenth and sixteenth centuries had brought
it into disrepute, when Mead, Dei.ius, Banyeu,
Stoerck, SciiMucKER, and some others, wrote in
favour of it, and endeavoured to establish it on a
more rational basis. II.\i:tesieek expressed him-
self favourably of it, and advised purgatives and
tonics to be perseveringly prescribed after its per-
formance. FoTiiERCiLL conceived that its want
of success arose from its being too long delayed,
and directed it to be resorted to early. In the
present day it is certainly more frequently per-
formed than circumstances appear to me to war-
rant ; and although it should not be prescribed
from practice, I believe that the cases are few
that will be benefited, and still fewer that will
be cured by it. The chief objections to it are
founded on its being inappropriate in a large num-
ber of cases, on its liability to induce inflamma-
tory irritation in the pevitoneum, and on the fa-
cility with \\hich air may enter the abdominal
cavity during the usual mode of performing it.
On these topics I will add a few words.

106. 1st. Paracentesis seems calculated to in-
crease the mischief, and to diminish the chances
of a complete cure, in acute and idiopathic ascites,
either by increasing inflammatory irritation, where
this already exists, or risking its supervention in
the asthenic forms of the malady. When ascites
depends upon altered structure of the kidneys, it
will seldom do more than give temporary relief ;
and a similar remark applies to the complication
with disease of the liver. This advantage is,
however, worth procuring, and is sometimes con-
siderable, especially when a more decided effect
is produced by medicines, as is sometimes the
case, after the abdominal distension has been
removed by it. But unfortunately this result is
not always obtained ; for inflammatory iriitation
often extends from the punctured jjart, owing to
the readiness witli which an asthenic or erysipe-
latous form of inflammation follows punctures of
serous surtaces, in a cachectic habit of body, and
particularly when the functions of either the liver
or the kidneys are obs;ru(;ted ; and thus, in addi-
tion to the original structural lesions, di.sease is
superinduced in the ])eritoneum, and the effusion
is renewed with greatly increased r.ipiJity, This
complication is, moreover, favouietl by the ef-
fects of the fluid upon the wound in tlie perito-
neum ; for, as 1 have already shown, this fluid,
owing to interruption of the depurating functions,
is often possessed of propeities which induce in-
flammatory irritation in the healthy pciitoueum,
and which are more likely to have a similar ellect

divided.

107. 2d. The introduction of air into the ab-
dominal cavity, although frequently unattended
by any inconvenience in a healthy state of tiie
fiame, and particularly when the peritoneum and
adjoining viscera are not in a morbid or irritable
condition, is certainly sometimes productive of
very serious and even fatal effects, especially in
that state of the constitution and of the abdo-
minal organs, in which ascites commonly pre-
sents itself. I believe that this inference is
conformable to the experience of the most en-
lightened pathologists. The instrument, aleo,
^^ith which paracentesis is usually performed, al-
though calculated to facilitate the removal of the
fluid, favours the introduction of air. The wound
it inflicts is such as to prevent the immediate
closure of the aperture in the peritoneum ; and in
some instances this membrane is pushed before its
point so far as to detach it to some extent from
the abdominal parietes, — circumstances which,
when viewed in connection with the cachectic
habit of body, weak powers of restoration, and
morbid state of the accumulated fluid, are cer-
tainly favourable to the occurrence of asthenic
inflammatory action, and its consequent effusion,
after the operation. On this account, therefore,
paracentesis may be preferably performed by the
lancet, as recommended by J. P. Frank ; or,
after the abdominal parietes are divided by the
scalpel, the lancet may be pushed through the
peritoneum, a bandage placed around the abdo-
men being tightened as the fluid passes off, and
care being taken to close the aperture with ac-
curacy as soon as the stream begins to cease.
But even in this manner the operation is not
likely to prove of much service, where there is
tenderness of the abdomen. Many of the cases
of recovery imputed to paracentesis, I am con-
vinced would have taken place without it, under _
an appropriate treatment ; whilst, doubtless, be-
nefit has been derived from it, both of a temporary
and permanent kind. Instances certainly some-
times present themselves, in which the symptoms
are so urgent tiiat it would be culpable to neglect
having recourse to it. It should, however, be the
last resource. In ascites appearing during preg-
nancy, it, or puncturing the foetal membranes, is
both requisite and successful ; although in two
such cases, in which I was consulted, the means
hereafter to be noticed prevented the necessity
of performing either. It is unnecessary to state
the number of times the operation has been
performed, and the quantity of water lemoved
either at once or altogether. Extreme instances
are comparatively rare,, and convey no useful
information. On this subject I will only add
fuilher, that tapping through the umbilicus has
been recommended by Dr. Sims, and several
other writers; that it has also been advised to
pel form the o])eration through the vagina; and
thnuigh llie bladder, by Dr. Biiciiannan'. 'i'he
objections to the second and third of these are
very obvious ; and, as respects the last, the
ri-k of urine escaping into the peritoneum must
put it out of the (|uestion. The recommend-
ation of conveying astringent fluids, or vapours,
into the cavity of the abdomen, advocated by a
few writers, both i5ritish and Continental, about
the end of the seventeenth and beginning of the

DROPSY OF THE ABDOMEN— PuEnpF.nAL—TBEATMEKT.

633

eighteenth centuiies, merely shows that medical
and surgical temerity is not a result of science,
but of its earliest dawn.

108. The diet and regimen in ascites is the same
as that briefly noticed above. In the more asthenic
states, a liberal diet of animal food of a ligiit and
nutritious kind is requi:-'ite, in addition to a tonic
treatment; and much benefit will sometimes ac-
crue from allowing the patient the use of malt
liquor, or gin-punch, in moderate quantity, and
from making either of them the vehicles for the
exhibition of diuretics, with gentle tonics, or
adding them to some one of the diuretic drinks in
the Appendix (F. 5B8. et seq.). In cases of this
description, Recipe 781., or the following, recom-
mended by RicHTEn, may likewise be used : —

No. 186. B Rad. Scillse Recent. 3j.; Cort. Aurantii,
Radicis Calami Arom., aa 3 iij. ; Juniperi Baccar. contus.
3 ij. ; Villi Albi Hispan. lb. iv. Digere per dies tres, cola,
et adde Oxymcl. Scillae 5 ij. M.

109. IV. Puerperal Ascites. — i. Pathology.
— The more frequent occurrence of ascites in
the female sex has been partly attributed to the
influence of the female organs in giving rise to
it (^ 35. 89.), independently of the puerperal
states. But effusion into the peritoneum may
occur either (a) duiing pregnancy, or (ft) after
deliverv — A. The associutiimoj ascites icith preg-
nancti has been noticed by several of the older
writers, and by many of the moderns, and is not
an infrequent occurrence. Either impregnation
may take place during the dropsical ihsease,
wiiich is very rarely the case ; or the effusion
may be excited by pregnancy, being favoured
by pre-existing obstruction in the liver, or a ple-
thoric state of the system. This latter is the com-
mon mode of its appearance. It is generally of
a sthenic or plethoric character, and is often
associated with impeded circulation through the
liver, or the right side of tlie heart; although it
may be occasioned solely by changes induced by
utero-gestation, and independently of visceral dis-
ease. In this latter case, the ascites seldom com-
mences until about the third month. When it
exists, the form or even the body of the uterus often
cannot be ascertained by a careful examination of
tiie abdomen, unless with difficulty, when the pa-
tient is quite supine, with the hips elevated. I'he
hypochondria become enormously distended and
elevated as the effusion and pregnancv proceed.
The urine is lateritious, scanty, and of a high
colour; and there is much tiiirst, and pains in
the back, loins, and thighs. Scarpa states, that
fluctuation is obscure in tiie hypogastric i^egion
and flanks, but distinct ii the hypochondria, par-
ticularly in the left. The state of the os uteri,
the patient's sensations, 'and the history of the
case, will generally enable the practitioner to
decide as to tiie nature of the complication and
the period of pregnancy. Tiiis state of disease
becomes remarkably distressing. The patient is
afllicted by dj'spncea ; and by cramps, pains,
and oedematous swellings of the lower limljs,
from pressure on the nerves and vessels supplying
them, and by sickness and voniitings. She is
unable to ascend the stairs, or to lie down in bed.
The bowels are very constipated, and the breathing
short and difficult ; to these often are superadded
great anxiety, lividity of the lips and counte-
nance, heavy and somnolent headach, leipothy-
mia, palpitations, and other sjm]>toms indicating

the propriety of having immediate recourse either
to paracentesis, or to the rupturing of the mem-
branes. When the disease is dependent upon
obstruction or structural lesion of the substance
of the liver, a fatal issue often takes place soon-
after delivery, whether that have been premature
or at the full tir:Te. But when it is occasioned
chiefly by the changes in the nervous and vas-
cular systems, and stale of the circulation con-
nected with pregnancy, a favourable termination
may be expected. Scarpa, Desormeaux, and
Lee, record cases, in which this disease was still
further complicated with dropsy of the amnion

C?n5.).

110. 73. Ascites more frequently occurs suli'
sequenthi to delivery, but at no definite time ;
either in a \ery few days, or not until some
weeks, or even months, afterwards. It may either
be a sequela of the adynamic form of puerperal
fever, of which I Jrave observed two cases; or of
peritonitis ; or of inflammation of the uterus,
ovaria, or of their veins, occurring at this period.
It may likewise be induced by suppression of the
lochia ; or by a diarrhoea which has been suddenly
arrested before disordered secretions and accu-
mulated faeces have been evacuated ; or which
has been long neglected, or injuiliciously treated.
It is generally acute or sub-acute, when it ap-
pears in this manner : but if it occur in females
who have been ill-fed, or who liave experienced
large losses of blood about the period of labour,
it ])Ossesses very different features.

111. ii. Treat5ient. — (a) Ascites associated
with pregnancy is seldom benefited by diuretics.
In two cases which came under my care, and
presented the symptoms described above, early,
repeated, and moderate venaesection ; a gentle
and constant action upon the bowels by cream
of tartar, and confection of senna ; and full
doses of opium, assisted by various other means
directed according to the symptoms ; carried
both patients to about the full period of gesta-
tion ; and both bore living children. After de-
livery, the rapidity with which the water passed
off by the kidneys was surprising. In one of
the cases, three large chamber utensils were
filled in twenty-four hours. Paracentesis was
urged by the ordinary medical attendant in one
of these, but was delayed as a last resource : it
was not performed in either. Utero-gestation
very seldom reaches the full time, when fluid is
effused into the abdomen, whether the operation
be resorted to or not. Scarpa advises its early
performance; and adduces a case in which this
complication was aggravated by diopsy of the
amnion, and in which it was pertbrnied under the
left false ribs, and the patient recovered. It was
also resorted to successfully in the one recorded
by i\Ir. Langstaff. In M. Desor-mfaux's case
there were ascites, dropsy of the a.iiuion, and
anasarca. He punctured the membranes, and
brought on labour. 'I'lie instance adduced by
Dr. R. Lee resembled that mentioned by Scarpa.
The cervix uteri being obliterated as in the ninth
month of pregnancy, he ruptured the membranes,
and brought on labour ; after this the patient
slowly recovered.

112. (6) As to the treatment of ascites oc-
curring soon after delivery, the same means, ap-
propriately to the circumstances of the case, as
have been already described, are to be put in

634

DIIOPSY OF THE AMNION — Treatment.

practice. The great majority of such cases will
recover under judicious management, if the liver
or uterine organs be not very seriously diseased.
Paracentesis is very seldom required ; and I be-
.lieve the risk of performing it to be greater in
this state of the disease, than in any other, from
its liability to induce asthenic inflammatory ac-
tion in the peritoneum, and to increase it if it be
already present. I may add, that instances have
occurred in which air has been extricated from
the decomposition of the animal matter in the
fluid effused, particularly when the disease has
depended upon atonic inflammatory action in
this membrane, and thus the ascites has become
complicated with true tympanites. This is more
likely to occur, after paracentesis has been em-
ployed in a case of this description. ( See Author,
in Land. Med. Repos. vol.xvii. p. 378.)

BiBLiOG. AND Refer. — i. Avicenna, Canon, l.iii. fen. 14.
tr. 4. cap. 5. et seq. — Tulpius, !. ii. cap. 33. — Riverius,
Praxis, 71. — Rui/sch, Observ. 70. (Ossification of vena

porta.) Yonge, in Philosopii. Trans. No. 333. — Mor-

gagni, De Caus. et Sed. Morb. ep. 38. art. 20— 34. — K
Hojfinann, De Hydrope Ascite. Halae, 1718. ; et Con-
sult, cent. il. No. 7().—Coschwiz, De Virgine Hydropica,
Uteri Mola simul lahorante. Hala^, 172.5. — R. Mead,
Monita et Pra?cepta Medica, cap. viii. p. Zl. — Pezu/tt,
Observ. Med.-Chirurg. obs. Gi., et obs. 77. — Jacqnart, Non
ergo Hydr. Paracentesis. Paris, 17-52 — Eoelimcr, De
TJtilitate Paracent. frequent, in Ascite. llal;e, 17."i9 —
Cartheuser, De Hydr. Abdominis Vario. Pr. 1760.—
Stoercic, Ann. Med. t. i. p. 129., et t. ii. p. 265.— Tog-W, Hy-

dropis Ascitis Semciologia. Goet. 1764 Lmnwus, De

Morb. Naut. India?. Lips. 1768.— Jto, Observ. Chirurg.

fasc. iil. p. 1. De Hacn, Rat. Med. par. v. p. 40. — Lieu-

taud. Hist. Anat. Med. t. i. p. 3. — Lentin, Beytrage,
&c. p. ISO. — Pringle, in Edin. Med. Essays, vol. iii. p. 378.

Monro, in Ibid, vol.iv. p. 428. — Sauvages, Nos. Meth.

vol. ii. p. 49S. — Hunter, in I\Ied. Observ. and Inquir.
vol.il. No. 2. — Futltergill, in Ibid, vol.iv. p. 114 —
Mackenzie, in Ibid. vol. i. p. Md. — SeUe, N. Beitriige,

b. ii. p. 17. VonBerger, Act. Reg. Soc. Med. Haun. vol.i.

p. 248 Young, in Duncan's Ann. of Med. vol. i. — Si7ns,

in Mem. of Med. Soc. of Lond. vol. iii. n. 27. — Warner,

in Ibid. vol. iii. p. 588 Flajani, Collez. d'Osservazioni,

t. in. OSS. 25., t. iii. oss. 55. — Albers, De Ascite, June,

1795. Thomann, Annalen ad 1800, p. 3-57. — Mac/can,

in Med. and Phys. Journ. 1S02. — Marteau, in Journ.
de Med. t. xxviii. p. 328. — Des Hydr. Ascites et Leu-
cophlegniasies qui rognent dans les Marais de la Vendee.
Paris, 1804. — Willicli, De Paracentesi Abdom. in Hy-
drope. Goet. ISOi. — Ric/iler, Die .Specielle Therapie,
&c. b. iii>-p. 26. — M'Lougliliii, Trans of Irish Co)l. of
Phys. vol. i. p. 199. — ^- Grottanelli, Splenis Morhi, &c.
8vo. Flor. 1821, p. 117. (Enlargement of spleen ivilh ctilo.
rosis and ascites.) — /-. Rostan, in Nouv. Journ. de Med.
t.iii. p. 215. (On the diagnosis of ascites.) — Godclle, Nouv.
Biblioth. Medic.t. vii. p. 5., ett.vi. p. 34. (On compression

in.) Speranza, Archiv. Gencr. de Med. t. xvii. p. 604.

tandr^-Beauvais, in Diet, de Medecine, t. iii. p. 49

J. J. Leroux, Courssurles Generalites de la Med. Pra-
tique, t. iv. p. 6. — Venablcs, in Lond. Med. Gazette,
vol. v. p. 397. — J. Bouilland, in Diet, de Med. et Chir.
Prat. t. iii. p. -524. — G. Andral, Clinique Mt'dic.ile, &c.
t. iv. p. 269. et seq. — Reyncaiid, in Journ. Ilebdom. de
Med. t. iv. p. 137. — A. Buchanan, in Glasgow Med. Journ.
vol. i. p. 195. — Elliotson, in Lond. Med. Gazette, vol. vii.
p. 313. ; and Ibid. vol. ix. p. 571 . 617. — Graves, in Ibid,
vol. vii. p. 584.

ii. Puerperal Ascites. — Ruysch, Observ. Chirurg.
Jjo. 70. — Berchelinann, De Ascite cum Quartaiia in

Gravida. Giess. 1752 Mauriccau, Traite des r,!;(!adips

des Femmes Grosses, vol. ii. p. 59. 204. — Bocliimr. Do
Complicata,cum Abdominis Hydrope Graviditate,eju.sque
Signis. Hala>. 1770. — Chnmhnn, Maladies des Femmes,
t. i. p. 28. — Baraillan, in Mem. de la Soc. 11. de Med.
an. 1784, 1785. — Lanrin, in Med. Observ. and Inquir.
vol. V. — Osiander, Ueobachtungen, IfiC. p. 114. — J. P.
Frank, De Curand. Homin. Morb. vol.vi. parsi. p. 278.

Scarpa, Sulla Gravidanza Snssequita do Ascite, cftc.

Trev. 1817.; et in Journ. of For. Mod. vol.i. p. 249.—
Langstaff', in Transac. of Med. and Chirurg. Society of
Lond. vol. xii. p. 372. — J. Burns, Principles of Mid-
wifery, 6th ed. p. 238. — Desormeaux, in Diet, de Mede-
cine, vol. xi. p. 391. — Portal, Observat. sur la Nature et
le Traitemcnt de I'Hydropisie, vol, i. p. 213 R. Lcc, in

Lond. Med. (lazctte, vol. vii. p.3K7.

V. Uuoi'sv OF Tin; A.mmon. — Hydrops Aniniosis,

Mercier ; Hydrops Amiiii ; Hydrometra of
Pregnant Women, Desormeaux.

113. Defix. Tlie preternatural distention of
the uterus, by an excessive secretion of liquor
amnii, giving rise to symptoms of ascites, sometimes
with obscure fluctuation.

114. i. Pathology. — A morbidly increased
secretion may take place, 1ft, within the amnion ;
and, 2d, between the membranes and uterus. The
former usually occurs during advanced utero-
gestation ; the latter in the early months, and
generally passes oflf without occasioning any dis-
turbance as pregnancy proceeds. The excessive
accumulation of fluid in the cavity of the amnion
was first accurately described by RI. Mercier ;
and it was imputed by him to inflammatory
action in this membrane. It has more recently
been noticed by M]M. JNIaunoir, Duci.os, and
Desormeaux ; but the researches of this last phy-
sician have not confirmed this view of its origin.
Dr. R. Lee has recorded five cases, in none
of which were any inflammatory appearances
in the amnion, and only in two were there in-
flammatory or dropsical symptoms in the mother.
But in all of them, some malformation or dis-
eased condition of the involucra, or of the foetus,
existed, and rendered it incapable of supporting
life subsequently to birth. It is sometimes con-
nected with a dropsical diathesis in the mother ;
but is more frequently entirely dependent upon
disease of the foetus and its envelopes. It pos-
sibly may also depend upon an affection of the
uterus itself, as hinted by M. Desormeaux.

115. The Diagnosis of dropsy of the amnion
in its simple form, and where the quantity of
fluid is not very great, is difficult. Fluctuation
is obscure, deep seated, or wholly imperceptible.
On examination, however, per vaginam, the body
of the uterus is prematurely enlarged ; the cervix
is almost entirely obliterated ; and there is a sense
of fluctuation in the vagina upon percussion of
the abdomen. The rapid increase of the uterus,
the gravative pain in its region, the feeling of
weight and pressure in the pelvis, the frequent
calls to evacuate the bladder, and scanty secre-
tion of urine, will further guide the practitioner.
The diagnosis, however, will be rendered more
difficult if it be complicated with ascites, as in
the instances recorded by Scarpa, Desorhieaux,
and Dr. Lee. In this case there will be fluc-
tuation on percussion, but this will be no sure
information as to the situation of the efl'usion.
'Jhe progress of the enlargement of the uterus,
and the result of vaginal examination, in con-
nection with an attentive manual investigation of
the abdomen, alone can furnish correct indications
as to the nature of the disease.

IIG. ii. TnEAT.MENT. — The chief intentions are
to relieve urgent symptoms, and to carry the
patient safely, if possible, on to the period of
delivery (Desormeaux and Lee).. These ob-
jects may be attained by the treatment 1 have
already advised (§ 111."), when the constitutional
powers will admit of it. 15ut if the symp-
toms become urgent, and the functions of the
stomach entirely overturned, the advice of Des-
ormeaux to puncture the membranes and induce
delivery should be followed ; when the disease
will be remedied, if not complicated with ascites ;
in v/hich case, the means already described must
be practised.

DROPSY OF CELLULAR TIS^SUE — CEdem.u

635

BiELioG. AND Refer. — F. Meicier, De Acute- Am-
niosis Ilydropc, :iut Amniosis Inflammatione quae evasit
in magnain Aquarum Colluvicni, X-c. Paris, 180'.). ; ft in
Journ. Gen. de Med. torn, xliii. el xlv. — Scarpa, Sulla
Gravid. Susscq. da Ascite, &c. Trcv. 1817. — Ductos,
L,ond. Med. Kepositorj', vol. xi. p. ."jli. — C. Maunui'r,
in Melanges de Chirurg. Etrangere, &c. t. i. Gen. 1824.

Dcsurmeanx, in Diet, de Med. t. xi. p. 385. — It. Lee,

in Ix)nd. Med. Gazette, vol. vii. p. 38ii. — A. Duges, in
Diet, de Med. et Chirurg. Prat. t. x. p. I.i4.

VL Dkopsy OF THE Cei.i.ul.'Vr Tissue. — Syn.
Anasarca (from ava,, through; and trap^, the
flesh), 'TTTotrapxa, Auct. Vet.; ' Avai-af no,, hos-
sius ; Leucophlegmasia, oi CdLTlhenser, and seve-
ral of the older writers ; Ilydroscirca, Ilijdrops
Anasarca, Auct ; HiidropsCetlularis, INI.Good ;
Die Haiitwassersucht, Zellegewebe-wassersacht,
Die Wassersucht des Zellegewehe, Germ;
Anasarque, Fr. ; Anassarca, Ital.

117. Defin. Diffuse swelling, pitting beneath
the pressure of the fingers, arising from an nn-
natural accumulation of serous fluid in the cel-
lular tissue.

118. Dropsy of the cellular tissue occur.^ in
various forms and states : 1st. In respect of its

form, it may be — (a) partial ((Edema) ; or (b)
'more or less general, aftecting either the tegu-
mental cellular tissue chiefly (Anasarca), or the
whole cellular substance (Leucoplilegmasia).
2d. As to its state, it may be the result of
increased action, or of obstructed circulation, or
of vascular oppletion (see Cellular Tissue,
§ 6.). I shall, therefore, treat of dropsy of the
cellular structure /i/-s<, in its partial, and secondly,
in its general forms ; and with strict reference to
the states of vascular action and vital powers.

119. i. P.4UTIAL' Cellular Dropsy. — CEdcma
(oiS))i«.a, from oliiia, I swell). A limited infillra-
tioii of the cellular tissue is characterised by
more or less swelling, which retains the impres-
sion of the finger for a short time. It is very
common both as a symptom of general debility,
or of disease of some adjoining or remote part,
or in connection wiih the dropsical diathesis, of
which it may be the earliest manifestation. It
often accompanies inflammatory action of the
other structures — as the mucus, the fibrous, &c.
the contiguous cellular tissue being then infiltrated
with serum, owing to its participation in the ex-
cited vascular action. Bronchitis, pneumonia,
oedema glottidis, rheumatic or gouty affections,
are illustrations of this occurrence. In cases
of phlegmonous or sthenic infl'ammation of any
part, especially of the cellular tissue itself, or
of parenchymatous organs, tl'.e parts surrounding
its seat are also often cedematous from the
same catise. It may also arise from obstructed
natural evnruntions, as suppressed catamenia,
the disappearance of this discharge at the decline
of life, constipated bowels, imperfect action of
the kidneys, &c. and, in such circumstances,
it usually appears in the feet and ancles. It ac-
companies several aftections of the skin, espe-
cially erysipelas ; and various structural and
malignant diseases, particularly those implicat-
ing the venous or lymphatic circulation. It
frequently follows the inoculation of animal
poisons, as the bites of serpents, &c. ; and it is
always attendant upon diffusive inflammation
of the cellular tissue, and induration of this
structure (see Cellular Tissue, § 9. et seq.).
Its dependence upon pressure or disease of the
veins, or of the nerves, especially in the puerperal

states, has been satisfactorily illustrated by the
researches of several modern pathologists, and
is fully shown in these articles. It may also
arise from extreme fatigue, from exhausted vital
powers, the result of previous disease or of old
age ; it then being generally limited to the lowei^
exlremitics, and uncounected with any change
in the urinary secretion.

120. B. The states of organic action and circu-
lation, from which partial cellular dropsy often
proceeds, may be resolved into the following : —
(a) Increased determination of the circulation,
sometimes with dimini^he 1 power of the ex-
halants, the cedematous part being firm, resist-
ing pressure, pitting very slightly, and without
any diminution, or sometimes with increase of
temperature; this constitutes sthenic or active
oedema. — (h) Inflammatory action in the nerves
of the part, occasioning augmented determination
of blood, and effusion of serum, with elevated
temperatui'e, and firm swelling, resisting or ad-
mitting only of slight and evanescent pitting,
and forming an acute or sthenic oedema of rare
occurrence.— (c) Obstructed circulation through
either the veins or lymphatics, the part being less
firm, pitting more easily, and the temperature
lower than in the former : in this case, the ob-
struction may be either internal or external as
respects the vessels, or it may exist in the glands ;
the oedema being either acute or chronic as to
its duration, and active or passive, generally the
latter, as to its grade of action. — (d) Vascular
plethoi-a, or relative increase of the watery parts
of the blood, owing to diminished exhalation or
elimination by the skin, pulmonary surface, or
kidneys, or to the stoppage of accustomed evacu-
ations, giving rise generally to sub-acute oedema,
chiefly in the feet and ancles. — (e) Diminished
tone of the extreme vessels or exhaling pores,
attended by a laxity or lessened vital cohesion
of the cellular tissue, producing passive or asthe-
nic oedema, the part being soft, pitting easily
and deeply, its teniperature very much lowered.
Attention to the foregoing pathological conditions
and distinguishing characters will readily sug-
gest an appropriate treatment (§ 132.).

121. ii. General cellular Dropsy, or Ana-
sarca, affects chiefly the sub-cutaneous cellular
tissue, usually in a great degree, and very
frequently in an acute or sub-acute manner.
The cellular tissue throughout the body may
possibly become dropsical ; but this must be a
very rare occurrence, and manifestly incompa-
tible with the duration of life ; although probably
it may exist slightly, and constitute the Leuco-
phlegmatia of Ccelius AuRELIA^'us, in which
he conceives that this tissue resembles wetted
bibulous paper, or a charged sponge. Indeed,
a state nearly approaching to this very general
or leucophlegmatical form sometimes appears in
the dark races of the species. The anasarca
described by jNIr. W. Hunter, as occurring in
Lascars, seems to have been of this kind ; the
lungs being especially affected, giving rise to
severe and often fatal dyspoena. Anasaica pre-
sents every grade of organic action and duration ;
anfl hence it may be divided into the acute or
sub-acute or sthenic; and the chronic, passive or
asthenic. It may be either primary, as when it
proceeds from cold or moisture ; or consecutive,
when it follows some one of the exanthemata ;

636

DROPSY OF CELLULAR TISSUE-

-PniMARY AND CoXSECUTIVE.

or sijmptomalic, when it depends upon obstructed
circulation about the heart or other viscera. ]
shall consider it accordingly.

122. A. Primaiii iicute and sub-acute ana-
sarca has been well described by Stoll, J. P.
Frank, Wells, AiiEncno-MBiE, and others. It
commonly occurs from exposure to cold and moist-
ure, or from drinking cold fluids, when the body
has been perspiring ; and chiefly in the young, or
in persons not much past the vigour of life.
Oppression and uneasiness of breathing are first
complained of ; occasionally only tightness about
the chest, without cough or pain, is felt ; and
sometimes cough with pain, aggravated by a full
inspiration, and inability to lie down, irom in-
creased oppression of breathing, are experienced.
In a few hours, seldom beyond twenty-four, the
dropsical swelling makes its appearance — com-
monly in the face, and descending downwaids to
the trunk and lower limbs ; sometimes in the
legs ; and often in both the face and lower ex-
tremities, nearly at the same time. The pulse is
either a liltle accelerated, or of natural frequency ;
but generally weak or unequal, or even irregular.
The urine is scanty, high-coloured, and in some
cases coagulable, but in others without traces of
albumen. The bowels are usually constipated,
and the tongue loaded. There are also |ieadach
and thirst. If the effusion be not arrested by
treatment, the swelling increases, and respiration
becomes more oppressed, or even difficult; and
the disease may terminate fatally in a few days,
or be protracted to several weeks, or even months.
This form of anasarca frequently attacks indi-
viduals belonging to the dark races, upon re-
moving to a cold climate, or when the perspiratory
functions, which are extremely active in them,
are suddenly checked ; and is generally attended
with extreme dyspnoea, owing to a sub-inflam-
matory and oedematous state of the parenchyma
of the lungs, which olten become affected to the
extent ot producing asphyxia.

123. The Diagnosis of this variety of anasarca
requires attention, as the swelling of the face,
and oppression of breathing, with the other
symptoms referred to the ciiest, often existing
without fever or acute pain, may cause it to be
mistaken for efl^usion into the pericardium, or
into the pleural cavities. But the nature of the
affection will be manifest on auscultation. These
symptoms generally proceed from active con-
gestion of the substance of the lungs, and in
some cases from a state of vascular action inter-
mediate between congestion and inflammatory
action, attended by more or less serous infiltratiTii
of the parenchyma of the organ. That such con-
ditions actually exist, to a greater or less extent,
when the respiratory functions are disordered, is
shown both by the stutho.-copic and the rat on :1
sii'ns, and by the appearances of inflammaioiy
action, or congestion observed in fatal case-:.

124. B. 'i'im consecutive Jhrm of anasarca was
noticed by several writers previously to J. P.
FitANK, more especially by Stole and Plenciz.
liut this celebrated physician first accurately de-
scribed it about 1790, and subseciuently his
pupil, GiiAi'ENoiiissEu and Dr. Wells. It has
more recently been illustrated by the observations
of seveial writers. It may occur after any of
the exanthemata, but most frc(iueiitly after scar-
lutina, of which it is rather a common sequela,

than a consequence of suppression of either the
eruption or the perspiration. It should not, how-
ever, be supposed that anasarca is the only form
of dropsy that appears after the exanthemata ;
ascites, or hydrothorax, or even hydrocephalus,
may likewise occur, and either of them may be
complicated with anasarca. From a number of .
cases that have come before me, I conclude —
(a) that it is dependent on excrementitial plethora,
arising out of the suppressed or imperfectly re-
stored functions of the skin, ard other eliminating
or depurating organs ; {h) that an incomplete or
suppressed eruption will not occasion it, unless
the internal secretions and excretions be also im-
peded ; (c) that exposure to cold, or to a cold
and humid air, or even to humidity alone, will
favour its occurrence, although it frequently ap-
pears without those aids, and even in very differ-
ent states of the atmosphere ; (d) that it is more
immediately induced by febrile or generally ex-
cited vascular action, arising out of an impeded
or interrupted secretion and excretion, and a
consequent morbid slate of the blood (a), and in-
crease of its fluid parts, accompanied by deficient
power or tone of the extreme vessels and exhaling
pores, either absolutely or relatively to the action
of the heart and arteries.

125. Plenciz describes the anasarca conse-
quent upon scarlatina as having been more fatal
in Vienna, about the middle of the last century,
than the original disease ; whilst Dr. Cullen states
it to be a mild and manageable afl^ection. Its
severity, probably, varies with the state of the pre-
vailing epidemic. It is often the most severe
when the cutaneous eruption and angina have
been slight. There is some difference observed
in the period at which it supervenes. Frank
often met with it as early as fourteen days from
the commencement of the fever; whilst, in other
cases, it has not come on until twenty-eight or
thirty-one days from that time. It commonly
appears in from sixteen to twenty-four days, and
is preceded by slight fever and languor. The
sore throat and fever of the primary malady ge-
nerally have partially or nearly altogether disap-
peared, and the appetite begins to return ; but
the bowels continue costive, the urine scanty
and high-coloured, and the skin dry and harsh.
Slight increase of the fever in the evening, the
patient being morose and restless, thirst, and some-
times pain about the throat, capricious appetite,
and sickne?s, come on, and arc soon followed by
oedema of the face, particularly of the cyeliils,
whirli is greatest early in the morning, extending
rajiidly over the body. With this extension of
the anasarca, there are often symptoms of vas-
cular fullness in the head, the patient becoming
somnolent, torpid, and the pulse less frequent.
In oilicir cases, syn.ptoms of effusion into the
peritoneum, or into the pleura-, or upon the brain,
or of an oedema of the lungs, are superadded, the
two latter affections being attended by evidence
of danger, occasionally as early as the third or
fourth day. As the anasarca becomes general,
or thus complicated, or even previously, the
urine, which had been long scanty, assumes a
still higher colour ; is turbid after standing, de-
positing slight albuminous ffocculi, or resembling
whey; is voided frequently, and in very sinall
(luaiuity.and often with pain in tiie regiori of the
bladder or in the loins, and vomitings. In some

DROPSY OF CELLULAR TLSSUE — Asthilkic.

637

instances, the urine has a brown appearance, from
the presence in it of some of the red particles of
the blood. Frank likens it to the washings of
flesh, owing to this circumstance. It generally
coagulates more or less on tlie application of the
usual re-agents.

126. In the less favourable cases stimptoms of
danger appear from the third to the ninth day
from the conimencernent of the oedema of tiie
face ; but after twelve or fourteen days, they very
seldom occur; convalescence often, under a ju-
dicious treatment, having commenced or pro-
ceeded far by this time. The danger in this form
of anasarca depends upon its complications. —
1st. Upon active congestion, inflammatory action,
or serous infiltration of the substance of the lungs,
as in the primary form of the disease (§ 122.) ;
dyspnoea, sense of oppression, constriction and
anxiety in the chest, with dry cough and inability
to lie down supervening, and indicating the nature
of the couiplication : — 2d. On effusion on the brain,
ushered in by headach, sickness, and vomiting;
and evinced by dilated pupils, slow pulse, con-
vulsions, strabismus, loss of sight, and other signs
of acute dropsy of the brain : — 3d. On effusion into
the pericardium, indicated by swellings of tlie
face, neck, and hands, fulness of the veins of the
neck, bloated countenance, irregular pulse, leipo-
thymia, and fulness and tenderness of the inter-
costal spaces, chiefly of the left side: — 4th. On
effusion into the pleura;, sometimes also associated
with some efl^usion into the pericardium, and the
symptoms of hydrothorax :■ — and, 5th. On disease
of one or more of the abdominal viscera, either
with or without effusion into the peritoneum ; se-
vere diarrhoea or dysentery occurring, and, whilst
it carries off the dropsy, causing a chronic disease
of the digestive mucous surface, occasionally with
ulceration and its consequences ; or suppression
of urine from congestion or inflammation of the
kidneys taking place, and aggravating all the
dropsical symptom- ; or obstruction of the liver
superinducing an obstinate and dangerous form
of ascites.

127. Anasarca consecutive of scarlatina is most
frequent in children, and is rare in adults. Other
eruptive diseases, beside this, give rise to dropsy
of the cellular tissue, especially measles, ery-i-
pelas, urticaria, miliary fever, and many chronic
diseases of the skin ; owing not only to their
suppression or retrocession, but aUu to impeded
secretion, and to the consequent ex( icmentitial
plethora often attendant, or consequent, upon
them, ^^'hen it is consecutive of these diseas',-,
it possesses either the sub-acute charac;er co n-
mon in that following scarlatina, or the n.ore
acute symptoms of the primary fcim.

128. C. Primarii asthenic anasarca is not so fie-
quent as the preceding. It is even questionable
whether or not the asthenic cases, usually con-
sidered as idiopathic, are not depending either
on structural change in an important emunc-
tory, as the kidneys, or on obstruction about the
right side of the heart, or conj^estion of the large
veins and of the lungs.' There can be little doubt
that many of them are thus connected ; yet some
instances will present themselves, in which the
asthenic state is primary, as far as can be ascer-
tained. These are most likely to occur in persons
living in cold, miasniatous, moist, low, imper-

those of a lympathic or phlegmatic temperament,
or who lead sedentary lives, and are insufliciently
nourished ; in those who have experienced copious
losses of blood, or are reduced by chronic or re-
peated discharges, as by htemoriliagia, diarrhoea,
dysentery, Sec, or who, whilst convalescent from
severe exanthemutous or other fevers, have been
exposed to cold and humidity ; and in persons
under the influence of depressing emotions, or
who have suffered some sudden alarm. This form
of the disease may accompany retention of the
menses, or chlorosis ; and it may supervene also,
in debilitated states of the frame, upon obstructions
of the catamenial or haBmorrhoidal evacuations.
JNIany of such cases, however, will approach
very nearly to the sub-acute form, and derive
beneJit from evacuations. The cases of anasarca
produced by terror, disappointment, surprise,
mental distress, &c., and termed spasmodic bv
Laxdre Beauvais, and some other writers, ap'-
pear to belong chiefly to tliis variety. 'That these
and simdar causes are sometimes followed by
anasarca, cannot be disputed ; but I question the
dependence of the disease on spasm. Even
granting the existence of spasm, what are the
parts affected by it, and how does it act ? Con-
vulsions will sometimes occasion oedema of cel-
lular parts; but they will also, during their
continuance, sometimes remove the effusion, as
observed by Dr. \Vells. The causes which are
supposed to act by spasm, merely deranoe or
inipede the circulation through the heart and
lungs, occasionally also rer;dering the hepatic
circulation more languid or difficult than natural,
whilst they lower the vital tone of the extreme
vessels, particularly in weak and irritable consti-
tutions, and interrupt the excretory functions,
thereby inducing the conditions of the vascular
system most favourable to the occurrence of
serous effusion. Cases rapidly produced by
fright have been recorded by Tissor, Desessart,
L'eauchene, Bresciiet, Bateman, and otiiers ;
and numerous instances connected with disor-
dered or delayed menstruation, and the exhaust-
ing diseases mentioned above, have been adduced
by Plater, Riedlin, Fore^tus Piso, Willis,
Eller, Hoffmann, Saovages, Leib, Melitsch,
and later writers.

129. Asthenic anasarca generally appears
slowly, and with all the signs of debility and
laxity of the soft solids : whilst the sthenic dis-
ease often forms rapidly, and with many of the
symptoms of fever, or increased action. The
infiltration usually commences in the lower ex-
tremities ; sometimes in the face, or in both ; slowly
extends over more or less of the body ; and is
most remarkable, as well as most early, in those
parts of the cellular tissue which are the most
lax, as the eyelids, genitals, &c. The pulse is
small, soft, and occasionally slow ; the skin be-
comes paler, whiter, and colder than usual. The
surface pits much more easily on pressure, and
retains the impression loni;er than in the acute
or sub-acute forms. At first, the infiltration of
the lower extremities is most remarkable at
night, and nearly disappears in the inornini';
but it subsequently returns earlier in the day,
and to a greater extent, and is incompletely or
paitially dispersed by the horizontal posture;
the reverse taking place as to the oedema of the

fectly ventilated, and dark places j particularly in J face. Ultimately it becomes much more con-

DROPSY OF CELLULAR TISSUE— Treatment.

siderable, more general, and more permanent,
sometimes with signs of coincident or consecutive
effusion into one or more of the serous cavities.
But the collection is very rarely so great, or so
complicated, in primary asllienie anasarca as in
the symptomatic. The urine is in small quantity,
and seldom contains albumen. The bowels are
either sluggish or irregular ; more commonly the
former.

130. D. Symptomiilic anasarca may present
either acute, sub-acute, or chronic characters.
But it is most frequently chronic, passive, and
asthenic, and nearly resembles the primary
asthenic variety now described, as respects the
constitutional powers. \Vhen, however, anasarca
is complicated with, or consecutive on, acute
diseases of the lungs (§ 29.), it is also acute or
sub-acute ; but it is rather, in this case, a con-
comitant effect of the exciting causes of the
pulmonary disease, than a symptomatic affec-.
tion. Organic changes of the heart and kidneys
are the most frequent sources of symptomatic
anasarca. I shall, therefore, notice this com-
plication more closely than the others. — (a)
Anasarca generally supervenes on chronic lesions
of the heart, and especially towards the close of
life ; usually commencing in the face, particu-
larly in the eyelids, and upon rising in the
morning. Sometimes the ancles begin first to
swell, and occasionally both the face and ancles —
the former in the morning, and the latter in the
evening. The inliltration gradually increases
and extends ; effusion into the pleura;, or into
the pericardium, or into both, also taking place
eitlier simultaneously or subsequently.

13L (b) Anasarca caused by disease of the
kidneys is very seldom seen unassociated with.
effusion into one or more of the serous cavities.
It is, when thus complicated, attended by pain
in the loins, by sickness, vomiting and diarrhoea :
it usually commences in the lower extremities ;
and is commonly in consequence of irregular
and drunken habits, or of the scrofulous dia-
thesis. It is very liable to recur, and is seldom
permanently removed {§ 34.). Anasarca is also
sometimes a consequence of chronic disease of the
lungs, particularly chronic' bronchitis, bronchor-
rha'a, chronic plearitis, and tubercular phthisis.
In these cases, the infiltration commences either
in the face or in the lower extremities, only oc-
casionally extends as high as the thighs or hips,
and seldom becomes general ; but is often asso-
ciated with effusion into the cavities of the chest.
Organic changes of the liver and uterine organs
but rarely occasion anasarca, until after effusion
into the cavity of the peritoneum. The ob-
servations alreiidy offered respecting the con-
nection of dropsy with disease of the blood-
vessels and lymphatics {§ 27.) are entirely appli-
cable to this species of the disease. Although
complete obliteration of one even of the largest
venous trunks has taken place, serous effusion
will not necessarily follow, especially if a col-
lateral circulation be established. A remarkal.'le
instance of this is recorded by INlr. W'iison,
where the vena cara was entirely oljslructed, but
no vestige of serous effusion existed, — evidently
proving that other pathological conditions, beside
venous obstruction, are requisite to the occur-
rence of effusion ; wiiilst in the case of obliterated
cava published by Laennec, ascites and anasarca

of the lower limbs existed. Of the agency c."
disease of the vascular systems in causing local
or partial anasarca, sufficient notice has been
taken (§ 25. et seq.). The causes, morbid appear-
ances, and prognosis, in anasarca, have been de-
scribed under these heads in the early part of this
article (§ 8. 14. 37.).

132. iii. Treatment. — 1st. Of partial or local
Anasarca. — After removing the remote causes
(§ 8.), the next object that we have to attain, is
to restoie the natural secretions and excretions,
when any of these are in fault, and to remove
the pathological state on which the affection
depends. 'I'he restoration of the secretions will
be attempted by the means appropriate to those
chiefly disordered, — by purgatives, diuretics, dia-
phoretics, deobstruents, &c., as the intestinal, the
renal, the perspiratory, and the biliary secretions,
may indicate more or less of disorder or of inter-
ruption. If the oedema depend upon the arthritic
or rheumatic diathesis, after the use of these
means, colchicum internally, and iodine exter-
nally, may be prescribed, and aided by the sup-
port of bandages : if it proceed from amenorrha'a,
or the final disappearance of the catamenia, a
moderate bloodletting, general or local, should
precede the means directed to act on the secre-
tions. In many of such cases, as well as in
others where there is no obstruction to the cata-
menia, particularly in females who have had
children, or who are subject to constipation, and
faecal accumulations in the large bowels, the
femoral veins are either chronically inflamed,
obstructed, or varicose. Their course should,
therefore, be carefully examined ; and if any
hardness or tenderness exist, leeches ought to
be applied. In old or chronic cases, however,
the veins will either feel hard and obstructed,
without much pain, or they will be nearly oblite-
rated, the superficial vessels being distended and
varicose, and tlie surface of the limb sometimes
purplish or dotted with dark red spots, cold,
tumid, and unyielding to the touch ; pain and
stiffness being referred chiefly to the lower part
of the leg and ancle. In several such cases, I
have prescribed, with marked benefit, deobstruent
purgatives, the biborate of soda, and iodine ;
causing the patient to wear a laced stocking,
and to have frequent recourse to frictions. Be-
nefit will be derived also from frictions with
mercurial liniments, united to one of those about
to be refeired to; Jiiid from a course of bitter
aperient medicines. W li-n the disease of the
veins is conntcted with n.urked debility and
weak powers of digestion and assimilation, gentle
tonic>, chalybeates, frictions witli stimulating
and deobstruent liniments (§ 65.), will accelerate
a cure. (See Phlegmasia Dolens and Veins ;
— Diseases n/.)

133. The connection of oedema with amenor-
rhaca, independodhj of obstruction in the veins, re-
quires a persevering internal use of iodine, or of
the biborate of soda, with tonic aperients, or
the compound decoction of aloes, &c., preceded
by general or local depletion when signs of ple-
thora or internal congestion are present. But
when there are chlorotic appearances of the
countenance and surface, or irregular manifest-
ations of hysteiia, with great mobility of the mus-
cular, and susceptibility of the nervous, system ;
a weak, soft, open, or uuduhiting pulse j and

DROPSY OF CELLULAR TISSUE — Tkeatmekt.

639

especially if the catamenia have not appeared, or I
having; imperfectly commenced, have disappeared ; [
the disorder may have been induced or per- j
petuated by raanustupratio, and require from the
commencement a tonic and stimulating treatment,
and tlie liberal use of the preparations of iron.
When aperients are necessary, the compound de-
coction of aloes with ihe compound mixture of
iron ; and the pii. ferri comp. wiih the aloes and
niyirh pill, or with aloes only ; are amongst the
best.

134. When oedema of the lower limbs depends
on the pressure of the gravid uterus, cooling
tiperients, especially the confection of senna with
cream of tartar, small bloodlettings if there be
vascular oppletion, a light diet, the recumbent
posture, pure air, and patience, are the chief re-
medies. U'lieii the local anasarca is caused by
the pressure of enlarged or diseased glands, mer-
curial deobstruents, internally and externally, the
preparations of iodine, or the ioduret of mercury,
may be used, and the secretions and excretions
promoted and duly evacuated by deobstruent pur-
gatives; or with a combination of tonics and
aperients. The taraxacum with the alkaline car-
bonates, and either the liquor potassae, or the
bichloride of mercury in very minute doses,
taken in the compound decoction of sarsaparilla,
or in the concentrated preparation of Jlessrs,
Savoky and Moore, have been of essential ser-
vice in several cases in which I have prescribed
them.

135. 2d. Of general Anasarca. — A. Of pri-
murii acute and t.iib-acute anasarca, little be3'ond
what has been advanced respecting the tieatment
of acute dropsies (§ 40, 41.) need be here stated.
If any difference in the measures is at all admis-
sible, it respects merely a more energetic adoption
of depletion, and a greater necessity for repeating
it, in this than in any other species of dropsy,
especially in its acute states, occurring in young,
plethoric, and robust subjects. The instructive
case published by Dr. Grahaim is an excellent
illustration of this practice. When the patient
complains of pain in the loins, and the urine is
very scanty, or nearly suppi'essed, general bleed-
ing will often be advantageously followed by
cupping on the region of the kidneys. In addition
to vascular depletions, the same remedies, espe-
cially purgatives or ca(/(art(cs, directed in nearly
the same succession and manner as described at
the places referred to, and at § 55., should be
employed; and lastly, rfun-ff/cs, associated in the
way there advised, may be resorted to. It is ob-
vious, however, that the extent to which the anti-
phlogistic treatment should be carried, must de-
pend upon the nature of the case, and the acumen
of the physician in detecting those latent states oi
active congestion, or of increased organic action,
to which acute dropsies so often are owing.

136. B. In consecutive acute anayirca, appearing
in the manner described ($ 124. et seq.), a nearly
similar treatment to the above, in a less active
form, however, in many cases, will be required.
The sources of danger, in this form of the disease,
particularly when it follows scarlatina or measles,
should always receive attention ; and the remedies
ought to be so directed as to prevent their acces-
sion. The directions already given (§ 40.) respect-
ing general or local bleedings, should be strictly
followed; and active counler-irritaiion and ex-

ternal derivation, — as the application of a laree
blister upon the nape of the neck, or between the
shoulders, — be afterwards resorted to, e3])(;cially
if symptoms of cerebral oppression, or of affection
of the thoracic organs, manifest themselves. If
tenderness on pressure be felt in any part of the
parietes of the chest or abdomen, or of the region
of the heart, inflammatory irritation in the plcuraj,
peritoneum, or peiicardium, should be dreaded,
and local depletions at somtr distance fi-om tlie seat
of pain, followed by external irritants and deriva-
tives (§ 57.), be prescribed. If sickness and
vomiting come on, an inflammatory affection of
the head should be suspected, and be treated by
active depletion and cathartics. In some cases,
however, the vomiting depends upon disease of the
kidneys ; attention, therefore, should be paid to
this circumstance. When diarrhaa is present, the
supervention of ascites, or the existence of lesions
of the kidneys, is to be feared. ^Vitllout suddenly
checking this discharge, means should be used
to moderate it if it be caused by iuflanmiatory ac-
tion, and to evacuate offending matters if it seem
to proceed from this cause. Leeches should be
applied to the abdomen or its vicinity — to the anus
or sacrum, if there be tenesmus — and be followed
by hot fo.iientations, especially the terebinlhinate ;
and, if the evacuations be offensive, scybalous,
knotty, &ic., a full dose of castor oil, or any other
purgative, as calomel and jalap, «Scc., should be
taken, and a full effect be prom.oted by purgative
.or laxative and emollient enem.ata. Afterwards
digitalis may be exhibited, with liquor aminoniaj
acetatis, infus. taraxaci, and syrupus scillae ; or
the ammoniated spirit of colchicum rnay be given
in a similar form.

137. In all cases, of both the primary and
consecutice disease, the propriety of acting upon
the secretions and excretions should be kept in
view. In the former state especiall}', the cathar-
tics, particularly those wiiich act as hydra gogues,
Siselalerium, croton oil, the euphorbia lathyris, and
others enumerated above (§ 66.), may be pre-
scribed with due cautiorr; but in the latter form,
the common purgatives, as calomel and jalap, or
the infusion of senna with some neutral salt, will
be sufKcient. The restoration of the cutaneous
functions should be a chief object in the treatment
of consecutive anasarca. \Vith this intention,
tepid bathing in acute cases, when the temperature
of the surface is increased ; and warm bathing
(Aaskow) in the sub-acute ; and the various me-
dicated baths already noticed ; may be directed,
dud be followed by gentle friction of the surface
\Mih warm oil, as advised by Sciimidtmann ; or
with sweet oil, as used by Oliver, Sec. ; or with
almond oil. I have adopted this treatment in
several cases of anasarca following scarlatina, and
seen benefit derived from it. As to the use of
diuietics, it is unnecessary to add to what is stated
in olherplaces ({ 71.) respecting them.

138. 3d. In Primary Asthenic Anasarca, the
preparations of iodine, the ferrum tartarizatum,
with cream of tartar ; the balsams and terebin-
thinates ; sulphur ; the association of tonics with
purgatives and the warmer diuretics ; chaly-
beates ; and the rest of the tonic treatment recom-
mended above (§ 42, 43.); are chiefly to be
depended upon. In many cases of this descrip-
tion, the preparations of digitalis or of squills
maybe added to bitter vegetable infusions and

640

DROPSY OF CELLULAR TISSUE — Treatment.

decoctions, and some one of the neutral salts;
and cantharides may be tried, as advised by
Chalmers, Alix, &:c. Tlie following also may
be employed; the first of which has been re-
commended by M. Dumas, the latter by Mr.
Sprague : —

No. 187. B Antimonii Pufver. gr. xx. ; Croci Martis
Aperit. gr. xxv. ; Pulv. Scilla; gr. xij. ; Gum. Amraoniaci
5j. ; Extr. Dulcamara 3ij.; Olei Juniperi q. ». M.
Contuiido in massam irqualem, et divide in Pilulas Ix.,
quarum c ipiat duas vel tres bis tc-rve in die.

No. 188. E Decucti SpartU Cacum. (F. 7o.) 3 x. ; Po-
tassa; Acet. 3 ij ; S]iirit. .Ether. Nit. et Tinct. Lavand.
Comp. aa .5j. M. Fiat Haustus ter in die sumendus.

No. 189. H Dccocti Scoparii 3x. hiq. Ammonis Ace-
tatis 3ss. ; Spirit. iEther. Nit. 3j.; Tinct. Scilla? 3ss. ;
Tinct. Capsici ll] x. M. Fiat Haustus ter die caplendus.

139. 4tli. The Symptomatic, Chronic, or Passive
states of Anasarca, require the same intentions
and means of cure as have been already stated
(j4A. et seq.), h\xt with a strict reference to the
nature of the organic change with which it is
connected, as far as that may be ascertained.
Anasarca dependent upon disease of the liuigs is
sometimes benefited by local bloodletting, but
the practice requires the utmost discrimination.
It is seldom admissible in aged patients ; but in
tiie younger and more robust, and when the pul-
monary disease consists of active congestion or
inflammatory action in the substance of the organ,
or if the congestion be associated with obstructed
circulation througii the heart, moderate local de-
pletions, repeated in the more acute cases, will be
of service: w!ien anasarca follows chronic bron-
chitis, or tubercular phthisis, it will seldom be pro-
ductive of benefit, and in the former may be inju-
rious. External derivation, actively and perse-
veringly employed, is more generally appropriate.
In this form of the disease, the preparations of
colchicum or of digitalis cautiously exhibited, and
the rest of the treatment directed in the manner
described above (§ 49.), will afford more or less
relief.

140. AVhen the disea.se of the heart, associated
with anasarca, is of an active kind, and the patient
is plethoric or robust, local depletions, followed
by hydrat^ogue purgatives and digitalis are requi-
site. But, if it be of a pas.sive or atonic kind, an
opposite practice is indicated. The particular re-
medies that may be used in these cases have been j
fully stated (§45. ei seq.). If the liuer be diseased
as well as the heart, the prolonged and daily use
i;f deobstruent purgatives {§ 66. et seq.) and
diuretics; the alkaline carbonates, with extractor
decoction of taraxacum ; a discriminating use of
mercurial jiurgatives; calomel with digitalis, as
advised by Wiedemann ; cream of tartar with sul-
phur and biborate of soda, as recommended by
PiDKuiT ; and the ammoniated preparation of
colchicum, with the carbonates and bitter infu-
sions, and some diuretic tincture of spirit ; will be
productive of advant:ige. When the effusion

derived from the practice. But when these
organs are manifestly diseased, no permanent
good effect can be expected from medicine.
The connection of anasai-ca with uterine disease
requires but little additional remark. The means
already de-ciibed (§ 53.) are quite appropriate
to this species of dropsy. When, however, hys-
teria is present, the more cooling tonics, as the
decoction of cinchona with the liquor ammoniaj
acetatis, nitre, and the nitric ffither ; or vegetable
bitters, with alum and opium, as advised by
Leib ; tonic infusions with an alkaline carbonate,
nitrate of potash and squills, &c. ; will generally
be serviceable.

141. The treatment now described will require
constant modification, in respect both of the
association of diflerent classes of medicines, and
in the combination of those possessed of analogous
properties — as regards conjoining tonics with
purgatives, or various diuretics one with another.
1 he remarks offered above, as to the numerous
medicines which have been employed in dropsies
(§ 54. et seq.), will assist the practitioner in select-
ing from, amongst them for the removal of anasarca,
whether this species exist simply', or in conjunction
with effusion into one or more ol the serous cavities.
Thepyrola umbellata, recommended by Dr.SoMER-
viLLE, and more recently by Dr. Bkatty and Dr.
Seymour; and the lireruort, employei in the
manner pointed out by Dr. Siiortt, should be
duly tried.

142. The propriety of having recourse to sca-
rijicalions and punctures has been much ques-
tioned. But it entirely depends upon the circum-
stances of the case, and the manner of making
them. When the limb is cold, pits deeply, and
retains the impression long; when the patient is
old, and, from the irregularity of the pulse, &c.,
probably has ossified ai'teries ; and when livid or
daik spots appear in the extremities ; scarifications
will be attended by much risk of being followed
by sloughing sores, although acupunctiiration may
be substituted with advantage, as recommended
and employed successfully by l\lr. Churchill.
Indeed, this seems to be the preferable mode of at-
tempting to evacuate the collected flui<l. Dr.
KoENiG advises the use of electro-punclurution.
It is a question whether or not acupuncturation
may not be preferable to any other mode of
puncturing in this disease. Several practitioners
direct small punctures with the point of a lancet,
as the safest and best v.. ode of directly evacuating
the infiltrated fluid, iliis practice was praised
by Col de Villa rs, Gulnault, Adet, 'J'lii-
LENius, and some later writers. In several in-
stances of sloughing sores consequent upon tiie
rupture of the skin, and upon scarification, 1 have
seen the most decided benefit derived from the
application of a cloth moistened with spirits of

seems to arise fi-om dist-ise of the kidnci/s, the j turpentine over them. This medicine causes

treatment already recommended {§ 52.) may be
tried. The eH'ects of remedies on the urine, and
on the symptoms referrible to the kidneys, ought
to be carefully watched. Cream of tartar with
biborate of soda, the alkalies wiiii the uva ursi,
the acetum scilla; saturated with potash (Sack-
ENREUTEn), the balsams with magnesia or the car-
bonates, and external derivatives, or counter-
irritation, may be em])loyed. J)r. Venahles re-
commends cupjiing on tiic ioins, and the insertion
of issues in that situation; audi havese'jn benefit

a rapid subsidence of the swelling, and restores
the cohesion of the rarified and weakened tissue
surrounding the divided or destroyed parts.

BuaioG. AND Refer. — n/ppocra/cs,Ui^i vomfun, 1. ii.
i. 10. — Celstis, 1. iii. cap. 21. — Galen, De Locis Affect.

1. V. cap. 7. — Oribasitis, vii. c. Sr) Ca'lhts Jiirclianus,

p. 470. — Ai'tius, Tetrab. iii. s. ii. cap. 28. — Alexander
Trail/anus, 1. iii. cap. 29. (bloodletting a7id Aniiplilogis-
lirs.) — Avicenna, Canon. 1. iii. fen. xiv. tr. iv. cap. 14.
U'enccsecliun.) — Plater, Observ. 1. Iii. p. G.'iO. — Willis,
I'liarmac. Kationalis, pars ii. s. ii. cap.."] — l.o.isiiis. Do
I.anguorc I.ymphatico Avark^xx. \\ itib. lC7.'t. — Fo-
restus, 1. xix. obs. 25, 20. 30 liieUlin, Millcnarius,

Ko.421., ct cent. i. obs.21. (Consequent on measles.) —
,7. Span, Apliorisnii Novi Hippocr. 1689. p.3;r2. (lilocd-
IcHhi^.) — ISuiiet, MOd. Septciitrion. l.iii. sect. 21. p.72.'5.;
et rolyalthes, 1. iv. cap. 46. 59. (Ant'pJi/ugis/us.) —
Col lie lillars, Ergo Leucoplilcginatias Leves Scaritica-

tioiies. Paris, 1738 Guenaull, Ergo Leucophl. Leves

Scarif. Paris, 1760. — Adet, Ergo Leucophlegmatla; Loves
Scarificationes. Paris, 1758 — Cart/teuser, De Leuco-
phlegmatia. Fr. \7G{). — Livingston, Edin. Med. and
Phys. Essays, vol. ii. p. 407. — Fleiiciz, Act. et Observ.
•Mt'd. p. 87. WT.—Stoll, Rat. Med. par. iii. p. 302. —^//>,
Obs. Chirurg. fasc.i. — Sauvagcs, Nos.M^th. vol.ii. p. 470.

— T/iilcn/7/s, Med. u. Chirurg. Bemerk. p. 168. — C/ieston,
Philos. Transac. 1780, p. 323. .578. ( Thoracic duct ohliler-
alcd.) — Bang, in Act. Reg. Med. Soc. Ilaun. vol. iii. p. 118.

— Aaskow, in Ibid. vol. iii. art. 15. — Hartmnnn, De
Anasarca, Lac Sulph. et Acid. Sulph. &c. Fr. 1787 —
Dove, in Edin. Med. Comment, vol. xviii. p. 13.5. — Tox-
zelti, Kaccolta, &c. No. 4. (Recommends blisters in the
anasarca consequent on scarlatina.) — Tode, Med. Cliir.
Biblioth. b. v. p. 432.— J. P. Frank, De Cur. Horn. Mor-
bis. 1- iii. p. 75. — Chabners, On the Dis. of South Ca-
rolina, vol. ii. p. 20 I'iensseux, in Journ. de Meil. Con.

tin. t. iii. p. 3 Leib, in Philad. Transac. vol. i. p. 1 —

Marcus, Magazin fiir Spccielle Therapie, b. ii. p. 342. —
Melilsch, in S/aWr's Archiv. b. iii. p. 724. — Beauchine,m
Journ. Gener. de Med. t. xxxii. p. 371. — U'ind?nann, in
Hufelandu. Him/i/'s Joarn. d. Pr. Heilk. Oct. 1809.—
Sa'ckenreuter, in Allgem. Med. Ann. Mart. 1811, p. 243.
— Desscssart, Recueil de Dissert, et Ob.serv. de Med.
Prat. Paris, 1811. —J. Wilson, in Trans, of Soc. for Imp.
of Med. and Chir. Knowledge, v.il. iii. p. 65. — W.C.lVells.
in Ibid. p. 167. et 187.— iJ.C. F.Harlcs, De Hydr. Inflam-
matorio, in Opera Minora, vol. i. p. 339. — Gairdiier, Ed.
Med. and Surg. Journ. vol. xiv. p. 479. — Steele, in Ibid.

vol. xvi. p. 545 Landre-Bcauvais, Diet, de Med. t. ii.

p. 192 I.aennce, Archiv. Center, de Med. t. vi. p. 619 —

Koenig, in llufeland's Journ. July, 1829. ; and Archiv.

G^ner. de Jled. t. xxi. p. 449 I'enables, in Lond. Med.

Gazette, vol. v. p. 397. — Beatli/, in Trans, of Assoc. Phys.

of Ireland, vol. iv. p. 23 J. Bouillaud, in Diet, de Med.

et Chir. Prat. t. ii. p. 320. {See also the Bibliography
AND References to Drojisies in Genere.)

VII. DnopsY OF THE Cavitils of the Chest.

143. Uefin. — Sense of oppression in the chest ;
nrgent ditspnxa on exercise or in the horizontal
posture; livid lips: a:dematoiis countenance and
extremities ; iceak, small, and irregular pulse ; dis-
turbed sleep, 7vith sudden sturtiugs, (Sfc.

144. As dropsy of the pericardium is so very
generally connected wlili more or less effusion
into the cavities of (he jileurce, that we seldom
find the one without the other, ailhough in vary-
ing grades and relative proportions; tfnd as the
former, as well as the latter, is a very frequent
conseciuence of structural change in the substance
of the lungs, or in the pleura?, or in the heart
itself and its valves; I shall, therefore, describe
them as species of the same genu>. The difficulty,
also, of determining whether the fluid is chiefly, or
altogether, in the pericardium, or in the pleurae,
even in cases where it is limited to one only, is an
additional reason for considering hydro-pericar-
dium and hydrothorax in connection with each
other. It is principally, however, when the eflfu-
sion is symptomatic of structural lesions of the
thoraric viscera, or of a more generally morbid
state of the frame, that we find them co-existent,
and without any remarkable prepondeiance in
favour of either the one or the other. IJut when
effusion is the more immediate result, or the se-
quela, of inflammatory action, or of a state of
organic action, closely allied to inflammation in
either the pericardium or pleura;, it is generally
limited accordingly, and it often accumulates to a
very great extent.

i. IJiiOPSY OF the Pericardium. — Syn. Hijdrops
Pericardii, Hijdro-pericardii, Hiidro-pericurdia,
Hydro-pericardium (from l&uf, water, and
TTspUap^iov, pericardium) of Authors; Herz-
heutelwassersucht , Germ. ; Hydro-ptricarde, Fr.
Dropsy of the Heart, Eng.

voL.i.

DROPSY OF THE CHEST — Pathology of. G4 J

145. Defin. — Oppressive dyspnaa, with a sense

of weight and tremor referred to the region of the
heart ; anxiety ; inability to retain the supine pos-
ture ; iveak, irregular, or intermitting pulse; livid
and (edematous countenance ; distension of the Jugu-
lar veins ; leipothymia ; fulness of tlie epigastrium,
and of the anterior intercostal sjiaces ; percussion
emitting a dull sound, and auscultation furnishing
a faint and diffused sound, over all the cardiac
region.

146. A. It is obvious that pathologists ought to
agree as to the least quantity of fluid in the peri-
cardium that should be considered to constitute
dropsy of its cavity. Vesai.ivs states, that it
always contains a small quantity of water in
health, and that he had observed it in criminals
who had been quartered while alive. Lower en-
tertains a similar opinion. ¥. Hoff.mann, how-
ever, comes to a different conclusion ; he having
observed no fluid in the pericardium of healthy
animals; whilst Littre found some in the ani-
mals on which he experimented. Hai.i.er believes
that this cavity contains a fluid destined to facili-
tate the functiorisof the heart, but gives no opinion
as to its quantity, in health. He remarks, that it
may be greatly increased in various diseases, and
that it maybe absorbed, (L7eHif)((a Physiol. &;c,
4to. vol. i. p. 292.). Senac infers that, in the
natural state, the pericardium contains no fluid ;
he having found none in several cases in which
this membrane and the heart were both healthy.
Corvisart, Testa, J. P. Frank, Kreysig, Ber-
TiN, Louis, Elliotson, Hope, &c., appear to have
adopted the opinion of Haller, in considering
that this cavity always contains a little fluid ;
but they differ in some respects as to the amount
which should be viewed as constituting dropsy
of it. M. ConvisAHT believes that, when it reaches
six or seven ounces, hydro-pericardium exists.
This inference has been adopted by Pinei,, Ber-
iiN, Elliotson, and flopE, who think that this
quantity will give rise to symptoms indicating,
although with great uncertainty, the seat of ef-
fusion ; whilst L'iE^^jNec concludes that double or
triple this quan:i.ty may not admit of a correct
diagnosis. Muclt, however, will depend upon
the rapidity of its collection, and the nature of
the pathological states either causing it, or con-
nected with it. A larger quantity than that now
named, has sometimes accumulated without
having induced such symptoms as could enable the
practitioner to decide as to the exact nature and
seat of the disease, particularly when chronic
affections of the lungs or heait have accompa-
nied it.

147. From one to five or six ounces of fluid
are sometimes found in the pericardium, in several
maladies either of adjoining or of remote organs,
especially in persons who have died of phlhi-is.
This collection, obviously greater — at least, the
higher amount — than exists in health, seldom
gives rise to specific symptoms, although the
larger quantity may occasion much disorder. It
may, indeed, form very shortly before death, and
may merely be contingent on the changes imme-
diately preceding dissolution, particularly when
the malady destroys life by asphyxia, or when
congestion of the lungs and di'-order of the respi-
ratory actions have been present for a short time
previously ; and its amount may even be increased
subsequently to the fatal issue. When fluid collects

Tt

642

DROPSY OF THE CHEST — P^TiiOLOGY of HYDno-pERicAnDiuM.

in the pericardium to an extent obviously consti-
tuting dropsy, and calculated, from its influence
on the functions of the heart and lungs, to be the
chief lesion by which life may be abridged, it
will give rise to a certain train of symptoms, ge-
nerally indicative of the presence of water within
the chest, although not always of its precise situ-
ation. The quantity that may admit of detection,
in this situation, cannot be stated absolutely.
The existence of eight or ten ounces, or even of a
smaller quantity, may be ascertained, in some in-
stances ; whilst in others, nearly double the amount
may not be recognised witli precision, as Frank
and Laennec liave truly contended.

148. jB. It is important to know the pathological
states on which effusion of Jiuid in this sitiuition
depends, and the conditions of life and of organis-
ation liuth U'hich it is connected. These points
have been but imperfectly ascertained ; but, from
some attention I have paid to the subject, I believe
that they may be referred to the following : — 1st.
Tiie efiusion may be one of the more immediate re-
sults of inflammatory action (see Heart and Peri-
cardium— Injiammation of), in some instances;
and, in others, a remote sequela of this disease. — a.
In this case it generally forms more or less rapidly;
may not be attended by any or much effusion
or inflammatory appearances in the pleural cavi-
ties, although it very frequently is so asso-
ciated ; and it may accumulate to a great extent.
The instances referred to by Corvisart, Frank,
and others, in which several pounds of fluid
were found in the pericardium, seem to have
been of this kind. Tiie nature of the disease, in
this variety, may generally be inferred with some
accuracy, when the effused fluid amounts to
more than six or eigiit ounces, — from ante-
cedent symptoms of inflammatory or acute dis-
ease referrible to the region of the heart, either
previously to, or attending, the eff'usion ; from
urgent anxiety at the przecordia, with continued
jactitation ; from a dull sound being emitted by
percussion to a greater or less extent over the
cardiac region, and a faint and diffused sound
being furnisiied by auscultation ; from the mo-
tions of the heart being perceptible beyond tiieir
ordinary limits, tiie impulse being undulatory,
unequal, and felt at various points ; and when
the accumulation is great, from a marked fulness
in the epigastric region, occasionally with a vibra-
tory pulsation, and with fulness of the anterior
intercostal spaces of tiie left side, or with some
degree of external a>dema in this situation. In
some instances of this form of the disease, these
symptoms suddenly supervene, and are attended
by oithopntea ; small, frequent, irregular, inter-
mitting, and weak pulse ; syncope or leij)otliymia,
followed by slight fits of obscure palpitations,
distension of the jugular veins, bloated livid
countenance, and cold extremities. — A, On dis-
section in these cases, marks of inflammation are
observed in the pericardium, witli thickening and
sometimes with lymph adhering to its surface,
or floating in the fluid in filaments or in the
state of albuminous flocculi. Occasionally the
fluid is serous and tuibid, resembling whey ; or
albuminous, or sero-])uriform, or nearly puru-
lent, or even sanguineous. In these, the rapid
effusion of fluid appears to be owing to the sud-
den loss of the tone of the extreme caj)illaries and
eximlants ; the increased and morbid action of the

vessels supplying them still continuing, sometimes
connected with an unhealthy state of the system.
— c. This form of pericardiac dropsy may exist
either alone, or it may be complicated with, or
consequent upon, pleuritis, or pneumonia, or
acute bronchitis ; or may be connected with the
rheumatic or gouty diathesis, and be even a me-
tastasis of these maladies.

149. 2d. Fluid may be effused in the pericar-
dium, as in other serous cavities, by a slower pro-
cess than that generally accompanying or following
inflammatory action ; and be attended by a very
different state of this membrane. — /(. In this
class of cases, the eft'u-ion commonly depends
upon impeded or disordered circulation through
the heart or lungs, arising from a variety of
organic changes of a chronic kind in these
organs ; or upon structural lesions of the pleura ;
or upon disease seated in the mediastinum, or in
the large vessels. It is, in such instances, often
connected with a leucophlegmatic, lymphatic, or
dropsical diathesis, and debilitated frame. The
fluid collects slowly, is accompanied by no local
or constitutional symptoms of an inflammatory
kind ; and the attendant disorder is aggravated by
an anti-inflammatory treatment. When it reaches
a very considerable amount, the patient feels a
weight in the cardiac region, with pain in the back
and loins; and if he be emaciated or thin, the im-
pulse given to the fluid by the dilatations of the
heart may be felt and seen between the third and
fifth ribs. The sensation of the organ floating in
a fluid, said, by some writers, to be felt by the pa-
tient, has not been confirmed by my observation ;
but the feeling communicated to the hand of
the physician, by the stethescope, is frequently
that of an impulse transmitted through a fluid,
and an undulation is sometimes felt. In addition
to these and the preceding symptoms (§ 148.),
there are often a dry cough, leipotliymia, some-
times followed by palpitation, which is occasion-
ally violent; inability to use any exertion; a
necessity of sitting up, and of leaning forward ;
a cold, leucophlegmatic, or ocdematous coun-
tenance, with lividity of the lips; cold and ana-
sarcous extremities; lowness of spirits; emaci-
ation, particularly of the trunk; scanty, red,
and lateritious urine. Inability to lie in the
supine posture is often an early sign ; although
theTpatient may lie on either side. But this,
like several of the other symptoms, is uncer-
tain ; for some persons in health are incapable
of retaining the supine posture even for a short
time. The above phenomena are also incon-
stant, owing to the nature of the primary or co-ex-
istent lesions ; and, when present, they are often
obscured by the more prominent symptoms
directly depending upon these lesions. — b. On
f//sser<(Vi», the ])ericardium is not reddened or in-
jected ; it is somewhat paler, or whiter, than na-
tural— occasionally of even a satiny whiteness ;
but it is generally opaque, slightly thickened,
and sometimes softened, and appearing as
having been macerated in the licjuid it contained,
— an appearance which has been doubted by
Laennic. 'I'he Jiuid itself is usually colourless
and limpid ; sometimes of a citron tint, or yellow ;
and occasionally turbid, of a brownish, or of a
greenish hue. — c. 'i'his form of the disease is
seldom or ever met with unconnected with the
lesions already alluded to; and is frequently

DROPSY OF THE CHEST— Diagnosis and Causes of IIydro-peuicardium. 643

merely a part of a more general effusion of fluid,
cither into otlier serous cavities — particularly the
pleural — or into the cellular tissue, J. P. Frank
could adduce only four cases from authors and
his own experience, in which hydro-pericardium
was not accompanied by some other change in the
membrane or related organs ; and even one or
more of these might have been tiius associated.
Whilst this variety of the disease is chronic, and
manifestly symptonwiic, the preceding is acute, at
least in its early stages, but sometimes assuming
a more chronic and passive character; and,
although it cannot be said strictly to be idiopathic
or primary, it may be viewed as a consequence of
a morbid state of vascular action not altogether
identical with the sthenic inflammation which
takes place in a healthy constitution. I have seen
several instances of it arising from metastasis of
rheumatism to the pericardium, occurring in weak
and unhealthy constitutions.

150. 3d. Fluid may be effused in the peri-
cardium in a third form, but seldom to the extent
of constituting the principal morbid change. It
has been shown that the lesion givmg lise to the
Jirst variety is chiefly seated in the pericardium,
and is nearly allied to, although it is probably sel-
dom identical with, the true inflammatory action,
or phlogosis, of the internal surface of that mem-
brane ; and that the second variety is caused by
impeded circulation from organic change of the
more immediately related organs, the effusion
taking place in a similar manner to other symp-
tomatic dropsies. — a. But the variety now about
to be described, is an attendant upon A veiy dif-
ferent and a more universal state of disease;
usually comes on not long before death ; is a con-
sequence of the generally perverted or alieiiated
conditions of life, occasioning deficient vital cohe-
sion of this membrane, and lost tone of the ex-
treme vessels and exhaling pores, in which
changes the rest of the organisation more or less
participates ; and is frequently unattended by any
prominent symptom. — b. It supervenes on the
latter stages of some malignant or adynamic dis-
eases, in the course of which tiie blood becomes
contaminated by morbid matters, either absorbed
from without, or generated in some part of the
body. Thus, I have observed it in several
cases of phlebitis, particularly in uterine phlebi-
tis ; in the true malignant puerperal fever ; and
in fatal cases of erysipelas, small-pox, and scarla-
tina. It likewise takes place after wounds
from dissection, and in carcinomatous and some
other maladies. In all these, the pericardium
only participates more or less in a similar al-
teration taking place in other shut cavities,
most frequently in the pleuraj, excepting in ady-
namic puerperal disease^, when the peritoneum
is also the seat of effusion to a much greater
extent. — c. On dissection, the tissues are found
soft, flabby, easily torn, and of a dirty or dusky
hue. In these morbid states, the heart and
pericardium participate, but tiiey are not in-
flamed. The blood is often dark, fluid or semi-
fluid, or grumous ; and the liquid effused is
turbid, greenish brown, or brown, or sero-san-
guineous, and seldom amounting to more than
ten or twelve ounces. — d. In this variety of
hydro-pericardium, the characters of the fluid,
the state of the textures, and the manifest-
ations of life, indicate that the vital cohesion, or

the organic contractility, and tone, of the mem-
brane, and particularly of the extreme exhaling
vessels or pores, are lost ; and that the more wa-
tery parts of the blood, with a portion of the
smaller globules, and even of the colouring par-
ticles, are thereby enabled to pass tiirough them.
It is evidently one of the ultimate lesions produced
by contamination of the circulating fluids, and of
the soft solids, irt the manner pointed out in the
articles Bi.ood (§ 132 — 152.), and Disease
{§ 148.). (See also Heart, and Pericardium.)

151. C. Diagnosis. — The difficulty of distin-
guishing dropsy of the pericardium from that of
tiie pleuraj has been insisted on by every writer
since jMorgagm. 'J'his has arisen from the cir-
cumstances already alluded to ; from the very
frequent co-existence of eflTusion into both these
situations ; and from the extent to which the
symptoms accompanying organic lesions of the
lungs, heart, and large vessels, producing the
effusion into the pericardium, obscure the phe-
nomena caused by it. No opinion, therefore,
can be formed from any one symptom ; and even
that founded on a careful investigation of the
history of the case, and of the tout ensemble of
the phenomena, must still be viewed with some
distrust. Early disturbance of the actions of the
heart, and irregularity of the pulse ; a lesser de-
gree of dyspnoea relatively to such disturbance
(Morgagni) ; the sounds heard on percussion
and auscultation ; the sensations depending on
the motions and impulse of the heart, felt either
by the patient or by the examiner, as that of the
heart swimming in water (IlF.i.MANNand Saxdnia),
and tliat of an impulse transmitted through a
fluid ; a fluctuating tremor (Senac) and fulness
either felt or seen at the epigastrium and anterior
parts of the left intercostal spaces ; a sense
of weight and oppression in the cardiac region
(Lancisi); absence of the fluctuation upon
concussion or succussion of the trunk observed
in hydrothorax (RIorgagni) ; an irregularity in
the situation of the heart's pulse, it being felt
at different times, in different parts of an exten-
sive circle ; oedema, or fulness towards the left
side of the chest (Corvisart); coldness and
oedema of the feet, legs, and hands ; and leipo-
thj'mia and palpitations; have been severally
insisted on, and are the signs most to be depended
upon ; but there is not one of them that is con-
stantly present, or, when present, that is caused
by hydro-pericardium only. When effusion is
limited to the left pleural cavity, as in the cases
recorded by Mv. Hendehson and M. Desault,
and in which paracentesis was performed, a cor-
rect diagnosis is most difficult.

152. D. Causes. — These have been noticed
in the description of the different slates of the
disease, and are nearly the same as those giving
rise to other forms of dropsy. The connection
of hydro-pericardium with debility, especially of
the vascular system, and with a softened and
flabby state of the substance of the heart, is
deserving of attention. I have seen it thus re-
lated, both in children and grown-up persons of
all ages, living in cold, low, and damp places,
or cellars, especially after the eruptive fevers and
rheumatism; and, according to Testa, it is most
frequent in females, particularly after delivery
($ 150.). In the third form which I have
described, it very often supervenes in the

Tt 2

64-1

DROPSY OF THE CHEST — Prognosis and Treatmext of Hydro-pericardium.

last stages of the more fatal diseases of the puer-
peral state.

153. E. The PaooNosis raust necessarily be
very unfavourable. Yet it should not preclude
the having recourse to a protracted treatment, as
life may be prolonged by judicious measures per-
severingly employed, and a cure may eventually
be effected, particularly when the effusion has
been consequent upon inflammatory action, or tlie
metastasis of rheumatism to the pericardium. The
prognosis should entirely depend upon the form of
the disease : it is unfavourable in the first-variety I
have described ; much more so in the second ;
and the worst in the third.

154. F. Treatment. — (o) The means of cure
in the 1st variety should be the same as are ad-
vised for inflammation of the pericardium, as long
as signs of phlogistic action exist. But as soon
as this lapses into a passive or an asthenic form,
no benefit will result from lowering measures.
Energetic derivation and external counter-irrita-
tion ought then to be directed. In most of such
cases however, unless the vital energies are very
greatly reduced, calomel with camphor, and small
doses of opium, or the bichloride of mercury with
sarsaparilla, — the former carried the length of
salivation, the latter of affecting the gums, — and
a seton, or issue, or open blister, kept discharging
over the margin of the left false ribs, will be pro-
ductive of benefit. Whilst these are being em-
ployed, the constitutional powers should be sup-
ported ; and, if they be much depressed, medicines
of a tonic and astringent operation, with light nu-
tritious diet, ought to be prescrihed. Care must,
however, be taken that inflammatory disorder is
subdued in the lungs and pleura, when the effu-
sion into the pericardium is thus complicated,
before tonics or stimulants of a heating kind are
administered. In such cases, the infusion of roses
with small doses of the «ulphate of zinc, and sul-
phuric acid, with digitalis, will be found the most
appropriate, liut the main reliance must be
placed upon external derivation. When the effu-
sion has been consequent upon the metastasis of
rheumatism, or of gout, active counter-irritation,
the combination of colchicum with camphor or
ammonia or with both, the alkaline hicarbonates
or carbonates in full doses, and tonic purgatives,
with the rest of treatment already recommended,
may be employed.

155. (b) In the 2d varieiii, or that depending
upon organic change in the heart, lungs, or large
vessels, but little benefit will be derived from
diuretics, or, perhaps, from any treatment that
can be ado[)t,ed. I believe that lowering mea-
sures, too generally resorted to in cases of this
description, will only hasten a fatal issue. INIuch
more advantage will be obtained from means
which increase the secretions and excretions —
the assimilating and eliminating processes. Very
small and frequent doses of bliie pill, with a
tonic extract, or the soap and opium pill ; bitter
or tonic infusions and decoctions, with an alka-
line carbonate, hyoscyamus, and extract of ta-
raxacum ; an issue in the side, kept freely and
long discharging ; and due attention to the de-
velopment of vital power, by appropriate medi-
cines, diet, and r.gimen, and a pure air, without
heating or exciting the vascular system ; are the
ino^t to be relied uj)on. 'i"he bowels and biliary
secretions ought to be moderately acted on by

medicines of a tonic, deobstruent, and laxative
operation, which will promote vital power, vvhile
they exert a derivative action on these \isctra.
With this view, diuretics of an analogous kind
may be added to the other remedies. The treat-
ment of the 3d variety must entirely depend
upon the nature of the primary disease, of which
it is merely a remote consequence. The indica-
tions of cure, in these maladies, and a review of
the most eflicient measures, will be found in the
aiticles Blood (^ 156. et seq.), and Debilitv
(§37,38.).

156. (c) Parace)itesis pericardii. — The pro-
posal of tapping the pericardium, made long since
by llioLAN and Senac, and sometimes practised,
is deserving of notice. It was attempted in the
case published by Mr. Henderson, and in one of
a siiuilar kind by M. Desault; the existence of
hydro-pericardium having been inferred in both.
Hut it was found, in both instances, that the fluid
had been effused into the left pleura, from partial
pleuritis, and that the pericar-dium adhered to the
heart. An opening, however, has been made
into the pericardium by Larrev, Rkherand,
and Romero. The last-named physician punc-
tured the pericardium, and drew off the accumu-
lated fluid, in three cases; and in two with
success. (See Diet, des Sciences Med. t. xl,
p. 371., and Medico-Chirurgical Review, vo\. i.
p. 477.) He made an incision between the fifth
and sixth ribs (but between the fourth and fifth in
a short person), and carried it through the
pleura, lie then introduced his finger, and,
iuiving thereby ascertained the presence of the
fluid in the pericardium, he made an opening
into it with small crooked scissius ; through this
the fluid escaped into the left pleural cavity,
whence it was discharged by placing the patient
in a proper position. By this procedure, if the
fluid be in this latter cavity, instead of the peri-
cardium, as in the cases of Henderson and
Desauet, the first opening gives it exit, an!
nothing further is requisite. The plan of Dr.
Romero possesses undoubted advantages, even
in this last respect ; and he has accordingly prac-
tised it in five cases of hydrothorax, and in three
successfully.

157. It is evident that this operation can be
productive of benefit only in those cases that
belong to the Jirst variety, or that consequent
on inflammatory action, when effusion fre-
quently is limited to the pericardiac cavity. In
states of the disease depending upon organic _
lesions of the adjoining viscera and parts, when
the effusion is rarely or never so limited, no
advantage can be hoped from an operation. In
itself, paracentesis, whether restricted to a. sim-
ple opening into the thorax, or exteuded to the
pericardium in the manner practised by Dr.
Romero, is attended by no greater risk than
when it is performed on the abdomen. The
chief dangers from it are entirely the same as
those pointed out above (§ 105.), when discussing
the propriety of it in this latter situation. The
fears of danger froiu the introduction of the
external air causing the collapse of the lungs,
is not well founded. If the wound be care-
fully closed after a deep expiration, the resi-
liency of this organ, and the absorption of the
air, will overcome the difficulty. 'J'he mischief
is occasioned in a different manner, — by the

DROPSY OF THE CHEST — Pat[iolocy of HvDnoTHonAx.

645

action of the air upon the inflamed or otherwise
diseased membrane ; and lieuce the impropriety
(and probable cause of failure in several eases)
of leaving a canula in the opening, or of intro-
ducing a tent sponge. I stale this from having
seen this practice adopted in cases of paracen-
tesis, and carefully observed the antecedent and
consequent states of diseased action. I would,
therefore, submit, when the last resource of an
operation is attempted, that it should be per-
formed with the utmost precautions against the
introduction of the external air ; and that the
opening should be carefully and accurately
closed, and kept closed, instantly upon the dis-
charge of the fluid ; and tiiat, instead of pre-
serving an opening for its continued flow, the
operation should be repeated when it becomes
really necessary. (See Heart and Peiucar-

BIUM.)

BiBLioG. AND Refer. — Galen, De Loc. Af. 1. v. —
Bar/Zwlin, Anat. Itefonn. 1. ii. p. 252. — I'iso, De Serosis
Moib. Observ. et Consil. sect. iii. cap. 2. — Diemerbroeck,
Op. Omn. 16S5, p. 615. — Riolanus, Antliropographia.
Paris, 1649, I. vi. cap. 7. (liecumnienils to tap the pericar-
(liuni.) — //. Saxonia, Piielect. Pract. pars ii.-cap. i. p. fil8.
e<i. Vic. 1620.— F. Hoffpiann, De Hydr. Pericardii. Hal:e,
1667. ; et Opp. Supp. ii. c. 2. — Bonet, Sepulchretum, &c.
1. ii. sect. i. ob. 101., et sect. ii. ob. 15. — Merckcr, De
Hydrocardia. Ultraj. 1711. — Duvcrney, Mem.de I'Acad.

Roy. desScien. 1703, p. 158 St'/inc, Traite de la Struct, et

des les Maladies du Coeur, 4tp. Paris, 1749, t. ii. 1. iv. cap.

6 — Maiiget, Theat. Anat vol. ii. p. 1727 Lancisi, lie

Motu Cordis et Aneur. Rom*, 1728. — Morgagni, De
Caus.&c. epist. xvi. art. 20., also epist. xvii. xxiii. xxxvi.
xxxvii. — Meckel, in Mem. de I'Acad. des Scien. &. Ber-
lin, 1755, p. 56 Lenii7i, Beytriige, b. ii. p. 61. {Recum-

niends purgatives, diuretics, and stimulants.) — Lieutaud,
Hist. Anat. Med. 1. ii. observ. 611. 621. 648. 653. 683. 857-
— Borsieri, Institut. Med. Pract. vol. iv. cap. 5. — Sidren,
in Act. Mt'd. Suecicorum, t. i. p. 407. {Efftis. in pericard.
only.)—Sandifort, Observ. Anat. Pract. vol. i. p. 40.,vol.iv.
p. 109. — J. P. Frank, De Curand. Horn. PJorbis, vol. v.
p. 241. — Quariti, Animad. in Morb. Chron. p. 99. —
Heiiielce, De Hydr. Pericardii, 8vo. Erf. 1709. — Por-
tal, Anat. Medicale,t. iii. p. 11 — Conradi, in ArnemantCs
Magazin, b. i. p. 81. (Advises paracentesis.) — Laiidvoight,

De Hydr. Pericardii dignoscendo. Haloe, 1798 Desault,

QLuvrei Chirurg. >S:c. t. ii. p. 304 Corvisart, Traite des

Mai. du Cceur, &c. Paris. 1818, ed. 3d.— Testa, Delle
Malattie del Cuore, &c. vol. iii. Bol. ISll. — Kret/sig, Die
Krankheiten d. Herzens, &c. b. iii. Berlin, \S\'i .— H'ood,
in Loud. Med. and Phys. Journ. vol. Ixi. p. 4U6. (Two
quarts of fluid effused.) — Hennen, in Edin.Med. and Surg.
Journ. vol. xvi. p. 539. (Eff'us. into pericard. only.) — Hen-
derson, in Ibid. p. C^SB. — I.aennec, Auscult. Med. t. ii.

p. 670. 2d. edit. ; etTranslat. by Forbes, p. 679 Hard,

in Diet, des Sciences Med. t. xxii.p. 322 Merat,\\\ Ibid.

t. xl. p. 370 Komero, in Ibid. p. 371 J. Frank, Praxeos

Medics Univers. PriEcep. vol. ii. parts ii. sect. ii. p. 168. —
Bayer, in Diet, de Med. t. xi. p. 394. — J. BouiUaud, Diet,
de Med. et Chir. Prat. t. x.p. \t>'i .—Bert<)i,'YxA\ti des Mai.
dn Cceur, ^c. 8vo. Paris, 1824. — Portal, Observ. sur la
Nat. et sur le Traitement de I'Hydr. t. ii. p. 131.

ii. Dropsv of the Pleural Cavitifs. —
Syn. Fliidrothm-ax (v^wp, water ; S-aJpa^, the
chest), Hi/drops Saccorum PleuriE, Auct. var. ;
Dropsy of' the Pleura; Hydropisie de la Pui-
trine, Ft.; Brustu'as!:ersHcltt, Germ.; Idro-
pisia di Petto, Ital. ; Water in the Chest.

158. Defix. — Dijspiura and oppression in the
chest,, increased hi/ tJie horizontal posture and ex-
ercise, with oedema commencing in the eyelids and
ancles ; startings from sleep ; the sounds on per-
cussion being dull, and the respiratory murmur
not heard on auscultation,

159. Hydrothorax has been divided into idio-
pathic or primary, and siimptomatic. It is very
rarely primary, as IM. Laennec has observed —
that is, without pre-existing disease of the pleurae,
lungs, heart, or lar-ge vessels. But it is often
consecutive of increased vascular action, or in-
flammatory irritation of the plcura», without any

lesion of other parts, particularly when it follows
the eruptive fevers: and it may be a termination
of pleuritis, especially in the lymphatic or phleg-
matic temperament, and in the cachectic habit
of body. Its symptomatic or complicated states
are tiie most common. As the consecutive hy-
drothoi-ax, in all its forms, is generally acute or
sub-acute, or possesses more or less of the sthenic
characters, it will be considered as such ; whilst
the symptomatic will be viewed as a passive,
chronic, or asthenic disease.

160. ^. Acute and sub-acute Hydrothou ax ;
Inftammutory Hydrothorax, Hydro-pleuritis, or
Hydro-pleurisy, of Rayer. — That this form of
pleural dropsy consists of increased exhalation
from the pleura-, depending upon increased vas-
cular action and determination to this surface,
will be admitted; but that it is identical with
inflammation, of an acute and healthy kind, may
be questioned. The symptoms, local and con-
stitutional, in hydrothoi'ax of the most acute
kind, and in pleuritis — either the pulmonar'y or
costal — are certainly not identical, particularly
in respect of severity. Hence, although much
similarity exists, as far as mere vascular injec-
tion, or determination of the circulation, is con-
cerned ; and although pleurisy may terminate
in, or give rise to, serous effusion in many in-
stances ; yet the kind of organic action affecting
the pleurae, and the attendant constitutional dis-
turbance, are not tlie same in both. The differ-
ence has already been alluded to (§ IS.); but I
may here add, that the formative processes — the
kind and grade of organtc vascular action — cha-
racterising pleuritis, are not observed either in
the local lesions or in the constitutional affection
of acute hydrothorax, unless when the ert'usion
supervenes on external injuries and inflamma-
lion, or is an earlier attendant on a modified
condition of such disease. The consecutive states
of acute pleural dropsy, as it may be studied
after scarlatina, either dui'ing life, or in the mor-
bid appearances, illustrate this view, and prove
that there is, as respects both the conditions of
the effused fluid, and the changes in the pleura;,
a difference in the kind of organic action whence
they have proceeded, frp.iu true inflatnmati'on,
find that such difference is eviilently connected
with constitutional causes. It is very common
to observe that, when an attack or attacks of
either pneutr.onia or pleuritis have been re-
moved by treatment, a slight exposur-e to their
exciting causes, or irregularities on the part of
the patient, before the diseased vessels have re-
gained their healthy tone and action, will give
rise to a less acute, or a smothering, state of dis-
ease, either attended by, or quickly terminating
in, effusion ; the reduced powers of the constitu-
tion, the lost tone of the exhaling pores, and the
general or local excited action, favouring this par-
ticular malady -T- this morbidly incrcase(l serous
exhalation — in preference to any other. In
this way acute or sub-acute hydrothorax super-
veries on a state of the frame which has not
recovered from previous disease — more particu-
larly from eruptive fevers — or which has been
impaired by age, excesses, or irregttlaritics ; the
powers of life, and the organic action thereon
depending, being insuflicieut to develope sthenic
or plilogistic inflanrmatiiin. The injerences, th^n,
from the causes, accession, phenoirjena, iind con»
T t 3

646

DROPSY OF THE CHEST— Diagnosis of IIydrotiiorax.

comitant changes observed in the aculc or sub-
acute disease, are, that it is not identical vvitli
healthy inflammation, although frequently so
nearly allied to it as to appear either as a ter-
mination, or as a lower grade, or as a modification
of it ; and that it is often connected with, even
although it may not be dependent upon, the
nature of the preceding malady, in which the
secretions and excretions have been interrupted,
and not sufficiently restored.

161. Tiiat inflammation of the bronchi, or of
the substance of the lungs, will sometimes be
propagated to the pleuraj, generally in conse-
quence of constitutional fault or injudicious ma-
nagement, and give rise to effusion into their
cavities, is well known ; that inflammation of the
surface of the liver, or of the peiitoncum, or of
both, will occasionally extend to the pleural, par-
ticularly in debilitated or cachectic subjects, and,
having reached this situation, terminate in effu-
sion, I have often remarked ; and that the state
of vascular action, whose siiniliarity or connection
with true inflammation has been noticed, but
whose identity with it has been denied, will occur
in the pleurae in various states of sequence and of
complication, has been a matter of daily observa-
tion, and maybe readily illustrated from the pages
of BoNET, INIorgagm, Stoli , Lepois, Lieutaud,
Leroux, and many other of tlie writers referred
to. In some localities, also, and during certain
epidemics, it has been remarked that peripneu-
inony has evinced a remarkable tendency to ter-
minate in this manner. Dr. Romero states, that
on the coast of Andalusia, hydrothorax and hy-
dro-pericardium are endemic, owing chiefly to the
prevalence of hot and humid winds, and sudden
atmospheric vicissitudes, particularly among those
who are ill fed, or live on unwholesome food,
and are given to intoxication or irregularities ;
and M. Pariset observed this form of hydro-
thorax prevalent in Geneva, in 1803, — the E7mp-
toms being so light that the patient's appetite and
ability of attending to his affairs continued antil
the pleural collection induced violent oppression.
He states, that the number who died among the
French conscripts was very considerable, — the ef-
fused fluid being limpid and inodorous, and the
pleura greyish and thickened, and the lung com-
pressed, or condensed.

162. 1 he morbid appearances in the acute form
of hydrothorax, whether it has been connected
with inflammation, or active congestion of the
substance of the lungs ; or has proceeded from a
modified form of pleuritis, cither occuriing pri-
marily, or consecutively on an eruptive fever, or
after the suppression of some chronic disease of
the skin, or of an accustomed discharge ; are
usually the following: — 'I'he Jluid presents every
shade of colour already remarked (§ II.) -^is
sometimes turbid, muddy, reddish, sanguineous,
whey-like, or sero-purulent ; but more frequently
transparent, of a citron tint, with /ilaments or
numerous albuminous (locculi floating in it. The
membrane is internally reddened, or injected,
thickened and somewhat softened, and occasion-
ally covered by an albuminous, granulated, or
tuberculous exudation. The lunga are generally
conqjressed, condensed, hcpatised, or tubercu-
lated ; and present appearances of chronic inflam-
iiialion. 'J'he (v/i/sts of this Ioi'iti of liydrothor.ix
are theuame as those described above (§ 8, 9. 19.).

163. jB. Symptomatic, passive, or compli-
cated HvDROTiioRAx. — This state of disease is
dependent upon some obstacle to the circulation
of the blood, or lymph. Its connection witii dila-
tation of the cavities ; with hypeitrophy, atrophy,
&c. of the substance, and with alterations of the
valves, ix.c. of the heart; has been long since pointed
out by Bonet, Morgagni, Lieutaud, Meckel,
Sandiiort, &c. Disproportion between the capa-
cities of the cavities, ossification of the valves, and
various other lesions of this organ, have been
still more minutely examined in relation to the
production of hydrothorax, by Corvisart, Laen-
NEc, Testa, Krevsig, Bertin, and others.
Varicose dilatation, also, of the veins of the lungs,
and compression or obliteration of them, from
chronic pneumonia, or tubercular and other pro-
ductions, are sometimes the immediate causes of
effusion. The dependence of this form of the
disease upon alterations of the lymphatics, either
in their glands or in their trunks, once so strongly
insisted upon by the able pathologists already
named in connection with this doctrine (§ 27.),
although not improbable, has not been established
so as to admit it otherwise than as an occasional,
and by no means frequent, occurrence.

164. The Jluid eft'used in this form of hydro-
thorax is commonly transparent, colourless, or of
a citron tint ; in rarer cases, it is of a light brown,
or reddish hue, or even sanguineous ; its quantity
varying from a few ounces to ten or twelve
pounds, in both the cavities. In some cases, a
quantity of aeriform fluid is also present. (See
art. Pleura.). On the evacuation of the serum,
the pleural are generally observed to be sound ;
or merely paler, or somewhat softer, than natural.
When the accumulation has been great, the
lungs are generally pushed up to the vertebral
column, are hardly crepitous, and are occasion-
ally pale as if macerated ; but they sometimes
admit of being distended by insufflation, when
they have not been inflamed and hepatised. In
this form of the disease, effusion frequently takes
place into the pericardium, as a coexistent result
of the same organic changes; and occasionally
some fluid is also found in the abdomen, or even
within the head ; but more commonly in the
cellular tissue, constituting a more or less com-
plicated or general state of dropsy. M. Rayer
justly remarks, that anasarca, hydro-pericardium,
and ascites, are more frequently associated with
hydrothorax when it is caused by organic lesions
of the heart, than when it is consequent upon
alterations of the lungs.

165. C. Diagnosis. — As hydrothorax is gene-
rally produced by anterior disease, it follows, tiiat it
will not become manifest until some days, or even
some weeks or months, afterwards; or, in cases of
organic change of the heart or lungs, not until a
few days or weeks previously to death. Even
with the aid of percussion and auscultation, small
collections of fluid are ascertained with much
difficulty, and are marked by the symptoms of
the lesions that cause them. But when the ac-
cumulation is considerable, it is generally evinced
by phenomena which are proper to it. The patient
feels an oppression and difficulty of breathing, great
in proportion to its quantity. He generally lies
upon the afflicted side, leaving the healthy one
iiiiincMMdicrefl in its fuuclions. \VhiMi the fluid
is in both cavities, the respiration is still more.

DROPSY OF THE CHEST— Diagnosis oi HvDnoTHonAx,

647

difficult and sliort ; the patient sits up in bed, and
calls in tlie aid of all the muscles of inspiration :
his countenance assumes a cast of anxiety. ' Cou-
\iSART describes the chest as being more distended,
and rounded on the side which contains tiie fluid ;
and, as the collection increases, the intercostal
spaces are widened ; the integuments of tiiis side
becoming oedematous, and, in a few instances, the
arm on the same side. On percussion a dull sound
is emitted, resembling tiiat produced by striicing
the thigh on the side containing the fluid, or on
both sides when efl'usion has taken place in both.
^Vhen the patient sits, or stands up, and the fluid
only partially fills the cavities, the lower part of
the thorax only will give out a dead sound. This
sound generally changes its place with tiie change
of position, owing to the gravitation of the water
to tiie depending part. This, as jM. Pionnv con-
tends, is an important diagnostic between the
dead sound of efl'usion and tiiat produced by
liepatisation of the substance of the lung, whicii
always retains the same situation. In the acute
states of the disease, a feeling of soreness, tender-
ness, or pain, is often complained of in or over the
seat of efTusion.

166. Upon auscultation, the respiratory mur-
mur is found to have ceased in the region corre-
sponding to the fluid collection ; and in its place is
heard the tubular or bronchial respiration. In
some cases aggophony is heard when the effusion
is not very great. If the fluid be accumulated
only in one cavity, mensuration of the thorax
then becomes a useful mode of diagnosis ; but
tlie increased fulness of one side, and widening of
the intercostal spaces already noticed, may be
recognised at sight. When the collection is
very great in one side, not only is the lung com-
pressed, but the diaphragm anil liver are pressed
downwards ; and, if it be in the left side, the heart
is pushed towards the right. Succussinn of the
trunk cannot furnish any information, unless air
accompany the effusion ; in which case fluctuation
may be distinctly heard. (See Pleura, &c.)

167. Fuisive hydrothorax, in itself frequently
occasions but little general disturbance, the func-
tions of respiration being only mechanically dis-
ordered by it, unless it exist to a very great de-
gree. The lesions of which it is the consequence
are the chief causes of both the constitutional de-
rangement, and the disorders of the respiratory
and circulating functions ; and, upon the nature
of these lesions, the ultimate result more intimately
depends, than upon the efl'usion itself. The great
diversity of the primary alterations — whether
seated in the lungs, or in the heart and large
vessels — is the chief cause of the very great
diff'erences remarked in the symptoms, and pro-
gress of the malady. It becomes, therefore, im-
portant to ascertain the nature and seat of these
alterations — the true extent of associated dis-
ease — on account of the diagnosis, and of the
indications of cure. The early history of the case,
and the immediately antecedent states of disorder,
are among our guides in this inquiry. The in-
vestij^ation of these should, therefore, not be over-
looked.

168. (a) When the efFus'on has been conse-
quent upon pneumonia, active congestion of tlie
lungs, pleuro-pneumony, phthisis, or lironchitis,
the oppression and dyspnoea, characterising the
effusion, supervene without the irregularity of

the pulse and palpitations attending the cardiac
complication. Either in addition to the symp-
toms of these diseases, or at an indefinite time
from their partial or apparently total disappear-
ance, the dyspnoea increases, particularly upon
exertion; tiie patient requires his slioulders and
head to be more elevated in bed than usual, and
oedema is observed in his eyelids and feet. In
this class of cases, the effusion is generally not
very great, nor are the oedema and lividity of the
countenance remarkable; but he is unable to lie
on the side op|)osite to the effusion, which is most
frequently limited to, or at least in greatest quan-
tity in, one cavity ; and ultimately he is often
unable to lie down in any position. A fatal ter-
mination is commonly slow, and attributable more
to the alterations of the lungs, which have been
increasing with the effusion, than to the effusion
itself.

169. (/)) When the accumalation of fluid has
aris-n from organic change about the heart and
large vessels, the oppression and dyspnoea at-
tending it are associated with irregularity and in-
termissions of the pulse, with leipothymia, pal-
pitations ; very disturbed sleep, sudden startings,
and frightful dreams; a livid and oedematous
countenance, sometimes anasarca ; and sinking of
the vital energies. The patient can often lie
upon the side most affected, but, more commonly,
there is fluid in both cavities, and sometimes in
the pericardium also. When it is confined to
both sacs of the pleura, he often lies upon his
back : but, if all the thoracic cavities be affected,
he sits up, leans forward, and brings all the re-
spiratory muscles into action. The quantity of
fluid collected is usually greatest in this class of
cases ; and a fatal issue, although frequently de-
layed or prevented for a longer or shorter time, is
more apt to occur suddenly, particularly in fat or
plethoric persons. But, occasionally, before this
event takes place, tlie organic lesions of the heart
superinduce congestions of the lungs, or brain,
which may accelerate dissolution. Also, if, in
either of these classes of cases, any important
emunctory ceases to perform its functions, more
especially the kidneys, whether from functional
or oiganic change, the effused fluid may excite a
low grade of inflammatory irritation or action iii
the pleura, giving rise to a modification of the
effusion itself, as well as to some of the changes
observed in the pleura and lungs after death, and
which have been too generally viewed as the ori-
ginal disease, instead of being considered a conse-
cutive and contingent occurrence. As to the
state of the excretions in hydrothorax, they are
generally either impeded or disordered. The
urine is very different in different cases ; in the
acute and sub-acute forms, it is commonly scanty,
high-coloured, or deposits a thick lateritious sedi-
ment, and often contains albumen, particularly
when it is consecutive of eruptive diseases and
suppressed evacuations, or associated with acute
dis^jase of the lungs, but in the passive and
chronic cases, itis often notmaterially diminished,
and is seldom coagulable unless the kidneys be-
come diseased. It should not be overlooked, that
the primary lesions in hydrothorax are generally
and often necessarily progressive ; and that to this
circumstance, as well as to the increase of the ef-
fusion, the exasperation of the symptoms and its
fatal issue are to be imputed. (See also (4 29,oU).
Tt4

618

DROPSY OF THE CHEST — Progn

170. D. PnoGNOsfs. — Tlie complicated nature
of this malady, the advanced stages of the organic
lesions producing it at which it supervenes, and
the age and habits of those among whom it is com-
monly observed, will always influence the prac-
titioner to give an unfavourable opinion of the
ultimate issue, although the results of repeated
observation will induce him to inspire hopes of
affording great relief. But every return of the
effusion diminishes the chance of even partial re-
storation. His opinion, also, will be founded on
the nature and extent of the primary lesions, either
of the lungs, or of the heart, &c., as made manifest
by the auscultatory and rational signs. In every
case, however, the prognosis should be guarded ;
for, under circumstances apparently favourable,
an unexpected change may occur from the pa-
tient's conduct, or the progressive changes in the
seat of disease : and his friends ought to be in-
formed that, even in a state of no very apparent
danger, he may be suddenly cut off.

171. E. Tbeatment. — 'Hie principles of treat-
ment, so fully described in the early part of this
article, are applicable to hydrothorax. In the
acute and sub-acute states, bleeding, general or
local — more frequently the latter — is required ;
but it must be practised with caution. The results
of experience will confirm the inference at which
I arrived above, that, notwithstanding the close re-
semblance of tile morbid appearances, in acute
hydrothorax, to those of true inflammation, yet
vascular depletions are not nearly so well borne
in the former as in the latter, evidently owing to
the differences, particularly constitutional, on
which I insisted. J3ut the extent to which it
should be carried, and mode of practising it, must
entirely depend upon the nature of the original
lesion, and the state of vital energy and vascular
action. GenerjUy, when the lungs are acutely
affected, and their substance congested, or when
the lesion of the heart is of an acute kind, ^s ac-
tive enlargement of its cavities, moderate depletion
is both requisite and beneficial. But in the more
passive states of the malady, our reliance must be
placed on digitalis, and other diuretics, with
tonics, &c. In many instances, where depletion

— especially local — is obviously indicated, the
propriety of supporting vital power, even at the
time of unloading the vessels, or immediately
aftervi'ards, by the exhibition of gentle tonics and
diuretics, caniv^t be disputed, more especially
when the vascular fulness, or morbid action, is
secondary merely, and the consequence either of
an excrementitial plethora, — in which cases, pur-
gatives and other medicines calculated to act
upon the emunctories, should be also employed,

— or of the irritation produced by the properties
of the retained fluid, (jeneral bleeding is but
seldom requihitc in hydrothorax ; for a suHicient
quantity of blood maybe taken by cuppintr, which
possesses the advantage of ])roducing a levulsive
or derivative action. On this account, I have
prescrd)ed f/ii/ cupping, where the abstraction
of blood was not indicated. In cases where
congestion is superinduced in the lungs, or where
hffirnoptysis occurs, cupping, or even dry cupping,
if a most important part of the treatment, as-
sisted by digitalis, acids, and external cnunler-
inilation.

I7'i. /ff'i:i(/,s(/)W.s are generally of great benefit,
conjoined with antiphh logistic and diuretic reme-

osis AND Treatment of HvDnoTiionAX.

dies, in acute, and with tonics, &c., in passive,
hydrothorax. Setons, or issues, near the margin
of the false ribs, on one or both sides, are among
the best modes of fulfilling this intention. Wendt
advises them to be inserted in the chest ; and Ao-
TENRiETH dh'ects a blister over the sternum to be
kept constantly discharging. Cathartics, and
purgatives, especially the hydragogues, above
enumerated, often afford speedy relief ; but they
are admissible only when the powers of life are
not greatly reduced, and in the more acute cases.
Diuretics are more certainly beneficial in this spe-
cies,of dropsy than in any other ; and of this class
digitalis is the most efficacious, particularly in the
form of infusion, and when combined in the
manner already shown. The praises bestowed
on it by Lentin, VViniEniNG, Darwin, Hamil-
ton, Frank, Maclean, Percival, and many
others, have been generally acknowledged to be
just. Squills rank next in utility; but they are
not always appropriate, and are even injurious in
some of the more acute states of complication,
particularly in that with pneumonia oi' hydro-
])leurilis. Senega and ammnniacum, and the others,
may be used in the passive form of the disease.
The propriety of exhibiting diuretics, with tonic
infusions, and with antispasmodics, as already ad-
vised, is especially evinced in the more passive
conditions of tiiis disease. Camphor, ammonia,
and the aUhers, particularly the spirit, atheris
nitrici, and spir. a^theris sulphur., are of great
utility, when thus associated, or when given with
purgatives and tonics. The importance of sup-
porting the constitutional power-, in all the more
passive states of the cardiac complication, cannot
be too highly estimated. In such cases, purga-
tives should be given only in combination with
tonics and antispasmodics; and digitalis will be
best exhibited in a similar manner. Formulfe
400. 516. 781. 856. 859. 893, 894., and the fol-
lowing, as well as other diuretic preparations in
the Appendix, exemplify some of the foregoing
combinations : —

No. 190. ^. Hydrarg. Submur. gr. j. ; Pulv. Digitalis

gr. j ij. ; Znici Oxydi gr. iij. ; Pulv. Opii Puri gr. ss. ;

Syrupi I'olutan. q. s. Fiant Pilula; ij., bis terve quotidid
sumend*. (Hufeland.)

No. ni\. B Tinct. Digitalis 111 x.—xvj. ; Tinct. Ca-
lumbiE 3 jss. ; Spirit, ^ther. Sulphur. 5 ss. ; Tinct. Opii
111 V. ; Blist. Campiiorae 3 xj. M. Fiat Haustus bis quo-
tidie sumendus.

No. 192. R Pulv. Scillae gr. j. ; Potassse Nitratis gr. vj.
— X. ; Soda? carbon, exsic.gr. viij. ; Sacchar. Purif. 5ss. ;
Olei Anisi ll) iij. Tere benesimul, et fiat Pulvister In
die capiendus. (Selle.).

No. 193. B Potassae carbon. ,3jss. ; Potassae Nitratis
5 ss. ; TInot. Colchici 3 iij. ; Tinct. Aurantii 3 iij. ; In-
fusi Junip. Coinp. 3 vij. Misce. Capiat Coch. ij. vel. iij.
larga quarlis horis.

When, in addition to diminished tone of the capil-
laries, the disease is complicated with atonic
bronchitis and mucous expectoration, the first of
the following recipes may be administered ; and
when it is associated with torpor of the liver, the
latter may be exhibited : —

No. 194. K Pulv. Scillic cxsic. gr. xij. ; Pulv. Fol. Di-
gitalis gr. xvj. ; Hydrarg. Sulimur.gr. vj. ; Pulv. Gum.
Myrrlia' 3 ss. : tore lieiic siiiiul, et adde Assafoetida; 3 ss. ;
et Syrupi q. s. Fiant I'iliil:f xxiv., quarum capiat unam
qiiater in die, vol duas niauc uoctcque.

No. 10'). B Gum. Amniciiii.ui, .Saponis Venct. Jia3 j. ;
Pulv. Srilla; ex.sic. gr. x. ; Pilul. Hydrarg. gr. xv. ; Olei
.luiiiperi 111 v. ; Kxtr. Taraxaci 3 j. Fiat massa a;qualis,
(|uatii divide in Piliilas xxx. Sumantur du.i" bis tervo
qtiotidie.

17:i. I'lirncentesis (/lomr/'s, once sn strenuously
advised, has now fallen into disuse, and is seldom

DHOPSY, CONGENITAL— Pathology or. 049

or never resorted to, excepting in empyema. In
some states of the acute disease, especially when
the effusion is prmcipally in one cavity, and is
not attended by organic changes in the lungs or
heart, of a necessarily fatal or dangerous kind,
the condition of the patient in oiher respects not
contra-indicating the propriety of performing it,
this operation may be as safely and beneficially
practised on the thorax as on the abdomen ; the
same risks — and no greater — existing in respect
of the one as of the other. It has been recom-
mended by GOULA, DXJVERXEY, BlANCHr, De-
LAPORTE, MoilELAND, HuETTER, jNIORAND, LuL-

LiER, J. P. Frank, iMursinxa, Bei.i,, Romero,
and Archer, and practised successfully by nearly
all of tiiem. The chief danger proceeds from the
introduction and action of the air; but not so
much from ils preventing the dilatation of the
lungs, as from its action on the diseased pleura,
and the fluid effused from it, as shown above
(^ 157."). (See arts. Lungs, and Pleura.)

sequent ttpon disease of the molhev, or upon organic
change in the appendages, or in so)ne of the viscera,
of the fetus, or upon both causes.

Hi). Congenital eifusions of fluid are found — ■
(rt)iuthe ventricles, or between the membranes
of the encephalon ; (J)) between the membranes
of or in the spinal cord ; (o) within both the
head and the spinal canal, in the same case ;
(d) in the abdominal cavity ; (e) in the sub-
cutaneous and other parts of the cellular tissue ;
(f) in the cavities of the chest — the pericardiac
and pleural ; and, generally, in the above se-
quence, as respects frequency of occurrence.
1 hey are observed in the fcetus at the full term
of utero-gestation, and in abortions chiefly during
the middle and latter months ; and are, with tiie
associated diseases either of the uterus or of the
appendages of the foetus, the cause of its death, or
of its premature expulsion.

176. i. Congenital Hydrocephalus (Hiidro-
ceph. congenitus) sometimes appears, as other

BiBLioG. AND Refer.— Got//«, Ergo in Thoracis quam forms of congenital dropsy, dependent upon dis-
ease of the uterus, or on constitutional taint in
the parent or parents, or upon organic change in
the placenta or umbilical chord. In rare in-

in Abdom. Hydr. Paracentesis tutior. Paris, 1621.

Baltonius, Opera, vol. i. p. 13 Bartholin, Hist. Anat. vol.

ii. p. 7. (ifj. — R'verius, obs. i. 60. — JVillis, Pharinac. Rat.

ii. i. 13. — flKcccwfy, in Mi5m.de r Acad. Roy.deScien.de

Paris, 170:5, p. 197. {Paracentesis.) — Boiiet, Sepulchret. | stances it has been associated with ascites in the

1. n. s. 1. ob.^. 72. 84., s. n. ob. 75. rt jjfi/. — Bianchi, Uistor.

Hepat.i. p. 662. — Mo>-ga!;7ii,'De Sed. et Caus.ep. x.a.ll.,

ep. xvi. a. 2 40 Berger, Sur I'Hydr. de la Poitrine.

Paris, 1730. (_P<iraceulesis recommended.) — B"i'i//e!, Sur

I'Hydr. de la Poitrine, Sec. Bes. 4to. 1758 Maraud, in

Mem. de 1' Acad.de Cliirurg. t.ii. p. -547. — Avenhrugger,
Invent. Novum. e.K Percussione Thoracis ut Signo, in-
tern. Morbi Pect. detegencU. Vind. 1701. — Murelnnd,
in Philos. Trans. 1706, p. 302. — Satmnges, Nos. Meth.
t. i. p. 688. —Gonter, lie Diagnosi Morb. Pect. Vien.
1764 Alston. Edin. Me.l. Essays, vol. v. partii.p. 609.

— Simson, in Ibid. p. 623. — Lieuiaud, Hist. Anat. Med.
I. ii. ob. 857- 875. — Delaporle, Ergo H3dropi Pectoris
Paracentesis. Paris, 1774. — De Haen, Rat. Jled. pars v.
c. 3., pars vi. c. 4., pars ix. c. 12. — Stoll, Rat. Med. pars i.
p.2o6. {Vllbs.in the left pleura.), et pars ii. p. 378., pars iii.
p..55.,pars vii.p. 216. ; et Prtelect. vol. i. p. 80. — I'allis-
neri, Opera,iii.p.]85.526.— SW/c, N. Beytriige, b. i. p.l2I.
■ — Ricliter, in Comment. Soc. Goet. vol. ii. (Complicated
with carcinoma mamynce.) — Boelityier,T)e Hydr. Pec-
toris. Hal. nSi.—Hiil/er, Observ. Med. No. 3.;. (Cured

by par ace nt.), et No.34 Letlsom, in Mem. of Med. Soc.

ol'Lond. vol. i. — Knebcl, De Hydrothorace, 4to. Witt.
1795. — Piderit, Practische Annal. st. i. p. 46. — Reil,
Memor. Clinic, fasc. iv. N'o. 3. — J. P. Frank, Interp.
Clinic, i. p. 118. (18 pints of water.) ; et Act. Inst. Clin.
Viln. Ann. ii. p. 266. — Darwin, Zoonomia, vol. ii. —
Harles, Opera Minora Acad. vol. i. p. 383. 8vo. 1815.
(Hi/droihorax phlogisticus.) — A. G. Bichter, Die Spe-
cielle Tlierapie, t. iii p. lO'.i. — Wendt, Annal. des Klin.
Instit. heft. i. p. 6i'. (Squills wi//i tartar, iron ayid arom.)

— Autenrietli, Observat. in Hydrothoracem, &c. Tub.
1889. — Spungenficrg. in Horn's .\rchiv. 1809, p. 40. —
Dnpuy,\a Journ. Gener. de Med. t. xxxiii. p. 19. (Digi-
tali.i with assaftetida and squills.) — Blilm, De Hydr.
Pectoris. Wurc. 1806. — harrey, in Mem. de la .Soc.
Med. d'Emulation,t. vi. p. .354. {Idpints ojwater.) — Lul-
lier, in Journ. de Med. Contin. t.xvii. p. 221. (Paracenle-
cis.) — Mursinua, Journ. f. d. Chirurg. b. vi. st. 2. p. 6.10.
— L. Maclean, On the Nat. Causes, and Cure of Hydro-
thorax,8vo. Ludb. 1810. — Kev.in Edin. Med. Journ. vol.vi.

p. 474. — Robertson, in Ibid. vol. x. p. 295 Hall, in

Ibid. vol. viii. p. 303 Henderson, in Ibid. vol. xvi. p. 529.

— Hamilton, On the Prepar. and Administration of Di-
gitalis, &c. Lond. 8vo. 1810. — Hiifetand, in Journ. der
Pract. Heilli. May, 1812, p. 24. (Calomel with oxide of zinc
and opium.) — Itard. in Diet, des Sciences Med. t. xxii.
p. 489 Brosius, in Journ. des Prog. t. xvii.p.260. (Di-
gitalis and lactiicarium. in large and frequent doses.) —
Laennec, On Dis. of tlie Chest. Transl. 3d ed. p. 491. —
Leroux, Cours sur les Generalites de la Med. Pratique,
t. vH. p. 36. et seq. — Laydet, Archives Gtner. de Med.
t. XX. p. 430. —Bayer, in Diet, de Med. t. xi. p. 460.—
J. Frank, Praxeos Medics;, Sec. vol. ii. pars ii. sect. i.
p. 675. (.S<v also the Bibliography 0/ Dropsy; and of
Drop-SY of the Pericardiu.m.)

VIII. Dropsy, Congenital (Hydrops Congeni-
tus ; Dropsy of the Falusand vew-honilnfnit.).
174. Defin. — Efusion of ualerii Jiuid in llie

serous cavities, or cellular tissue, generally cou'

mother, or with dropsy of the amnion; but it more
frequently occurs without any such connection.
In these latter cases, it may be imputed to a mor-
bid action seated in, and more strictly limited to,
the membranes, or internal cavities of the brain.
It is often attended by an arrest of the formation
of the encephalon at some stage of the jirocess ;
but, in other cases, the brain is fully, if not more
than usually, developed. When the fluid effused,
either in the general cavity of the arachnoid, or in
the ventricles, is considerable in amount, the ossi-
fication of the cranial bones is interrupted gene-
rally towards their sutures, but occasionally in
other parts ; and, in these situations, the mem-
branes are often protruded to a greater or less
extent, forming, with the scalp, a watery tumour
(JiydrencephaloceLe) , which may be large at birth,
or scarcely perceptible, and may subsequently
disappear altogether, or become larger. When
the effusion is chiefly in the ventricles, the dis-
tended cerebral substance, and the membranes,
with more or less of the fluid, constitute the
tumour ; unless the effusion has taken place pre-
viously to, and thereby prevented, the develop-
ment of the cerebral substance and hemispheres.
Hence the character of the rupture depends upon
the situation of the fluid ; and its form, upon the
size of the aperture through which it presses.
Some forms of the disease approach to hemi-
cephaly ; a large portion of the cranium beino-
wanting, and the protruding brain being covered
by a thin membrane. In other cases, the opening
is small, narrow, or cleft-like, and the protrusion
is either small, or has a narrow neck ; the fluid
being, in such cases, usually effused between the
membranes. These ruptures are most frequent
in the back of the head, in different parts of the
occipital bone, and in the lambdoidal suture ; and
less frequently in the top, sides, and fiont of the
cranium. (6ee the Cases, and Writers referred
to.).

177. Congenital hydrocephalus arises at va-
rious epochs of fcrtal existence. At the earliest
periods, it interferes more or less x» ith, or entirely
arrests, the formation of the brain, and cranial

650

DROPSY, CONGENITAL — OF the Spine.

bones. At a later epoch, or tliat most nearly
approaching parturition, the brain and its enve-
lopes may be not merely lully formed, co-exist-
ently with effusion, in the ventricles, but even
more than usually developed for the period
of existence. A very large propoition of cases of
chronic hydrocephalus commences before birth ;
the effusion slowly increasing after this period,
and expanding the sutures. Meckel, indeed,
supposes that all cases of the chronic internal
dropsy of the head begins at this epoch ; but
certainly in some, although the smaller number,
the disease originates after birth. Not infre-
quently water colljcts to an extent that pre-
cludes delivery until the head of tlie foetus is
opened, and the water evacuated. Occasionally
the collection is so small at birth, as to render its
existence somewhat doubtful, the signs of its pre-
sence gradually disappearing with the growth of
the infant. In a few cases, in which effusion is
more evident, an ecpially favourable result takes
place. Congenital hydrocephalus is olten asso-
ciated with congenital dropsy of the spine, and
various malformations. (See Dropsy of the
Head — Chronic).

ii. Congenital Dropsy of the Spinal Cord. — ■
Syn. Hydrorachis, Hydrorhacliilis (from Wajp,
water, and p^X'^' ^^'® spine). Water in the
Spine, Spina bifida, Cleft Spine; Hydron-ha-
chia deliiscens, J.V. Frank; Hiidrops Spiii^ ;
Wassersucht des Pi'dckgrates, CJerm. ; Idro-
rhachitide, Ital.

178. Defin. — A collection of a watery fluid
between the membranes of Uie spine, generally
occasioning a tumour through an aperture in the
canal, occurring during fecial existence, or be-
coming apparent soon after birth, and observed
either in the prematurely born, or in the full-timed
fcrtus, whether dead or liDi]ig.

179. Congenital dropsy of the spine is often
complicated with internal dropsy of the head,
hemicephaly, and with hydrencephalocele ; and
generally terminates fatally with paralysis. Cases,
however, have occurred, of children living seve-
ral years, and reaching puberty, with the disease.
Palletta and Acrel met with one at seventeen
years of age; Henderson saw it at eighteen;
VVarner and Hochstetter, at twenty ; Camper,
at twenty-eight ; and Cowper, one who lived to
thirty. I saw the disease, in 1822, in a female of
nineteen, who menstruated regularly through ul-
cers in the thighs. The tumour was about thirty
inches in circumference, 'i'he excretions were
passed involuntarily ; but, in other respects, she
was then in good health. She died, however,
in a few months afterwards. Although generally
congenital hydrorachis, with an aperture in the
canal, has occurred after birth (Frank and IIey-
dellet). In the most complete, but the most
rare, form of the disease, the spinal marrow is
entirely wanting, the membranes having fallen
together, usually slit at one or more places, or
more or less degenerated, and adherent to each
other, forming sometimes a closed sac filled
with lymph (Ono). This condition may even
occur witliout cleft of the vertebral canal. In
the less complete states of this disease, the spinal
marrow presents its rudimental forms, like pulta-
ceous iiiii>scs of medullary subslance and blood;
or loose and separate nervous bundles; or the
anterior columns running parallel, but separate

from each other ; or, as in tlie early stages of
formation, open, broad, and flat behind.

180. In the more common stale of the disease,
there is found only in one, or very rarely in two,
distinct places in the spinal column, a more or
less large swelling containing water : in some
cases flat ; in others, semilunar; and in several,
necked ; their parietes consisting of the expanded
spinal membranes, often adherent and otherwise
morbid, protruded through the cleft in one or
more vertebra; ; and connected with the thin and
distended common integuments. This watery
tumour most commonly appears in the lumbar
region, more rarely in the dorsal and sacral, and
still more rarely in the cervical, excepting in
cases of co-existing hemicephaly or hydrencepha-
locele, in which the spina bifida always occurs
in the neck, and, from this point, protrudes more
or less outwards. The dropsy of the cervical
spinal marrow is merely, in this case, a process
from that of the brain ; the degenerated brain
being directly connected with the diseased origin
of the spinal marrow, which is sometimes per-
fectly natural below. The size of the cleft in the
spine varies greatly: generally more than one of
the veriebraa are open ; and rarely there is found
only a small round hole in one bone, by which
the tumour is connected with the spinal canal.
It is extremely rare to find the bones healthy, and
the aperture merely through the intervertebral
substance.

181. The seat of the water is originally of
naturally in the spinal marrow itself ; which, at
the part affected, is very much expanded, broken
up, and even entirely destroyed ; and often ex-
hibits the canal in the axis of the marrow, open
and expanded up to the brain. The water is
also sometimes contained, at the same time, be-
tween the membranes of the cord ; and, in rare
cases, in them alone ; whilst the cord itself is
either healthy, or merely compressed (Acrel,
Palletta, Vacca-Berlinghieri, Urquhart).
In those cases where the fluid is contained be-
tween the membranes only, there is generally
co-existent effusion between the membranes of the
brain. When the fluid is in the marrow itself,
there is likewise often effusion in the vetitricles.
Sometimes the swelling also contains hydatids.
Dropsy of the spinal marrow occurs, in some
raie instances, without any external swelling,
and without cleft in the spinal column ; so that
the canal running in the axis of the spinal cord,
and which is generally closed, becomes more or
less widely expanded by the water, with co-exist-
ing increased thickness of the cord itself (San-
TORiNi, Portal, Otjo) ; or the water is effused
only in the substance of the cord, and one part
of the oigan is distinctly swollen (P. Frank).
About one half of the hemicephalic monsters
have also spinas bifida;.

182. Whatever may be the seat of the external
tumour, it presents three rarielies as to its aspect
(Bii.i.AHi)): — 1st, That with the integuments
covering the tumour in a healthy and uninflamed
state; 2d, That with the skin discoloured, thinned,
and sometimes peimitting the exudation of a
serous or seio-sanguineous fluid, indicating the
approaching ru])ture of the parietes ; 3il, That
which is opened, and allows the efluscd fluid to
escape through a fine ulcerated perforation, the
vicinily of wliicli is surrounded by a red, rugous.

DROPSY, CONGENITAL -

and unequal elevation. Tiie patient may live
several niontlis or years with the first variety of
the disease ; but death usually soon follows upon
the second and third. The Jin id effused varies
in uppearuHce with the state of vascular injection
presented by the membranes. When these are
injected, or apparently inflamed, the fluid is ge-
nerally more or less turbid, or even flocculent ;
but this change may arise from the inflammatory
action preceding the rupture of tlie external part
of the parietes of the tumour. In other cases,
the fluid is commonly limpid and pale.

183. Tiie general symploms of congenital
hydroracliis, or cleft spine, are very diveisified.
They consist chiefly of debility, emaciation ; pa-
ralysis, generally, of the lower extremities ; reso-
lution of the sphincters ; antesthesia ; inability to
take the breast ; convulsions; and stertorous
breatliing. The tumour has usually a globular,
or pyriform shape ; sometimes a broad base, and,
at others, a narrow neck ; and varies from the
size of a hazle-nut to that of the adult head, or
even larger when the patient lives many years
with the disease. Congenital dropsy of tlie spine,
with external tumour, is sometimes associated with
other congenital diseases or malformations; as
dropsy either of the head or of some other ca-
vity ; vices of formation in the digestive canal
(\'oisiN, Jimrn. de Mtd. t. xxi. p. 57. ; Revo-
I.AT, in Ibid. t. xxvii. p. 378.) ; umbilical hernia
(Preuss, in Epliem. Nat. Cur. vol. viii. p. 128. ;
Sandifort, Observ. Anat..Pr. t. iii. p. 1 — 41.;
BIeckel, L cit, p. 679.) ; malformations of the
urinary or genital organs, or the absence of one
or more of tliese (Delfini, Opusc.Scelti di Mi-
hino, t. vi. p. 21. ; Lobenmvein', De Monst. Genit.
Dijformitiite, in Mem. de I'Acad. Imp. des Scieii.
de St. Petersb. t. vi. 1817.) ; imperforate anus
(LAiMARc, in Roux's Journ. de Med. t. xxxiii.
p. 516.) ; and defect of various parts.

184. iii. Congenital Anasarca, and Drop-
sies OF the Cavities of the Chest avd Ab-
domen, are occasionally observed, particularly in
the prematurely born foetus, either dead or liv-
ing ; and under the circumstances already stated
(§ 176.). The occuirence, unless when the effusion
is very great, or associated witli extensive vis-
ceral disease, should, however, not be viewed as
necessarily fatal. Cases have been observed,
wherein the collection of water in the abdominal
cavity of the new-born infant has been very con-
siderable, and yet recovery has taken place. In
some instances, the eflfusion, in this situation, has
been so great as to impede parturition ; and, in
very rare cases, it has been found necessaiy to
punctuie the abdomen of the tcetus before de-
livery coull be effected. Cougenital encysled
dropsy is very seldom met with. The case re-
cently recorded by M. Petit Mengin is one of
the most reniarkable on record.

185. iv. Causes of Congenital Dropsies. —
(a) The remote causes of congenital dropsies
are not frequently very obvious. They have
been stated to consist of constitutional vice in the
parents, particularly the mother ; the syphilitic
taint ; the scrofulous and rickety diathesis ; vio-
lent mental emotions, as fits of anger, fright, &c. ;
whatever inordinately excites the circulation in
the uterine organs during pregnancy, as excessive
venereal indalgencies (Ki.inko-ch, .1. Fuank);
external injuries affecting the uterus or its con-

- Causes and Treatjient of. 651

tents ; violent concussions of the trunk ; and sup-
pressions of urine in the mother (Frank, Ril-
L(XRD, &c.). — (ft) The more immediate causes
are organic changes, and hydatids, in the pla-
centa ; alterations in the umbilical coid ; tu-
mours or other lesionsof the uterus ; inflammations
or congestions in the viscera of the foetus, or
inflammatory irritation in the serous membranes ;
tubercles in the liver and lungs; and tubercular
thickening of the serous surfaces. The three
cases recorded by Dr. II. Lee occurred in con-
nection with dropsy of the amnion, and with dis-
ease of the placenta, and of some one of the
viscera of the foetus. In two, the effusion was
seated in the peritoneal cavity, and in one of
them it was associated with anasarca. It has
been remarked by RIichaelis and some other
writers, that congenital dropsies, especially spina
bifida, often occur in the same families with
rickets.

186. v. Treatment. — Congenital dropsies
may be somewhat benefited by medical treatment.
When the aqueous collection is not great, and
when the infant is well- formed, fully developed,
and evinces little or no disease of any vital organ,
we should not despair of success. — (a) Of the
treatment of cougenital hydrocephalus, particular
mention will be made in that part of this article
in which chronic hydrocephalus is discussed ;
and the same measures which will be recom-
mended in dropsy of the spine with external
tumour, are in great measure applicable to the
congenital collection within the head, but more
particularly to that form which is attended by
imperfect formation of the cranial bones and pro-
trusion of the membranes and other parts external
to the seat of the collection {Hydre)icephalocele,
see § 176.). In most instances of congenital
hydrocephalus, bandaging the head, and con-
tinued but gentle pressure, aided by the rest of
the means advised in the next paragraph, seem
most appropriate.

187. i^h) Of dropsy of the spine, &;c. — The
removal of this form of disease by ligature was
practised unsuccessfully by Heister ; and was
more recently recommended by R. Rell. Rut
what lias been stated above relative to the patho-
logical relations of the tumour, independently of
the circumstance of its form being such as not
frequently to admit of this treatment, will show
that this method can be but seldom appropriate,
and that it must be generally hazardous. Centle
pressure has been advised by JMr. Abernethy,
and successfully employed in a case by Sir A.
Cooper, who also resorted to puncture in another
case, with a similar result. These methods have,
however, been often practised in tlie dropsical tu-
mours, both of the spine and of the head, but very
rarely with advantage. In a case, however, of
the latter kind, j\Ir. E. Thompson succeeded by
applying a ligature. Richter recommends setons
to be inserted at a short distance from the tumour •
Camper and Agree, the application of discutient

*lotions ; De Haen, the employment of defensive
plasters; and Rillard, gentle and continued
pressure. Camper, Rorsieri, the Franks,
Racchetti, and Ollivier, are strongly opposed
to repeated punctures ; and state, that they excite
inflammatory action in the membranes, and hasten
aii unfavourable termination. I believe that the
tumour should be as little interfered with as

652 DROPSY, ENCYSTED

possible; that, if any local medication be resorted
to, a simple discutient lotion — as one of vinegar,
rose water, and spirit, or liq. amnion, acetatis —
or a defensive and discutient plaster, with gentle
pressure, will be found the safest and most suc-
cessful ; — that, in addition to tiiis, the abdominal
secretions and excretions should be promoted, by
means the least calculated to lower the vital
powers; — that a healthy wet-nurse should be
provided, to whom a gentle course of iodine may
be administered ; — that change of air, or resi-
dence in a warm and dry air and locality, be
directed; — and that the infant should wear soft
flannel next the skin, and be warmly clothed.
These have been tlie means I have employed in
most of the cases of the disease I have treated ;
and they have often prolonged life, and dimi-
nished the tumour, altiiough, in many instances,
I was unable to learn the ultimate result.
When the exterior of the tumour becomys in-
flamed, or the integuments thinned and disposed
to ulceration, puncture may be then resorted to,
as in the case recorded by Mr. Abeunethy ; but
care should be taken to close the opening accu-
rately after each operation, and to protect the
part from the air and external injury by suitable
applications. (See Dropsy of the Head —
Treutineiit of Chronic.)

188. (c) As to the treatment of the other forms
of congenital dropsii, but little need be added to
the above. In some instances, it may be requi-
site to commence with the application of one or
two leeches. Purgatives are generally requisite,
and should be often repeated, and alternated
with, or followed by, diaphoretics and diuretic^,
and assisted by the use of sligiitly alkaline baths,
of a temperature ranging from 85° to 94°. Many
of the cases of these forms of congenital dropsy
are beyond the reach of medical aid ; but, when
the infant is in other respects well formed and
strong, the existence of active congestion in, ov of
vascular determination to, some one of the viscera
of the cavity in which the collection is formed^ or
of inflammatory irritation in the serous membrane,
may be suspected, and moderate local depletions,
and active alvine evacuations, aided by means
calculated to relax the cutaneous surface, should
be employed.

BlBLlOG. AND RePER. — i. CoXGENIT. DrOPSY OF THE

Head. — Eiii/sc/i, Thesaui. Anat. ii. ohs. Si.—Blancard,
Anat. Pract.'Kar.cent.i.<>bs.80.,ceiit.ii.ol)s. \5.—HaUer,
Disput. Anatora. t. vi. p. 320. — Soem, Dissert, de Foetu
Ilydropico. Bas. }15\.—Gekler, De Partu diffifili ex
Hydrope FcetCis. Lips. \lW..—Marcorel, Mem. pres. a
I'Acad. t. iv. p. 458.— Orf«'r, Recueil Perioii. t. vi. p. 289.

— Memle. in Nova Acta Acad. Nat. Cur. vol. xi. pars ii.

p. 44:! Pcnadn, Sa^U'io d'Osscrvazioiii e Memorie, 4to.

Padua, Vim. — Osidiiilcr, Ihiiulbucli der Entbindungsk.
&c. part ii. p. '291 . ( /" uii oiihnin of two ur three mont/is.)

— II. Etirle, in Mf<lu()-Clnring. Trans, vol. vii. p. 427.
—Huilolphi, lab. i. fig. i. -(In nfcetusof txvo months.) —
Meckel, llaridbuch der Path. Anat. b. i. p. gilO. (Con-
siders thai oil coses of chrimic hijdroceph. are congenital. )
—A. J. Wenxel, De Hydrocephalo fongenito, 8vo. Ber.
1823. ~J. Frank, Praxeos Medica; Universa; Priecepta,
&c. pars. ii. vol. i. sect. i.p. 2.">1. — .B. Thomson, Loud.
Med. Repos. Nov. 1824. — Mecliel, Descriptio Moiistro-
rum nonnul. &c. 4to. Lips. WM, p. « : (/" afieliis oj sij:
weeks.) — BillardyDes, Mai. dos lOiilaiis Nnuvcaux-iies,
&c. Paris, 1828, p. 4.'">1. — A. /»'. Otto, C'cmp- "1 Vnih.
Anat. by Stiiith, p. Tib. — Caucal, Lancette l'ran<;aise,
No. 7H. IS.3.3.

ii. CoNfiKN. Dropsy oftme Spinb.— /7»//.'ir«, Obsorv.
Anat. Chir. obs. .'Jt, ;», 'M. — ISoncl, Sc|)ulchret. 1 i.
nect. xvi. obs. 4. (.With hi/dror.eph.) — Iloclistettcr, De
.Spina Bifida. Alt. 17():J. - Salzmann, Do Ouibu.sdain
'I'liinoribns tiuiicatis extern. Arg. X'W.—Morifonni, De
C. et.S M. epist. xii. xlviii.— A/«//C)-, Klement. Physiol.
vol. iv. p. 87 Portal, Mcui. de I'Acad. des Sciences, an.

— Causes and Pathology or.

1770, 1771. {With kydroceph.) — Warner, Observ. in Sur-
gery. Lnnd. 1784, p. ISd.— Slo/l, Rat. Me<i. pars vii.
p. 47. ( Wit/i kydroceph.) — Oehme, De Morb. Recens Nat.
Lips. 17/3. — Sandifort, in Observ. Anat. Pathol. 1. iii.
cap. i. — Obertevjfer, in Stark's, N. Archiv. f. d. Ge-
buctsh vol. ii. par. iv. p. 624. — Oke.f, An Account of
Spina Bifida, &-c. Cambr. 1810.— F/W/x, in Richter's
Cliirurg.-Biblioth. b. ix. p. 185. ( The ivhole spine bifid, the
spinous processes being wanting.) — Miehaclis, m Ibid,
b. vi. p. 133. — J. P. Frank, De Curand. Iloni. Morb. 1. vi.
pars i. p. 198. — Moeckel, De Hydrorrhachitide Coinmen-
tatio. Lips. 1822. — yfSt'jvfrt^, Surg, and Physiol. Es-
says, part i. p. 75. — Meckel, Handbuch d. Patholog.
Anatom. b. i. p. 35. 37 .—Patlelta, Exercit. Path. cap. 10.

art. 3. Nov. 1821) A. Cooper, Trans, of Med.-Chirurg.

Society, vol. ii. p. 324. — Neuendorf, De Spinae Bifidae
Ciiratione radical!. Berol. 1820. — Facca-Berlinghieri,
Storia di una Idrorachia. Pav. 1820. — Jukes, m Med.
and Phys. Journ. Feb. 1822. — Jos. Frank, Praxeos Med.
Univers. Prscept. vol.i. pars ii.sect. ii. cap. 4. — RoTiCtti,

in Journ. des Progres des Scien. Med. t. v Baron,

lyondon Med. Repository, ed. by Copland, Aug. 1824. —
Ollivier, Traite de la Moelle Epiniere et de ses Mai. t. i.
J). 207. — Duges, in Kevue Medicale, &c. April, 1823. —
Otto, Coiiipend. Anatom. Pathol. 8vo. Bresl. 1829. {Re-
snlts of the c.raininationef thirty-three cases.) — Brewer-
ton, m Ellin. Med. and Surg. Journ. vol. xvii.p. 251

I.ocock, in Ibid. vol. xviii. p. 378. — Lindsay, in Lond.
Med. Repos. Jan. 182fi, — Billard, 'J'raite des Mai. des
Ent'ans, c\:c. p. 582. — 5. Malins, in Liverpool Med. Gaz.
vol. i. p. 27.

iii. CoNGEN. Dropsy of the Cavities of the Thorax,
Abdomen, &c. — Blancard, Op. cit. cent. i. obs. 93. —
Reidlin, Lin. Med. 1696. p. 38. ; Ephemer. Nat. Cur.
dec. i. ann. i. obs. 42., cent. ii. ann. iii. obs. 153. — Dc
Haen, Opusc. quaedam inaedit. pars i. p. 4. — Roux, Journ.
de Med. Chir. et Pharm. t. xvii. p. 180. — Humberg, in
Stark's Archiv. &c. b..vi. p. 396. — Ollivier, in Archives
Gejit'r. de Med. t. viii. p. 383. — Andry, in Journ. des
Prog, des Scien. Mtd. 2d ser. t. i. p. 126. — R. Lee, in
Jled. Gazette, vol. vii. p. 38.5. — Petit Mengin, in Gazette
Medicale de Paris, No. 50. 18.33. {One case of abdominal
dropsy, and another of encysted.)

IX. Dropsy, Encysted. — Svn. Hydrops Sacca-
tus ; Hiidrops Cy sticus, Anct. va.r.; Die Sack-
ivassersucht, Germ.; Hydropisie enkysiee, Fr.

189. Defin. — The Jiuid enclosed, in a ct/st, ge-
nerally of a serous structure internally, and of
adventitious formation ; giving rise to local symp-
toms resembling those caused by effusion into natural
cavities.

190. The origin of serous cysts is discussed in
the article Disease (§ 114.) ; it therefore remains
only to notice those excessive collections of fluid
in them, which are distinguished with difficulty
from accumulations in natural cavities. The en-
cysted productions, which either contain more or
less consistent secretions, or are of so small size
as not materially to affect the bulk of the organ
in wiiich tliey are seated, or the functions of
parts adjoining, are considered in connection with
the other lesions of their respective seats. In
the view about to be taken of encysled collec-
tion of fluids, mention will be made only of
those which possess, in many respects, a dropsical
ciiaracter, and which have generally been con-
sidered as such by writers and practilioners,
although even they may possess no true claims
to tins distinction.

191. A. Causes. — The causes of common
dropsy have generally no influence in producing
tiic encysted. The same state of action, to whicii
the formation of tiie cyst in the first instance is to
be attributed, evidently is the main agent in the
secretion of its accumulated contents. Of what
this state consists, and of the causes in wliicii
it originates, but little is really known. When
remai'king on this and similar changes (.see
Disease, § HI.), 1 staled that the origin of
seroiis cysts cannot be considered as truly inflam-
niaroiy ; but that it may be imputed to a modified
uultition, frequently connected with a weak-

DROPSY, ENCYSTED — PnoGNOsis and Treatment of.

653

oncd or depraved state of the constitution ; mo-
diliciitions of the formative pioces>es — of the
organic actions of secretion and nutrition — being
move apt to occur from causes wliich deflect them
from their healthy course, in such constitutions,
tlian in the sound and vigorous. This view is
important, inasmuch as it is based on an attentive
observation of a number of cases of this descrip-
tion, and as it leads to a more successful practice
than is too frequently adopted.

192. B. Prognosis. — Encysted collections of
fluid, as long as they do not reach the extent of im-
peding the functions of adjoining organs, seldom
occasion any serious disturbance. In this respect
they are different from effusions into natural cavi-
ties ; and, when they give rise to dangerous or fatal
results, it is owing more to this injurious action on
surrounding parts, than to any change they induce
in the circuhiting, secreting, and natural func-
tions. When not injuriously interfered witii, and
when the system is not improperly lowered, or if
it be enabled to resist their increase, all the func-
tions frequently proceed without any material
disturbance, and these collections often remain
long stationary. But, when the constitutional
powers receive a severe shock from any cause ;
when the patient is imperfectly fed, or is made
the subject of a meddling or active surgery ; the
cysts become the centre of a inorbid determination
of the organic actions ; chronic inflammation
supervenes in them ; the accumulation of fluid
advances rapidly, and the vital resistance is
subdued. In some cases, the secretion proceeds
in the interior of the cyst with greater rapidity
than the cyst itself can either yield or be deve-
loped, and hence it is ruptured, and its contents
efl^used. This circumstance may hasten an un-
favourable issue; or, vv-hen the cyst is small,
favour its disappearance or transformation.

193. Encysted dropsies are, with some excep-
tions, incurable when they have reached a large
size, and when, either from this circumstance, or
from their situation, they adinit not of being re-
moved entirely. But, in many instances, especi-
ally when they are seated in the ovaria, a
judicious constitutional treatment will of en pre-
vent their increase for years, — sometimes during
the greater part of a very long life, — or will even
cause their entire disappearance, or transformation
into an inert substance.

194. C. Treatment. — As to the indications
of cure, only a few geneial observations are here
necessary. In all encysted formations, particu-
larly in those now under consideration, it may
be viewed as a law, from which there are ex-
tremely few exceptions, that, in proportion as
vital power, and its manifestations in tlie secreting,
assimilating, and excieting organs are promoted,
without materially exciting the vascular action,
or heating the body, will the progress of these
productions be overcome, or their diminution
eflected ; whilst their increase will be both great
and rapid in an equal ratio with depres-ion of
constitutional energy, or with disorder of any of
the functions now alluded to. A healthy and
vigorous performance of the various organic ac-
tions resists the progress of all adventitious form-
ations; and an opposite state favours their increase.
'J'his rule holds in respect of all productions of a
parasitic kind, and in all tha kingdoms of or-
ganised nature, and is observed in both the

physical and moral maitij'estdlious. 1'he parasitic
formation or animal can grow only at the ex-
pense of the weak ; the robust frame resists it,
and denies it nourishment; whilst the weak fur-
nishes it with means which are slowly but surely
turned to its own destruction.

195. During the treatment of encysted dropsies,
care should be taken not to resort to any measures
that may irritate or inflame them, particularly
when they have acquired a large size. On this
account, funcxuriiig or paracentesis should be re-
sisted to the utmost — until extinction of life
would follow on its being longer deferred j and,
when thus made a dernier ressort, the operation
should be performed by a scalpel and lancet,
with which latter the sac should be opened ; the
utmost care being taken not to admit the air. I
have seen, on numerous occasions, the ill effects
of not attending to this injunction, and of leavinp'
acanula, or tent, in the wound, the inflammation
thereby induced in the cyst, giving rise to so ex-
tensive a secretion, and so much constitutional
disturbance, that the patient has rapidly sunk.

196. The preparations of iodine, when judi-
ciously exhibited, are the most generally appli-
cable and efficacious means that can be employed
in this class of diseases. But they ought to be
exhiljited in very small doses, much diluted or
reduced, and long persisted in. They become
injurious as soon as they give rise to the slightest
indication cf irritation of the digestive organs. I
have employed them extensively and constantly
since 1819, when I brought some of them with
me from the Continent. At that time they could
not be procured in London. They are most be-
neficial when prescribed internally; but they
are also of use externally, if they be directed
so as not to inflame the part to which they are
applied (see F. &32. 7G6— 769.). When the
debif ty is considerable, the iodide of iron, taken
in any aromatic infusions, the secretions and ex-
cretions being at the saine time promoted by an
aperient pill at bedtime, will be of essential ser-
vice. I have lately prescribed it in several cases
of cachectic disease, with reinarkable benefit. The
diet, in all encysted dropsies, should be light and
nutritious ; and the patient's mind be agreeably
engaged : change of air, or residence in a pure,
temperate, rather warm, and dry air, ought also
to be recommended.

197. The situations in which encysted
DROPSY is most FREQUENT, aic HuiTierous ; and
if all the places in which large serous cysts have
been developed were taken into the account, it
may be said that they comprise every part and
organ of the body. Encysted dropsy, however,
has been observed under the integuments, by
Schenk,Van Swieten, CRuvEii.HiEr!, and others,
forming very large lymphatic tumours; irithin
the head, as shown in the article Brain ; between
the pleura and the intercostal muscles (Haller,
Desault, &c.) ; in the mediastinum ; in the sub-
stance of the lungs (Stoerk, MaeoIst) ; in the
('avity of the thorax, and in that of the pericardium
(Mercker, Dupuytren, Itard, &c.) ; between
the peritoneum and abdominal parietes (Achot.-
zius, MoRGAGNi, RloRAND, and J. P. Frank) ;
in the ovarium, forming ovarian dropsy; in the
Fallopian tubes (Riedlin, Douglas, Blankard,
Baillie, Seymour, &c.) ; in or connected with
the uterus, — Hydrumetra, ^c, (Geuner, Odier,

654 DROPSY. ENCYSTED, OF THE OVARIUM

Lafosse, Rayer, Thomson, &c.) ; connected

■ Pathology of.

with the liver ( Alix, Con\'isAnT, Leroux, Frank,
Lassus) ; in the kidney (Morgacni, Houston,
Walteh, Corvisaut, J, Johnson, Howison) ;
in the omentum (Hasenoerhl, De Haen, Por-
tal) ; in the mesenterii (Horstius, Tulpius,
Sauvages, RIoranh) ; and in the spleen (JMon-
gagni, Baader, (Sec.)- Of the most important
only of tliese, 1 now proceed to take a m,ore
particular notice. In some cases of very large
encysted dropsy seated within the abdomen, the
exact origin of the cyst can hardly be ascertained.
Of this kind appears to be the instance recorded
by Sir. CouLSON {Med. Gazette, vol. ix. p. 577.),
which was frequently tapped. Upon dissection,
the cyst was found to adhere to the abdominal
parietes, and to several of the viscera, and to
consist of three layers. The ovaries were healtliy.
Similar cases are published by Portal and Cru-
veii.hier (Antit. Palholcg. vol. i. p. 268.).
i. Dropsy of the Ovarium. — Syn. Hydrops

Ovarii, Ocarian Dropsy, Dropsy of the Ovary ;

Hydroophnrie, Boivin and Duges ; Die Was-

sersucht der Eierstocke, Germ.; Idrnpisia di

Ovaria, Ital.

198. Defin. — Swelling, commencing icith ten-
derness, pain, or weight in the iliac region of
one or both sides, and irregularilif of the menstrual
discharge ; the swelling gradually extending over
the abdomen, and attended bij obscure fuctuation.

199. A. Pathology. — This is the most frequent
species of encysted dropsy, and of the greatest
importance in a practical point of view. It is
very often complicated with otlier organic changes
in tlie ovaria (see article Ovaria — Diseases
of), peritoneum, uterus, and tubes ; but it also
frequently consists only or chiefly of a collection
of a greater or less quantity of fluid in one or
more cysts, into which the substance of ihe ova-
rium seems to have been converted ; owing
to the enlargement of one or several of them
giving rise to atrophy of the proper structure of
the ori3;an. These cysts have been mistaken for
hydatids, from which, however, they may be dis-
tinguished by their being nourislied by vessels sup-
plied from the parts in which they are formed;
whilst hydatids are not thus supplied, but are
nourished by their own vessels, and have an in-
dependent life. Sometimes " one or both ovaria
are converted into simple cysts ; the whole of the
cellular substance and vesicles disappearing, that
which was the fibrous coat of the ovarium becom-
ing the fibrous coat of tiie cyst." (Dr. Seymour.)

200. The Graafian vesicles, vvhich, in the
healthy state, are of the size of millet seeds, fre-
quently become as large as almonds, are filled
with a limpid fluid, and their internal membrane
is very vascular. This appears to be the com-
mencement of the simplest form of ovarian dropsy ;
or, at least, a change, which may j)rocced no
further, but which sometimes does proceed to an
extent wliich constitutes this disease. W hen tliese
vesicles enlarge to a greater degree than the size
of a filbert or almond, it is always on the side
nearest the proper coat of the ovarium ; the rest
of the ovarium, as shown by M. Cuuvfilhier
and Dr. Sf.vmour, appearing, when the cyst
reaches a large size, as if atrophied at the parietes
of the cyst. In this manner is sometimes formed
an enormously large single cyst, having the proper
fibrous coat of the ovarium and peritoneum for an

external covering ; the internal membrane, or the
parietes of the vesicle, secreting a prodigious quan-
tity of fluid. In many of these cases, especially in
those of long duration, the parietes of the cyst un-
dei'go various changes, and are thickened, hard-
ened, cartilaginous in parts, or even ossified. Their
external surface, in their earlier stages, are some-
times smooth, not infrequently inflamed or very
vascular ; and form adhesions with adjoining parts
of the peritoneum and contiguous viscera, or with
the fimbriated extremities of the broad ligament,
or with the fundus of the iiterus (Boivin, Sey-
mour, Duges). In their more advanced states,
also, their surface becomes the seat of chronic in-
flammation, of tuberculation, or both; and in this
change the rest of the serous surface of the abdo-
men, or parts of it only, may participate. In some
instances, the marks of associated inflammatory
action in the peritoneum are indistinct ; but this
membrane not infrequently contains in these
cases, more or less fluid, the encysted dropsy thus
being complicated with ascites. The interior of
the sac, or cysts, is commonly smooth, and re-
sembling a serous surface (Morand, Burns) ;
or it is lined with a false membrane : it is, in
some cases, irregular or mamelonated ; and, in
others, imperfectly divided by incomplete parti-
tions (Cuuveiliueu).

201. The y^Kfrf contained in these cysts varies
remarkably. In some cases, particularly when it
is lodged in one, or a few cysts of a very large size,
it is serous, or mixed with a ropy or mucous mat-
ter. In others, it is dark-coloured and resembles
cofl'ee. Where the cysts are more numerous,
their contents are generally thick, gelatinous, and
of a brown colour of varying depths of shade. The
fluid is also, but more rarely, of the appearance
and consistence of custard ; and occasionally it
resembles honey. I have seen it, in some instances,
where the accumulation was remarkably great,
brown, thick, and gelatinous ; and in others, its
characters have changed at subsequent stages,
especially after tapping ; and it has become grey-
ish, dissolved, ichorous, flaky, or puriform and
even offensive. The quantity which collects,
particularly when there is only one cyst, and when
its contents are serous or watery, is sometimes very
great. Wepfer, IIaller, jMonro, and Frank
have found as much as 120 pounds of fluid in a
single cyst, and Mijller as many as 140 pounds.
When the necessity of resorting to puncture has
once become imperative, the rapidity with which
the fluid is again formed is often remarkable.
MoRAND drew off 427 pints in ten monihs ; and
IMartineau nearly 500 in a twelvemonth ; and,
from the same patient, upwards of 6600 pints,
by eighty operations, within twenty-five years.
Sir A. Cooper thinks, with great probability,
that the case of Mrs. INIumford, who was tajipcd
155 timesin less than fouryears, wasone of ovarian
dropsy. W'hcn the ovaiitim contains a number
of cysts, is lobular, and irregular in its surface
and firmness, each of the individual cysts often
is filled by a different and peculiarly charac-
terised secretion — which is cither watery, gela-
tinous, sanguineous, fatty, &c. ; and, when the
tumour has been punctured, partially decom-
posed or putrid, and mixed with gaseous fluids
( De IIaen, Boivin, Duces, and myself). In
rare instances, sebaceous matters with long hair
have been found in the same ovarium that con-

DROPSY, ENCYSTED, OF THE OVARIUM — Causes, Symptoms, etc.

655

tained large dropsical cysts, and even in the i
same cyst, with the watery collection : the cyst
ill which the hair and fatty substance had been
formed having subsequently become the seat of
dropsical effusion.

■202. li. Causes. — (^a^ The predisposing causes
are, the scrofulous diathesis ; debility, however
induced ; frequent or excessive menstruation, and
venerea] indulgences. The disease occasionally
commences as early as the first appearance of
puberty. J. P. Frank saw it at thirteen, and
JM. Itari) at fourteen years of age. Marjolin
states, that it may begin before puberty ; but
I know of no such occurrence. It is most com-
mon between the ages of twenty and fifty. It
may commence soon after the cessation of the
catameuia ; but, although chronic cases of it are
found in very old females, yet it rarely originates
at an age much beyond fifty. It often follows
abortions.

203 {b) The exciting causes have not been
satisfactorily shown : but it has been very gene-
rally imputed to external injuries, succussions of
tiie pelvis, the mismanagement of parturition and
abortions ; or to cold, fright, and anxiety of mind.
From much attention to this disease, I have
inferred that it is occasionally consequent upon
inflammatory action in the ovaria or uterus, or
connected with this change in its earlier stages.
Hence its causes may be considered to be, in
some cases, those in which inflammatory ac-
tion in these organs generally originates. Yet
there are numerous objections to this view ; for
even wiien the tenderness and pain in tiie region
of the ovaria, accompanying its commencement,
are greatest, there is also a frequently recurring
and copious menstruation, indicating an excited,
rather than an inflamed, state of these organs.
From various considerations, and a review of the
circumstances in which the disease seemed to
originate, it is not improbable that it is connected
with an often excited, but an imperfectly gratified,
sexual appetite. Hence its frequency in females
who are sterile, or whose state of heaitii is insuffi-
cient to the developement of a healthy and vigo-
rous orgasm, owing either to premature and illicit
indulgences, or to previous disease.

204. C. Symptoms and Progress. — Ovarian
dropsy is very commonly far advanced before
recourse is had to medicine. It usually com-
mences with irregularity of the menstrual dis-
charge, and disorder of the excretion of urine,
which is either voided frequently, or is long re-
tained. There is also severe pain in the loins,
with pain, tenderness, and swelling in one or both
iliac regions.. In some instances, the ])ain shoots
througli the abdomen, and down the thighs; and
occasionally there is numbness, ha'morrlioids, or
complete strangury, owing to the pressure of the
enlarged ovarium before it rises out of the pelvis.
The catamenia, at this period, is frequently either
copious or of too frequent occurrence ; but it is
rarely altogether suppiessed. Various hysterical
symptoms also come on ; and disappear at a later
stage. The bowels are usually costive ; but they
are sometimes irregular, or relaxed. As the ma-
lady proceeds, the patient experiences various
dyspeptic symptoms, and ofien nausea and vomit-
ings, as in the early months of pregnancy. The
mammas also enlarge, and tiie areolaj around the
nipples assume a darker shade. Dr. Seymour

states, that, when both ovaria are aflfected, the
catamenia are always absent ; but, when one only
is diseased, this evacuation is eitlier absent or irre-
gular. 'J'iiis does not agree with my experience,
the results of which I have just novv given, as
regards the early stages of tlie disease ; but, as
respects the last stages, particularly in the more
chronic cases, the observations of this physician
seem to be correct. With the increase of the
tumour, various inflammatory phenomena, referri-
ble chiefly to the peritoneum, and commencing
in the pelvis, but often extending upwards to parts
of the al)domen, supervene.

205. The progress of the tumour and abdominal
enlargement is extremely various. Occasionally
the ovarium, whether it consist of a number of
cysts, or of one or few, increases very slowly. It
sometimes remains long stationary ; afterwards
augments rapidly, and fills, ultimately, the whole
abdomen ; and in rarer instances it recedes, or
even entirely disappears. It proceeds more re-"
gularly, however, in most cases, until it gives
rise to appearances rendering the diagnosis very
difficult. The general health, as already stated
in respect of encysted dropsies, continues but little
impaired, until the morbid accumulation has ad-
vanced so far as to disturb the functions of ad-
joining viscera; but this is not uniformly the
case ; for the means used to cure it not infre-
quently are sources of disorder, deranging the
natural functions, and thereby favouring the in-
crease of the disease. When the collection rises
as high as the epigastric region, and the abdomi-
nal distension is great, the functions of the
stomach are often completely overturned, and
the constitutional powers rapidly sink : singular
and unexpected changes, however, sometimes
occur, even in the most chronic cases. Dr.
Baillie mentions an instance of its spontaneous
disappearance, after it had existed thirty years ;
the patient remaining, subsequently, in good
health. The accumulated fluid is also occasionally
discharged into some part of the large intestines,
having previously formed adhesions with it ; or
into the vagina, pressure on the tumour increas-
ing the discharge. Instances of this have ac-
curred to Dr. Elliotson, Vr. IMontgomery,
myself, and others. In a case treated by me some
years ago, and put upon a course of iodine, the
catamenia were profuse every fortnight or three
weeks. The tumour, which filled the whole ab-
domen, remained long stationary, anrl ultimately
burst into the large intestines. It did not return
again until upwards of a twelvemonth : ultimately
the patient was so much benefited as to leave off
treatment. Dr. Seymour adduces an instance,
in which the morbid collection was discharged
both by the intestines and by the vagina, and
recovery took place. Sometimes it forms adhe-
sions to the abdominal parietes, and bursts exter-
nally at the umbilicus. A permanent cure is often
effected by judicious management under the fore-
going circumstances. A case was seen by me, in
\i'hich adhesion of the tumour took place, to the
parts adjoining the puncture by which its contents
had been drawn oft'. 'I'he cicatiix ulcerated, and
the fluid was afterwards discharged by degrees
through the opening, and the patient recovered.
A nearly similar instance of recovery occurred in
the practrce of JMr. Barnwell. When the fluid
finds its way into the peritoneal cavity, the result

DROPSY, ENCYSTED, OF THE OVARIUM

656

is, in my opinion, generally fatnl, althougii some
autiiors contend that the fluid may be absorbed
from this situation, and the patient recover, 'i'his,
however, is certainly a very rare occurj'ence. 'J'he
best authenticated case of restoration from effusion
of the contents of the ovarian tumour into the ab-
domen is recorded by Dr. Blundeli,, in his pub-
lished lectures.

206. ]J. 'J"he Diagnosis of ovarian dropsy is
not always easy. It may be mistaken for preg-
nancy, foV ascites, for hydrometra, or for tumour
or abscess of some adjoining part. The appear-
ance of swelling and pain in one side, or both, of
the pelvis, in connection with irregularity, with-
out suppression, of the catamenia ; this swelling
being at first but little, or not at all, changed by
position — by lying on either side, or by the erect
posture ; — obscure fluctuation as it expands,
with a sense of elasticity, and sometimes of irre-
gularity in it ; — the motions and activity of the
patient not being very materially impaired, or not
in proportion to the magnitude of the tumour; —
the principal abdominal organs not having evinced
much disorder, or signs of organic change, previ-
ously to the swelling, and their functions not
being greatly disturbed during its course; — its
slow increase, its situation, its direction to one
side and limitation to the lower regions of the
abdomen when the patient is supine, until a late
stage of the disease ; — the inefficacy of purgatives
and of diuretics in producing any diminution of
it, and the nc^t materially lessened secretion of
urine, until after the disease has advanced very
far, or until the fluid has been drav\'n off by art ;
— the more healthy aspect of the patient than in
ascites, — and pain, stupor, or oedema of the
thigh, leg, and ancle, having been complained of,
on the same side with that where the swelling
commenced, — will serve, when carefully consi-
dered, either separately or in conjunction, to guide
the practitioner. These phenomena, however,
may not be uniformly present, but many of them
will — and will be so associated as to leave
little doubt as to the nature of the disease, par-
ticularly when aided by an examination per vagt-
7iam, and also per rectum. At the commencement
of the malady, the local symptoms have some-
times been so manifest, and attended by so much
pain in the back, and pain and oedema of the
lower extremity of the same side, as to have been
mistaken for psoas abscess. 'The disordered excre-
tion of urine and strangury, and the evidence
obtained by examination, will, however, gene-
rally indicate satisfactorily the nature of the dis-
ease. Dr. J\1.4ciNT0sii states, that the tumour
may sometimes be felt between the vagina and
rectum, before it become? much enlarged ; the
OS uleri being in such case tilted forwards close
to the symphysis pubis, so as to resemble retrover-
sion of the. uterus ; but an examination by the rec-
tum will make the nature of the affection evident.
^VlH;n the increase of the ovarian tumour is slow,
ami it ri-es in the abdomen by a narrow neck
before it is perceived, it may be mistaken for eit-
lurgemeiU of some other organ; especially if it
liave formed adhesions with the parts in contact
with it. 'I'he dilliculty of diagndsis is also in-
creased by the presence of fluid in the peritoneal
cavity, — a circumstance which occasionally oc-
curs. WIk'Ii this is suspected, or when the diag-
nosis is didicult, the patient should be examined

■Diagnosis — Treatment,

in the recumbent posture, when the ascitic fluid
will be found to gravitate towards the hypochon-
driac and lumbar regions; and the limits of the
ovarian tumour may be ascertained. The history
of the early stages of the case, and the recurrence
of the catamenia during the greater part, or even
the whole, of its course, its chronic duration, and
the absence of the progressive changes of the OS
uteri characterising /))eg)«mci/, will sufUcientiy dis-
tinguish it from that state ; the uterus being move-
able and light upon examination per vagincim,
pressure on the hypogastiium at the time not affect-
ing, or propagating any movement to, this organ.

207. E. I'he Prognosis will depend entirely
upon the constitutional powers of the patient, and
the progress the disease has made. Although it
should be generally unfavourable, and always
expressed with caution, and with much reser-
vation, even in cases apparently the most favour-
able, yet we may entertain reasonable hopes that
the progress of the disease may be checked by
careful regimen and treatment, particularly when
the energies of the constitution are unbroken, and
the digestive and excreting functions are not ma-
terially disturbed, nor the progress of the swell-
ing rapid. J. P. Frank met with a case where
it commenced at thirteen, and yet the patient
reached the great age of eighty-eight years. The
occurrence of tenderness in the abdomen, any
manifest diminution of the patient's activity, its
complication with ascites, emaciation, accelerated
pulse, great disturbance of the functions of the
stomach, and the necessity of having recourse to
paracentesis, are all unfavourable circumstances, i:^

208. F. Treatment. — 'I'he utmost care should
be directed to the removal of all sources of irrita-
tion from the uterine and adjoining viscera. 'The
urine ought to be drawn off, if its excretion be in-
terrupted ; and particular attention should be paid
to the state of the bowels, the evacuation of which
must be procured daily, by cooling aperients,
or laxatives conjoined with gentle tonics, when
they require it, or by means of tepid and emol-
lient injections. In the early stages of the dis-
ease especially, and when pain, tenderness, and
other symptoms of inflammation are present, par-
ticularly if the catamenia are deficient or delayed,
local depletions by cupping on the loins or sa- ^
crura, or the application of leeches, or cupping
about the tops of the thigh, are requisite. Ex- — -"
ternal irritation should afterwards be prescribed ;
and, as soon as the symptoms of inflammation are
ren;oved, the patient should be put upon a mild
course of i()d(/(e. The mode of counter irritation
deserves attention. Blisters increase the stran-
gury that is often present at this stage, and excite

the vascular system. I have usually, therefore,
had recourse to the ointment of the potassio-tar-
trate of antimony, or to the insertion of issues or
setons in the insides of the thigh-. When symp-
toms of irritation exist in the uterine and urinary
organs, they must be removed, by the carbonates
of the alkalies, with nitre, taraxacum, and hyoscy-
amus given in the infusion of calumba, or the in-
fusion of cinchona. 'I'he course of iodine should
be assiduously persisted in, and the preparations
adopted should 1)6 given in small doses, much di-
luted. The inilide of poldssiidii, or the ioduret of
irnn,;\.Yii upon the whole the preferable combinations
of this substance. Iodine, in some one of the ))re-
parutions — liniment or ointment — may also be

DROPSY, ENCYSTED, OF

used externally. In this case it should be rubbed
upon the insides of the tl)ighs ; where, if it should
produce irritation of the integuments, the effect
will be the more salutary.

209. Cathartics and {liuretics have no influ-
ence upon the disease, further than to accelerate
its progress, if they be used in such a manner
as to weaken the powers of life. Purgatives of a
tonic kind, however, may be employed to evacuate
faecal matters, and to promote the intestinal se-
cretions ; but such only, as are not calculated to
excite or irritate the large bowels, should be se-
lected ; as the bitartrate of potash with con-
fection of senna, or the infusion of calumba or of
gentian with infusion of senna. As to diuretics, I
have seen no benefit derived from them, with the
exception of those which possess tonic and astrin-
gent properties, as the balsams and terebintiiinates;
the latter of which have been productive of benefit,
particularly when used in the form of liniment or
epithem. Camphor and narcotics are also useful
palliatives, especially, opiates. Tiie liquor potassie,
and Brandish's alkaline solution, in suitable
vehicles, and aided by sarsaparilla, by local de-
pletions when tenderness in the situation -of the
tumour is perceived, and by setons, have also been
of great service in some cases in which I have
prescribed them. The good effects of vomit-
ing in swelled or inflamed testicle have induced
some practitioners to have recourse to emetics in
the early stage of this malady. Dr.PEnciVAL
records a ease in which they proved of service ; but
I have had no experience of the practice. JNIr.
Abernetiiy prevented the reaccumulation of the
fluid after tapping, by repeated blistering. Dr.
Hamilton (On Mercurial Medicines, ^'c. p.202.)
states that he has cured seven cases by percussion,
or patting, for a long time daily, on the tumour,
using a bandage so as to make constant compres-
sion, giving a solution of the muriate of lime, and
employing the warm bath. Many instances will,
however, be found to confirm the opinion of
Dr. W. HuNTEU (Med. Ohserv. and Inquiries,
vol. ii. p. 41.) "that the patient will have the
best chance of living longest under it, who does
the least to get rid of it." In addition to the above
means, but little can be attempted with much
hopes of success. The chief objects are to sup-
port the vital energies throughout the frame, — to
promote a healthy assimilation, and the excretion
of effete matters, — to ward oft' all irritation, phy-
sical and moral, from the uterine organs, — to
adopt a light, cool, and moderately nourishing
diet, — to engage the mind agreeably, — to reside
in a dry, airy, moderately warm, or temperate
locality, — to take regular but genlie exercise in
the open air, — and to have frequent change of
scene and atmosphere.

210. Paracentesis in some instances becomes
imperative, ovWng to the urgency of the symptoms,
particularly after it has been once performed ; and
the extirpation of the tumotir has been recom-
mended by VaNDER HaAR, DELAPORTE,MonAND,

Logger, Siebold; and practised by L'Aumonier,
Smith, Lizars, Blundell, Granville, M'Dow-
AL,and DiEFFENBACH. Of these measures a brief
notice is required. — (n) The observations which
have been already offered on paracentesis apply to
the treatment of ovarian dropsy even more fully
than to any other. It often accelerates a fatal issue
by inducing inflammation of the sac. Of this I
Vol. I.

THE FALLOPIAN TUBE.

657

saw a remarkable instance many years ago in a
near relative. Dr. J. Johnson has adduced an ex-
ample of it (Medico-Chirurgical Review, vol. xi.
p. 258.). Dr. Macintosh refers to one in his
practice (Practiceof Phifsic,vo\. ii. p. 374.) ; and
many others have been recorded, and observed by
experienced practitioners. I therefore agree with
Dr. DENMAN,thatparacentesisought to be deferred
as long as possible. In such circumstances, this
operation occasionally gives temporary relief; but
there is a frequently recurring necessity for its
repetition until the patient sinks. It has been pro-
posed to effect a radical cure by evacuating the
matter, and either laying open the tumour, or keep-
ing a canula inserted in the wound. Le Dran
mentions two eases which recovered from great suf-
fering consequent on this measure ; and analogous
examples have been recorded by Houston, Voi-
soN, and Portal. But these are few compared
with the numerous instances in which it has either
failed, or accelerated afatal issue by the severe in-
flammation and constitutional disturbance thereby
induced. In two cases in which I was consulted,
a canula had been left in the puncture, and ra-
pidly produced these effects ; the introduction of
air and the mechanical irritation having inflamed
the cyst and peritoneum, and converted the se-
cretion to a foul, foetid, and ichorous discharge :
both rapidly proved fatal. It has hkewise been
proposed to inject the cyst. Dr. Denman men-
tions a case in which this was practised, but the
patient died on the sixth day afterwards.

211. The extirpaPion of the tumour, although
entertained by the older surgeons, was discounte-
nanceJ by MoROAGjii, De Haen, Sabatier, and
Murat. L'Aumonier, of Rouen, however, per-
formed this operation successfully tov/ards the
close of the last century ; and it has recently been
practised by Dr. Smith and Dr. Macdowal, of
the United States, with a like result. Notwith-
standing the favourable issue of these cases, I
stated, in the Medical Pepositnrii,at the time of
their publication, reasons against resorting to this
measure. The issue of several cases in which it
has since been performed, both in this and other
countries, confirms the opinion I then expressed.
The operation has no chance of succeeding unless
it be resorted to during that stage, at which a judi-
cious constitutional treatment may either delay, or
even remove the disease : and 1 believe that the
cases in which it has succeeded are such as would
have terminated favourably if they had been left to
nature or to medical management. The results of
the cases in which it was performed by Mr. Lizars
and Dr. Blundell, are well known ; and I may add
that it has likewise been attempted at least five
times at Berlin, by Dieffenbach, Chrysmer,
and ]Martini (Graefe and Waltiier's Journ.
b. xii. h. i.), and, excepting in one instance, it en-
tirely failed. Three of the patients died in con-
sequence of the operatianv. In one case the
surgeon did not proceed in the operation, on find-
ing the tumour adherent on all sides.

212. ii. Dropsy of the FALLoriAN Tube —
Hydrops tubalis — is not to be distinguished from
ovarian dropsy ; nor, indeed, does it differ from it
further than that, instead of the cyst being in the
ovary itself, it is developed in the fold of the liga-
ment, near the uterus, or close to the ovarium, or
to the fimbriated extremities of the tube ; these ex-
tremities being either adherent to the ovarium, or

Uu

G58 DROPSY, ENCYSTED, OF THE WOMB — PERITONEUM — LIVER.

closed by coagulable lymph, or adhesions. In

either case the cyst is solitary. Tlie disease has been
described by Dr. Baillik ; by AIcnnik, who found
the cyst contain as much as 110 pounds of fluid ;
by Cypriani, who found 150 pounds ; by Haii-
DER, wlio found 140 pounds ; and by others, who
have observed much smaller quantities. Dr. Good
defines this variety of dropsy as commencing with
a heavy elongated intumescence of the iliac region
spreadincr transversely, with obscure fluctuation ;
but no distinction can be made between it and
ovarian dropsy, in respect either of its causes or
proTcss. The treatment of tliis variety is also the
same as that of the ovarian disease.

213. iii. Dropsy of the Womb — Hydrome-
tra — Encysted Dropsy of the Uterus — has been
doubted by some authors : but it has been not in-
frequently observed by physicians of the greatest
reputation. The cysts which are, in rare instances,
found attached to the exterior surface of the womb,
do not belong to this disease, which consists of
a collection of fiuid in the cavity of the iinimprcg-
vated uterus, contained in a membrane or cyst.
It has, however, been disputed whether the fluid
is thus surrounded, or whether it has accumulated
in consequence of inflammation having occluded
the OS uteri by the deposition of coagulable lymph,
or of the developement of some tumour or growth,
plugging up this outlet ; the morbid action which
occasions the latter also giving rise to the secre-
tion of a great quantity of serous fluid, which ac-
cumulates in consequence of this obstruction.
It is very probable that this affection may arise
from either of these causes, in different cases ;
and that, in its slighter grades, it is not so infre-
quent as some writers suppose, — the dilatation of
the uterus, and the pressure of its parietes, over-
coming or rupturing the obstruction at the mouth
of the womb, and causing the fluid to escape. A
considerable proportion of the cases vulgarly, but
probably correctly, called false conceptions, is of
this kind; they seldom becoming the object of
medical attention, owing to the little disturbance
produced by them, either during their increase, or
afterwards, as well as to the deception to which
they give rise. Some of these cases may also
consist of hydatids, or other morbid productions,
which may be associated with hydrometra, as in
cases recorded by Baudelocque, Boivin, Duces,
and others. (See Ovaria, and Uterus.)

214. iv. Encysted Dropsy of the Peritoneum
— Extra-peritoneal Dropsy — Hydrops Peritonei of
Tui.pius, and some other authors — consists of
tlie collection of water between the parietes of the
abdomen and the peritoneum, enclosed, in a cyst.
It was first noticed by Morgaoni, and accu-
rately described by Morand. Twenty-six cases
of it have been adduced by Lieutaud, twenty-
four of wliicii occurred in females. It presents
the same constitutional features as have been
noticed in respect of encysted dropsies generally ;
and although, when the accumulation of fluid is
very great, it can hardly be distinguished from
ascites, excepting in its early stages, it may ge-
nerally be suspected from the less uniform en-
largement of the abdomen, the greater anterior
prominence of this cavity, its much slower ])ro-
gresH, and the less constitutional disturbance;
the countenance and surface not presenting the
cachectic apjjearanccs generally accompanying
ascites, and the patient often retaining mOch

vigour and activity of all the natural and animal
functions. Still the prognosis in this disease is
unfavourable. The sac generally continues to
enlarge, and sometimes forms adhesions with the
contiguous viscera , and if not evacuated, it event-
ually bursts into the cavity of the peritoneum, as
in the cases recorded by Chomel (J\/(?/». de I' Acad.
Roy. des. Scien. an. 1728.), Morgaoni (De
Cans, et Sed. ep. xxxviii. art. 51.), and Taver-
MER (Le Dran's Obs. G5.) ; or externally, as in
those of Degner (Acta Cur. S^e. vol. v. obs. 2.)
and La Motte. M. Chantourelle met with a
case wherein the sac opened into the intestines
after a puncture had been made for the discharge
of the fluid, and faecal matters passed out at the
external opening.

215. The treatment of this form of disease has
not been satisfactorily illustrated. It seems not
materially benefited by purgatives or diuretics ;
but it is stated, in some instances, to have been
permanently removed by paracentesis. And cases
have been adduced by Nuck, Degner, Le Dran,
La JMotte, and others, in proof of the propriety
of the practice. But in cases of recovery from a
disease, of this description, there must still exist
doubts of its nature. If puncture be resorted to
when the tumour has reached a very large size,
the opening should be valvular, and graduated
pressure subsequently employed. The terrible
eflPects occasioned by keeping open the orifice in
order to drain the cavity, were fully demonstrated
in I\I. Ciiantourelle's case, the cyst having
become inflamed and gangrenous, with the adjoin-
ing parts ; as well as in two interesting cases
recently recorded by Mr. C. Hawkins.

216. v. Encysted Dropsy* of the Liver is
liable to be confounded with abscess of this organ
or with large accumulations of bile in the gall-
bladder, from obstruction of its duct, or of the
common duct. The cysts which are sometimes
found in the substance of the organ, whether of
a simple kind, or containing hydatids, are different
from those encysted collections of fluid, which
either form between the peritoneum and its proper
covering, or are apparently attached merely to
tills viscus. These last evidently consist of hy-
gromatous cysts developed on the adhering sur-
face of the serous membrane, and reaching an
uncommon size.' When large cysts containing
hydatids are formed near the surface of the liver,
although essentially different from the simple
cysts, and seldom reaching the same magnitude,
they generally occasion similar symptoms, both
local and constitutional, to tliose which attend
the latter. In some instances, tiiese cysts be-
come inflamed ; thereby occasioning great tender-
ness of llie external surface, and changing the
contained fluid to a sero-puriform matter, as well
as increasing its quantity.

217. Encysted dropsy of the liver is generally
accompanied with more disturbance of the ge-
neral health than the other forms of encysted
dropsy of the abdomen, and its progress is usu-
ally more rapid. Although a dangerous disease,
recovery sometimes takes place from it. Cases
terminating favourably have been recorded by
several writers referred to in the liibliography.
This is most likely to occur if the cyst is attached
to the anterior part of the surface of the organ.
In this case, a large fluctuating tumour is com-
monly formed below the right false ribs, or near

the epigastric region, extending more or less
downwards and in oilier directions, according to
its size and situation. Inflammation may take
place in the more prominent portion, and the cyst
may discharge its contents through an external
opening, either made artificially or occurring

DROPSY, ENCYSTED, OF THE KIDNEY. 659

the serious consequences always arising from aa
interruption to the urinary secretion. In an in-
teresting case which occurred to Dr. Seyjiouii,
and is described by Wr. C. Hawkins, a single
cyst was found in the substance of the kidney, un-
connected with its pelvis, and containing five pints

spontaneously. This latter termination, however, of fluid, not possessing any urinous characters,
is rare; but it may be followed by recovery ; two
instances of which are adduced byM. Itaud.
More frequently the cyst opens into the abdomi-
nal cavity, or into some part of the alimentary
canal, or even into the tliorax ; and in either
case a fatal result generally ensues. In some in-
stances, the rupture of the cyst has been occa-
sioned by external violence. The difliculty of
distinguishing this state of disease from abscess of
the liver pointing externally, or from distension of
the gall-bladder, is always great, or nearly impos-
sible. In both these latter cases, however, there
are generally more or less jaundice, more consti-
tutional disturbance or greater pain in the region
of the liver, more disorder of the bowels, and more
interruption to the biliary secretion, than in the
encysted collection ; the purulent formation being
preceded by the usual signs of chronic hepatitis,
and distinguished in the manner pointed out
in another place. (See Liver — Diseases of.)
Interesting cases of this form of encysted dropsy
have been published by JMr. Brodie, Dr. Thom-
son, Dr. Thomas, Dr. Abercrombie, Dr. Hast-
ings, and Blr. C.isar Hawkins. In three of
these cases, the early puncture of the tumour,
before inflammation supervened, seemed to have
been successful. But in nearly all the instances
on record, where this operation was performed in
a far advanced stale ot the disease, or when in-
flammation of the cyst was present, a fatal termin-
ation has occurred.

218. vi. Encysted Dropsy of the Kidney is
sometimes observed as a consequence of obstruc-
tion of the ureter, the pelvis of the organ becoming
distended, and the glandular substance either
atrophied or absorbed as the accumulation of
fluid and distension are increased. This is evi-
dently the manner in which the largest collec-
tions of fluid are formed in the kidneys, and inter-
esting cases of it are recorded by Bonetus (^Sepul-
chretum,\. iii. sect. xvii. obs. 22.), and by Dr.
Howison and Dr. J. Johnson (^Medico-Chirvrg.
Beciew, vol. iii. p. 657.). In this state of disease
there have been observed great irregularity in the
appearances, and in the excretion of the urine.
The abdomen has been very much enlarged,
chiefly towards the side of the diseased kidney,
with obscure fluctuation and severe pain in the
spine and lumbar region. Simple cysts may also
be developed in the substance of the kidney, and
contain a limpid or yellowish fluid. They are
generally of small size, but occasionally they are
found very large. Portal describes one which
contained a pint of clear fluid ; and JM. Itard
another, in which there were found two cysts,
the larger of which was a foot in diameter. This
communicated with the pelvis of the viscus, the
structure of vv-hich was absorbed, and contained a
fluid of a urinous odour and colour; and most
probably originated, as in Drs. .Toiinson's and
Howison's cases, in obstruction of the ureter.
This species of encysted dropsy generally termi-
nates unfavourably in a shorter time, than, per-
haps, any other, probably owing principally to

219. vii. E)icyiled dropsies oj the omentum, of
the mesentery, and of the spleen, are of rare occur-
rence, and can seldom be distinguished from some
other diseases during the life of the patient. When
fluid is found in the omentum, it is generally
effused, or infiltrated between its laminae. But
simple cysts containing a watery or serous fluid, of
various sizes, are, in rare instances, found in these
situations.

220. viii. Encysted Dropsy is very rarely seen
in the thoracic cavity . Hai.ler observed it be-
tween the pleura and intercostal muscles, this
membrane having become so distended by the
fluid as to occupy nearly all that cavity of the
chest; the pericardium being also filled with
water. Stokrck relates a case in which a female
with consumptive symptoms experienced great
difliculty in lying on the left side. On dissection,
a large simple pellucid cyst, formed in the sub-
stance of the right lung, and containing eight
pounds of a yellowish serum, was detected. Ma-
loet found, in a person with all the symptoms of
hydrothorax, and who was obliged always to sit
up, a similar cyst, but not so large, in each lung ;
and the same productions have been observed by
M. Dupuytren, in this situation and in the peri-
cardium.

BiBLioG. AND Refer. — i. Encysted Dropsy gene-
rally Merc/inus, i)e Hydrope Saccato. Altd. 1695.

— Jiuverney, Mem. de I'Acad. de Scien. de Paris, 1703,

p. 178 Morgagui, Epist.lxv. art. 16. — Slevogt, De In-

felici Hydr. Saccati Curatione. Jense, \72l. — Schetfler,
Hist. Hydr. Saccati. Altd. 1724. — Afead, Monita et
Pra?cep.'Med. cap. 8.— Bresl. Samml. 1728, p. 873. (Case
containing 163 lbs. oJ fluid.) — Meckel, in Hist.de I'Acad.

de Berlin, 1758, p. 58 Le Dran, in Mem. de I'Acad. de

Cliirurg. t. ii. p. 431. — De Haen, Rat. Med. t. Iv. p. 71.,
t. V. p. 55., t. xi. p. 272. — Stoerck, Ann. t. i. p. 149. —
Eisenlohr, De Hvdr. Cystico. Arg. 1784 — -Hautesierck,
Recueil, t. ii. p. 3G0. — I'allisncri, Opera, vol. iii. p. 270. —
Wins/lip, in Mem. of Med. Soc. of Lond. vol. ii. No. 32.
— Lowdcll, in Ibid. vol. iii. p. 594. — Hebenslieil,Ve Hydr.

Saccato. Lips. 1792 Langcnbcck, in Goet. Auz. 1812,

p. 19.

ii. Encysted Dropsy of the Ovaria, Uterus, &c. —
Blancard, Anat. Pract. cent. ii. obs. 98. — Bonet, Sepul-
chret. 1. iii. sect. xxi. obs.47. 70.77. ; N. Act. Nat. Curios,
vol. v. obs. 69. (Extirpation proposed.) — De Graaf, De
IMul. Organis, p. 1 60.— S/oanc, in Phil. Trans. No. 252.—
S/iort, in Ibid. No. 381. 446. — Morgagjii, De Sed. et
Cans. Morb. ep. xxxviii. art. 69,70., xlvii.art. 12 — IVerl-
AoA Opera, iii. p. 771. — Paisley, Edin. Med. Essays,

vol. V. part ii. p. 766 Morand,m Mem. de I'Acad. de Chi-

rurg. vol. ii. p. 455. — Harder, Apiar. obs. 87, 88. — Mai-
ler, Disp. Med. vol. iv. p. 401. 447. 541 — Lieutaud, Hist.
.\nat. t. i. p. 357. — B««rfftoc5;/<?,L'Art.des Accouch.1694.

— De Haen, Rat. Med. pars v. c. 2., vi. 38., vii. 117., xi.

281 Monro, Edin. Essays, vol. vi. p. 409 — Meckel, in

Mem. de I'Acad. de Berlin, 1758, p. 63. — /F. Hunter,
Med. Observ. and Inquir. vol. ii. p. 41. — Murray, De
Hydr. Ovarii. Ups. 1780. — Sandijbrt, Mus. Anat. vol. ii.

tab. 109 Walter,m Nouv. Mt'm. de I'Acad. a Berlin,

1786, p. 106. ; and Anat. Mus. vol.i.p-2G9.— Fwrf, in Med.

Communications, &c. vol. ii. No. 14 Martineav, Pliilos.

Trans. 1784, p. 471.— iVo//, Rat. Med.vol.vii.p.S5.— Ca>«-
pcr, in Mem. de la Soc.de Med. 1788, p.46. — French, Mem.
of Med. Soc. of Lond. vol. i. p. 234. — Wa/ker, in Ibid.

voi. V. No. 41. — Fultcney, in Ibid. vol. ii. p. 265 Fer-

cival, in Trans, of Phil. Soc. of Philadelphia, vol. i. p.i. ;

and I'ssays, vol. ii. p. 1G6 Denman, Med. and Phys.

Journ. vol. ii. p. 20 — Bosch, in Ibid. toI. viii. p. 444

Portal, Cours. d'Anat. Med. t. v. p. .551. — Thumann,Aa-

nalcs histit. Med. Clin. Wirceb. vol. i. p. 1.39 Miil/er,

in Sicbuld's Samml. Chirurg. Beobacht. b. iii. p. 440. —

Baillie, Series of Engravings, &c. fasc. ix. pi. 6. Petit,

in BuUel. de la Faculte de Med. 1812, p. 3 Edwards,

in Edin. Med. and Surg, Journ. vol.xiv. p. 351 Voisin,

U u 2

660

DROPSY IN THE HEAD-

Pathology or.

Recueil Period, t. xvii. p. 372 Stark, Archiv. fur Ge-

burtshiilfe, b. i. st. \.—Osiunder, Neue Denkwiirdigkei.

ten, b. i. st. 2. p. 198 J. P. Frank, De Cur. Horn. Morb.

1. vi. pars i. p. 31 1 . 317. and 476. — Lcofflcr, in TJtif eland's.
Journ. der Pr. Heilk. b. xxiv. st. 4. p. 42. — Rostan, in
Nouv. Journ. de Med. t. iii. p. 215. (The diagnosis of.)—
Chevalier, in Med.-Chirurg. Trans, vol. iii. p. iO.—Mcr-
riman, in Ibid. p. il— Thomson, in Ibid. vol. xui. p. 170.
(Hydrometra.) — Thomas, in Ibid. vol. xiii. p. 330.—
Strambio, Nouv. Biblioth. M£d. t. iii. 1826, p. 287. —
Cruveithicr, Anat. Pathol, livr. v. pi. in.— De/pec/i, Chi-
rurg, Clinique t. ii. p. 192. — Andral, Anat. Path. t. li.

Lizars, Observ. on Extraction of diseased Ovaria, fol.

Edin. W25.—Julia-Fontanclh', Archives Gener. de Med.
t. iv. p. 257. {Analtjsis of the fluid.)— Smith, in Med. and
Phys. Journ. Oct. and Nov. 1822.— J5«)-«s, Principles of
Midwifery, Gth ed. p. \32.— Nauche, Des Malad. propres
aux Femmes, 8vo. Paris, 1829, p. 104. — Ha?)iilton, On
Mercurial Medicines, p. 202.— Seymour, On Diseases of
the Ovaria, fol. Lond. 1830, p. 43. et seq.—Boiuin, Rech.
sur r.-^vortement, p. 103. 131.— Dawce, in Archives Gen.
de Med. vol. xxi. p. 214. — Diejffenbaeh, in Ibid. t. xx.

p. 92. ; et Journ. Hebdom. de Mfid. 1829, t. ii. p. 246

Mme. Boivin et A. Duges, Traite Prat, des Malad. de
I'Uterus et de ses Annexes, &c. 8vo. Paris, 1833, t. ii.
p. 520. — EUioison, in Medical Gazette, vol. viii. p. 291.,

and vol. xii. p. 4.54 C. Hawkins, in Ibid. vol. xii. p. 458.

iii. Of the Peritoneum and Abdominal Paiuetes.

— I'ander Wiel, Observ. cent. ii. obs. 28. — Anhornius,
Ephem. Nat. Cur. cent. ix. obs. 100. n. I.—Tulpius, 1. iv.

c. 44 Rhodius, cent. iii. obs. G. — Garengeot, i. p. 435 —

Morgagni, De Sed. &c. epist. xxxviii. art. 47. 49. 53. 58.

— Chotnel, Mem.de I'Acad. des Scien. de Paris. 1728,
p. \6.— Liltre, in Ibid. 1707, p. 667.— Watson, in Philos.
Trans. No. 2()i. —Buchner, Miscell. 1728, p. 871 — Mon-
ton,m Mem. de I'Acad. de Chirurg. t. ii. p. HB.—Blasius,
Obser. Med. Rarior. pars i. No. 18. — Vogel, De Hydr.
Peritonei Saccato, &c. Goet. 1761. — Lieutaud, Hist.
Anat. Med. 1. i. obs. 1124. — Sandifort. Exercitat. Acad.

I. ii. c. 10. —De Haen, Rat. Med. pars xi. c. 4 Allen,

Synop. Med. Pract. p. 294. — Van Swieteu. ad \ 1226. —
Porcherie, Journ. de Med. t. x. p. 422. — Portal, Anat.

Med. t. v. p. 128. Jacquin, Med. Observ. and Inquir.

vol. i. p. 7 Horn, De Hydr. Peritona;i Sac. Giess. 1790.

— Mailer, in Posetvitx.'s Journ. fiir die Medicin, &c. hef. i.
n. 2.—HufeUind, Journ. d. Pract. Arzeneyk. b. viii. p.l 16.
—Sclig, in Ibid. b. iii. p. 21l.—B/odie, Lond. Med. Gaz.
vol. i. p. 334. — Thomso7i, in Ibid. vol. i. p. 468. — Aber-
crombie. On Dis. of the Stomach, &c. p. 356 — Hastings,
Midland Med. Reporter, Aug. 1829.— Chantortrelle, De
I'Hydr. Enkystee de Parois Abdom. &c. ; in Archives
G^ner. de Med. t. xxvii. p. 218. — Dance, in Diet, de
Med. 2d ed. t. i. p. 113. — C. Hawkiyis, On Aqueous En-
cysted Tumours, &c. in Trans, of Med. Chirurg. Soc.
vol. xviii. p. 98. (An able and instructive paper.)

iv. Of the Liver. — Donatus a Mutiis, In Galeni In-
terpretationes, &c. 1547 — AHj^, Observat. fasc. iii. p. 12.
—Caille, in Hist, de la Soc. Roy. de Med. ad 1778, p. 212.

— Carron, in Sedillot's Journ. &c. t. xxxiv. p. 159

.Ho?we, Clinical Observ. and Expei. p. 380. — /foMx, in
Journ. de Med. t. xlii. p. 214. 314. — Frank, De Curand.
Horn. Morb. I. ii. p. 21S.— Lassus, in Journ. de Med.
Contin. vol. i. p. 115.

v. Of the Kidneys. — Houston, in Philos. Trans.
No. 381. — Glass, in Ibid. No. 482. — Heuermann, Be-
merkungen, i. 244.— Boehmer, Observ. Anat. Rar. fasc.ii.

— Haller, in Goijt. Gel. Anzeig. 1777, p. 1196. —Saudi-
fort, Observ. Anat. Path. 1. iv. c. 6. p. 56. — Walter,in
Nouv. Mem. de I'Acad. a Berlin, 1790 et 1791, p. 107.
159. ; and Krankheiten der Nieren, p. 8. — Martincau,
in Edin. Med. Comment, vol. ix. p 282. — C. Hawkins,
in Trans, of Med. and Chirurg. Soc. vol. xviii. p. 175.
X. Dnopsy in the Head. — Syvi. Dropsy in the

Head and Ih-ain ; Hiidrocephalus ; Hydrocepha-
lum ; Iliidrorephale (vioop, water, and netpaXri, the
head) ; 'TJpt)KE<f>a.Xov, 'TJpoKS^jttXof ; Hydrops Ca-
7>;t/s, Auct. var. j Hydropme du Cerveau, Hy-
drociphule, Fr. ; Der V/asserhopf, Kopjwasser-
sucht, Ilirnwassersurht, Germ.; Jdrocephtilo,
Ital. ; Water in the Head.

221. Defjn. — Sopor, with paralysis, ancrslhesia,
or convulsions, and often xvith slowly increusins; size
of the head, from a collection nf watery Jluid ivithin
the cranium.

222. Jt is not my intention to notice the very
rare and unimportant disease, called external
hydrocephalvs. JMy limits will be more profitably
occupied with the consideration of tiie very
conninon, dangerous, and somewliat imperfectly
vndevptood iiiiiliiily — internal hydrocepiialus.

Dropsy within the head, internal dropsy of the
head, or water in the head, as it is usually de-
signated, may be divided into — (a) dropsy of the
mend>ranes, and (6) dropsy of the ventricles. Either
may occur singly, but both may exist in the same
case, in various degrees. The former variety is
much rarer than the otlier, and takes place
usually to a much less extent. In it the water is
contained in the geneial cavity of the arachnoid,
and is in some instances a congenital disease, pro-
ducing watery tumours, protruding through aper-
tures in the cranium (j 176.). The fluid is rarely
effused in any considerable quantity between the
arachnoid and pia mater, and still more rarely
between the latter and the brain. In dropsy of
the ventricles, which is the most common, and
which Meckel designates the internal dropsy of ■
the head, the water is collected in the bags of the
arachnoid and vascular membranes, lining the in-
ternal cavities of the brain, and is contained in all
or the greater number of these cavities in the same
case.

223. Dropsy within the head is idiopathic or
primary, and stjmptomatic or secondary, — more
frequently the latter. It is also either acute or
chronic, or of intermediate grades. It occasionally
commences in an acute or sub-acute form, and
insensibly and gradually passes into the chronic
state. It is often congenital, — in which case it
is usually chronic or quickly becomes so ; and
it occurs at all periods after birth, particularly
during the earliest epochs, — when it is gene-
rally acute or sub-acute. These circumstances
are important in respect of its nature and treat-
ment.

224. Hydrocephalus cannot be said to have
been known to the ancients ; this term having
been applied by them chiefly to collections of fluid
exterior to the cranium. Hippocrates, however,
in speaking of the maladies which arise from the
head, notices one which hasa marked resemblance
to the symptoms of the acute or sub-acute form
of this disease ; and at the same time assigns water
on the brain — iJJajp Itti tm Iyx6<f>dx«, — as its
cause (De Mortis, lib. ii. cap. 15. edit. Vander
Linden, t. ii. p. 41 .). From IIiPPOcnATES to
RiiAZEs, no mention is made of internal hydro-
cephalus. But this latter writer states, in his
book on the diseases of children, that the head
sometimes acquires an increased bulk, owing to
tiie collection of fluid within the cranium. The
chronic form of this malady was described nearly
a century before any notice was directed to its
acute states ; but, during the last fifty years, these
states have attracted attention great in proportion
to their prevalence and fatality in the early stages
of life.

i. Acute Dropsy in the Head. — Syn. HydrO'
cephalus Acutus ; H.Acutus iuternus ; Hydren-
cephdlus (from v^aip, water, and l-yiii>poi\oi, the
brain); Febris Hydrocephalia ; Curtis Hydro-
cephalus; Apoplexia Hydrocephalica, Cullen ;
IJi/drencephalon, Ilufeland ; Hydrops Cerebri
Acutus ; Iliidroccphale aigu, Fifvre Ccr^brale
des Knfins, Auct. Gall. ; Hydrocephalite,
IJrachet.

225. Defin. — Fever, with sopnr headach, and
morbid sensibility to light, &;c. ; inability to bear
the erect posture ; vomiting ; costiveuess ; sereaw-
ing ; dilated pupils ; squinting; convulsions and
paralysis.

DROPSY, ACUTE, IN THE HEAD— History of.

661

226. Lit. Hist. — Acute hydrencephalus, not-
withstanding the remark of Hippocrates already
referred to, was formerly confounded with cere-
bral fever, or fever with determination to the
brain. A case, in which it is accurately de-
scribed, but considered as one of fever merely,
was published by Dr. St. Ci-aik, in 1733, in the
Edin. Med. Essai/s and Observations, vol. ii.
p. 287. Mr. J. Paisley of Glasgow, in the fol-
lowing year (in Ibid. vol. iii. p. 333.), recorded a
case, with the post ??)0i7f?n examination, and first
recognised it as a specific form of disease. It
was not, however, until the appearance, in 1768,
of Dr. \Vh\tt's " Observations on the Dropsy oj'
the Brain," that the history of the malady and its
nature were made subjects of investigation. The
observations of Dr. Fothergii.l {Med. Observ.
and Inquir. vol. iv.) contributed something to the
knowledge of its symptoms ; but those of Dr.
Watson, in the same work, furnished evidence
merely of its extreme danger. Dr Dobson's
case, published in 1775 (Ift/d. vol. vi.), was va-
luable, inasmuch as it showed the possibility —
at the time, very generally doubted — of curing
the disease ; and of the influence of mercury in
bringing about this result. Harris, however,
had long before stated, as Dr. Chevne has re-
marked, that a physician of experience had saved
children in fevers attended by unusual stupor,
and even coma, by giving them mercurius dulcis
six times sublimed.

227. The opinion of VVhytt, that the disease
depends upon laxity of the exhalants, or upon a
watery stale of the blood, had been generally
received, until Dr. Quin, in 1779, maintained that
it is allied to inflammation, — a doctrine which
had suggested itself both to Dr. Withering and
Dr. Rush, before Dr. Quin's views had become
known. Dr. Withering stated explicitly, that
the malady originates in inflammation, and that
the water found in the ventricles of the brain is
not its cause, but its consequence. Dr. Rrsn
made an important addition to its history, by
showing that it may be produced by other dis-
eases, especially by fevers, rheumatism, pulmo-
nary consumption, the exanthemata, and worms ;
and that death may supervene, preceded by hy-
drocephalic symptoms, and little or no water be
found in the ventricles, — circumstances which
will be fully enquired into in the sequel. Dr.
Percival demonstrated its frequent connection
with scrofula, and seemed impressed with the
idea that it is not altogether identical with in-
flammation in its nature. Its inflammatory origin
was afterwards supported by Dr. Patteijsion and
Dr. Garnett, although neither appeared to con-
sider it advisable to carry the depletory and anti-
phlogistic treatment so far as such a doctrine
might have warranted. This last writer believed
that in hydrocephalus, a local inflammation with-
out much general sthenic diathesis obtains ; and
that a depletory treatment, injudiciously em-
ployed, may weaken the general tone of the
system, and increase the efTusion, without materi-
ally diminishing the local morbid action, for the
removal of which such means are employed. Of
the justice of this view there can be no doubt.
The local action, which has been called inflam-
matory, merely because it is attended by injec-
tion of blood-vessels, has been too generally
treated as true inflammation occurring in a

healthy constitution, and without reference eithe''
to the series of vessels affected, or to the grade
or the product of action ; and, what is equally
important, without regard also to the diathesis,
or state of vital manifestation and power. It is
unnecessary to notice here the opinions of more
recent writers, as the chief of them are referred
to in their proper places.

228. Descriptive History. — The Precursory
or Earhj Si/mptonis of acute hydrocephalus are
remarkably diversified, owing to the circumstance
of their dependence upon disorder of the digestive
organs, or of the circulation in the brain and
membranes ; and it is chiefly owing to the pre-
dominance of the symptoms referrible to one or
other of these parts that the disease has been
divided by some writers into the primary or idio-
pathic, and the secondary or symptomatic. The
possibility, however, of making the distinction in
practice, is not so easy as some writers would
make it appear. For the dependence of the
functions of the liver, and digestive organs, upon
the state of circulation in the enceplialon, and
of the latter on the former, is so very intimate,
that it is often impossible to ascertain which is
primarily affected. The majority of writers on
the disease in this country, consider that the diges-
tive organs are the first to betray disorder ; whilst
the French pathologists and Dr. Abercrombie
believe that the morbid action very frequently
commences either primarily or simultaneously in
the brain itself. I am convinced, that the true
acute hydrocephalus originates more frequently
in the encephalon, than the abdominal functions
indicate, and at a period anterior to the disorder
which these functions manifest, — such dis-
order often proceeding from the silent morbid
action in the brain, reacting on it, and promoting
the evolution of those changes constitutmg the
disease ; and that, when hydrocephalic symptoms
supervene more suddenly and violently, and with-
out much previous disorder of the chylopoietic
viscera, or nervous system, they have a more
intimate relation to acute or sub-acute inflam-
mation of the brain and its membranes, than to
those states of morbid action which terminate in
copious efTusion, and to which the term hydro-
cephalus is more strictly applicable. The chief
exceptions to these inferences will be found in
those who inherit a peculiar morbid diathesis or
predisposition to the malady — who are scrofu-
lous or weakly constituted, — and in these the
brain and its membranes will often coetaneously
suffer, in a greater or less degree, with one or
more of the digestive organs; the excited action
it experiences being either attended, or soon fol-
lowed, by deficient power, and by relaxation of
the exhaling surfaces. In these cases, as well
as in those m which it is ushered in, or predis-
posed to, by derangements of the abdominal vis-
cera, it does not, as in true cephalitis, readily
occur in a previously healthy constitution, but
chiefly in states of pre-existing ailment, or as a
cdnsequence of inflammatory action arising under
such circumstances, — in which not only the
chylopoietic viscera imperfectly perform their
functions, but also the organic nervous system
is weak, and the capillary vessels and exhalants
are so deficient in tone as to be readily relaxed
or exhausted when over-excited. In other words,
that acute hydrocephalus is a consequence of
Uu 3

CS2

DROPSY, ACUTE, IN THE HEAD — Foums, etc. of.

disease, which originates variously ; — in some it
is the result or termination of inflammatory action,
occurring ia a weak or morbid state of consti-
tution,— in others of general febrile excitement,
affecting patients similarly constituted, or occa-
sioned by accumulated morbid secretions and
excretions, or by local irritation ; — that it stands
in the same relation to inflammation as other acute
dropsies ; and, even when most inflammatory,
that it differs from encephalitis much in the same
way as phlegmon differs from erysipelas, or as
acute peritonitis differs from the true puerperal
fever. From what I have now stated, it will
appear important to be acquainted with the
symptoms indicating the pathological states ter-
minating in acute hydrocephalus. These may
be referred to two principal seats, viz. the head
and the abdomen, but with the understanding that,
in many instances, although the more distressing
ailments seem to proceed from the one, the pri-
mary and principal disease may exist in the other.

229. Foums and Stages of the Disease. —
('a) The Forms have been chiefly referred to the
mode of attack and symptoms of the first stage.
Dr. Cheyne has particularised three varieties ; the
gradual, the sudden and violent, and the second-
ary. These answer to the nervous, the inflam-
matory, and the consecutive, respectively, of
HopFENGAUTNER and KunN. GuEiiSEXT dividcs
the disease into the ataxic or febrile, and the
apoplectic; Itard, and several writers, into the
idiopathic and symptomatic. M. Braciiet desig-
nates three forms; the nervous hydrocephalitis,
the inflammatory, and the gastric ; but it is very
diflicult to distinguish the nervous from the gastric
form. GoELis distinguishes merely the acute, and
the hyper-acute or waterstroke. The division re-
commended by Cheyne and HoPFENGARTNER is,
upon the whole, the best ; it matters but little
how the forms are named. The terms, however,
used by the German writers seem to be the least
objectionable. — (ft) Since the appearance of Dr.
Whytt's description, the disease has usually been
divided into periods or stages. But much difference
has existed as to the number of stages, and as to
•what symptoms indicate them. Goelis points
out four periods, viz. of turgescence, of inflam-
mation, of effusion, and of palsy. WlIYTT, QuiN,
TissoT, Baader, Sprengel, Cheyne, and others,
mention three, according to the three different
states of the circulating and nervous systems
that obtain in the course of the malady. Some
vi^riters notice, with P. Frank, Rush, and Con-
BADi, only two stages; whilst Formey, Von
PoRTENscHLAG, and GuERSENT descHbe none.
This diversity depends chiefly on the irregular
progress of the disease, its uncertain commence-
ment, and the circumstances referrible to the
constitution and previous health of the patient
under which it occurs. I shall adopt the divi-
sion, employed by Dr. Cheyne and .others, into
— 1st, that of increased sensibility; 2d, that of
diminished sensibility ; and, 3d, that with palsy
or convulsions.

230. A. The Nervous form is generally pre-
ceded by, or rather coniiiiences with, a great va-
riety of symptoms, which continue a longer or
shorter time before the disease is so fully deve-
loped as to be recognised, or as to excite the
attention or alarm of the friends. For several
days or weeks, or even for months, the cliild is

vertiginous, liable to fall or stumble while at
play or running about, is nervous, and starts or is
fearful from slight causes, and more or less ca-
pricious in its appetite, or without appetite. The
tongue is slightly furred, and white ; the bowels
are costive ; the motions offensive, unnatural,
clay-like, and indicating a morbid or deficient
biliary secretion ; the breath is foetid ; the urine
is somewhat diminished in quantity ; the com-
plexion fades ; the features collapse ; the sleep
is disturbed and dreamy ; the eyes become
heavy, very sensible to light, have a dark line
under them, and lose their animation ; the hypo-
chondria and abdomen are often tender or tumid ;
and the child complains of occasional pains,
which resemble rheumatism, in these regions, par-
ticularly in the region of the liver, and some-
times in the limbs. Various other symptoms are
conjoined to, or supervene upon the foregoing,
which continue frequently for a considerable time,
without additional ailment, or confining the pa-
tient. But sooner or later they become aggra-
vated ; the surface assuming a harsh, sallow, or
unhealthy aspect. The movements are now lan-
guid; the sleep more and more disturbed and un-
refresliing, and the disposition to it often greater.
Giddiness, slight pain or noise in the head, tender-
ness of the scalp, and pains in the neck and limbs,
are complained of. The countenance is heavy ;
the sense of sight and hearing often very acute ; the
intellect precocious ; and the pulse is quicker,
and more excitable than natural. The child is
drowsy, silent, or appears as if in a reverie, and
indifferent to those persons and objects he was
formerly interested in. He is also irritable, or
dejected, sighs often, and yet frequently makes
no complaint when questioned. Purgative me-
dicines usually procure scanty, clay-like, pale, or
greenish and slimy evacuations. These symp-
toms are very frequently removed by active purg-
atives; and although they often run into those
indicating unequivocal disease within the head,
yet they indicate nothing beyond a general and
grave disturbance of the functions. But when
they persist after proper treatment, or are neg-
lected, the Jirst stage may be considered as being
actually present, although it should be rather
viewed as commencing with the first signs of
ailment; more pathognomonic symptoms super-
vening on the foregoing indefinite ailments.
The above series of symptoms nearly agrees
with the first period, or that of turgescence, of

GOEEIS.

231. (a) The pain in the head returns more
frequently and acutely ; and is often attended by
severe ear-ach, by aching of tlie eyes, and more
commonly by increased sensibility to light and
noise, and alternate chills and flushes. 'The
pulse is now quick, excitable, and of irregular
strength and frequency. The gait is unsteady ;
the skin warm, dry, and unhealthy ; the pains
through the trunk and limbs more frequent and
severe, and accompanied with sickness and vo-
miting, particularly on getting up in the morn-
ing. The tongue is loaded or furred. There is
occasionally dragging of one leg, or a raising of
the foot as if stepj)ing over something in the way,
or a painful crick in the neck. The stools, from
being scanty, costive, and clay-like, pass to dark
green, and a gelatinous or spinach-like state, ex-
hale a sickly and peculiar smell, and are still

DROPSY, ACUTE, IN THE HEAD — Forms and Stages of.

663

procured with difficulty, this change depending
chiefly upon the morbid condition of the secretions
poured into the digestive canal : the urine is
scanty and turbid, and lias often a milky appear-
ance (OniER, CoiNiJET, and Vieusskux). The
erect posture or motion, paiticularly rotating the
head, brings on sickness and retchings, without
the appearance of offensive matters. There are
also great fretful ness and restlessness ; contracted
pupils; frowning, or knitting of the brows; in-
ability to sit up ; a whining or moaning noise when
lying down ; and sometimes a slight cough, with
irregular suspirious breathing. The sleep is short
and restless ; the infant rolls its head on the pil-
low, or often wakens with a scream or crying, and
raises its hands to its head. The nostrils and lips
are dry and cracked. This period is very variable
in duration, but it usually continues from ten to
fifteen days.

232. (/)) Second stage. — The pulse, from
being very quick, excitable, irregular, and weak,
now becomes slower — sometimes as slow as
natural, or even more so ; but chiefly when the
patient is in the horizontal position ; for if he
attempt to sit up, it generally acquires its former
frequency. The sensibility is now remarkably
impaired : sopor or stupor gradually supervenes,
witli dilated pupils, squinting, and imperfect or
double vision. The eyes are dull, heavy, vacant
or staring; the eyelids drooping or half closed.
Sickness or retchings are now less frequent, unless
the child be raised up, when one or both often
occur. The excretions are passed unconsciously,
and are scanty, and procured with difliculty. The
stupor is interrupted by exclamations, or shrill
piercing screams; the hands, which are tremulous,
being raised to the head or neck, or occupied in
picking the lips or nostrils. Emaciation pro-
ceeds rapidly ; but food is generally swallowed
greedily when presented. These symptoms are,
however, by no means uniform ; for the pupil is
frequently, particularly at first, oscillatory, or,
although dilated, affected b}' light. The stupor,
also, is not always constant ; nor does the pulse
always become slow. Deep inspirations, hectic
flushings of the cheeks, catchings of the muscles,
cold extremities, low delirium, and an almost total
suppression of urine, are occasionally observed.
The duration of this period varies from four or
five days to two weeks.

233, (c) The third ituge has been generally re-
cognised by the returning frequency of pulse,
which is often remarkably rapid, thready, and
weak ; by the occurrence of general or partial
convulsions ; by paralysis of one side or limb ; by
twitching of one or more of the muscles ; and by
suffusion of the eyes, the eyelids being motion-
less, and the cornea becoming dim and filmy.
Often, when one side is paralysed, the other is
more or less convulsed. The patient is now
either insensible or delirious. He rolls his head
on the pillow, grinds his teeth, moves the unpal-
sied hand in the air, and moans or breathes heavily
and hurriedly. Alternate flushings and pallor,
or flushes of one cheek, the other being pale;
irregular distribution of the circulation ; partial
sweats; cold extremities; irregular, or stertorous
breathing ; an eruption of vesicles about the
mouth, or on the face and upper part of the chest
(FoRMEv, GoELis, ScHsiAi.z, Rai.-\iann, and
myself); collapse of the countenance; blucness

or paleness of the lips ; and more rarely, spha-
celating sores ; are remarked towards the close of
the disease. 'Jlie dilatation of the pupil and
strabismus generally continue throughout this
stage, which may terminate fatally (generally in a
violent convulsion) in a few hours, or it may last
for ten or twelve days or even longer. Such is
the common course of the most frequent form of
the disease, which comprises the Nervous and
Gastric of Bkachet; and which may either
originate in the encephalon, or in the digestive
oryans. But it is seldom that the early history
of the case is so precise as to enable the physician
to draw a correct inference as to its commence-
ment. In some instances, I have observed slight
symptoms of cerebral disease, for some weeks, or
even months, after repeated attacks of congestion
or of inflammatory action within the head, of a
well maikcd character, but supposed to have
been removed by treatment. In some of these
cases, the disorder of the digestive organs was so
evident as to give rise to the idea of the primary
affection of these viscera, indicating the difficulty
of ascertaining the parts first deranged, 'i'he in-
formation furnished, in most instances, seldom
enables us to carry our pathological analysis
sufficiently far back to connect the early ail-
ments with their causes; and, consequently, we
often fail in ascertaining the quarter where disease
commences.

234. B. The InJIammatory variety, or the
second form of Dr. Cheyxe, of M. Coindet, and
of IIopFENGAUTNER, is morc acute than the pre-
ceding. The precursoi-i/ symptoms are generally
of short duration, and sometimes so slight as to
be overlooked. 'i'his variety nearly resembles
fever, with predominant affection of the head ■
and in many cases it is not to be distinguished
from inflammation of the brain and its membranes
(see Brain, § 174. et seq.), the disease being
merely a modification of inflammatory action, de-
pending upon diathesis, and previous state of
health ; and, owing to these circumstances, giving
rise to effusion. After the child has been drooping
for a short time, fever, with slight, short, and irre-
gular remissions, flushings, severe headachs, in-
creased heat and sometimes soreness of the scalp,
augmented sensibility, thirst, hot skin, brilliancy of
the eyes, and tenderness over the abdomen, super-
vene ; the pulse being rapid, hard, or small ; and
the tongue white or loaded. Stupor or unwilling-
ness to be roused, alternating with violent screams,
and complaints of the head and belly; great irri-
tability of the stomach ; retching readily brought ou
by changes of position or by sitting up ; a morbid
and scanty state of the al vine evacuations ; a vacant,
dejected, or heavy expression of the eyes ; a pained
and terrified look; occasional cramps of the extre-
mities ; and diminution of all the secretions and ex-
cretions; commonly characterise this form of the
malady. This first stage is usually accompanied
wilh many of the phenomena of the first period of
the foregoing variety : the chief difference being in
the more febrile condition of that now under consi-
deration, in the earlier and more evident connection
of the symptoms with the brain, and in the shorter
continuance of this stage. As soon as the changes
which attend ihe second period, viz. dilated pupils,
strabismus, stupor, diminished frequency of pulse,
&:c. appear, the progress of this is in all respects
the same as that of the first variety ; the stages being
U u 4

664

DROPSY, ACUTE, IN THE HEAD — Remarks ox.

more distinctly marked, but frequently of shorter
duration, than in it. This form is generally idio-
pathic, whilst the foregoing is often symptomatic
of disease of the liver and digestive organs.

235. C. The Consecutive variety is observed in
an advanced stage of some acute disease, or soon
after its decline, assuming either of the foregoing
forms. It may follow the disappearance of some
scrofulous affection ; in which case it generally
presents the characters of the first variety. It may
come on after scarlatina or measles, and early in
hooping cough ; and it then commonly makes its
attack with all the violence of the second variety.
When it appears during remittent fever, difficult
dentition, and in the latter periods of pertussis, it
often steals on so imperceptibly, as not to be re-
cognised until dilated pupil, strabismus, convul-
sions or paralysis, and other symptoms of the ad-
vanced stages, are remarked. In such cases,
the symptoms of the early period are liable to be
confounded with those of the malady of whicii it
is consecutive. Pain, which is one of the most
prominent features of hydrocephalus, is sometimes
but little felt in this form.

236. Remarks. — The varieties now pointed
out can be recognised only during the first stage,
and chiefly by the mode of attack, which, in the

Jirst, is always slow and insidious. This is the
most frequent form of the disease. In the second
the attack is more suddep and tumultuous ; its
first stage lapsing into tiie second in from two to
four or five days. This, however, is the least fre-
quently observed in practice, and is hardly to be
distinguished in its first stage from inflammation
of the brain and its membranes, of which it is only
a modification or termination, when affecting the
more central and internal parts of the encephalon
It occurs in more healthy children than the other
forms do, and is commonly idiopathic or primary.
The third variety often proceeds not only insid
ously, but rapidly ; and is generally the most
fatal. It -may present very unequivocal inflam
matory chai'acters in some cases, particularly
when it follows the exanthemata ; and in others
neither the symptoms, nor the appearances upon
dissection, of true inflammatory action, may be
observed; as when it is consecutive of hooping
cough, remittent fever, and other affections, chiefly
referrible to the digestive organs. During the
progress of all the forms of the malady, espe-
cially the first and third, the febrile symptoms
are very irregular, and often only occasionally
present. The thirst and appetite are also various ;
and the breathing is sometimes calm and soft,
and, at others, laborious, quick, and suspirious.
The circulation is at times irregularly distributed,
the head being hot and the cheeks fluslied, while
the lower extremities are cold -, and at other times
it is more equable, the countenance being pale,
the skin warm, and even perspirable throughout.
The bowels are genera II V as already described;
but, in some cases, a bilious purging attends the
vomiting. In a few instances, after the delirium,
insensibility, and convulsions in the last stage, a
return of the senses and intellect has ushered in
dissolution.

237. In young infants, hydrocephalus is ascer-
tained with much difficulty, and is liable to be
confounded with disorder of the digestive organs,
'i'lic knitting of the brows, watchfulness, moaning,
fevcrishness, the throwing back of the head, starting

from sleep with a cry of alarm, frequent vomiting,
aversion from light, the peculiar character of the
stools, the half-closed eyelids, the full or dis-
tended fontanel le, and hanging or rolling of the
head on the nurse's arms, are the chief symptoms.
The expression of pain is not violent at this epoch ;
and there are not, in this disease, the drawing up
and flinging out of the legs, with screaming and
crying, as in colic or griping pains. It seldom,
however, appears before the period of dentition ;
but, when it occurs about this period, it is often
ushered in by convulsions, or convulsions appear
at an earlier stage of the malady than in older
children,

238. The duration of acute hydrocephalus is
extremely various. When it has reached the
second stage, its duration is very uncertain ; for
death may supervene in a few hours, or not until
after two or three weeks. In young infants, it
frequently advances most rapidly. Fothergill,
CoiNDET, Sprengel, Cheyne, Goelis, &c. con-
sider that it commonly runs its course within
three weeks. Whytt, Frank, C. Smith, Yeats,
and others, believe that it may be protracted much
beyond that period. The consecutive form may
terminate in about a week; and the inflammatory
seldom lasts longer than three weeks ; but the first
or nervous variety may continue for four, five, or
even six weeks or longer, if the earliest symptoms
be taken into the account. In some instances,
especially of the first form, the disease may assume
a nearly chronic character, or a state intermediate
between the acute and chronic, or may pass alto-
gether into the latter, especially in young chil-
dren ; a slight separation of the sutures, enlarge-
ment of the head, sallowness, marasmus, palsy,
&c. taking place ; and a larger collection of fluid
being found in the ventricles than in the more
acute states, although less than in the congenital
and chronic. The most common duration of the
disease, according to my experience, is from two
to four weeks. There is great difficulty, as re-
spects the first and third forms particularly, in de-
termining the period at which the malady giving
rise to the effusion begins. As to the efiusion it-
self, it may commence coetaneously with the
second stage, or not until a subsequent period.

239. Appearances on dissection vary remarkably,
even in cases belonging to the same form of the
disease. — (a) In the first form, the veins of the
membranes are generally found congested, with
dark-coloured blood. In a few instances, I have
observed inflammatory appearances in the longi-
tudinal sinus; and a similar observation has been
made by Biicnoi.z. The ventricles usually con-
tain from two to six or eight ounces of limpid
serum. The substance of the brain is soft and
blanched, especially towards the central parts ;
and in the vicinity of the ventricles it is often very
much softened, the fornix and septum lucidum
being more or less disorganised, and soft like curd.
Tiie choroid plexus is pale, sometimes granulated.
The pituitary gland is occasionally infiltrated,
or otherwise slightly altered (Morcagni and my-
self) ; a slight watery infiltration of the substance
of the brain has also been noticed, 'i'ubercular
formations have been found in various situations
within the cranium (Laennec, Merat, &c.).
Several other slight lesions of the encephalon have
been observed ; but they are by no means con-
stant, and may be viewed as merely contingent

DROPSY, ACUTE, IN THE HEAD — Grades of.

665

changes. The liver is often inflamed, some-
what enlarged, and extensively adherent to the
adjoining surfaces. Dr. Cheyne has remarked
small white tubercles on the surface of this organ ;
and I have seen them in this and other parts of it,
as well as in the spleen. The mesenteric glands
are frequently enlarged, and contain caseous de-
positions. The stomach and intestines are some-
times inflamed, the latter constricted, and even
intus-suscepted. The mucous follicles of the di-
gestive canal are often enlarged.

240. {b) In the second, and in most of the
third, forms of the disease, the brain and its mem-
branes, particularly towards the base and central
parts, present many of the usual appearances of
inflammatory action, especially injection of the
vessels, and thickening and opacity of the mem-
branes, in addition to effusion of serum. The
fluid is not so generally limited to the ventricles
in these forms as in the first, is usually in less
quantity in these cavities, but is effused also be-
tween the membranes, especially in the general
cavity of the arachnoid, or between this membrane
and the pia mater, elevating the former, and
thereby exhibiting a gelatinous appearance. Bonet
and Greding observed effusion between the
cranium and dura mater ; and Dr. Abercrombie
tliinks this not a rare occurrence, and that it is
the source of the fluid which escapes upon open-
ing the head. Thejluid itself is much less limpid
in these varieties, than in the first ; it being often
turbid, or whey-like, containing minute shreds of
lymph, and presenting evident traces of albumen.
In many of the cases belonging to the second
form, the cerebral substance retains its consistence,
its cut surface indicating increased vascularity. In
some cases, the surface of the ventricles is covered
by a fine film of lymph, which hardly adheres to
it. la several instances of the disease consequent
upon scarlatina, I have observed the effused
fluid of a turbid, brownish, and sanguineous ap-
pearance.

241. D. Hyper-acute Hydrocephalus;
Apoptexia Hydrocephalica ; Wasserschlag, Germ.;
or Waterslruke, — The sudden effusion of water on
the brain, although noticed by some other writers,
was first described by Goelis. He stales that it
may take place eitlier idiopathically, or in con-
sequence of various diseases. Although I have
met with many cases of its consecutive occur-
rence, I have seen none that could be strictly
called idiopathic. It most commonly appears in
the advanced stages of the exanthemata, after
the repulsion of chronic eruptions, as tinea ca-
pitis, crusta lactea, discharges from the ears ; or
after the arrest of habitual evacuations and ex-
cretions, as chronic diarrhoea, dysentery, the
choleric fever of infants, habitual perspirations,
&c., and when the powers of life are much re-
duced. In all such instances, it is to be consi-
dered merely as a more rapid form of the third,
or consecutive, variety of hydrocephalus already
described ; taking place, in some instances, with
surprising suddenness, and terminating fatally with
great rapidity — sometimes in from twelve to
twenty-four hours. The attack, under these cir-
cumstances, is seldom or ever recognised until the
symptoms of the second or third stage of acute hy-
drocephalus supervene. Goelis supposes, from
the appearances of vascular turgescence observed
in some cases after death, that a degree of inflam-

matory action may suddenly supervene, and be
coincident with effusion. But it is very rare that
marked vascularity of the membranes and brain
of children is not observed upon dissection, what-
ever may have been the disease of which they
died. It is very probable that increased deter-
mination of the circulation has preceded, or accom-
panied, the efliusion in these cases ; but the vascu-
larity is no proof of inflammation. 'Wg. effusion,
in the several mstances of this kind that I have
examined, was chiefly in the ventricles, although
partly also between the membranes; was generally
in less quantity than in the common acute disease,
— in all the cases, under four ounces ; was less
turbid than stated by Goeljs ; and occurred in
children who were of an unhealthy habit, lax
fibre, and much reduced by disease.

242. E. SuE-AcuiE Hydrocephalus. — This
form of dropsy in the head, already alluded to, is
deserving of more particular notice, from the fre-
quency of its occurrence. I have met with it
most commonly as a slighter grade of the^'?st ru-
ne;!/ described above (§ 230.). It generally oc-
curs between the second month and the com-
mencement of the second year of age. After the
continuance of many of the symptoms characteris-
ing the first stage of that form, the head begins to
enlarge, with slight separation of the sutures, and
imperfect develof>ement of the symptoms of the
second stage. In many cases, the disease is
slighter, and the duration longer, than in the first
form; but, in others, the symptoms are quite as
severe for several days, when the yielding of the
cranial parietes before the eflfused fluid seems to
abate their violence. In some cases, the malady
is prolonged merely for a few days ; in other cases,
for a much longer peiiod, so that it runs into the
chronic. In rare instances, recovery is slowly and
insensibly established, the patient — especially if
nature be judiciously assisted by art — outgrowing,
as it were, the disease. During its progress, the
symptoms vary but little in kind from those al-
ready described. The bowels are generally irre-
gular after havingbeen long torpid, and they some-
times become lax, the stools being mucous, unna-
tural, and offensive. In some instances, diarrhoea
comes on during the advanced stages ; and if this
be not checked, and if the powers of life be sup-
ported or promoted, and appropriate remedies pre-
scribed, recovery may take place. But more fre-
quently the loss of flesh, general cachexia, disorder
of the bowels, sopor, paralysis, &c. advance slowly,
until convulsions or exhaustion terminate life.

243. Dissections. — In all the cases I have ex-
amined,the fluid eftused was altogether in the ven-
tricles, has exceeded eight ounces, and was either
entirely or nearly limpid. I'he brain surroundino-
the ventricles was frequently softened ; but, ex-
cepting a common injection of the membranes,
there were no remarkable inflammatory appear-
ances in the encephalon. A thin film of mucous
lymph covered the surface of the ventricles in
some instances. An increased quantity of fluid
was occasionally found about the medulla oblon-
gata, and in the spinal canal. The liver was
often more or less inflamed or enlarged, the di-
gestive mucous surface also inflamed in various
parts, and Fever's glands were enlarged — in
some cases ulcerated. The mesenteric glands
were frequently diseased in the manner stated
above (§ 239.).

666 DROPSY, ACUTE, IN

244. Dr.\GX0Sis. — Although the disease is rea-
dily ascertained in its far advanced stages, when
it is nearly or wholly beyond the reach of me-
dical aid, it by no means admits of easy recog-
nition at an earlier period. Indeed, as will be
hereafter shown, the effusion being often an oc-
currence contingent on a variety of ailments, and
often arising out of a morbid condition of the
system, and of the parts contained within tlie
cranium, no early diagnosis can be formed; for
the functional disturbances and general febrile
commotion characterising the commencement of
the disease, are readily removed in many in-
stances, whilst, in others, apparently as slight, or
even slighter, the symptoms commonly attributed
to the effusion will rapidly supervene, notwith-
standing the most judicious treatment : and, after
all, it remains very questionable, whether or not
the symptoms commonly attributed to the effusion
are not rather the results of the changes which
have taken place in the organic nervous influence,
in the circulation, and in the structure of the
brain, upon which changes the effusion is merely
contingent, than the consequences of the efi'usion
itself ; for I have observed, in several cases, as
much fluid eflfused within the cranium, there hav-
ing been no hydrocephalic symptoms during life,
as in the most marked form of the disease. We
have, moreover, seen that, in many of the cases
of inflammation of the brain, or of its membranes
(see Brain, § 175.), very nearly tiie same train
of symptoms appear as in acute hydrocephalus,
and yet little or no effusion takes place ; and that,
in the more inflammatory variety of this malady,
where the symptoms characterising the advanced
stages are most marked and uniform, the quantity
of the fluid eflfused is generally the least. Where,
however, we see a ciiild in a state of insensibility,
rolling his head upon the pillow, frequently
grinding his teeth, screaming acutely, moving one
hand in the air, while the other is palsied, with a
hectic on the cheek, drooping eyelids, heavy
vacant stare or strabismus, dull filmy cornea,
dilatation of the pupils, collapsed features, general
emaciation, partial sweats, suspirious, laborious,
or rapid bi'eatliing, and convulsions, after having
been ailing for some time, and more recently
affected by febrile action, with marked disorder
of the digestive organs and of the head, it may be
infened that effusion has taken place within the
ventricles, and at tiie base of the brain, chiefly in
the former; but of this there is no complete cer-
tainty, for very nearly the same phenomena may
arise from extensive encephalitis, or from inflam-
matory softening of the brain, at their most ad-
vanced stages.

245. (a) I have already staled that the disease,
in its inflammatory form, is nearly related to iii-

Jiammiilion nf the brain and its inenibrmies ; and I
may now add, that, in tiie first form descriiied, it
is often ciiually closely connected with softening
of the organ (see Urain, § 214.). In many cases,
the distinction is made with great difficulty, and
in some it is not to be made at all ; for the effu-
sion is, in such, merely one of several coexistent
changes either immediately consequent upon, or
more remotely following, the inflammatory act in
the former class of cases, and the softening in the
latter. When, however, any diagnosis can be
established by the close and experienced observer,
it is most important to be guided by it. Tlie tur-

THE HEAD — Diagnosis.

gescence, which attends inflammation of the brain,
often gives rise to symptoms which nearly resem-
ble those produced by watery efl^usion : and it is
only by estimating the history of the case in con-
nection with the causes and a number of existing
phenomena, that an opinion can be formed as to
the exact state of disease. — a. Encephalitis oc-
curs more frequently in previously healthy
ciiildren ; its attack is sudden, and the progress
of its early stage rapid and tumultuous : hydro-
ceplialus appears in the unhealthy ; and consecu-
tively either of previous attacks of congestion or
inflammation of the brain, or of disease of the di-
gestive and chylopoietic viscera, — generally in a*
gradual, slow, or insidious manner; the former
being commonly an idiopathic, the latter often a
symptomatic disease. — /3. In encephalitis, pain
is constant and throbbing, increased by any ex-
citation of the circulation, frequently preceded,
or attended, or followed, by distinct chills or
rigors : in hydrocephalus, pain is intermittent or
remittent, shoots with great violence, occasioning
anguishing screams, wants the pulsating charac-
ter, is not increased by what excites the circula-
tion, often alternates with pains in the abdomen,
and is seldom attended by chills or rigors. — >-.
The sickness and vomiting, symptomatic of the
former, are unaccompanied by the fulness and
tenderness of the hypochondria and epigastrium
which commonly precede and attend these symp-
toms in the latter malady. — ^. The coun(e-
nance in encephalitis is tumid and injected, the
features enlarged, the attendant fever of a sthenic
or phlogistic character, and its progress very
acute : in hydrocephalus, particularly its first and
most common form, the countenance is not very
sensibly tumid ; the cheeks only are irregularly
flushed; the thirst is not so great, nor the ano-
rexia so complete ; the febrile heat is not so high,
so general, or so constant ; the surface is not so
full and animated, nor is the pulse so steady and
strong as in the former disease. The pulse is
more excitable, irregular in strength and fie-
quency, in tiie respective stages ; more rapid and
weak at the commencement, and partakes more
of the asthenic character, in the latter malady ;
the emaciation is also greater and more rapid.
— £. Tiie stools in encephalitis are devoid of the
peculiar characters they present in acute hydro-,
ccphalus; they are not of tiie same dark greenish
colour, have not the gelatinous consistence, with
the oilincss and glossy appearance, of those in the
latter; nor do they possess the peculiar sickly,
but not foetid smell. — ?. The contractions and
spasms of particular limbs and muscles, often
observed in encephalitis, are seldom met with in
hydrocephalus ; whilst, in the latter, paralysis
is more common. From the circumstance of in-
flammatory appearances in the membranes, as
well as of softening in the central parts of the
brain, having been often found in hydrocephalic
cases, in addition to the effusion of fluid, it may
be legitimately inferred, that the disease will often
jiartake more or less of the symptoms usually
caused by these lesions (see BitAiN,§§ 146 — 182.
214. et seq.) ; and that cases will occur but
slightly modified in their characters from those
consisting of inflammation on the one hand, and
of softening on the other ; the former commenc-
ing suddenly and acutely, the latter slowly and
insidiously.

DROPSY, ACUTE, IN

246. (b) Acute hydrocephalus may be dis-
tinguished from fever, by the somnolency, knit-
ting of the brows, tlie great irritability of tlie
stomach, which is increased by motion and the
erect posture ; by the raising of the hands to the
head, the throwing back the neck, the excitability
and irregularity of the pulse, the peculiar charac-
ter of the evacuations, and obstinate costiveness ;
by the pains shooting in various parts, and the
overpowering headach which admits not of the
head being raised, — the pain darting at intervals
through the centre of the brain, and not throbbing
as in phlogosis, nor being increased or brought
on by excited circulation ; and by the starting,
peculiar scream, and the expression of anguish
when the child is awakened by it 'from the con-
stant dozing, into which he instantly afterwards
falls. — a. The infantile remittent fever is distin-
guished from this disease by the absence of the
above symptoms, by the expression, by the regular
morning remissions, and by the feculent, brown,
and more easily procured evacuations. — i3. Typhoid
or adynamic fever is rare in children, and is to
be distinguished from this malady, by the more
ecjuable pulse, by the dark and foetid stools and
diarrhoea, low muttering delirium, supine posture,
tumid abdomen, sometimes by petechias ; by the
dark brown, tough sordes on the teeth and gums;
by tlie slipping down in bed ; and by the absence
of acute pains, convulsions, paralysis, and of the
other remarkable symptoms of hydrocephalus. —
y. The febrile disorders produced by worms are
generally more protracted than this disease; are
without distinct stages, but with manifest remis-
sions,— the sleep being sound, and pulse uniformly
quick. In worm fever, the pains in the head and
abdomen are dull and not much complained of;
the appetite is ravenous, the stools spontaneous
and copious, the urine abundant and pale, the
perspiration free, the cheeks generally pallid, the
sight and hearing are unaltered, the mouth and
nose moist, the abdomen is constantly tumid,
and the body but little or not at all emaciated ;
and if convulsions occur, they are not followed
by paralysis. It should not be overlooked, that
either of these states of fever may give rise to
aqueous effusion on the brain, the early symp-
toms proceeding insidiously, or being masked by
the primary disease, and thus often escaping de-
tection until some of the characteristic symptoms
of hydrocephalus supervene.

247. (c) Various organic lesions within the
head may occasion very nearly the same series
of morbid phenomena as constitute this disease;
but generally they are of much longer duration,
and are not attended by so much emaciation, or
such overpoweiing pain in the head. The stages
of the malady are not so well marked. Rarely,
however, do organic changes occur in the ence-
phalon or its membranes, in children, without the
effusion of more or less fluid.

248. yd) The strangulating or crowing in-
spiiation, with purple complexion, not followed
by cough (see Larynx — Spasm of), but often
accompanied by clenching of the hand on the
thumb, with spasms of the toes, has been con-
sidered by many as connected with acute hydro-
cephalus. Without denying that this affection
may occur as a symptom at an early stage of the
disease, it should be recollected that it often dis-
appears after scarifying the gums, or cutting the

THE HEAD — Diagnosis, 667

teeth, or removing morbid secretions. The con-
vulsions attendant on hydrocephalus are generally
characterised, as Dr. Ciieyne justly remarks, by
a greater affection of one side of the body than
of the other ; one arm or leg is, with some re-
gularity, retracted and flung out, while the other
is affected with spasmodic catchings ; the eyes
are suffused ; there is often a circumscribed flush
on the cheeks, and the breathing is slow, or irre-
gular and sobbing.

249. (e) Exhaustion of vital power may oc-
casion symptoms often closely resembling acute
hydrocephalus. The circumstance of exhaustion
giving rise to hydrocephalic symptoms — in some
cases without any effusion, in others with the
collection of more or less fluid — has been well
known to me, and acted upon in my practice at
the Infirmary for Children, for many years. It
was first very imperfectly alluded to by Dr.
Cheyne ; and subsequently by Dr. ABEncROaiBiE,
Dr. Goocii, Dr. Dahwall, and others, who ap-
pear not to have clearly understood it. These
writers consider this consecutive affection as one
of exhaustion of nervous power only: but I
infer that something approaching to hydroce-
phalic is occasionally connected with it; for the
benefit afforded by nutrients, stimulants, or tonics,
is no proof that the exhaustion has not been
attended by some degree of effusion. Indeed,
the physical condition of the brain renders it
most probable that some fluid is collected, owing
to exhaustion, diminished nutrition, and the state
of the cerebral circulation ; and that it is absorbed
as the pathological states that occasioned its effu-
sion are removed by appropriate treatment. The
appearances observed in the fatal cases fully con-
firm this view. I am at this time attending two
cases of this affection that fully illustrate its
nature. It is generally consequent upon wean-
ing, improper or imperfect feeding, protracted
diarrhoea, and exhausting treatment; and is
usually attended by loss of flesh, increased sen-
sibility and irritability, a feeble quick pulse,
tiansient and irregular flushings, quick breath-
ing, sometimes sighing or moaning, a white loaded
tongue, scanty urine, and a mucous diarrhoea, —
the evacuations being flatulent, unnatural, green-
ish, or gelatinous. Sometimes there is increased
heat of the head towards night, but seldom any
pain or screaming. In addition to evidence of pre-
existing or attendant irritation of the digestive
mucous surface, the bronchial lining, also, often
indicates iriitation by a dry hacking cough. Tliis
first, or irritative stage of the complaint is fol-
lowed by one of more marked exhaustion, with
stupor or torpor, particularly if the causes con-
tinue in operation. The pupils become dilated ;
the eyes vacant, and sunk in their sockets ; the
eyelids half shut ; the countenance pale and cool ;
and the extremities, especially the lower, cold. If
the complaint occurs during dentition, sometimes
squinting, with partial convulsions, or with crow-
ing or croupy inspirations ; slow, irregular, or
suspirious breathing ; clenching of the hands, or
s)iasms of the fingers and toes ; are observed. The
feet and legs are always cold, and with difficulty
kept warm, especially if the head be hot. The
fontanelle is sometimes depressed, or nearly na-
tural. The pulse seldom or never loses its fre-
quency. This torpid stage may terminate fatally
with increased coma, a rattling respiration, sink-

668 DROPSY, ACUTE, IN THE

ing and disappearance of the pulse, and profound
exhaustion. Convulsions occasionally occur, but
,at no particular period of the complaint. A fa-
vourable issue frequently follows an appropriate
treatment. In some of the cases which have
ended fatally, I have found, on dissection, more
or less fluid in the ventricles. The membranes
were even less vascular than commonly observed
in young subjects. In these cases, death is more
to be imputed to disease in other viscera, and the
attendant exhaustion, than to any change witiiin
the head.

250. (f) When acute hydrocephalus is con-
secutive of scarlatina, measles, small-pox, &c., it
becomes important to detect it as early as pos-
sible. These diseases may terminate fatally, in
their latter stages, copious effusion having taken
place in the ventricles, and between the mem-
branes of the brain ; or the symptoms of this
malady may not commence until a few days or
even weeks after they have disappeared, more
particularly after scarlatina. Severe and fre-
quently recurring pain in the head at this pe-
riod should always receive attention; and when
this is attended with other symptoms of tiie first
and second stages, decided measures should be
adopted. Wlien it follows scarlet fever, the
occurrence of headach, stupor, or convulsions,
either with or consequent on anasarca, may be
viewed as evidence of approaching or commenc-
ing effusion in the head, which may be averted
by antiphlogistic and other appropriate reme-
dies.

251. Prognosis. — This disease is not now so
fatal as it was viewed by the first writers on it.
If recognised early, a large proportion of cases
will recover ; even in the most advanced periods,
the patient should not be despaired of. I have
repeatedly seen recoveries take place, although
strabismus, paralysis, convulsions, blindness, un-
conscious evacuations, and other unfavourable
symptoms, had existed some time. Data fur-
nished by the writings of Odier, Cheyne, Mills,
Bricheteau, Goelis, and others, show that from
a sixth to a third of the cases has recovered. But
a perusal of the cases they have adduced, has
convinced me, that some of those which recovered,
as well as of those that died, belonged to acute
or sub-acute encephalitis — little or no effusion
having taken place — several of them presenting,
on dissection, this as the least important change ;
the fluid sometimes amounting only to two or
three drachms, — a quantity not nearly sufficient
to warrant the designation given to the disease.

252. Although the prognosis should always be
given with much caution, and be generally un-
favourable ; yet in few circumstances, indeed,
ought the anticipation of such a result to para-
lyse our treatment. Dr. CiiEVNE justly observes
that, whilst the pulse continues steady, and the
breathing natural, the most alarming symptoms
should not prevent the use of active remedies.
I would even go beyond this, and say, that the
supervention of hurried breathing is the only
symptom that should lead us to despair of the
case. We should be cautious not to be misled
by the falling in the frequency of the pulse in the
second stage ; and not to be induced to give a
favourable prognosis from this circumstance. Tlie
coming down of the pulse should, therefore, be
viewed in connection with the state of the eyes,

HEAD — Prognosis — Cal'ses.
and of the evacuations, and with the other symp-
toms, before any opinion should be formed from
It. More copious and more readily procured
bilious stools, and their more feculent appear-
ance and natural smell, an increased flow of
urine, mucous or watery discharges from the
nose, and an abundant warm perspiration, are
favourable signs. The occurrence of the disease
in comparatively sound constitutions, in an in-
flammatory form, or after scarlatina, admits of
greater hopes of recovery. This opinion is ac-
cordant with that of Goelis and Abercrombie,
although it is different from that expressed by
Dr. Cheyne. The idea of effusion in the head
being necessarily fatal, has operated unfavourably
in the treatment of the disease. I believe from
extensive and attentive observation, that, notwith-
standing the uncertainty of the existence of this
change, it may be removed, when the powers of
the constitution are not sunk too low.

253. When hydrocephalus follows protracted
ill health, in scrofulous constitutions, in families
where others have died of it, after remitting states
of fever, during protracted convalescence, er
when it steals on so as not to be recognised until it
is far advanced, an unfavourable opinion of the
result may be entertained. The breaking out of
a vesicular eruption about the lips and face ; total
insensibility of the retina ; great rapidity, small-
ness, and feebleness of pulse ; dryness of the mouth,
lips, and nostrils ; boring of the finger in the ears ;
hurried respiration, and partial sweats, particu-
larly on the neck and back of the head ; indi-
cate approaching dissolution. Even when the
treatment is followed by very striking amendment,
we have no certainty of the recovery of the pa-
tient ; for most of the unfavourable symptoms
have been removed ; but, in one or two days, they
have recurred, and death ensued. Even when
an improvement has become more permanent, we
cannot be sure of the result, until the actions of
the iris return, and the alvine excretions, and
other functions, become natural, — until then^ a
cautious opinion of the issue should be given.

254. Causes. — (a) The predisposing causes. —
Goelis and several others suppose that the disease
is more common now than formerly, owing to the
less frequency of eruptions on the heads of child-
ren. He also believes, and refers to facts in
support of the opinion, that terror and anxiety
in the mother during the last months of preg-
nancy predispose to it, — the disease often appear-
ing in the child soon after birth. The epochs of
iiifancii and childhood are, however, the most
remarkable predisposing causes. At these periods,
the rapid developement of the encephalon, and
the great susceptibility of the nervous system,
dispose the cerebral circulation to frequent ex-
citement ; and in proportion as the cerebro-spinal
system acquires a predominancy in capacity and
function over other parts, is the predisposition to
vascular determination, to inflammatory action, to
increased exhalation of serum, and other disorders
of the cerebral vessels, augmented. The more
fre(|uent occurrence of tlie disease, often in an
inflammatory form, in children with precocious
intellects and large heads, is a common observ-
ation, and is confirmed by the experience of
Gahdiex, Hopfengartner, Guehsent, and
others. The more usual period of attack is from
the first to the eighth year ; its frequency dimin-

DROPSY, ACUTE, IN THE HEAD— Pathological Opinions.

669

ishing as we depart from this epoch, down to the
period of birth on the one linnd, and up to pu-
berty and manhood on the other. I believe, that
previous to the tenth year, the disease is most
frequent in boys. Dr. Cheyne thinks, with
LuDwiG, that, after ten, girls are more subject to
it. A scrofulous diathesis is also one of the most
remarkable predisposing causes, — sometimes seve-
ral children being carried off in a family where it

&c.) ; the extension of inflammation from the
ear (Itard, Lallemand, &:c.) ; the retrocessioa
of acute eruptions, and suppression of chronic
evacuations or discharges ; the extension of irri-
tation to the membranes or brain, from inflamma-
tions of the organs of sense, from the throat,
scalp, face, &c., and from erysipelas of those
parts ; too copious general depletions in the ex-
anthemata and acute diseases, in relation to the

exists. Cheyne, Sprengel, and others, consider : form of the malady and strength of the patient ;
that hydrocephalus and scrofula are convertible , the too liberal use of narcotics in young children,
into each other. That the former sometimes fol- i or their employment too early in several diseases,
lows the disappearance of other scrofulous affee- I particularly in hooping cough, spasmodic croup,
tion, admits not of doubt; but it rarely happens spasm of the larynx, and flatulent colic; whirl-

that the latter is influential in the removal of the
former ; indeed, effusion on the brain much more
frequently proceeds simultaneously with tuber-
cular and other strumous diseases in other parts
of the body.

255. Hereditaria disposition has also been
viewed as a cause by Quin, Odier, Formey-, P.
Frank, Portenschlag, Baader, Goelis, &c. ;
some, however, with Cheyne, imputing such dis-
position to the scrofulous diathesis. But I have
repeatedly remarked the hereditary tendency,
without its dependence on scrofula. Goelis,
Brachet, Coindet, and Girtanner ascribe this
disposition to a peculiar connate irritability of
the nervous system ; this, however, does not ad-
vance the question much further. The children
of parents addicted to drunkenness, particularly
if the mother be given to the use of spirituous
liquors during suckling, are also, according to my
experience, prone to be attacked. In addition
to these, may be enumerated a syphilitic taint of
the parents CThom) ; frequent congestions in the
head, however induced ; the use of too stimu-
Jating food and drink in early age ; keeping the
liead (00 warm ; the premature and excessive
exercise of the senses and of the intellects ; vio-
lent mentai emotions, as terror, anxiety, anger,
fear ; the exhibition of anodynes to the child by
nurses, or in the treatment of other diseases; re-
peated falls; injuries during parturition (Stoll,
Arantius, Goelis) ; rocking in cradles (Blan-
CARD, Anat. Prat. c. i. obs. 18) ; the early and
repeated application of cold to the head or other
parts (Percival) ; concussions of the body ; too
frequent motion and depending positions of the
head; whirling round on the toes; the injudi-
cious use of emetics ; the continued irritation of
worms in the prima via, and of dentition during
both the second and first periods ; congestions,
inflammations, and enlargements of the liver
and spleen ; previous attacks of encephalitis, or
of cerebral congestion ; interruptions to the se-
cretion and discharge of the bile ; disorders of the
stomach and bowels ; enlargement and obstruc-
tion of the mesenteric glands ; long continued
costiveness ; remittent and exanthematous fevers ;
pertussis ; previous diseases imperfectly cured ;
and affections much disordering the respiratory
functions. Dr. Thompson, of Jamaica, observed
it frequently consequent on worms in the dark
races.

256. (6) The exciting causes are, cold to the
head of young infants; external injuries from
falls, blows, &c. ; concussions or agitations of the
brain, from jumping, whirling, or depending po-
sitions of the head ; the suppression of eruptions on
the scalp, and behind the ears (Conradi, Goelis,

tossing, or rudely rocking children in order
to quiet them, when crying ; from disorders of
the digestive oigans, or erethysm or irritation of
the encephalon ; insolation ; the early use of
fermented liquors ; carrying heavy loads on the
head (J. Johnson); allowing children to sit on
stones or other cold seats ; and the metastasis of
various maladies. Rush, Lettsom, Goelis, and
Coindet mention its occurrence from metasta-
sis of rheumatism. I have seen this take place
in a grown-up person, — the effusion being chiefly
between the membranes, — but not in children ;
although I have met with metastasis to the heart
in many cases of children — in one case now
under treatment, which is the second in the same
family. (See also Brain, §§ 182, 183-)

257. Pathological Opinions. — Acute hydro-
cephalus has been generally classed as a dropsical
disease, although its claims to be thus arranged
are somewhat equivocal. Its similarity, however,
to other acute dropsies, particularly those of the
chest, is most striking. Indeed, it seems to hold
such a relation to inflammation on the one hand,
and to chronic dropsy on the other, as to entitle
it to be viewed as an intermediate disease, and as
identical in most cases with other acute dropsies ;
in some instances approximating more nearly to
the one than to the other. Whytt considered
it as altogether a dropsical malady ; and Dr. Cul-
LEN, in designating it apoplexia hydrocephalica,
did not seem to entertain a very different opinion.
PiNEL fell into the same'views, after having de-
scribed it as a species of cerebral fever ; which was
the idea conceive<l of it by Dr. IMacbride. Con-
temporary with, and subsequent to, the appear-
ance of Dr. Quin's work, numerous authors,
particularly Rush, Rand, Withering, White,

ACKERMANN, GaRNETT, JMaRTINI, HeINECKEN

Gardian, Goelis, and Raimann, treated it as in-
flammatory in its origin ; and a number of French
pathologists, especially JNIartinet and Parent-
Duchatelet, have viewed it as arachnitis of the
ventricles and base of the brain. Others, again, have
supposed, with Lallejiand and Abercrombie
from the frequency of disorganisation of the cere-
bral structure in the vicinity of the ventricles, that
it is a consequence of inflammatory softenino- or
cerebritis; the disease either commencing in, or
extending to, the arachnoid of the ventricles.
RpsTAN {Clin. Med. t. ii. p. 321.) has stated it to
be'' a result of inflammation or other lesions of the
brain and membranes, and seldom or never an
essential disease. This is doubtless the case, if
we consider all sensible lesions as sequences of
anterior changes; but when the nature of the
early changes cannot be readily inferred from
the alterations they induce, we must be contented

670

DROPSY, ACUTE, IN THE HEAD — Pathological Opinions,

to grapple with the obvious malady, until we
know more of its antecedent pathological states.
If we adopt the views of M. Rostan, no changes,
excepting those immediately consequent upon
remote causes, will be considered essential.

258. Several writers, observing the history and
lesions of hydrocephalus to differ in several re-
spects from inflammation, yet still to resemble it
very closely, have viewed it as a peculiar form of
inflammatory action aft'ecting the more interior
surfaces and substance of the brain. Thus, Con-
RADi termed it Encephalitis e.vudatoria infantilis ;
Braciiet, Hydroctphulite, or watery inflammation
of the brain ; and Coindet, Cephalite interne hy-
drenctphaitte. Other writers, particularly Aber-
>ETHy, Curry, Cheyne, Yeats, Thomson, &c.,
have considered it as most commonly proceeding
from disease in the digestive organs, and seldom
arising from primary inflammatory action in the
brain or its membranes. This opinion has been
carried too far, for I have often had evidence to
convince me, that morbid action had been pro-
ceeding in the brain long before it was suspected,
and that one of its chief effects was to disorder
the liver and digestive canal ; this sympathetic
disorder being frequently considered as primary,
and its reaction on the brain as the sympathetic
production of hydrocephalus. I believe that the
malady often originates in the substance of the
brain ; and that, conformably with what is ob-
served in respect of lesions of this structure, the
digestive viscera, frequently at one time the most
remarkably deranged, are merely sympathetically
afiected. Formey- and Dr. Shearman have
viewed the effusion as a consequence of simple
excitement of the cerebral circulation entirely in-
dependent of inflammation. The latter writer has
considered it to be contingent on various diseases,
and to arise from a diversity of causes ; but that
its occurrence is chiefly owing to the predisposition
or previous state of the membranes, — the essential
character of the disease consisting in tliat previous
• state or predisposition vvhich, in connection with
an excited state of the circulation, gives rise to
increased exhalation or effusion. Dr. C. Smyth
lias argued against inflammation, and in favour of
debility as tlie cause of the effusion ; but whdst
he has strenuously contended for the latter patho-
logical condition as respects the tone of the ex-
treme vessels, he has admitted the existence of
accelerated circulation, and its influence in pro-
ducing the disease. There is one inference, liow-
ever, in which nearly all modern pathologists
agree, viz., tliut the effusion itself does not consti-
tute the malady, but is only its consequence, —
contributing to tlie production of the more ad-
vanced symptoms, but in a less degree than many
suppose.

•259. Pathological Inferences. — (a) The first or
nervous form of acute hydrocephalus is frequently
consequent upon changes in the substance of the
bram, in the membranes lining the ventricles, and
in the vessels and circulation of the encephalon,
probably arising from the state of the organic
nervous influence supplied to tliis quarter, and to
the perversion of the vital actions. (See Disease,
^87 — 92.) — (h) That these changes often com-
mence gradually, or almost imperceptibly, and
proceed far before they disorder the functions,
either of organic or of animal life, in a remarkable
degree ; and when such disorder becomes manifest.

it is often diflicult to trace the quarter in which it
has originated, owing to the intimate dependence
of both classes of functions upon the organic ner-
vous system. — (c) That the changes observed on
dissection in this variety have evidently been in
progress a considerable time before effusion has
taken place ; the effusion being the consequence
of these changes,[assisted by the physical condition
of the encephalon. — (d) That nervous, as well
as inflammatory and consecutive, hydrocephalus
being merely contingent upon lesions of the organic
nervous influence of the circulation, and of the
substance and membranes of the brain, such le-
sions actually constitute the disease during its
early periods. — (e)That the nature of the cere-
bral affection, and the exact state of vascular ac-
tion, in the-e periods, are not manifest ; but if it
be at all inflammatory — which admits of dispute

— the vascular action possesses more of an as-
thenic or ataxic, than of a sthenic, character ; or
is attended by a perverted, rather than by a dy-
namic, state of vital power; and by imperfect
performance of the digestive and assimilating
functions. — (f) That, although the frst for?n
of the disease be consecutive of changes in the cir-
culation, or in the organic nervous influence of
the brain, the resulting phenomena may be such
as to be mistaken for tlie exciting causes ; the
organs of locomotion may be so enfeebled as to
occasion falls, which will aggravate the primary
affection, and develope a state of sub-inflamma-
tion, or of vascular reaction in the encephalon,
and its usual consequences, viz. determination of
blood, injection of vessels, and effusion of serous
fluid ; or the viscera of digestion and sanguifac-
tion may become so congested, or otherwise dis-
ordered, as to appear the parts primarily affected,

— (g) That when this form is coincident with, or
consecutive of, congestion, inflammation, or other
disorders of the digestive and chylopoietic viscera,
effusion into the ventricles cannot be viewed as
the earliest changes that take place within the
head ; but that this effusion is merely consequent
upon similar changes to those which have been
already alluded to (d, e) ; the lesions in the diges-
tive organs, as well as the earlier alterations in
the brain, being, very probably, coetaneous results
of pre-existing disorder of the system, or of con-
stitutional vice. — ih)ln. whatever quarter dis-
order commences, it is probable that, sometimes,
at least, the sensorial power becomes exhausted,
possibly coetaneously with the supervention of
the second stage, and the cerebral tissue itself
more or less wasted ; but it is difficult to say
whether this wasting be the consequence, or the
cause, of the effusion into the ventricles, — pos-
sibly the latter. — (i) That, in the early stage of
the disease, as well as in its progress, the vascular
excitement, or febrile disturbance, attending it, is
characterised by general adynamia or perversion
of vital power. — (/c) That great cerebral excite-
ment does not necessarily imply the existence of
inflammatory action in the encephalon ; for acce-
lerated circulation in a weakened state of the
frame, and susceptible condition of the sensorium
and nervous system generally, will produce cere-
bral excitement, particularly towards the close
of febrile or protracted diseases; but this, in-
stead of being inflammation, is a state very dif-
ferent from, or sometimes even opposed to, it, as
shown by the tudehlia and juvantia, and by

DROPSY, ACUTE, IN THE HEAD — Treatment,

671

the 7)osO)W)'((?m appearances. — (I) In the second
form, and in many ot'tlie i/nrJ, particularly as oc-
curring after the exanthemata, the symptoms, as
well as the appearances after death , are more mani-
festly inflammatory ; cases varying in grade from
such as are described in the article Brain (^ 174.),
until the characters of the nervous form of the
disease are nearly approached ; the inflammation
differing in kind accordingly from sthenic inflam-
mation, owing to the diathesis and the state of
vital power. — (?)!) That the xcaterstroke or hiiper-
acute disease, in every case in which I have
observed it, has arisen independently of inflam-
mation, although generally consequently upon
determination to, or congestion in, the head. —
(n) That hydrocephalus, particularly its nervous
form, may assume intermediate states or grades
between the acute and chronic, which grades may
be denominated sub-acute. — (o) That the disease
may, in some instances, commence in an acute or
sub-acute form, and become chronic, especially
in infants whose cranial sutures have not closed.
— (p) In some cases, also, the acute or sub-
acute may supervene on the chronic state. — (9)
That acute dropsy in the ventricles, although
most common previously to puberty, may occur
at any subsequent period, especially during the
decline of life, and in old age. — (;•) That it is,
in such circumstances, generally attended by in-
flammatory appearances in, or softening adjoin-
ing, the surface of the ventricles; but it some-
times is unattended by any of these lesions. — (s)
That in these cases it often terminates fatally in
a short time, with apoplectic or comatose sj'mp-
toms; constituting the Serous Apoplexy of authors,
which is sometimes consequent upon other forms
of dropsy in persons advanced in life ; they being
cut off by the effusion into the ventricles, without
any other material change within the head, — the
coma, or apoplexy, gradually becoming more and
more complete until life is extinguished. *

260. Treatment. — Lit. Hist. oj'. — The opinion
of Dr. WiiYTT, as to the nature of acute hydro-
cephalus, and which was for a time very generally
adopted, led to an inefHcient treatment. Dr.
Watson, who adduced one of the first successful
cases, trusted chiefly to blisters, purgatives, means
to lower the attendant fever, and to the powers
of the constitution for a cure. Drs. Haygaiith
and DoBSON were the first to prescribe mercury
in the disease, particularly calomel, — a medicine
which had been very largely employed about a
century before, but had fallen into disuse ; and
which, having proved extremely efficacious in
many of the maladies incidental to Europeans in
the East Indies, was then finding its way, through
means chiefly of Dr. Lysons, Dr. Hamilton, and
Dr. Clarke, into the practice of this country.
Dr. DoBSON exhibited mercury with the intention
of thereby increasing the function of absorption :
and Dr. Haygarth, in order to induce sali-
vation, with the expectation that, by procuring an
aqueous evacuation from the neighbourhood, it

* Since the above was sent to press, the fiftli volume of
M. Andual's ''' Cliniquc MedicaJc" has appeared. It
contains a few cases of idiopatliic and acute effusion of
fluid into the ventricles, occurring in adults.both without
and with slight inflammatory changes or softenings of
the surfaces of these cavities, or parts adjoining. The
symptoms, in these cases, were those of waierstroke, or
of serous apoplexy. Two cases occurred in persons who
were labouring under dropsy of other cavities.

might be the means of removing the fluid accu-
mulated in the ventricles. Drs. A. Dawson, Sim-
mons, and ^\'IIITE placed their chief reliance on
blisters and opium, — means which, in the present
state of our knowledge, amount merely to useful
adjuvants. The views of Drs. Qiin, \\'itheri.\g,
and Rush caused a revolution in the treatment
of acute hydrocephalus. Dr. Quin, observing
in dissection evidences of inflammatory action in
the membranes of the brain, advised bloodletting,
and cold applications to the head, in the first
stage, and mercury afterwards ; Dr. Withering
used dii;italis, but his cases were not sufliciently
demonstrative of its efficacy ; and Dr. Rush
placed confidence chiefly in large bloodlettings
and active purgation.

261. Dr. Percival was amongst the first
who appears to have been aware of the fact,
that, however nearly acute hydrocephalus may
approach true inflammation, it is no more iden-
tical with it, than the adhesive form of inflamma-
tion is the same as the diffused, or as erysipelas.
He directed the means which had been previously
recommended, according to the circumstances of
the case ; and combined the use of blisters, mer-
curials, and opiates, with that of squills, musk,
and other diuretic and nervine medicines. Con-
sistently with these views, he was cautious in the
employment of blood-letting. Dr. Paterson
prescribed calomel and opium, and a more anti-
phlogistic treatment than was risked by Dr.
Percival; but Dr. Garnett, although he be-
lieved in the infiamraatory nature of the com-
plaint, hardly ventured beyond local depletions ;
and confided more in digitalis conjoined with
mercurials, than in other internal remedies.

262. It is impossible for the experienced reader
to have perused the writings on the disease, as
far as I have now proceeded, without being for-
cibly struck with the circumstance, that great
misapprehension prevailed as to the succession
and ensemble of morbid phenomena, on which
the name acute hydrocephalus has been imposed.
This is shown by many of the cases adduced by
authors in support of the inflammatory nature of
the. disease ; these cases exhibiting the usual re-
sults of inflammation only : whilst those who
observed the fluid collection unattended by very
remarkable inflammatory appearances, limited
their idea of this malady to such as these only,
and considered them as distinct from those evin-
cing changes strictly referrible to inflammation,
without any, or with but little effusion ; which
latter cases they viewed as constituting true in-
flammation of the brain and its membranes, and
not falling w-ithin their definition of hydrocepha-
lus, however nearly the symptoms of the one
resembled (in consecpience of the physical con-
dition of the brain) those of the other. The
fact is, that the larger number of writers down
to the present day applied the term acute hydro-
cephalus to a certain succession of phenomena,
without regard to the difl^erent pathological
states giving rise to it, and the shades of diver-
sity by which each may be recognised ; and
were either unaware of, or unheeded, the circun-
-stance, that an inflammatory state of the brain
and its membranes in young subjects may ter-
minate without eflTusion, or may give rise to effu-
sion to an extent warranting the denomination of
hydrocephalus; and that, moreover,, water may

672

DROPSY, ACUTE, IN THE HEAD — Treatment.

be collected within the cranium, without any truly
or sthenically inflammatory action of the vessels;
and, nevertheless, the most experienced observers
ofte'n will hardly be able to distinguish, by means
of the symptoms, between these classes of cases.

263. The intentions with which the treatment
of acute hydrocephalus should be conducted, are
resolvable into the following. — 1st. To remove
all causes of irritation or morbid action oper-
ating either directly or sympathetically on the
brain. — 2d. To lower vascular excitement in the
head, and equalise the circulation. — 3d. To
guard against efTusion, by fulfilling the above
objects, by diverting the morbid determination of
fluids from the head, and by changing the action
of the extreme vessels. — 4th. To restore dis-
charges and eruptions, when these have been sup-
pressed.— 5th. To alleviate pain and sickness.
— And, 6th. To support the powers of life, and
to recruit them when they are sinking. It is
obvious that the means which will accomplish
one of these intentions, will oiten also fulfil one
or more of the others.

264. The physician, having considered the
origin, pathological states, the constitutional
relations, the form, history, and stage of the
disease, as well as the means which may have
been already employed, should cause the patient
to be placed in a well-aired chamber, and to be
screened from strong light. The bed or couch
should approach a slightly inclined plane, from
which he ought to be slowly raised, and on which
gently placed, when removal is necessary. All
quick motions, or changes of position, as well as
excitement of the senses, and irritation of the
temper, must be carefully avoided. The tem-
perature should be rather cool than warm, and
the bedclothes only sufficient to preserve the
natural heat. With these preliminaries, the re-
medies determined upon should be promptly and
faithfully administered. During both the first and
second epochs of dentition, the patient's gums and
teeth ought to be carefully examined, and the
former freely incised, or the latter removed, as
often as may be requisite.

265. A, Vascular Depletion. — In estimating
the reported success of treatment in this disease,
it is very necessary to keep in recollection that
often no distinction has been made between it
and encephalitis: indeed, many modern writers
consider inflammation of the brain and its mem-
branes, occurring in children, to be identical with
acute hydrocephalus, — or, in other words, that
this latter is the same as the phrenitis of adults.
IS'ow this sophism, so general atxl injurious
in medicine — this affirming as true of the genus,
what is tiue merely of tlie species — has had a
most baneful influence on the treatment of this
disease, inasmuch as it has led practitioners greatly
to over-estimate the advantages of sanguineous
depletions ; a large proportion of their cases of
imputed acute hydrocephalus being acute and
sthenic meningitis or encephalitis, in which this
evacuation may be carried much further than in
the former malady ; and has induced them to re-
commend, and others to employ, the practice with
too little reservation. This circumstance is espe-
cially manifest upon perusal of the histories and
treatment delineated by Rush, iVTAXWFi.r., and
several others, who have carried bloodletting as
fur as it is admissible in sthenic inflammation

of the membranes. Having perused these
authorities, after the experience derived from the
treatment of very many hundred cases of cerebral
diseases in children, I am convinced that the
larger proportion of those which they considered
hydrocephalus, was neither that malady, nor
would have given rise to efl^usion in such quantity
as to have justified the designation : the details
they have furnished are decisive of the fact in the
mind of the competent judge. Therefore, let not
the inexperienced practitioner be led astray by
the circumstance of its having been recorded by
authors, thatarteriotomy, large bloodlettings, &c.,
cured half the cases in their practice ; I am con-
vinced that the majority of such cases were sim-
ple encephalitis, or inflammation of the mem-
branes of the base of the encephalon. Dr. JNIax-
WELL avers that he cured sixty cases out of ninety
— two thirds — by bleeding them in the horizontal
posture until insensibility — occasionally for some
hours — afterwards ensued. Would the most
heroic practitioner of the present day attempt
such practice in an undoubted case of acute hydro-
cephalus I I believe not.

266. (a) In the more inflammatory states- of
the disease, and especially in the Jirst st-age
(§ 234.), the same means, as are fully described
in the treatment of inflammations of the Brain
and its membranes (§ 191. et seq.), should be
employed ; and to an extent which the pulse,
the febrile excitement, and previous health and
strength of the patient, will point outi These
means consist of general or local bleeding, active
purging, the application of cold to the head,
derivatives and counter-irritants, mercury, seda-
tives, and diuretics, &c. In the inflammatory
form, as it occurs either primarily or consecu-
tively, these remedies may be prescribed very
nearly in the manner explained in the article re-
ferred to. When the disease supervenes sud^-
denly on any of the exanthemata, as decided
depletory measures, as are advised for encephali-
tis thus occurring, must be purs-ned. (SeeBnAI^F,
§ 191.) In children under three or four years of
age, leeches, or cupping behind the ears, on the
occiput, or on the nape of the neck, will be pre-
ferable to venaesection ; but, after this age, the
latter method may be practised in the first stage of
the disease. I have observed no greater advan-
tages obtained by bleeding from the jugular, than
by bleeding from the arm. Many Continental phy-
sicians consider depletion more derivative when it
is practised in the feet, and numerous facts favour
the inference. In the second stage, local deple-
tions, if they have not been already employed,
or carried sufficiently far, and if circumstances
indicating tlie propriety of the practice exist, may
still be resorted to ; but with strict reference to
the pulsation of the carotids, the pain and tem-
perature of the head, to the warmth of the extre-
mities, and to the state of vital power. I have
often derived advantage from repeated local
bleedings even in this stage, aided by the other
remedies enumerated, when employed in the
manner about to be described.

267. (h) In the first form, as well as in such of
the third as partake chiefly of the same charac-
ter, vascular depletion must be employeil with
greater caution, and as early as possible in the

first stage. I have seen hardly any benefit from
it when the second period of this variety had com-

DROPSY, ACUTE, IN THE HEAD — Tueatment.

tnenced. When the disease has been detected
sufficiently early, and when it has followed pre-
vious attacks of congestion or inflammatory action
in the head, the febrile excitement being neither
general, continued, nor well marked, the applica-
tion of blisters behind the ears, and of leeches
around, or close to, the blisters, has been of
much service. But it will be requisite to repeat
this practice every second or third day, or oftener,
and to carry it as far as the circumstances of the
case may warrant. If the cerebral affection
appear to have been induced by disease of the
digestive and chylopoietic viscera, a blister should
be placed on the epigastrium or right hypochon-
drium, and leeches applied around it, as soon as
redness is caused by it ; when it ought to be re-
moved. This method may be repeated, according
to circumstances, after intervals of one, two, or
three days ; it possesses great advantages in this
state of the disease, inasmuch as, whilst it relieves
the gastric symptoms and the affection of the
liver, it is a most energetic derivative from the
head, without reducing vital power so far as ge-
neral depletion does ; for general bleeding, how-
ever early employed in this variety, is seldom
productive of much benefit. Indeed, I have
seen it detrimental in many instances ; and I
consider both it, and local depletion, if carried to
any considerable extent, as decidedly injurious
in some states of this form, particularly in weak
and cachectic children.

268. jB. Cathartics. — The discharge of morbid
secretions and faecal collections should be pro-
cured as early as possible by remedies calculated,
at the same time, to derive from the brain, and
to diminish vascular plethora and excitement.
The fulfilment of this intention is appropriate to
all the slates of the disease. A large dose of
calomel, either alone or with James's powder,
ought to be immediately exhibited, and, after
three hours, repeated with the addition of toasted
jalap, or scammony ; and its operation should be
promoted by an active terebinthinate enema. If
the irritability of stomach be such as to prevent
the retention of medicine taken by the mouth,
vascular depletion, a blister or mustard cataplasm
on the epigastrium, and an active cathartic ene-
ma, will often remove it. Calomel, in full doses,
will generally be retained, under any circum-
stances ; but, in conjunction with cathartics, it is
frequently ejected, unless after the measures now
stated. Elaterivm, in small and repeated doses,
has been suggested by Dr. Ei,liotson ; but it,
as well as croton oil, will seldom be kept on the
stomach. When retained, they are occasionally
of use. I have seen most advantage derived
from the latter, when it has been added to the
terebinthinate enema, or applied over the abdo-
men as a rubefacient. Dr. Cheyne found a
drachm or two of magnesia saturated with lemon
juice, given every two or three hours, most use-
ful in such circumstances ; and I believe that
this will act more certainly than irritating purg-
atives, particularly if a full dose of calomel have
been taken a few hours previously. A gruel or
broth enema containing some purgative salt
may also be administered two or three times in
the course of the day ; and if the bowels be very
torpid, and the sopor considerable, the terebinthi-
nate enema should be repeated daily, or even
oftener. Saline purgatives may also be given in

Vol. I.

.673

the infusion of senna, when they can be retained.
Active catharsis at the commencement of the
disease, after vascular depletion has been instituted
to an extent which the nature of the case demands,
will have a more decided effect than any other
means whatever.

269. C. Cold applications to the head, the
hair having been removed from it, should be em-
ployed in the manner, and with the precautions,
directed in the article Brain, § 192., whenever
the temperature of the head will admit of them.
But, like the measures already advised, it is only
early in the disease, and in the inflammatory
states more especially, that they are productive
of much benefit. In these states they may be
used simultaneously with the tepid semicupium
or pediluvia, salt and mustard having been added
to the water. Rush, Quin, Conuadi, Formey,
GoELis, and nearly all the writers on tiie disease,
are favourable to cold applications in its treat-
ment ; and, in some form or other, they are ap-
propriate to most of its states.

270. D. Mercurials. — These are, perhaps, the
next important means that can be employed.
They have been very generally prescribed since
they were first adopted by Dobson and Hay-
garth, and subsequently by Eason, ]Mackie,
Reeve, Lettsom, Hooper, Hopfencahtner,
Ferriah, and more recent writers. Early in the

Jirst stage of the disease, calomel, given every
three or four hours, in full doses, either alone or
with James's powder, in small quantities, is, in
ordinary circumstances, the best preparation.
In children under one or two years, neither sali-
vation, nor much intestinal disorder, will be pro-
duced by it. In those above three or four years,
its specific action may be obtained, but with little
certainty, even although it be conjoined with
opium or the compound ipecacuanha powder.
When no essential benefit has accrued from the
foregoing means, and the bowels have been fully
purged as directed above (§ 263.), then calomel
may be given with digitalis and narcotics, or with
the latter only, particularly opium or hyoscya-
mus, with the view of fulfilling the third and
Jifth intentions of cure (^ 263.). But in young
children, especially when the bowels are griped,
or are irritable, the hydrarg. cum creta, with small
doses of compound ipecacuanha powder (F. 653.),
will be most serviceable. The bowels, however,
should always be kept sufficiently free by either of
the enemata recommended (§268.). I may add,
that calomel has been prescribed with eantharides,
by DoBSGN ; with James's powder, by Camp-
bell ; with opium, by Leib and others; with
digitalis, after local depletions, by Weaver,
GoELis, and Fischer ; with digitalis and arnica,
by J. P. Frank ; and with active purgatives (in
which form I believe that it is most generally
beneficial), by Hufeland, Chetne, Abercrosi-
bie, and many others. Dr. JNlERHrMAr* and my-
self have given very small doses of the bichloride
of mercury, every four or five hours, with ad-
vantage. In the second stage, this is one of the
best preparations that can be prescribed ; but it
requires much caution ; and, in this period of the
Jirst and third forms of the disease, it shonld be
prescribed in tonic and diuretic infusions. The
utmost care should be taken in exhibiting mercu-
rials in these forms, particularly io cachectic
subjects, and where the powers of life are much
X X

674

DROPSY, ACUTE, IN THE HEAD — Treatment.

reduced. The state of the gums, mouth, and
tongue, should be always carefully observed
during their use ; for I have seen fatal sloughing
of these parts follow from them in such cases.
The external employment of mercurials has also
been recommended by Campbell and others.
The ointment may be rubbed into the scalp, or
between the shoulders, in the more urgent cases ;
but I have seldom seen advantage derived from
tliis method. Mercurial ointment may also be
employed in dressing blistered surfaces ; or the
liniment may be applied to them on warm bread
and water poultices. This plan has sometimes
been productive of benefit, particularly in children
of two or three years of age or upwards.

271. £. Derivatives and Counter-irritants are
often serviceable, especially in the second stage.
They are also admissible in the Jirst stage of the
first and third forms, when there is little febrile
heat, or when the lower extremities are cold or cool.
Blisters have been very generally preferred by
JMoNDscHiEN, Rush, Odier, Percival, Cheyne,
HopFENGARTNER, GoELis, &c. Much difference
of opinion, however, exists as to the places to
which they should be applied. They may be
placed between the shoulders, on the thighs or
legs, on the epigastrium, and on the neck and
occiput, and behind the ears, in the earlier stages
of the disease ; and in infants they should be re-
moved as soon as they produce redness. In the
Jirst stage they ought to be preceded or ac-
companied by depletions (§266,267.); and in
older children they may be kept discharging
for several days, or be repeated. Some writers,
and especially Portenschlag, White, Hop-

FENGARTNER, SiMMONDS, GaRDIEN, and El-

LiOTSON, have advised them to be placed upon
the head or occiput; but I have never seen be-
nefit derived from them in the former of these
situations, unless in cases where the disease has
followed the suppression of tinea capitis, or in
the second or third stages, when the sopor has
been great; and then the blister may be large,
and the part over the occiput kept discharging
for some time subsequently. In infants, sina-
pisms to the epigastrium, or lower extremities, are
often preferable to blisters in these situations.
The tepid or warm semicupium and pediluvia,
salt and mustard having been put into the water,
are often of use in the second stage, or in the
first, when the extremities are cool ; but when
there are general febrile excitement, and much
heat in the head, they are seldom of service,
unless in a tepid state, and in conjunction with
cold applications to the head after evacuations
liave been directed. The warm bath is less ser-
viceable than the semicupium, and is as often
detrimental as beneficial in the early periods of
the more inflammatory states of the disease. The
vapour hath has been proposed by Dr. A. Hunter.
M. Itard advises it to be impregnated with vine-
gar. This practice is admissible chiefly in the
second stage. Setmis and issiies are too slow in
their effects for this disease ; and the same may
be said of the tartariscd antimonial ointment.
But I have seen benefit result from producing
erubescence by croton oil. In the latter stages,
nrtication may be practised. Moxas I'.ave been
applied to the occiput and behind the ears, by M.
KiitiNAui.T. Dr. AIerriman has had recourse,
in several instances, to the tinclura lyttx ia doses

of from five to ten minims, given every four hours,
until severe strangury was caused by it ; and in
three of these cases the disease was arrested. It
may act beneficially, not merely as a derivative,
but as an excitant of nervous power.

272. F. Sedatives and Narcotics. — (a) Digi-
talis has been much employed in this disease
since it was first recommended by Withering.
Brown, White, Cheyne, and others, have men-
tioned it favourably. Any of its preparations
may be used. Gardien prefers the stherial
tincture, which he directs both internally, anl
externally in liniments. Goelis and Merriman
prescribe half a grain of the powder with a grain
of calomel every four or six hours ; and Wendel-
STATT, any of its formulae with opium. Kleber
advises that it should be rubbed in over the scalp,
with the vinum scilla;. It may be given in both
the Jirst and secqtid stages ; — in the former as a
sedative of vascular excitement ; in the latter, to
modify the state of the capillary circulation, and
prevent effusion. Much discrimination, how-
ever, is necessary in distinguishing the effects of
this medicine from the symptoms of the second
stage — particularly the vomiting, slowness of
the pulse, and dimness of sight. Dr. Cheyne
points out certain differences between them ; but
they cannot be relied on. The sopor and stra-
bismus, however, of this stage will generally dis-
tinguish it from the depression produced by
digitalis. When this substance is prescribed in
the first stage, it should be given at once in a full
dose, and be repeated every four or five hours.
In the second stage it may be conjoined with
squills, the spiritus aetheris nitrici, or with ser-
pentaria, or the decoction of the flowers of arnica,
as advised by several German physicians. Col-
chicum has also been employed in this disease,
within the last few years, with the same inten-
tions as digitalis. I am unable to speak of its
eflfects, as 1 have considered it less appropriate
than this and some other remedies. It may,
however, be prescribed in the same stages as
digitalis. Little benefit can be hoped from it,
especially in the second period, unless it act upon
the kidneys or bowels.

273. (6) Opium. — Percival, Odier, Cramp-
TON, Brooke, and many of the writers already
referred to, recommend this substance in the
second and third stages, particularly when the
pain in the head, the convulsions, and irritability
of the stomach and bowels, are very prominent
symptoms. In the earlier part of the second
stage it may be given with calomel, James's
powder, or antimony. When the bowels are
very irritable, without sickness at stomach, it is
preferable in the form of Dover's powder, with
hydrarg. cum creta ; and, when the general irri-
tability is great, or the convulsions violent or
frequent, with full doses of digitalis. Later in
the disease, I have seen benefit from it in small
doses given in the terebinthinale enema directed
above, or with serpentaria, or diuretics, Ilyoscy-
amus may be employed with the same intentions,
and in similar states of combination, as opium ;
but I doubt its being equally efficacious.

274. G. Antimonials. — The potassio-tartrate of
antimony, in large doses, — in from five to twenty
grains in the twenty-four hours, — has been ad-
vised by the followers of the new Italian doctrine,
and employed successfully by M. Laennec in a

DROPSY, ACUTE, IN THE HEAD — Treatment.

675

few instances. Although long in the habit of
having recourse to this practice in pulmonary
and some other diseases, 1 have had no experience
of it in acute hydrocephalus. Small doses of
James's powder with calomel, or with calomel
and active cathartics, or with calomel and opium,
as prescribed by Dr. Cheyne, appear the most
judicious mode of directing this mineral. I have
seen, however, benefit follow moderate doses of
the potassio-tartrate of antimony, either with or
■without opium, as recommended by Dr. SIills,
in the first stage of the disease, when vascular ac-
tion and febrile excitement were great.

275. H. Diuretics, S^c. can be but little con-
hded in ; yet I have believed them to have been
of much service in the second and third stages
of some cases. The most energetic is certainly
tlie spiritus terebinthinae, in the form of enema,
or of liniment rubbed on the scalp. Squills,
digitalis, spiritus Etheris nitrici, spiritus juniperi,
or hydro-chloric aether, — formerly Glutton's
febrifuge spirit, — may be used, in these periods,
with small doses of opium, or with a weak infusion
of serpentaria, or decoction of the flowers of arnica.
Ei.AjANi and Kleber prefer squills to other diu-
retics ; and I believe that they are not altogether
without efficacy.

276. I. Palliatives and Restoratives. — The
pain in the head and vomiting are to be relieved
by the local depletions, — behind the ears and
from the epigastrium, — and blisters in these situ-
ations ; by the cold afi'usion on the head ; by
calomel with opium, and by the terebinthinate
enema ; or a warm terebinthinate epithem or
sinapism placed over the stomach, till redness is
produced. Convulsions, in the earlier periods, will
be abridged by the cold afl'usion, and most cer-
tainly by the enema just recommended. A to-
bacco enema ought not to be hazarded. The
oxide of zinc, or musk with ammonia, or with
small doses of opium may also be employed to
relieve this symptom in the latter stages. I be-
lieve that practitioners in this country* have been
too often deterred from the use of restoratives in
the advanced periods, particularly of the nervous
form of the disease. I have, in several instances,
seen benefit follow the cautious exhibition of them
along with diuretics and enemata with assafoetida.
The preparations of ammonia with tincture of
squills ; or camphor mixture with magnesia, the
tincture of valerian, and syrup of roses ; or the
weak infusions of arnica or of serpentaria, with
liquor ammoniaa acetatis, digitalis and syrup of
squills ; or a weak infusion of green tea, either alone
or with digitalis, and spiritus aetheris nitrici ; and
either of these, with a drop or two of laudanum,
in small doses at short intervals, are the medicines
I have most frequently had recourse to in the latter
stages; allowing the patient beef tea, warm jellies.

* The following is an abstract, made in my note book
many years since, of the practice of the most able German
physicians in this disease. In the nervous or typhoid
variety, co\A applications to the head, sinapisms to the
arms and legs, and purgative clysters. If these fail,
digitalis, with the decoction of flores arnicae or infusion
of serpentaria ; blisters from the occiput to between the
shoulders to be kept open, the inunction of mercury three
or four times a day ; and, if the vomiting persist, sina-
pisms on the epigastrium. Subsequently musk and am-
monia, chiefly on account of the convulsions. In t/ie
inflammatory form, and in that consequent on the exan-
themata, local bleedings, digitalis, calomel and jalap, and,
in the latter stages of these forms, the treatment directed
for the nervous or typhoid variety.

&c. in addition. In several cases approaching the
sub-acute form of the disease, I have prescribed a
solution of the iodide of potassium indistilled water,
with or without a little iodine added to the solu-
tion, in small but frequent doses, and with evi-
dent advantage. In a few cases, the compound
infusion of roses, or a weak infusion of cinchona,
or of valerian, have been given with some aro-
matic water, and with squills or spirits of nitric
a?ther.

277. Treatment of the hyper-acute Hydro-
cephalus.— But little can be done in this form
of disease, owing to the circumstances under
which it usually occurs, and to its severity as well
as rapidity. In cases consequent upon exhaus-
tion, the sopor or coma being profound, a blister
on the head, the terebinthinate enema, and the
treatment advised for the advanced stages of the
acute hydrocephalus, are most likely to be useful.
When it appears with less evident signs of ex-
haustion, leeches to the occiput or behind the ears,
or cupping between the shoulders ; active de-
rivatives ; a cold terebinthinate epithem applied
around the head, and a blister on the epigastrium,
with such internal medicines as the circumstances
of the case require, conformably with what has
been above stated ; seem to be the most active
and appropriate measures. The bowels should be
energetically acted on, by medicines given by
the mouth and exhibited in enemafa whenever
the malady has not been consequent upon diar-
rhoea. When it supervenes during, or soon
after, the eruption of any of the exanthemata,
particularly scarlet fever, it is more or less inflam-
matory, and requires very decided treatment.
Bleeding from behind the ears, or nape of the
neck, should be carried as far as an attentive
observation of its effects will indicate, par-
ticularly in children that have been well fed ;
and the rest of the remedies now advised, and
especially the active enemata already directed,
should be promptly, or even simultaneously, em-
ployed.

278. In the sub-acute form of hydrocephalus,
a similar treatment to that which has been re-
commended for the acute, should be adopted
early in the disease ; vascular depletions being
then practised, according to the circumstances of
the case : and when it seems disposed to pass into
a more chronic state, small doses of iodine, or of
any of its preparations, should be given during the
day. A few grains of hydrargyrum cum creta,
with digitalis, may be also taken at bed-time, and
blisters be applied behind th« ears, and kept dis-
charging for some time. The bowels ought to be
freely opened by the means already advised, espe-
cially the terebinthinate enema ; and, in the latter
stages, the same measures as have been directed
for these stages in the more acute states of the
malady should be prescribed". If the disease as-
sume a chronic form, the treatment about to be
recommended (^297.) will then be necessary ; but
I have seldom seen benefitdetived from any mode
of treatment in such eases, probably owing to
tlie disorganisation that has taken place in the
brain.

279. Diet, ETC. — During the early periods of
the disease, cooling diluents only, given fre-
quently and I in small quantities at a time, are
required ; but in the latter stages, particularly
when the emaciation and debility are consider-

Xx 2

676

DROPSY, CHRONIC, IN THE HEAD — Causes.

able, suitable nourishment is necessary. If the
child be still at the breast, the milk of the mother,
or of a healthy nurse, in moderation; or asses'
milk, beef tea, jellies, and the various farinaceous
articles of food suitably prepared, are generally
the most appropriate. During convalescence, the
same kind of nourishment must be adopted for
some time, but in more liberal quanlities ; and
animal food should, at first, be cautiously and
sparingly employed. Gentle tonics may also be
exhibited, as a weak infusion of cinchona, or the
compound infusion of roses. German writers
prefer a weak infusion of valerian ; and my ex-
perience leads me to concur with them. Either
it or the infusion of cinchona, may be given with
magnesia, wliich will render it less unpleasant,
and gently aperient ; and, if the urine be not suf-
ficiently copious, a little tincture of squills, or
compound tincture of colchicum may be added;
or the compound infusion of roses may be taken
with a neutral salt. In the latter stages of the
disease,"or during early convalescence, if the secre-
tions and excretions be morbidly increased, suit-
able nourishment, as well as restorative medicines,
should be administered more liberally than in
other circumstances ; but, in every instance, the
influence of the diet and of the remedies, upon the
pulse, the temperature of the head, and the general
surface, ought to be carefully watched. Change
of air to a warm and dry situation, or, in summer,
to the sea-side, will have a very beneficial effect,
and should be adopted as early in convalescence
as possible.

280. Prophyi-actic Treatment. — We are
frequently consulted in the cases of children who
are drooping in health, or who evince incipient
symptoms of cerebral disorder ; and even re-
specting those who have no manifest ailment ; but
for whom, owing to the circumstance of one or
several of the children of the family having had
the disease, measures of prevention become abso-
lutely requisite. The best of these are, — 1st, the
increasing of the abdominal and cutaneous secre-
cretions and excretions — 2d, the establishing
an artificial irritation and discharge ; — 3d, strict
attention to diet and regimen ; — and, 4th, change
of air. — (a) The evacuations should be carefully
examined ; and, when the bowels are sluggish, or
the bile deficient, hydrarg. cum creta, or calomel,
with rhubarb or jalap, should be given at bed-
time, in gentle doses. James's powder should
also be prescribed, whenever the skin becomes
dry, either alone, or with small doses of calomel.
— (ft) Issues, moxas, or repeated blisters, may
be employed with the second object. Blistering
behind tlie ear, the discharge being kept up for a
considerable time, is very beneficial. Issues,
either in the usual way, or by means of the inner
bark of the mezcreon, or scraped horseradish,
will also be very eflScacious. Dr. Cheyne refers
to llie circumstance often children in one family
having died of the dise;ise; the eleventh, for
whom this means was employed, having been
preserved. I'he nape of the neck, the occiput,
or the upper arm, are tlie most suitable situations
for issue-. — (c) Moderate diet, and that chiefly
farinaceous, of a bland (juality, and easy of
digestion, is extremely re<iuisite. All stimulating
aliments or drinks ; warm opiates, and loo much
animal food, are very injurious. Children should
also be instructed not to retain any of the ex-

cretions after the first intimations to evacuate
them ; and their limbs and trunk should be freed
from all close cinctures. Premature, or too
great, exertion of their intellectual powers, par-
ticularly in forward or quick children, should be
guarded against ; and sufficient exercise in the
open air should be imposed on them. — (d) In
recommending change of air, the nature of the
locality should not be overlooked. A dry, warm
air is the most appropriate to hydrocephalic
cases.

ii. Chronic Dropsy in the Head. — Chronic
Hi/drocephalus.

281. Defin. — Effusion of a Hmpidjiuid in the
ventricles, commencing previously to, or soon after
birth ; frequently with enlargement nf the cranium ;
and generally either unaccompanied by acute
symptoms, or supervening gradually with signs of
debility.

282. — Chronic hydrocephalus has been stated
above (§ 177.) to occur most frequently before
birth, and sometimes to occasion the death of the
foetus. Some females have given birth to a suc-
cession of hydrocephalic foetuses, either dead or
alive, at some time during the latter months of
utero-gestation. In such cases, the effusion is
usually connected with defective developement of
the cerebral organs, and with some other mal-
formation or congenital disease. When it conies
on after birth, it either commences so insensibly
as to escape notice, until far advanced, or it is
attended by symptoms of increased excitability of
the nervous system : it seldom is consequent upon
the acute disease, or upon other maladies. Boehme
and WiGAND believe that an hereditary dis-
position to be affected by chronic hydrocephalus
after birth exists in some children ; and Rosen-
stein, Strove, Loder, Goelis, and Breschet
consider, that, when not congenital, it usually
begins a few days or weeks after birth, and very
rarely after some months or years. It may, how-
ever, occur in old age. Goelis mentions a fewr
cases of this kind ; but they seldom are of long
duration. Instances are not uncommon of con-
siderable collections of fluid having formed in the
ventricles of the brain, consecutively either of
chronic diseases of the thoracic or abdominal
viscera, or of prolonged affections of the brain
itself, in persons far advanced in life; but these
usually take place a short time only before
death.

283. A. The Causes of chronic hydrocephalus
are chiefly those assigned above as productive of
congenital dropsies (§ 185.) ; family and consti-
tutional predisposition, and a scrofulous and
ricketty diathesis. Goelis states the circumstance
of a mother having had successively six dead-
born hydrocephalic children, at the sixth month ;
and three which became hydrocephalic after
birth ; and .1. P. Frank mentions another, who had
seven children similarly diseased. The frights,
passions, and diseases of the mother during gest-
ation, have apparently some eflPect in producing
this disease of the foetus ; and weakness of consti-
tution in either parent is evidently not without
a similar influence. M. Breschet thinks that
the old age of the father is an influential cause;
and I believe that both it and drunkenness in the
mother may be included in the enumeration.
This writer states, that a drunken man of about
sixty, married to a young and healthy woman.

DUOPSV, CHRONIC, IN' THE

had three hydrocephalic children. Independently
of diseases of the appendages of the foetus, some-
thing, perhaps, may be imputed to the dress of
the mother, particularly if it be sucii as may em-
barrass the developement of the uterus ; for it has
been observed by several pathologists, particularly
GoELis and Breschet, that hydrocephalus has
occurred more frequently, either previously to,
or soon after, birth, in the children of unmairied,
than in those of married, females. Injuries ex-
perienced by the mother during pregnancy, and
by the infant during parturition ; improper diet
and regimen of the infant ; exhausting affections
of its digestive organs; difficult, delayed, and
disordered dentition, particularly when attended
by disease of the prima via, and emaciation; as
well as the causes assigned for the acute disease ;
may all occasion this species of it. Goelis states,
that a physician in Vienna, an ardent admirer of
the doctrines of Brown, allowed his children wine
and other stimulants from their birth ; they all
rapidly became emaciated, and died with chronic
hydrocephalus.

284. B. Varieties. — Chronic hydrocephalus
is most frequently idiopathic or primary ; com-
mencing during the latter months of foetal life,
and sometimes after birth; and is occasionally
consecutive or symptomatic o( severe and exhaust-
ing diseases of the abdominal or thoracic viscera.
It may be accompanied — (a) by a diminution of
the size of the head, a variety which is always
congenital ; the fontanelles being frequently
closed, and the sutures united, at birth ; — (6) by
a normal size of the head ; — and (r) by more
or less increase of the volume of this part. — a. In
the first variety, the head has a conical form, being
depressed laterally and anteriorly. The eyes are
in constant motion, insensible to the light, and the
pupils dilated. INIost of these infants die in convul-
sions, either soon, or a few weeks after birth, and
but very few live a few montlis, or a year or two.
Those who live so long are entirely deprived of
sense, and of every intellectual manifestation.
Their appetite is generally voracious, but nutrition
is very imperfect. Their legs are crossed and
drawn up, and the feet distorted. The excretions
are all involuntary, and life with them is entirely
vegetative.

285. 6, The second variety, or that in which
the head is not materially increased in size, is sup-
posed, by GoEEis and BnEscnET, to be the most
common ; but I think that such is not the case.
It may be congenital, or may appear any time
subsequently to birth. The writers now referred
to believe that it is most frequent during youth
and puberty, but that old age is not exempt from
it. When chronic hydrocephalus occurs after
the closure of the fontanelles, this necessarily is
the form it most frequently assumes. Selle has
termed it cephalic dropsy. The symptoms of this
are the same as those of the next variety.

286.)/. The third variety, or that with increased
volume of the head, according to my own experi-
ence, is the most frequent. It is very often con-
genital, the size of the head even in the foetus be-
ing enormous. More commonly, however, the
volume of the cranium is not much augmented at
birth, but becomes so very rapidly afterwards.
When the patient lives so long, the increase of
size is slower after the third or fourth year, and
ceases at the age of manhood, at which period the

HEAD — Varieties — Svmpto.ms. 677

cranial bones are firmly united. When the cra-
nium is very much enlarged, the countenance pre-
sents a nearly triangular form, owing to the bones
and the lower features of the face retaining their
natural size, or being smaller than usual. As the
disease proceeds,, the sutures are more and more
separated — sometimes so far as to admit of fluctu-
ation being felt, as remarked by Tulpius, Dreys-
siG, Monro, and others. The veins of the neck
become enlarged, (Lentin saw them varicose);
the carotid arteries pulsate with much force ; and
the head generally hangs on one side, or on the
breast. Owing to the unequal yielding of the
cranial parietes, some one pan of the head is oc-
casionally more prominent than another. The
eyes are generally watery, covered by the eyelids ;
the pupils dilated, directed upwards, — occasion-
ally downwards, (Feller, Goelis, Schmidt), —
and sometimes horizontally to either commissure
of the eyelids. The senses, the intellectual facul-.
ties, and the locomotive organs ajad functioas, be-
tray more or less disorder. Sight is first impaired,
and all the other senses subsequently fail ; the
countenance is pallid and without expression ;
the complexion of the surface is unhealthy ; the
body emaciated; the gait unsteady; and the
power over the muscles ultimately lost.

287. C. Symptoms. — (a) It is important to
ascertain the symptoms indicating the commence-,
went of the malady, in such eases as occur, or
seem to occur, after birth. In many instances,
however, these are so slight as to be overlooked
both by the nurse and the physician ; and the age
of tlie patient generally precludes many of them
from being discovered. According to Goelis, the
nervous system is uausually excitable, the temper
irritable, and the sense of smell perverted. At this
period the eye is brilliant (Frank, INIichaelis,
Schoeffer), but the sight soon becomes more and
more imperfect. Vooel and Monro have no-
ticed pains in the globe of the eyes, that subside as
the effusion is increased. The nose is dry, subject
to itching, and is frequently picked by the patienj.
Hearing is, at first, morbidly acute, sudden noises
sometimes inducing convulsions ; but it soon be-
comes obtuse, and often altogether lost. Dis-
charges from the ears are rare. The senses of
touch and taste remain the longest. Rotation of
the head occasions vertigo, or stupefaction ; and,
if the fontanelles be not closed, pressure on them
produces convulsions, which sometimes supervene
spontaneously at night. Sleepiness, or stupor;
dull pain, or heaviness of the head ; grinding of
the teeth during sleep, the patient sometimes ut-
tering a piercing or peculiar cry upon being
awakened ; and defect of memory ; are also ob-
served. Thus early in the disease, the appetite is
often irregular or voracious ; there is sometimes
vomiting ; the bowels are commonly constipated ;
and the urine diminished. Articulation is gene-
rally slow, nasal, or difHcult. During this period,
if the patient be old enough, he commonly is able
to go about ; but he is very feeble, and loses flesh.
He ;Walks, however, with great diflficulty ; totters ;
places one leg in the way of the other, and turns
the toes inwards. Anger, and joy, are expressed
with great vehemence ; and the mental manifest-
ations are more or less weakened or deficient.
Such is the first period of chronic hydrocephalus ;
but it most frequently comes before the physician
when the second stage has supervened.
X x 3

678 DROPSY, CHRONIC, IN T

288. (6) ScHMALZ, Feiler, Goelis, and
others, coasider the copious flow of saliva from the
mouth — wliich is always open — as indicating the
second stage of the disease. When the patient can
speak, he is now at a loss for words, or forgets them
as he is about to utter them, and his voice is sad
and monotonous. He is no longer able to go
about ; and is often sick. The bowels continue
sluggish, and the urine scanty. The erect and
sitting postures ai;e attended by retchings, or ver-
tigo, or pain in the head and stupefaction. The
pupils are dilated ; sight is more or less completely
lost ; the eyes roll from side to side ; and squint-
ing is sometimes observed. The pulse is small,
irregular, and occasionally intermittent. Respira-
tion, which was, in the first stage, scarcely affected,
is often somewhat difficult, in some cases suffoca-
tive, and attended by a nervous cough. The
position is often with the bead very low, or drawn
backwards ; or upon the abdomen, with the face
sunk in the pillow (Feiler and Breschet) ; and
automatic movements of the limbs are frequent.
Deglutition becomes difficult; but the appetite is
still unimpaired, or even increased. All the senses
and mental powers are more or less injured, or
nearly lost.

289. (c) The third and last period may be said
to commence with the involuntary discharge of
the excretions, and abolition of all the senses ;
the patient lying with the lower limbs paralysed,
or drawn up to the abdomen. Towards the close
of the malady, the extremities become cold, damp,
and often cedematous ; the whole body extremely
emaciated; and, if the patient has all his teeth,
they are frequently worn to the stumps by the
constant grinding of them in the early stages.
Ultimately, either the symptoms of acute hydro-
cephalus, sometimes with convulsions, or those of
apoplexy or coma, come on, and terminate life.
Occasionally the patient is carried off by a pa-
roxysm of convulsive or suffocative cough. The
duration of these periods, especially the second
and third, is extremely uncertain ; and not infre-
quently very prolonged.

290. (d) Such is the usual progress of the dis-
ease, especially when it has seemed to have com-
menced after birth. But in these, as well as in
such as have been congenital, modifications or
anomalies present themselves. The senses and
intellects may be quite unimpaired; or certain
senses or faculties, only, may be impaired or lost,
althougli the head is remarkably enlarged. The
moral emotions, in such cases, are sometimes af-
fected ; the patient being passionate and vindic-
tive ; and fits of anger often excite convulsions.
The sexual organs are sometimes prematurely de-
veloped, and the venereal desires strong even in
children of both sexes. Great differences also
exist as to the closure of the sutures and fonta-
nelles ; which very frequently remain much longer
open than natural, especially when their separation
has been considerable. Cavai.i.ini mentions a
case, in which the fluid continued to ooze from be-
tween the sutures for some time before death ; and
Dr. Bahon and Mr. l\Iir,j-i,n have recorded in-
stances wherein it dribbled from the nostrils, the
dura muter having been ruptured, some days or
weeks before dissolution.

291. (e) The size of the cranium is sometimes
enormous, liolli previously, and subsequently, to
birth. It is frequently, in the foetus, increased to

HE HEAD — SvMrTOMS, ETC.

fifteen, seventeen, or twenty inches in circum-
ference. WitisBERG records an instance in which
it reached thirty inches and half. Meckel has in
his museum the skeleton of a hydrocephalic fuetus
of seven months, the horizontal diameter of whose
cranium is sixteen inches, and the vertical diame-
ter— from the occipital hole to the vertex — fif-
teen, being a circumference of forty-eight inches.
And cases in which the head had acquired the
volume of seventeen, twenty-five, twenty-nine,
thirty, and thirty-one inches, soon after birth,
have been recorded by Lechel, Malacaune,
WiLLAN, Baron, BLjttner, and Miller re-
spectively. It is only, however, the cranial part
of the head which is thus distended ; the bones of
the face generally retain the natural size, or are
developed in an inferior degree, especially in those
cases which are prolonged to, or which pass the
period of, puberty. The only instance in which
the contrary was observed, is recorded by Har-
TELL, — the bones of the face having in that
case acquired such a size as to resemble those
of a giant. The form of the head is often not
materially different from that of the foetus ; but,
as the collection becomes greatly increased, it
commonly extends in the direction of those parts
where ossification is the least advanced. In some
cases, one side either is more elevated, or is pro-
truded more anteriorly or posteriorly, than the
other, or both, the cranium assuming an oblique
form in all its aspects.

292. (f) The Duration of the disease varies
extremely. It has already been stated to termi-
nate fatally in the fcEtus at any time during the
latter months of pregnancy, or immediately, or
shortly, afterbirth. Whether it commence previ-
ously, or subsequently, to birth, its duration may
be indefinitely prolonged from some weeks to a
number of years. Hartell, Malacarne, Mil-
ler, and Goelis adduce instances of hydrocepha-
lic patients having lived seventeen years ; Loder
mentions one aged twenty-two years ; Breschet,
another who was twenty-eight ; Michaelis saw
a case aged thirty ; Buttner, one at thirty-one ;
Schneider, one at forty-three; Aurivill, an-
other at forty-five ; SciiOMnERC, an instance of its
having been prolonged to forty-eight years ; and
Gall, another, where life was prolonged to fifty-
four years. A patient died a few years ago, in
Guy's Hospital, at the age of thirty-two years:
his head was thirty-three inches and a half in cir-
cumference ; his appetite and digestion were un-
diminished ; and his mental powers not much im-
paired. Walking induced vertigo ; and costive-
ness, convulsions. Coma came on a few weeks
before death, and passed into fatal apoplexy.

293. D. Appearances ON Dissection. — The
cranial bones are generally found very thin, flex-
ible, sometimes transparent, occasionally wider
than usual ; and the osseous fibres imperfect and
radiated. In very young subjects, the bones are
separated from each other by a greater or less
interval ; which is filled up, in somewhat older
cases, by distinct points of ossific deposit, wliich
ultimately constitute the ossa Wormiana. In rarer
instances, the bones are thicker than natural, as in
those recorded by IIarteli,, Reidlin, Alhinus,
MoLLiNEUx, Sandifort, uud Loder. The ossa
Wormiana are, at first, scarcely in contact with
the margins of the normal bones ; but when the
case Ims been protracted, they fully occupy the

DROPSY. CHRONIC, IN THE HEAD — PnocNosis.

679

space, and ultimately become indented into, or
nearly consolidated with, them. Entire obliter-
aii(m of the sutures is very rare. The Jiiiid is ge-
nerally effused in the ventricles, — always when
the disease commences after birth ; and but
seldom in the general cavity of tke arachnoid,
excepting in the congenital disease ; when the
cerebral hemispheres are sometimes either partially
or entirely wanting, the base, the pona Varolii, &c.c.
only existing. When much fluid is effused into
the ventricles, the brain is distended, its convo-
lutions are unfolded, and it is reduced to a sac, thin
in proportion to the distension ; its structure with
difficulty, or not at all, admitting of being distin-
guished into cineritious and medullary substance.
The corpus callosum is much raised, and thin-
ned, and the septum lucidum torn ; the lateral
ventricles communicating freely with tlie third,
and this with the fourth, the whole forming one
cavity. The cineritious substance is of its usual
consistence ; but the medullary is generally
firmer than natural. The brain, however, does
not appear to be diminished by interstitial absorp-
tion, as its weight is not materially less than the
healthy brain at the same age. The arachnoid
is occasionally whitish, opaque, and in some
places thickened. The choroid plexus often con-
tains small cysts ; and the corpora striata, as well
as the thalami optici, are small and flattened.
The parts near the base of the brain, in some
cases, present only slight alterations, varying
with the duration of the disease, and the extent
of the eftusion ; and, in other instances, they are
so much changed, as hardly to be distinguished
the one from the other. The cerebellum is seldom
materially altered. The quantity of fluid varies
from ten to twelve ounces to as many pounds ; and
cases are recorded of as much as ten or twelve
quarts having been found. Fabricius Hildanus
(cent. i. obs. 10.) found eighteen pounds ; and
hoyET (Sepulchret.\, i. sect. xiv. obs. 11.; see
also Ephemer.Nat. Cur. dec. iii. an. i. obs. 10.)
twenty-four pounds. The unaliises of Bostock,
Marcet, Bareuel, Berzelius, and John, agree
in showing that this fluid is of the lowest specific
gravity, and contains the smallest quantity of
albumen, and of saline ingredients, of all the
dropsical fluids (§ 11.). Although in the con-
genital form of hydrocephalus, the formation of
the brain may have been so early arrested, as to
occasion the absence of a great part, or of the
whole, of it, yet its envelopes — the cranial bones,
the dura mater, the arachnoid, and even the pia
mater — may exist nevertheless. In some cases,
the falx cerebri is wanting (Breschet), and,
according to some authors, the pia mater also ;
yet it seems to be generally present, but so thin,
from the distension of the fluid, as to be detected
with difficulty. The arachnoid is more dense, and
less transparent than natural.

294. In the case that occurred, some years ago,
at Guy's Hospital, upwards of ten pints of fluid
were contained in the great sac of the arachnoid,
with which the ventricles communicated freely,
the corpus callosum being wanting. The brain
was lodged at the bottom of the immense cranial
cavity ; was somewhat flattened ; and its con-
volutions unobliterated and unfolded. In a case
recorded by Dr. Baron, the dura mater was
found ruptured; a tumour of the cranial integu-
ments having taken place over the seat of rupture

some time before death. In a case described by
Dr. Duncan (Trans, of Med.-Chirurg. Soc. of
Edin. vol. i. p. 205.,) the dissection of which
was made by Dr. Gordon, the circumference of
the head was twenty-nine inches and a half, and
the fluid was contained in the general sac of the
arachnoid, with which the ventricles freely com-
municated ; the corpus callosum and fornix being
entirely wanting, as in the case noticed above ;
the brain thus having a bifid or cleft appearance.
A nearly similar instance is recorded by Mr.
LoFTiE, in the ]\Ied!Cal Observations and Inquiries,
(vol. v. p. 121.). In the one published by Mr.
IMiLi.ER (Trans, of Med. and Chirurg. Soc. of
Edin. vol. ii. p. 245.), the dura mater was rup-
tured, and water seemed to have been lodged be-
tween it and the cranial bones, as well as in the
general sac of the arachnoid. But it seems pro-
bable from the appearances observed, that the
fluid had been originally in the ventricles, from
whence it had escaped by a lacerated opening,
caused by their uncommon distension ; nearly
nine pints of fluid having been found.

295. Chrome hydrocephalus, especially the
congenital, is often associated with other vices of
conformation (Meckel, Osiander, Murray,
Deslandes, Otto, Autenreith, Breschet, &c.),
as with cleft palate, single or double hare-lip,
spina bifida (§ 178.), imperforate anus, distorted
or club foot, and absence of one or more of the
abdominal viscera.

296. E. Prognosis. — When the disease is
congenital, as it most frequently is, even although
it may not become manifest until some days or
weeks after birth, or when it appears soon after
birth, little or no hope of benefit from treatment
can be entertained ; for, in such cases, it is often
dependent upon imperfect or arrested develope-
ment of the brain. When, however, it is either
obviously, or very doubtfully, not congenital, I
agree with Richter, Dheyssio, Blane, Por-
TENscHLAG, GoELis, CoNQUEST, and somc others,
in considering that it often admits of cure, par-
ticularly if it be treated early, if it be uncom-
plicated, and if the powers of the constitution be
not much impaired. J. P. Frank states, that he
has seen it disappear upon the occuirence of
scrofulous disease in another part. Goelis and
most other writers have seen more or less advan-
tage accrue from spontaneous eruptions and sores,
particularly behind the ears, and from chronic
discharges from the bowels and skin, if they do
not much reduce the patient's strength. When
the disease occurs in those of a manifestly scro-
fulous or syphilitic taint ; or follows the acute ;
or is far advanced ; strangulating cough, difficult
or suffocative respiration, coma, frequent con-
vulsions, delirium, or other symptoms of the last
period being present; hardly any hopes of recovery
should be entertained. The exanthemata or
hooping cough occurring in its course, generally
induce a fatal termination in a short time. Its
complication with hydrorachis, or with other
forms of dropsy, is also very unfavourable.

' 297. F. Treatjient. — The indications of cure
are, — 1st, to subdue irritation in the encephalon,
when the symptoms of the first stage indicate its
existence ; 2d, to counteract the disposition to
aqueous effusion into the ventricles; 3d, to remove
the fluid, and prevent its re-circulation; and 4th,
to palliate urgent symptoms. — a. The ^rst of
X X 4

680

DROPSY, CHRONIC, IN THE HEAD— Treatment.

these intentions applies chiefly to those cases
wliich occur subsequently to birth, and when
evidence of nervous excitement or vascuhir irri-
tation can be detected. In such cases, one, two,
or more leeches, according to the age and strength
of the infant, should be applied behind the ears,
and means used to drive the irritation to some
part of the cutaneous surface, or to the intestinal
canal. In the majority of instances, the same
measures as will subdue irritation, will also tend
to the fulfilment of the secnnd indication ; more
especially mercurials, aperients, purgatives, and
artificial eruptions and discharges. In the use of
this last, much circumspection is requisite ; for
tartar emetic ointment, or blisters kept open, may
produce sloughing sores in young and delicate
children.

298. b. To fulfil the second intention, various
measures have been recommended, — a. Goelis
places most reliance upon small doses of calomel,
— from a quarter to half a grain twice a day;
and on the mercurial ointment applied to the
head, either alone or with an 'ointment of juniper
berries. He advises a flannel cap to be, at the
same time, worn constantly upon the shaved
scalp to promote the insensible perspiration.
This covering, in a few days, becomes charged
with the ointment or ointments employed, and
thereby tends to bring the system more quickly
and fully under the influence of mercury. But
affecting the constitution with mercury will rarely
remove the disease ; and, in very weak children,
will only reduce more rapidly the powers of life,
to which we should chiefly trust, as the more im-
mediate agent by which this indication is to be
fulfilled. My experience leads me to confide
more in the hi/drarg. cu7n ereta than in calomel,
in most cases of this disease. The best part of
the treatment resorted to by Goelis is the daily
use of mildly stimulating baths. I have seen
considerable advantage derived from them, es-
pecially when those first employed contained an
alkali. Various tonic, astringent, diuretic, or
slightly stimulating substances or infusions may
be directed in this manner ; as well as the pre-
parations o( iodine, or the nitro-hi/drochloric acids in
very weak solution. M. Recamier states, that
benefit has been derived from baths holding tartar
emetic in solution ; this substance being gradually
increased to three or four times the quantity first
employed ; and that tt acts as a diuretic.

299. In those cases, especially, which have
commenced after birth, all morbid secretions and
faecal accumulations having been removed from
the prima via, by purgatives and cathartic enemata,
from one to two or three grains of hjdrarg. cum
creta should be given night and morning, and the
scalp shaved, if the head be quite cool, and
without signs of vascular excitement, it should be
kept moderately warm, and washed daily with a
weak,tepidsolutionof the nitro-hydrochloric acids ;
the baths now recommended being also employed.
'J'his treatment, with proper diet and regimen,
should be tiied for some days, especially in deli-
cate children ; but in those who are stronger, it is
preferable to exhibit, once, twice, or tlirici! a day,
from five to ten or twenty minims of oleum teie-
binthins, with from twenty to forty or fifty of
oleum ricini, according to the age of the patient,
and effects produced upon the bowels and urinary
organs. For infants, iliese oils may be mixed in

syrup ; but, by older children, they will be most
easily taken on the surface of fennel water, or of
milk. \Vhen this medicine does not act fully on
the bowels, it may irritate the kidneys or produce
strangury. In this case, it should either be inter-
mitted for a few days, or given in larger doses, at
longer intervals — or sometimes only twice or thrice
a week — so as to act as a gentle purgative. An
enema containing from one to four or five drachms
of each of these oils, according to the age of the
child, may also be administered every third or
fourth day, in a suitable vehicle, either in addition
to the above medicine, or when it is not prescribed ;
and the liniment (f. 311.) maybe rubbed once
daily upon the loins, or over the shaved scalp,
the head being covered by a thin flannel cap.
The hydrarg. cum creta should also be taken night
and morning; and, if these oils be not employed
so as to act sufficiently upon the bowels, as they
ought, a full dose of calomel, or an active ca-
thartic, should be occasionally given at bed-lime.
The above treatment was, for thirteen years, very
generally adopted by me in chronic hydrocepha-
lus, at the Infirmary for Children ; and, in many
instances, with marked success.

300. B. In other eases, particularly in private
practice, and where the measures now detailed
are not regularly pursued, owing to their unplea-
sant nature, a course of iodine should be entered
upon, and continued for some weeks ; but the pre-
parations of this substance ought to be exhibited
in doses which will not gripe or olherwise irritate
the digestive canal ; the alterative mercurial being
taken at bed-time, and an occasional cathartic, or
a terebinthinate enema, administered in the morn-
ing, during the course. If evident advantage
follow not the iodine within a fortnight or three
weeks, a liniment (F. 302.) or ointment (F. 767
— 769.) of it, or an ointment of the iodide of
mercury should be rubbed upon the head twice
or thrice a day. If it occasion irritation in the
scalp — which will seldom be the case with the
preparations now referred to — the circumstance
need not be considered unfavourable. If the
internal course of iodine be not adopted, gentle
aperients and diuretics, with mild tonics, should
be taken in the course of the day. The above
plans of treatment I huve found more successful
than any other ; but they require great discrimin-
ation, and nice adaptation to the circumstances of
the case -. — that by the terebinthinated medicines
has appeared most beneficial in the stronger chil-
dren ; and, whilst it has acted freely on the
bowels, it has often greatly increased the quantity
of urine : that by iodine is better borne by delicate
children, but its operation is slower, than the
former. The mouth sometimes becomes affected
by the mercurial preparation during either of these
courses, particularly in the older cliildien ; but
this is to be viewed as a favourable occurrence. As
long as the powers of the system continue but little
impaired, and the patient does not lose flesh, either
the one or the other course should receive a full
trial ; light and suitable nourishment being given,
and the bowels kept freely open, always avoiding
the supervention of diarrhoea.

301 . y. When these internal and external means
fail of affording evident benefit in a few weeks, or
when they cannot be satisfactorily tried, blisters
should be applied, or issKes inserted behind the ears,
or over the occiput; and (on/ci., with laxatives and

DROPSY, CHRONIC, IN

diwrgtics exhibited internally. Of these last, the
acetate of potash, with oxymel of squills ; and the
spiritus cetheris iiitrici, with a small addition of
nitric acid ; are amongst the best, and should, in
the more debilitated, be given in tonic infusions.
After the mercurial alterative has been continued
sufficiently long, and the modes of treatment now
detailed have been fairly but ineffectually tried, a
very weak solution of the nitro-hydrochloric acids ;
or of the hifdrocliloric acid, with the chloric tether ;
or of the aromatic sulphuric acid, with Hoffmann's
anodune ; may be prescribed internally : but the
exhibition of mercurials should be fully relin-
quished, and their effects satisfactorily ascertained,
before any of these be taken, otherwise very serious
disorder of the stomach and bowels may be occa-
sioned by them. A succession of blisters to different
parts of the head, the one side or part being allowed
to heal whilst the other is discharging, is sometimes
serviceable ; but the blisters should not remain
on after they have produced redness of the part, and
the practice should be persisted in for some time.

302. J'. If acute symptoms supervene in the
course of treatment, leeching or cupping, sometimes
followed by dry cupping, and generally by calo-
mel, and active purging, must then be resorted to
appropriately to the strength of the patient, with
such of the measures recommended for the acute
disease, as the peculiarities of the case may require.

303. e. If debility, languor of the circulation,
and flabbiness of the soft solids, be considerable,
in addition to the hydrargyrum cum creta, as ad-
vised above, the powder or infusion o( calumba, or
of cascaritla, or of valerian, or of cinchona ; or
small doses of the sulphate of quinine, or of the
sulphate ((/'iro«, witii the neutral sulphates — as
the sulphates of magnesia, soda, or potass ; or the
sulphate or oxide of zinc ; will be sometimes bene-
ficial early in the second stage. The ferri-
potassio-tarti-as also should not b^ overlooked
in the treatment of these cases. I have lately
seen ihe iodide of fro/j of service in two such in-
stances. Several years ago, the oxide of zinc, or
the tris-nitrate of bismuth, was frequently pre-
scribed by me, in doses which woMld not offend
the stomach, either alone, or with mild vegetable
tonics, and taken during the day ; the mercurial
alterative being continued night and morning, and
a terebinthinate enema exhibited twice in the week.
Some patients certainly improved, or recovered,
under this treatment. But as most of these cases
occurred in dispensary practice, the result in
several of them was not ascertained. During the
exhibition of tonics in chronic hydrocephalus,
the secretions and excretions — both abdominal
and cutaneous — ought to be freely promoted by
means of slightly alkaline baths, and laxatives,
otherwise the disease may assume an acute form,
or pass rapidly into the third and irremediable
stage.

304. ^. Warm and other diaphoretics are directed
by several writers: Hopfencartner advising tlie
fjowers of arnica, and serpentarii root; and Dr.
Temple, the doronicum Germanicum, with the
more common medicines of this class. Digitalis,
and the internal use of cantharides, are recom-
mended by many respectable authorities. These
two may be conjoined ; for the former will be
given, with greater benefit, in this state of disease,
with tonic infusions and stimuli, than in any other
combination ; but its effects must always be care-

TIIE HEAD— Treatment,

681

fully watched. The internal use of the chloride of
barium and chloride of calcium, is suggested in the
more manifestly scrofulous cases, by Autenreith.
The repeated exhibition of irritating enemata is
enjoined by Mei.lin and Michaef.is, and has
proved of great benefit in my practice, particularly
the one already named {§ 299.). Sialugogues are
favourably noticed, especially by the older authors.
They deserve more attention than has been lately
paid to them, and are certainlj' useful adjuvants
especially about the period of dentition, when the
gums and teeth should be frequently examined ;
irritation of the former being removed by incisions.
— Errhines are also prescribed, particularly by

IIj-USTER, FoRESTUS, End MuNDSCHIEN.

305. n. Various applications — some of them the
most opposite in their natures and effects — have
been directed to be applied to the head, with the
view either of promoting exhalation from its sur-
face, and thereby transferring this action from the
interior of the head ; or of diminishing effusion
in this situation, by restoring the healthy action of
the capillary and exhaling vessels. Blancahd
and Fabricius recommend that the head should
be kept warm by bladders filled with hot sand, or
by sponges squeezed out of hot water ; and
MoNDsciiiEN, that bags containing either un-
slacked lime, or roasted salt, be applied to it.
BoERHAAvE, BoRsiERi, and Hecker advise fo-
mentations with aromatic wines; Flajani,
Plenk, Itard, and Kleber, epithems with the
wine or vinegar of squills; and Psab, Deleurye,
and others, dry fomentations with warm aromatic
plants. ZwiNGER, SoRBAiT, and Mellin direct
the scalp to be rubbed with oiiitments containing
the etherial oils, especially the oil of turpentine or
naphtha with alcohol ; and Perdulcis, Jopin-
STONE, Monro, &c. favour the use of woollen caps,
which have imbibed the essential oils. Besides
these, a variety of p/asters, especially such as pos-
sess a deobstruent and tonic quality, are mentioned
by writers. Of this class of means, the plasters
F. 116, 117, 118. and the liniments F. 300. 311.
are the most efficient. Acrid applications, and
scarifications of the scalp, are likewise noticed by
Heister and Diemerbroeck ; and the actual or
potential f(j«fe?-v, and /noxas, by Chesneau,Tana-
RON, and several other Continental authors.

306. &. Gentle and continued compression by
bandages is recommended by Riverius, Formey,
PiTsciiEL, Blane, and Hood ; and has mani-
festly been of service in some instances. Com-
pression by means of strips of plaster, composed of
equal parts of the emplastrum picis comp., and of
the emp. ammoniaci cum hydrarg.,or of these and
the emplast. cumini, and spread on stiff linen, has
been found by me preferable to the common
method by bandages, and has commonly been
employed in addition to the means detailed above
(§ 298. et seq.). The plaster, thus composed,
should be cut into slips ; and, whilst each should
partially surround the head, the number applied
ought to be sufficient to cover the whole scalp,
vyliich must be kept closely shaven. In the case
treated by compression, by Sir Gilbert Blank,
leeches and purgatives were also employed ; and
a favourable termination resulted. Mr. J. F. Bar-
nard resorted to pressure successfully in nearly
the same manner as I have now advised, and used
for the purpose broad strips of adhesive plaster.
He also kept the head covered by linen wet with

68-3

DROPSY, CIIIIONIC, IN THE HEAD — TKrATMrNT,"

cold water ; a practice which should not be omitted
whenever the temperature of the head rises above
natural.

307. c. The remnval of the fluid by puncture
has been recommended from Hippocrates to the
present time. But it has never been practised
with success until recently; and it is doubtful
whether some of the cases which have been said
to have recovered by the operation have ultimately
been cured. Indeed, great difference of opinion
has existed as to the propriety of performing it.
LeCat, JunckeRjSorbait, Remmett, and many
recent writers, have advised and practised it ;
whilst Heister, Boerhaave, Morgagni, Monro,
BoRsiERi, Mercati, Richter, Flajani, Por-
tenschlag, GoELis, Breschet, Hecker, &c.are
opposed to it, on the grounds that it has
never cured the disease, but has often accelerated
a fatal termination. After the medical treatment
above detailed has been appropriately, sufficiently,
and ineffectually tried, this operation, as it is not
attended by any immediate risk, when cautiously
performed, may be resorted to. In such circum-
stances, I have concurred in it, where it has been,
in several instances, performed by my able col-
league, Mr. Dendy, at the Infirmary for Children ;
but I recollect no case in which it has ultimately
succeeded, although the management of the
cases could not have been in more experienced
hands. Many of the older writers, who advised
the operation, conceived the water to be collected
in the sac of the arachnoid, and not in the ven-
tricles, and, consequently, that, in making the
puncture, the cerebral substance would not be
penetrated ; but such is not often the case. In-
stances of its performance are adduced by Tulpius,
FABRicius Hildanus, De La Motte, Petit,
Wepfer, E. Ferdinand, G. Fabricius, D. Pa-
narolius, and several recent writers. The fol-
lowing is a brief notice of those which are the
most instructive.

308. a. Le Cat (^Philosnph. Trans, vol. xlvii.
p. 267.) operated on a child three months and a
half old, affected subsequently to birth, thrice in
three successive days ; death occurred on the fifth
day after the first puncture. The pineal gland
was found nearly destroyed, and the ventricles
much expanded. Dr. Oppenheim (Rust's
Mag. fur die Gesammle Heilh. b. xxiv. 1827.)
operated on an infant of seven months witli a
trocar, leaving the canula in the puncture. It
died on the seventh day. The membranes were
somewhat thickened, and the brain soft and
pulpy. Dr. WniTMOHE (Amer. Med. Recorder,
July, 1821.) punctured the head of an infant of
six months, hydrocephalic after birth ; and in
eight days withdrew, without a canula, 116
ounces. Death followed on the tenth day, the
membranes being found inflamed. Dr. Hood
(^Ediithurgh Med. and Surg. Journ. Oct. 1821.)
operated on a child of nine months by a trocar.
Death took place on the third day. The brain
was softened and the tuhercula quadrifiemina were
suppurated. Mr. Dendy (Loud. Med. Repos.
vol. xix. p. 446.) operated on a congenita! Iiy-
drencephalocelic case, aged ten weeks, witii a
large, deeply grooved needle, and removed eigiu
ounces at three operations, with three days inter-
val between each. Death occurred on the tenth
day. The fluid was lodged in the left ventricle,
over which the brain had not been formed. The

membranes were found inflamed, and the brain
surrounding the effused fluid softened, ]\Ir. Brown
(Med. and Phys. Journ. vol. li, p. 102.) punc-
tured the head of an infant of five months, on five
occasions, in the course of thirty-six days. The
last puncture was followed by great haemorrhage
and dissolution. Mr. Gray (Ibid. vol. liv.
p. 204.), from a child whom he had cured of spjjia
bifida by compression, but who became hydroce-
phalic soon afterwards, drew off forty-five ounces
of fluid at three tappings. The symptoms were
mitigated for a time ; but death followed on the
thirty-first day. Dr. Freckelton employed five
successive punctures with a trocar, in the course
of fifty-six days. Death occurred on the fifty-
ninth day. Mr, Callaway (Amer. Med, Recorder,
July, 1821.) operated on an infant five weeks old,
and repeated the punctures on four successive
weeks ; but it died of marasmus and gradual ex-
haustion on the seventieth day. JNIr. Remmett
(Edinburgh Med. Comment, vol. vi. p. 422.), in a
congenital case, punctured the head with a lancet,
two months after birth ; and in the first six days,
on three occasions, drew offthirty-idx ounces in all.
He repeated the operation twice subsequently ,'with
a month's interval between each. The infant died
of atrophy ninety-three days after the first puncture.
On dissection, the fluid was surrounded by the
membranes ; the rudiments merely of a brain, in a
softened state, being lodged at the bottom of the
cavity, Mr, Money (Meil. and Phys. Jouvn,
vol.lii. p.462.) operated on a congenital case ten
months after birth, by a small trocar, on ten diffe-
rent occasions, during seventy-four days. The
child died on the eighty-fourth day after the first
operation. The membranes were inflamed, and
the brain dilated into a large sac, Mr, S\M(£di«.
Med. and Sxirg. Journ. vol. xxiv,), in an infant of
eleven weeks, punctured the head, and repeated
the operation five times in the course of ninety days,
withdrawing about seven ounces of fluid each
time. Death occurred on the 104th day. The
arachnoid was thickened. The fluid was contained
in its general cavity, and the brain imperfectly
developed. Dr. Glover (Neiv York Med. Repos.
vol. iv.) operatedin a congenital case, nine months
after birth ; and, in four months, withdrew 156
ounces at eight tappings; but death took place
after a considerable period of amendment, on the
120th day. Mr. L,iz,\r5 (Edinburgh Med. and
Surg. Journ, April, 1821.) operated on an infant
four months old ; and in the course of 90 days
repeated the puncture fifteen times, at intervals of
from three to seven days, taking away each time
from three to ten ounces of fluid. The child did
well until convulsions occurred during teething ;
and the head was again enlarged. Puncture was
again tried ; but it died on the following day, and
on the 17 1st after the first operation. Dr. Vose
(Med. Chirurg. Tra?is. vol. ix.), in a congenital
case, operated seven weeks after birtli, and thrice
subsequently, at considerable intervals. The su-
tures afterwards ossified ; and, three months later,
when he published the case, the child was doing
well. Dr. Monro, however, states (Morbid Ana-
tomy of the Brain, &;c. p. 146.), that symptoms of
pressure appeared after the sutures were ossified,
and tlie child ultimately died.

309. /3. Mr, Greatwood (Lancet, No, 299,
p, 238.) records a case of a hydrocephalic child
of fifteen months, who, falling on a nail, punc-

DROPSY, CHRONIC, IN THE HEAD — Treatment.

tured the head at the upper third of the lamb-
doidal suture. The wound continued to dis-
charge fluid for several days, and it afterwards
perfectly recovered from the disease. In the
same work, for April and November, 1830, the
operation of puncture is stated to have been
successfully performed in St. Bartholomew's Hos-
pital. Graefe (his Journ. for 1831, b. xv.
p. 3.) punctured the head of an infant hydro-
cephalic from birth, in the fourth month, and re-
peated the operation about eleven times during
six months. The fluid was allowed to escape
slowly each time ; the canula being removed,
and the wound closed, as soon as the pulse became
weak. After the last puncture, the sutures closed.
The child could walk and speak when a year old.
At the age of two years and a half, it was shown
to the Medico-Chirurgical Society of Berlin.
Mr. RussEL (^Edin. Med. and Surg. Journ, July,
1832, p. 43.) operated on a girl eight months old,
hydrocephalic from birth, and whose head was
twenty-three inches in circumference, when he first
punctured it. The operation was repeated four
times, after intervals of about ten days ; but the
quantity of fluid withdrawn each time was small.
After the last puncture, calomel was given so as
to affect the mouth ; when the hydrocephalic symp-
toms disappeared, and ossification of the sutures
proceeded. The case is stated to have been
cured. Dr. Conquest is reported, in a con-
temporary work, to have operated in nine cases,
— successfully in four of them. The greatest
number of punctures in one case were five, and
the intervals between them from two to six weeks.
The largest total quantity of water removed was
fifty-seven ounces, by five operations; and the
largest quantity at one time, twenty ounces. The
trocar was introduced through the coronal suture,
below the anterior fontanelle, and the wound care-
fully closed after each evacuation. Pressure was
made by means of strips of adhesive plaster.

310. The cases in which I have been con-
cerned in directing the operation, have all been
unfavourable to its success. Medical treatment
had been actively and perseveringly employed in
all of them ; and it is therefore probable, that such
of them as admitted of recovery were amongst
the number that was cured. Whilst in those in
which the operation was resorted to, and which
were mostly congenital, either the stale of the
brain and its envelopes precluded recovery, or the
circumstances in which out-door patients of public
charities are placed were such as to render tliis
operation less successful than it otherwise might
have been.

311. y. Havingstated theevidencewe at present
possess of thesuccess of the operation, inferences as
to the propriety of performing it may be easily
drawn. Those who argue against it contend — (a)
that it is apt to induce an irritative state of inflamma-
tion in the substance or membranes of the brain,
particularly in the weakened and otherwise predis-
posed systems of such subjects — 1st, by the me-
chanical injury done to those structures ; and
2dly, by the entrance of air through the punc-
ture; — (6) that the collapse consequent upon
the removal of the fluid is injurious to the organ
and system ; — (c) that the operation cannot
change the state of the organ or function giving
rise to accumulation ; and hence that it cannot
be permanently successful ; — and (</) that the in-

683

stances of success from it are not so numerous as
those from medical treatment.

312. Those in favour of tiie operation, on the
other hand, argue — (u) that greater inj\iry than
that by the puncture is often done to the brain
and membranes, without bad consequences ; — (ft)
that the air may be prevented from entering by
the aperture ; — (c) that danger from collapse is
readily obviated ; — (d) that cures from medical
treatment, in an advanced stage, and when the
head has become greatly enlarged, are very rare,
and are then most likely to be obtained by an oper-
ation ; • — (e ) that the instances of success on record
are sufficient to warrant its performance.

313. J. From much experience, I conclude that
inflammatory irritation of the brain and its mem-
branes does follow the operation in some instances ;
that the state of these parts, and of the system,
favours its occurrence ; and that the encephalic
structures are in a very different condition in this
disease, both mechanically and vitally, — but es-
pecially as to proneuess to inflammatory action,
and softening, — from what they are in health. —
((i) Whilst, therefore, I so far agree with those who
argue for the operation, as to advise it to be tried
after the measures I have detailed above have
failed, yet I would not recommend its perform-
ance early in the disease — 1st, because medical
treatment has then sometimes effected a cure, es-
pecially when the head has not been very greatly
enlarged ; and, 2dly, because, when the fluid is in
the ventricles, as it generally is in cases com-
mencing after birth, a greater depth of brain must
be penetrated to reach it at an early, than at a
later, period. — (6) When punctures are resorted
to, medical treatment must not be abandoned,
or even relaxed ; for we should still endeavour,
according to the principles explained above, to
remove the disposition to effusion, as well as to
promote absorption ; and, as a certain degree of
pressure is requisite to the healthy performance of
the cerebral functions, strips of plaster, as are
already directed (§306.), should be applied around
and over the whole scalp, in order to prevent the
collapse consequent upon the operation. — (c) I
believe that the punctures ought not to be fre-
quent, nor much fluid withdrawn at one time;
that gentle pressure should be made around
the cranium during the discharge ; that the dis-
charge ought to be stopped, and the puncture
accurately closed, so as to prevent the entrance
of air, as soon as the pulse begins to sink; and
that restoratives should be exhibited, in order to
prevent convulsions, or other nervous symptoms. —
(rf) The operation seems to be best performed by
a small trocar, or grooved needle ; but it is difficult
to withdraw any fluid with the latter, as the sur-
rounding pressure fills up the groove. The appli-
cation of a cupping glass may, however, procure
a discharge. A thin trocar, with a two-edged or
lancet-shaped extremity, — not a thick triangular
pointed instrument, — is preferable, upon the
whole.

, 314. d. Urgent siiwptoms, especially convul-
sions and inflammatory action, require to be
palliated or removed. — a. Convulsions should be
treated according to the manner described in that
article, particularly by the terebinthinated me-
dicines and enemata already prescribed (§ 299.);
by these, conjoined with the syrup of white
poppies, or this latter with the oxide of zinc ; by

684 DROPSY, CHRONIC, IN

foetid enemata ; by cold or tepid effusions on the
head ; and by dry cupping on the nape of the
neck, or between the shoulders. — 0. The appear-
ance of acute svmptnms requires the treatment
stated above (§ 302.) ; with mustard pediluvia,
or mustard poultices to the legs and thighs ; cold
affusions and applications to the scalp, &c. —
y. In the third stage, the disease is generally
beyond the influence of medicine ; the disorgan-
isation which has then frequently taken place in
the encephalon not admitting of restoration ; and
it is chiefly in it that the palliation of urgent
symptoms is required. But little beyond the
fulfilment of this intention can then be attempted,
unless puncture be resorted to as a last resource.

315. e. Diet and regimen form no unimportant
part of the treatment. The diet should be light
and nutritious, and care should be taken not to
allow the patient to eat so much at a time as to
load the stomach. For infants, the milk of the
nurse is sufficient ; but she should be healthy, and
fed upon digestible and nutritious food, and her
bowels carefully regulated. Children who are
weaned should have a small quantity of animal
food; and be debarred from all acescent vege-
tables. Change, particularly from the close parts
of a city, to a country air, which is warm and
dry ; and frequent exposure to the open air, and
to sunshine, in mild weather, are very serviceable.
Many children have ravenous appetites, espe-
cially as the disease advances ; these require suffi-
cient nourishment, but more than that is in-
jurious. In these cases, the terebinthinated
medicines, more than any others, allay the insa-
liable craving, symptomatic of the malady, and
tending to aggravate it when indulged ; whilst they
exert a very favourable influence on the disease.
The drink allowed to the patient should be or-
dered with strict reference to the treatment pur-
sued at the time, and should be as much as
possible adjuvant of it.

316. /. The prophiilactic Treatment may be
comprised in a few words. — When any one of a
family has had the disease, particularly if there
exist a scrofulous or rickety diathesis, the state of
the secretions and excretions ought to be carefully
wa'ch^d, and the earliest deviation of them from
he: 1th combated by appropriate means. Cuta-
neous eruptions should not be interfered with, un-
less with great caution ; all external medicaments
to them should be avoided ; and internal remedies,
of an alterative, deobstruent, and diuretic kind
only, be prescribed. The skin ought to be kept
clean and perspirable. External injury of the
head, and premature exertion of the mental facul-
ties, must be avoided. Free and daily exposure
to the open air and sunshine ; moderate, light,
and suitable diet ; an open state of the bowels ; a
healthy nurse, whose mind is not liable to anxiety ;
and wliat has been already advanced above
(279,280.); are all requisite to the prevention
of the malady, particularly under the circum-
stances alluded to.

Biuuiou. ANn REVEn.— Hippocrates, Ui^'i vi>u(rm, ^'.
{j XV. and d xvii. — CtUsus, l)e Medicina, 1. iv. cap. '■2 —
Actius, I. iv. cap. i. p. !I9. — Tulpius, Observ. Med. 1. i.

obK. 2.5 Fab. HiUaniis, cent. iii. obs. 17— 1!> — Furesti/s,

(;l>'<crv. Chirurg. I. i\\. oba. ti. — Jlcisfer, Inst. Chirnrg.
p. /jiio. — Rivirius, Obscrv. Commun. p. 4()6. ft p. G7fi. —
Jloiict, Sepulchrelum, I. i. sect. xii. ob.s. 37., sect. xiii.
obii. 1. &c., sect. xvi. obs. 9. 11. — Dicmrrhrocck, Dc
Morb. Caj). et Thor. p. 71!l. — lie la Motic, Traite comp.
de Chirnrg. t. ii. p. \'.i\.— VVepfcr, De Cap. A (lect. obe. 49.
— J.itire, Mem. Uc I'Acad. Jic. de I'uris, 17''5, p. 70.—

THE HEAD — TnrATMtxT.

Fiicml, in Philo«. Trans. No. 2jo Albert!, De Hydroce-

phalo. Hals, 1125.— Blajicard, Anat. Pract. c. i. obs. 48-

— Kattsclimiil, De Hydroceph. Interno rane Magni-
tudinis. Jenae, 1752. — Morgagni, De Sed. et Cans. Morb.
ep. xii. art. 1.3. et seq.—Freysinger, De Diagnosi Morb.
Capitis. Vien. 1701. — Fothergill, Meii. Obiex\. and In.
quiries. vol. iv. 1771. — KUnkosch, Prog, de Hydroceph.
rariori. Prag.- 1773 Loftie, ia Med. Observ. and In-
quiries, vol. V. p^ 121. — Watson^n Ibid, vol.iv. No. 6. 25.

— Aurivillius, De Hydroceph. Interno 45 Annorum, iu

Sandifort's Thesaur. vol. ii. No. 14 Grating, in Lud-

viig, Advers. Med. Pract. vol. ii. p. 469. — Ludwig, De
Hydr. Cerebri Puerorum. Lips. 1774 Pohlius, De Hy-
droceph. Inl'antis recens Nati interno et externo. Lips.
1777. — A Dawson, Thoughts on Hydroceph. Inter. Lond.
8vo. [llS.—Odier, Mem.del'Acad. R. de Med.]779,No. 13.

— C. IV. Quirt, De Hydrocep. Interno. Edin. 1779. ; and

Treatise on Dropsy of the Brain. Lond. 1791 Uanit,

Med. Papers, ^-c. vol. i. No. 7. — PUschel, Anat. u. Chi-
rurg. Aumeriv. Dresd. 1784. — Sandifurt, Excitat. Acad,
t. ii. part i. ; et in BIus. Anat. t. ii. p. 6. — Hooper, in Mem.

of Med. Soc. of Lond. vol. i. No. 8 Lettsom, in Ibid.

vol. i. — Jameson, in Ibid. vol. iii. No. 13. — Cribb, in
Ibid. vol. iv. p. 402. — Saxtorp/i, De Febre Hydrocepha-
lica. Hafn. 178fi. — Percitial, Med. Facts and Observat.
vol. i. p. 646. — Tho7n, Erfahrungen, und Beraerk. p. 84.

— K. F. Bader, Geschichle der Wassersueht der Ge-
hirnhoehlen,oderdes SchlagtlussesderKinder,8vo.Frankf.
\TJi.—I,ode>nann, De Hydr. Cerebri. Goet. 1792 — Fla-

jnra/, Osservazioni Pratiche sopra I'ldrocefalo, &c. Rom.
1791. — Hartmann, De Hydrocephalo. Stuttg. 1794. —

Meckel, De Hydrocep. Interno. Hal. 1793 Rush, Med.

Inquiries, vol. ii. No. 5. and 15. — Leib, in Trans, of Phil.
Soc. of Philad. vol. i. part i. No. 2. — Cavallini, Collezioaii,

&c. t. ii. — Bliimenbach, Biblioth. vol. iii. p. (US Buck-

holz, in Baldinger's N. Mag. b. i. p. 481., b. il. p. 130. ;
Ibid. b. viii. p. ISO. — Conradi, in Hufeland's Journ. der
Pract. Arzneyk. b. vi. p. 453., b. vii. st. 2. — Fischer, in
Ibid. b. i. p. 280. — A. Monro, Three Treatises on the
Brain, the Eyes, and the Ear. Edin. 1797. — Thomann,
Ann. Wurceburg. &c. vol. ii. p. 64. 92. 104. — J. P. Frank,
Acta Instit. Clin. Viln. ii. p. 451., iii. p. 44. ; etCur. Horn.
Morb. vol. vi. p. 161. 183. 197. — Duncan, in Edin. Med.

Comment, vol. ii. — S. F. Simmons, in Ibid. vol. v. p. 415

Percival, in Ibid. vol. v. p. 174 Dobson, in Ibid. vol. vi.

p. 219. — II. B. Remmett, in Ibid. p. 423. — Mackle, in

Ibid. vol. vii. p. 21. — Willan, in Ibid. vol. vii. p. 330

A. Hunter, in Ibid. vol. viii. p.' U)6.— Easun, in Ibid,
vol. viii. p. 325.— r. Aerff, in Ibid. p. 332.— A. Campbell,

in Ibid. vol. ix. p. 240 Evans, in Ibid. vol. x. p. 299

Dixon, in Ibid. p. 312. — IV. L. Perkins, in Ibid. vol. xi.
p. 298. ; Cases of, vol. xiv. p. 401., vol. xix. p. 173. —
Paterson, On .Acute Hydroceph. 8vo. Dubl. 1794. —
Ackermann et Fischer, Klinischen Annalen von Jena,
St. i. p. 1,')2. — haiioix, Mem. de la Soc. Med. d'Emulation,
t. i. p. 13. — Wichmann, Ideen zur Diagnostik, th. iii. p.
48—117. — Baillie, .Series of Engravings, &c. fasc. x, pi. 3.
— P. F. Hupfcngdrtner, Untersuchungeii fiber die Natur
und Behaiidlung der Verschiedenen Arten der Gehirn-
wasscrsucht. Stutt. 1802. — Hujeland, Bemerkung. iiber
Blattern, &c. p. 476. et seq. — Kreysig, De Hydrocephali
Inflammatorii Pathol. Viteb. 1800.— fV. Rowlii/, Traat.
of the Dropsy of the Merab. of the Brain, and Watery
Head of Children. Lond. 1801, 8vo. — Weaver, in Med.
and Phys. Journ; vol. xv. p. .'i32. — Horsch, Annalen, h. i.
p. 210. — Bard, in Journ. Gin. de Mi^d. t. xxxii. p. 2!). —
Bouvier, in Ibid. t. xxx. p. 377 — CoUinet, in Ibid. t. xxxi.
p. 157. — Jadelot, in Journ, de Med. Chirurg. et Phann,

Paris, 1806 Spry, Med. and Phys. Journ. vol. ii. p, 131.

— Cluilerbuck, in Ibid. voL ii. p. 154. — C. Brutun, in Ibid,
vol. ii. p. 258. 321.— Ford, in Ibid. p. 261.— IV. Uhite, in
Ibid.Jvol, iii. p. 113. 325. 3.58 Shaiv, in Ibid. vol. iii. p.517.

— Schmidt, in Ibid. vol. vi. p. 6 J. B. Davis, in Ibid.

vol. viii. p. 98 Garnett, in Ibid. vol. v. p. 121. — Bartlett,

in Ibid. vol. xi. p. 401. — Patterson, in Ibid. vol. xv. p. 119.

— Coxe, in Ibid. vol. xviii. p. 213. — Futhergill, in Ibid,
vol. xviii. p. 481. — Inquirer, \n Edin. Med and Surg. Journ.

vol. ii. p. 5'2. 409 G. G. Kuhn, in Ibid. vol. iii. p. 13

Clarke, in Ibid. vol. v. p. 264., vol. vi. p. 282., vol. xii.]).!'."*.

— Male, in Ibid. vol. ix.p.398 Bateman, in Ibid. vol. xii.

p. 119. — Salter, in Ibid. vol. xvi. p. 393. — Dickson, in
Ibid. vol. xvi. p. 412 — Trail, in Ibid. vol. xvii. p. 237.
— {Analysis of fluid removed by tapping in clir. hydr.) —
I.ixars, in Ibid. vol. xvii. p. 243, 471. (On puncture in
chr. hydroceph.) — Hood, in Ibid. vol. xvii. p. 510. —
Thom/json, in Ibid. vol. xviii. p. 46. — Afzclius, Hydr.
Ventriculorum Cerebri Hist, Morbi et Sectionibus Ca-
davrrum illustratus. Ups. 1804. — ■/. et C. IVenxel, Be-
iiurkungon fiber die Hirnwassersucht,4to. 1806. — Lange,
1).- Hydr. Ventr. Cerebri. Erf. ISOl. — Portenschlag.
I.cdi-ri'iai/cr, Ucber den Wasserkopf. VVien. 1812. —
H'endclstatt, in Stark's N. Archiv. fiir die Geburtshiilfe,
b. ii. p. 711. — Autenrielh, Observ. de Hydroceph. Acuto.
Tub, 1811, — Formry, Von der Wassersueht der Gehirii-
hfihlen. Berlin, 1810. ; et in Horn's Archiv., March,
1810. — //cc/kt, Mag. ffirdie Path. Anat. u. Phys. h. i.

— Hcinccken, in HuJ'elandu. Himly's Journ. d. Pr. Ileilk.

DRUNKENNESS."

685

Wars, 1811, p. 23.; Ibid. 1812, p. Zo.— Schajffer, in Ibid.
Sept. 1811. — Mtchae/is, \n Ibid. Feb. ISV2. — Thomson,
in Lond. Med. Repos. vol. i. p. Ifi. — Cloquet, in Ibid,
vol. ix. p. 410 — J. Cheyne, Essays on Hydrocep. Acutus,
&c. i'd ed. 8vo. Lond. 1819. — J. F. Coindet, Mem. sur
rilydreneeph. ou Cephalite interne Hydrencfephalique,
8vo. Gen. 1818. — Cooke, in Trans, of Med.-Chirurg.
Soc. vol. ii. p, 17. — Baron, in Ibid. vol. viii. — Vase, in
Ibid. vol. ix. p. 354. (Paracentesis.) — J. C. Smith, On
Hydrenceph or Dropsy of the Brain, 8vo. Lond. 1814.
—Kasori, in Giornale della Soc. Med.-Chirurg. di Parma,

vol. ii. No. 4 L. A. Goelis, Ueber d. Vorziiglichsten

Krankht. d. Kindl. Alters. 8vo. 182U— 1824. Wien. ; also
on Hydr. Acutus, or Inflammatory Water on the Head,
translated by A". Gooc/i, 8vo. Lond. 1821.— G. X). Yeats,
Of the early Symptoms that lead to Water on the Brain,
2d ed. 8vo. Lond. 1823.— J. Cou/ce, Treatise on Nervous
Diseases, &c. vol. i. p. 319. — Hnfc/and, in Nouv. Journ.
<le Med. t. xii. p. 42. — J. CratKpton, in Trans, of Irish
College of Phvs. vol. i. p. 176. — J- B. Evamon, in Ibid,
vol. iv. p. ISfi' — Mills, in Ibid. vol. v. p. 350. — Hard,
m Diet, des Scien. M^d. t. xxii. p. 219. — Duncan, in
'J'rans. of Med.-Chirurg. Soc. of Edin. vol. i. p. 205. —
JVW/e;-, in Ibid, vol.ii. p. 24o. — Fallot, in Med.-Chirurg.
Rev. vol. ii, p. 902. — O/ipenheim, in Edin. Med. and
Surg. Journ. vol. xxix.p. 3.68. — G. Blanc, in Med. and
Phys. Journ. Oct. 1821.— i/oerf, in Efiin. Med. and Surg.
Journ. Oct. 1821. — Gttersent et Breschet, in Diet. deMed.
t. xi. p. 300. 320. — Gardien, Tr. ri'Accouchem. et des
Mai. des Femmes et des Enfans, 3d ed. t. iv. p. 139. —

Reynault, Med. and Phys. Journ. vol. xl. p. 539

Girdlestone and Costei'ton, in Ibid. vol. xlvii. p. 183. —
Bitter, Morbi Hydrocephali Historia, Svo. Ber. 1824. —
J.'^Abercrumbie , Pract. Researches on Dis. of the Brain
and Spin. Chord, sect. vi. p. 130. ; and Edin. Med. and
Surg. Journ. vol. xiv. p. 292. — A. Duges, in Dict.de
Med. et Chir. Prat. t. x. p 130. ; et in Ephemerides Med.
tie Montpellier, t. s. p. 292., t. ii.p. 132 — 275. — Charpen.
tier, in Med. and Surg. Journ. and Repos. vol. iv. p. 36. ;
and Archives Gener. de Med. t. xxi. p. 315. —Dance, in
Arch. Gen. &c. t. xxi. p. 5u8., t. xxii. p. 295. — Loben-
stein-Lobel, Die Erkonntniss und Hoilung der Gehirn-
entziindung, des innern Wasserkopfes u. der Krampf.
krankhciten im Kindlichen Alter. Leips. 1813. — D. A.
G. Richter, Die Sijecielle Tlierajne, &c. b. iii. p. 158. —
/'. N. Ab. Hildcnbrand, Institut. Practico- Medica?, t. iii.
p. 88. — Meckel, in Hand, der Path. Anat. b. i. p. 260.

— Breschet, in Magcndie's 3o\\xn. de Physiol, vol. i. p. 92,
vol. ii. p. 269., vol. iii. p. 241. — Burdach, Worn i^ehen
und Ban des Gehirns, b. iii. p. 514. — J. L. Bracket, Sur
I'Hydrocephalite, ou Hydr. Aigiie des Vent, du Cerv.
Svo. Paris, 1819. — Porter, in Med.-Chirurg. Journ. and
Rev. No. iii. — W. Shearman, On the Nature, Causes, and

Treatment of Water in the Brain, 8vo. Lond. 1825

Abercr07nbie, On Dis. of the Brain and Spinal Chord,
Svo. p. 126. et seq. — Underwood, On Diseases of Children,
ed. by Merri?nan, Svo. Lond. 1827, p. 357. note by editor.
— A. Monro, Morbid Anatomy of the Biain, vol. i. ; Hy-
drocephalus, 8vo. Edin. 1827. — Letiiat, Sur les Causes,
la Nature, et le Traitement de I'Hydroceph. Aigiie, &c.
Lyons, 1S28. — C. Himly and Langenbeck, in Comment.
Soc. Reg. Scient. Got. Recent, vol. vi. Class. Phys.

p. 61. el 73. pi. 1 — 5 J. Mackintosh, in Lancet, No.

247. p. 237—266.'— Conquest, in ^Ibid. for 1830. — Great-
wood, in Ibid. No. 299. p. 238. — Elliotson, in Medical

Gazette, vol. xi. p. 405. 43i) Gracfe, in his and Wal-

t/ier's Journ. fiir Chirurgie, 1831, b. xv. p. 3. — Trail, in
Trans, of Provin. Med. Associat. vol. i. 1853. — Craigie,
in Edin. Med. and Surg. Journ. July, 18.32. {An interesting
case, with remarks.) — Busscl, in Ibid. July, 1832, p. 43.

— F. W. Oppenheim, in Bi/st's Mag. f. d. Gesammte
Heilk. b. xxiv., reviewed in Edin. Med. and Surg. Journ.
vol. xxix. p. 3.")8., where arguments for and against punc-
ture are adduced.

DRUNKENNESS — Intoxication,— Syn.
Temulentia, Pliny, Plater, &c. Paraphrositne
temulenta, Sauvages. Ehrielas, Lat. Ivresse,
¥r. Trunkeuheit , Rausch, Germ. Ebbro, Ital.
Ebriety, hiehriation.

Classif. III. Class, I. Order (Author.')

1. Defin. — Mental excitement, followed hy stu-
por or coma, from the excessive use of' fermented or
distilled liquors.

2. The frequent occurrence of intoxication,
either casually or as a confirmed habit, would
justify the notice I am about to take of it, even
independently of its influence in causing and
modifying disease. But it is ciiiefly to the more
complete states of intoxication, and especially
those demanding medical care, that attention will

be here directed. Drunkenness, in its various
phases — from the daily indulgence in more
vinous or spirituous fluids than is required, but
short of affecting the nervous system in a very
evident rr.anner, up to that degree of excess by
which the senses and intellects become obscured
or entirely lost — predisposes to many diseases,
and directly causes others. Slighter excesses ia
the use of fermented liquors — particularly wine
and malt liquors — occasion plethora, with all
I the consequent ills, especially gout, apoplexy,
' paralysis, and congestion of the abdominal vis
cera. Greater excesses, and the too f ree use o
spirits, exhaust nervous and vital power, in-
ducing tremors, nervousness, delirium tremens,
encephalitis, paralysis, and insanity ; occasion
affections of the digestive organs, particularly
anorexia and dyspepsia, diarrhoea and dysentery,
inflammation, and structural changes of the biliary
organs; and produce disorders of the urinary and
sexual functions, even sterility and impotency ;
and, ultimately, lesions of the kidneys, and
dropsies.

3. Drunkenness is not a vice of recent date,
although it may have become more common with
tiie progress and diff'usion of luxury. We find it
mentioned in the early history of the Jews ; and
Tacitus informs us that it was prevalent amongst
the ancient Germans. It is tolerably evident, from
the ancient lyric and dramatic poets and satirists,
that it was by no means infrequent amongst the
higher classes in Greece and Rome. Hippocrates
notices Us worst states, both in his Aphorisms and
in his Prognostics ; and it does not appear to have
been considered a very culpablesort of indulgence
even by some of the sages of antiquity. Plato
cautions against allowing wine to youths at an
earlier age than eighteen years, and against be-
coming intoxicated before forty ; but, after this
age, he considered some degree of indulgence in
this way pardonable. This was pos.sibly, also,
the opinion of Socrates.

" Hoc quoque virtutem quondam certamine, magnum
Socratem palmam promeruisse ferunt."

Corn. Gall. Eleg. i. ver. 49.

And Horace states, that Cato the Censor often ■
warmed his virtues by wine.

" Narratur et prisci Catonis
Saepe mero caluisse virtus."

It is evident that the vice increased amongst the
ancients with the diffusion of luxiiry ; until, at
last, even the ladies occasionally followed the
example so generally set them. Valerius
RIaximus (1. ii. cap. i.) states, that in the earlier
periods of Roman history, the women seldom
drank; and Seneca {Epist. 95.) remarks, that
at a later period, they indulged so freely in this
way, that they became nearly as subject to the
diseases occasioned by the practice as the men.
Erroneous opinions as to the effects of intoxication
upon the frame seem to have been very early
entertained, and were generally prevalent in the
fifteenth and sixteenth centuries. Montaigne
mentions, that the celebrated Sylvius informed
him that an occasional debauch was beneficial,
inasmuch as it roused the energies of the stomach ;
an opinion long entertained by medical men,
but zealously combated by MM. Hommets and
Langlois. There can be no doubt, however,
that, as expressed by the late Dr. Grigorv, an
occasional excess is, upon the whole, less injurious

686

DRUNKENNESS —Symptoms,

lo the constitution, than the practice of daily taking
a moderate quantity of any fermented liquor or
spirit.

4. i. Causes. — This destructive habit, not many
years ago but too prevalent even in the upper
classes in the more northerly countries of Europe,
fortunately now no longer exists, or not nearly to
the same extent as before : but it is still as general
as ever amongst the lowest orders, and those of
weak constitutions, who have been indulged in
youth, or uncontrolled, or accustomed at that age
to taste cordials and spirituous liquors, or who pos-
sess little force of character or firmness of resolu-
tion. The unfortunate and unhappy, those of un-
certain occupations, or whose homes are made mi-
serable ; also tavern-keepers, coachmen, commer-
cial travellers, singers, working mechanics, persons
whose parents have beendrunkards, and those who
are idle and unoccupied, and frequent clubs or
meetings of lodges, &;c. ; often have recourse to it.
The weak, good-natured, and social, not infre-
quently become addicted to it, from the manners
and indulgences of those with whom they associ-
ate, until the want of the accustomed stimulus be-
comes distressing, and the resolution gives way
before the desire of gratifying it, and thus the
habit is confirmed.

5. ii. Symptoms. — A. The earlier phenomena
of ebriety are, mental exhilaration, joyousness,
dissipation of care, with talkativeness, flushed
countenance, increased animation of the features,
especially of the eyes ; a more copious transpira-
tion from the cutaneous and pulmonary surfaces,
and secretion of urine ; augmented thirst ; and
full, frequent, and strong pulse. If the intoxicat-
ing fluid be more largely partaken of, vertigo, tin-
nitus aurium, double vision, and unconnected
trains of ideas, generally uncontrolled by the will,
supervene. During slight intoxication, the pre-
vailing disposition and pursuits are made mani-
fest ; and hence the saying, " In vino Veritas."
The irritable and ill-tempered become quarrel-
some; the weak and silly are boisterous with
laughter and mirth, and profuse in off"ers of ser-
vice ; and the sad and hypochondriacal readily
burst into tears, and dwell on mournful topics.
In a more advanced state, the excitement ap-
proaches nearly to that of delirium ; the concep-
tions become disordered, the ideas confused, and
various hallucinations sometimes are observed ; the
voice is thick ; the eyes vacant ; tlie face pale ;
the voluntary motions imperfect and unsteady ;
and the limbs tremulous, or incapable of their of-
fices. Vomiting occasionally occurs in this state,
and either diminishes or shortens the consecutive
slate of stupor. In a still more advanced stage,
all the phenomena about to be described some-
times occur — occasionally with convulsions, and
signs of dangerous coma, or even of asphyxy.
The phenomena of drunkenness are happily and
briefly expressed by Lucketius : —

" Cum vini penetravit —

Consequitur gravitas membrorum, prippcdiuntur

Crura vacillanti, tardoscit lingua, madet mens,

Nant oculi ; clamor, singultus, jurgia gliscunt.'

6. B. The phenomena of deep Intoxication hiivc
been very closely and accutely studied by Dr.
OosTON ; whose opportunities of witnessing them,
particularly in their more dangerous associations,
and as foUovvitig the use of ardent spirits, have
been unusually great. 1 shall, therefore, follow,

in great measure, the description he has given of
them. It should be recollected that the effects of
spirits or other intoxicating liquors on the frame
will vary with the habits of the individual ; with
his state of body, especially as respects vascular
plethora; with the kind ''of inebriating agent in-
dulged in ; and the existing condition of stomach,
chiefly as respects the presence of alimentary
matters. But the most powerful modifying agent
is temperature. Warmth increases the nervous and
vascular excitement characterising the early stage ;
and diminishes the consequent exhaustion. Cold
suppresses and shortens the early excitement, and
hastens as well as augments the oppression and
exhaustion of the advanced stage. — a. In the
larger proportion of cases, however, after a longer
or shorter period of unusual mental vigour, nervous
excitement, and increased action, varying accord-
ing to the surrounding temperature, the brain be-
comes oppressed ; the powers of voluntary motion,
which are early impaired, fail entirely ; the mental
manifestations are suspended ; and, in the most se-
vere cases, sensation is lost completely. In most in-
stances, this stage supervenes gradually ; but sud-
den exposure to cold will often induce it rapidly.
The person feels drowsy, and appears to fall into
a sound sleep ; but it is discovered, when the at-
tempt is made, that he cannot be aroused to con-
sciousness by any effort, or, if it partially succeed,
he is hardly sensible of surrounding objects, and
immediately lapses into his former state ; the
limbs remaining in whatever position they may be
placed. At this period the face is pale, with or
without nausea ; or it is flushed ; the eyes are va-
cant and suffused, sometimes glazed ; the pupils
dilated, aud contracting very imperfectly, or not
at all, by exposure to light. The temperature of
the head is generally above natural ; but that of
the extremities, and often of the surface generally,
is considerably lowered, or but little affected in
the milder cases. The pulse, which was at first
({uick and excited, becomes feeble, small, and ul-
timately slow, and entirely wanting at the wrist,
according to the degree of intoxication. Respir-
ation is usually infrequent ; the separate acts of
inspiration and expiration, particularly the former,
occupying a very short time ; and is wholly or
chiefly abdominal. The breathing is often labo-
rious in the most advanced states ; and in these,
the inspirations are convulsive, the chest expand-
ing by the rapid contractions of the associated
muscles of respiration. Strabismus, or tetanic
convulsions, or spasms of particular parts, some-
times supervene in the more advanced states, and
are unfavourable signs.

7. h. Such is the more common state or form of
deep intoxication : but alcohol occasionally causes
modified effects; and, without much previous ex-
citement, but always with more or less mental
disturbance, produces prostration of the functions
of the brain ; the intellects, volition, and sensation
failing almost simultaneously. In these cases, the
face is pale, the eyes are more or less lively or in-
jected, the pupils contracted ; the pulse frequent,
full, and soft; the respiration laborious or ster-
torous; the temperature uniform, and either at
or above the natural standard, but seldom below
it, Tiie circulation, respiration, and generation
of animal heat, may go on for a considera-
ble time, in these, notwithstanding the paralysis
of the brain ; or continue until this organ iias

DRUNKENNESS — PATHOLOGy and Diagnosis.

687

recovered from its torpor, provided the body be
not exposed to a cold atmosphere, or placed in
unfavourable circumstances.

8. C. Apjyearances after death. — These very
nearly resemble those produced by asphyxia.
'J"he countenance presents marks of anxiety or of
convulsion ; the eyes are prominent, the pupils
dilated; the face livid or swollen ; the lips blue ;
the cellular tissue injected with dark fluid blood ;
the air-passages reddened ; the lungs dilated, and
loaded with fluid dark blood, and more or less
frothy mucus in the air-cells. l"he right cavities
of the heart, the vense cava;, and the pulmonary
artery, are filled with blood of a similar appear-
ance. The left ventricle, aorta, and coronary
veins, also contain a little dark blood ; and the
liver and kidneys are loaded with it. Blood pos-
sessing the same characters also fills the sinuses,
veins, and even the smaller vessels of the ence-
phalon. The cerebral structure is generally
firmer than usual, fllore or less serum is found
in the ventricles and between the membranes of
the brain. Dr. Ogston confirms the testimony of
Wepfer, A^oight, Carlisle, and others, as to
the effused fliud being impregnated with alcohol.
In describing the appearances in one of his cases,
he states, that about four ounces of fluid were
found in the ventricles, having all the physical qua-
lities of alcohol ; as proved by the united testi-
mony of two other medical men, who saw the body
opened, and examined the fluid. He thinks that
the effusion takes place previous'ly to the coma of
intoxication ; as he found it in considerable quan-
tity, in two cases of drowning in the stage of
violent excitement from spirits. Mijller states,
that he found air in the sinuses of the encephalon.
The mucous coat of the stomach, particularly
in habitual drunkards, is thickened and softened ;
this latter change sometimes existing throughout
the whole extent of the small intestines. In rarer
cases, the coats of the stomach are remarkably
thickened and hardened. Injection, and some-
times ulceration, of the small intestines, are also
met with. The liver is frequently mottled, en-
larged, and otherwise diseased. The kidneys are
often enlarged, softened, paler than usual, gra-
nulated, &c. : the urinary bladder greatly en-
larged and thickened.

9. iii. Pathology. — That a portion of the
alcoholic constituent of the intoxicating fluid is
absorbed and carried into the circulation, is proved
by the odour of the expired air, and by the phy-
sical properties of the fluid effused within the
head of persons who have died soon after having
taken spirits to excess ; and it is probable, if the
urine were analysed, that a considerable quantity
would be found to have passed oft' in this excre-
tion. Deep intoxication seems to be occasioned
as follows : — During the general nervous and vas-
cular excitement consequent on the stimulus, in-
creased determination to the head takes place,
attended by excited vascular action ; which soon
terminates in congestion, as the excitement be-
comes exhausted, and gives rise to drowsiness,
sopor, or coma. With this state of disorder,
effusion of serum takes place in the ventricles and
between the membranes, heightening the sopor
and coma. When the congestion or effusion
amounts so high as to impede the functions of the
organs at the bas» of the encephalon, and of the
respiratory nerves, respiration becomes infrequent

and laborious ; and, consequently, the changes
produced by it on the blood insufficiently per-
formed. In proportion as the blood is less per-
fectly changed in the lungs, the circulation
through them is retarded, and the phenomena of
asphyxy — congestion of the lungs, right side of
the heart, brain, and liver ; the circulation of the
unarterialised blood ; the imperfect evolution of
animal heat, and sedative effects upon the brain
and nervous system generally — follow in a more
or less marked degree, according to the quantity of
intoxicating fluid which has been taken ; and
either gradually disappear after some time, or in-
crease until life is extinguished. These pheno-
mena are heightened by cold, which depresses the
vital actions in the extremities and surface to
which it is applied, and increases the congestion
of the above organs. The fatal consequence of
intoxication is often averted by the occurrence of
vomiting; the stomach thereby relieving itself
from a great part of the poison ; and the person
recovering, after some hours of the above state of
comatose intoxication. If the intoxicating fluid has
been thrown or drawn off" soon after its ingestion,
the recovery of consciousness is more immediate.
When intoxicating liquors are taken frequently,
and to an amount short of intoxication, the diges-
tive canal and liver are the first to suffer : — first in
their functions, and subsequently in their circu-
lation and organisation ; this being one of the
most fruitful sources of all the diseases, functional
and organic, of these viscera, as well as of the
nervous and vascular systems.

10. iv. The Diagnosis of intoxication is not
always easy. It is difficult to distinguish it, in
its more profound states, from — (a) apoplexy,
or concussion of the brain ; (6) asphy.ry ; and (c)
the extreme effects of cold. The odour of the
breath is one of the best means of diagnosis;
but is not to be depended upon alone : for a
person may be apoplectic, asphyxie, or exposed
to severe cold, after having taken only a small
quantity of spirits ; and apoplexy, asphyxy, and
the eflfects of cold, often come m aid of the intox-
icating agent, and heighten its effects : apoplexy,
in those of a plethoric habit ; asphyxy, from po-
sitions interrupting respiration, in addition to the
operation of the poison as above explained ; and
cold, in the manner already mentioned. It will
be very difficult to distinguish those cases of in-
toxication, where stertorous breathing is present,
from apoplexy, unless by the smell of the breath,
and of the matters thrown off the stomach. (See
Apoplexy, § 67.) It will readily be distin-
guished from syncope, by the laborious infrequent
breathing, by the smell of the breath, by the suf-
fused eyes, and the livid or tumid features.

11. v. The Prognosis is unfavourable, when
the pulse is indistinct, or nearly gone from the
wrist ; when the respiration is laborious, ster-
torous, or puffing; when the countenance is pale,
or livid and tumid ; the pupils either much
dilated or much contracted ; the coma profound,
and the extremities cold. Strabismus and tetanic
i^pasms are also very dangerous symptoms ; the
former having been observed in three out of four
fatal cases recorded by Dr. Ogston. When
these symptoms do not appear, the ill effects pass
off, in a great measure, within twenty-four hours,
although it is often much longer before all the
functions regain their healthy tone.

688

DRUNKENNESS — Treatm£nt.

12. vi. Treatment. — A, Of deep Intoxication,
— a. The propriety of immediately removing the
intoxicating liquor from the stomach cannot be
disputed. This ought to be instantly done by the
stomach-pump ; for, in extreme cases, the stomach
has become too torpid to be readily acted on by
emetics. Mr. Macnish advises the fauces to be
tickled, and the sulphate of copper, or the sulph.
of zinc, to be used as an emetic. Pressure on the
epigastrium, when this organ is full, will insure
the efTect of emetics, when the pump is not at hand.
When the stomach is not distended, the introduc-
tion of warm water will be often necessary before
its contents can be withdrawn by this instrument ;
and, when it contains much solid food, the same
measure will be requisite ; the distension thus
produced, often of itself causing the leaction of
the organ, which may be assisted by pressure on
the epigastrium. Sometimes the glairy state of
the contents will render their removal by the tube
somewhat difficult; but this may also be over-
come by dilution, and the mechanical means now
noticed. When the temperature of the head is
high, or not below natural, and that of the sur-
face generally not greatly reduced, the affusion
of cold water on the head is both a safe and effi-
cacious remedy.

13. b. I agree with Dr. Darwin, Dr. Trotter,
Mr. Macnish, and Dr. Ogston, in reprobating
indiscriminate bleeding in deep intoxication. Cases
which seemed urgently to require it, were injured
by it in the practice of this last physician. Dr. Dar-
win remarks, that, when drunkenness " is attended
with an apoplectic stupor, the pulse is generally
low ; and venisection has sometimes destroyed
those who would otherwise have recovered in a
few hours." The antidotes most to be relied upon
are the preparations of amtnonia (Masurer,
Broomley, Macnish, and Ogston), particularly
the sesqui-carbonate and liquor ammonite acetatis,
and cold or tepid affusion on the head. M. Gerard
prescribes the liquor ammonice, in repeated doses of
seven or eight drops. Vinegar has little effect ; and
it, as well as other acids, are considered injurious
by Alberti. Coffee and green tea are much more
efficacious ; and have been very generally recom-
mended. Alberti advises the application of cam-
phorated spirit to the crown of the head.

14. c. When the temperature of the surface is
at all reduced, means should be used to raise it.
In many cases, the removal of the contents of the
stomach, and the preservation of the natural tem-
perature, with elevation of the head and a proper
position of the body, all ligatures being removed
from it, are the only measures required. In ihe
more profound states of intoxication, however,
external warmth to the extremities and epi-
gastrium must not be dispensed with. It should
always be kept in recollection, that a degree of
cold which would not be injuiious in other cir-
cumstances, may prove fatal to a person in this
condition. As long as coma continues, the pa-
tient should not be left, lest he get into a position
that may induce asphyxy. When violent deli-
rium follows drunkenness, the shower bath, or
cold affusion, and afterwards the exhibition and
frequent repetition of tartar emetic, will often
calm the patient.

15. (/. 'J'he removal of the distressing symptoms
consequent ujwn irilojiicalimi is sometimes a matter
of medical duty. The principle contended for by

the celebrated Brown, and but too uniformly
practised by him, of keeping up the excitement,
was inculcated, and no doubt followed, by the
monks of the Schola Salernitanu ; they, good
souls, recommending —

" Si nocturna tlbi noceat potatio vini,
Hoc tu mane bibes iteruni, et fuerit medicina."

If there be no sickness, black and green tea»
mixed, may be taken, as advised by Alberti ;
but where nausea exists, soda water, spruce beer,
Seidlitz powders, the citrate of ammonia in a
state of effervescence, and any neutral aperient
sail in effervescing and aromatic draughts, will
be of service. Afterwards, moderate doses of
sulphate of magnesia in compound infusion of
roses, with a little additional sulphuric acid,
will restore the digestive functions. If diarrhoea
exist, the liquor ammonioe acetatis, and spirit,
ammoniee aromat., with infusum calumbaj, and
tinct. camphorae comp., will soon remove the dis-
order. When headach is distressing, and the skin
hot and dry, the shower bath, cold sponging the
head, saline aperients in an effervescing state, and
tea, are, upon the whole, the safest means. Tonics,
in conjunction with purgatives, may also be taken.

\G. B. Prophiilactic means. — a. The propen-
sity to drunkenness, or even to that degree of
excess which falls far short of intoxication, is
seldom or ever removed when ooce established.
In early life, and when the evil begins to mani-
fest itself, the possibility of checking it may be
indulged ; but even then it is a difficult matter to
succeed. Success will mainly depend upon the
constitution and character of the individual, and
the society he is allowed to keep. But instances
liave occurred, where there appeared to have been
a growing addiction to it, of the evil having been
arrested, by tartar emetic and other nauseous
matters having been given to persons in a state of
intoxication, or soon afterwards, I have, in seve-
ral cases, advised some tartar emetic to be put into
a glass in which soda water was about to be taken,
in order to remove the disorder and sickness oc-
casioned by extraordinary excess. The distress-
ing sickness thus induced, and which may, in
the helpless slate of such persons, easily be pro-
longed, has occasioned such disgust at, and dread
of, all intoxicating beverages, as to cause them to
be relinquished for a long time afterwards. But
tiiis plan, or even repetitions of it, will generally
fail with those who have become habituated to
this species of indulgence ; particularly those who
drink spirits, and who resort to it before dinner,
and when unallured by conviviality : these are
either altogether irreclaimable, or to be reclaimed
only by careful management, and a very gradual
diminution of the daily quantity of the intoxicating
agent. 'Ihe use of sulphuric acid in tonic infusions
is sometimes of service in such cases as are checked
at their commencement, the mind being actively
and agreeably occupied. But medical means
cannot be much relied upon, unless in conjunction
with a judiciously managed moral restraint,

17, b. It may be gathered from Pliitarch,
Pliny, and others, that various substances were
sometimes taken by the ancients, with a view of
counteracting the intoxicatingeffects of wine. Some
of these were both disgusting and ridiculous enough.
Others, as olives, and olive oil, absinthium, crocus,
and resinous purgatives, were, perhaps, not alto-
gether destitute of some influence. The Greeks

DUODENUM — Fl'nctiona

are said to luive used common salt for tliis pur-
pose ; and itie Ilomans surrounded tlieir lituds
by wreaths, formed of various refreshing plants.
Nothing further, however, may be said on this
topic, than that intoxication, and perhaps various
consecutive ill effects, will not so readily he pro-
duced when wine is taken upon a very large
meal ; but if this become a habit, it will very
speedily induce gout or apoplexy. Cold applica-
tions, or cold sponging the head, will also delay
or prevent intoxication, unless excess be carried to
to a worse than beastly length.

BtBLioG. AND Refer. — Hippocrates, Aph. v. 5. ; De

Mori), ii. xxii. 2 — t. ; Prsedict. ii. 24 — 26 Horace, Ode

21. 1. iii. V. 11. — Lucretius, 1. iii. v. 475. — Siromer, De-
creta Medicade Ebrietate. Lips. 1531. — Willich, Prob-
lem, de Ebriar. Affect, et Morib. Fr. 1543. — Montaigne,
£ssais, I. ii. cap. 2. — Magiras, De Vinolentia ejusque
Malis. Fr. 1618. — Hommets, Non ergo singulis Mensi-
bus semel repetita Ebrietas salubris. Paris, 1643. —
Lanc^lois, Noii ergo unquam Ebrietas salubris. Paris,
imS. — Jto/Jincl:, De Ebrietate et Crapula. Jen. 1667. —
JVepfer, observ. p. 7. — JValdschmidt, de Ebrietate et
insoientibus aliquot ejus affectibus. Geess. 1677. —
Etimiillcr, De Tcmulentia. Lips. 1678 — Hannemann,De

Usu et Abusu Inebriantium. Kiel, 1679 linsl, Ebrietas

medicd considarata. Reg. 1682. — Alberti, Therapia
Medica. Hal;c, 1721, 4to. p. 10.33. ; et De Ebrietate Foe-
minarum. Halse, 1737. — Ebrietatis Encomium, or the
Praise of Drunkenness, &c., 8vo. Lond. 1724 and 1812.
— Coj/^tHSf)-, DeNoxa et Utilitate Ebrietatis. Fr. 1740.
— Darwin, Zooi'.omia, vol. iii. p. 497. — Plainer, De Ebri-
ositate. Lips. 17''9. — Trotter, Essay, Med. Philosoph.
and Chemical, on Drunkenness, and its Effects on the
P.ody, 8vo. Lond. 1804. — Voight, Mag. fiir den Neuest.
Zustaiid der Nat. b. iii. p. 326. — Gerard, Med. and Phy.
Journ. Aug. 1821. — R. Macnisk, Anatomy of Drunken-
ness, 3d cd. 12ino. 1829 — F. Ogslon, On the more ad-
vanced Stages of Intoxication. Edin. Med. and Surg.
Journ. vol. xl. p. 276. — J. Frank, Praxeos Med. Univ.
Pracepta, vol. i. pars ii. sect. i. p. 671.

DUODENUM — Its Diseases.

1. That the duodenum performs an important
part in various diseases, and that it is itself the chief
seat of serious ailments, which are with great diffi-
culty, or not at all, distinguishable from disorders
of the stomach, pancreas, gall-ducts, liver, or right
arch of the colon, cannot be doubted. Some writers,
especially Dr. Yeats, Broussais, and his fol-
lowers, suppose that affections of this viscus may
be ascertained by attentive observation. They
may in some cases ; but with no degree of cer-
tainty ; for, after the most diligent investigation of
a train of phenomena apparently emanating from
this organ, the inferences we shall arrive at will
often possess only a certain degree of probability ;
for the same, or very similar symptoms, may pro-
ceed from the other viscera now named. It must,
however, be admitted, that serious disorder of the
duodenum will seldom exist without the functions
of these organs being more or less disordered, as
well as those of the stomach and small intestines ;
and ultimately organic change may be propagated
to a greater or less extent from this viscus to one
or more of them. It becomes, therefore, a mat-
ter of great importance to be acquainted with the
symptoms occasioned by the more common patho-
logical conditions of the duodenum, although we
are at the same time convinced that these symp-
toms may be produced by changes in some one or
more of the immediately adjoining organs. With
all this uncertainty, however, the experienced
observer will often come to just conclusions as to
the seat and nature of the disease, founded on his
knowledge of the functions and morbid relations of
this and the surrounding parts. The duodenum
is liable to all the functional and organic changes
described in the article Digestive Canal, but in
different relative degrees of frequency.
Vol. 1.

L Disordeu of — Pathology. 689

I. Functional Disohdeu of the Di'odenu.m.
Classif. — 1. Class, 1. Ordeu (.iK/Zror).

2. i. Pathology. — (o) It is extremely probable
that impaired function of this viscus gives rise to
various symptoms of indigestion ; warranting the
designation oi duodenal dyspepsio, if they could be
distinguished from those proceeding from the
stomach. But, granting that they can, we have
no proof that the duodenum is the sole, or the chief
seat of disorder, even in those cases which seem
to admit of the least degree of doubt of such being
the case. For, owing to the intimate structural
connection — by continuity of tissues, blood-ves-
sels and nerves — even functional disorder cannot
exist to any sensible amount in it without being
extended to the stomach, intestines, pancreas, and
biliary organs. j4sf/ic/tw, or deficient vital action
of the duodenum, may be inferred in cases charac-
terised by an unimpaired, irregular, or ravenous
appetite ; by constipation, and a deficient secre-
tion and excretion of bile, tiie stools being light-
coloured, greyish, or foetid j by a loaded sediment-
ous urine ; by a feeling of langour and drowsi-
ness, with fulness at the right epigastrium, and
oppression and sense of distension towards the
right hypochondrium, or right shoulder-blade, or
loin, two or three hours after a lull meal ; occa-
sionally by head-ache or vertigo ; or by pain, or
a burning sensation in the soles of the feet ; by
absence of fever, and a pale or foul lurid appear-
ance of the cutaneous surface. But, in this state
of disorder, the collatitious parts are coetaneously,
and some of them even co-ordinately , affected. In
attempting a fine series of pathological analysis, let
us not be carried away either by flights of imagina-
ation or by efforts at mathematical precision, and
attribute to a single organ what proceeds from seve-
ral. But let us merely endeavour to interpret the
phenomena of nature aright, according as they
actually exist, and not as we suppose, or would
have them to be. (See Indigestion.)

3. (6) Accumulations of sordes, the presence
of acid and acrid matters, of worms, or of morbid
bile, may very probably take place in the duode-
num as a consequence of indigestion, or atony of
the stomach, or of torpor of the liver, or even of
the preceding affection ; may irritate more or less
its mucous surface ; and, from its nervous and
other structural connections, disorder the func-
tions of digestion, chylification, assimilation, and
faication ; but the eiisemble of symptoms that
result can seldom be distinguished from those pro--
ceeding from disease of the stomach, pancreas, and
biliary organs, owing to the reasons already
assigned. These reasons will also explain the
fact that irritations seated primarily in this pait
maybe propagated, along the digestive tube, to
the stomach on the one hand, and to the intestines
on the other ; and along the ducts, to the liver and
gall-bladder on the one side, and to the pancreas
on the other : and I believe further, that fre-
quent repetitions of such irritations, occasioned
either by the nature of the ingesta, or by the
statft of the secretions poured mto it, may take
place without this viscus suffering materially in
structure ; and yet the disorder propagated from
it to its collatitious organs may terminate in struc-
tural change of them. Such results are most
likely to supervene in those who partake of a
highly seasoned and stimulating diet ; who indulge
in vinous or spirituous liquors, or take too much

Y y

690 DUODENUM— Inflammation op

or improper food. Irritation of the duodenum
very probably constitutes a part of certain forms
of dyspepsia ; and even pyros/s, and other ailments
frequently imputed to the stomach and the biliary
apparatus may, with equal justice, be referred to
thisviscus; but it cannot be said to be the only
part in fault, or even that primarily disordered ;
for it may be affected simultaneously with its re-
lated organs by changes primarily implicating its
nerves and circulation.

4. ii. TnEATMENT. — But little need be here
added to what is advanced on this topic in the
article Indigestion. It is obviously of importance
to promote the functions of the duodenum by
those means which are the best calculated to pro-
cure a due secretion of bile ; as this fluid is essen-
tially requisite both to the performance of those
functions, and to the preservation of the tissues of
the viscus in their healthy condition. But at the
same time accumulations of faecal or morbid mat-
ters in the bowels should be removed. A full
dose of blue pill, or of hydrargyrum cum creta,
should be given at bedtime with the common pur-
gative extracts, and in the morning any of the
aperient medicines in the Appendix, particularly
F. 266. 382. 872, Dr. Yeats recommends either
the infusion of chamomile flowers, with the wine
of aloes and liquor potassae, or an infusion of
quassia and senna with sulphate of potass, taken
morning and mid-day. These, or F. 506. 547. 562.
will be appropriate in most cases. But in those in
which irritation ispresumed to exist,! have preferred
the following, which may be given daily, or on al-
ternate days, until the evacuations become natural.

No. 196. R Pilul. Hydrarg. gr. iij. ; Pulv. Ipecacuanlioe
gr. ss. — j. ; Extr. Colocynth C'omp. ; Extr. Hyoscyaini,
aa gr. ij. ; Saponis Duri. gr. j. M. Fiant Pilula; duae
hora somni sumenda;.

No. 197. R Sods carbon, gr. xij. ; Extr. Taraxaci .3j. ;
Infus. Calumbae et Infus. Senns Comp. aa 3 ss. ; Spirit.
Ammon. Arom. 5 ss. ; Tinct. Cardam. Comp. 3 j. M.
Fiat Haustus primo mane capiendus.

5. When these fail of fully evacuating the
bowels, the stools still continuing unnatural, or
devoid of healthy bile, it will be advantageous to
exhibit a full dose of calomel at bedtime, with
the extracts of colocynth and hyoscyamus, and a
grain of ipecacuanha ; and a draught with the
compound infusions of gentian and senna, with
some neutral salt in the morning. Havingevacu-
ated morbid matters, it will be requisite to give
tone to the digestive organs, and to preserve a
healthy secretion of bile, by prescribing two or
three grains of hydrargyrum cum creta, or one or
two of blue pill, at night, with extract of tarax-
acum, or with soap ; and the infusion of calumba
or any other tonic, or the decoction of sarsaparilla
with taraxacum, in the course of the day. When
the mercurial is relinquished, small doses of the
nitro-hydrochloric acids, with the spiritus aHheris
nitrici, or the chloric a;ther, may be taken in the
infusion of cinchona. A course of Carlsbad, or
of any other alterative and aperient waters, either
alone or assisted bv the above alterative pill, par-
ticularly when the biliary secretion continues dis-
ordered, will often be adopted with advantage.

6. As much benefit will often accrue from a
well-ordered tliet and regimen, as from me<licine
in this complaint, the |)alieiit should be careful
to partake only of light food in moderate (jiiantity,
and at regular hours. Jle should masticate slowly
and perfectly, avoid malt and spirituous liijuors,
and partake sparingly of wine. He ought to cs-

■PAIIIOLOGY.

tablish regular and habitual evacuations of the
bowels, and take active exercise in the open air.
Horse exercise, and the energetic emi)loyment of
the muscles of the trunk and upper extremities,
are preferable to walking. The shower-bath, or
cold plunge bath, followed by frictions of the sur-
face, will also prove of great service.
II. Inflammation of the Duodenum, and
THEIR Results.

Classif. — III. Class, I. Order (Author).
7. i. Injiammatorx] Irritation of the Dtivdeintm.
(n) The uneasiness or sense of fulness and weight
which sometimes follows a meal in the course of
two, three, or four hours, occasionally with a deep-
seated, dull pain, or feebng of distension in the
right hypochondrium, and extending to the right
epigastrium, and backwards to the right shoulder-
blade, may depend upon chronic or sub-acute in-
flammatory irritation or action in the duodenum ;
and, if nausea or vomiting, or pain on firm pres-
sure directed towards the situation of the intestine,
accompany these symptoms, the latter state very
probably exists, either as a primary affection, or
as a consequence of the disorders already noticed,
and of affections propagated from the stomach or
adjoining organs. The above inference will be
further confirmed, if the tongue be loaded or
furred at its root, its edges and point being red,
and the papillje erect; if the appetite be unim-
paired, or even sometimes ravenous ; if the palms
of the hands and soles be hot, and the countenance
and cutaneous surface more or less unhealthy ; and
the bowels relaxed, griped, and the stools crude or
offensive. Chronic Injiammation of the duodenum,
especially affecting its mucous surface, is generally
associated with disorder of the stomach, biliary
organs, and intestines ; and often with chronic
eruptions of the skin, particularly herjies, psoriasis,
pityriasis, and acne. The bowels are in these cnses
usually irritated or irregular, the evacuations offen-
sive and otherwise disordered, very rarely natural,
occasionally containing much unhealthy bile, or
evincing a deficincy or obstruction of this secre-
tion. The skin is dry or harsh. There are also
frequently slight fever, sometimes with chilliness,
increased thirst, a gnawing sensation at stomach,
or cravings for food, and variable capricious ap-
petite. The spirits are often dejected, and occa-
sionally disturbed by hypochondriacal or fanciful
feelings. This state of disorder is not infrequent
in females, and is in them often complicated with
scanty, painful, and difficult menstruation, espe-
cially in unmarried females ; and with headaches
and various nervous complaints (See Indigestion
— Irritative and Injiammatory States of).

8. (ft) It has been supposed that cholera and
bilious diarrhoea are chiefly owing to the acute
inflammatory irritation of the internal surface of
the duodenum by the morbid secretions poured
into it; and doubtless such is tlie case in a great
measure. But it should not be overlooked, that
the organic nerves supplying the digestive tube
are morbidly impressed at the same time by these
secretions, and that the same agents quickly affect,
by their presence, the whole canal, although the
impression is more directly and powerfully made
upon the mucous surface and nerves of this part.
In cholera, and certain kinds of poisoning, there-
fore, where the internal coats of the stomach are
violently irritated, the consequent phenomena are
not to be imputed altogether, or even chiefly, to

DUODENUM — Acute Inflammation op — Symptoms.

691

ihis circumstance ; but in a great measure, and
sometimes chiefly, to tlie cliange produced in tlie
nerves of the organ, and propagated throughout
the system to which they belong, as well as to the
parts which they directly or indirectly influence.

9. ii. Acute Injiammation i// ihe Duodeniini. —
Duodeuitis (Duodeiiite, Fr.)may be interred with
much probability, but with no certainty ; for
acute disease of the liver and of the gall-ducts, or
of the pancreas or of the pylorus, will give rise to
very nearly the same phenomena. I believe that
acute inflammation is not frequent in this viscus,
or, if it be, that it does not so often give rise to
disorganisation, as in other parts of the digestive
canal. There can be no doubt that acute, sub-
acute, and chronic inflammations are sometimes
propagated to it from the stomach on the one side,
and from the intestines on the other, as well as
from other adjoining parts ; and it would appear
from cases which I have examined, and from
some recorded by M. Andtial (^Archives Gen. de
Med. t. vi. p. 161.; and Clinique Medicate, t. iv.
p. 344.), that inflammation may commence in the
mucous surface of the duodenum, extend along
the ducts, giving rise to obstructions of their
canals, either with or without jaundice, and even
advance to the organs to which they belong. We
more frequently, however, meet with the conse-
quences of inflammations of these parts, in post
mortem examinations, than with the early inflam-
matory appearances themselves ; whilst some of
the associated lesions admit of doubts being enter-
tained whether they be the results of inflamma-
tions, or of some other state of action ; but that
inflammation, in one or other of its forms, often
attends these alterations, cannot be denied. Thus
we occasionally observe thickening and injection
of the mucous and submucous coats of this viscus,
with obliteration of the common ducts, and these
alterations with lesions of the biliary organs, a
scirrhous or enlarged state of the pancreas, or ad-
hesions of this last with the duodenum, or of the
duodenum to other adjoining parts. Scirrhus
of the pylorus not infrequently extends a con-
siderable way along this intestine ; and enlarge-
ments of its mucous glands, or ulcerations, to
w'hich it is less liable than almost any part of the
digestive canal, are also observed in some in-
stances in the parts more nearly adjoining it; but
we very rarely meet with a case presenting evi-
dence of acute inflammation, and its undoubted
results, upon dissection, confined altogether to the
duodenum.

10. Symptoms. — a. Duodenitis, in any of its
forms, is, therefore, very seldom limited, unless at
its commencement, to this viscus ; and, owing to
the varied connections of this part of the canal, it
may implicate more than one part of very difl^erent
structures and functions. It may originate in any
of the functional disorders already noticed ; or
may directly proceed from the kind and (juantity
of the ingesta, whether food, drink, medicines,
or poisons ; or from the irritating effects of the
secretions poured into it from the liver or pan-
creas. Admitting, with Broussais, Andral,
BoissEAu, Abkrcrombie, Rostan, and others,
the difficulty of recognising the disease during
life, the existence of a dull, deep-seated, and
dragging pain, in a direction from the epigastrium
to the right hypochondrium, right shoulder-blade,
and loin, increased upon pressure made on these

regions, or upon torsion of the spine ; sometimes
but little felt, excepting in these circumstances,
and two or three hours after a meal, when it occa-
sionally becomes severe, and is attended or fol-
lowed by sickness or vomiting ; a sense of heat,
or of gnawing, or of a foreign body in the region
of the duodenum; great thirst; unimpaired or
even a ravenous appetite ; and an irregular or re-
laxed state of the bowels, the evacuations being
copious, crude, unnatural, and offensive, are strong
evidences of inflammatory action in the duodenum,
especially when attended by febrile commotion of
the system, similar to that already described (§ 7.),
and by emaciation : but, in such cases, the imme-
diately collatitious organs may also be diseased.
Even in the more severe states of inflammation of
this viscus, the pain and sickness may be very ur-
gent a few hours after a meal, and yet but little
complained of at other times, as in the rare case
related by Dr. Irvine, where the duodenum only
was inflamed and extensively ulcerated.

11.6. JMore frequently, acute duodenitis is con-
sequent upon gastritis ; or complicated either with
it, or with a similar change in the jejunum and
ilium, or with both. When it has arisen from the
extension of inflammation from the inferior surface
of the liver, or biliary apparatus, or when this
latter proceeds from it, the stomach generally par-
ticipates in the disorder, at least of function.
When an irritative or inflammatory state of action
extends from the inflamed duodenum to the liver,
the pain rises often high in the right hypochon-
drium, sometimes to the right side of the thorax,
especially after a meal ; and is attended by bilious
vomiting, occasionally with bilious stools or diar-
rhoea, followed by constipation, nidorous eruct-
ations, prolonged digestion, a bitter taste in the
mouth, a yellow coated tongue, and a slight yel-
lowness of the conjunctiva, and unhealthy or yel-
low appearance of the skin. (See Jaundice.)

12. c. The consequences of inflammatory action
in the mucous surface of the duodenum are, its
extension — 1st, to the stomach or small intestines,
or to both ; and, 2d, to the ducts, occasioning,
first, obstruction or obliteration of them ; and, ul-
timately, congestion, engorgement, enlargement,
or various other lesions either of the liver or of
the pancreas, or of both, -with jaundice, and other
contingent changes. When the inflammatory ac-
tion attacks the whole thickness of the parietes of
the intestine, whether originating in its mucous
coat, or extended to its more exterior tunics from
collatitious parts, the pancreas, pylorus, duotle-
num, ducts, and even the liver and colon, not in-
frequently become accreted or welded into one
mass ; in which the panci'eas is often remarkably
enlarged, hardened, or scirrhous, the ducts obli-
terated or obstructed, and the accreted serous sur-
faces and cellular tissue hypertrophied, or indu-
rated, or granulated and tuberculated. A case
of this description, of which I kept notes at the
time, occurred in a dispensary patient, in 1820 ;
since when, I have met with several others — two
of., them with Mr. Painter and Mr. Byam. In
three ca-es of this description, recorded by Dr.
Bright, and in one by Mr. Lloyd, fatty mat-
ters were voided in the stools ; but this phenome-
non either did not exist, or was overlooked in
those which occurred in my practice. The in-
stances adduced by Dr. Bright presented
ulceration of the duodenum, which this able
Y y 2

69-2 DUODENUM— Acute Inf

physician considered of a malignant kind ; the
pancreas presenting the same diseased appearances
as in the cases observed by me.

13. d. rhiche»ittg is one of the most frequent
lesions to which the coats of the duodenum are
liable ; and occurs often in connection with a
similar or more remarkable change in the pylorus.
Softening of the interior tunics is equally if not
more common. Gangrene is very rare ; as also
are thinning or atrophy of the coats, nlceration,
and erosimi or destruction of the villous membrane.
Although enlargement of the mucous glands is
more common in the duodenum than in the
stomach, yet ulceration is, accordmg to M. Bois-
sEAu, ten times more frequent in the latter than in
the former.

14. e. In the cases of ulceration of the duode-
num on record,most of the symptoms accompany-
ing chronic inflammation (§ 7.) were present, with
diarrhoea ; and, in Dr. liniGHT'scases, a discharge
of fatty matters from the bowels. In M. C.
Broussais's case, fatal haemorrhage took place
into the intestinal canal, owing to the extension of
the ulcer to the coats of a large artery. In a
case detailed by Dr. Hastings, the patient had
complained, for two months, of occasional vomit-
ing and costiveness ; with pains and tenderness,
on pressure, in the epigastrium and right hypo-
chondrium, below the margins of the right libs,
and extending to between the shoulders. The
pulse was ninety-six, the countenance anxious,
and the skin yellow ; and the body much emaciated.
The liver and stomach were liealthy. In the duo-
denum, beyond the part into which the ducts en-
tered, a cancerous ulcer was found, larger than a
crown-piece, with ragged and everted edges. Its
surface was irregular from fungous excrescences.
The coats of the intestine, around the ulcer, were
much thickened. The rest of the bowels were
natural.

15. /. Perforation^^ the duodenum may occur
from ulceration, and give rise either to fatal perito-
nitis, as in the cases adduced by Dr. Abercrombie
and M. Roberts, or to adhesions and communi-
cations with other viscera ; but these occurrences
are rare. A case has been described by Dr.
Streeten, in which a communication took place be-
tween thisviscus and an external opening between
the seventh and eighth ribs, through which articles
of food and drink were frequently discharged. The
duodenum was found much contracted beyond the
perforation in it, wliich communicated by a canal,
two inches and a half in lengtli, through thickened
cellular tissue, to the external aperture. This le-
sion was complicated with extensive disease of the
liver and thoracic viscera. The most common
changes consequent upon inflammatory action in
this viscus, are, jaundice, and adhesions to the ad-
joining parts(^ 12.) ; its coats becoming thickened,
hardened, and otherwise changed ; the morbid
mass forming a tumour, which sometimes may be
recognised towards the right of the epigastrium,
near the end of the eighth rib, upon a careful ex-
amination.

16. iii. Treatment. — A. In tlie slighter forms
of diiodevilis, local dejjlctions by cupjiing or
leeclies will freriuentiy suffice ; but when they are
associated with manifest plethora and congestion
of the portal circulation, a moderate bleeding from
the arm will be preferable, in the first instance. A
blister, or rubefacient plaster, applied over the

LAMMATIOX OF TREATMENT.

epigastrium and hypochondrium, after depletions
have been carried sufficiently far, will act benefi-
cially on the seat of disease, and will favour the
secretion and excretion of bile. A full dose of ca-
lomel may also be given, and be followed either
by a moderate dose of castor oil, or by a purgative
enema. I'he efl'ect of calomel upon the upper
part of the alimentary canal is satisfactorily shown,
both by direct experiment and therapeutical observ-
ations, to be sedative of inflammatory action in
that situation. As the bowels are generally freely
open in this disease, the object will be rather to
correct than to increase the secretion from them.
With this view, small or moderate doses of hydrar-
gyrum cum creta, with pulv. ipecacuanhae comp.,
or pulv. Jacobi, may be given at night ; and the
nitrate of potash, with carbonate of soda in the
infusion lini comp., or decoctum althaeae comp.,
with either extractum humuli or extr. taraxaci,
according to the state of the bowels, during the
day. After the alterative pills have been con-
tinued a few nights, a teaspoonful eacli of fresh
castor oil and olive oil may be taken on the sur-
face of some aromatic water ; and, if the stomach
does not nauseate it, this dose may be repeated at
bedtime, or in the morning, for some days. If
the biliary secretion be not improved after a few
days, a full dose of calomel should be given
again, and the milder preparations continued in
small doses for some time, and conjoined with ipe-
cacuanha, extract of hop, or hyoscyamus, or tarax-
acum, according to the state of the bowels. Where
the bowels are very irritable, and the secretions
morbid, the mercurials may, at first, -be given with
the extract of lettuce, or opiates, or Dover's
powder; laxatives being subsequently resorted to
for the removal of morbid collections.

17. B. In the more acute states of inflamma-
tion, one or more of the allied organs are often
implicated, and both general and local bleedings,
blisters, and other counter-irritants, and a full
dose of calomel, or of calomel and opium, a?'e
requisite ; after which purgative and emollient
enemata may be thrown up, and gentle and
cooling laxatives be given internally with
anodynes, demulcents, and diaphoretics. If fe-
ver, or a sense of heat, be felt, the nitrate of
potash may be given, with the carbonate of soda
and the sweet spirits of nitre, in camphor mixture,
to which either the extract of taraxacum, or of
hop, or of lettuce, may be added, accordipg to
the state of the bowels ; the mild mercurial alter-
ative being taken at bedtime. Afterwards the
solution of acetate of ammonia and camphoi
mixture, with the wine of ipecacuanha, and tinc-
ture of henbane, in small doses, may be resorted
to through the day. If diarrhoea prevail, or su-
pervene, the hydrargyrum cum creta should be
given twice or thrice in the twenty-four hours,
with small doses of rhubarb, or of compound
ipecacuanha powder, in the form of pill; with
small doses of magnesia in the compound infusion
of orange peel, or in any aromatic water. If cos-
tiveness occur, a full dose of calomel, with rhu-
Ijarb or jalap, may be taken at bedtime, and the
oils, as directed above, or the compound jalap
powder, the following morning ; their operation
being assisted by enemata, or by any gentle ape-
rient conjoined with emollients and anodynes, as
maybe found re((uisite. If much disorder still
continue, especially of the biliary and other se-

DYSENTERY— Seat and Forms of.

693

cretions, a large plaster, consisting of the ammo-
niacum plaster with mercurj', and the compound
pitch plaster, in equal proportions, or of the former
only, should be placed over the epigastrium and
right hypochondrium, and renewed after a week.
In some cases, the opium plaster may be substi-
tuted for the latter; particularly if the bowels be
irritated. W hen there is much irritation of the

I 3 Class, 2 Order (Good). HI. Cr.ASs,

I. and II. Ordehs (Author, in Preface).
1. NosoL. Defin. Tormina, follnwed by strain-
I ing and scanty mucous and bloody stools, containing
I little or no J'cecuI matters; and attended by febrile
' disturbance.

2. Path. Defin. — Inflammatory action of a
sthenic m- asthenic kind, seated in the mucous sur-

nervous system accompanying the disorder of the 'face of the intestines, chiefly of the large intestines.

digestive canal, much benefit will accrue from the
hydrocyanic acid exhibited in demulcent or dia-
])horetic vehicles, as the camphor or almond mix-
ture, or in both ; and from the following, especi-
ally after morbid secretions have been evacuated
by the foregoing means : —

No. 19S. R Camphoras rasae et subactas gr. vj. — viij.
terecum Magnesiae ustfe3j., ct Sodse carbon, (vel Potassae
carb. 3ij. ; deinadde, Infusi Valerianae (vel Aq. Menthae
Virid.) 3 viij.; Tinct. Colchici Composit. 3 ss. ; Syrupi
Papaveris 5 iij. M. Fiat Mist, cujus coch. ij. larga bis
terve quotidie sumantur.

18. Having removed the inflammatory state, by
these and other medicines appropriate to the pe-
culiarities of the case, a similar treatment to that
recommended in functional disorder of this viscus
(§ 4.) may be adopted, and nearly the same diet j
and regimen pursued. At first, however, _very
light, and chiefly farinaceous, articles of diet
should be taken, and the beverage should consist ;
of small glasses of spruce beer, or Seltzer or soda
■water, and the bowels regulated by an aperient
and tonic pill (F. 558. 561, 562.), or by lave-

accompanied with more or less constitutional dis-
turbance, and retention or disorder of the natural
secretions and excretions.

3. Litt. Hist. — Dysentery, owing to its preva-
lence in ancient as well as in modern times, has
attracted a large share of the attention of medical
writers. Hippocrates (Opera, edit. Vander Lin-
den, vol. i. p. 252., vol. ii. p. 101. 176. et passim)
notices it in various places, both as a sporadic and
as an epidemic disease ; and in such a way as
shows that he was acquainted with several of its
pathological states and relations, and even with
its complication with functional and organic dis-
ease of the liver. Celsus (DeMed. 1. iv. cap. 15.)
mentions it by the name of tormina, as distinct
from tenesmus, from lientery (levitas intestino-
rum), and from diarrhoea. Aret^eus (De Sig. et
Cans. Morb. Dint. 1. ii. cap. 9. ed. Boerhaave,
p. 59.) attributed the complaint, with Hippo-
crates, to ulceration of the intestines; and was
the first to describe it in an accurate and connected
manner. Galen (De Cans. Sympt. 1. iii. cap. 7.),

ments of warm water. As the general health im- ! although, perhaps, not the firs"t to distinguish the
proves, a more generous diet, and a small quan- ; difl^erent forms of the disease, has furnished us

tity of wine, may be taken ; regular and active
exercise in the open air being enjoyed. After the
more protracted cases, or when the secretions and
alvine evacuations still continue, or readily be-
come disordered, a course of taraxacum, with mi-

with the earliest attempt of this kind that we
possess. He particularises a sanguineous, an he-
patic, an atrabilious, and an ulcerated variety.
Subsequent writers, — Greek, Latin, or Arabian,
— down to the commencement of the sixteenth

nute doses of a mild mercurial, subsequently of century, when the wntings of the celebrated
the nitro-muiiatic acids, with compound decoction Fernel first appeared, added but little to the ma-

- . . - terials scattered through the works of Galen.

From Fernel to the present age, the disease has
been nearly as well understood, as respects both
its nature and treatment, as at the present time.
The numerous epidemics, however, that have oc-
curred, and been described by experienced writers,
from the time of this physician, have furnished
diversified facts, illustrative of its varied forms and
of its treatment.

4. I. Seat and Forms of the Disease. — A.
The ancient writers, from Hippocrates to Avi-
CENNA, considered dysentery to be seated in the
internal coats of the intestines — particularly the
large intestines — and attributed it too generally
to erosion and ulceration. C/elius Aurelianus,
Aetius, Alexander Trallianvs, and others,
who wrote between Galen and Avicenna, enter-
tained the same view as to its nature and seat, and
imputed the modifications it presented to the par-
ticular part of the bowels chiefly aflfected. They
even attempted, and not without some degree of
justice, and even of accuracy, to point out, from
the character of the discharges and the appear-
ance of the blood in the stools, its seat in the
small intestines, in the colon, or in the rectum.
Aetius (Tetrabibl. iii. s. i. cap. 43.) believed that
the jejunum is sometimes the part chiefly diseased,
and described the symptoms — many of them
really concomitants of inflammation of the mu-
cous surface of the small intestines — that cha-
racterised this variety. Similar views were
Y y 3

of sarsaparilla ; or a course of either the Harrow
gate, or the JXIarienbad, or the Carlsbad mineral
waters may be tried.

EiBLioc. AND Refer. — F. Hoffmann, De Intest. Duod.
imiltorum iMalorum Sede, in Opp. vol. vi. — Bonnazoli,
Trans, of the Acad, of Bologna, 1745. — Schmiilel, De
Dignitate Duodeni in Dijudicandis et Curandis Morbis.
Erl. 1757. — A. Monro, Edin. Med. Essays, vol. iv. ed.
1752. — Clausscn, in Sandifurfs Thesaurus, vol. iii. 1778.
— Warren, in Med. Trans, of Col. of Phys. vol. iv. p. 233.
— Ferriar, Medical Histories, vol. ii. p. 27. — G. D. Yeats,
in Med. Trans, of Col. of Phys. vol vi. p. 325. — Roche
et Sanson, Nouv. Elemens de Pathol. Medico-Chirurg.
&c. 8vo. Paris, 1825, t. 1. p. 485. — Irvine, in Philadelphia

Med. Journ. Aug. 1824 C. Broussais, Sur la Duodenite

Chronique, 8vo. Paris, 1825. — Roberts, in Nouv. Bib-
lioth. Med. Jiiin, 1828. — F. B. Boisseau, Nosographie
Organique, 8vo. Paris, 1828, t. i. p. 389. — C. Hastings,
Midland Med. Reporter for May, 1829, p. 292.— Streeten,
in Ibid, for November, 1829. — J- Abercrombie, Researches
on Dis. of the Stomach and Abdom. Viscera, &c. Edin.
1830, 2d ed. p. 103. — F. J. V. Broussais, Comment, des
Proi>ositions de Pathologie, &c. 8vo. Paris, 1829, t. i.
p. 297. — R. Bright, Ohserv. connected with Dis. of the
Duodenum and Pancreas, &c., in Trans, of Med. and
Chirurg. Soc. vol. xviii. p. 1. — E. A. Lloyd, in Ibid,
p. 57 T. J. Todd, in Cyclop, of Pract. Med. vol. i.

DYSENTERY. Syn. — At/s-evTEpia, Gr,

Dysenteria (from S^uj, difficulty, and hrepov,
an intestine). Difficultas hitestinorum ; Tor-
mina, Celsus. liheumatismus intestinorum
cum Ulcere, Caelius Aurelianus. Flu.rus
Cruentus cum Tenesmo ; Fluius Dysentericus ;
Flumen Vysentericum ; Tenesmus, Auct. Var.
IJyssenterie, Flux de Sang, Fr. Die liuhr,
Germ. Dissenterie, Ital. Bloody Flur.

Classif. — 1 Class, 5 Order (Cullen),

694

DYSENTERV — Forms of.

entertained, also, by Alexander TnALLiANns,
Paulus jEgineta, and Actuarius. An atten-
tive consideration of the various manifestations of
the disease, especially in an epidemic form, will
show that these opinions are not without founda-
tion. How far they are consistent with the results
of modern researches, will appear in the sequel.

5. B. Thii forms of dysentery are extremely di-
versified : — (a) As respects its Origin, it is — a
primary; 0. consecutive ; and y. symptomatic. —
(b) In regard of the Circumstances under which it
occurs, it is — a. sporadic; B. endemic ; y. epide-
mic; and, J. both endemic and epidemic, in the
same locality, on certain occasions.— (c) As to its
Type, it is — a.. remittent ; and, B. continued ; most
commonly the latter, especially in temperate cli-
mates.— (d) As regards its Character, it is — a.
injlammatory ; B- bilioxis-injiammatory ; y. simply
asthenic ; ^. bilious-asthenic ; t. adynamic or
tiiphoid ; !^. malignant or putrid; n. scorbutic;
and, &. complicated. — (e) As to Intensity and
Duration, it is — a. hyperacute ; $. acute ; y. sub-
acute; and, ^. chronic. These modifications, or
varieties of character and i)itensity, are, however,
merely arbitrary distinctions, founded on the
more prominent symptoms of the malady, and
adopted chiefly in order to guide us in the appro-
priation of remedial measures. Indeed, it should
not be overlooked in this, more than in other dis-
eases which possess very specific and distinct
features in a majority of cases, that it will fre-
quently assume forms intermediate between cho-
lera on the one hand, and diarrhoea on the other ;
between /(?iifr with enteric characters, and colic or
simple tenesmus ; that it may be but very slightly
different from some one of these complaints; and
that, in one or other of its forms, it may be conse-
cutive of, or lapse into, any one of the maladies
now named. This connection between disorders
of parts intimately associated in function and struc-
ture, is merely what may be expected a priori,
conformably with the pathological principles de-
veloped in the article Disease. The diversified
forms and close relation of dysentery to other
maladies are readily explained on these principles ;
especially if considered in connection with the
nature of'the diflTerent causes in which it originates ;
with the condition of the vital actions, the circu-
lating fluid, and thesecretionsand excretions, at the
time when its causes make their first impression ;
with the changes which concurrent causes induce
from the commencement, and with the circum-
stances modifying the state of the circulating and
secreted fluids in the progress of morbid action.

6. In describing the varieties or states of the
disease, it is of the utmost importance — consider-
ing its great prevalence and fatality in certain cir-
cumstances, on many occasions — not to multiply
distinctions beyond such as are well ascertained
and are practically important ; not to neglect to
notice such as have been accurately described —
as are contingent on certain combinations of
causes of occasional, but not of common oc-
currence; and, although neglected or over-
looked, from an injurious spirit of simplifying
or generalising, as nevertheless exist, and may
be manifested in a prominent manner whenever
the causes in which they originate prevail.
'J aking my own experience merely as a guide
since 1812, when 1 first treated the disease —
an I subsecjucntly observed it in the tracks of the

great armies which traversed Europe at the close
of the Continental war — and as I was brought
in constant intercourse with it for a time, in the
most sickly climate within the tropics, in both
European and native constitutions — independ-
ently of the graphic delineations of it in many
of the works referred to, I consider dysentery
neither so simple in its nature, nor so unvarying
in its seat and forms, as some recent and con-
temporary writers in this country have stated.
That writer will but imperfectly perform his duty
who, in giving a history of a most prevalent and
dangerous malady, confines himself to the parti-
cular form it has assumed during a few seasons,
within the single locality or the small circle of
which he is the centre, and argues that it is always
as he has observed it ; thereby affirming as true of
the genus, what may be hardly true of the species,
and even of it only under certain circumstances.

7. The different forms of dysentery are so en-
tirely dependent upon certain states of the organic
or vital actions, and of the secreted and circulat-
ing fluids, that these constitute the true basis of
all distinctions between them, and of all rational
indications of cure. These states, which are so
important, are so difficult to ascertain and estimate
truly, even by the most profound and experienced
observers, and are so continually varying, that
attempts to describe them must be received as ap-
proximations only to some of those which will fre-
quently present themselves in practice : for the
one will so insensibly pass into the other, both in
different persons, and even in the same person at
different stages, when certain agents are in opera-
tion, that the forms of the disease are not to be
viewed as constant, but as changing according to
ciicumstances, so as frequently to assume cha-
racters intermediate between those which are
described. Although the features of the disease
are so numerous and so changeable — as may,
indeed, be expected from the operation of numer-
ous agents in ever-varying states of combination
upon the economy — yet the necessity of deline-
ating certain of them which are the most promi-
nent and the most common, as guides for the inex-
perienced, must be apparent. In our inquiries
into the nature of, and the means of removing,
morbid actions, the conditions of life are the chief
subjects of interest ; for these conditions constitute
not only the chief changes, but also the sources,
whence those which are organic spring. They
are, moreover, the most directly and energetically
impressed by remedial agents, and are the chief
media by which structual lesions are removed.
I shall, therefore, describe the forms of this ma-
lady, conformably with these views. It was evi-
dently with a conviction of the practical import-
ance of early and exactly recognising the states
of organic or vital action, that J. P. Frank and
Horn divided the acute states into (n) sthenic,
and (h) asthenic ; the former comprising the sim-
ple, the iufammatirry, and the bilious varieties ;
the latter the malignant or putrid, the scorbutic,
and the nervous of IIiciiter, KnEvssic, and some
other authors. Without adverting to the divisions
by Sacar and Sauvagks, which are formed upon
no consistent principle, but chiefly upon the causes
that produce the disease, I will notice such as have
been adopted by some of the most experienced
writers. Whilst they agree in the more general
division into acute and chronic, they diflTer mate-

DYSENTERY, ACUTE — Causes

the arrangement of the acute states,
particularises

■ SVMPTOMS.

69;

rially

ZiMMERMANN particulaHses the injiunnmilory,
malignant , putrid, and chronic states. RirirrEH
describes the simple, injiamwatory , bilious, and
nervous forms ; and Kreyssig adds to these the
jiituitous or mucous, and the putrid or malignant.
AIM. FouHNiER and Vaidv adopt nearly tiie
same division as Kreyssig, but they adduce
in addition, the association of the disease with
tiiphus and ague. Schmidtmann distinguisiies
the simple, the injiammatory , the bilious, and
bilious-ill fiammatory, the nervous, and the putrid
varieties. M. A ignes, one of the most recent
and experienced writers on dysentery, consiJers,
first, its benign or purely injiammatory states, under
the denomination of mucous and bilious ; and,
next, its malignant forms, comprising the typhoid,
adynamic, ataxic, and complicated. In the de-
scription I am about to give of the disease, I shall
follow a nearly similar arrangement to the most
a])proved of those adopted by the ablest and most
experienced of my predecessors. In the^csf
place, those acute forms will be noticed which are
the most simple, which are more or less sthenic
or inflammatory, and in which the vital energies
are either not materially affected, or not per-
verted to the extent of subduing the natural ten-
dency of the economy to resolution and to a
restoration of the healthy action. Secondly, the
asthenic, or more unfavourable and complicated
states, which have been variously denominated,
according to the predominance of certain charac-
ters, arising out of particular circumstances and
epidemic influences, will be considered. Thirdly,
tile chronic and complicated forms will be de-
scribed.

II. Of Acute Dysentery. — i. Its Simple, Sthe-
nic, OR PURELY- Inflammatory' States.
Classif. — III. Class, I. Order.

8. Defin. — Tormina, tenesmus, mucous or bloody
stools, and a sense of heat or pain in the colon and
rectum, with tenderness on pressure, and symptorr-
alic fever ; the nervous, circulating, and muscular

functions not indicating vital depression until late
in the disease.

9. A. Causes. — (a) The predisposing causes of
the sthenic states of the disease are chiefly high
ranges of temperature following wet and cold
seasons ; whatever favours the production and
accumulation of morbid secretions in the biliary
apparatus and prima via ; debility of the digestive
organs, particularly of the intestinal canal ; a ple-
thoric state of the vascular system ; unnatural
flexures of the colon favouring faecal accumu-
lations in the bowels ; neglect of the functions of
digestion and faecation : the habitual use of spirit-
uous liquors, or other inebriating beverages in
excess ; rich food, and highly seasoned cookery.
Dysentery is generally most common in autumn
and in the beginning of winter ; in persons of the
rheumatic diathesis ; and in those who have un-
dergone great fatigue ; or who have been recently
affected by continued, remittent, or intermittent
fevers ; but, in such circumstances, it is as often
of an asthenic as of a sthenic kind.

10. (fc) The eiciting causes of the sthenic forms
of the disease are drunkenness ; exposure to vicis-
situdes of climate or of temperature, and especially
to cold and moisture, or to the night-dews; sleep-
ing in the open air, and more particularly on the
ground, without sufficient protection intervening.

or without requisite covering, as in the case of
armies in the field ; wearing damp or wet clothes,
or too thin clothing ; acerb, acid, unripe, or over-
ripe and stale fruit and vegetables ; raw, cold,
and indigestible fruit, &c., as cucumbers, melons,
pine-apples, &c. ; the stones and seeds of fruit ;
unwholesome food, especially unripe or blighted
corn or rice; and acid or unwholesome drink, as
sour or bad beer and wine. The exhalations
from wet, cold, and clay soils and marshes, or
from the banks of lakes, rivers, and canals ; and
the use of marsh, stagnant, or brackish water for
drink, with many of the causes mentioned in con-
nection with the other forms of the disease (^22.6.),
will also produce this form in persons of a san-
guineous and plethoric constitution. Mr. An-
nesley states, that dysentery became, at one time,
remarkably prevalent amongst the British troops
in India to which he was attached, and that, upon
investigation, lie traced it to their eating the pork
of the country with their breakfasts. Upon a stop
being put to this practice, the disease altogether
disappeared.

1 1.J3. Symptoms and Progress. — Sthenic dys-
entery presents various states and grades of severity,
depending upon the nature ef the cause, the state of
the secretions, and the degree of inflammatory irri-
tation or of spasmodic action of the bowels result-
ing therefrom. It is often preceded by constipation
when occurring sporadically, and frequently by
diarrhoea when arising from endemic or epidemic
causes ; but in many instances the dysenteric
symptoms appear from the first, and are attended
by chills or rigors. When it is caused by endemic
causes, or is epidemic, the inflammatory symptoms
may be very slight, and yet the constitutional dis-
turbance and morbid action of the bowels very con-
siderable ; or the irritation and inflammation may
be along the small as well as the large intestines.

12. (a) The milder state of the complaint, espe-
cially as it occurs sporadically in Europe, com-
mences either with liquid and feculent or with
mucous stools, the latter being occasionally
streaked with blood, and always becoming so in a
few days. Generally, horripilations or chills pre-
cede, accompany, or follow these evacuations,
which are consequent upon gripings and a sense
of increased action in the course of the colon ; and
are often passed with heat and scalding in the rec-
tum, followed by straining or tenesmus. The stools
are frequent ; commonly from eight or ten to
more than double this number in twenty-four
hours, and are streaked with more or less blood.
They subsequently become less mucous, more
watery, and sometimes contain traces of faiculent
matter. There is little or no pain in the abdomen
between the calls to stool , but often an irksome sen-
sation is felt in the situalidn of the sigmoid flexure
of the colon and of the rectum. The pulse is
either very slightly aftected, or quick and small ;
the tongue is generally loaded or furred ; and the
thirst increased. The appetite is frequently not
much, or even not at all impaired. This slightest
grade of the disease may terminate favourably in
from six to nine days, or it may pass into a chronic
form. — Relapses, and organic changes iri the large
bowels, sometimes also/follow it.

13, (6) In its more severe states, dysentery is

preceded either by diarrhoea, or by disorder of the

stomach and bowels ; or by nausea, flatulence,

constipation, and occasionally vomiting. These

Yy 4

696

DYSENTERY, ACUTE —

symptoms may be of two or three days' duration,
before the characteristic evacuations are observed,
or be accompanied or followed by distinct chills
or rigors, ushering in increased heat and frequency
of pulse. In other cases, very frequent, scanty,
mucous, and gelatinous motions, streaked with
blood, preceded by gripings and tormina, and
attended by straining, at once introduce the dis-
ease. Frequently the horripilations or chills con-
tinue to alternate for some time, with increased
heat, and other febrile symptoms. The pain at
first is often limited to the rectum and sigmoid
flexure of the colon, occasional griping only being
felt in the abdomen. The pulse is slightly acce-
lerated, and the tongue white and loaded. If the
disease be not subdued or mitigated in this early
stage, tlie calls to evacuation become more fre-
quent ; are preceded by more severe griping and
tormina; are attended by greater straining; and
are sometimes jnefTectual. The tongue is more
loaded, aud the pulse more frequent and small.
In many cases, however, little or no pain is felt,
excepting when the patient is about to pass a
motion, although the matters discharged are most
morbid, and the constitutional affection severe.
This, however, is do evidence of the absence of
inflammation j for the mucous surface of the large
bowels may be inflamed, and even ulcerated, and
yet but little uneasiness, unless upon firm pressure,
will be complained of. Often, where pain in the
intervals between the tormina is absent, a sense
of heat in the course of the colon, or of soreness
in the abdomen, is felt, and indicates, even more
than acute pain, the existence of inflammatory
action. As long as disease has extended no fartiier
than to the mucous surface of the large bowels,
the patient seldom feels more than the above
sensations, or a dull aching pain, not increased on
pressure, which he describes as shooting, at times,
through the abdomen ; but when the region of
the cfficum is minutely examined, pain or fulness
is generally detected in that situation, even when
neither can be felt over the sigmoid flexure.

13. As the disease proceeds, the stools become
more frequent, the tenesmus more severe, the dis-
charges of blood greater and more mixed with the
matters evacuated, which gradually pass from a
mucous, slimy, or gelatinous, to a watery and
dark muddy appearance, either with an intimate
admixture of feculent matter, or occasionally
with hardened faeces, and even with pure and
unmixed blood. The tenesmus is now attended
by a feeling as if the bowels themselves would
pass ott"; and, in children and delicate persons,
j)rotapsis aid not unfrequently occurs. In some
instances, as the disease advances, substances
resembling fat or pieces q( flesh, and consisting
chiefly of masses of coagulable lymph, or of the
fibrine of the blood poured out in the bowel, come
away. The urine is now, and often early in the
complaint, of a high colour, voided frequently, al-
ways with scalding pain, or difficulty; and some-
times the dysuria amounts to strangury, owing to
the vicinity of the chief seat of disease. The
tongue is at this period loaded towards the base,
and its papilla; are excited. 'I'lie pulse is quick
and small ; the skin harsh, hot, and dry, especially
over the abdomen ; the tormina and tenesmus in-
crease, and the calls to stool are more incessant,
especially during the night and early in the morn-
ing, when tho febrile symptoms are also much aug-

SviMPTOMs — Progress.

mented. The thirst is urgent and the appetite lost ;
every thing taken to assuage the thirst being fol-
lowed by tormina, and a desire of evacuation, as if
it had rapidly passed through the bowels; and the
patient desponds. Subsequently pain becomes
more fixed in the hypogastrium, the abdomen more
tense, full, or tender ; the strength sinks ; and
dyspnoea sometimes supervenes, — indicating the
extension of inflammatory action to the peritoneum.
If no amelioration take place before the appear-
ance of these latter symptoms, the pulse becomes
more quick and feeble, the extremities cold ; the
tongue either brown, or dry and hard, or glazed,
red, and aphthous ; the strength more reduced, the
emaciation great; the discharges dark, watery,
oflTensive, cadaverous, and like the washings of
flesh ; and the spirits dejected. Hiccup sometimes
occurs ; with delirium, relaxation of the sphincter
ani, leipothymia, and death, at a period varying
from a fortnight to thr^e or four weeks. In other
instances, the disease is arrested some time before
dangerous symptoms supervene, or is mitigated
only, and thence passes into the chronic form.

14. Simple dysentery presents every grade of
severity between the two now described ; and
such are the most common appearances which it
assumes in this and in temperate climates ; but
the symp>toms often vary much, according to the
causes, the age, and strength of the patient ; the
parts of the canal first affected ; the pre-existence
of collections of morbid secretionsor fa;cal matters,
the external agents operating during treatment,
and the means employed. To some oT these
viodijications and their pathoh'gical- rehitions it is
necessary to advert. When it arises sporadically,
febrile action, ushered in by chills or rigors, seldom
is observed until the dysenteric symptoms are
formed, and is merely symptomatic of the local
disease, which may commence in the cfficum, or
in the colon and rectum, or in this last, and be
there in a great measure limited, or may extend
more or less to other parts. Thus patients are
frequently affected with diarrhoea, uneasiness and
fulness of the abdomen, particularly in the region
and vicinity of the caecum, several days before
mucous and bloody stools or straining are com-
plained of, especially when the disease is conse-
cutive of fever ; and occasionally they experience
tenesmus some days before the disorder is fully
formed. In these cases, the progress of afl^ection
from the caecum, or even from the small intestines,
along the colon to the rectum, as well as in the
opposite direction, may be traced by the symptoms,
when tlie patient comes early under treatment.
In other instances, especially those consequent
upon fever, and in some epidemics, febrile action
may co-exist with, or even precede, the earliest
symptoms. It is, therefore, important, in a prac-
tical point of view, to ascertain the early seat and
extent of morbid action, as well as its constitutional
relations ; as, together, they furnish tlie chief basis
of therapeutical indications ; for, in proportion as
constitutional disturbance is great, previously to
the formation of the bowel affection, the less
should antiphlogistic or depletory measures be
relied upon in the treatment. In general, although
the straining be severe, and the calls to stool fre-
quent, yet if uneasiness or pain be not occasioned
by pressure over the region of the caecum and sig-
moid flexure of the colon, if heat in the course
of the colon be not felt, and if tormina be not

DYSENTERY, HYPER-ACUTE
violent, nor the abdomen tense or tender, the
rectum may be considered the cliief seat of the
disease ; the secretions poured out in the upper
parts of the intestinal canal having produced, first,
irritation, and afterwards, inflammation of this
part. But, if there exist much primary constitu-
tional disturbance, this inference should not be
drawn ; for, in such cases, the mucous surface of
both the small and the large bowels may be
seriously affected, and yet these symptoms may
not be present in any evident degree. Cases will
also occur, characterised by tormina, twisting
pains about the umbilicus, borborygmi, tension of
the abdomen, more or less febrile commotion, and
frequent calls to stool ; the evacuations being
mucous, bloody, and subsequently watery, &cc. ;
and yet little or no tenesmus will exist. In these
the seat of disease is chiefly the ilium, the caecum,
and upper part of the colon ; which often become
speedily ulcerated if the morbid action be not
arrested. When, in addition to these symptoms,
tenesmus is urgent, the rectum and sigmoid flexure
ot the colon are also affected.

15. In this form of disease, the quantity of
matters evacuated from the bowels is extremely
various. In severe or advanced casts, from
twenty to thirty, or even forty, eflbrts at stool are
sometimes made in the twenty-four hours, and
often without any further discharge than a little
mucous and blood ; but occasionally much serous
or watery matter, with broken-down faeces, slime,
mucus, and blood, is voided, exhausting and
emaciating the patient. In some instances, the
evacuations are muco-puriform, more or less
streaked with blood, without the least trace of
fa;ces ; and in others, they contain scybalas. It
would seem, that the retained faeces are frequently
broken down or semi-dissolved by, and mixed up
with, the serous and sero-sanguineous fluid exhaled
from the irritated mucous surface ; and hence the
infrequency of scybalag in many states of the dis-
ease. The evacuations are often very offensive
from the commencement, but as frequently they
are not manifestly so. They generally become
foetid, or have a peculiar raw cadaverous odour in
the last stage of the worst cases ; especially when
portions of the mucous surface are sloughed off.
They are sometimes of a singularly variegated hue ;
consisting of glairy mucus, with a greenish or ge-
latinous substance, resembling morbid bile ; seldom
with pure bile ; often without any trace of this
secretion ; occasionally with large pieces of albu-
minous concretions of coagulated lymph or fibrine,
formed upon the internal surface of the bowel, and
afterwards detached ; and either with streaks of
fluid blood, or with small dark coagula. When
the blood is in large quantity, and is fluid and
distinct from the other matters, it is evidently
poured out by the lower parts of the large bowels.
When consisting of dark grumous clots, intimately
mixed with the discharges, it probably proceeds
from the caecum, or upper portion of the colon.
It may, or may not, even when most copious,
depend upon ulceration ; but it most commonly is
exuded from the irritated mucous surface, espe-
cially early in the disease. It may be very abun-
dant, even at this stage, and continue so till death,
particularly in drunkards ; or it may be trifling
throughout ; or be copious only at the close of the
disease.

16. The state of the abdomen also varies. In

Symptojis.

697

some, tension with fulness, proceeding generally
from fffical accumulations ; and flatus is much
complained of from the commencement. Iti
others, the abdomen is natural in size. Pain and
tenderness on pressure are uncertain symptoms in
the early stage of the disease. When it is fixed
in one place, we should suspect inflammation or
disorganisation to be proceeding there. It is, in
the plethoric, most frequently complained of in
the hypogastrium and region of the caecum ; and
it may often be traced up the right side and in
the course of the colon. Often there is little or
no pain, nor even soreness ; the patient bearing
pressure without expressing any uneasiness, and
yet, upon examination after death, the morbid ap-
pearances will be as extensive, in respect of the
inner surface of the bowel, at least, as in those
who complained of the greatest pain ; the chief
difference being in the more complete limitation of
the lesions to the mucous surface in those cases
wherein no pain was felt. It is chiefly in the last
stage, when inflammatory action has extended to
the serous surface of the bowels, that fulness, pain,
and tenderness of the abdomen have been com-
plained of.

17. (c) Hy]ier-acute dysentery, or dysentery in
Europeans removed lo warm countries, is generally
occasioned by a too rich and stimulating diet, and
a regimen entirely unsuited to the climate ; by the
too free use of ardent and intoxicating liquors ;
by exposure to the night air, or to cold and mois-
ture ; and by the endemic and other causes men-
tioned above (^5> 9, 10.). It often assumes the
severe character now described ; and, in persons
who are plethoric, who have neglected their
bowels, have lived highly, or are of a phlogistic
diathesis, or who possess rigid fibres and great ir-
ritability, it puts on a still more violent or a
super-acute form. In them, the sense of heat and
soreness ; the tormina, fixed pain of the hypogas-
trium, the tension of the the abdomen, the conti-
nual calls to stool, and the straining, are most dis-
tressing. The region of the caecum is full and
tender. The tongue is white, loaded, excited ;
sometimes clean and natural, but afterwards dr^'.
The skin and pulse are frequently, at first, and for
some time, very little affected ; the constitutional
disorder not being commensurate with the severity
of the local symptoms; but the former subse-
quently becomes dry or hot, and the latter quick,
hard, and small. In many cases, the disease be-
gins as common diarrhoea ; in others, it comes on
suddenly, and rapidly reaches its acme ; and then
the thirst is excessive ; the urine scant}-, voided
with great pain, or altogether suppressed ; tiie testes
drawn up to the abdominal ring ; the stools mu-
cous, slimy, streaked with florid blood, sometimes
attended by prolapsus ani, and rapidly passing to
watery, serous, or ichorous discarges, resembling
the washings of raw beef, in which float particles,
or even large shreds of coagulable lymph, thrown
off from the acutely inflamed surface, often with
copious discharges of blood. Great depression of
spirits, nausea, vomiting of bilious matters, and
distressing flatulence or borborygmi, which aggra-
vate the tormina, are also present, and, in many
of the fatal cases, continue to the last. In some of
these the inflammatory action extends to the sub-
mucous coats, and detaches portions of the mucous
tissue, which come away in the stools, in the last
stage, or even hang from the rectum ; any effort

698 DYSENTERY, ASTHENIC

to withdraw them occasioning a remarkable in-
crease of suffering. The constitutional disturbance
has now become very severe, and a foetid or cada-
verous odour proceeds from the patient. De-
tached portions of the mocous membrane will be
recognised by their sloughy appearance ; by the
ichorous character and putrid smell of the dis-
charges which contain them ; and by the period at
which they are observed, the albuminous exuda-
tions that resemble them being thrown off at an
earlier stage.

18. In somewhat less violent and more pro-
tracted cases, especially as the disease approaches
an unfavourable close, the motions are sometimes
streaked with a puriform sanies, or with a whitish,
opaque, or greyish matter, apparently depending
on ulceration ; and they frequently are involun-
tary, owing to the paralytic state of the sphincter,
the anus being excoriated, livid, relaxed, and
widely open. The surface of the body, also, is
shrunk, occasionally yellowish ; the superficial
veins deprived of blood, and the extremities
moistened with a cold sweat. At last, the patient
is affected by leipothymia, or stupor, or by deli-
rium, and otber nervous symptoms, and dies in
from four, five, or six days, to three weeks, unless
the disease is of a milder or more chronic form, or
is arrested by treatment.

19. In Europeans, long resident in an inter-
tropical or hot country, the disease assumes either
a less inflammatory form than the preceding, or
some one of the asthenic states about to be de-
scribed : it also frequently becomes chronic in
them, and is often consequent upon, or associated
with, ague, remittent fever, or with diseases of the
liver, spleen, and other abdominal organs. (See
§ 20. et seq., and Complications.^
ii. The Asthenic Forms of Dysentery,

Classif. — III. Class, I. Order (^Authoi-),

20. Uefin. — Depression oj the organic actions ;
oj' the tone of the circulating, nervous, and 7nnscii-
lar functions, preceding or accompanijing the oc-
cui~rence of tormina and tenesmus, with mucous,
bloodu, and offensive stools, and giving rise to fcetid
exhalations, and infection in confined places and
predisposed persons.

21. The asthenic forms of the disease have
been variously denominated, according to the
more prominent features assumed by them under
certain circumstances, endemic as well as sporadic,
and especially in different epidemics. Whilst the
foregoing states are generally attended, especially
in their early stages, by sthenic vascular action,
those about to be noticed are usually charac-
terised by fever, of a low, nervous, or adynamic
kind ; by greater prostration of the constitutional
powers than the preceding ; by an earlier mani-
festation of febrile commotion or constitutional
affection, whicii may even precede the dysenteric
symptoms ; and by a much more remarkable af-
fection of the whole economy: and while the
above forms are generally sporadic, sometimes en-
demic, and seldom epidemic or infectious, those
about to be described are commonly epidemic and
infectious, under circumstances favourable to thi^
mode of propagation; sometimes endemic; and
more rurely sporadic, excepting in the daiker
races of the species, in which it is extremely apt
to become infectious, when occasions promote its
spread in this manner.

22. /I. Causes. — (a) The predisposing canses

•Cause3.

of the asthenic forms of dysentery are, chiefly, epi-
demic states of the atmosphere ; cold and variable
weather after long heats, or after hot and moist
seasons ; prolonged heat and humidity ; accumu-
lations of morbid secretions in the prima via ; a
cachectic habit of body ; deficient and un-
wholesome food ; pre-existing debility, especially
that caused by low fevers ; an impure and mias-
matous state of the air, especially when connected
with humidity ; worms in the prima via ; and the
predisposing causes already enumerated (§ 9.).

(6) The exciting causes are, famine or pro-
longed fatigue ; exposure to a moist cold ; the
excessive use of intoxicating liquors ; exhalations
from animal and vegetable matters in a state of
decay ; the use of marsh, stagnant, or river water
holding decomposed animal and vegetable matters
in solution, or containing, either with or without
these, animalculse and minute insects, or of
brackish waters ; the flesh of diseased animals, or
meat kept too long, or tainted ; stale fish ; blighted,
unripe, or ergoted rice, rye, &c. ; unwholesome or
insufficient food ; breathing the stagnant or in-
fected air of low, crowded, and ill-ventilated
places, especially when u case of the disease oc-
curs in such circumstances — as in hospitals,
camps, prisons, ships, barracks, &c. ; and the
exhalations proceeding from the discharges, and
from the sick, either confined and concentrated in
a stagnant, or floating in a warm, moist, mias-
matous, or epidemic atmosphere. But there is
reason to suppose, that the concurrence of two or
more of the causes enumerated in connection with
the sthenic states of the malady will also produce
some one of the asthenic forms, during certain
conditions of the air which have been called
epidemic, especially in persons of a weak frame
and depressed vital and mental powers. The
least energetic, also, of the above causes, acting
on persons already affected by the preceding form
of the disease, will convert it into some one of the
asthenic stales. Owing chiefly to the diversity of
the exciting causes, to their concurrent operation,
and to the difference in the state of constitutional
predisposition, &c. are to be imputed the modifi-
cations which the disease presents when epidemic,
or at different seasons.

23. a. Of the influence of exhalations from ani-
mal bodies in a state of decomposition, in causing
the low forms of dysentery, 1 could produce, if my
limits would permit, numerous proofs. One of
the authors of the article Di/senterp, in the Dic-
tionnaire des Sciences Medicates, states, that, hav-
ing been detained on horseback in a field of battle,
in August, 1796, where several hundred men
and horses lay in the first stage of decomposition,
he was seized with a dangerous dysentery on the
following day ; that three out of four of those who
accompanied him were similarly infected ; and that
his hor'se died of the same disease soon after. Si-
milar facts are adduced by Zimmermann, Osian-
i)EH, Desoenettes, and others. Of the agency of
impure water, in producing dysentery, proofs are
likewise numerous. 1 have myself seen several
instances, in a warm climate, where it was tire
cause of the disease being endemic there. In
temperate countries, waters containing decayed
animal matters, or an excess of uncombined alkali,
cause diarrhoea more frequently than dysentery,
or the former passing into the latter. But in warm
climates, especially where water is collected and

DYSENTERY, ASTHENIC — Forms and Symptoms.

699

preserved in tanks, and in autumn, after warm
summers, in colder countries, dysentery is the
most common result. The water of the Seine at
Paris, from this cause, often produces the disease ;
and Dr. M. Barry states, that such of the inha-
bitants of Cork as used the water of the river
Lee, which receives the contents of the sewers,
and is, moreover, brackish from the tide, are
subject to a very fatal dysentery ; and that, at the
time to which he especially refers, at least one in
three of those affected died of it. I have no
doubt that the dysentery epidemic in London
during several successive autumns after the great
plague, was owing to the same causes, as well as
to the exhalations from the burying-grounds, which
received the bodies of those who died of that
pestilence ; and that the prevalence of the disease
in besieging, as well as beseiged armies, is
caused by the exhalations from the decomposition
of the dead ; by the impure state of the water,
from decomposed animal matter carried into it ;
by night exposure; irregular living, deficient
food or clothing, and the other contingencies ou
encampments and operations in the field ; and by
crowded and ill-ventilated barracks, &c. The
frequent occurrence and fatality of dysentery in
fleets, in former times, evidently arose from the
putrid state of the water, and the foul and stag-
nant air between decks, sometimes breathed by
several hundred persons. During the slave trade
dysentery was, and even now is, among the nume-
rous small vessels engaged in this disgusting traffic,
the chief pestilence ; one half of those conveyed
in these floating receptacles of misery, on some
occasions, having died of it during the passage
across the Atlantic. It may be here mentioned,
that the dark races, particularly negroes, are more
liable to dysentery than any other disease ; that
it assumes an extremely low or putrid form in
them, when confined in ill-ventilated situations ;
and that, when a number, even of those in health,
are shut up in such places, the cutaneous secre-
tions, which are so abundant and offensive in
these races, accumulate in and vitiate the sur-
rounding air, so thatif it benot frequently renewed,
the systems of those thus circumstanced are thereby
infected, and, instead of an infectious typhus, which
would be the result in the European constitution,
a putrid dysentery, spreading rapidly through all
breathing the impure air, is developed. I had, in
1817, an opportunity of witnessing what I now
state. The disease is considered by the native
Africans asinfectitious as small-pox, and is dreaded
by them equally with it ; these two being the
most fatal diseases to which they are liable.

24. /3. The contagion of dysentery has been much
disputed ; chiefly owing to the circumstances of
the different forms of the disease not having been
distinguished with any degree of precision, and of
the loose notions attached to the words contagion
and infection, by those who espoused different
sides of the question. In the article Infection,
these terms, and their true value, are attempted
to be estimated w-ith more precision than hereto-
fore. As respects this malady, it may be stated,
as the result of observation and acquaintance with
what has been written, that the sthenic forms are
seldom or never infectious — and chiefly for this
reason, that the circumstances in which they
occur are unfavourable both to the generation of
infectious emanations, and to their accumulation,

concentration, and operation, in healthy persons —
that, in short, they, like all other sthenic maladies,
do not evolve infectious effluvia, because the
vital energies are not depressed nor perverted to
such a degree, even in their advanced stages, as
to give rise to the depravation of the circulating
and secreted fluids requisite to the production of
infectious emanations, these changes taking place
only when some one or more of the causes which
produce these effects — the causes of the asthenic
states — come into operation ; — that febrile dis-
eases, attended by depravation of vital power and of
the fluids, evolve effluvia capable, under favourable
circumstances, of infecting or contaminating those
disposed to be impressed by them ; — and that, as
the asthenic forms of dysentery are characterised by
these properties, and as the emanations disengaged
in their advanced stages become cognisable to the
senses, as well as by their effects, it must be
inferred, that these forms are infectious on occasions
favourable to the action of the emanations which
proceed from them. These inferences, founded
on an important pathological principle, are con-
firmed by enlightened and most numerous observa-
tions ; and, independently of such confirmation,
this principle must be shown to be unfounded
before the inferences drawn from it can be denied.
Thus it will appear that the great difference of
opinion that has existed on this subject is to be
referred, first, to the fact that certain states only
of the disease are infectious, and these chiefly in
circumstances favourable to the development
and operation of the infectious emanation ; and,
secondly to the incorrect notions entertained re-
specting contagion and infection ; many believing
because the disease is not propagated by me-
diate or immediate contact of the diseased person,
or of a palpable secretion or virus, that therefore
no contagion nor infection is produced by it.
But the spread of dysentery very closely resembles
that of scarlatina or measles, which cannot be
propagated by innoculation, or by the application,
either direct or indirect, of the morbid secretions
to a confined part of the external surface ; and
yet the efHuvium from the sick or the faecal
evacuations, floating in a close or stagnant air,
will readily induce the disease, in persons who,
constitutionally, or from the influence of con-
rent causes, are disposed to it, and who breath
the air thus contaminated. In such cases, the
effluvium operates, as in other infectious diseases,
chiefly through the medium of the respiratory
organs ; the system being aflPected, although not
very manifestly, before the dysenteric symptoms
are developed. Several respectable authors, how-
ever, have conceived it to be propagated, when
persons repair to the water-closet or night-chair
used by dysenteric patients, by the action of the
infected air or effluvium upon the anus, the affec-
tion extending upwards, along the rectum. IIurE-
LAND and some others state, that they have seen
the complaint communicated by the pipe of an
enema apparatus. But, in most of the instances
of the infectious disease that I some years ago
li'ad an opportunity of seeing, constitutional dis-
turbance, and often diarrhcea, preceded the fully-
formed dysentery.

25. B. Forms AND Symptoms. — a. The simple
aatJienic or adynamic diisentery. This variety is one
of the most common, particularly in this country.
It may occur sporadically in delicate persons,

700 DYSENTERY, ASTHEN

bwing chiefly to the more debilitating causes as-
signed above. It is also frequently epidemic,
especially among the poor in times of scarcity,
and after very wet and warm seasons ; it often
follows attacks of adynamic fevers, or prevails at
seasons when they are prevalent. It was epi-
demic in Glasgow in the autumn of 1827 ; and is
described by Mr. Wilson, Mr. Brown, Dr.
Macfarlane, and Mr. Weir (Glasgow Med.
Journ. vol. i. pp. 39. 48. 99. 223.) It generally
commences with diarrhoea, succeeding a con-
stipated state of the bowels ; and very frequently,
especially in the more severe cases, coldness, chills,
or rigors are observed, attended by griping pains
about the lower part of the abdomen, with fre-
quent calls to stool ; and sometimes followed by
fixed pain in the hypogastrium, particularly at its
right and left sides. Want of appetite, increased
thirst, furred tongue, clamminess of the mouth,
and acceleration of pulse, usually are superadded.
As the disease becomes fully formed, the pulse is
more or less frequent, small, weak, and soft ; the
skin is sometimes but little warmer than natural,
or only hotter over the abdomen ; it is commonly
harsh and dry. The countenance is pale, shrunk,
and anxious ; sickness and vomitings occasionally
occur; and singultus is not infrequent in the latter
stages, when the tongue, from being white, slimy,
furred, and yellowish, generally becomes red,
glazed, and chapped, and occasionally dark red
and dry. The stools sometimes are not mucous,
slimy, or bloody, although very frequent, until
the second, third, or fourth day ; but, in other
instances, they present these characters from
the first. They are always of this description
as soon as chilliness or rigors are felt. The eva-
cuations vary greatly in frequency and quantity ;
but they are generally characterised by a deficiency
of bile, by great foetor, and by the absence of
scybala, excepting in a very few cases. Remis-
sions of the symptoms, and of the urgent calls to
stool, often occur about the middle of the day.
The tormina and straining are sometimes followed
by prolapsus ani, especially in children and deli-
cate females. In a few instances, a puriform fluid is
voided towards the close of the disease. The urine
is usually scanty, passed with pain, and rarely re-
tained. This is the least infectious of any of the
states of the disease comprised under this species ;
unless in close and crowded places ; and then it
manifests this property, and passes into some one
of the states next to be described, particularly the
typhoid.

26. 0. The nervo-adqtiamic, or tifphoid. —
Asthenic dysentery sometimes appears in a modi-
fied form under certain circumstances, especially
where numbers are collected in a close and impure
air, as in barracks, garrisons, crowded ships, &c. ;
and in years of scarcity among the poor. 'The
patient complains at first of general depression,
vertigo, violent headach, increased sensibility
to light, pains in the limbs and joints, and of
gripings and purgings followed by anxiety at
the pra;cordia, stupor; foul, clainniy tongue and
mouth, which soon becomes dry and covered
by a brownish coating; a penetrating, ofl'ensive
odour of the breath ; antl intense thirst, 'i'he
pulse, at first, is very (|uick and small ; and, after-
wards, weak and irregular. 'I'he stools are, from
the commencement, very frequent, in small quan-
tity, preceded by tormina and tenesmus; and

IC — Typhoid — PoTitiD.

glairy, or serous, very foetid, and "contain more 01'
less dark blood. The urine is scanty, thick, and
dark-coloured. About the fourth or sixth day, a
miliary eruption, or petechiae, sometimes appear
about the neck, breast, arms, or abdomen ; and,
occasionally, epistaxis occurs, between the fourth
and eighth days, in young and robust subjects,
but without becoming critical. The intensity of
the tormina and tenesmus generally diminishes
with the progress of the disease ; and often about
the ninth or eleventh day, is replaced by a col-
liquative diarrhoea. The stupor is now attended
by low delirium ; the soft solids waste and be-
come flaccid ; the surface assumes a dirty hue ;
and an offensive penetrating odour issues from the
body and the evacuations. If not ameliorated,
or arrested in its progress, this form terminates
fatally from the sixth to the twenty-fourth day,
the symptoms described {§ 13. 18.) as indicating
a fatal issue supervening. Such are the charac-
ters it usually assumes; but they are modified by
age, constitution, and concurrent causes. It is less
frequently epidemic than the other asthenic states,
but is more evidently infectious than they.

27. y. The malignant, or putrid. — 'This form
is most common amongst the poor, especially in
years of scarcity ; in soldiers during campaigns ;
in besieged towns, and in countries laid waste by
war, &c. It also arises from the existence of en-
demic causes in full force, especially those which
occasion malignant fevers — as animal and vegeto-
animal exhalations floating in a warm and moist air;
foul water, and other septic agents. It usually com-
mences with a general feeling of debility, lassitude,
and aching pains, referred particularly to the
limbs and joints; with anorexia; foul, loaded
tongue ; sometimes nausea, borborygmi ; relaxed
bowels; pale, sunk, or anxious countenance ; gid-
diness ; and with a small, soft, frequent, and
sometimes slow or natural pulse. 'To these super-
vene griping pains in the abdomen, followed by
foul, offensive, scanty, and bloody stools ; some-
times without tenesmus, particularly at first. Hor-
ripilations, or chills, rarely rigors, sometimes occur,
at irregular intervals, during the early progress of
the disease ; but they are often absent. 'I'he mental
energies are greatly depressed, especially as the
disorder advances ; when the tongue, which was
moist and slimy, becomes covered by a dark, mu-
cous, or fuliginous sordes ; the breath is foetid ; and
a dark mucus occasionally collects about the sides
of the tongue and on the lips ; or aphthae form in
this situation. Tenesmus is now complained of;
and the stools are cadaverous, watery, dark, and
bloody ; the soft solids flaccid ; and the skin
harsh, dry, and of a sickly, dirty, sometimes ap-
proaching a yellowish, hue. Tlie patient after-
wards sinks into a state of complete apathy ; but
stupor or delirium seldom comes on until shortly
before dissolution : the position in bed is supine ;
the dejections are involuntary, frequent, and
mixed with dark blood, often followed by syncope
or leipothymia ; the temper.iture of the extremi-
ties sinks rapidly, whilst it continues much higlier
over tiie abdomen ; the urine is scanty, dark, and
fu'tid ; and the body exhales an infected odour.
Anxiety at the pra-cordia, singultus, and difficult
deglutition supervene; and the patient sinks "in
fioni five to sixteen or twenty days, according
to the violence of the symptoms. This form of
the disease is frequent in the most miasmatous

DYSENTERY, ASTHENIC ~ Bilious Adynamic.

701

localities ill liol climates, both among natives and
seasoned Europeans, particularly when remittent
fevers are prevalent or malignant ; and it occa-
sionally assumes a remittent type, when it may be
prolonged to twenty-eight or tiiirty days. 1 saw
many cases of it in Africa in 1817 and 1818. *

28. S". The bilious adiinomic. — When bilious,
remittent, and gastric fevers are prevalent, a form
of dysentery often also prevails, very nearly re-
sembling the first or simple variety; and differ-
ing from the foregoing or third form, chiefly
in presenting more evident attempts at vital and
vascular reaction than it. The present variety
sometimes appears, sporadically, in autumn and
winter; it is often endemic, in hot climates,
among Europeans, arising from the same causes
as endemic fevers, aided by cold and moisture ;
and it occasionally prevails, or becomes epidemic,
in temperate countries, during autumn and the
beginning of winter, especially after hot sum-
mers. This and the immediately preceding variety
frequently co-exist, in the same localities, in warm
climates, or after hot seasons in temperate coun-
tries : this, in the plethoric, sanguine, and robust ;
that, in the debilitated, ill-fed, and weakly con-
stituted. Bilious adynamic dysentery is generally
caused by a less intense operation, relatively to the
powers of the constitution, and to the predisposi-
tion of the same exciting causes, particularly such
as are endemic, as those which occasion the ma-
lignant form. I have seen it prevalent in Eu-
ropeans, in warm climates, in the same locality
and in the same season as when that form was
most destructive in the dark races. Many epi-
demics recorded by authors belonged to the
present variety ; although, during an epidemic
dysentery, more than one form or state of the
disease will be met with, owing to the different
circumstances, intrinsic and extrinsic, as respects
those affected, in which it will occur.

29. This variety generally co?;imences with bilious
or serous diarrhoea, which may continue for seve-
ral days ; with debility, pain in the forehead,
vertigo, and a mucous yellow coating on the
tongue. To these supervene horripilations, chills
or rigors, tormina, very frequent calls to stool, a
sense of scalding at the anus, and tenesmus. The
chills often return during the early stages, and are
followed or accompanied by a frequent, hard, or
irritable pulse, great thirst, and an acrid heat of
the trunk, especially over the abdomen. Nausea,
sometimes vomiting, want of appetite, loathing of
animal food ; a sense of heat in the abdomen ; ful-
ness in the seat of the cfficum ; pain above the
pubis ; complete prostration of strength, referred
chiefly to the spine and lumbar region , and scald-
ing on the passage of urine; are commonly pre-
sent at an early period. The pulse, from being
quick and irritable, becomes soft ; subsequently
small, irregular, and very weak. The stools

* Most of the crew of the ship in which I was a pas-
senger to that country were treated by me, for seasoning
and remittent fevers, soon after their arrival. They
alt recovered before I reached my destination. The
vessel subsequently went in pursuit of trafiic up one of
the rivers in the hay of Benin, where the crew there be-
came ill of this form of dysentery ; of which all died ex.
cepting the second mate and carpenter, whom I chanced,
long afterwards, to meet in England. Not one third of
the crews of the many vessels that proceed up these rivers
survive this disease and fever. The men, who are often
deceived into undertaking the voyage, have not even the
benefit of medical aid ; for none of these vessels is pro-
vided with, or is within reach of, this kind of assistance.

sometimes continue copious and yellowish for two
or three days ; but they are usually streaked
with blood at the time when tormina and tenes-
mus are complained of, or soon afterwards. As
the disease advances, the blood is more abundant;
either mixed with the stools, or fluid and distinct, or
in large coagula, and usually of a dark colour; and
the abdomen becomes tense, or tumid and tympa-
nitic. The frequency and the quantity of the
stools vary greatly ; but the distress and tormina
are worst at night, the abdominal pain and un-
easiness occasionally remitting in the morning, or
subsiding for a short time after each evacuation.
The odour of the discharges is, from the first,
foetid ; and, in very severe cases, it becomes
putrid and cadaverous. With the progress of dis-
ease, emaciation proceeds rapidly, the surface
being harsh, and of a dirty appearance. Towards
an unfavourable state, the temperature sinks ; the
tongue being dry, dark red, or raw ; and anxiety,
restlessness, singultus, delirium, leipothymia, with
other symptoms described as characterising the
last stage of the preceding variety (^ 67.), super-
vene. This form is seldom prolonged beyond
twenty-six or thirty days ; unless it assumes a
milder aspect in its progress, when it often passes
into the chronic state. It is frequently epidemic
after hot and moist seasons.*

* Epidemic dysentery often presents various modifi-
cations in respect both of violence and of the occurrence
of phenomena not commonly observed. Of these latter,
the most frequent are burning pains or great heat in the
abdomen ; whilst the extremities and surface are cool or
even cold, and the pulse sometimes not much affected;
boulimia ; very copious, mucous, bloody, or gruelly and
frothy, or, more rarely, oleaginous, evacuations ; great
weakness of the lower extremities ; gangrenous eschars ;
a parchment-like or scaly state of the skin ; hasmaturia,
or entire suppression of urine ; an aphthous state of the
mouth and throat ; retraction of the abdomen, or the
great tension, fulness, or meteorismus of this cavity ;
frequently the excretion of worms in the stools, or by
vomiting ; miliary, petechial, phlyctenous or tubercular
eruptions on the trunk ; catarrhal or pneumonic symp-
toms ; and rheumatic pains in the muscles and joints.
Generally, as the quantity of fluid matters evacuated from
the bowels are increased, the excretions by the kidneys
and skin are diminished. In most epidemics, especially
those of the asthenic forms, constitutional symptoms, cha-
racterised by lassitude, debility, foul tongue, disordered
state of the stomach and bowels, unhealthy aspect of the
countenance and skin, and weak, quick, and soft pulse,
with evident disorder of the circulating and secreted fluids,
precede the pathognomonic symptoms.which appear after
these have continued a longer or shorter time. It will
be instructive to review the characters of, and the reme-
dies employed in, those epidemics of which we have
authentic accounts, as valuable illustrations of the nature
and treatment of this destructive malady will be thereby
furnished. It will, moreover, appear, even from the very
meagre account to which my limits oblige me to confine
myself, that our knowledge of the disease, even at the
present day, is but little in advance of what existed two
centuries ago ; and that even the most recent writers on
the subject are distinguished rather by confined or ex-
clusive ideas as to its nature and treatment, than by
comprehensive views of its forms and manifestations, as
well as of the means of removing it, in connection with
the various combinations of causes producing it, and the
diversified circumstances in which it prevails. Exclusive
notions of a disease are the result of a knowledge merely
of what has occurred within the sphere of the author's
observation J whilst more extended ideas are acquired
from what he has remarked in various climates, on dif-
ferent occasions, and at distant periods, and from an
acquaintance with what has been observed by others :
believing, truly, that nothing is constant but change-
that what has occurred or prevailed formerly will recur
again ; and that one form is as likely as another to appear
in future, whenever the concurrence of causes, of which
it is a necessary or contingent result, shall take place.

1 . Gregory of Tours states that dysentery ravaged the
whole of France in 334.

2. Its destructive effects in the army of Henry the
Fifth, before and after the battle of Azincourt, are well
known.

702

30. E. In the Dark Races, dysentery is perhaps
the most prevalent and fatal disease ; and in

DYSENTERY — Epidemics.

3. Fernel says, that in 1538, it was so general through
Europe, that neither village nor town escaped, although
the seasons had been regular.

4. Camerarris observed it, in the autumn of 1583, in
Germany, where it was malignant and destructive. The
preceding summer had bsen hot and dry.

5. Zacutus (Curat, cent, iii.) notices an infectious and
destructive dysentery in Lisbon, in 1600, for which fumi-
gations were employed.

G. Lammoniere describes it as it occurred m Lyons,
in 1607, 1624, and 1625, where it had been imported with
the troops from Italy. In proof of its infectious nature,
he states that the medical attendants and nurses were
nearly all attacked. Marks of inflammation and gangrene
were found from the pylorus to the anus, the liver and
omentum being also disorganised.

7. Sen.neht (Mid. Pr. 1. iii.) mentions an epidemic
which pervaded all Germany in the summer and autumn
of 1625; and Hoffmann states, that it reappeared in
autumn 1626, after a wet and warm spring, and a dry and
hot summer; that it was contagious; and was best
treated by bleeding at the commencement, in some cases,
by laxatives and demulcents, by nitre and absorbents,
and l)y milk with Seltzer water.

8. DiEMERBROECK records, that the disease was most
fatal in Brabant, in 163-^, then the seat of war. It first
appeared amongst the troops, and afterwards among the
inhabitants. The prostration of strength was great ; and
infection was proved by the attendants having been all
affected. The most successful remedies were rhubarb,
and, afterwards, one or two drachms of wax melted in
warm milk.

9. Bartholin relates, that a malignant dysentery suc-
ceeded to ague in Copenhagen, in 1652, and carried off
many thousands. The odour of the evacuations was
most oficnsive.

10. The plague of London, in 1665, was followed, in the
autumn of 1666, by an epidemic and infectious dysentery.
Morton was attacked, and escaped with difficulty. It
appears to have been occasioned by the infected air ema-
nating, in the summer, from the numerous bodies buried
in and about London during the preceding year. The
fatality was very great ; and cinchona seemed to have
been the chief remedy.

11. In an epidemic described by W. Wedel (Act. Nat.
dec. ii.), and which occurred, in 1669, at Gotha, the eva-
cuations were ftetid and sanguinolent ; and yet, in many
instances, unattended by pain or tormina. Those in
whom the tormina was most severe, recovered ; but those
who experienced no pain, died suddenly, the disease
having passed rapidly into gangrene.

12. Sydenham states, that the cholera which prevailed
in London, in the summer of 1670, having ceased, dysen-
tery took its place. The disease commenced with chills
or rigors, followed by increased heat. The treatment
was directed to remove inflammation, and evacuate mor-
bid humours.

13. Bhandt notices the occurrence of dysentery, in an
epidemic form, in the Danish army, and in Copenhagen,
in the summer of 1677 ; and attributes it to the use of
stagnant water and of bad beer, and to an atmosphere
loaded with impure exhahitions.

14. Dysentery prevailed in Zurich in August, in 1680,
after a hot summer. It appears from Muralto to have
been of an inflammatory type.

15. An epidemic, observed by F. Hoffmann, in 1684, in
Westphalia, was also inflammatory. Favourable cases
terminated by the fourteenth day ; those that were pro-
longed beyond it, generally terminated unfavourably.
Persons in communication with the sick were infected.
Bleeding at the commencement, and nitre with camphor,
were the chief remedies : astringents and stimulants were
injurious.

16. LoEscHER states that the epidemic dysentery of
1709, in Misnia, was attended by acute lever, petechia;,
lividity of the countenance, meteorismus of the abdomen,
and depression of strength and of the pulse ; followed, in
many instances, by delirium, convulsions, and death.
Clysters, ipecacuanha, laudanum, and sometimes bleed-
ing, were employed.

17. In August, 1718, the disease appeared, in a malig-
nant form, among the Prussian military in Berlin and
Pomerania, and extended to the inhabitants. Aiihlha'
were a common and an unfavourable symptom. A change
usually occurred towards the fourteenth day. Itelai)srs
were fatal. Evacuants and diai)horetics, followed by
tonics and antiseptics, were the most successful means.

18. MAiinRAAFdetails the history of an epidemic which,
In some cases, was mild and remittent; but, most com-
monly, of the bilious-adynamic and malignant forms.
Ipecacuanha was the most useful medicine.

i;i. A bhnilnr visitation took jdace at Nimegucn, in
173G (DEUNiiR). The malignant cases were frequently

negroes it generally takestlie place of fevers ; being,
in the language of Sydenham, a low fever turned

fatal on the third or fourth day, and were contagious.
Ipecacuanha, rhubarb, and subsequently, simarouba, were
cliiully confided in.

20. Dysentery was epidemic in Plymouth, in 1744
(HuxHAM), in an inflammatory form. Early bleeding,
ipecacuanha, rhubarb, and, at the close, opiates, were the
chief remedies.

21. It prevailed in Zurich, in 1747, and was attributed
to bad water (Gruber). Diaphoretics, emollients, opiates,
and tonics were most generally prescribed,

22. It was the most destructive disease in the British
army in Holland, in 1748 ; and was acutely inflammatory,
often rapidly terminating in gangrene (Grainoer, &c.).
Bleeding, emetics, and purgatives were employed.

23. The epidemic, in several parts of France, in 1750,
was chiefly of the simply asthenic and malignant forms.
Astringents were injurious, evacuants, emollients, and
antiseptics beingmostserviceable(MARTEAU and Navier).

24. That which occurred in Hanover (Lentin) was at-
tended by a burning heat in the abdomen, without much
attendant general fever ; and by foetid or purulent stools.
Antimony, rhubarb, mucilages, and, afterwards, sima-
rouba or copaiba in the yolk of egg, were usually directed.

25. Strack states that the French army brought with
them, and communicated to the inhabitants of the parts
of Germany through which they passed, in 1767, dysen-
tery of a malignant form ; which was entirely similar to
the description I have given of that variety. It was also
prevalent in various other quarters of Germany. Women
in the puerperal state, and their infants, were also at-
tacked. Ipecacuanha, followed by rhubarb, the tartrate
of potash, and, lastly, simarouba, was chiefly employed.
The too early use of astringents, absorbents, and narcotics
were said to have been dangerous. Isolation of the af-
fected, and lime, as a disinfectant, were resorted to.

26. Dysentery was epidemic, in the autumvi of 1760, in
Gottingen ; and of an inflammatory and asthenic charac-
ter, the local inflammatory action being attended bydefi.
cient vital power. Theca;cum and rectum were ulcerated
and gangrenous. Bleeding, vomits, laxatives, emollients,
and antiseptics, with opiates and bark, were principally
trusted in (Roederer).

27. According to Grimm, the same epidemic was ob-
served in Thuringcn, where it was infectious. A similar
treatment to that now stated, with the addition of cam-
phor, was adopted.

28. Lecleuc describes the dysentery to which the
Tartars of the Ukraine were subject, in consequence of a
meagre and indigestible diet, consisting of much salted
or smoked fish and meat, and the use of ardent spirits. It
seems to have been simply asthenic or malignant ; and to
have been most successfully treated by ipecacuanha, rhu-
barb, nitre with camphor, opium, mucilaginous clysters ;
and, in the last stage, balsam of tolu, &c. Procidentia ani
was cured by conveying to the part the vapour from tur-
pentine thrown upon burning coals.

29. Dysentery succeeded, in July and August, to the
catarrh which prevailed in London in 1762 ; attacked
chiefly the poor and children ; and assumed the bilious
adynamic form. Bleeding, at the beginning, in the more
inflammatory cases ; emetics and diaphoretics ; laxatives
and emollient injections ; mucilages and astringents, &c.,
were successively prescribed (Ct. Baker).

30. This disease also followed catarrh, at Vienna, in the
autumn of 1763 (De Mertens) ; and was attributed to
cold and moisture consequent upon great heat. Blood-
letting was borne by very few. Ipecacuanha, rhubarb,
mucilages, and, afterwards, bark, were exhibited.

31. The epidemic in Berne, and adjoining parts, in
autumn, 1765, was in all respects the same as that which
I have denominated the bilious adynamic, according to
the description of Zimmermann ; who states it to have
been infectious in circumstances favouring the action of
this property ; and that females, far advanced in preg.
nancy, in some instances gave birth to infants affected by
it. Ipecacuanha emetics, gentle ))urgatives, diluents and
emollients, mucilaginous enemata ; subsequently, camo-
mile tea and opiates, were chiefly confided in : astrin-
gents were injurious.

32. In an epidemic observed, in the same year, by M.
Chevssiol, camphor, blisters, sinapisms, dry-cupping,
and cinchona, were most beneficial.

33. According to Dr. Sims, the disease was very pre-
valent in London in the autvunn of 1768 ; it having suc-
ceeded rheumatism, and continued during 176!) and 1770.
One form proceeded chiefly from cold, was ushered in by
rigors, and required bleeding and iiiecacuanha emetics.
The second and most common form prevailed among
those who lived on poor diet. The pulse was low, quick,
and unequal ; the skin cold ; the face pale and haggard}
and the stools firtid and putrid. In this, ipecacuanha,
o))ium, astringent bitters, bark, aromatics, and claret,
proved most successful.

DYSENTERY -

in Upon the bowels. It commonly ar/ses, sporn-
dically, from cold and moisture — from suppression

34. Malignant dysentery was prevalent in Jamaica, in
1771. Dr. WiiiGHr found antiseptics, especially a satu-
rated solution of common salt in lime-juice, talven in aro-
matic or sweetened water, most serviceable.

3"). MM. M.vRET, DuRAND, and Caile state, that the
epidemic throughout France, in the autumn of 1779, was
an illustration of the aphorism of Hippocrates, — " Hieras
sicca et aquilonia, ver autem pluviosum et australe ;
necesse est fieri febres acutas et dysentarias maxime," —
and assumed an inflammatory, bilious, and malignant
form ; the second and third being very infectious. In
many places, children, females, and the aged were prin-
cipally affected. Blood-letting, which was repeated in
some cases ; laxatives, with tamarinds and manna ; mu-
cilages and emollients, in the form of drink and in clys-
ters ; cam|)hor and anodynes, lime, and gum-water ;
cinchona, with camphor and the anodyne liquor, were
prescribed according to the form and stage of the disease.

36. BiKNSTiEL records that diarrhoea prevailed, in the
spring and summer of 1780, on the Rhine ; and was fol-
lowed, in autumn, by a violent dysenteric epidemic of a
bilious adynamic form — the symptoms being entirely the
same, but more intense than I have described them.
Evacuations by ipecacuanha and rhubarb, mucilages and
diaphoretics, and, towards the close, cascarilla and opium,
were confided in.

37. In the years 178.5 and 1786, the disease, in simply
asthenic and malignant forms (^ 25. 27.), was general
through the Venetian states — chiefly in females and
children (Capovilla). Fomentations, mucilaginous in-
jections, emollient drinks, ipecacuanha, rhubarb, almond
oil, absorbents, and, afterwards, cinchona, wine, opiates,
and astringents, were most beneficial.

38. The epidemic in Champagne, especially in the
French, Prussian, and Austrian armies, during the au-
tumn of 1792, assumed inflammatory, bilious, malignant,
and typhoid forms, according to the causes and circum-
stances in operation ; and w as remarkably fatal among
both men and horses (Chamserl). Bleeciing in some ;
ipecacuanha, antimonials, emollients, cinchona, rhubarb,
tamarinds, lemonade, &c., were principally employed.

39. The dysentery that prevailed in the army of Italy
(Desgenettes) was rarely inflammatory ; but very gene-
rally malignant, arising from endemic causes concurring
witli extreme fatigue and exposure. Aromatics, vege-
table acids, and opiates ; antiseptic and anodyne eneuiata,
cinchona,andsimarouba,were most frequently prescribed.

40. HuFELAND states that it was epidemic at Jena, in
1795, in the simply asthenic and malignant forms. He
treated it most successfully by ipecacuanha and extract
of nux vomica. It was infectious in favourable circura.
stances.

41. ScHMiDTMANN States that dysentery was epidemic,
through the north of Germany, in 1800; and so pre-
valent in the town in which he resided, that very few
escaped. It assumed inflammatory, bilious, nervous, and
malignant forms, according to circumstances, and the
constitution, &c., of those affected. Bleeding in some
cases; gentle emetics in others; opium nearly in all;
and camphor, decoction of bark, various astringents,
tonics, and antiseptics were employed. Arnica was given
in the malignant cases, but with little benefit ; and tama-
rinds, cream of tartar, manna, or other mild purgatives,
were also exhibited.

42. Dysentery, chiefly in the bilious-inflammatory
passing into the advTiamic form, was remarkably pre-
valent and fatal, at the Cape of Good Hope, in 1804
(LicHTENSTEiN) ; and was often associated with inflam-
mation and structural change of the liver. This epidemic
was at first very injudiciously treated by stimulants,
astrigents, and antispasmodics; and one in four died.
The mortality was subsequently reduced vnc half, by
means of small doses of calomel and opium, given every
hour or two ; sometimes with camphor and rubefacients.

43. This disease was very prevalent in Holland, in
1809, particularly in the British troops composing the
Walcheren expedition ; and proceeded chiefly from en-
demic causes, and often either followed, or was converted
into, intermittent or remittent fever (Davis, Dawson).
It was frequently associated with disease of the liver and
spleen ; and presented the inflammatory, asthenic, and
bilious forms. Bleeding, purgatives, calomel, and sudori-
fics were chiefly employed ; but the disease was too gene-
rally injudiciously treated.

44. Dysentery became epidemic, in and around Vienna,
in autumn, 1809, particularly in the French army ; and
assumed, according to circumstances, an inflammatory,
bilious, adynamic, typhoid, or malignant form ( Vignes).
It often was infectious ; and few of the medical oflicers
escaped. Ipecacuanha, opium, emollients, clysters, sina-
pisms, and blisters ; camphor, jether, arnica, serpentaria,
cinchona, valerian, and aromatics, variously combined,
appear to have been chiefly employed.

•EpiDliMlCS. 703

of the function of the skin, which is in them a
much more important excreting organ than in the

45. The more simple asthenic states of dysentery were
prevalent in Flanders, in July, 1810 (Tonnelier) ; and,
in the summer of 1811, in various parts of the north of
France (Caron). In some villages, nearly all the inha-
bitants were attacked the same day. Ipecacuanha, gentle
purgatives, rhubarb, calumba, simarouba, mucilaginous
clysters, opiates with diaphoretics, warm baths, arnica,
aromatics, Hoff.mann's anodyne, &c., were generally
employed. Favourable changes occurred between the
tenth and fifteenth days. The disease sometimes passed
into entiritis, and was occasionally followed by dropsy.

46. Dr. PisANi states, that dysentery of an asthenic
kind, but presenting either inflammatory, malignant, or
nervous symptoms, was so prevalent in the garrison of
Mantua, in 1811 and 1812, that about 1000 cases were
received into the hospital. It first appeared in some
felons ; from whom it extended to the soldiers in the
wards, and by them was conveyed into the barracks. The
medical attendants and assistants were attacked ; but
those who had no communication with the sick escaped.
.Small depletions, ipecacuanha, laxatives, emollients ;
with nitre, fomentations, mucilaginous clysters, neutral
salts, rhubarb, Hoffmann's anodyne, camphor, and wine,
according to the features of the disease, were most em-
ployed. Ventilations and|fumigations were also resorted to.

47. In theexpedition to New Orleans, dysentery, owing
to cold, moist, and miasmatous air, wet clothing, and the
use of foul, brackish water, and fatigue, was the most
fatal disease, assuming inflammatory, bilious, asthenic,
and malignant forms. Bleeding, emollients, foment-
ations, opium, Dover's powder, and very large doses of
calomel, appear to have been principally confided in. In
fatal cases, the liver was frequently found diseased ; and

the colon very slightly ulcerated, but not sphacelated

{,Edin. Med. Journ. vol. xii. p. 13G.)

48. Dysentery, although it may not be said to have
been epidemic in the strict sense of the word, was the
most fatal disease in the British army during the Penin-
sular war. It was often connected with intermittents and
remittents, and frequently supervened on these and other
forms of fever (Sir J. M'Grigor) ; and attacked con.
valescents. It assumed inflammatory, bilious, typhoid,
or malignant and chronic forms, according to the causes
and concurrent circumstances. It was most prevalent and
fatal at Ciudad Rodrigo, which was obliged to be made
an hospital station for a time ; and where, shortly be-
fore, " nearly 20,000 bodies were calculated to have been
put into the earth, either in the town or under its walls,
in a few months." It was unhealthy, independently ot
this circumstance. It was commonly treated by vene-
section, in the first stage ; and by the warm bath, full
doses of Dover's powder every hour, calomel and opium
at night, sulphate of magnesia, in broth, in the morning ■
in the second stage, by demulcents, aromatics, opium,
astringents, tonics, and flannel rollers.

49. This disease has been more or less prevalent in some
part or other of Ireland, owing to the presence of endemic
and even of epidemic causes. During 1817, 1818, and 1819,
it was, conjointly with fever, epidemic throughout the
island. The seasons were cold and wet ; and, with this
cause, famine, unwholesome food, and infection con-
curred. It was very often consequent upon the early
stage of fever, or it appeared as a crisis of fever, or it
occurred during convalescence. It was infectious in cir-
cumstances favouring this property ; and presented in-
flammatory characters, but often associated with the
asthenic diathesis. It was treated chiefly by moderate
bleeding, ipecacuanha, the warm bath, opium in doses of
four or five grains, calomel with opium, copaiba mixture,
and farinaceous diet (Cheyne).

.50. It was prevalent in several parts of Ireland, in 1822,
at the same time with lo%v fever, owing to scanty and bad
food. It commenced with debility, pain about the umbi-
licus, mucous dejections, general cachexia, rapid and
weak pulse, &c. ; on which the pathognomonic symptoms
supervened in an adynamic form. It was very fatal until
wholesome and nutritious food was pbtained (Dr. Graves
in Trans, of Irish Col. of Phi/s. vol. iv. p. 429.)

51. It was again prevalent in Dublin and the vicinity,
in the autumn of 1825, after great heat and drought ; af-
fected first the better classes ; sometimes appeared as
fever for two or three days, and then passed iuto dysen-
tery ; or it occurred during convalescence from fever, and
wis infectious (Dr. O'Brien). It was of an asthenic and
complicated form ; the skin being of a dirty or dark hue,
and harsh to the touch ; and was very generally treated
by bleeding, in robust persons, at an early stage ; by the
warm bath, and friction of the surface with camphorated
oil ; by calomel gr. x., and opium gr. ij., repeated in eight
hours, and followed by purgatives, especially castor oil
with a few drops of laudanum ; by flannel rollers around
the abdomen ; and by Dover's powder, and the repetition
of one or more of these means, according to circumstances.

704

DYSENTERY — ITS Type.

white races; from insufficient and unwliolesome
food ; and, eiidemically from bad water, marsh
efHuvia, and animal and vegetable emanations
floating in a moist atmosphere. It assumes some
one of the asthenic forms, according to the causes
■which produce it, and the circumstances which
influence it in its progress. Even when it appears
sporadically, it is more liable to become infectious
than in Europeans, owing to its passing more
readily into a low, malignant, or putrid form, on
occasions of imperfect ventilation or crowding of
the sick. In such circumstances, it is sometimes
quite pestilential in the rapidity ofits dissemination
and the extent of its fatality. In its sporadic
states, it is frequently nssoc/aterf with rheumatism,
or the one passes into the other; both generally
arising from the same exciting causes — from cold
and moisture. It is also very often complicated
with worms, especially the round worm, in the
prima via ; these being passed with the stools in
the advanced stiige of the more severe and danger-
ous cases ; and, in its less severe grades, it some-
times assumes intermittent or remittent types.

31. When dysentery attacks the dark races spo-
radically, and sometimes, when itseizes Europeans
who have resided very long in a warm climate, it
frequently commences with chills and much febrile
reaction or irritation, the vascular excitement
rapidly passing into an adynamic state — into
great prostration of the vital and animal actions,
and depression of spirits. The pulse is, at first,
more or less quick and irritable — sometimes
sharp and full ; but it always becomes, in the space
of one, two, or three days, small and soft. The
rapidity of the change is seldom owing either to
the loss of blood from the bowels, or to the quantity
of matters evacuated, but rather to these conjoined
with the exhaustion produced by the causes of the
complaint, by the severity of the tormina, the want
of sleep, and by the febrile irritation of the system,
in less vigorous constitutions than those of the
white race. In this class of patients, flatulence,
nausea, sometimes porracious or bilious vomiting,
quick small pulse, and occasionally scybalous
evacuations, often containing worms, are very

52. The disease was epidemic, in some parts of France,
in the aut'.imn .and winter of 1825 (MM. Denoyer, L,e-
MERiiER, and BiENVENu); and was, in several places, pro-
pagated by the exhalations from the sick and the eva-
cuations ; children, females, the weak, ill-fed, the aged,
and those living near unhealthy and moist localities, be-
ing chiefly attacked. It assumed inflammatory, asthenic,
and malignant forms ; and, in several places, the small
intestines and stomach were also affected. It was treated
chiefly tiy local depletions, opium, repeated application of
blisters and demulcents. Tonics and antiseptics were
required in the advanced stages and chronic states.

.'')3. It again prevailed, in some parts of that kingdom,
in October, 1827 ; and was, in several localities, attributed
to the water, which aboimded with decayed animal and
vegetable matters, animalcula;, &c. (M. Compagnv). It
presented either inflammatory, mucous, asthenic, or
malignant characters ; and was treated by leeches,
opiates, demulcents, and, afterwards, by camphor and
cmchona.

54. The disease was epidemic in Glasgow, in the .autumn
of 1H27, in a simply asthenic and mild form. Opi.ates, ca-
lomel juid opium, ipecacuanha, demulcent enem,ata, blis-
ters, warm baths, astringents, and bitter tonics were most
serviceable. Blc>eding, unless by leeches, was very seldom
required, and was often injurious (Wilson, Bhown, and
Maofarlane.)

55. Infectious dysentery, in a<tynamic or typhoid forms,
has frequently appeared in ships, in prisons, and where-
ever many persons have been collected in ill-ventilated,
and particularly in moist and miasmatous situ.itions. In-
Btances of such occurrences are so numerous, have been
so often noticed, and are so well known, that it is un-
necessary to refer to them.

early observed ; the surface of tiie body being
shrunk, the superficial veins deprived of blood, and
the extremities moistened by a colliquative sweat.
In these persons, however inflammatory the dis-
ease may be at its commencement, it soon exhausts
vital power, and passes into the asthenic form ;
and, in seasoned Europeans, is sometimes contin-
gent on, nnA com-plicated with, disease of the liver,
or of the spleen, or even often of the absorbent
glands ; or is consequent on fevers, both periodic
and continued, either in their course, or during
convalescence from them.

32. III. Of the Tvi'e of Dysentehy, — The
inflammatory typhoid, and more malignant forms
of the disease, are generally continued, or obscurely
remittent. But the other forms may assume
an obviously remittent, or even an intermittent
type, owing rather to the concurrence of those
causes to which periodicity in fever is owing, with
those on which the dysenteric phenomena are
more immediately dependent, than to the produc-
tion of two distinct kinds of disease. We have
seen, that dysentery often arises from endemic
causes, very nearly similar to those which pro-
duce periodic fevers ; the causes of the latter
chiefly impressing the nervous system, those of
tiie former vitiating the secreted and circulating
fluids, and disordering the functions of the bowels.
Therefore, when both kinds of causes concur, as
they frequently do, in unhealthy situations and
seasons, a form of disease is directly produced, in
which many of the characters of both disorders
are blended. In such cases the ingestion of foul
water, or of unwholesome food, and cold and
moisture, contaminate the fluids, determine them
to, and irritate, the prima via ; whilst malaria,
concurring with these causes, impresses the ner-
vous system so as to impart a certain degree of pe-
riodicity to the morbid actions resulting from the
combined agents. It also not unfrequently occurs,
that during the progress of agues and remittents,
the secretions accumulated in, or poured into, the
intestines will acquire such irritating or morbid
properties as to superinduce dysentery, which will
often for a while retain the periodic character ; but
in most instances, a continued or obscurely remit-
tent type will be the consequence of this change.
A distinctly intermitting type is incompatible with
either a considerable extent of inflammation, or
much depravation of the circulating fluid ; and one
or other, or even both, of these changes obtains in
those forms of this disease which I have stated to
be generally exempt from this chaiacter. It is
frequently observed, that when animal or infectious
emanations enter largely into the causes of this
disease, it assumes a continued and more or less of
a malignant character. Numerous instances, illus-
trative of these views, came before me in warm
climates; and the histories of the epidemic occur-
rences of the disease, when examined in their de-
tails, further confirm them. Sir J. M'GnicOR, in
his excellent review of the diseases of the army
during the Peninsular war, states, that, in the
hospitals in the Alemtejo and Estremadura, the
type of dysentery was intermittent ; that it became
remittent in .luly, August, and September, when
the army advanced rapidly and remained sometime
stationary inihe two Castiles ; and that it was con-
tinued, typhoid, and very fatal, at Ciudad Kodrigo,
where the sick were exposed to the efl'luvium ex-
tricated by twenty thousand dead bodies. Here we

see the disease presenting increased .grades
severity as the causes augmented in intensity.

33. IV. Complications. — Having considered
the forms of dysentery depending more directly
upon the nature of the predisposing, exciting and
concurrent causes, I now proceed to notice those
complications occasionally observed, especially in
unhealthy seasons and localities. IVIany writers
conceive that the asthenic varieties described above
are complications of simple dysentery with different
kinds of fever ; and that, when tliey are infec-
tious, it is not the dysentery but the fever which
possesses this property. Some authors suppose
that the typhoid variety especially is a compli-
cation of this description. But, if such be the

DYSENTERY — its Complications— Hepatic.
of

70S

the former. It is also consequent upon acrues,
remittents, and continued fevers; and it is evi-
dently often produced by endemic causes, es-
pecially in persons addicted to ardent spirits.
\Vhen hepatic dysenterj' , proceeds from these
causes, the spleen is sometimes also diseased, as
well as the pancreas, and mesenteric glands. Sir
J. M'Grigou states, that in the fatal cases of
dysentery that occurred in the Peninsula, the
spleen was as often diseased as the liver ; and that
both the pancreas and mesenteric glands were also
frequently enlarged or otherwise changed. When
acute dysentery is complicated with disease of the
liver, this latter is frequently likewise, of an acute
or sub-:icute character ; and consists chiefly of in-

case, wherefore should the disorder which is com- I flammation of the substance of the organ • abscess
municated be always dysentery and not fever? and the chronic changes of this viscus being more
Moreover, this form of dysentery is often present j commonly associated with sub-acute and chronic
where a case of typhus cannot be found. 'J'he dysentery than with the acute,
fact is incontrovertible, that the asthenic forms, | 35. a. Acute hepatic Di/senteru generally com-
some of which are considered as complications by ' mences with horripilations, chills or rigors fol-
many writers, are direct, and necessary, and uni- i lowed by pains in the forehead ; bilious vomiting •
form results of certain diversified but concurrent bilious and variously coloured stools, voided with
causes ; and not contingent associations of two scalding at the anus, and urgent tenesmus. The
diseases capable of separate existences, such as I discharges are often at first greenish, greenish
those about to be described : thus, cold and mois- black, or reddish brown and ochre-like • or watery
lure will of themselves sometimes occasion simple with a greenish frothy slime on the surface. A
inflammatory dysentery — as frequently occurs,
where no other causes can be in operation ; but
when, with cold and moisture, there concur mala-
ria, unwholesome food or water, or emanations
contaminating the fluids, as is often the case, the
disease assumes some one of the more severe and
asthenic forms ; the nervous and circulating func-
tions having been thereby more seriously im-
pressed. The local affection is occasioned, in

fixed pain, weight, or uneasiness, increased on
pressure, is generally felt in the epigastrium, fre-
quently extending to the right hypochondrium,
right scapula, or top of the right shoulder ; with
a sense of pressure or tension in the right side of
the thorax, anxiety at the pra:cordia, fits of dys-
pnoea, or a dry teazing cough, vertigo, and an
accelerated and irritable pulse, particularly at

, i^'ght, when the patient becomes very restless, and
these cases, by the nature of the ingesta, or by the ' the calls to stool more frequent and distressino-.
morbid secretions consequent upon the action of | The tongue is at first white, the papillje erect or
the exciting causes, or by the retention of morbid [ covered by a yellowish fur. At an advanced
or faecal matters, or by two or all of these com- \ stage, it is clean, dry, smooth, red, or lobulated •
bined. (See § 70 — 72.) The complications of [ or it is covered at the root with a dark crust. The
which more particular notice will be here taken are skin is dry, harsh, of a dirty appearance, and hot •
most commonlyoccasionedby theendemiccausesof -- --^ '- • • • •

dysentery, and are those — (a) with diseases of the
liver, spleen, and some other abdominal viscera ;
— (ft) with jaundice ; — (c) with scurvy, or scor

or it is covered by a greasy perspiration, copious
sweats sometimes occurring in the last stage of
the malady. There is great thirst, and desire of
cold fluids. In other respects, the progress of the
butic dysentery ; — (d) with worms in the prima ' disease is similar to the more inflammatory form
via ; — (e) with haemorrhoids; — and (/) with ! described above (§ 13.) ; but it often presents »
rheumatism. ' ' " ■ ..-

34. A. Dysenterxi complicated ivilh Disease of the
Liver, Spleen, dSfc. — Hepatic Di^sentery of writers
on intertropical diseases. — (a) I have already no-
ticed an asthenic form in which the bile is excreted
more or less in excess, or ;s otherwise disordered.
In this form, which is frequently epidemic, there
has generally taken place, for some time pre

greater range of symptoms in diflFerent cases, or at
diflerent stages of the same case.

36. B. In the above form of hepatic dysentery,
the affections of the large bowels and liver seem
to be nearly cct;taneous ; but, more frequently,
the hepatic disease follows dysentery, or does not
appear until this latter begins to decline. In
these cases, the patient is irritable, the cheeks
viously, an accumulation of this fluid in the biliary [present a hectic flush, and, upon examining the
apparatus, without any actual disease of the liver ; abdomen, the right rectus abdominis muscle resists
the discharge of much altered or acrid bile con- pressure by an involuntary action. Little or no
tributing, probably, with other morbid secretions ' enlargement of the organ is at first felt ; but either
and actions, to the production or perpetuation of ' enlargement or tenderness becomes manifest es

the dysenteric symptoms. But, in the complication
now about to be considered, the liver is generally
inflamed, enlarged, or otherwise altered in struc-
ture, either previously to, coijtaneously with, or
consecutively on, the dysenteric affection. Al-
though this association of diseases of distinct but
related organs is most frequent in the sub-acute
and chronic states, it sometimes also occurs in any
of the acute forms, as well in temperate as in
warm climates ; but oftener in the latter than in
Vol. 1.

pecially when blood has entirely disappeared from
the stools, which are generally scanty, viscid, and
dark. This form of the complication is evidently
caused by the sudden cessation of the dysenteric
affection ; which being very intimately dependent
upon the excretion of morbid matters from the
circulation and the economy in general, cannot be
abruptly suppressed, without inducing continued or
remittent fever, or inflammation, congestion, or en-
largement of excreting organs. Both these mo-
Z z

706

DYSfiNTERY — its Complications — Scorbutic.

difications of hepatic dysentery are often attended
by much pain about the umbilicus, by irritability
of stomach, and other indications of severe asso-
ciated disease of the internal surface of the small
intestines, and even of the stomach ; particularly
in warm climates, or in hot seasons when dysen-
tery is epidemic, and in persons addicted to spirit-
uous liquors. In some cases of hepatic dysentery,
the liver is the only viscus, besides the large
bowels, which is diseased ; but, in many, the
spleen, or the pancreas, and the mesenteric glands,
are also affected.

37. (/)) The complication with enlargement, thick-
ening of the envelopes, or softening or other dis-
orders, of the spleen, is of frequent occurrence where
dysentery depends chiefly upon endemic causes,
and when it is consequent upon agues or remit-
tents. Thus, in places abounding with malaria,
tiie splenic association of dysentery is much more
frequent, especially among the natives of India,
than the hepatic ; the pancreas and lacteal glands
being often also changed, and the disease assuming
an intermittent or remittent type. Like the he-
patic, the splenic affection may precede, may be
coetaneous with, or consequent upon, the bowel
disease ; but it is a more common result, par-
ticularly when the dysentery presents a periodic
type, of the suppression of the discharges by means
of astringents, before evacuants have been carried
sufficiently far, or morbid matters evacuated.
Thus 1 have seen dysentery consequent upon ague
or remittents, when abruptly suppressed, to have
been followed by a return of these forms of k\er,
and by enlargement of the spleen, in loc.dities
abounding with malaria ; and nearly similar occur-
rences appear, from the comprehensiveaccountfur-
nished by Sir J. M'Grigor, to have been observed
in the peninsular war. In this complication,
the symptoms are but little different from the
simple states of dysentery above described ; but
they more frequently assume a sub-acute and
chronic, than an acute, form. In the cases that
have come before me, the splenic affection could
seldom be detected unless it consisted chiefly of
enlargement, when a careful examination readily
disclosed the state of disorder. In all endemic
maladies, where we suspect disease of the spleen,
the examination should be made with caution, as
this organ may be most seriously injured by rough-
ness. In some cases, as well, indeed, as in those in
which the pancreas and mesenteric glands have
been enlargeil, the countenance and skin have
presented a dirty or leaden hue, and the limbs
have been much emaciated. But these compli-
cations are more common in chronic dysentery.

38. B. Jaundice is sometimes observed asso-
ciated with dysentery, especially when the liver
is diseased. ]5ut it may occur without any struc-
tural change of this viscus, owing to obstruction
of the ducts, or to occlusion of the orifice of the
common duct by inflammatory tumefaction of the
mucous surface of the duodenum. It may pos-
sibly also arise from the absorption of morbid bile
from the intestinal canal ; or from the state of the
soft so'ids themselves ; these having ac(juired
during disease the power of separating the colour-
ing principles of the bile from the blood. (See
IJisEASE, § 108., and jAUNDicii.)

39. C. With >Scurvy, or Scorbutic Dysentery. —
This complication of dysentery was formerly
niuch more frequent than at the present day ;

particularly in ships on long voyages, before
lime-juice was introduced as an antiscorbutic.
When, however, the particular concurrence of
causes whence it proceeds takes place, and is not
counteracted by appropriate means, we must ex-
pect this form of the disease to prevail. Its de-
structive prevalence among the troops — British
and native — employed in the Burmese war ; and
its occurrence in a modified form in the Peniten-
tiary at Milbank ; prove this position. On occa-
sions of long navigation, and the transport of
troops ; in campaigns, sieges, or active military
services, when there is a scarcity of fresh and
wholesome provisions, with the usual causes of
dysentery ; this complication sometimes presents
itself at the same time as the more malignant states
of tiie disease ; and in such circumstances, it is
occasionally the prevailing and most destructive
form.

40. a. The Causes which usually give rise to the
disease are generally the concurrence, or subse-
quent operation, of those which produce dysentery,
with such as occasion, or have already occasioned,
scurvy, — especially living long on salted provi-
sions, particularly pork, without a due supply of
vegetables or farinaceous substances ; innutritions,
deficient, or unwholesome food, or the prolonged
use of a fluid and greatly diluted diet ; debility
from previous disease ; excessive fatigue ; stagnant
and foul water; concentrated marshy exhalations,
or night- fogs in low situations and places border-
ing on the sea, or banks of rivers or lakes ; confine-
ment, or want of exercise in the open air and in the
light of day, especially in miasmatous localities ;
nostalgia ; anxiety of mind, disappointments, and
depression of spirits; and, in some circumstances,
particularly in the natives of warm climates, an
insufficient supply of salt, or of warm spices and
aromatics ; or living on a poor, watery , and vegetable
diet. Persons who have had dysentery, are very
liable to this complication when subjected to the
causes of scurvy. These causes lower the nervous
and vital power, contaminate the circulating and
secreted fluids, and ultimately deteriorate the vital
properties of the soft solids ; favouring serous or
sanious exudations from the mucous surfaces, and
those capillaries which derive the least support
from the cohesion or density of the tissues they
supply. Hence result the phenomena of this
coniplication, when the weakened bowels are ir-
ritated by the morbid secretions poured into them
from the collatitious viscera, and from their own
glands and mucous surface; or by injurious in-
gesta.

41. b. Symptoms. — In this complication, very
evident signs of scorbutic cachexia generally pre-
cede, for a longer or shorter time, the dysenteric
symptoms, which, when they are developed, re-
semble the malignant variety above described
(§ 27.), excepting that they are not attended
by any febrile commotion ; the antecedent conta-
mination of the system being much more manifest
than in the variety referred to, and symptoms indi-
cating increased vascular action being usually
absent : the countenance is pale, heavy, dark, de-
jected ; in some cases sunk, in others slightly cede-
matous ; the abdomen is drawn inwards, or sore
upon pressure ; the lower extremities are oedema-
tons, with livid patches extending to the hams, fre-
quently with ecchymoses, or petechia;, or the break-
ing out of old ulcers, and with coldness of the sur-

DYSENTERY, CIIROXIC

707

face. The gums are spongy, daik, livid, tumid,
and bleed upon the slightest pressure ; the tongue
is flabby, often raw, red, or reddish brown. The
pulse is small, weak, and soft; and afterwards
quick, fieble, and undulating. Sometimes, nearly
coetaneously with the above appearances, but more
frequently after they have commenced and pro-
ceedtid some length, diarrhoea occurs. The eva-
cuations soon assume a serous or sanious appear-
ance,with mucous, and grunious dark blood, mixed
with feculent matters; and they are usually accom-
panied by griping and tenesmus, but in a much
le:5S degree than in the more simple forms of dysen-
tery. J^ecal matters are seldom retained, the stools
being free and sometimes copious. The biliary se-
cretion is often more or less disordered ; it being
either copious or morbid — and then it increases
the excoriation of the intestinal mucous surface;
or diminished, or altogether obstructed. 'I'he
urine is scanty, of a dark muddy appearance, or
sanguineous ; and a peculiar foetor is often exhaled
from both the alvine and cutaneous excretions. In
the more severe cases, or towards the close, there
is occasionally vomiting of a bilious, bloody, or
dark and grunious fluid, with distressing flatulence,
and pain or soreness in the hypochondria. The
functions of the stomach are generally disturbed ;
and there is much disrelish of salted meat, or of
the food on which the patient has been subsisting,
with great desire for vegetable acids, vegetables,
fruits, warm spices, fresh meat, milk, &c. In the
progress of the more dangerous cases, copious efTu-
sions of fluid dark blood, with detached portions of
the mucous surface, are seen in the dejections ;
with coldness and lividity of the surface, leipothy-
iiiia, and sometimes with paralysis of the sphiucler
atii, and excoriations about the anus. Discolour-
ation of the surface, breaking out of old sores,
falling out of the teeth, great loss of flesh and
prostration of strength, and extreme despondency,
further characterise the advanced stage.

42. D, Dysentery is so J requentlii complicated
with Win-ms in the prima via, that many writers
consider them to predispose to it ; and with
much probability. The large round worm is the
species most frequently observed ; but others are
occasionally seen. The excretion of worms has
been viewed by many as an unfavourable symp-
tom ; and I believe that it often is so, as it indi-
cates a grave affection of the system, or the exten-
sion of disease to the small intestines. When
dysentery is prevalent among the inhabitants of
unhealthy localities, or the natives of hot climates,
this complication is observed in a large proportion
sometimes in more than one half, of those attacked;
and, in the latter class of subjects especially, it is
characterised by more or less asthenia, and assumes
some one of the forms arranged under this head,
according to the nature of the exciting and concur-
rent causes.

43. E. The disease may also occur in a person
liable to, or affected by, Hce.marrhoids ; especially
in those of a plethoric or sanguine constitution, or
who are subject to vascular determination to the
prostate gland and rectum, from too frequent
sexual congress. In such cases, the tenesmus is
often the chief symptom ; and, in consequence of
the tumefaction of the vessels, and coats of the
rectum, a complete retention of fa?cal matters and
constant straining are present. The disorder is
commonly local, chiefly simple, and inflammatory.

and often subsides upon a copious discharge of
blood fi'om the internal haemorrhoidal vessels,
which takes place after longer or shorter suffering,
and frequently oftener than once. In some cases,
prolapsus ani occurs, and aggravates the symp-
toms. In other respects, this complication differs
but little from the mild or inflammatory forms
(v^ 12.) described above.

44. F. The association of lihenmatic Symptoms
with Dysentery has been so frequently observed,
thai many authors (§ 74. e.) have contended for the
rheumatic nature ol the disease. The connection
of rheumatism with dysentery occurs in one or
otiier of the following ways: — 1. Rheumatism
may be prevalent either before, or at the same
time as, or subsequently to, dysentery : — 2. It
niay also precede, accompany, or follow, the
bowel disease in the same person. In all these
forms the connection has been observed by au-
thors, and in some of them by myself, — but
chiefly in the slighter or more inflammatory forms
which are most frequently occasioned by the
same causes as those which produce rheumatism,
viz. cold and moisture, or vicissitudes of tempera-
ture, with terrestrial emanations : dysentery
attacking those who are predisposed to it by the
accumulation and stagnation of morbid secretions
or acrid fa;cal matters in the digestive viscera,
&c. ; and rheumatism, those who possess the rheu-
matic diathesis, or in whom the morbid secretions
are not set loose, or the balance of circulation and
exhalation is not thrown in upon the intestinal
canal. Conformably with this view, it will be
evident that both affections may occasionally co-
exist, and that either may supervene upon the
disappearance of the other, especially when the
above causes continue in operation.

45. V. Sub-acute AND Chronic Dysentery,
AND Chkomc Diarrhcea. — i. Dysentery may
occur primarily in the mild and sub-acute form de-
scribed above (§.12.); and yet, in consequence of
neglect, or of the continued exposure of the patient
to its endemic or other causes, it may run on to a
very chronic duration, or assume the form of
chronic diarrhcea or lientery. It may lapse into
either cf these foims from the acute, in a gradual
manner ; or either of them may commence as
diarrhoea ; the characters of sub-acute or chronic
dysentery appearing gradually, or more or less
suddenly, in their progress. When the disease
arises chiefly from malaiia or other endemiccauses ;
or follows agues, remittents, and diseases of the
liver or spleen ; it more generally assumes a sub-
-acute and chronic form, or passes into chronic
diarrhoea, than in other circumstances. In other
respects, the causes of the chronic states of dysen-
tery, even when occurring primarily, are the same
as those that produce the acute forms. These
states, however, are oftener met with in those who
have had disorders of the stomach, liver, or bowels,
in long residents in warm climates or unhealthy
localities, and in the natives of such places, than
in others ; and they are more frequently compli-
cated witli diseases of the liver, spleen, omentum,
pancreas, &c. in persons thus circumstanced. In
most cases these states of the disease differ from
the acute, chiefly in the greater mildness of the
symptoms, in the absence of a few of the more vio-
lent phenomena, and in the much more uncon-
trollable and persi-^tent nature of such as are pre-
sent. Besides following upon, or being rather pro-

Zz 2

708

DYSENTERY, CHRONIC — Complicatioks or.

longations of, the acute, they may be the sequela
of any of the forms of diarrhoea, of common or
pestilential cholera, and of fevers that have been
neglected in their early stages, or improperly
treated. When it occurs primarily, which is com-
paratively rare, it may, after a considerable time,
assume the acute characters.

46. a. The Symptoms of chronic dysentery differ
chiefly in degree from those characterising the
more simple inflammatory form of the acute dis-
ease (§ 12, 13.), The fever of the latter generally
subsides, especially during the day ; and the ap-
petite and strength frequently return for a time.
Tormina and tenesmus either altogether disappear,
or are present in a slight degree ; but sharp,
griping pains, and soreness in the abdomen, are
often complained of. The stools are more or less
serous, mucous, muco-puriform, or gelatinous ;
contain some fluid faaculent matter, or ill-digested
substances ; and vary from a white albuminous, or
white of egg, appearance, to a dark olive green or
greenish black ; being sometimes marbled, or one
day like chalk and water, and on another like a
dark jelly, or the green fat of a turtle. Blood is
often either so intimately mixed with the evacua-
tion as to give it an uniform brick-red colour, oris
quite distinct and fluid, or partially coagulated.
The puriform or muco-puriform matter generally
exists as small streaks ; but this matter may not
be detected, although ulceration of the large
bowels is present. The discharges are more
copious than in acute dysentery, but much less
frequent ; being commonly from three or four to
ten or twelve in the twenty-four hours. The
pulse is not accelerated in the early part of the
day, but it usually becomes quicker towards even-
ing ; and is feeble, unequal, and sometimes slow,
or intermitting.- The tongue is often dark red or
glossy; the countenance sunk .and anxious ; the
surface cold, lurid, dirty, hairah, dry, or even
scaly ; the body emaciated ; ;.and the abdomen
hard, tumid, not very painful &n pressure, except-
ing about the caecum or sigmoid flexure of the
colon, with griping pains in the course of the
colon. In the more advanced stages of the dis-
ease, the feet and legs become oedematous; the
lips and surface exsanguineous ; the surface and
the evacuations exhale a peculiar, offensive, and
sub-acid odour; sometimes jaundice or ascites
supervenes, and the patient at last sinks under
the irritation and hectic symptoms, after many
weeks or even months of continued or remittent
suffering.

47. ^. Chronic dysentery sometimes assumes
a modified character, which is essentially the
same as the ulcerated and lienteric forms of
DiARRHfEA (§ 11, 12.). In these cases, the
mucous follicles and coat of the small, as well as
of the large, intestines are affected ; but in warm
climates and unhealthy situations, disease extends
much further, and generally comprises lesions
either of the liver, spleen, pancreas, mesenteric
glands, or of two or more of these. Repeated
attacks of dysentery, in these places, frequently
terminate in chronic dysenteric diarrhoea in a
simple or complicated state ; and 1 have seen
cases where it has continued for years, with slight
remissions ; the stools being lienteric, copious, and
crude, and the appetite ravenous. In some
cases of this protracted state of disease, especially
w-herc the stools are gleety or mucous, and voided

with tenesmus, but without tormina, the rectum
only is affected ; one or more ulcers being
seated at a greater or less distance from the
anus. The sub-acute and chronic forms are not
infrequent in children, are in them often accom-
panied by procidentia ani, and are generally in-
flammatory, particularly when occurring sporadi-
cally. Chronic dysentery in the dark races
assumes the appearance of a gleety discharge
from the bowels, and depends upon deficient
tone of the vessels and follicles of the intestinal
mucous surface, rather than upon inflammatory
action.

48. ii. Complications of Chronic Dysentery are
most frequent in countries within the tropics, and
in places abounding with terrestrial emanations.
(H)When chronic dysentery is complicated with
disease of the /iuej', the symptoms often approach
those of diarrhoea ; and the hepatic affection is
generally latent, insidious, and also chronic ; the
internal structure of the organ being chiefly im-
plicated. In this state of disease, the evacuations
are frequent ; attended by griping pains about the
umbilicus ; and are of a dark green colour,
indicating a morbid state of the bile ; or of a
pale clay colour, showing torpor of the liver or
obstruction of the ducts. In some cases, they
are dirty, watery, and offensive ; and in others,
of a whitish appearance : whence has arisen the
term " white Jiux." These last seem like chalk
or lime mixed in a dirty fluid, or intermediate
between this and whites of eggs ; occasionally
they resemble cream or yeast ; and they are often
slimy, and contain broken-down, clay -coloured
faeces, and half-digested substances. These
sometimes continue for a long time ; or they
change to a darker colour, apparently from a par-
tial discharge of bile or the medicines takeu ; and
afterwards return to their former hue. This
state of the dejections is evidently owing to the
obstruction of bile, to the consequent impair-
ment of chylifaction, and to the increased and
morbid secretion of the follicular glands and
mucous surface. In addition to these the patient
complains of tightness, fulness, or oppression at
the epigastrium and lower part of the thorax, par-
ticularly on the right side ; and of slight evening
exacerbations of fever. The eyes have fre-
quently a pearly appearance ; and the countenance
is livid or sallow. Thiscomphcation is often caused
by the excessive use of spirituous and other intox-
icating liquors ; and by the concurrence of the
causes of hepatitis with those of dysentery ;
and it frequently is consequent upon hepatitis;
upon intermittent, remittent, or continued fevers ;
and upon the acute disease, when it arises from
endemic causes. The dysenteric symptoms are
manifestly occasioned or perpetuated either by a
morbid condition, or by deficiency, or total ob-
struction, of bile: this secretion being indispensa-
ble to the due performance of the assimilating
processes, and to the healthy state of the mucous
surfaces and follicles. In other cases of this com-
plication, the enlargement of the liver, or the symp-
toms of hepatic disease, are less equivocal, and
approach more nearly those stated above ($35.).
(See, also, Liver — Abscess in.)

49. (a) — a. When chronic dysentery follows
the diseases just now mentioned, or the prolonged
or intense operation of endemic causes, it may
become associated with scorbutic symptoms ; or

DYSENTERY — Terminations and Prognosis of.

709

dysentery, in a sub-acute or chronic form, may
be consequent upon scurvy, as in the scorbutic
complication already described (§ 39. )• '^'he
chronic states of the disease may also asso-
ciate with them changes of other viscera beside
those of the liver. In the hepatic complication,
especially in hot countries, the internal surface
of the small intestines is very frequently also in-
flamed or ulcerated, and the spleeu, pancreas, me-
senteric glands, or omentum, may be affected in
addition. When chronic dysentery follows pe-
riodic fevers, the spleen and mesenteric glands
seldom are altogether sound. I have never wit-
nessed an inspection of a case, either in temperate
or in warm climates, that did not present lesions
in one or more of these organs, beside those in
the bowels ; but some of these were manifestly
consequences of the disease, and not associated
with its early stages. With the exception of the
complications with disease of the liver and spleen,
the exact pathological state can seldom be ascer-
tained during life. When the patient is very
much emaciated, enlargement of the pancreas or
of the mesenteric glands may be suspected, from
hardness and fulness in the abdomen — usually
between the pit of the stomach and umbilicus ;
and from aching pains in the back. — 0. In the
dark races, the complication of chronic dysentery
or diarrhoea with disease of the liver is very rare ;
but those with enlargement of the spleen and of
the mesenteric glands, with icarins, and with
rheumatism, — especially the last two, — are very
common. — y. In children, the association of the
complaint with enlargement of the mesenteric
glands, or with worms, is not infrequent ; and the
complication of the slighter or sub-acute states
with bronchitis is sometimes also met with among
them.

50. VI. Terminations and Prognosis. — i.
The Acute varieties of the disease may terminate —
1st, in a return to health; — 2d, in periodic or
continued fever, or some visceral disease ; — 3d, in
ulceration, and the extension of inflammatory action
to the peritoneum or perforation of the bowels ;
— 4th, in sloughing of the internal tunics, and
gangrene of portions of the intestinal tissues ; — and,
5th, after having assumed a chronic form, in con-
striction of the colon, and other organic lesions ;
or in gradual exhaustion of the powers of the con-
stitution. — (a) A favourable issue may be expect-
ed, if the stools become less frequent, more copious
and feculent, and the biliary secretion more natu-
ral ; if the tormina and tenesmus abate, and the
patient be less disturbed in the night ; if the abdo-
men be less painful, especially on pressure; and
if tumefaction or tension be not present ; if the
febrile phenomena be alleviated, the pulse, tongue,
and skin become more natural, between the
sixth and seventeenth days in the asthenic forms ;
and if the symptoms indicating the other termina-
tions be not observed.

51. (6) When the disease is suddenly arrested,
by astringents, or otherwise injudiciously treated,
particularly when it arises from endemic and epi-
demic causes, it may pass into ague, remittent or
continued lever ; or into inflammation and abscess
of the liver, or into peritonitis or enteritis. These
results evidently arise from the stoppage of the dis-
charge of morbid matters that require elimination
from the system, and the consequent irritation these
matters produce upon the nervous and circulating

systems, or upon the organs chiefly concerned in
excreting them. But, on some occasions, these
maladies may supervene, without any aid from
the practitioner. When dysentery occurs in the
puerperal state, particularly soon after delivery
(and, when the disease is epidemic, females thus
circumstanced are very liable to it), it is very apt
to pass into peritonitis ; or to be followed by
efliision into the peritoneum, and even by inflam-
mation of the womb. In 1832, 'I treated a case
of sporadic dysentery iu a lady who had not been
pregnant for several years. It was followed by
hysteritis ; which, in its turn, was followed by
phlegmasia dolens, first in one thigh, and then in
the other. She is now in good health. In some
instances, particularly in hot climates and in
young children, introsusception of portions of the
intestines may take place, and give rise to grumous
or faeculent vomitings, and all the symptoms of
ileus. I have sometimes seen children seized,
during dysenteric complaints, with convulsions,
obstinate vomiting, distressing colicky pains in the
abdomen, and stupor, followed by various sympa-
thetic phenomena, and death ; and, upon dissec-
tion, the only lesion, besides signs of irritation in
the digestive mucous surface, has been invagi-
nation of more or IcrS of the intestinal tube, and
the usual consequences of this occurrence. In
a case of this kind, which was supposed to have
died of acute hydrocephalus by the medical
attendant, and which was opened by Mr. Alcock
in my presence, the greater part of the ilium had
passed into the caecum ; and the caecum', with its
contents, into the transverse arch of the colon.

52, (c) If a favourable change take not place,
in the more sthenic varieties, before the twenty-
fourth day ; and in the asthenic states, previously
to the eighteenth or nineteenth days; or if only a
partial change be observed ; the disease usually
either passes into the chronic form, or assumes
still more severe characters.

53. (d) An unfavourable termination may be
lookedfor, if the foregoing symptoms ($50.) be ag-
gravated ; or if no impression have been made upon
the complaint, about the time stated above ; or be-
tween the ninth and fourteenth days in the severe
asthenic forms : if the abdomen become enlarged,
tense, or tender, or preternaturally hot, especially
about the umbilicus ; or if pain increase rapidly,
and be constant and fixed in one part ; if the watery
discharges, loss of blood, or the harassing fre-
quency of the calls to stool, particularly at night,
sink the powers of life, or be attended by cramps
in the lower extremities, leipothymia, or syncope ;
if the face be anxious, or Hippocratic, and the
body emaciated ; if stupor, delirium, picking of
the bed-clothes, starlings of the tendons, super-
vene ; if the extremities or surface be discoloured,
or the former be cold or clammy, or the latter of
a lurid hue, or exhale a cadaverous or an offensive
odour ; if drinking be followed by tormina and a
desire to go to stool ; if the tongue be raw, glossy,
or very dry, and dark red ; or dark sordes collect
about the teeth, or aphthae appear in the mouth or
on the lips ; if the pulse be very weak, irregular,
oV intermittent, or rise in frequency to upwards of
120; if respiration be rapid, laboured, or difficult;
if the breath be foetid and cold ; if the matters
vomited be offensive or grumous ; if ecchymoses
or sphacelating ulcers appear on the surface ; if
sight or hearing be partially lost; if paralysis of

Z z3

710

DYSENTERY-— Morbid ArpEAnASCfiS

the sphincter aui take place, and the stools be
involuntary or grumous, or like washings of
meat, cadaverous, or mixed with small black
coagula,or with light muco'puriform streaks, and
especially if they contain sphacelated portions of
the mucous coat ; if the stomach be so irritable
as to reject whatever is taken 5 and if complete
strangury or suppression of urine take place.
Hiccup is not an unfavourable symptom, if it
occur early in the disease ; but when it comes on
at an ailvanced stage, it is often an indication of
the extension of the disease to the peritoneum, or
of the sphacelation of the mucous membrane.

54. a. Ulceration may take place early, even
in the mildest forms of the disease, without
causing any decided change. Most frequently,
however, it is attended by aggravation o the
symptoms; the stools passing from a mucous to a
serous, sero-puriform, or grumous state. At its
commencement, especially in the less inflam-
matory cases, little fixed or constant pain is felt ;
but as it advances through the coats, pain, in
some form, is experienced. At an advanced
period, especially when sphacelating ulcers exist,
the stools become dark brown, muddy, or watery,
and smell like washings of meat. The blood
discharged is often of a darker colour, and some-
times mixed either with an ichorous sanies, or, in
the more sub-acute or chronic cases, with puru-
lent streaks. When the blood is in large quan-
tity, and unmixed with the rest of the dejection,
ulceration low in the canal may be inferred.

55. (3. Extension of inflammatory action to the
peritoneum, or the omentum, or to the mesentery,
is generally owing to ulceration, and may occur
either previously, or subsequently, to pofonition
of the intestinal parietes. If great increase of pain,
with heat, fulness, and tension of the abdomen,
distressing anxiety, restlessness, inability to sleep,
frequent retchings, and copious discharges, per
anum, of morbid secretions and fajcal matters
which had been retainefl while the spasmodic
action of the bowel was in full force, supervene
at an advanced stage, extension of inflammation
to the peritoneal coverings may be inferred ; and
if these symptoms take place suddenly, and are
quickly followed by very painful meteorismus,
hiccup, cold sweats, sunk countenance, jactita-
tion or delirium, rapid and laborious breathing,
a very wiry, or small, irregular, and weak pulse,
cold extremities, &c., they maybe imputed to per-
foration of the bowel. Inflammation may also
extend, generally with ulceration of the tunics,
from the Cfficum to the appendix vermiformis, and
thence to the peritoneum ; or to the external con-
necting cellular tissue, giving rise to abscesses in
the right iliac fossa, that may open either into the
caecum, or externally. (See C«cu.\i, § 19.21.)
A case of this description was treated by 11, e in a
warm climate, in 1817. It had been neglected in
its early stages, and a very large abscess had formed
and burst into the ca;cum ; extensive ulceration
and sphacelation of this part being found on dis-
section.

56. y. Gangrene seldom proceeds, even in the
most severe cases, further than the mucous and
submucous tissues; excepting in warm cllmatis,
where sloughing ulcers, somelimes of large size,
penetrate all or most of the coats. This change
is commonly occasioned by the extension of the
inflammatory action to the tissues underneath,

and the consequent detachment and death oi thd
portion of this coat covering the parts particularly
afl^ected ; as the cuticle is detached by the effusion
ot fluid underneath it, when the vascular tissue of
the skin is acutely inflamed. In such cases,
portions of the partially sphacelaled membrane
hang loose in the canal, whilst the more external
tunics are altered in colour, and softened. The
symptoms indicating the commencement of spha-
celation of portions of the mucous coat, are those
detailed in the preceding paragraph, followed by
leipotliymia, or syncope when the patient is raised ;
a sudden remission of the tormina, abdominal pain
or heat; singultus; cold, shrunk, and bedewed
countenance and extremities ; sense of cold in the
abdomen ; involuntary motions ; lividity of the
lips and cheeks ; partial convulsive movements ;
extreme prostration, and the supine posture ;
glassy, inexpressive state of the eyes ; cadaverous
or very foetid smell from the evacuations, and the
body ■ and, lastly, insensibility.

57. ii, Tlie Chronic forms, besides terminating in
ulceration and extension of inflammatory action to
the serous surfaces, often superinduce thickening
of the coats and stricture, in some parts of the co-
lon or rectum, or of both, frequently with dilatation
of the portion above the contraction ; ultimately
terminating, in some instances, in rupture of the
more dilated and attenuated or ulcerated part, and
effusion of the intestinal contents info the perito-
neal cavity. In some cases, ascites comes on, or
cedema of the lower extremities, or both, and the
patient sinks in an exhausted and dropsical state.

58. VII. Appearances on Dissection vary
with the form of the disease. In the inflammatory
varieties, they are limited to the large bowels, and
parts immediately connected with them ; but in
the asthenic and complicated states, especially in
the scorbutic, the changes are much more exten-
sive.— a. Upon opening the abdomen, the (wne^itMHi
is sometimes adherent to the superficial convolu-
tions of intestines, or to the brim of the pelvis, or
to some part of the abdominal parietes, but it is
oftener drawn up to the arch of the colon, or to
one side. The bowels, externally, present meiely
changes of capacity and colour, unless partial
or general peritonitis have supervened. 1 hey
are commonly distended by flatus, and variously
coloured in different cases or parts, and frecjuently
without the external colour having reference to the
state of internal change. The large bowels feel
in one place thick and doughy, in another thin
and membranous. The colon is sometimes dis-
placed or elongated, from relaxation of the lon-
gitudinal bundles of fibres : the transverse arch
hanging down in a loop, or the sigmoid flexure
passing over to the right side (Anneslev, &c.).
Contractions of a considerable part of the colon
are frequent, and sometimes the constrictions
resemble those made by a ligature, — ihe parts
above being distended and thinned ; they are firm
and almost cartilaginous in some chronic cases,
and sealed chiefly about the sigmoid flexure and
arch of the colon, and more rarely in the rectum.
Adhesions of the peritoneal surface of the colon
to the adjoining parts, and efl'usions of lym])h, or
of scrum, into theperitune;il cavity, aho, arc often
seen.

60. h. Internally, the bowels present extensive
and numerous changes. The villous coat is dif-
ferently shaded in different parts ; and varies

DYSENTERY — Diagnosis.

711

from n pale grey or sea-gieen to a botlle-green
or violet colour ; or from a pale pink to a bright
red, or reddish brown, shaded with black. In
some, the most opposite colours pass abruptly
into one another. Large portions of coagulable
lymph are sometimes found partially adherent on
tliis surface. Eicoiialiotis of the mucous epi-
thelium, the excoriated parts presenting a choco-
late tint ; detachment of portions of the villous
coat, sinuosities existing underneath the parts in-
tervening ; softening of the internal tunics ; ulcer-
ations, in all the forms described in the article
Digestive Canal (§ 36 — 40.) ; and sphacelation
of portions of the mucous and submucous tis-
sues ; are the most frequent appearances, and are
met with, in various grades, in all the forms of
the disease. The tttcers are either small, nume-
rous, and clustered, or large, distinct, and few.
They are often dark, extensive, and sloughy ; the
parts in which they are seated, as well as those
surrounding them, being softened, or very easily
torn, particularly in the asthenic varieties, and in
the scorbutic complication. They are frequently
elevated on a thickened or hardened base, in the
more chronic cases (as described in § 36. e. of the
article now referred to) : or they present exuberant
fungous or fleshy granulations on their surfaces.
In some instances, their centres are very dark or
blackish (Pringle, Monho, &c.). Deficient
vital cohesion of the coats of the bowels, they
being occasionally torn as easily as wetted paper,
is very common in the more asthenic varieties.
In prolonged inflammatory cases, thickening and
almost cartilaginous induration of a considerable
part of the colon are not infrequent, the thickened
or indurated portion being also contracted in
calibre. In such cases, the part above the con-
tractions are greatly distended, the coats being
thinned, ulcerated, and even lacerated; the con-
tents of the bowel having passed into the peritoneal
cavity, and occasioned rapidly fatal peritonitis.
The ccEcum is extensively disorganised ; and the
parts suriounding it are, in some cases, inflamed,
or in a state of suppuration, or sphacelation (An-
neslev and myself). The appendix vermiformis is
also occasionally inflamed and ulcerated. The
small intestines are very often inflamed, especially
in the internal surface ; and ulcerated in their
lowest third, particularly in the asthenic varieties,
and in the hepatic and scorbutic complications.
In some instances, the ileo-ceecal valve having
been ulcerated, extensive intus-susception of the
ilium takes place into the cajcum and colon. In-
vaginations occur also in other portions of the
intestinal tube, especially the ilium. (See Di-
gestive Canal, § 18 — 48.)

60. c. The collatitio^is viscera are generally dis-
eased in the asthenic and complicated states. The
mesentery and mesocolon are more vascular than
usual ; and the glands of the former are inflamed
or enlarged, more readily suppurated, especially in
situations corresponding to large ulcers. A dirty-
coloured fluid is occasionally affused in the peri-
toneal cavity in malignant or typhoid cases ; and
sometimes, also, in the thoracic cavities. The
spleen is either enlarged or softened in the asthenic
varieties, or when the disease is consequent upon
periodic lever ; and the liver is congested, in-
flamed, suppurated, or otherwise disorganised, in
the hepatic and scorbutic complications. Con-
gestion of the portal vcsiels is very common in

both the asthenic and sthenic forms. Injection
antl changes of colour of the internal surface of the
sto7nuch and duodenum, and accumulations of
viscid thick bile in the gall-bladder, are frequently
observed. The pancreas is sometimes enlarged,
and presses upon the common duct. The urinary
bladder is occasionally inflamed about its neck, or
in its external tunics ; and the prostate somewhat
enlarged. In the dysentery, recently epidemic in
Ireland, Dr. O'Brien found the liver diseased in
one half the dissections ; the spleen in one fourth ;
the small intestines in two tliirds ; and the colon
and rectum in all. In chronic cases, in the Brit-
ish army in the Peninsula, the spleen, liver,
pancreas, mesenteric glands, &c., or any two or
all of these, were more or less diseased (Sir J.
RI'Grigor, Dr. Ferguson, Dr. Somers, Dr,
Forbes, iStc).

61 . rf. In the most malignant varieties, and in the
scorbutic complication, the internal surface of the
whole digestive tube is of a livid, purple, or dark
colour ; with patches of ecchymoses, excoriation,
ulceration, and sphacelation. The villous coat,
particularly in the seat of ecchymoses, may rea-
dily be rubbed off; and the ulcers have a foul
and dark appearance. The liver is sometimes
large, soft, and spongy ; at others, pale and soft,
especially in cases where the loss of blood has been
very large. The spleen is sometimes so softened
as to appear semifluid or sphacelated. The heart
is often partially softened or flaccid ; the peri-
cardium and pleural cavities containing a bloody,
dark, and dirty serum. The lungs are often con-
gested ; the bronchial lining dark, or ecchymosed ;
and the blood \u all the large vessels is semifluid,
black, and of a very loose texture. Indeed, the
vital cohesion of all the tissues is, in these forms
of the disease especially, more or less lost. In
the dark races, the digestive mucous surface is
usually paler and softer than natural, or dis-
coloured or sphacelated; the follicles enlarged or
ulcerated ; the coats of the caecum and colon very
easily torn ; the liver pale, soft, and small ; the
spleen enlarged and softened ; the pancreas occa-
sionally enlarged, and the mesenteric glands always
enlarged, or otherwise diseased.

62. VIII. Diagnosis. — Dysentery often very
nearly approaches either fever, diarrhea, cholera,
or colic; and it frequently supervenes upon one or
other of these diseases ; fever, diarrhoea, &c. almost
insensibly passing into it. — (a) Fever, especially
some of its endemic and epidemic forms, sometimes
assumes an enteric character, closely resembling
the asthenic states of dysentery, particularly as
respects both the frequency and character of the
evacuations ; a circumstance which led Syden-
ham, Blane, Jackson, and others, to consider
the latter as fever turned in upon the bowels.
Although, in some cases, the one may in-
sensibly pass into the other, yet idiopathic fever,
with predominant enteric aftection, will be dis-
tinguished from dysentery by the more marked
constitutional afTection before the bowels become
disordered, by the much less pain and difticulty
ir^ the excretion of urine, by the absence of
severe tormina and straining, and by a more
faeculent state of the evacuations, than in any of
the forms of the latter disease. It has been sup-
posed by many writers, that the more asthenic or
malignant states are mere associations of dysentery
with adynamic or typhoid fever : but, instead of

Z z 4

712

DYSENTERY — Diagnosis.

viewing these states as complications of two '
diseases distinct from each other in their nature
and seat, it would be more philosophic to consider
them as coexistent results of the operation of cer-
tain concurring causes upon the economy ; which
causes, according to their natures, and the pre-
disposition and habits of the affected, induce effects
partaking more or less of the characters of either
fever or dysentery. In most instances, where the
disease seems to have been thus mixed, animal
emanations, a close and impure air, or other de-
pressing and contaminating agents, acting either
internally or externally, and aided by epidemic
influence, have manifestly existed. But it is
rather to the presence of those agents, in such a
form as to act upon the excreting viscera and
prima via, or in such combinations as to deter-
mine their effects to this quarter, assisted by ante-
cedent disorder or predisposition of the digestive
and excreting viscera, that the adynamic states of
dysentery are to be imputed. Thus an impure or
infected air — either short of inducing, or even
sufficient to induce, the worst forms of fever —
may produce a malignant or typhoid state of dy-
sentery, when aided by unwholesome water or diet ;
and this latter cause, unassisted by the former,
may also occasion the same disease in a similar
or a less severe form, in those greatly predisposed.
Hence according to the nature and concurrence
of causes, will effects upon the frame be induced :
which will insensibly approach fever on the one
hand, and the most simple and perfect dysentery
on the other.

63. This modification of the disease, with the
nature of the disposing and exciting causes, is
further illustrated by the intermitting and rheu-
matic characters occasionally assumed by it in
both its endemic and its epidemic states of pre-
valence. In localities where marsh miasmata
abound, and where the water or the food are
unwholesome, or other causes of dysentery pre-
vail, this disease often either assumes, in both its
acute and chronic forms, in warm climates espe-
cially, an intermittent or remittent type — most
frequently the latter — or supervenes upon or
passes into these, or into continued fever. Of this
I have seen numerous instances ; and similar facts
have been recorded by nearly all the writers on
the diseases prevalent in the armies engaged in
the last wars. In certain of its epidemics, espe-
cially those which prevad in cold and moist sea-
sons, dysentery sometimes follows, or is otherwise
connected with, catarrhal affections, as observed
in those recorded by Strom, G. Baker, and
Neumann ; and it occasionally is complicated
with rheumatism, particularly in one or more of
the joints or extremities, the amelioration of the
one affection being often followed by aggravation
«f the other. The association of dysentery and
rheumatism, and their conversion one into the
other, are stated by Dr. Sims to have been re-
markable, in the epidemic in London, during 1769
and 1770. A somewhat earlier and a moie distin-
guished writer, — Dr. Akensiuk, — likewise alludes
to this subject, in a mannei' worthy of the most
philosophic of our poet", and observes ; — " No-
vimus prajterea, eadem tcmpcstatc et ob easdem
causas rheumatismum (juoque fre(iuenlissimum
fieri ; " whilst he states, in another place, that,
although these diseases prevailed separately, they
wore, owing to the similarity of their causes, often

coexistent, or consequent the one on the Other '
a circumstance not confined to this climate, and
occasionally observed in certain seasons, but also
remarked amongst the natives of intertropical
regions.

64. (b) Diarrhoea is so very closely allied to
dysentery, that they may be viewed as varieties or
grades of the same morbid actions. Nosologists
in their rage for drawing distinctions, which exist
only in extreme cases have wittingly overlooked
the fact, that between both diseases, there often
scarcely exists a shade of difference ; whilst, be-
tween the extremes, the distinction is sufficiently
wide, and easily made. Dysentery frequently
follows simple diarrhoea, or diarrhoea, attended by
fever ; and is itself also followed by diarrhoea, in
some one or other of the forms in which it is
described : and both diseases may be merely the
sensible phenomena either of the irruption and
excretion of morbid secretions, or of inflammatory
irritation, affecting somewhat different portions of
the alimentary canal. Yet, although thus very
closely allied in nature and form, they are very
often distinct, as respects — 1st, the seat of dis-
ease ; 2d, the affection of the system generally ;
and, 3d, the symptoms resulting from each. —
a. Diarrhaa is generally sporadic, and never in-
fectious ; — S. It occurs at any season, and is more
commonly a chronic disease than dysentery ; — y. It
is usually neither preceded nor attended by fever ;
— J. It is unaccompanied by severe tormina and
straining; — e. In it, the evacuations are more or
less abundant, and not bloody ; — ^. It is seldom
attended by vomiting or heat of skin, or by early
depression of the powers of life, as observed in
dysentery : — w. The history of the disorder, par-
ticularly in relation to its causes and constitutional
disturbance, will point out many points of dis-
similarity between it and dysentery.

65. (c) Cholera differs from dysentery, — a. In
appearmg only during the latter part of summer,
and in autumn ; — ^. It is a most acute disease,
running its course in from one to two or three days ;
— -y. It is unattended by straining, or blood in the
stools ; — J. In it, the stools are abundant, very fre-
quent, and the vomiting almost constant; — £.
Spasms of the legs and abdominal muscles, cha-
racterising cholera, are seldom met with in
dysentery, excepting towards an unfavourable
termination of the super-acute cases. It should
not however, be overlooked, that cholera some-
times runs into dysentery, evidently owing to the
irritation excited in the large bowels by the
morbid secretions poured into the digestive canal.

66. (d) Dysentery can hardly be confounded
with colic, if due attention be paid to the history
of the case. — C^dic from lead, bilious colic, and
ileus from hardened substances in the bowels, or
from invagination, sometimes present features of
resemblance to dysentery ; particularly the violent
pains in the abdomen, vomiting, and occasionally
abortive eflx)rts at evacuation, with very scanty
watery or bloody discharges. But in these, there
is neither antecedent diarrhoea, nor attendant fever,
nor frequent calls to stool, nor tenesmus, nor any
considerable evacuation in the aggregate, nor
fixed pain in the hypogastrium, nor scanty, dif-
ficult, and painful excretion of urine, or tenesmus
vesicalis, — all which characterise dysentery. In
these, also, vomiting is much more urgent, some-
times becoming faiculent, and the paroyxsms of

DYSENTERY — Pathological Inferences respecting.

713

puin more violent, particularly around the um-
bilicus, than in this disease ; the matters received
into the stomach being ejected from it without
exciting either a desire Tor stool, or tenesmus. It
should, hovv^ever, be kept in recollection, that the
bilious or endemic colic of warm climates (see
Colic, § 16.) in some cases differs but little from
dysentery, and that chiefly as respects the more
complete retention of the morbid secretions and
excretions, as will be seen from the history of both
diseases.

67. (e) Internal H<smurrhoids sometimes give
rise to symptoms resembling dysentery, — or rather
to tenesmus, an affection entirely of the rectum,
the seat of these internal tumours. The tenesmus
of haemorrhoids, whether attended by discharges
of blood or not, is strictly a local complaint, is
seldom severe or preceded by tormina, or frequent
calls to stool, or much constitutional disorder;
and is a simple obstruction to the passage of con-
sistent stools, which are not mucous, and not
streaked with blood, which, if passed at all at
stool, is entirely distinct from the faecal evacuation ;
the haemorrhoidal tumours often protruding at the
time. These, independently of the different cir-
cumstances under which both diseases occur, and
the history of their progress, are sufficient to dis-
tinguish them from one another.

68. IX. Pathological Inferences. — i. The
Modes of Operation of the Causes. — There
is, perhaps, no other disease which requires a more
accurate analysis of its pathological conditions,
with strict reference to their causes, than dysentery,
for these causes induce so very different states of
morbid action in connection with tiiat wiiich espe-
cially constitutes the malady, that the practitioner
will often attempt in vain either to limit its spread,
in circumstances requiring this precaution, or to
arrest its progress in particular cases, without being
acquainted with the operation of its diversified
causes upou the system, and the nature of the
effects they induce.

69. 1st. Operation of causes which dispose to
the disease (§9. 22.). — These, when their nature
is known, and their mode of operation ascertained,
may be sometimes averted, and an attack thereby
prevented, especially when the malady is preva-
lent. — (a) High ranges of temperature, and con-
sequently hot seasons (Piso, Hillary, Strom,
Hufeland, &c.) and climates, so very generally
predispose to dysentery, that it most commonly
occurs either during, or subsequent to, these states
of atmosphere. The effects of a high temperature
upon the pulmonary functions, and consecutively
upon the blood, and the biliary and other secretions
and excretions, are such, as fully explained in the
article Disease (§ 32 — 34.), as greatly to increase
and disorder these latter, especially when the cir-
culation is determined towards the abdominal or-
gans by exposure to cold, or when assisted by
other concurrent causes. — (h) Peculiar states of
air, connected with the epidemic manifestations of
the disease (HuxH AM, Horn, Schmidtmann,&c.),
and with certain features which different epidemics
often present, whether referred to noxious exhala-
tions floating in this fluid, or to extreme humidity,
or to electrical conditions of it affecting the electro-
motive states of our frames, most probably influ-
ence the organic or vital actions, especially the
circulating and secreting functions, in such a man-
ner — although slightly or latently — as to render

them remarkably liable to this species of disorder
upon exposure to any of the exciting causes. And
it is not improbable that these states, as well as
high ranges of temperature, favour the production
and accumulation of morbid secretions in the bi-
liary apparatus and in the prima via; and that
these secretions, aided by consecutive causes, in-
duce that form of action constituting the disease,
although lending to their evacuation from the
frame. — (c) An asthenic or exhausted state of
the constitution, and of the digestive canal in par-
ticular, insisted upon by Marcus, has certainly
no mean influence as a predisposing cause, as
shown by the greater prevalence of the disease in
persons of this description in all climates and in
most epidemics, in soldiers after very fatiguing
marches, and in convalescents from fevers and
other diseases. — (<0 To these may be added the
use of intoxicating fluids, as disordering both the
digestive mucous surface and the secretions
poured into the intestinal canal.

70. 2d. OJ the operation of causes wliich, either

individually or conjointly, excite the disease. A.

Those which act locally, m- affect chiejiy the lar<re
bowels. — (a) Many of these irritate "or inflame
the mucous surface of the caecum, colon, and
rectum. These bowels perform chiefly an ex-
creting function ; and consequently, when the
excretions which are proper to them, as well as
those which are poured into them from the small
intestines, are allowed to accumulate, irritation or
inflammation of the mucous surface, with in-
ordinate action of the muscular coats, may be
expected to occur. Irritating purgatives, injudi-
ciously prescribed ; a dose of rancid castor oil ;
foreign bodies lodged in the intestines ; the too
liberal use of fruit, especially that which is unripe
(Horst, Girtanner, M'G rigor, &c.), or the
fruit of hot climates (Buchner, Twining, my-
self, &c.) ; various indigestible substances; un-
cooked or imperfectly cooked meat or other food ;
pork ; sour or bad wine ; minute insects, or their
ova and animalcules, in the water used for drink
(LiNN^us, Sebastian, May, Latreille) ; and
intestinal worms (constituting the Dysenteria
verminosa of Bonet, May, and Baume) ;
seem to act in this manner. — (6) Several
agents determine inflammatory irritation of, and
an inordinate flux of fluids to, the mucous sur-
face of the large bowels, and tlieir usual results.
'The causes just enumerated necessarily act in
this manner, although not so immediately, nor to
the same extent, as the following : — Exposure to
cold, or cold and moisture, especially during or
immediately after great atmospheric warmth, has
been considered by Bijchner, Stoll, Fischer,
Larrey, and others, to produce the disease, and
at the same time to impose on it a rheumatic cha-
racter; whilst Osiander considers that, of itself,
cold will not have this eflTact ; and that the pre-
sence of morbid matters in the prima via, or the
concurrence of some other cause, is necessary to
its operation. The influence of the causes of
common catarrh, insisted on by Strom, Schle-
CEL, and Neumann, although not so great as
these writers suppose, is often well marked, espe-
cially in sporadic cases, and in some seasons.
These, and several other authors, consider that
the disease is catarrh, or catarrhal inflammation,
of the large bowels, from remarking its prevalence
about the same time as that aflfection. The sup-

714 DYSENTERY

pression of other evacuations, or tlie drying up of
accustomed discharges, and misplaced gout (Mus-
GRAVE, Stoll, &c.) — the Dysenteiia arthritica
of Sauvages — are probably also concerned in
its production in some instances ; contingent cir-
cumstances causing the determination of morbid
action to this quarter.

71. B. Causes which disorder the secretions
poured into the intestinal canal, and thereby affect
its mucous surface. — (a) Suppression ot the
secretions and excretions poured into the large
bowels, especially the biliary fluid, and accumu-
lations of mucus in the follicles, are not altogellier
without effect in causing or prolonging the disease,
especially some of its protracted states ; and
several of the exciting agents, particularly cold,
moisture, and malaria, partly act in this way.
In many cases, both sporadic and epidemic, the
absence of bile from the stools is a prominent
symptom ; the free discharge of this fluid being
generally followed by more or less rapid amend-
ment. Deficiency of this secretion evidently
renders the chyle irritating or otherwise hurtful to
the bowels ; their mucous surface and follicles
being moreover deprived of the salutary influence
which a healthy state of this secretion exerts upon
them ; whilst accumulations of mucus in these
glands irritate or inflame them, and favour th€
changes they usually present in fatal chronic cases.
— (6) Other causes may operate by changing one
or more of the secretions poured into the large
bowels, either in quantity or quality. Thus, excess,
and acridity with excess, or even with diminution,
of these secretions, may irritate or excoriate the
villous surface of the large bowels, during a pro-
longed retention of them occasioned by the con-
formation of the caecum and colon, and by the
spasmodic action of the muscular fasciculi of the
latter. Many endemic causes act by disordering
or vitiating the abdominal secretions and excretions,
especially those of the liver (Forster, Wendel-
STADT, Fischer, Bruninc, &c.) ; and antecedent
diseases, as agues, remittents (Pringle, Hu^■TEn,
J. M'GuiGOR, Ferguson, &c.), and continued
or epidemic fevers (Chevne, O'Brien, &c.),
operate in a similar manner. Pre-existing affec-
tions, also, of the collatitious viscera, particularly
of the liver (I'iso, Menjotiis, Juncker, Boag,
BiANCHi, J. Johnson, &c.) and Pancreas, have
a still more common and manifest agency ; and
it is probable that the influence of imagination,
fear, and terror, mentioned by Hcffman, Vogel,
Hargens, and Naumann, is exerted through the
mediiim of the secreting organs, as well as upon
the bowels themselves.

72. C Other causes seem to affect the intestinal
mucous surface, the secretions youred into the
canal, and the circulating fluids, disordering,
also, the organic nervous influence by which lliese
are controlled or modified. — (a) The use of
unripe and blighted grain (Wright, Gedner,
&c.) ; of the flesh, and especially the viscera, of
diseased animals (Hoepfner, &c.) ; famine and
unwholesome food (Mum.ius, Desoenettes,
ViGNES, Graves, &c,); water holding putrid
animal and alkaline substances in solution (Pro-
copius, RiiODius, Moeglino, I'irniiaum, Bei.i,,
&c.) ; and stale fruit or vegetal)le'^, act in this
complex manner ; putrid water especially exert-
ing a septic action upon the digestive mucous
surface, upon the circulation, and, ultimately.

Pathological Inferences respectino.

upon the soft solids. — {b) The causes which pro-
duce scurvy also give rise to scorbutic dysentery
(§ 39.), by a nearly similar mode of operation.
— (c) Morbid matters absorbed from ulcerating
surfaces and parts, especially from sloughing,
malignant, or phagedenic ulcers, by contami-
nating the blood, disorder the secretions, poured
into, and those elaborated by, the intestinal canal,
so as frequently to occasion asthenic dysentery
or diarrhcEa. Of this form of the disease, nume-
rous instances occurred in naval and army hospi-
tals during the war. Mr. Copland Hutchison
has devoted a chapter of his able " Practical Ob-
servations en Surgery," to this procession of mor-
bid action, as it occurred in the navy, during his
extensive public service.

73. D. Lastly, some causes, and these the mosi
energetic, affect the circulation, and, through it,
the secretions poured into the bowels ^ ultimately
contaminating, more or less, the solids as well a»
fluids, and disorganising the intestinal canal, if

the disease be not arrested in its progress. — (a^
Miasmatous exhalations (Lind, Kreysig, Mi-
chaelis, &c.) ; the emanations from animal ex-
uviae (OsiANDER, Sec); or a mixture of both
(Annesley, myself, and others) ; and the efflu-
vium proceeding from the bodies of a number of
persons confined in small space, and in a close
air (Atcheson, &c.); by vitiating the air used ir»
respiration, aft'ect the whole mass of blood as it
circulates through the lungs ; those or;,ans, espe-
cially the liver, whose office it is to eliminate in-
jurious matters from the circulation, and thereby
to preserve the purity of this fluid, necessarily
forming, from the morbid elements furnished Ihem
in it, acrid, septic, or otherwise morbid secretions,
which, as actually proved by experiment, irritate
and excoriate the tissues with which they remain
anytime in contact. — (i) No doubt can be
entertained by any one whose range of obser-
vation has embraced the more asthenic varieties of
the disease of the emanations which proceed
either from the bodies of the affected, or from the
faical discharges in circumstances of concen-
tration, and of predisposition on the part of those
exposed to them, being capable of producing and
spreading the malady, either in the manner now
stated in respect of other animal emanations, or
tiirough the medium of the saliva and upper por-
tion of the digestive canal. The contagious pro-
perties of dysentery have been keenly disputed :
Willis, Piso, Stoli., Horn, Vander Haar,
Renton, Ballingall, &c., asserting that it does
not possess these properties ; and Houstius, Fo-

RESTUS, HlLLAriY, MoRTON, PrINGLE, BaRBOU,

Bruning, Balfoc'r, J. Hunter, Chisholm,
Osiander, Neumann, Boner, Harty, Har-
gens, G. Blane, Hufeland, Penada, Mi-
ciiAJEi.is, Halloran, Poole, Chevne, C. Hut-
chison, Rutherford, Jones, and others, contend-
ing that it generally is infectious, especially when
epidemic, or when occurring in camps, crowded
ships, and under circumstances contended for
above (§ 24.), and more fully illustrated in the
article Infection. I believe that the views exhi-
bited at these places are conformable with those
entertained by every well informed and experi-
enced observer and writer at the present day.

74. ii. Morbid Conditions. — A. It is imjjos-
sible to contemplate aright the changes constitut-
ing the various forms and stages of the disease, apart

BYSENTERY — Pathological Inferences rsepectiko.

715

from Us causes and their modes of operation. —
(a) Many of these affect more or less immedi-
ately the large bowels, without any previous
constitutional derangement (§70. A.); and ac-
cordingly the morbid action is chiefly local,
sthenic, or phlogistic in its character, as described
under the first species of the disease (§ 12, 13.),
and, in many instances, is simply inflammation
of the caecum and large intestines. — (b) In cases
produced by suppression or vitiation of the secre-
tions poured into tiie bowels (§71. B.), previous
disorder, of either a latent or manifest kind, is ne-
cessarily present; diarrhoea frequently ushering in
the disease ; and the local affection, as well as
the constitutional disturbance, evincing more or
less of sthenic or asthenic characters, according to
the state of the patient and the nature and concur-
rence of the causes. Some of these are also conse-
cutive, complicated, chronic, or even symptomatic,
hepatic dysentery belonj;ing to this class of cases.
— (f) In most such cases, and in many of the
simple as well as of the most severe forms, conges-
tion of the portal vessels, and obstruction of this
part of the circulation, are concerned in the pro-
duction and per[)e* lation of the dysenteric symp-
toms.— (d) Although dysentery is frequently oc-
casioned by offending matters in the prima via, as
believed by Sydenham, and many others, yet
these matters are not so generally retained, either
in the form of scybala, or in any other state, as
CuLLEN, and many more recent writers, seem to
have supposed. — (e) There appears not to be
sufficient evidence of the inflammatory forms being
rheumatic in their nature, as suggested by Vogler,
Stole, Richter, Fischer, Sims, Schmidtmann,
Hufeland, Hargens, ficc. ; although both com-
plaints are sometimes allied, especially in respect
of the exciting causes, as justly remarked by
Akensioe, &c., and are occasionally associated, or
consecutive the one of the other. — (f) In cases
that proceed from unwholesome food or water
{§ 72. C), and in those caused by animal exhal-
ations and infectious effluvia (§ 73. D.), although
there may be at the commencement excited vas-
cular action, the circulating and secreted fluids,
and ultimately the soft solids, become more or
less contaminated, and the disease assumes either
a simply asthenic, or malignant form, disorganis-
ation of the internal surface of the large bowels
often taking place earlier than in other cases,
with the exception of the hyper-acute inflam-
matory form met with in hot climates. In most
of these malignant cases, the vitiated or morbid
matters either conveyed into, or generated in, the
circulation, in the process of their discharge by
the emunctories give rise to an acrid or excoriating
state of the excretions (or the morbid action ex-
cited in the secreting organs and surface occasions
this change in the fluiils they elaborate, as occurs
in coryza, &c.), together with an increase of their
quantity ; but these changes frequently occasion
at the commencement merely diarrhoea ; the
dysenteric symptoms being consequent upon the
evacuation of the intestinal contents, and caused
by the excoriation of the mucous surface, by the
vitiated secretions, and by the irritation of the
muscular coat; the local disorder reacting upon
the constitutional disturbance.

75. B. In the early stage of most forms of the
disease, the irritating effects of the morbid se-
cretions and excretions are first exerted upon the

cajcum and rectum ; the latter being often so
spasmodically constricted as not to allow the dis-
charge of the more solid matters that may exist
in the bowels ; the retention of these and of the
fluid secretions increasing the diseased action in
the large, and ultimately in the small, intestines ;
ulceration, excoriation, sphacelation, &c. being
frequently the result. — (a) In those cases which
originate in a morbid state of the secretions, &c.
(§ 74. b. c), fajcal matters are generally fully
evacuated before the tenesmus, distinctive of this
affection of the rectum, comes on ; the only
morbid matters retained being those thrown out
upon the mucous surface of the intestines, and
poured into them from the collatitious viscera ;
but these are so vitiated and injurious, that their
correction or evacuation becomes indispensable.
• — (h) In the asthenic varieties, to which most of
such cases belong, the dysenteric symptoms are
consequences chiefly of the vitiated secretions
poured into the large bowels ; this vitiation result-
ing from constitutional disorder, and the state of
the circulating fluid: these morbid conditions
should, therefore, be made objects of primary
attention in the treatment of the disease. —
(c) The matters poured into, and retained in, the
large bowels, in asthenic cases especially, are to
be considered as formed of elements which would
be speedily noxious if retained in the circula-
tion : they are excretions, in the strictest sense of
the word, removed chiefly by the liver and di-
gestive mucous surface ; occasioning, from the
morbid elements of which they are composed,
and acrid properties they possess, severe irrita-
tion of the parts upon which they are retained,
or along which they pass, in the progress of their
discharge from the body. — (d) Granting that
the dysenteric phenomena are thus produced, and
that the morbid matters causing them are thus
formed, it is manifest, that the mere suppression of
these phenomena, or the retention of the morbid
excretions, must be followed by disorganising
effects upon the large bowels ; and that the sup-
pression of the secretions, being an arrest of the
depurating functions, must be productive of a still
more serious change in the circulating fluid, and
ultimately in all the soft solids. — (e) In many
cases of all the forms of the disease, the excreling-
function of the skin is more or less completely
put a stop to, and that of the kidneys materially
impeded ; the excretions of the intestinal canal,
and frequently those of the liver, being in
excess, as well as otherwise disordered, — con-
ditions, equally with the foregoing, requiring to
be made tiie basis of therapeutical indications.
— (/) Whilst, therefore, the cutaneous and
urinary excretions are interrupted, the sudden
arrest of those poured into the intestinal tube
would endanger the patient, by increasing the
morbid state of the circulation, and by super-
inducing either fever of a bad form, or inflamma-
tion and its consequences in the abdominal organs,
or dropsy. — (o-) In the varieties consequent upon
a morbid state of the secretions poured into the
bowels, the small intestines are frequently also
diseased, but in a less degree than the large, as
they present no obstacle to the speedy transit of
these secretions along them, excepting near the
caecum, where they are usually more altered than
in any other part.

76. C. The most frequent associatimi of dysen-

716

DYSENTERY — Pathological Inferences nESPECTiNO.

tery, and one often very imperfectly manifested
by symptoms, is that with disease if the liver.
— (a) The hepatic affection may be primary, in
which case it is either functional or structural ;
the functional disorder consisting — a. of torpid or
suppressed function and passive congestion ; or,
B. of increased secretion, and of the vascular de-
termination requisite to such increase ; — the struc-
tural disease being — a. acute, or consisting of active
congestion, or inflammation, or of abscess in the
substance of the organ ; or, B. chronic, with vari-
ous alterations, occasioning obstructed circulation
through the portal vessels, and an insufficient
as well as a morbid biliary secretion : in these
states, the bowel complaint may be viewed as
symptomatic of the hepatic disease. — (6) The af-
fection of the liver may be a co'itaneous effect,
with that of the bowels, of the same causes : in
this case, the former will be oi X\\e functimial and
acute kinds enumerated above ; abscess occasion-
ally supervening in the advanced stages of the
associated malady. This form of complication is
most common in warm countries, where, the
causes of both diseases being nearly the same,
these associated results may reasonably be ex-
pected.— (c) The hepatic change may be conse-
quent upon the dysenteric malady, especially in its
more chronic states. In cases of this description,
the substance of the liver is either inflamed, soft-
ened, and discoloured ; or it contains one or more
purulent collections, with or without any sur-
rounding cyst ; the matter being sometimes in-
filtrated into the softened, and apparently not in-
flamed structure of the organ. Here the hepatic
change is contingent upon the bowel disease, in
its advanced stages, and is favoured by constitu-
tional vice or injudicious treatment, or both ; and
occasionally by the nature of the predisposing and
exciting causes, as by habits of intemperance.
In these three states of this important com-
plication, the symptoms are often obscure. In
the frst and second, they are frequently very ma-
nifest ; but, in the third especially, they seldom
admit of more than suspicion, arising from the
obstinacy of the disease, the lurid and lightly
jaundiced appearance of the surface, the morbid
state of the biliary and other secretions, and the
irregular or hectic form of febrile disturbance ;
chills, rigors, or even horripilations, being seldom
felt. The severity, also, of the dysenteric symp-
toms sometimes masks, or draws off the attention
of both patient and physician from, the hepatic
disorder.

77. The frequency of the third, latent, or su-
perinduced form {§ 76. c.) of hepatic complication,
especially in the more chronic cases of dysentery,
has given it much practical importance ; and,
as a knowledge of the manner in which it arises
is necessary both to its prevention, and to its
removal, several attempts at explaining the oc-
currence have been made. These have been
remarkably vague and unsatisfactory. I shall
therefore state, with but little reference to them, the
only ways in which it can be brought about. —
1st. The irritation and increased vascular action
in the intestinal canal must necessarily be fol-
lowed by augmented circulation through the
portal vessels, by a more copious secretion of
bile, and, if at this time the liver be congested,
or its ducts loailed, and especially if the blood
abound with excremcntitious elements, by an

acrid and morbid, as well as augmented, secretion*
— 2d. The absorption of injurious ingesta, or of
morbid matters formed or retained in the prima
via ; or of puriform matter from the inflamed or ul-
cerated raucous surface, into the mesenteric veins
and portal circulation, must necessarily be pro-
ductive of the following effects: — a. A vitiated,
or an increased, or both a vitiated and in-
creased, secretion of bile; — 0. Irritation of the
structure of the liver, followed by inflammation or
softening, often rapidly passing into suppuration,
without much tumefaction or previous sthenic
or phlogistic action ; — y. The deposition or infil-
tration of puriform matter in the substance of the
organ, especially when a puriform fluid is carried
from the diseased bowels; — J. Inflammatory action,
and its consequences, in the vessels along which
the morbid matters pass, and on the blood they
contain. — 3d. It is extremely probable that in-
flammation extends from the ulcerated mucous or
submucous membranes to the radicles of the veins,
and from thence along their ramifications and
trunks, the product of the morbid action mixing
with and contaminating the blood which circu-
lates to the liver, as in the foregoing — the 2d —
case, and producing the same effects, the in-
flammatory action extending more or less to the
ramifications of the portal vessels. It seems most
probable that the above are the chief modes in
which disease of the liver is superinduced in the
course of dysentery ; and that one or all of them
more or less obtain, in different cases, or even in
the same case. Without, however, denying that
the procession of morbid action contended for by
some writers, and about to be noticed, sometimes
takes place, I may state, in support of the pre-
ceding, that M. Kibes (T{tvue M£d. 1825, t. iii.
p. 5. et seq.) found puriform matter in the veins,
and inflammation of their coat, in several cases
where purulent collections had formed in the
liver after ulceration of the inner surface of the
bowels. M. Gendrin (Hist. Anat. des Infiam-
mat. t. i. p. 707.) observed similar changes in the
veins in the vicinity of intestinal ulcers; and
M. Andral {Anat. Pathol, vol. ii. p. 421.) de-
tected false membranes lining the ramifications of
the vena portEe, in a person who died from disease
of the bowels and liver. The very frequent col-
lections of pus, and puriform infiltrations in the
mesenteric glands, in the protracted states of dy-
sentery, should also not be overlooked, as sup-
porting the above inferences, especially if we lake
into account the intimate connection of this part
of the absorbent system with the veins contributing
to form the portal system. — 4th. It has been sup-
posed by ]NI. BnoussAis and his followers, that
inflammatory action extends from the small intes-
tines, along the bile ducts, to the liver ; and some
cases, that have been observed by him, Mr. An-
NESLEY, M. Andral, and myself, where inflam-
matory action or its results were seen in the
common and cystic ducts, would seem to favour
this view, if they could not be otherwise accounted
for. It may be admitted, that the extension of
disease to the small intestines, is very frequent in
the hepatic complication ; but it is most probably
excited, as stated above (§ 75. c), by morbid bile,
which also may have produced the inflammatory
appearances occasionally observed in the ducts
by which it is excreted. — 5th. The irritation in
the bowels, or the operation of substances given

DYSENTERY — Treatment of its Acute States.

to cure the disease, may be sufficient to excite a
sympathetic irritation, and its occasional conse-
quence — suppuration — in an asthenic state of
the system, in an organ so intimately connected,
in its circulation and nervous influence, with the
bowels, as the liver is. This, certainly, may pos-
sibly occur, but we have no proof of it ; nor, in-
deed, does it admit of unexceptionable evidence.
It is, however, very likely that tiie constant, or in-
judicious, use of calomel and irritating purgatives,
when the substance of the liver is congested, and
the bowels in a state of irritation, may give rise to
abscess or other structural change in the liver;
whilst, on the other hand, a similar practice during
hepatic disease, may superinduce dysentery, with-
out removing the primary complaint.

78. D. Chronic as well as other forms of dysen-
tery may be associated with disease of the spleen,
pancreas, or mesenteric glands ; either, or even
all, of which may occur, and indeed, often does
occur, in the same case, especially where endemic
causes are in operation, — the hepatic complica-
tion being sometimes also superadded. — (a) As
respects the disease of the spleen and pancreas,
the procession of morbid phenomena is not often
manifest ; but these lesions are most frequently
seen where dysentery has arisen from these causes,
or has been consequent upon periodic or con-
tinued fevers; the splenetic enlargement having
often preceded the bowel affection. — (6) In re-
spect of the lesions of the mesenteric glands, there
can be no doubt of their being the results of intes-
tinal irritation or ulceration ; the most remarkable
change-:, especially purulent collections, having
been seen in those corresponding to the seat of
large ulcers.

79. E. Relapses, or repeated attacks after the
patient has once had the disease, are very com-
mon, especially if he remain exposed to the en-
demic or other exciting causes, as in hot climates
and during campaigns or sieges; or if he be ad-
dicted to intoxicating liquors. They are also fre-
quent when the complaint has been associated
with affections of the liver, or spleen, or conse-
quent upon obstinate intermittents, and when re-
covery had not taken place until after it had
assumed a chronic state. In such circumstances,
slight errors of diet, or exposure to cold, and noxi-
ous emanations, will often speedily reproduce it.
The numerous relapses observed in unhealthy lo-
calities, and amongst soldiers and sailors, are
chiefly attributable to a too early discharge from
medical care, and return to irregular habits and
injurious exposures; and to the abrupt resumption
of a stimulating diet.

80. X. Treatment. — Towards the close of the
last century, and at the commencement of this,
the treatment of dysentery, as set forth in various
papers and works, by authorities confided in at the
time, was absolutely below the standard furnished
by the ancients, and by writers in the sixteenth
and seventeenth centuries, not merely in respect of
the knowledge and appropriation of therapeutical
means, but even as regards the justness of patho-
logical views ; without which, indeed, no me-
dicinal agent can be even safely prescribed. If
any one think this assertion paradoxical, let him
refer to the sources pointed out to him in the
sequel; and, with a slight allowance for phrase-
ology, he will perceive that, as to this disease, as
well as to many others, knowledge has not been

717

always progressive; and that the unsound and
narrow doctrines in medicine that sprang up soon
after the middle of the last century, have con-
tributed not merely to its retardation', but to its
retrogression. The cant about experience, so
recently raised, and kept up by those the least en-
titled to the distinction it should rationally confer,
threatens an equal, although very diflferent, obsta-
cle to the progress of medical knowledge, by being
made without reference to the fact, that experience
in medicine consists not in opportunities, or the
number of objects seen, or even in the repetition
of the same experiments or observations; but in
the qualities of the mind of the observer ; in due
preparation for the task by literature, philosophy,
and science ; and in the application of them to the
objects successively investigated. Thus qualified,
opportunities will seldom be wanting, and the re-
sults will soon accumulate so as to enrich the mind
of the inquirer to an extent to which the empirically
— the ignorantly experienced, will ever remain a
stranger; and will be of such a description, as
can be attained only by a mind so constituted, and
so instructed.

81. i. Of AcpTE Dvsenterv. — The general in-
dications of cure, are — 1st, To remove the causes
predisposing, exciting, and concurring ; and when
it is requisite, or circumstances will permit, to place
the patient in a pure and open air. — 2d. To sub-
due inflammatory action by antiphlogistic measures
when its presence is rationally inferred, or when
the state of the attendant constitutional afTection
will admit of them, or to the extent to which it
may be benefited by them. — 3d. To promote the
excretions of the skin and kidneys, and to deter-
mine the circulation to the cutaneous surface. —
4th. To remove, by gentle and appropriate means,
the morbid matters that may remain or collect in
the prima via, and to dilute and correct them. —
5th. To protect the mucous surface of the bowels
from their irritating and excoriating action. — 6th.
To correct the morbid condition of the circulating
and secreted fluids, in the asthenic and malignant
varieties, or whenever this condition may be in-
ferred, conformably with the views explained in
the articles Blood, Debility, Disease, and Sym-
ptomatology.— 7th. To support vital power,
if it fail in the progress of the sthenic forms, and
early in the asthenic varieties, as being indispen-
sably requisite to the correction of a morbid state
of the fluids. —-And 8th. To palliate urgent
symptoms, or tb arrest such as are attended by
immediate danger, as soon as they appear. An
appropriate use of energetic means will generally
accomplish, simultaneously, two or more of these
intentions.

82. ^.Treatment of the Sthenic Forms. —
(a) Bleeding, general, or local, or both, according
to the severity of the disease and constitution of
the patient, and repeated accordingly, is generally
requisite. The application of a number of leeches
to the abdomen in the slighter cases, or after
venaesection in the more severe attacks, and of
fomentations, or warm poultices, frequently re-
newed, after the leeches have fallen off, will give
much relief. If tenesmus or dysuria be urgent,
and pain be felt along the sacrum, the leeches may
be placed there or on the perineum, or cupping
on these parts may be directed. Although vas-
cular depletion is most serviceable early in the
disease, yet it should not in these forms, be

718

DYSENTERY— TrtEATMKNT of its Acute States.

neglected in the advanced stages, when it has
been either omitted, or directed in too small a
quantity, unless the symptoms are such as contra-
indicate it. When fixed pain is fell in the region
of the caecum, or in the course of the colon,
leeches should be repeatedly applied until it is
removed.

83. (b) Purgatives and laxatives have been
long recommended, and employed with a most
injurious want of discrimination, on the supposi-
tion that the disease is caused, and kept up, by
the lodgment of fa;cal matters in the colon ; and
yet, notwithstanding the general fallacy of the
views which led to their employment, when ju-
diciously selected and combined, they are often of
much service. It must be obvious that such pur-
gatives as act principally on the colon and rectum
are not suited to an inflammatory disease of these
parts ; and that, when there can be no collection
of faecal or morbid matters to remove, the exhi-
bition of them will merely aggravate the symp-
toms. It is, therefore, most important to ascertain,
upon entering on the treatment of a case of the
disease, as far as may be done, whether or no sucii
matters may exist to the extent of requiring these
remedies. If the patient has been seized after a
constipated or even natural state of the bowels, if
hardness and fulness can be felt in any pa it of the
colon or caecum upon careful examination of the
naked abdomen by the hand ; if, together with these,
the tongue be much loaded, and the matters
evacuated offensive from the commencement ; if
the palientcomplain of a sense of stuffing or fulness
in the course of the large bowels, and if pellets of
fieces be evacuated ; suitable evacuants are indi-
cated. But, if the disease has been preceded by
diarrhoea, or by free faecal discharges, as it fre-
quently is, they should either be withheld for a
time, or very cautiously employed; the selection
also being made with much care. When the
patient is well informed, his sensations and account
of the early symptoms should be duly weighed and
attended to. ]\Iuch mischief may arise, and dis-
credit be reflected on the practitioner, by neglect-
ing this very obvious indication — by following
blindly the dictates of either unsound theory or
worthless authority, instead of being guided by
common sense. I have repeatedly known persons
who have been accounted ignorant, but who were not
necessarily without sound sense, complain bitterly,
and lose all confidence in their medical attendant,
and hopes of recovery, when directed to take ca-
thartics, after, as they have expressed it, their
insides had been nearly purged out of them. —
When, however, the patient has not had any fe-
culent discharges for a considerable time, during
the progress of the disease, although they may
have been cojjious and frequent before the acces-
sion of the dysenteric symptoms, a mild purgative
should he prescribed, as being much less irritating
than the retention, even for a short time, of morbid
excretions ; and its operation should be promoted
by iin emollient enema. Cooling or oleaginous
purgatives are preferable to others : and |)erfectly
sweet castor or olive oil ; or the following pre-
j)aratlon, recommended by Vogki,, and piaised by
SciiMiDTMANN ; Or Fomiuliu 144. and 790.; or
either of the subjoined electuaries ; may be
tried : —

No. 199. B Extr. Jalapac Resin, gr. xij. ; Sap. Veiift.
fjr. vj. ; Ktp |irol)c ciiin Olci Oliv.-c (vol Ol. Liiii. vcl Ol.
Ainygiinl.Uulc.) 3 ij. Ciiiiiat i ss. omiii noctc.

No. 200. R Pulv. Jalap. 3 ss. ; PotassjB Bi.tart 3 iij. j
Pulv. Ipecacuanha^ gr. j. ; tere bene simiil, tt acUle Pulv.
Had. Glycyrrh. 3 jss. ; Syrupi Zingiberis (vel Theriac.
Commun.) 3 ss. M. Fiat Elect., cujus sumatur dimi-
dium.

No. 201. R Potassae Bi.tart. in Pulv. trit. 5 jss. ; Po.
tassa; Nitratis3j. ; Confect. Senna; 3ij. ; Syrup. Aurantii
q. s. ut fiat Electuarium, cujus capiat coch. j. vel. ij. mi-
nima ; super bibita dose mist. seq.

No. 202. R Magnes. Calcin. 3 j. ; Camphorae subacts
gr. ij. ; tere et adde Vini IpecacuanhiE 3 jss. ; Aqua;
MenthtB Virid. 3 vijss. ; Syrupi Aurantii 3 ij. Fiat Mist.,
cujus capiat coch. iij. larga, cum dose Elect, supra prae-
scripti.

If castor oil be employed, it will be advisable to
exhibit it on the surface of son)e mucilaginous or
emollient vehicle, and to add to it a few drops of
laudanum. Whatever may be the purgative pre-
scribed, it should be assisted by emollient and
laxative injections, such as F. 144. ; or of tepid
water ; or fat mutton broth, well strained ; or lin-
seed, or sweet, or almond oil. Tenesmus is some-
times aggravated by large enemata. They should,
therefore, be of small bulk ; or the irritation should
be first allayed by an opiate, or an opiated and
litharge (see F. 682, 683,), or a belladonna,
suppository.

84. (c) Befrigerants may be exhibited, eitlier
alone, or with diaphoretics and diuretics, and in
emollient and mucilaginous vehicles (F. 866.) ;
especially after the above means have been em-
ployed, and when there are much fever and sense
of internal heat. The nitrate of potash may be
given with ipecacuanha and opium (F. 642.), or
with small doses of camphor (F. 36.460.), and
of ipecacuanha (F. 39.); or, in solution with
spirit, ajther. nit. (F. 436.). liquor ammonia; acet.,
and opiates. The hydrochlorate of ammonia may
likewise be exhibited, as in F. 352. and 431.

85. (d) Opiates, &;c. are productive of the
greatest benefit, after depletion ; and should be
prescribed in large doses. If facal matters have
been carried off, during the diarrhoea often usher-
ing in the disease, they ought to be exhibited
directly after depletion ; and, in all cases, after
the operation of a purgative. But much will
depend upon the medicines that may be given
with them. Of these, ipecacuanha is the most im-
portant. From two to four grains of opium with
as much ipecacuanha should be prescribed for a
dose ; and, if not retained, repeated in a short
time. These should be taken in the form of
pill, which may be washed down by a refrigerant
and emollient draught ; or the ipecacuanha may
be given in a similar vehicle, with liom thirty to
forty drops of the tiuc. opii conrp. (F. 729.), and
repeated according to circumstances. This medi-
cine will ameliorate the symptoms and determine
to the cutaneous surface, especially if its action
be promoted by the slightly warm bath, or semi-
cupium or hip-bath ; and by frictions of the sur-
face subsequently. After a decided effect has
been jiroiluced by these, Uoveh's powder may be
prescribed at siiort intervals, so as to keep up the
action on the skin ; and the abdomen should be
swathed in flannel. Opiates may be employed
also in the inucilaginous enemata already recom-
mended (F. 143. 147. 152.), and in the form of
sujqjository.

8(). (<;) External derivatives and rnhej'acients
are sometimes of service after depletion and the
above means have been duly employed. A large
blister may be placed upon the abdomen ; but it
should be removed as soon as it has produced
redness, and be followed by warm bread and

DYSENTERY — TnEATMEXx of its Acute States.

719

water poultices. The turpentine epitliem will be
found still more generally of use, and will not so
much increase the irritation experienced in the
urinary passages as the blister frequently does.
Iq cases where this symptom is severe, mucilages
with soda, nitre, small doses of camphor, and
opium, will give relief. When it is urgent, tenes-
mus is also a prominent feature ; the means al-
ready advised, especially local depletions, either
from the sacrum, or from the perineum, small
emollient and cooling injections, and opiate sup-
positories, being the principal remedies. If the
sthenic forms of the disease yield not to the treat-
ment now advised, or if it pass into the chronic
state, recourse must be had to such of the methods
of cure, and medicines, hereafter to be noticed,
as may seem most appropriate to the circumstances
of the case. When much debility is complained
of, after tormina and tenesmus have been re-
moved by an antiphlogistic treatment, mild bitters,
as the infusion of calumba, or infusion of cinchona,
with liquor ammoniaj acetatis, tinctura caniphora;
compos., and small doses of the vinum ipecacu-
anhae, will be productive of much benefit. Cos-
tiveness should be carefully guarded against, by
the occasional exhibition of a gentle purgative, as
directed above (§ 83.), and of aperient and emol-
lient enemata.

87. Among Europeans in hot climates, the dis-
ease requires a prompt and decided use of anti-
phlogistic remedies, inasmuch as the inflammatory
action is, in these cases, more intense, and arrives
more rapidly at an unfavourable termination.
The treatment, however, in principle, is the same
as that advised above. The good eft'ects of large
doses of ipecacuinha and laudanum — from half
a drachm to a drachm of each — after bleeding,
have been shown by Mr. Playfair; and of
smaller doses — from three to seven or eight, with
an equal quantity of some bitter extract — also
after requisite depletions, have been found equally
beneficial by Balmain and Twining ; whilst the
impropriety of an indiscriminate use of mercury,
especially calomel, in this disease even as it oc-
curs in India, has been acknowledged by these
writers, Mr, Annesley, and others. Although
dysentery, in persons thus circumstanced, as-
sumes the inflammatory form, or that of colonitis
(as it has been improperly called by some writers,
as the rectum, caecum, and often the small intes-
tines, are also affected), especially soon after their
migration to a hot climate ; yet the attendant con-
stitutional affection is not always of a sthenic
kind, but frequently assumes either the simple
asthenic (§ 25.), or the bilio-adynamic (§ 28.),
or malignant forms ; especially in those who
have resided long in the country, and where the
endemic causes abound. In many cases, also,
the symptoms are acutely inflammatory at the
commencement, and rapidly pass into a very
asthenic state, even before either of the unfavour-
able changes pointed out above have begun.
In such, the antiphlogistic treatment should be
early employed, and exhaustion met, as soon as
its signs appear, by the remedies about to be
recommended for the asthenic varieties. In some
instances, also, particularly in persons circum-
stanced as now stated, tiie dysenteric affection is
entirely symptomatic, either of abscess in the
liver, or of interrupted circulation through the
ramifications of the vena portae, — pathological

conditions which should be carefully investi-
gated, as they require very different plans of cure.
(See Liver — Chronic Injiammation and Snpptir.

88. B. Of the Asthenic Forms. — (a) In the
simple asthenic form, ipecacuanha with opiutn, the
warm bath, and gentle purgatives with aperient
and emollient enemata, conformably with the
views now stated (§ 83.), will frequently remove
all disorder. In most instances it will be requi-
site, and particularly if the biliary secretion be
obstructed or vitiated, to give a full dose of calo-
mel (from ten to fifteen grains) with two or three
grains of opium, and one of ipecacuanha, a few
hours before the purgative is exhibited ; and, when
dull and constant pain is felt in any part of the
abdomen, or tenderness on pressure, a number of
leeches should be applied, and be followed by the
warm turpentine epithem. Venaesection has been
found injurious in this form of dysentery, especi-
ally when epidemic during very moist seasons.
An ipecacuanha emetic will often be of service at
the commencement; but if retching become ur-
gent, opium in the form of pill, sinapisms on the
epigastrium, croton oil rubbed on the abdomen j
the warm bath, or hip bath, or semicupium ; and
nitre, with emollients ; will both relieve this symp-
tom, and allay the tormina and tenesmus. Muci-
Ifiginous mixtures, with paregoric elixir and vinum
ipecacuanhae, are generally serviceable. Emol-
lient clysters and suppositories, with opium, are
also requisite. I have seen the preparations of
hop productive of great relief in this form. They
may be prescribed with camphor mixture and
liquor ammoniae acetatis, or with emollients
(F. 839, 840. 871.) and diuretics. In the more
severe cases, or when the disease does not yield
to the above remedies, full doses of camphor, with
opium, or with Dover's powder, or with the
addition of nitre ( F. 36. 39. ), may be given every
five or six hours, and pieces of flannel made warm
and moistened with either of the liniments, (F. 297.
307. 31 1 .), be kept upon the abdomen until relief
is obtained. Although faecal matters and disor-
dered secretions may have been evacuated before
the dysentery symptoms had appeared, yet it will
be necessary to have recourse to mild purgatives,
from time to time during the progress of the dis-
ease, in order to excite the functions of the excret-
ing organs, and to evacuate such morbid secre-
tions as may have collected. The purgatives and
aperient enemata recommended above ($ 83.)
may be exhibited, or the compound infusion of
senna, with an equal quantity of infusion of
calumba or gentian, and a little soluble tartar and
compound tircture of cardamoms. If the disease
be likely to become obstinate, equal quantities of
turpentine and castrr oil, taken on the surface of
milk, or of an aromatic water, and repeated every
second or third day, v.'ill be most eflScacious.
After the tormina and tenesmus are removed,
tnild hitters and tonics ; and, in some cases, as-
iri/igent tonics and absoi-bents, with the treatment
advised in the article Diarriicea (§ 29— 33.),
will generally remove all remaining disorder, if
the state of the secretions and of the bowels be
duly attended to. If the complaint degenerate
into a chronic form ; or debility become a pro-
minent feature ; and if the excretions indicate,
with the state of the surface and tongue, a pro-
gressive deterioration of the fluids and soft solids ;

720

DYSENTERY — Tbeatment of its Acute States,

the means about to be directed lor these conditions
must be employed.

89. (6) In the nervous or typhoid, and malig-
nant forms {§ 26.), the sixth and seventh indica-
tions of cure should [be particularly entertained,
and with due reference to the third, fourth, and
ffth. From one, to three, four, or even more
grains of camphor may be given every three or four
hours, with three of hydrargyrum cum creta, two
of ipecacuanha, and one of opium, in the form of
pill ; and if it be thrown off the stomach, it
should be persisted in nevertheless. The patient
should also be put into a warm bath ; the tem-
perature of which ought to be gradually raised
while he is immersed in it ; and, having been
well rubbed upon coming out of it, be placed
between warm blankets, in order to promote the
action of this medicine on the skin. This inten-
tion will be furthered, if the stomach be not very
irritable, by draughts containing liquor ammonia;
acetatis, potassa; nitras, or any other appropriate
neutral salt. — The action on the skin should be
kept up for a considerable time by the medicine,
and promoted by emollient diluents, such as the
decoction of liquorice or of linseed, &c. If these
means fail of giving relief, flannel wrung out of
hot water, and moistened with spirits of turpen-
tine, should be applied to the whole abdomen,
and allowed to remain as long as the patient will
endure it. The usual effects of this epithem are,
a most copious perspiration, with burning heat
of the skin where it is applied ; and, consequently
on these, a total remission of the tormina and
tenesmus, followed by sound repose procured by
the pills which have been taken. In advanced
stages of the complaint, when the internal con-
gestion or determination is very great, and the
skin is harsh, dry, and livid, repeated applications
of this epithem, as warm as the patient can endure
it, are sometimes requisite to its full effect. In a
case which I lately treated under very unfavour-
able circumstances, it having been consequent
upon continued fever, in a lady long subject
to disorders of the colon and rectum, a quart
of the spirit was thus employed before redness
of skin was produced ; although it was warmed
by immersion in warm water before the flannel
was moistened with it. This patient ultimately
recovered. To these means may be added,
the emollient and anodyne enemata already re-
commended ; and suppositories of opium, if tenes-
mus and dysuria be urgent, and the rectum very
irritable.

90. In these dangerous forms, notwithstanding
full evacuations of fajcal matters, may have
ushered in the disease, it will be requisite to carry
off, from time to time, by suitable purgatives,
such morbid matters as may have accumulated.
To many cases, the purgatives and enemata pre-
scribed above will be appropriate ; but where the
stools are very offensive, or contain much dark
blood ; when the powers of lil'e are depressed ;
or when stupor is present ; and more especially if
petechias or discolouration of the skin be observed ;
the draught with castor oil and turpentine di-
rected above (§ 88. or F. 216.), should be exhi-
bited, and its effect promoted by either of the
enemata, (F. 135. 150. and 151.) In tliis state of
disease, it is important to evacuate morbid mat-
ters by such means as will at the same time
restore the tone of the digestive mucous surface,

and of the vessels opening on it ; and I believe
that there is none that exerts this influence more
efficaciously than those now named. Next to
these, rhubarb, in powder, with camphor, and
calomel, or hydrarg. cum creta ; or cinchona,
with senna (F. 86.) ; or the infusion of gentian
and senna (F. 266.) ; or infusions of cinchona
and rhubarb ; or the preparations of cusparia and
rhubarb ; will be found the most efficacious.

91. If the powers of life be much depressed,
the circulating and secreted fluids will generally
become more and more vitiated. Our chief efforts
should then be directed to counteract this ten-
dency. With this view, the decoction or infusion
of cinchona and serpentaria, with camphor, and
small doses of nitrate of potash, or of hydrochlo-
rate of ammonia, or with the chlorate of potassa, or
of soda, may be prescribed ; and either of these,
or the chlorate of lime, may likewise be adminis-
tered with camphor in mucilaginous enemata, es-
pecially when the stools are very offensive ; taking
care to prevent the accumulation of morbid se-
cretions by occasionally resorting to the aperient
draught and enema directed above (§ 90.). The
infusions of cascarilla, of calumba, or cusparia
(F. 201.), or the decoction of iormentilla (F.78.),
may likewise be taken, with these or similar
additions. When the evacuations are copious,
as well as morbid, their excess occasioning vital
depression, it will be necessary to control them
by adding opium, and the usual astringents, to
the tonics now mentioned ; and to excite the
functions of the skin by the warm bath, frictions
of the surface, and the application of the turpen-
tine epithem to the abdomen. The terebinthinated
medicines, also, already mentioned, are the most
active aperients, and astringents at the same
time, in this complaint, as well as the most
certain and beneficial in their effects. Upon the
whole, these severe states of the disease re-
quire similar remedies to those enumerated in
the articles Blood (§ 157. et seq.), and Debi-
lity ($ 38)., and in the sections on the treat-
ment of the adynamic and malignant forms of
Flver.

92. (c) The hilio-ad\fnamic form presents con-
siderable diversity of character in different seasons
and epidemics, and requires a modified treatment
accordingly. When there is no tenderness or
fulness at the epigastrium, an ipecacuanha emetic
will generally be serviceable ; but its operation
should be followed by a full dose of calomel ; and
that, in a few hours, if faecal matters have not
been already evacuated, by either of the mild
purgatives prescribed above (§ 83.), and by
emollient injections. When the patient complains
of a burning sensation in the colon, or of scalding
in the rectum, with great irritability, nitrate of
potmh, or hydrochlm-ale of ammoniii, should be
given in emollient or mucilaginous vehicles; and
an opium and litharge suppository (F. 683.) ad-
ministered ; a similar combination of refrigerant
and mucilaginous medicines being afterwards ex-
hibited in enemata. In some cases, liiis form ap-
proiiches nearly to that of sthenic vascular action,
and then leeches are required to the abdomen ; and
will be most advantageously followed by the tur-
pentine epithem. After these remedies, small doses
of camphor, hydrargyrum cum creta, and Dover's
powder, or simple ipecacuanha, may be taken
every two or three hours, and the warm bath, in

DYSENTERY — Tni-.A-rMENX of its Complicat£d States.

721

the manner above directed (§ 89.), occasionally
resorted to. If this' variety be characterised by
great vital depression, the treatment already
directed (§91.) must be employed. In all its
states, and stages, it will be requisite to evacuate
the morbid bile that is secreted, and to correct
the diseased action in the liver ; but beyond
one or two full doses of calomel, either with or
without opium, this medicine should not be
persisted in ; as it increases the irritation of ^lie
colon and rectum, and depresses vital energy.
The hydrargyiTira cum creta, as now directed,
will be more efficacious ; especially when assisted
by the above means, and by emollient and muci-
laginous diluents.

93. In the Dark Races, dysentery assumes the
simply asthenic or malignant forms. In them,
the treatment may safely be commenced by an
ipecacuanha emetic, and followed by a purgative,
the warm bath, and warm diaphnretics. Early in
the disease, calomel with rhubarb and ginger ; or
powdered jalap with cream of tartar and some
warm spice, will be appropriate ; but enemata
are also required. The habits and modes of living
generally adopted by these races, independently
of their more lax fibre, and much less tendency to
inflammatory action, require an earlier and more
active use of tonics, stimulants, astringents, and
aromatic spices, with opium, than can often be
safely attempted among Europeans. Purgatives,
also, should be of a more stomachic and warm
kind, and the functions of the skin especially pro-
moted. The combination of ipecacuanha with
tonics, astringents, opiates, and absorbents, ac-
cording to the peculiarities of the case, is
generally extremely efficacious after fajcal matters
have been evacuated. Camphor, catechu, the
hot spices, and warm clothing, with the rest of
the tonic and astringent treatment advised for the
chronic state, and in Diariuicea (§ 37.), stiould
be resorted to, as soon as exhaustion supervenes,
or when the disease becomes protracted. To
Europeans long resident in hot climates, a nearly
similar method to that now recommended is
applicable, if the hepatic functions be regular ;
but, as in them the liver is very seldom unaffected,
the means directed for the chronic form, which it
usually assumes, is more generally appropriate ;
and the treatment should chiefly depend upon
the nature of the primary or attendant hepatic
disease.

94, C. Treatment OF THE Complicated States.
— (a) The association of acute dysentery with in-
Hammatimi of the liver {§ 34.) requires decided
and early general or local depletion, or both,
followed by cooling purgatives, sufficient merely
for the evacuation of morbid secretions. In this
complication, the morbid state of the bile, and
the rest of the hepatic symptoms, are the conse-
quence of inflammation, andean be removed only
by antiphlogistic treatment, and not by inordinate
doses of mercury, which will merely over-excite
an already excited organ, and accelerate sup-
puration. Refrigerant, therefore, and cooling
aperients, as the bitart. and tartrate of potash,
tamarinds, manna, or the potassio-tartrate of soda ;
antimonial or ipecacuanha diaphoretics ; small
doses of camphor, with nitre and opium ; cooling
and emollient enemata, and a very low diet ; con-
stitute the principal means of cure. When the pa-
tient complains much of burning heat or soreness

Vol. I.

in tiie abdomen, with scalding, &c. in the anus and
urethra, the nitrate of potash, with carbonate of
soda, and spirit, aither. nit., in emollient vehicles ;
the hydrochlorate of ammonia in mucilaginous
mixtures; suppositories of opium; and local de-
pletions, followed by the warm terebinthinate
fomentation over the abdomen ; are chiefly to be
depended upon. If blisters be applied, they should
be surrounded by a number of leeches, the former
being removed as soon as they have produced red-
ness, and succeeded by warm poultices. As tlie
substance of the liver is generally more or less
acutely inflamed in this complication, and as mer-
curials will not readily produce their specific
effects, or act beneficially, whilst this state con-
tinues, but will rather increase it, the exhibition
of them with this intention can only occa--ion
abscess, irritative fever, and exhaustion ; and fur-
nish one of the most injurious proofs of the
" nimia diligentia," which is but too common in
the treatment of this as well as of hepatic disease.
Can any practice be more empirical than to give
the same substance to subdue over-excitement,
which we find the most active in rousing torpid
function, of an organ ? Having removed the acute
symptoms by the above means, the insertion of
one or two setons in either side, and keeping up a
free discharge from tiiem for a long time, with
appropriate diet and regimen, and change to a
healthy air, will generally complete the recovery.
When the dysenteric affection is merely symptom-
atic of abscess in the liver, the treatment advised
for this condition (see Liver — Suppuration of)
should be employed,

95, (6) The complication with disease of the
spleen is most common after intermittent and re-
mittent fevers, and in unhealthy localities; and
the symptoms are either but little inflammatory or
more or less asthenic. Local depletions even are
seldom required in its treatment. Warm sto-
machic aperients, as cinchona with rhubarb,
ipecacuanha, and aromatics; emollient enemata
with anodynes ; the warm bath, followed by fric-
tions of the abdomen with either of the liniments,
F. 297. 311., upon coming out of it ; ipecacuanha
with strychnia or sulphate of quinine, or sulphate
of iron, or with tonic extracts ; camphor with warm
diaphoretics, and the medicines directed for the
more chronic states, which it more frequently
assumes, or passes into ; are the most appropriate
in this state of the complaint. When dysentery
follows continued or periodic fever, disease of the
liver or spleen, or of both, should be dreaded, as
well as its rapid termination in ulceration ; and
means, conformably with what has now been ad-
vanced, should accordingly be promptly put in
practice. The most efficacious of these, are early
local depletions — but only when the symptoms
clearly indicate the propriety of resorting to tliem ;
the terebinthinate epithem applied to the abdomen,
or large blisters, followed by poultices, and re-
peated according to the urgency of the case ; with
the rest of the treatment directed for the asthenic
staler, according to the peculiarities of the case.

96. (c) The association of acute dysentery uilh
scurvy, requires the removal of the exciting
causes ; a suitable. diet, especially fresh meat and
vegetables ; the liberal use of lime juice, with
sugar, mucilage, and opium ; tlie bi-carbonate of
potash or soda in effervescence, with an excess of
lime juice, particularly when the secretions re-

3 A

722

DYSENTERY — Theatment

quire evacuation by gentle means ; the decoction
of cinchona with hydrochloric acid, or citric acid, or
hydrochloric aether ; and the draught and enema
consisting of turpentine and castor oil, when the
haemorrhage is considerable, and the abdomen
tumid or tympanitic, or when the stale of the dis-
charges indicates the propriety of exhibiting a pur-
gative. If lime juice is not to be procured, lemon
juice or citric acid should be substituted. When
the debility and oozing of blood from the bowels
are great, the tincture of the sesquichloride of iron
may be given in the infusion of quassia, or the in-
fusion of catechu may be exhibited with other astrin-
gents, and with aromatics,and warm spices, and the
tinctura opiicomp. (F. 729.). Sesquicarbonate of
ammonia may also be taken in effervescence with
an excess of citric acid, or lime juice; ipecacu-
anha, aromalics, and the above preparation of
opium, being added. In the more urgent or ob-
stinate cases, the warm nitro-hydrochlcnic solution
should be daily applied over the abdomen, or
added to mucilaginous and emollient enemata. It
may likewise be used as a gargle, when the state
of the mouth requires sucli means. The nitro-
hydrochlonc acids may also be taken internally
with small doses of the compound tincture of
opium, when citric acid or lime juice cannot be
obtained. The chlorates may be prescribed with
camphor, and opium, in mucilaginous vehicles ;
and administered, in a similar form, as enemata.
During treatment, the diet should be regulated,
and the excretions carefully observed. When
the bile is scanty, and the stools without fagces,
a few grains of blue pill may be given at night,
and a full dose of magnesia in aromatic water the
next morning, followed immediately by a glass of
lemonade, or a draught with lime juice or citric
acid, — the combination thereby formed in the
stomach proving an agreeable purgative ; or the
liydrargyruin cum creta, with rhubarb, may be
taken at bedtime, and the oily draught and
enema already mentioned the following day.
Aromatic confection, with magnesia ; or creta-
ceous and other absoibents, with ipecacuanha
or Dover's powder ; are also serviceable, when
the bowels are much relaxed and griped, and the
stools become frothy and acid. Cretaceous me-
dicines should not be given while the citric acid
or lime juice is continued; but subsequently, in
the form now directed, or with astringents, tonics,
and warm spices, when the disease seems dis-
posed to assume a chronic form, they are often
beneficial, assisted by warm clothing, suitable
diet, and the occasional exhibition of mild pur-
gatives, so as to prevent the injurious retention of
morbid matters, and promote the digestive and
secreting actions. In the early stage of con-
valescence, a similar treatment, witii vegetalde
tonics ; and the exhibition of these with aperients,
when the bowels become sluggish ; should be per-
sisted in. The daily use, for some time, of either
of the balsams, according to the peculiarities of
the case, condjined with a sufficient quantity of
magnesia to form a pilular mass, will more ef-
fectually restore the tone of the digestive mucous
.surface, and keej) the bowels open, tiian any
other means. Jxeiiiovai to a dry, pure, and warm
air will accelerate and establish recovery.

97. (d) Dysentery is less freciuently cotnj)li-
ralcd wilh voniis, in this country, than, perhaps,
in any other. Worms arc cither so extremely

OF ITS Complicated States.

common in the inhabitants of low and moist
localities, and still more so in the dark races,
especially among those who have not a sufficient
supply of salt as a condiment ; or they predispose i
so remarkably to the disease— or rather, the state I
of the digestive organs that favours their gene-
ration, disposes to it; that a very large proportion
of dysenteric cases in the former, and nearly all
in the latter, are thus complicated. The judi-
cious use of anthelmintics — the decoction of the
bark of the pomegranate root ; the male fern,
&c., followed by castor oil ; and especially the
terebinthinated draught and enema already re-
commended (§ 90.), — will generally remove the
disorder. When the disease has arisen from the
want of salt, this substance in sufficient quantity,
with warm spices, vegetable tonics, and subse-
quently chalybeate preparations, will soon have a
decided ed'ect ; but, without salt, other means can-
not be depended upon. This complication is not
infrequent in children ; the above remedies, or such
as are most appropriate of those mentioned in the
article Worms, being also suitable to them ; but
when the disease is removed, a course of chaly-
beates and change of air should be prescribed,

98. (e) The hicmorrJioidal complication is most
speedily relieved by local bleeding from the sa-
crum or perinaeum, followed by fomentations;
the hip-bath ; full doses of Dover's powder, es-
pecially at bedtime ; opiated, or opium and
litharge, suppositories ; and by the bitartrate
of potash, with nitre and confection of senna,
when an aperient is required. Cooling diapho-
retics, and various refrigerants in mucilaginous or
emollient vehicles, taken by the mouth, and in-
jected per anum, in small quantity, are often use-
ful adjuvants. When the disorder is attended by
much pain about the anus, a cooling and anodyne
ointment, after having recourse to warm foment-
ations, will often give relief. The extract of bel-
ladonna, in an ointment of this description, will be
most effective, as it subdues the morbid sensibility,
and removes the spasm of the sphincter, which
aggravates the pain in these cases.

99. (_/) The complication with rheumatism.
(§ 44.), or catarrh, requires the frequent use of
the warm bath or semicupium ; and full doses of
camphor, and ipecacuanha, or Dover's powders,
in oleaginous or mucilaginous vehicles; or anti-
monial diaphoretics with opium, if there be much
febrile excitement and heat of skin. If the symp-
toms are inflammatory, general or local deple-
tions, or both, should precede the exhibition of
these ; and, if the biliary secretion be either ob-
structed, or vitiated, a full dose of calomel, or of
the milder mercurials, should be given, and be
followed by a gentle purgative, and that by an
aperient and emollient enema. When the disordered
secretions are evacuated, warm diaphoretics,
especially camphor wilh opium ; small anodyne
injections ; o])ium suppositories, and the constant
use of flannel next the skin ; will remove the dis-
order. When severe rheumatic pains are felt in
tiie lower extremities, opiate suppositories, after
morbid matters are evacuated, will give great re-
lief. In some instances, liic pains in this situ-
ation depend upon the retention of fascal or hard-
ened substances in the caecum, or about the sig-
moid (lexure of the colon. In this case, fulness
or hardness will be felt in these regions, ona care-
ful examination of the abdomen ; and appropriate

DYSENTERY — TntATMEKT of its CnnoKic States.

723

purgatives, aiJed by laxative clysters, will be re-
quired, and should be repeated until the collection
is evacuated.

100. ii. Treatment of the Sud-acute and
CiinoNic Forms. — A, Of tlie more simple states,
— The intentions of cure by which we are guided
in the acute, should, with little modification, be
entertained in the chronic, forms. When the
symptoms continuing after an acute attack consist
chiefly of either frequent or copious evacuations,
without tormina or straining, the appetite, pulse,
and strength improving, or remaining unimpaired,
astringents or opiates should not be prescribed;
for the discharges are the means of bringing about
a resolution of the inflamed and tumefied viscera.
In such cases, the stools are usually of a good
colour, and are feculent and fluid. But, if the
motions be attended by abdominal soreness, in-
creased on pressure ; or by a sense of heat ; or by
griping, tormina, or tenesmus ; if they be slimy,
or sanguineous ; and if the patient complain of
thirst, with fever and restlessness at night ; nature
requires the judicious assistance of «rt. Here
vascular depletion, most frequently local, although
it may have already been practised, and more espe-
cially if it have not been resorted to, is required
to an extent which the constitutional symptoms
will indicate. If, however, the strength is too
far sunk, or the asthenic characters are too pro-
minent to admit of this measure, the warm epi-
them already described (§ 89.), or blisters to
the abdomen, followed by a succession of poul-
tices, and these by the warm bath, a thick flannel
bandage around the abdomen, and stimulating
frictions of the surface, and of the lower limbs,
will sometimes be serviceable.

101. In all cases, the state of the biliary secre-
tion and of the liver should be carefully ex-
amined. If the investigation furnish no proof of
acute disease, or of abscess of this viscus, and if
the bile be scanty or altogether obstructed, cam-
phorated mercurial frictions on the hypochon-
drium, blue pill or hydrargyrum cum creta, with
ipecacuanha or Dover's powder at bedtime, and
a mild purgative, such as cream of tartar, with
confection of senna and extract of taraxacum in
the form of electuary, in the morning, will often
increase and improve the bile. If mercurials
have not been previously used, and if no tender-
ness or soreness be felt in the region of the liver,
nor oppression of breathing, dry cough, nor recur-
ring chills or horripilations alternating with hectic
flushings, &c., one or two full doses of calomel,
with or without opium, may precede these medi-
cines ; the operation of which may be assisted,
and the state of the large bowels improved, by
emollient and oleaginous injections. After these
means have been tried without benefit, the em-
plastrum ammoniac! cum hydrargyro may be
placed over the abdomen ; and one or two grains
of hydrarg. cum creta, or of blue pill, with one of
ipecacuanha, and as much camphor, taken thrice
daily, with a draught containing a drachm of the
extract of taraxacum, or consisting of the decoc-
tion of the recent root. As long as the stools are
deficient in bile, astringent tonics will seldom
prove permanently serviceable ; but if the above
medicines run ofl'too rapidly in the stools, the com-
pound tincture of opium should be added to them.

102. Wiien the foregoing means have failed,
nitric acid with opium or laudanum ; and the ap-

plication of the nitre-hydrochloric acid lotion over
the hypochondria and abdomen, maybe tried ; or,
instead of the nitric, thenitro-hydrochloric acid may
be taken internally, in a very weak state of solu-
tion, or employed as an enema, with the laudanum,
F. 729. Enemata consisting of a weak infusion of
ipecacuanha, or of the decoctum lini, with muci-
lage, or of both, may be administered once or twice
a day, while the acids are taken. If these fail,
and if the debility be great, the chlorates, especially
those of potassa or lime, may be given by the
mouth, or in clysters.

103. In the advanced stages, the infusion of
cinchona, of cinchona and rhubarb, either with or
without laudanum, or of catechu with aromatics
and warm spices, are generally requisite, more
especially in the dark races ; the same preparations
being also advantageously administered as enemata,
eitlier with or without mucilaginous substances.
When the disease, like agleety discharge, proceeds
from relaxation of the internal surface of the large
bowels, and a habit of increased secretion, these
means will prove of essential service. In many
cases, the disorder is kept up either by too great
indulgence in food, or by the use of stimulating
liquors. The diet should, therefore, be restricted ;
and the digestion of what is taken promoted
either by the above medicines, or by the sul-
phate of quinine or the sulphate of zinc in the
form of pill, with inspissated ox-gall, or other
medicines suited to the case. If we succeed in
controlling the increased action of the bowels, an
opposite state should be carefully guarded against,
by the occasional exhibition of the means directed
above (§ 83.); or of the draught and enema
already mentioned (§ 90.). Inattention to this
precaution, and errors in diet and regimen, are
frequently productive of relapses.

104. If diarrhoea continue after the acute
symptoms longer than seems sufficient for the
resolution of inflammatory action in the large
bowels, and of congestion of the portal vessels, we
may suspect that the quantity or kind of aliment
is such as the digestive organs, and the biliary
and other secretions, are incapable of changing
into healthy chyle, — a large proportion of it en-
tering into such acid or acrid combinations as its
constituents dispose it to form. In these cases, the
stools are frothy, have a sour odour, or are lien-
teric ; and tonics, with mild mercurials and anta-
cids ; the sulphate of quinine, as above recom-
mended ; the balsams with magnesia, and the
liquor potassaj, or the sesqui-carbonate of am-
monia, with tonic infusions, aromatics, and small
doses of Sydenham's laudanum (F. 729.) ; are
required ; whilst the abdomen and hypochondria
are sponged with the nitro-hydrochloric solution ;
and the large bowels fortified by the tonic and
mucilaginous injections already mentioned.

105. In the cases denominated " JVhite flux,"
from the muco-purulent and gleety appearance of
the discharge from the muciparous glands, and
the absence of bile, a similar treatment to the
abpve is required ; with an occasional dose of
calomel, or frequent and small doses of the
mildest mercurials, as above directed (§ 101.).
The infusion of either cusparia, catechu, sima-
rouba, calumba, rhubarb, cinnamon, &c., with
vinum ipecacuanhre, aromatics, absorbents, and
astringent-:, according to circumstances ; the chlo-
rates, or nitre with soda and emollients, in aro-

3 A 2

724

DYSENTERY — Tiii:atm£kt op its CiinoKic StAts.

matic Vehicles, and in clysters; assafoetida, with
camphor and mucilage, in enemata ; and the daily
use of the salt-water warm bath, followed by
frictions of the surface with a rubefacient and de-
obstruent liniment (F. 311.), and a flannel roller
around the abdomen ; may also be resorted to.

106. If the evacuations indicate ulceration
(§ 54.) — which, indeed, is seldom altogether
wanting in protracted cases— the above treatment,
or mucilaginous mixtures with either of the bal-
sams; emollient clysters, and the repeated appli-
cations of large blisters, or rubefacients, to the
abdomen, or the insertion of setons, are chiefly to
be relied on, with the other means advised in the
treatment of Diaurijcea (§ 32.), arising from this
pathological state.

107. A form of chronic dysentery depends upon,
or is kept up by, ulceration, or even by a single
large ulcer, in the rectum, with or without pro-
lapsus ani (§ 47.), the abdominal symptoms being
slight, but the tenesmus constant and painful.
For it, small injections of a solution of the sul-
phate of zinc, or nitrate of silver, or dilute nitric
acid with opium, or acetate of lead, with pyrolig-
neous acid and laudanum; or of paregoric elixir
with mucilage ; or of simple camphor mixture ;
the balsams, or sulphur with cream of tartar,
and tonics with deobstruents, being taken inter-
nally, and a gently open state of the bowels
preserved ; will remove the disorder. In nearly
all the more simple states of chronic dysentery,
also, the same treatment may be appropriately
employed as is recommended in the chronic states
of diarrhoea, lientery, &c. (See Diaurikea, §29
— 33. and § 41. ef seq.)

108. B, The complications of chronic dysentery
are much more common than the simple slates;
and the most frequent are those with chronic
affections of the liver, with disease of the mesen-
teric glands, and with enlargement of the pancreas
and spleen. — (a) If the liver be free from acute
disease of its substance, or from purulent form-
ations (see Liver — Inflam. and Stippurat. of),
mercurials are often essentially requisite. But,
even in such cases, they have been much too
liberally employed, on the supposition that sali-
vation is indispensable to tiie cure of tlii^ com-
plication. Where, however, these forms of hepatic
disease exist, they should almost altogether be
proscribed ; and also, where the powers of the
.system are much reduced, even in the simple
states of the disease, the extention of inflammatory
irritation to the mesenteric and portal veins, or
the absorption of morbid matters from the bowels
(§ 77.), and consequent disease — especially
])urulent collections — in the liver, may be fa-
voured or induced by prescribing them so as to
produce their specific effects.

109. (n) We often have little or no proof of the
presence of chronic change in the liver, beyond
the torpid state of its functions already noticed
(§ 48.), viewed in connection with the habits of
the patient, and the history of his former com-
jjlaints, and of his j)resent attack ; but, in these,
mild mercurials, in frecjuent and small quantities,
in conjunction with alteratives and deobstruents
($ 101.), especially minute (juuntitios of antimony,
with ainmoniacum, soaj), and opium ; or these
witii taraxacum in full doses ; or this latter with
the infusion of calumba ; will be found the safest
as well as the most efficacious remedies, paiti-

cularly when assisted by a camphorated mei'duilal
ointment or liniment applied over the hypochon-
dria ; or by the nitro-liydrociiloric acid solution,
employed either as a wnsii, a lotion, or on the
surface of warm poultices ; or by repeated blis-
ters; or by issues or setons, and the ammoniacal
and mercurial plaster over the abdomen, or a
combination of it with other deobstrueut and warm
plasters. In these cases, we must be guided by
the evidence we may have of change of the liver,
and direct our treatment to its removal, conform-
ably with the views stated in the article on the
diseases of that viscus. When the stools are
frothy, and deficient in bile, the hydrargyrum
cum creta, or the blue pill, will be advantageously
combined with inspissated ox-gall, extract of ta-
raxacum, and small doses of Doveh's powder, or
opium. The carbonates of the alkalies, or biborate
of soda, may also be given with vegetable tonics,
ipecacuanha, and the preparations of hop ; either
of the liniments (F. 296. 311.), alone, or with the
mei-cuiial liniment, bein;^ daily rubbed upon the
abdomen, or applied by means of a piece of flan-
nel moistened with it and placed under wash-
leather, — which will protect the clothes from it,
and prevent its evaporation. In tiie foregoing
states of hepatic complication, change of air, horse
exercise, or travelling, and a regulated diet and
regimen, will materially assist the treatment.

110. /5. A sub-acute, slight, or chronic form of
dysentery is sometimes merely symptomatic of the
advanced states of hepatic abscess, and occurs
more frequently than the very acute complication
alluded to above ($94.). Itrequireseitherasimiiar
treatment to that now stated, or simply support of
the powers of life, in order to enable tiiem to over-
come the disease. The arrest of tiic discharges in
this state of the complaint frequently increases the
hepatic malady, or occasions severe constitutional
disturbance. Gentle tonics and restoratives, light
or farinaceous food, and such astringents, anodynes,
and emollients as will merely control and sooth
the bowel aflfection, until the above treatment, or
that recommended for su]y])nration of the Liveh,
shall remove the principal or primary disease, are
the most deserving of confidence.

111. y. When purulent matter collects in the
liver, in an advanced stage of dysentery, the oc-
currence can be explained only as attempted above
(§. 77.) ; and, during the life of the patient, the
symptoms will seldom warrant more than a suppo-
sition of its having taken place. The facts, that a
bad habit of body, and an asthenic state of the
powers of life, are the chief causes of the absorp-
tion into the blood of morbid matters from the seat
of disease, and of the extension of inflammation
from an ulcerated part along the veins; and tiiat
these changes induce those observed in the liver in
such cases, should be kept in view in the treatment
of the advanced stages of dysentery, — particularly
as it has been satisfacioiily shown that a large pro-
portion of unfavourable eases tcriiiinate fatally,
owing to the contamination of tiie circulating
fluid produced in this manner, either witii or with-
out the concomitant lesions of tlie liver, of which
particular notice has been taken. Conformably,
therefore, with these facts, the remedies I have
shown, in the article Veins, to be most efficacious
in arresting the extention of inflammation along
them, in preventing or counteracting the conta-
mination of the blood, and in supporting the vital

DYSENTERY — TnF.ATMENT

powers, will be most beneficial, not only where this
complicated state is inferred, but also in an ad-
vanced stage of the malady, and especially in its
astlienio forms, where it is most desirable to pre-
vent or arrest these very dangerous occurrences.
When the disease is symplomatic of the absorption
of morbid matter from carious bones, foul ulcers,
Cvc. (72. c), the principles and treatment now
stated should be adhered to, and the chlorurets
applied to tlie ulcerated parts.

112 . {!>) The complication with disease of the
mesenteric glands frequently cannot be distin-
guislied from that with chronic change in the
liver; but, when tiie stools are lienteric, and the
abdomen hard and tumid, the former association
may be inferred, although the hepatic complication
may also be present ; the means now recom-
mended being equally appropriate to both. I
have seen benefit derived, in some cases of the
mesenteric complication, occurring in children,
from liquor potasscc, or Ur.indish's alkaline solu-
tion, in tonic infusions, with syrupus papaveris
or tinctura opii ; and from the chlorate of potassa
with Dover's powder, a terebinthinate draught
and enema being administered every third or
fourth day. More recently, the ioduretted solu-
tion of the iodide of potassium, with very small
doses of laudanum, or the iodide of mercury in
minute quantities, has also been prescribed with
advantage, especially when assisted by the warm
bath, and some one of tiie liniments or other
external applications enumerated above. If the
patient, however, complain of tormina, or if the
stools be bloody, the daily application to the abdo-
men of some one of the ointments containing the
preparations of iixiixe (F. 766. et seq.) willbepre-
feral)le to the internal exhibition of this substance.
In this class of subjects, change to a dry and
pure air, and the prolonged use of these medicines
in very small doses, are requisite to success. I'he
same treatment may be also employed in the
hepatic complication. But in the acute maladies
of the liver, the preparations of iodine are often
injurious.

113. (c) The complication with disease of the
pancreas is even more difficult to be ascertained
than that with mesenteric enlargement ; but, even
when confidently inferred, it does not seem to re-
quire a difl'erent treatment from that now re-
commended.— In the splenic association, nemly
similar measures to those already stated aie also
applicable. The preparations of bark ; the sul-
phate of quinine, and of the metals ; and stomachic
purgatives ; are more especially indicated in it ;
particulai-ly when aided by emollient clysters, and
the external applications described above (§ 109.).

114. (rf) Chronic dysentery in the dark races,
being characterised by relaxation of the mucous
surface of the large bowels, and an adynamic
state of the system, and differing not materially
from chronic diarrhoea, will be most successfully
treated by tonics conjoined with astringents, ab-
sorbents, aromatics, and hot spices ; by the warm
bath ; by injections with lime water and other
astringents ; and occasional stomachic or warm
purgatives, in order to prevent fa;cal matters from
collecting. Its principal complications, in these
races, are with enlargement of the spleen, with
worms, arid with mesenteric disease ; the two latter
especially. In the association with enlargement of
the spleen, the sulphate of iron or other chaly-

OF CONTINGENT ClIANOIS IN. 725

bcatcs, with rhubarb, and occasionally stoniacln'c
purgatives, are the most eflicacious medicines. To
the other complications, the treatment already pre-
scribed {§ 97. 112.) is also appropriate. (See
also DiAHHHUiA — Trcalment of, in the Dark
Races, § 37.)

115. iii. Treatment of crnTAiN States and
CONTINGENT Changes. — A. When dysentery is
prevalent, a recognition of the early symptoms,
particularly these premonitory of an attack, as
sunk pale countenance, griping pains with bor-
borygmi, and irregular chills or horiipilations,
witli or without diarrhoea or tenesmus, should
lead to the adoption of means which will often
ward off the disease or cut it short. Of these,
the most efficacious is an ipecacuanha emetic;
which may even be repeated until its free oper-
ation is procured, followed by a single full dose
of calomel ; and that, in two or three hours, by a
purging draught, and a laxative enema. AJter
these, a warm bath, the patient being well rubbed
upon coming out of it, and placed between warm
blankets ; and pills with camphor, ipecacuanha,
and three or four grains of opium, repeated subse-
quently in smaller doses ; will frequently remove
all disorder. This plan, if employed sufficiently
early, is equally applicable to all the varieties of
the disease.

116. B. — (a) Extreme irritability, want of sleep,
and distress at night, during the most acute attacks,
often exhaus^t the strength of the patient, and
re(|uire either very large doses of opium, or opiate
suppositories, or small opiate injections, especially
after coniing out of a tepid or warm bath — a tepid
bath if there be much heat of skin or attendant
sthenic diathesis, and a waim bath if the con-
stitutional affection be of the asthenic kind. —
(6) Excessive iiiifuti'du in the rectum, and dysuria,
may be alleviated by tlie treatment directed above
(§ 84, 85.) and by small injections — from three
to five ounces — containing either opium, or the
extract of hyoscyamus, or the extract of bella-
donna, or i\ 137.; recollecting, however, that
this latter will often produce much disorder, if too
freely employed. In a case where I prescribed
it, in 1826, with remarkable benefit, it afl'ected
the head, and caused a most copious scarlet erup-
tion on the skin. — (c) Very copious effusions of
blood alarm the patient ; and although they fre-
quently relieve the sthenic forms, yet, if often re-
peated, or occurring too largely in the asthenic
varieties, they require to be moderated, or arrested. .
In the former states, general or local depletions
will be the best means of removing them ; but in
the latter, or when they sink the vital energy, the
terebinthinated draught and injection prescribed
above (^90.), or the acetate of lead in draughts
with acetic acid and laudanum, or in enemata ; or
the tincture of the sesqui-chloride of iron in the
infusion of quassia, by the mouth, or in clysters;
or lime juice and opium, similarly prescribed;
will generally prevent further discharge. — (d)
DiMresim^Jlatulencenndmeteorismus will often be
relieved, especially in the adynamic states, by a
terebinthinated or an assafoetida injection (F.136.),
and by the warm epithem ; or by the infusion oi'
the leaves of rue, employed as fomentations over
the abdomen ; or by the bruised macerated leaves
applied warm to the same situation. — (e) Leipo-
thymia or sinking, or even full syncope, may
follow the efforts at evacuation — particularly if the

3 A 3

726

DYSENTERY — Consequences of Acute and Ciironic.

patient get up to tlie night-stool, at an advanced,
or in an adynamic state of the disease ; and death
may even take place from this circumstance, espe-
cially in the scorbutic complication, or when the
patient has been kept too low, or has been addicted
to spirituous liquors. Restoratives, the supine
posture, and the use of the bed-pan, should not be
■ neglected in these casss.

117. C. (a) Prolapsus ani indicates severe
irritation about the sigmoid flexure of the colon,
and upper part of the rectum, and requires the
careful replacement of the part, local depletions
from the sacrum, astringent fomentations with
opium to the anus, astringent lotions, and injec-
tions with an urethra syringe, especially if the
rectum be ulcerated; small injections of the
dilute black wash, if sloughing of the bowel be
suspected ; and the belladonna plaster over the
sacrum, or above the pubis, in order to remove the
spasm of the muscular coats of the intestine.
When this symptom occurs in chronic dysentery,
we may infer the existence of ulceration. In
such cases, injections of a solution of nitrate of
silver will give permanent relief. — (6) Excoria-
tions about the anus often occur, in all the forms
of the disease, but most frequently in the hepatic
complication, and require warm anodyne foment-
ations and poultices ; small narcotic injections ;
and ointments with opium and mineral astrin-
gents, as the sulphate of zinc or the acetate of
lead. — (c) Abscess in the vicinity of the anus
should be treated at first by local depletions and
cooling discutient applications ; and if these fail,
by warm poultices, and early external openings,
in order to prevent internal fistula. If the sup-
purating part assume an unhealthy aspect, injec-
tions with the dilute disinfecting fluid, and a tonic
constitutional treatment, should be adopted. — {d)
Ulceration in the bowels, of a sloughing kind
(§ 54.), is a very unfavourable occurrence in the
acute forms, for which a tonic and an emollient
treatment — the internal use of the chlorates with
opiates, and mucilages, clysters of the same de-
scription, and the other measures directed for the
malignant variety {§ 89.) — should be employed.
The ulceration that takes place in the progress of
the chronic form ought to be treated by the remedies
recommended for the obstinate states of that form
(§ 105, 106.).

1 18. iv.OfcERTAINCoNSEQUENCESOF Acute AND

CimoNic Dysenterv. — A. — (a) In the acute
varieties, and occasionally in the chronic, the e,r-
tension of injlainmat ion, w'llh or without previous
ulceration, from the internal to the external surf ace
of the bowels, or to the omentum, or mesentery, is one
of the most dangerous results ; and requires very
decided treatment, as soon as the symptoms of tliis
change (§55.) appear. General or local deple-
tion, if the state of the circulation and of the con-
stitutional aftection permit either or both, should
be practised ; a full dose of calomel, camphor,
and opium being exhibited immediately afterwards.
These may be followed in a few hours by the tcre-
binthinated drauglit, or enema, or by both ; but
more especially by the warm turpentine ei)ithcm
(§ 89.), which ought to be repeated until the peri-
toneal inflammation is subdued. Nothing short of
these means, ])romptly practised, will, in such
cases, save the i)ati(jnt ; but these will sometimes
be successful, if properly employed, and not left
to ignorant or careless persons. — {b) Adhesions

of various parts of the serous surfaces sometimes
remain after these attacks ; as shown upon dissec-
tion of cases that have been carried off a long time
subsequently by other diseases. The signs of this
sequela are very obscure and uncertain. But
I believe, that these adhesions will gradually
diminish, and ultimately also disappear, if we
succeed in restoring the natural functions to a
healthy state ; all adventitious productions being
removed by a due manifestation of the vital ener-
gies in the assimilating and absorbing organs ;
and by derivation to, and counter-irritation in,
distant parts. Either with, or without, the effu-
sion of lymph necessary to these adhesions, a
copious effusion of serum into the peritoneal cavity
may take place ; the dysenteric affection being
suppressed, or very rarely persisting. This occur-
rence is most frequent when there is c-oexistent
disease of the liver, or when the dysentery has
followed fevers. The treatment, in such cases,
must be much the same as that directed in
Droi'sy of the Abdomen. The application to|the
abdominal surface, twice daily, of about a drachm
of an ointment consisting of from six to twelve
grains of veratria to an ounce of prepared lard,
as first recommended by M. Magendie, and very
recently adopted in this country, promises to be
extremely beneficial, as being more especially
appropriate, in dropsy occurring in these cir-
cumstances.

119. B. Contractions or strictures of the colon
are among the most unfavourable changes attend-
ing the advanced stages of the chronic disease, or
remaining as its sequela. It is important, in re-
spect both of the diagnosis and treatment, to form
some idea, although we cannot often be certain, of
their existence during life. Yet I have seen the
diagnosis fully established, in some instances, by
rational inferences from the phenomena of the
case. The use of bougies, for the purposes of
diagnosis or cure, is entirely out of the question :
the legitimate exercise of medical science is here
only required. If there be great difficulty or
impossibility of procuring full or feculent stools,
the patient not complaining of tenesmus or the
acute symptoms of dysentery ; if the evacuations
be scanty, or contain semi-dissolved fasces, with
shreds of white mucus or of albuminous exuda-
tion, and if they be preceded by an uneasy sen-
sation in the course of the colon, with that
of load or fulness about the cajcum and righ:
hypochondrium, or between the epigastrium and
umbilicus ; if there be distension of the abdomen,
with flatulent eructations and a foul or fseculent
odour of the breath ; if an injection cannot be
fully thrown up, or if it return immediately, or
before the last part is thrown up, although tht
pipe is fully introduced, and carefully guarded ;
and particularly if these symptoms occur in an
advanced stage of the chronic disease, or in per-
sons who have had previous attacks ; then stric-
ture in the left and sigmoid flexures, or even in
the transverse arch, should be dreaded. In such
cases, the patient will occasionally complain of
a sense of tearing, scraping, gnawing, or of
dragging in some part of the colon, previously
to the operation of the bowels ; the regions of
the caicum and ascending colon being hard and
tumefied.

120. The chief objects in these cases are to
preserve the contents of the large bowels in a

DYSENTERY — Treatment advised by Authors. 727

fluid state, and prevent thereby the accumulation
of fajcal matters above the stricture, and the con-
sequent irritation and distension ; endeavouring,
at the same time, to subdue the chronic inflam-
mation and ulceration frequently existing in tiie
strictured part. These intentions arc to be ful-
filled by gentle and cooling laxatives ; by refri-
gerants vvitli anodynes and emollients, and by
injections of a similar kind, slowly and carefully
tiirown up by the improved apparatus, (jentle
friction, also, of the abdomen, with oleaginous
or antispasmodic liniments, following the exhi-
bition of these medicines, will also be serviceable.
As to tlie particular remedies that may be em-
ployed, the bitartrate of potash with borax, or with
magnesia; the potassio-tartrate of soda; manna;
olive oil, or oil of almonds, either alone, or with
sweet castor oil ; ipecacuanha with soap, small
doses of blue pill or hydrarg. cum creta, and extract
of hyoscyamus or of conium ; the nitrate of potash
with carbonate of soda and small doses of
camphor ; tiie confection of senna with sulphur,
and cream of tartar ; the decoctum lini in enemata
with olive oil, or with biborateof soda ; the common
soap injection ; the emplastrum ammoniaci cum
hydrarg., either alone, or with extract of belladonna,
placed on the abdomen ; or the linimentum hy-
drargyri, with the linimentum saponis cum opio,
and the linimentum camphoraa compositum, rubbed
assiduously on this part ; or external irritation of
it by F. 311., or by croton oil ; and a regulated
farinaceous diet ; have appeared to me the most
successful remedies. Aloetic, saline, resinous,
or irritating cathartics are obviously injurious.
During this treatment, febrile excitement of the
system should be guarded against, and removed
by cooling diaphoretics. The occurrence of stric-
ture in the rectum, as a sequela of chronic dy-
sentery, is not infrequent, and should be treated
upon the same principles and in the manner ex-
plained in the article Rectum.

121. v. Notices of Methods of Cure and
Rejixdies recommended by Writers. — In the
treatment of no other disease, perhaps, has the
baneful influence of exclusive medical doctrine
been more fully exerted than in that of dysentery.
This is fully evinced by the much less rational
measures very generally employed, towards the
end of the last century and at the commencement
of this, wherever the theory of Brown was
adopted. — A. Vascular depletions have been di-
rected in dysentery from the earlier periods of
medical history. They were recommended by
Aetius, Alexander, and Rhazes; and by Go-
RiON (Ergo Dys. Phlebotomia. Paris, 1604.), Ri-
vERius, Prosper Alpinus, Lespicier, Botal-
Lus, Sydenham, Ellain, Zacutus, and many
other writers of the sixteenth and seventeenth
centuries ; but had fallen into disuse, when Dr.
Jackson and Dr. WHYTE(Mfrf. and Phys.Journ.
vol. ii. p. 283.) revived the practice. During the
Peninsular campaigns, general and local bleeding
were freely employed by Drs. Somers, Fergu-
son, Forbes, and other physicians of the British
army. Indeed, it had never been altogether
neglected by judicious practitioners during the
last century, notwithstanding the injurious in-
fluence of theory upon medical observation and
practice ; for we find it directed by Hillary,
Akenside, Cleghorn, Pringle, Baker, Stoll,
M'G RIGOR, &CC., and strenuously contended for by

JuNCKER (De Util. Venasect. in Dys. Hal. 1770.)
in the early stages of the inflammatory disease.
From what has been stated above, it is apparent
that bloodletting, although applicable to certain
forms of dysentery, should be employed with
much discrimination, and with due reference to
the exciting causes, and to the prevailing epidemic
constitution. This is well illustrated by its in-
jurious efTects in the asthenic forms; especially
those proceeding from depressing causes and con-
taminating sources; and by the history of dysen-
teric epidemics (§'29.). Mr. Bacot states, that
when the malady was consequent upon fever, in
the Peninsula, or arose from the same exciting
causes, bleeding could seldom be borne. It
would also appear, that from 1817 to 1827,
during which period the seasons were tolerably
regular and the summers dry and warm, this
disease was attended by more or less of the in-
flammatory diathesis ; and that, from this latter
date, when they became less regular and much
more wet and cold, it has assumed more of the
asthenic characters. The application of leeches
to the anus, advised by Weumann, Hunnius,
and many French writers, is often productive of
benefit ; but irritable sores, owing to the excre-
tions coming in contact with the bites, are apt
to follow.

122. B. Evacuants. — (a) Emetics are extolled
by some writers, and considered injurious by
others. The circumstances in which they may be
employed (92. 115.) have already been pointed
out. They are certainly more beneficial in some
seasons and epidemics than in others ; as, indeed,
admitted by Chomel (Ergo Dysent. Vomitus.
Paris, 1698.), Fischer, Goeden, ^Iichaelis, and
Schmidt (De Emet. Usuin Dysent. Jenae, 1803.),
and Hunnius (Horn's Archiv. 1811, p. 151.),
who are amongst the most strenuous believers in
their efficacy. Hippocrates directs early re-
course to be had to them. Cleghorn advises
them in the bilious form : Wendelstadt in the
same variety, or when the disease is complicated
with rheumatism ; and he prescribes diaphoretics
and opium after their operation. Stoll very
justly considers them most appropriate where
there are little fever, and no constant pain or
tenderness in the abdomen. In these cases, they
generally promote diaphoresis, especially if opiates
be given soon afterwards. As to the choice of
emetics, some difference exists. Antimonials are
preferred by Pringle (Editi. Med. Essays, vol. v.
art. 15.), Baker, Adair, and Saunders; and
ipecacuanha by Hargens, Weber, Annesley,
and the great majority of the most recent writers.
Dr. Wright found ipecacuanha emetics, followed
in succession by cream of tartar and castor oil ;
afterwards by Dover's powder, as soon as the
digestive tube was evacuated ; and, lastly, by
cinchona or cascarilla ; the most successful
method in West Indian dysentery.

123. (b) Purgatives, generally of a mild de-
scription, are directed by Du Brevil, J. Hunter,
Lo.MBARD, jMiJLLEn,and HEssE(De Usu Evaciian-
ti^im in Dys. Jenae, 1800.). Sydenham pre-
scribes thos'e of an active kind, after bleedin"
and a full dose of laudanum. Jackson and
Annesley' adopt a nearly similar practice. Hun-
nius and Wendelstadt prefer laxatives, or mild
and cooling purgatives, and consider them most
serviceable in the bilious variety ; whilst Lind,

3 A 4

728

DYSENTERY — Treatment advised by Autiiohs.

VoGEL, TiiOMANN, Weber, and Neumann be-
lieve all purgatives injurious, and advise only
the gentlest oleaginous luxatiies. The circum-
stances in which tliese medicines are most appro-
priate will be apparent from what has been stated
above; as well as those which should be selected.
Calomel is preferred by Jackson, Ballingall,
Bampfield, and Annesley, when assisted in its
purgative operation by other medicines, either
combined with it, or given subsequently. Sulphur
is recommended as a laxative by Wedekind and
Lange {Miscel. Veiit. p. 30.) ; and certainly full
doses of the precipitated sulphur, with one or
two drachms of cream of tartar ; or these with
confeciion of senna, in the form of electuary ; are
amongst the gentlest and most certain aperients
that can be exhibited, in an advanced stage of the
acute, or in the chronic disease ; and may be
given every two or three hours, until the effect
is produced. The neutral salts are, in general,
not so serviceable as the laxative oils, although
Clarke, Balmain, and Mursinna are favour-
able to the use of the sulphate of soda. Stole
recommends the saline aperients only in the
bilious variety ; and anodynes after their opera-
tion ; and several writers extol them when conjoin-
ed with antimonials. The bitartrate and tartrate
of potash, or the potassio-tartrate of soda, are, upon
the whole, the most serviceable of this class of
purg^itives. The hitartrate of potash, finely levi-
gated, and given to the extent of three or four
drachms every six hours, in the form of electuary,
with the pulp of tamarinds and syrup of ginger,
will often open the bowels and procure the ex-
cretion of bile, when other means fail. The
practice is recommended by SELLE.(i>e Curandis
Morbis, S\c. p. 157.), and was found to succeed
is some hopeless cases by Dr. Cheyne. It is
the more efficacious after the exhibition of mer-
curials; and, when the substance of the liver is
acutely affected, may be depended upon as an
appropriate refrigerant purgative. But, in or-
dinary circumstances, there can be no doubt of
tlie propriety of the decision of C'ullen, Bang,
ToDE, Clark, and Piuerit, in favour of oleagi-
nous laxatives given by the mouth, and in muci-
laginous enemata. When we suspect, from the
existence of scybala, or the appearance of the
stools, or from fulness or hardness in the course
of the colon, the accumulation of faecal matters
in the cells of this bowel, the oleaginous draught
prescribed above (§ 83.) maybe exhibited ; or the
following pills may be given every two hours until
a full evacuation is procured : —

No. 203. R Scaminonia?, Pulv. Rhei (vel Pulv. Jalap.),
aii gr. ij. ; I'ota.ssic Sulphatis gr. iv. ; turn probe simul,
et adde Olei aut Syrupi q. s. ut fiant PiluliE diia?.

124. (c) Enemala arc amongst the mo.st effica-
cious means for eitiier the evacuation of morbid
matters, or tiie removal of the diseased action
going on in the large bowels, or both. Those
with the laxative and emollient oils are preferred
by Celsus, Cullen, Bang, Horn, Radem aciier,
and some others, when the first intention reciuires
to be fulfilled ; and to these substances may be
added laudanum or hyoscyamus, dccording to
circuuisiances. Amylticeous, einollieut, or muci-
/iigiuoiis iiijeitioiis, with or without anodynes, are
directed by 11ii"|'()ci;ates, Alexander, J'aulus,
1-iM), Sciii.r.GEL, Duncan, Njumann, Tiiomann,
&!•., chit-fly witii tlic SLCotiil of thesi' intentioi).s.

Small acetous clysters with opium are prescribed
by Vander Heyde, Birnstiel, and BrUning ;
decoction of linseed with laudanum, by Celsus,
Clark, and Horn ; decoction of quince seeds, by
Wendt ; the decoction of the root of marsh mal-
lows, by Paulus ^gineta and Ecker ; milk,
by Celsus, Alexander, and Forestus (lib. xxii.
obs. 36.) ; and milk with iheriaca, in the acute
varieties, and with Venice turpentine, in the
chronic, by Sydenham. Injections, as directed
in the foregoing sections, should have strict refer-
ence to the state and stage of disease, and not be
bulky. HuNNius considers large enemata in-
jurious; they are very seldom long retained.
Many substances, besides those now mentioned,
may be thus administered ; especially in the
chronic states. Galen, and the Arabian phy-
sicians, exhibited nearly all the vegetable and
mineral astringents, the anodynes, and even the
escharotics, as the preparations of arsenic and
cojyper, in this way. Dr. Jackson advises a weak
solution of bichloride of mercury with myrrh, and
demulcents ; and Mr. Annesley, the black or
yellow wash, to be thrown up in enemata, in the
chronic complaint.

125 C. Emollients and Demulcents areheneficia.],
not only in themselves, prescribed in the form of
draught or injection, but also as the vehicles of
more active substances. They constitute one of
the chief means employed by Hippocrates in
dysentery. Several oils are exhibited in this
manner, either in the state of emulsion, or on the
surface of other fluids. Linseed oil is preferred
by Ruland {Curat. Erup, c. iv. n. 40.); al-
mond oil, by Heuermann ; and sueet oil, by nu-
merous writers. This last, in sufficiently large
quantity, is one of the most efficacious remedies
that can be administered as an enema. Mucilages,
prepared chiefly from the gums, either alone
(Gilirert, Advers. Fract. Prim. p. 417.), or
with absorbents and opium (Pfenninger and
Staub) ; the decoctions of marsh mallows or of
the common mallow (Paulus, Kortum, Ecker),
drunk warm, in large quantity; saleb (VVeber
and Hargens) ; and the decoction of the Cara-
geen moss, or of Iceland moss (Hargens, 1. c,
and Herz, Briefe, b. ii. n. 2.) ; are useful medi-
cines.

126. D. Anodynes, especially after vascular
depletions where they are required, and alvine
evacuations, are very generally recommended.
— (a) Opium is the most to be depended on, and
the most generally appropriate in some combin-
ation or other, according to the intentions to be
fulfilled. If its sedative effect chiefly be desired,
and if inflammatory fever be present, it may be
given in doses of from one to four grains, either
alone, or with nitre, or with antimonials, as di-
rected by Blane, Himly, Jawandt, Ciieyne,
Neumann, and Horn {Archiv. b. vi. p. 103. et
seq.). When it is desirable to procure a diapho-
retic operation, it is best conjoined with ipeca-
cuanha (Cardin, MiJLi.ER, &c.), or small doses
of caniplior and nitre ; or in the state of laudanum,
with considerable quantity of the spiritus ffitherls
nit] ici, or with other diaphoretics (Hinze, Jack-
son, &c.), especially in the asthenic forms. If
the biliary secretion be scanty, the liver not being
actively diseased ; or if the intention be to excite
salivation ; opiun) may be conjoined with mode-
rale doses of calomel, and given every four or

DYSENTERY — Theatment advised dy Authors

six hours, as directed by J, Johnson, Leiden-
frost, Rf.nton, and others — partieuUirly in the
sub-acute and chronic states. If the powers of
life be depressed, and the circulating and secreted
fluid vitiated, it will be necessary to exhibit it
with tonics and antiseptics (JMouton, Wedk-
KiND, &c.), as cinchona, the clilorates, &c. ; and
with astringents (Riedlin), when the evacu-
ations are profuse, the digestive mucous surface
relaxed, or the disease chronic. Consbuuch
considers opiates injurious, unless preceded by
emetics ; and Sydenham, Mursinna, and others,
either premise evacuations, or alternate them with
anodynes, i'lie opinion of Wendelstadt, that
opium, as well as astringents, are injurious in
the bilious variety, until morbid secretions are
evacuated, is judicious, and may be extended to
most forms of the disease. In the nervous or
typhoid variety, they should be given with great
circumspection. Morton found that, when
mainly depended on, in the epidemic of 1G66,
they augmented the exhaustion and muttering
delirium frequently attending it. Opium, in iup-
])ositoiie3{ Hateman, Sec), and in liiiimentsTuhhed
on the abdomen, or externally in other forms
(Hargens and Tiiomann), has been already re-
commended in various states of the malady.

127. (h) Amongst those substances which act
most energetically in removing spasm of the
intestinal hbres, and diminishing morbid sensi-
bility, liyoscyamus, belladonna, and tobacco, are
the most deserving of notice. Hyoscyamus is re-
commended by Matth;f.i, Withering, and Hun-
Nius; and, in the acute and febrile states of the
disease, uiay be exhibited in the same manner and
forms of combination as opium. The recent juice
of belladonna is praised by Gesnlr (Haller's
JJiblioth. Med. Pract. vol. ii. p. 55.), and Ziegler
{Beobachtung, p. 35.); but the powder of the
root, and the extract of this plant, are equally
efficacious when properly preserved. A strong
infusion of tobacco is prescribed as a fomentation
to the abdomen, by Urs. Graves and 0'13eirne.
These narcotics are appropriated only to the
early stages of the sthenic states of the disease,
and require much discrimination and caution.
The hydrocyanicacid, with camphor, ipecacuanha,
and mucilages, is of benefit when judiciously
prescribed.

128. E. Diaphoretics are extremely beneficial
in the early stages of the disease. 'Those of a
cooling and relaxing kind are most suitable to the
sthenic forms, and such as are warm and ex-
citing in the adynamic states. — (a) Antimonials
are preferred by Pringle, Sims, Fischer, Baker,
APOGEE, Adair, Richter, and Hufeland ; whilst
Heuermann {Bemerk. b. i. p. 184.) considers
them injurious, — an inference, which I believe
to be correct as respects their exhibition in the
advanced stages, or in the asthenic states. Of
these preparations, the most serviceable is James's
powder, given with calomel, or with calomel
and opium in the first stage. Liquor ammoniic
ucetatis, with mucilages, emollients, and opiates
(Hardens) ; or with small doses of camphor
and nitre, and either with (Richter and Saun-
ders) or without anodynes, is more generally
appropriate ; and, in persons who have been ad-
dicted to spirituous liquors, or in the asthenic
forms, with camphor mixture, the spiritus am-
monias aromaticus, or the spiritus tctheris nitrici

729

and laudanum, is very beneficial. The infusions
of serpentaria or ef arnica, either alone, or with
liquor ammoniaj acetatis, or with camphor and
opium, are indicated ciiiefly in the malignant
or nervous varieties, or in the advanced stages of
the other asthenic forms. The infusioo or powder
of the root oi arnica (Miciiaelis, Collin, Birn-
stiel, and Fischer), may be employed in similar
combinations and states of the disease, as advised
by Richter. Stole (2?at. JVI^fZ. vol. ii. p. 421.)
recommends it after emetics, depletions, and
evacuants, in the acute ; and in the chronic
complaint. Ipecacuanha is, however, the most
certain in its effects, when combined with opium,
and the most to be depended upon, in arresting
the train of morbid actions. The injunction of
Sir G.Blane, to have recourse to diaphoretics
after evacuations have been procured, should not
be overlooked. — (/;) The importance of restoring
the functions of the skin has been duly estimated
by Gruber, Jackson, Neumann, Vogler, and
Schlegel, and should not be confided to internal
remedies merely. Tepid or slightly warm baths,
in the highly inflammatory states, and ivarm baths
(Blane, Horn, Richter, Konig, Goeden, &c.),
or baths with aromatic and stimulating herbs in-
fused in the water (Tiiomann, Ann, ad 1800,
p. 237.) are also important means. Vapour
baths, and the application of dry heat (Heister,
Voglek, and Hargens,) are also deserving of
notice. Frictions of the surface, or, as Prosper
Alpinus and others advise, frictions with sweet
oil, upon removal from the bath to a warm bed ;
and the internal use of diaplioretic diluents, are
useful adjuvants. — (c) Warm poultices (An-
nesley and Author) and epitheras or foment-
ations frequently applied to the abdomen, as
directed by Alexander, Riverius, Brijnner,
Stole, Richter, &c.,are often serviceable, when
they are so managed as not to wet the bed-clothes.
Warm cataplasms of aromatic and antispasmodic
herbs, &:c., are praised by Heister, Blanchard,
Thomann, BriJning, Klinge (in Hufeland,
Jonrn. der Pr. Arzneyk, b. vi. p. 900.), Hinze
(Horn's Archie, b. iv. p. 516.), Goeden (/6(c?.
Mart. 1812, p. 331.), and Horn {Ibid. b. vi.
p. 263. )• These also act as derivatives, as well
as diaphoretics.

129. F. External derivation is very generally
prescribed. IMoseley and ]Mattha:i recommend
it chiefly in the complication with rheumatism,
for which Paulizky {Beobachtung. st. ii. n. 1.)
directs blisters lo the thighs ; where, also, they
are generally ordered to be applied by MiiLLER,
EcKER, and Amelung. Schlegel, Lind, Stole,
Blane, Fischer, jMijrsinna, Neumann, and An-
NESLEY advise large blisters to the abdomen ; and
Hunnius to the sacrum ; whilst other writers think
that they increase the dysuria. Sinapisms are
noticed by Blane and Fischer ; and camphorated
liniments rubbed on the abdomen, by Lind.
These are less rapid in their effect-;, and much less
efficacious, than the turpentine epithem described
above (§ 89.), or friction with croton oil, either of
wiiich may be also applied to the insides of the
thighs and legs in urgent cases.

130. G. Astringents form a principal part of
the means employed in dysentery by Galen and
the Arabian physicians. Various substances of
this kind are recommended. Dr. Wright advises
Citric acid and common salt, which Ere often of

730

DYSENTERY — Treatment advised dy AuTHons.

much service either with or without opium, espe-
cially in the asthenic states, and as they occur in
the dark races. Goeden (in Horn's Archiv.
Mart. 1812, p. 284. and 323.), prescribes tartaric
acid witii refrigerants, and opium ; Bang, sul-
phuric acid with mucilage; Annesley, the witj-o-
Ai/droc/i/onc acids, with anodynes ; and M'Grigor
and Hope, iiitric acid with opium ; this last being
chiefly appropriate to chronic cases, and those as-
sociated with disease of the collatltlous viscera.
BiRNsTiEL directs alum conjoined with camphor;
Loos (Horn's Archiv. Jan. 1810, p. 193.) alum
with tormentilla root ; Hunnius, Michaelis
(HuFELAND, Joitrn. der Pr. Arzneyk. b. vi.
p, 280.), and Hardens {Ibid. b. vii. p. 137.),
alum with mucilages, opium, &c., chiefly in the
chronic and atonic states; Moseley and Jack-
son, alum with sulphate of zinc, by the moutii
and injections ; and Adair, alum with spermaceti,
or gum, opium, and aromatics, in epidemic dysen-
tery occurring among negroes. Lime water with
milk, or with mucilages, is praised by Grainger,
Brefeld, and Lange ; but is most serviceable in
the chronic and asthenic states, and in the form
of enema ; in wlilch cases, various other astrin-
gents are recommended, especially after morbid
matters are evacuated. In this manner the pre-
parations of catechu are directed by Brande
(Tode's Med.Journ. h. x. n. I.) and others; kino,
by Weber; the infusion of galls with opium, by
Elliotson and Roots ; hainatoxylon with cinna-
mon and other aromatics, by Pringle and
Wendt ; the tnrinentilla root, by Hoffmann; the
lythrum salicaria, by Quarin and Gardane; the
root of the ledum palustre, by Biornlund ; betel,
by Peron ; the inner bark of the brucea antidy-
senterica, by several writers ; and the decoction of
the pomegranate hark, or of the rind of the fruit, by
the ancients, and by many modern authors. All
these, especially tormentilla, catechu, and betel,
are advantageously combined with ipecacuanha
or Dover's powder. Several mineral astringents
are also exhibited, especially in the asthenic and
chronic states, or in far advanced stages ; inter-
nally as well as in enemata. Arsenic, and the rust
o( copper, are prescribed by Galen, Rhazes, and
most of the ancients ; and the sulphates of zinc, of
copper, and of iron; and the nitrate of silver,
either with or without opium ; by the authorities
referred to in the article Diarrhcea (§ 50.). The
acettile if lead Is recommended by Fep.nelius,
Cameraruis, and Nardius, and is now frequently
employed, in pills, draughts, or injections, gene-
rally with opium and ipecacuanha, both in the
acute and chronic forms; particularly the latter.
It should be recollected, when prescribing astrin-
gents In this disease, that they are injurious when
exhibited early in the acute states, and wliilst there
is much fever, or when morbid matters remain to
be evacuated. In other circumstances, they fre-
quently are of much service ; particularly when
altered secretions and accumulated excretions are
discharged from time to time by a ju<licious exhi-
bition of mild purgatives ; and wiicn they are con-
joined with demulcents, with ipecacuanha, or with
absorbents, or with anodynes, according to the
forms of the disease and the state of the patient.
Morton found them injurious, altliough they di-
minished tiie discharges ; In the malignant or col-
liquative epidemic of IfififJ ; and similar results
have been remarked l)y others.

131. //. Tonics are required in nearly the same
states of the disease as astringents ; but they are
less frequently injurious, as they do not so com-
pletely suppress the discharge from the intestinal
mucous surface as astringents usually do. They
admit, also, of similar combinations with anodynes,
demulcents, and absorbents, to those found most
serviceable with astringents ; and possess the ad-
ditional advantage of promoting the operation,
and, in some instances, counteracting the ill con-
sequences that might result from the exhibition,
of purgatives or aperients. In the asthenic forms,
they may be exhibited as early as the morbid
matters are evacuated, particularly in conjunction
with ipecacuanha, or diaphoretics and opiates ;
and when evacuation should be promoted, they
are beneficially associated with laxatives. Cin-
chona is praised by Wiiytt, Linke, Clark, and
Douglas (De Dysent. Putrida, ed. 1766, p. 35.).
Bang prescribes it with rhubarb {Act. Reg. Soc.
Med. Haun. vol. i. p. 105.) ; Schmidtmann, with
Ipecacuanha; Whytt, Quarin, and Pringle,
with cateciiu and ipecacuanha, after bleeding and
alvlne evacuation; and Morton with opium.
Heuermann restricts it to dysentery following
fevers; and Cullen advises it chiefly when the
disease assumes an intermitting or remitting cha-
racter. Huxham and Pringle prescribed an in-
fusion of it and serpentaria, with great benefit, in

the asthenic and malignant stales, and during
convalescence. Marcus considers the bark in-
jurious; which it doubtless is in the early stage of
the inflammatory forms. Most of the other tonics
are recommended by authors, and admit of similar
forms of exhibition, in the states which require
the lighter preparations of bark ; for where the
infusion or decoction of cinchona, with liquor
ammonia; acetatls, vinum ipecacuanhas, and ano-
dynes, are of service, the other tonic infusions
will also be of use. Indeed, some of them, as
the infusion of calumba (Percival and Mertens),
or of the cusparia 6ar/c (Brande, in Hannover
Magaz. b. xxvlii. p. 1101.), will be preferable
in certain forms of the disease, especially in
the combination now stated. In the advanced
stages of the acute, or in the chronic and more
asthenic forms, where tonics are chiefly required,
simarouba (Wright, Gooch, Wendt, Quarin,
Baumes, Decner, and Sumeire) will be also
found an excellent remedy, either alone, or with
the medicines just enumerated. Dr. O'Brien
found it very serviceable in the advanced stages
or tiie dysentery that was lately epidemic in
Ireland, in conjunction with opium. The willow
hark ( Loeffler and Osiandeii), and cascarilla
(Werer, and Horn, Archiv. July, 1820,p.301.)
may be employed in similar circumstances, and
in the same combinations. It should not
be overlooked, that tonics ought to be preceded
by vascular depletions, or alvine evacuations,
where either is required ; that the promoting
of the latter, by suitable laxatives conjoined
with, or intervening between them, or exhibited
in enemata, will occasionally be re(|uired ;
especially when the disease proceeds from a
niorliid slate of the secretions ; and that they
should be very cautiously resorted to in the sthenic
or phlogistic varieties, even in their advanced
stages.

132. /. Aromatics and Absorbents are often
"«oful adjuvants in the advanced periods, or asthc-

DYSENTERY — Treatment advised by AuTiions.

731

nic forms of the acute, or in the chronic affection ;
more especially when occurring in the dark
races. — (a) Blane prescribes anvnalics with
bitter inlusions. Horn (Ardiiv. b. iii. p. 317.)
prefers the calamus aromaticus ; and Puingle,
the preparations of cinnamon. The hot spices,
especially Cayenne and black pepper, are most
commonly used in warm countries, and are best
suited to the natives, combined with tonics,
absorbents, or mucilages. Active sthmilants are
too indiscriminately recommended by Brown,
Marcus, and Zixcke; but Vogler justly con-
siders them injurious, unless in the adynamic or
malignant stales, in which, as well as in many of
the chronic, the hot spices, thus combined, or given
with ipecacuanha, camphor, and opiates ; or
with honey and small doses of the chlorates, or
even of biborate of soda, in the chronic ; will fre-
quently be of great service. — -{h) Theammoniacal,
calcareous, and magnesian absorbents are most ser-
viceable in the chronic and asthenic conditions, in
the states of association here mentioned. In the
phlogistic varieties, the carbonates of the alkalies,
with refrigerants, anodynes, and diaphoretics, are
most appropriate.

133. A'. Mercurials are ])rescribed — 1st, as
chologogue purgatives or laxatives — 2d, as
simple alteratives ; and, 3d, to procure their spe-
cific effects whereby their alterative operation
may be better secured, and a derivation from the
seat of the disease established. — Cleghorn, Ly-
soNS, Clarke, Wright, Saunders, Richteh,
Jackson, Bampfield, and Annesley direct calo-
mel, either alone, or with some purgative, generally
at bedtime ; and sometimes oleaginous laxatives
and enemaia subsequently, in order to accom-
plish the first of these intentions : and Duncan
and Lemi'riere combine it with rhubarb. The
chief objection to this practice is, tliat, however
appropriate it may be in respect of tlie hepatic
functions, a full dose of calomel generally in-
creases the tenesmus; and the more, the oftener
it is repeated, or the larger the dose.* This I
have often remarked ; and Sir J, M'Grigor
states that calomel, given in the early stage of
the acute unmixed disease, aggravated the symp-

• A most important fact was determined by the expe-
riments performed by Mr. Annesley (Sketches of Dis. of
India, 2d ed.Svo.p. 374.). in order to ascertain tlie oper-
ation of calomel ; and these experiments presented uni-
form resnlts, viz. that, whilst the stomach and duodenum
of dogs that had taken large doses of this preparation
were much paler and less vascular than in ordinary cir-
cumstances, the colon and rectum, from the caecum to
the verge of the anus, were most acutely inflamed :
thereby explaining the results of clinical observation ;
namely, that, although large doses of calomel calm those
symptoms usually caused by increased vascular action, or
inflammation of the mucous surface of the stomach and
duodenum, they lower the vital energy of these important
organs, and occasion tenesmus, griping pains in the course
of the colon, mucous or bloody stools, haemorrhoids; and,
if persisted in, many more of the symptoms of dysentery,
or even structural change of the colon and rectum. I am
confident that dysentery becomes chronic ; that an occa-
sional indigestion lapses into a constant dyspepsia ; and
that habitual constipation often passes into strictures of
the rectum, and haemorrhoids into fistulEe ; from the fre-
quent exhibition of large doses of this medicine. Inge-
nuity cannot possibly devise a more successful method
of converting a healthy person into a confirmed invalid,
of destroying many of the comforts of existence, and of
occasioning hypochondriasis and melancholy, than the
practice of prescribing large doses of calomel on every
trifling occasion,or when the bowels require gentleassist-
ance ; or because the patient erroneously supposes him-
self to be bilious, or is told so by those who should know
better. The unfortunate word " bilious" is the scape-
goat of the ignorant.

toms. A similar observation is also made by
Dr. Chevne. IIargens and Consbruch pre-
scribe calomel as a purgative in the verminous
complication ; whilst IIorn and some others con-
sider it, as well as mercurials generally, when
frequently repeated, or, in large quantity, very
injurious. Lind recommends the exhibition of
the pure quicksilver with sulphur, gum acacia,
and ipecacuanha, after emetics, with the view of
removing obstructions in the large bowels. Lei-
DENFROST directs small doses of calomel with
opium. Johnson and Renton give four or five
grains every four or six hours, or much larger
doses less frequently, also with opium, until
salivation is produced ; and Dr. Ferguson, half
a grain with a grain of ipecacuanha, every hour,
till the gums become affected ; bleeding having
been premised in the early stage of the inflam-
matory disease. rHw?icJ(OH is preferred by Boag
(Med. Facts and Observ. vol. iv. n. 1.), Clarke,
and HouLSTON, for procuring the specific effects
of this medicine, in the chronic and complicated
forms of dysentery. The observations already
(§ 101.) offered respecting mercurials, will show
the circumstances in which they may be em-
ployed, and the preparations that may be pre-
ferred. 'I'hey are most appropriate to the sub-
acute and chronic states, after depletions, when
the substance of the liver is not actively diseased ;
and are best combined with James's powder,
or ipecacuanha, or Dover's powder. Calomel,
or the hydrargyrum cum creia, should then be
given ; and if their specific effects soon follow,
the circumstance may be considered favourable ;
but the former should not be persisted in. The
latter, however, may be continued longer ; par-
ticularly in conjunction with ipecacuanha, as
being much less liable to increase the tenesmus
than calomel ; especially in the chronic disease.
When dysentery proceeds from endemic sources,
or when it assumes a very adynamic form, little
benefit beyond its chologogue operation is pro-
duced by it ; as I have had sufficient reason to
believe, that when given with the view of affect-
ing the system, it favours relapses, and protracts
convalescence.

134. L. //)ec((cHa?i/!n was first employed in the
cure of the disease by Piso, who brought it from
the Brazils (De Med. Braz. lib. ii. de Indite
xitrinsque Re Katurali et Medica, S^c. Amst
1658, fol. p. 231.), and had given it in drachm
doses, and in the form of infusion. But it was
not until Helvetius, who had come from Holland
to Paris, gave some of it, witii a knowledge of its
vitues, to the physician of Louis XIV., who
employed it successfully in the case of the Dau-
phin, then dangerously attacked by dysentery,
that it came generally into use. Marais (Ergo
Dyseiit.ajf'ect. Radix Brasiliensis. Paris, 1690.),
and soon afterwards Sloane (Philos. Trans.
No. 238.), Heister, Vater, &c., further demon-
strated its good effects. It has subse([uently been
very generally recommended, more particularly
by Akenside, Lind, Hillary, Desdois, Lin-
nSus, Duncan, Richter, and Hunnius. Since
its exhibition by Piso, in very large quantities,
JMr. Ealmain* seems to have been the earliest

• The importance of the subject has induced me to
give the substance of Mr. Balma'in's communication.
He states : — " I found the ipecacuanha, in small doses,
hvays useful (in dysentery) ; and, in an accidental con-

732

DYSENTERY — Treatment advised by Aurnons,

to employ it in this manner, in conjunction with
large doses of laudanum. A few years after-
wards, Mr. Playfair adopted this practice in
India; he giving from half a drachm to atlrachm,
with as much laudanum, and directing this dose
to be repeated again and again if it should be
rejected. JMr. English prescribed fi-om a scruple
to half a drachm, with double this quantity of
laudanum ; and Dr. ]3ateman confirmed the
propriety of this method in all the stages and
Ibrms of the disease, as he has observed it in this
country. More recently, Mr. Twining has
modified this practice, and directed from four to
eight — more frequently six — grains of ipecacu-
anha, with nearly as much extract of gentian,
and occasionally also with blue pill or calomel,
twice or tlirice daily ; premising bleeding and
alvine evacuations in the acute disease, and
resorting to mild purgatives once a day, during
the treatment. I had, in 1817 and 1818, given
from eight to ten grains of ipecacuanha with
opium, and sometimes also with calomel or blue
pill, with the best results ; having at first, by
mistake, prescribed the simple powder for the
compound; and afterwards continued the practice
when tlie circumstance and the effects became
known to me. Fischer directs ipecacuanha
when opiates fail of affording relief. Riianoe
(^Act. Reg. Soc. Haun. vol. i. p. 33.) combines it
with rhubarb ; and Claiike, Sciilegel, and An-
NESLEY give it in the form of infusion, which may
also be exhibited as an enema. Dr. Dick praises
it in the dysentery of India ; the bowels being
freely opened by clysters, whilst it is frequently
given by the mouth. It may be conjoined with
nearly every other medicine that can be exhibited
in this disease — with refrigerants and evacuants
in the inflammatory states, and wilii tonics and
antiseptics in the malignant ; and it will occasion
as much nausea in one or two grains, as in sixty ;
this effect being less remarkable after its exhi-
bition in the form of pill, and with bitters or
opium, or even with calomel, than when taken in
sim])le powder.

135. M. Rhubarb may be given either as a
mild purgative, or as a gentle astringent. It is
approved of by Bouellus (Cent. ii. obs. 82.)
Heister, Riedlin, Phingle, Jacobs, and
Baker; is considered injurious by Kortum,
Jawandt, Weber, Neumann and IMuusinna,
and is prescribed only in the most advanced
stage by Lino, Stoi.l, and Richter. It is

vci -nation with a Mr. Wentworth, who assisted me, I
formed the design ofgiving it in larger quantities. He
informed me, that a man, who lived in the same town
where he did, was uncommonly successful in the cure of
dysentery, hy using from a drachm and a half to two
drachms of ipecacuanha, with laudanum. Mr. W. had
just previously to this conversation, given ninety grains
• if the powder, with forty drops of tinct. opii, to a man
v,i!i(ise life was apparently near a dose, and with whom
evacuants had been used. There was a wonderful ahate-
ment of every symptom in the course of one night; and
a repetition of the medicine in smaller quantities, com-
l)leted the cure in a few days. I did not hesitate to follow
this practice ; and gave the ipecacuanha frequently to the
•juatitity of two drachms, with the addition of sixty drops
of tinct. o])ii : and, in many ca.ses, found that a dose or
two was suflicient to remove every dangerous symptom.
It answered the purpose best when given in the form of
pills; and if the patient kept still, and lay on his back,
with the head and chest tolerably elevated, nausea sel-
dom or ever followed it ; and oftentimes it happened that
he had not a stool the succeeding day, although, pre-
viously, the gripings were violent, and the discharges of
blood frequent and in largcquantitics." (Mem. of Med.
hue. (if Lund, vol, v. p. 210.)

much praised by PRiNGLE.in the camp dysentery ;
especially when exhibited in large doses after
emetics; and it is often of much service in the
dysentery of chUdien, conjoined with hydrargy-
rum cum creta, and minute doses of ipecacuanha,
or with absorbents and Dover's powder. It is
one of the best purgatives in the more asthenic
forms; but it is injurious in the early stages of
the inflammatory disease, or when the bile is
obstructed ; and it then often increases the tenes-
mus, as remarked bv VVendki.stadt and myself.
It is apt, in many constitutions, to suppress the
excretion of bile, even althougii it may open the
bowels ; and, upon the whole, it requires much
discrimination in its use.

136. iV. Camphor is favourably noticed by
Brefeld, Marcus, Sponizer (IIufeland, Joiirn.
der Pr. Ueilk. b. v. p. 546.), and RIende {Ibid.
Aug. 1810, p. 88.). Chambon directs it to be
dissolved in oil ; Michaelis conjoins it with
opium ; and Osiander and Tiiomann (Annalen,
1800, p. 258.) employ it freely, both internally
and externally. It is an excellent adjunct in
small do~es, to refrigerants or diaphoretics, in the
inflammatory or acute states ; and, in large
doses, with otiier antiseptics or tonics, in the
malignant variety, and in the verminous and
rheumatic complications. It is particularly ser-
viceable in the nervous or typhoid state ; and in
the advanced stage, when nervous symptoms su-
pervene. It may be given with ipecacuanha,
either in pills, or in demulcents ; and in emollient
enemata. In ihe infectious conditions, it should
seldom be omitted ; and may in these, especially
such as are malignant, be given in doses of ten
or twelve grains.

137. O. The terehinthinates are valuable re-
medies in the asthenic and clironic forms. They
were recommended by the author (Med. and
Phi/s. Journ. vol. xlvi. p. 107.), and have since
been employed by several physicians. The cir-
cumstances in which they n)ay be resorted to, and
the manner of prescribing them, are manifest from
what has been stated. They ate not contra-in-
dicated in tiie inflammatory varieties, although
bleeding should be premised ; and, when ex-
hibited so as to act gently on the bowels, or in
small enemata, they counteract the tendency to
sloughing or ulceration ; particularly in the as-
thenic varieties. Any of the /)u/.s«;hs — but more
particularly the Peruvian (F. 843.), Canadian,
and copaiba — may be given with aromatu^s,
magnesia, and demulcents; or with opnates ; and be
administered in enemata. They are most service-
able in the chronic diseases, especially when
assisted by frictions of the surface, deobstruent
plasters, flannel bandages, and regulated diet.
When the stools are frequent, and without pain,
they are particularly serviceable, the hydrargy-
rum cum creta being taken with Dover's powder
at night; or they may be alternated with either
the ha;matoxylon, catechu, or kino, in mucilagin-
ous or absorbeiit vehicles.

138. F. Aiitiscjilics are praised by Wedekind.
With a view to its antiseptic as well as to its ape-
rient operation, Jackson and Crawford advise
the use of charcoal, in doses of half a drachm or
a drachm, frequently repeated. It may be ad-
vantageously given rubbed up with camphor.
But the cliloruies are much more powerful agents.
The chlorate of potash is prescribed byGARNETT,

DYSENTERY — Theatmunt advised cy Auriions.

and the hyJio-chloruret of lime by Reid. This
latter, and the liydro-chloruret of soda, have
been employed by me in this disease since their
introduction into practice (see communication
from the Autiior to Mr. PIoui.ton, in the Appen-
dix to this gentleman's excellent translation of
Magendie's Formularu), and may be given with
demulcents, or in various other states of asso-
ciation, and in enemata ; especially in malignant
states, or when sloughing is dreaded.

139. Q. Besides the foregoing, various other
remedies have been recommended. — (o) All the
ancients, and Diesucrbhoeck (^Observ. et Curat.
Med. C. n. 29.), Rhefeld, and Paulini {Cent.
iii. obs. 76.), among the moderns, prescribe cold
applications to the abdomen, in tlie phlogistic
states of the di-ease. Lotions and poultices,
with the uitru-hiidro-chloric acid solution, are di-
rected to this quarter by ISlr. Annesley. — (fc)The
■nitrate o/'sixfu (Niemann, Mayer, &;c.) has been
recently exhibited in dysentery, in doses of about
a drachm, every four or five hours; or half the
quantity each hour or two, in demulcent mixtures,
with ipecacuanha (F. 929.). It acts as a refri-
gerant sedative and laxative, and is suited to the
phlogistic states. The trisnitrale of bismuth,
particularly with ipecacuanha and opium, is ex-
tremely serviceable in some acute, as well as
chronic, forms of dysentery. M. Lombard, and
several others, had employed it with or without
opium ; and, more recently, RIM. Recajiieii
and Trousseau have found it to possess much
efficacy as an antispasmodic sedative and astrin-
gent in this disease, and deserving adoption after
depletions and evacuations have been practised in
cases refjuiring them. (Gos. Med. Feb. 26. 1833.)
— (c) Nux vomica, or its extract, and its active
principle, strychnia, are recommended in the
chronic disease by Hufeland, Fischer, Haak-

MANN, GoeDEN, KlINGE, OdIIELIUS, HaGSTROEM,

Graves, and Oswald; but Hargens, Weber,
Mich AiJLis, and Horn state that they derived little
or no benefit from it. In the particular condition
now mentioned, either of the -above preparations
is often of use ; more especially the extract, or
strychnine, with ipecacuanha. — (rf) Hedera ar-
horea and h. terrestris are prescribed by Ca-
iMERARius (Memorab. cent. iii. n. 79.) ; the fruit
of the Adansonia, by L. Frank ; Armenian hole,
and the terra lemnia, or sigillata, by many of the
older writers; castor, with nitre, by Sciilegee ;
viusk, with camphor and absorbents, &c., in the
malignant states and last stages, by Hunnius ;
irax, with gum acacia, by Wedekind ; the decoc-
tion of vaccinium myrtillus, or bilberry, with burnt
spirit, by Fraser ; and the preparations of the
hop (F. 871. 900.), and of the diosma crenala
(F. 231. 396.), by the Author. In the com-
plication with rheumatism. Raker recommends
valerian, castor, and musk ; and, if there be little
or no fever, the preparations of guaiacum with
ipecacuanha and opium.

140. The chronic fonri of the disease will
occasionally baffle every method of cure. Mr.
Hooper states, that, in the cases of chronic
dysentery, forming a large proportion of the sick
which reached tiiis country from Corunna in
1808, emetics, purgatives, calomel to salivation,
Dover's powders with aromatics ; opium in large
doses, alone or with acetate of lead ; starch in-
jections with astringents, and various other medi-

733

cines, were given without benefit. Ralsam of
copaiba, with aromatics and opium, rhubarb being
also prescribed occasionally ; and, in other in-
stances, the decoction of bark with acids, opium,
and a small dose of calomel being taken at night ;
were, upon the whole, most successful ; a small
quantity of wine having been allowed, 'I'he
chronic disease is frequently prolonged by too
much food, especially in children, and sometimes
also in adults. The following are formula of a
few medicines not commonly prescribed, but oc-
casionally beneficial in the chronic states of the
disease : —

No. 204. R Infusi Cusparia; 3 xj. ; Acidi Boracici gr. x.
— 3 j. ; Vini Ipecacuanhte 711 xx. ; Tinct. Campliora:
Comp. 5 j. ; Syrupi Papaveris o jss. Fiat Haustus.

No. 205. R Sodaj Nitratis 3 ss. — 5 j. ; Pulv. Acacite 3 ij. ;
tore simul, et adde A(\. Pimenta; (vet Cinnam.) 3 vij. ;
Villi Ipecafuanlioe 3 iij. M. Capiat Coch. unum, tccunda
vel tenia quaque hora. (Mayer.)

No. 206. R Extr. Nucis Vom. gr. vj.; Pulv. Ipeca-
cuanha; gr. xij. ; Extr. Huiinili 5 j- Miste probe, et
divide in Pit. xxiv., quarum capiat duas, quarta vel sexta
quaque hora.

No. 207. R Extr. Nucis Vomica; gr. x. ; Mucilag.
Acacia; 3 j- ; terebene, et adde Mist. Amygdal. JJulc. et
Mist. Caniphoveeaa 5 iij. ; Vini Ipecacuanhje 3 ij. ; Tinct.
Caniphoree Comp. 3ss. ; Syrupi Altha'a;, 3 ss. M. Sumatur
Coclileare unum omni bihorio.

No. 208. R Strychniae gr. ij. ; Pulv. IpecacuanhEB
gr. xij. ; Conservae Rosar. 3 ij. Misce probe, et divide in
Piliilas xxiv. Capiat duas, quartis horis.

141. It. The Diet and Regimen, in all the states
of dysentery, should be strictly regulated. In the
phlogistic variety, abstinence must be strictly
enforced. In the more asthenic, gentle nourish-
ment should be tried, and its effects upon the
bowels and the constitutional affection carefully
observed. Milk, either recent or boiled, is recom-
mended by Alexander Trallianus, and most of
the ancients. C.^lius Auhelianus directs it
with honey. This last is both an excellent article
of diet, and vehicle for medicines, in many in-
stances, and it may often be advantageously
given with small doses of biborate of soda. Milk
is praised both as food and medicine by Schmidt
(Ergo Dysen. Lac. Monsp. 1649.), Borellus, and
De Haen. Sydenham gave it by the mouth and in
enemata. The celebrated Royle (]Vorks, vol. v.
p. 113., the Advantages of Simple Remedies,) di-
rected milk, boiled witii an equal quantity of
water, until there remained as much as the milk
first amounted to. A decoction of the leaves and
flowers of the verbascum thapsus in milk is a
popular remedy in Ireland. Mursinna and Van-
derHeyde prefer buttermilk ; and Richer, whey.
JMilk may also be taken witli the gums, honey,
and lime water. Animal gelatin (Gautieri, ia
Hufeland's Journ. d. Prac. Ilcilk. b. xviii.
p. 137.), in the form of jelly, or beef-tea, may be
tried with spices, in the asthenic and chronic
forms; but they are not always found to agree.
Farinaceous articles, as sago, tapioca, rice,
biscuits soaked in beef-tea, mutton or veal broth,
&c., are the most genen.lly useful. If the patient
have been habituated to a liberal use of wine or
spirits, a little burnt brandy or wine may be given
with these or with his beverages ; and, in the
more urgent cases, aromatics may be added. For
drink, he may have weak gruel, or barley water,
or either of the beverages prescribed in the Ap-
pendix (F. 588. et sei/.) that will suit the case,
and the treatment employed. He ought, from
the first, to be placed between warm blankets ;
the beil-pan being used, to prevent his getting out
of bed to the night-chair, and ,the chills con-

DYSENTERY — BiDUOonAPny and References.

734

sequent thereon. In chronic cases, a large warm
deobstruent plaster (§ 109.) should be applied over
the abdomen, whicii ought to be surrounded by a
flannel roller. (Dewar, &c.) During conva-
lescence, also, the diet and clothing should be care-
fully attended to ; as an error in the former, and
insufficiency of the latter, particularly at nigtit, will
often occasion relapses, to which there is a greater
tendency in this, than in almost any other disease.
Chauo;eofuir, exercise on horseback, and travelliug,
with due precautions against cold and other injuri-
ous contingencies, are also very beneficial. After
repeated attacks, or after the chronic disease, the
Harrcugate water, or the artificial mineral waters
of Carlsbad, or oiMarienhad,\n quantity sufficient
to act gently upon the bowels; and subsequently
those of Eger, Pyrmont, or Spa with the occa-
sional alternation of those of Seidschutz or Pullna ;
this plan being varied according to the peculi-
arities of the case ; will often prove of service.
Warm or tepid salt-water bathing, or the affusion
of tepid salt water over the abdomen, will also
promote a perfect lecovery.

142. .S'. Fropliijlactic measures are sometimes
necessary ; particularly where the endemic causes
abound, in autumn after rains, or in cold and wet
seasons in warm climates ; and when the disease
is epidemic. These measures consist chiefly of
avoiding the predisposing and exciting ca\ises,
especially injurious ingesta(§ 10. 22.) ; of filtering
or boiling impure water, and of purifying it, by
mixing with it antiseptic absorbents, as lime, the
chlorates, &c.; of regular habits, and wholesome
and digestible food ; of wearing flannel next the
skin, and shunning exposure to the night dews,
or to cold and moisture ; of sleeping in warm
beds and airy chambers, elevated far above the
soil ; of avoiding the air of close apartments in
which the sick are confined, and the emanations
from the bodies of those thus circumstanced, or
from the evacuations, when the disease presents
any of the asthenic characters ; of not using the
water-closet or night-chair resorted to by those
affected ; of having recourse to the chlorurets, to
destroy the noxious effluvia ; by sprinkling the
apartments with them, or throwing them into the
vessels containing the evacuations, or into the
water-closets ; and of the absence of all dread of
being affected.

BiBLioG. AND Refer. — Hippocrates, Aphor. iii. 11, 12.
16. 22. HO., vi. 48., vii. 5. 23. ; PrEenot. ii. US. 121. ; De
Affect, xxiv. 4—8. ; ETiStifj-iuv , 1. v — Celsus, 1. iv. c. 15.
— Arclieus, Chron. 1. ii. cap. 9. — Galen, De Locis Affect.

1. iii. cap. 5, 6 Ciclius Aurelianus, Morb. Chron. 1. iv.

c. (j. — Oribasius, Synopsis, 1. ix. cap. 14,1.5 Aetius,

Tetrabibl. iii. s. i. cap. 43. — Alexander Trailianus, Opp.
1. viii. cap. 3, 4. 8, 9. — Paulus JEginela, Medicina, 1. iii.
cap. 42. — Aviccnna, Canon. 1. iii. fen. 16. tr. i. cap. 2., et

tr. ii.cap. 7 Fcrnclius, De Morb. Iiitestin. Patliol. 1. vi.

c. in. — //. Bonacosms, De Dysenteria, 4to. Bon. 1.5.52.

— l)u lirevU, Ergo Dysent. Catliartica. Paris, 1.578

Fabricius llildamts, De Dys. hoc est Cruento Alvi Fluorc,
8vo. Openh. IfilG. — C. Lcpuis, vel Piso, De la Nature,
Causes, ct Uemedes des Malad. Populaires accompagnt'cs
<le Dyssenterie, &c. 12mo. 1023. — J. Delatiwnikre, Ob-
serv. Fluxfts Dysen. Lugduni Gallo Grassantis, a.d. 1(;2.5,
12mo. l.ugd. \rm. — Ilorstins, i. p. 274., iii. p. 108. —
forcites, 1. xxii. obs. 38. — /.V/Hi'n, lirgo Dys. Phlebo.
tomia. Paris, IfiTO. — Lnpel, Krgo Dys. Opium. Paris,
IfiOO. — H. Morion, I'yretologia, sive Tract, de I\I<jrb.
Aeutis. Gen. l()!)(i,ii.UiO'. — Jones, De Morbis UilirriKiruin,
speciatim d(^ l)ys. llybcrnica, 4to. I>nnd. KiUS — Iltinliiis,
D(! Med. Indonim, cap. iii. \k 218. — (liiiirlier. An Inci-
I>ii'nti Dys. pnestantiiis .-ib Astrini,'ciitil)ns aiit ICincticis,

•jiiani uVeiKesectioneKeiricdiuin ? i'aris,1703 M.Al/ierli,

Do Dys. cum Petecliiiset I'lirptirfi, 4to. niila',1718 J.J,

ll'filrl.iclimirlt, De Dysen. Mali^'na, 4t<>. Marl). 1730, —
A. Vuler, Dc Ipecucuanlio; Virtute t'ebrif. ct Antidysen-

terica, 4to. Viteb. 1732 F. Uqff'mann, Dc Dysenteria,

Opera, Supp. Ii. Hals, 1734.— X IJ.Degner, De Djs.
Bilioso-contagiosa qucE 173G, Neomagi, &c. epidemic^
grassata fuit, &c. 8vo. Traj. ad Rh. 1738. — Baglivi, De
Pr. Med. 1. i. cap. 9 — C. J. Hempelius, De Dys. Maligna,
&c. 4to. Erf. 1739 — L. R. Desbois, An Dysen. Ipecacu-
anha? 4to. Paris, 174.5. — L. Griiber, De Febre Acuta
Epideraica E.xanthematico-Dysenterica,4to. Bas. 1747. ;
et A. later, De Dysent. Epid. maxime Contagiosa et
Maligna, .Super. Auno Pat. Davastante,4to. Viteb.1747. ;
in Halleri Collect, vol. iii. 380. et 399. — Costa, De Diar-
rhota et Dysenterica Epid. quae grassabantur, &c., 4to.
Pusel. Rba-t. 17t7. — Morgagiti, l5e Sed. et Caus. Morb.
epist. xxxi. eh. 5—2.5. — J. T. Laurich, De Sing, quadam
Indorum Orientalium Dysen. ejusderaque pra?cipua a
nobtrate Differentia, 4to. Halae, 1752, in //a/iere Collect.
vol. iii. p. 421. — liuxham. Opera, vol. i. p. 283. — J. F.
Cartheuser , De Profluviis Alvi Cruentis, 4to. 1760. —
G. Baker, De Catarrho et Dysenteria Londinensi Epi-

demicis. 1762. Lond. 1764 R. A. f'ogel, DeDys. Cura-

tionibus Antiquis, 4to. Goet. 1765. — Isenfiamm, De
Dys. Affinitate. ErI. 1760. — M. Akenside, Commentarius

de Dysenteria. Lon. 1706 A. E. Biichner, De Cautius

Defcndenda Fructuum Horeeorum in Produc. Dj^sent.
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1760. — A. Monro, in Edhi. Med. Essays and Observ.

vol. iii. p. 516 Whytt,m Ibid. vol. iii. p. 300 — Grainger,

in Ibid. vol. ii. p. 282. — Linneus, Amceuit.'Acad. vol. v.
p. 82. — G. Pringle, in Edin. Med. Essays, &c. vol. v.
art. 15. ; and On Dis. of the Army in Camp and Gar-
rison, 8vo. 7th ed. — P. G. Schroeder, De Dys. Analecta
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Ruhr unterdem Volke, im Jahre 170.5. 8vo. Ziir. ; trans-
lated by Hobson. Lond. 1772, 8vo. — Ackermann, De
Dys. Antiquitatibus. Lips. 1777.— S/ws, On Epidemical
Disorders, 8vo. Lond. 1773, p. 103. — C. F. Eisner, De
Dysen. Differentiis, 4to. Keen. 1781. — M. B. Moseley,
Observ. on the Dys. of the West Indies, 8vo. Lond. 1781.

— Vcrhagen, De Dys. Biliosa Putrida, 8vo. Col. 1782

Duncker, De nonnul. PriEJud. et Abus. circa Dys. Curam
vitandis. Duisb. 1782. — J. tiollo, Observ. on the Acute
Dys. 8vo. Lond. 1780.— i^. H. Birnslicl, De Dysen. 1778,
1779, et 1780, Epidemica, &c. 8vo. Manh. 1786. — Cowley,
in Lond. Med. Journ. part iv. 1786. {Complicat. with
scurvy.) — J. Hunter, On the Diseases of the Army in

Jamaica, 1796 Lind, On Dis. of Hot Climates, p. 248.

— Clark, in Edin. Med. Comment, vol. ii. p. 13. — Adair,
in Ibid. vol. ix. p. 210. {In negroes.) — Atcheson, in Ibid.
vol. ix. p. 268. {In negroes.) — Dick, in Ibid. vol. x. p. 217.

— Jf'rig/it, in Ibid. vol. xi. p. 190 — J. Hunter, in Ibid.
vol. xiii. p. 130. — M. Stall, Rat. Medendi, &c. vol. iii.
p. 97., vol. iv.p. 68., vol. vii. p. 219 — Cleghorn, On the
Dis. of Minorca, p. 252. — Balfour, On Sol-lunar In-
fluence in Fevers, p. 17. — Barbou, De Dys. Contag.
prascipue qu;v in Ind. Orient. Observata, 8vo. Lug. Bat.
1788. — J. Clurk,On the Dis. that prevail in long Voyages

to Hot Countries, &c. 2d ed. 1792, p. 317 Durondeau,

Traite de la Dyssenterie, 8vo. Brux. 1789. {Contains a/t
account of the epidemics of 1779, 1780, 1781, 1782, and
1783: a learned tvork.) — G.H. Jairandt, Beobacht. einer
Ruhrepid. in Meiningischen, &c. 8vo. Riga, 1794.— C
Himly, Observ. qua'dam circa Epid. hujus Anni Dysent.

4to. Goet. 1794 Hufeland, Annals of Medicine, vol. i.

p. 44 Wright, in Ibid. vol. ii. p. 309. — Slierwen, in

Ibid. vol. vii. p. 269. — J. P. Wade, Evidences of a suc-
cessful Method of healing Fever and Dysentery in
Bengal. Lond. 1792. 8vo — Vandorpe, Essai sur la Dys.
Epid. qui a rcgiie en Flandres, 4to. Courtray, 1705. —
Leidenfrost, De Usu Opii et Mercurii in Dys. 4to. Erf.
1795.— G. C. T. Wedekind, De Morb. Primarum Viarum
veraNotitiaet Curat. 4to. 1797 — W. Bay, On the Oper-
ation of Pestilential Fluids on the large lntestincs,termed
Dysentery, 8vo. New York, 1797. — F. W. C. Ilunnius,
Abhandl. iiber die Ursachen u. Hcilung der Ruhr u. d.
Complicationem, 8vo. Jenae, 1797 — Lindenmann, Ucber
die Ruhr u.d. Heilart. Bresl. 8vo. \mO. — Osiander,
Dcukwiirdigkeiten, b. ii. p. 240. — J. F. Engelhard, Ueber
die Ruhr, &c. 8vo. Wint. 1797 — Kreyssig, Dc Peculi.iris
in Dys. Epidemica Miasmatis Pra;sentia,&c.4lo. Vit.1799.
—Hesse, Disquisit. circa Usum Evacuantium in Dys.

4to. Jen. 1800 P. Assalini, Observ. sur la Peste, ctsur

le Flux Dys. I2mo. Par. \H0\.— Atkinson, in Lond.
Med. and Phys. Journ. vol. xi. p. 508. — Whyte. in Ibid,
vol. ii. — O. Blanc, Oliservat. on Dis. of Seamen, 3d edit.
Lond. IS(I3. /).7,v,n//«.— //. 7);'(/'((j-, Observat. on Diarrhcea
and Dy.sent. as they a)iiii':ircd in the Brit, Army in Egypt,
8vo. r.on-.l. 18(12. — J.A.Fl.tiry, Sur la Dys., avecquelques
Consid.sur la Frci|Ucnec a biird des Navircs, 8vo. Paris,

1803. — Vcsgenclles, in Kecueil de la Soc.de Med. t. ii

Assalini. On the I'lague, Dysentery, &c. of I'^gypt, &c.

j'.'inii. 18(14 JK. Harty, Observ. on the Simi)le Dys. and

its Cuniliiuations, 8vo. Lond. 1805 L. Deplace, Consid.

sur la Dys. des P.ays Chauds, 4to. Paris, 1808. — J. I'.

Frank, De Cur. lloniin. Morb. &c. vol. vii. pars ii

A. a. IHrhler, Die Specielle 'I'berapie, b. ii. p. 112

F. Schumacher, Beitriige zur Nosogenie, u. Nosol. des

EAR — Noises in —

Ruhr. Erf. a M. 8vo. lS\2.—Latour, in BuUut.des Scien. i
Phys. d'Orl^ans, t. i. 1810. (^Chiefly on opium in tigs.) —
Tonnclicr, nel'Epid. Dys. quiaregne dansTArroiid. de
Tournay, dans les An. 1810 et 1811, in Joutu. do Med.

t. xxviii G. fyrde/cind, Ueber die Kulir. Frankf. 1811.

— Schceffir, in Ht(fcland u. Himly's Journ. der Heilk.
Sept. 1812, p. 38. 46. — /iadt'?7i«cA(?;-, in Ibid. Aug. 1810.
Mendc,m Ibid. Aug. 1810. — Horn, Archiv. fiir Pr. Me-
dicin. b. vi. p. 91. 126. et 330. — Goedcn, in Ibid. Mar.
lSV2,p.3l3.— J. M'Grigor, in Edin. Med. and Surg.
Journ. vol. i. p. 179. (/n Bombay.) — Batenian, in Ibid,
vol. V. p. 12G., vol. xi. p. 531. — Hooper, in Ibid. vol. v.

p. 399. — LicMenstein,\n Ibid. vol. vi. p.29G I'layfair, in

Ibid. vol. ix. p. 27. — English, in Ibid. vol. x.p. 4 J8. — Craw-
ford, in Ibid, vol.xii.p. 27. — Batcman, in Rees's, Cyclo-
paedia, art. Dysentery ; and in Edin. Med. and Surg.
Journ. vol. iv. — Hope, in Edin. Med. and Surg. Journ.

vol. xxvi. p. 35. — Burke, in Ibid. p. 56 So/h^-.*, Suggest

for the Treat, of Dy sent. Lond. 8vo. 1816 Broussais,

Hist, des Phlegmasies Chronlques,8vo. 3d ed. Paris,1829.
— J. M'Origor. in Trans.of Med. and Chirurg.Soc.vol.vi.

p. 430. — Ferguson, in Ibid. vol. ii Bacot, in Ibid. vol. vii.

— Cheyne, in Dublin Hosp. Reports, vol. iii. p. 1 -Barry,

in Ibid. [). 10. — Perst07i, in Ibid. p. 21. — Halluran, in Ibid,
p. 9. (Epidemic in im&and 1821.)— 0' Ilrintc, in Trans, of

Irisli CoU. of Phys. vol. iv. p. 386 0'/>';7V»,iii lliid.vol.v.

p. 221. — Hi/son and Broum, Glasgow Med. Journ. vol. 1.

p. 39. 48 Macfarlane, in Ibid. vol. i. p. 101 G. Bal-

lingall, Pract. Observ. on Fever, Dysentery, and Liver
Complaints, 8vo. 2d.ed. Edin. 1823. — Jackson, Hist, and
Cure of Fever, part i. ch. 13. p. 324. — O'Brien, On the

Acute and Chronic Dys. of Ireland. Dub. 1822 G. S.

7i«//it;,7b>-rf,DeDysenteriaBatavia;Orientalis,&c.8vo. Ed.
1H18. {infectious.) — Fournieret f'aidy, in Divt.des Scien.

Mcd.vol.x.p.315 f frg!/4o», Trans.of Med.. Chirurg.Soc.

t. ii. p. 181 Renton, i\\ Trans, of Med. and Chirurg. Soc.

of Edin. vol. ii.p. 374. — Pisani, Archives Gener. de Med.
t. v. p. 584. — Trousseau, in Ibid, t.xiii.p.l. (Epidemic.) —
Denoyer, in Ibid. p. 444., et t. xiv. p. 33. (Epidemic.) —
Compagny, in Ibid. t. xvii. p. 295. (Endemic.) — /.. ./.
Schm!dt7nan7i, Surama Observat. Med. &c. t. i. cap. x.

p. 176.— Frame, Rev. Med. t. iv. 1825, p. 68 L. Frank,

De Pcste Dysenterica, &c. 8vo. Vien. 1820 Chiskolm,

Climate and Dis. ofTrop. Countries, 8vo. Lond. 1822.
p. 54. — Bamp/ie/d, On Tropical Dys. particularly as it
occurs in the East Indies, and on Scorbutic Dys. &c. 8vo.
Lond. 1823. — M. Good, Study of Med. by Cooper, vol. ii.
p. 595. — Jo7ies, in Medico-Chirurg. Review, voi. iii. p.272.
( Typhoid and i7ifeclious in crew of ship of war. ) — J. A .F.
Uxanu77i, Uistoire Mtd. des Maladies Epidemiques, &c.
t. iv. p. 90. — J. Johnson, On the Influence of Tropical
Climates on Europ. Constitut. &c. 4th edit. p. 225. —
P. Vignes, Traite. Complet de la Dys. et la Diarrh. &c.

8vo. Paris, 1825 Re7iton, in Trans, of Edin. Med. and

Chirurg. Soc. vol. ii. p. 376. — Elliotson, in Trans, of

Med. and Chirurg. Soc. vol. xiii. p. 451 Baillie, Lect.

andObserv. on Med. Lond. \9i2Z.—J.A7i7icstey, Sketches
of the most Preval. Diseases of India, &c. 8vo. 2d edit.
Lond. 1831. — J. Annesley, Researches into the
Causes, Nat. and Treat, of Dis. of India, and of Warm
Climates, &.c. 4to. Lond. 1828, vol. ii. passim.— Bright,
Reports of Medical Cases, &c. 4to. vol. i. Lond. 1827,
p. 176 — J. Abercro77ibie, Path, and Pract. Researches on
Dis. of the Abdominal Viscera, &c. 2d edit. Edin. 1830,
p. 230. rt Acy. — Kreyssig, in Encyclopadisches Worter-
buch d. Medicinisch. Wissensch. &c. b. ix. p. 627. — A.
Bompard, Traite des Mai. des Voies Digestives, &c. 8vo.
Paris, 1829, p. 128.— IValsh, in Trans, of Med. and Chi-
rurg. Society of Edin. vol. iii. p. 512. (O71 the Scorbutic
Dys. in the Burmese War.) — W. Ttcinijtg, On largeDoses
of Ipecacuanha in Dys., in Trans, of Med. and Phys. Soc.
of Calcutta, vol. iv. p. 170. ; andOn the Pathol. andTreat.
of the most important Dis. of ISengal, 8vo. Calcutta,
1832, p. 1.

DYSMENORRH^EA. See Menstruation.

DYSPHAGIA. See Deglutition, Diffi-
cult.

DYSPNCEA. See Respiration, &c.

DYSURIA. See Urine, &c.

EAR — Nervous Affections of the.

1. Certain diseases of the ear will be here con-
sidered ; which, although sometimes attended by
disorder oi lieuring ; and often terminating in im-
pairment, or loss of this sense ; are not necessarily
accompanied by either. — In the article He.vring,
the affections or this function will be viewed with
reference to the lesions producing them, seated in
different parts of the organ.
I. Noises in hie Ear. Syn. — Tinnitus, Susnr-

rus, Sonitus, Sibiius, Syrigmus, Bombus, Aurium,

Pathology of. 735

Auct. Paracusis illusoria. Good. Das Ohrent'ii-
lien, Ohrenkliiigen, Ger. Tiiileinent, Bourdoiine-
meiit de COreille, Fr. Singing in the Ear.
Classif. — 4. Class, 2. Urder (Good.) —
I. Class, IV. Oroer (^Author).

2. Defin. — A sense of ringing, whizzing, or
beatiiig sounds in one or both ears, without external
causes.

3. i. These sounds vary in their characters. They
are sometimes sharp, shrill, ringing, and succes-
sive ; occasionally whizzing, roaring, acute, and
continuous; and in other instances, beating or
throbbing. They may be recurrent or intermit-
tent, or devoid even of remissions, and be heard
either in one or in both ears. M. Itard — the
highest authority on diseases of the ear — divides
them into, — ■ 1st, The false, or those which have
no existence whatever; and, 2d, the true, or
such as are seated in the interior of the head, or
of the ear, but without being caused by external
sonorous bodies. Tiiiniius uHriu7n is most fre-
quently attended by a slight degree of deafness,
which, in some cases, it produces, and in others
is merely coincident with it. (a) True tinnitus
may proceed from — a. cerebral plethora, con-
gestion, or determination; — B. the impeded or
obstructed return of blood from parts within the
head ; — and, y. mechanical obstacle to the free
circulation of air in the different compartments of
the ear ; but without completely preventing its
entrance, for then the noise would be replaced by
simple deafness, ^^'hen the noises depend upon
the state of the cerebral circulation, tiiey are ge-
nerally beating, heavy, hissing, or whizzing ; fre-
quently correspond with the pulsation of the
carotids, which also is often strong ; and are ar-
rested by pressure of these vessels. (6) False
tinnitus is — a. idiopathic, as when a very loud
noise has injured the functions of the auditory
nerve : and, ^. symptomatic, when allied to some
nervous affection, often unappreciable in respect
either of its cause or of its nature, or sympathetic
of disorders of some other organs. Thus, this af-
fection often attends indigestion, and hypochon-
driasis, especially in persons devoted to prolonged
and exhausting mental exertions ; sometimes de-
bility or hysteria, particularly in delicate females,
who have suffered from excessive discharges, or
who are addicted to venereal indulgences or ma-
nustupratio ; and occasionally disorders of the
prima via, as worms, torpid states of the colon,
lice. In this variety, the noises are, in some
cases, of a very unusual and even singular kind ;
and in hypochondriacal, nervous, or melancholic
persons, give rise to various fancies or even ImlUi-
cinations. In the case of a lady, for whom I
was lately consulted at the same time with two
other physicians, and who complained of noises
in the ears after having suffered in her general
health from too frequent returns of the catemenia,
in excessive quantity, theie gradually arose in the
mind of the patient, an idea that persons were
engaged whispering behind her; and ultimately
it took so firm a possession of her mind, that it
amounted to an hallucination, influencing both her
judgment and her actions.

4. ii. Noises in the ears are most frequently
caused by interruption to the free circulation of
air through the Eustachian tube. Hence they are
common attendants on catarrhs, and on enlarge-
ment of the glands, &c. in the vicinity of the tube ;

736

EARACHE — Pathology — Causes of.

anil are often produced by currents of cold air
falling on one side of the head or directed towards
the ear, as by travelling in an open carriage, or
with a carriage window open ; or by having the
hair cut, when abundant, in cold weather. \Vhen
caused by partial obstruction of the eustachian
tube, a loud noise or crack is heard upon yawn-
ing ; and the sounds often cease, or are diminished
for some time afterwards. They are frequently
a troublesome symptom during convalescence
from fevers; and are sometimes attendant upon
rheumatic affections of the head or neck ; in both
which circumstances, they are probably depen-
dent on morbid sensibility of the auditory nerves,
or on determination of blood to the head, or on
both. JMr. I'oD imputes them chiefly to a faulty
state of the secretions of the ear, in respect either
of quality or quantity; INIr. Buchannan, princi-
pally to an imperfect secretion of cerumen. Their
dependence upon derangements within the head,
as well as upon affections of distant organs, should
always be kept in mind, whilst investigating their
nature and relations, and hence the propriety of
viewing them in the comprehensive manner adopt-
ed by M. Itard.

5. iii. Tkeatment. — The ancients, especially
Celsus, paid considerable attention to this affec-
tion ; many of these remedies are active and ap-
propriate. It is obvious that the means of cure
should be directed to the pathological conditions
on which it depends. In the true tiimitus, es-
pecially when it is of a beating kind, vascular
depletions should be prescribed. M. Itard has
seen it instantly vanish upon opening the jugular
vein. Active and continued purging, with due
attention to the digestive organs, is also requisite
ia these cases. Symptomatic false tinnitus should
be treated according to the nature and seat of the
primary affection. When it is connected with
rheumatism, Grapengiesser and Ritter advise
having recourse to electricity or Galvanism. For
the true nervous or idinpalhic affection, tonics,
nervines, blisters behind the ears, stimulating
gargles, and antispasmodics may be prescribed.
Heister recommends in such cases fumigations
of the ears with the vapour of a hot vinous in-
fusion of rosemary and lavender ; M. Itard, fu-
migations with ajther directed to the meatus, fiic-
tions of the scalp, and warm applications, with
the view of promoting an abundant transpiration
ia this situation ; and iVIr. Buchannan, two drops
of the mixture of equal parts of pyroligneous
acid, spirit of sulphuric lether, and spirit of tur-
pentine to be introduced into the ear. The di-
gestive organs should be assisted by stomachics,
aperients, or purgatives ; and transpiration pro-
moted by gentle diaphoretics, and moderate ex-
ercise in the open air. When tinnitus arises from
cold, the same means, or those usually resorted
.to in Catarrh, with attention to the state of the
bowf^ls, will be ajipropriate. Gargles al«o vvith
the hydrochlorate of ammonia, or nitrate of potash,
or this latter and the biborate of soda, will also
be useful. In this form of the affection, little fur-
ther should be attemjiteil, unless it become chnmic,
from partial obstruction of the tube, or diminisiied
secretion of cerumen, in which cases it is gene-
rally associated with some degree of deafness,
when it will require the treatment advised, in such
circumstances, in the arliclc Heauing — diini-
ituliun of, &^c.

BiBLioG. AND Refer. — Cclsiis, 1. vi. c. 7, 8.— Aetius,
Tetral)!. ii. Serm. ii. c. 78 — Paiilus ^ginefit, 1. iii. c. 23.

— Aviccnna, Canon. 1. iii. fen. 4. Tract, vol. i. c. 9. —
Schenk, DeTinnitu Auriiim. Jena;, 1607. — Helbick, De
Sonita et Tinnitn Aurium. Altd. \&W.—Finclccnau, De
Tinnitu Aurium. Reg. 1706. — Hoffmann, De Auditus
Vitiis, Opera, vol. iii.obs. i. p.243. — lantkc, De I'iiinitu
Aurium ejusdemque Speciebus. Altd. 1746. — Sauvages,
Class VIII., Order IV. Nosol. Method.— Leidenfrost, De
Tin. ct Susurro Aurium. Duisb. 1784 — Doering, vol. i.
p. 20.5 — Louis, Med. Comment, vol. iii. p. 52. — Wegener,

De Susuno Aur. Duisb. 1785 Grapengiesser, Versuche,

p. 130 2iitter, in Hufeland, Jourii. d. Pract. Heilk.

I), xvii. St. iii. p. 40.— J. M. C. Itard. Traite des Mai. de
rOreille, &c. 8vo. Paris, lt<21, t. ii. p. U. — Andral,
Diet, de Med. t. xx. p. 42.'>. — T. Buchannan, Illust. of
Acoustic Surgery, 8vo. Lond. 1825, p. fiO.— i>. 7'orf, The
Anat. and Pliys. of the Organ of Hearing, with Remarks
on its Diseases, &c. 8vo. l.ond. 1832. p. 121.

II. Earache. Syn. — Otalgia (from oSj iStoj,
the ear, and aXyeai, I pain) ; Ohrenschmerz,
Ohrenzwaiig, Germ. ; Otalgie, Fr.

6. Defin. — Violent pain, generally in one ear,
suddenly supervening, and ojten abruptly depart-
ing, without fever.

7. i. Eucac/fe is most frequently s(/OTpfoma<ic of
inflammation of the ear, or of the presence of
foreign bodies, or of insects in the meatus, or even
of congestion or inflammation within the head.
It sometimes also attends inflammation of the
pharynx, or of the tonsils and fauces, or of the
parotid gland ; and is occasionally consequent
upon small-pox, scarlet fever, and erysipelas of
the adjoining parts. More rarely it is idiopathic,
or a purely nervous affection, seated either in the
nervous filaments sent to the internal parts of the
ear, or in that part of the facial nerve passing
through the aqueduct of Fallopius, or in tlie
filaments of the acoustic nerve, which seems the
least probable seat. The idiopathic, or true nerv-
ous otalgia, is at its maximum of intensity on its
invasion ; and, unlike the pain attending otitis,
does not gradually increase in severity, nor is it
attended by throbbing, and inflammatory fever.
Its duration is very uncertain. Sometimes it dis-
appears abruptly in a very short time, occasion-
ally being followed by neuralgic or rheumatic
pains in some part of the face or head, or even in
u remote part of the body — an occurrence fur-
ther distinguishing it from otitis — and frequently
again returning to the same ear, and very rarely
to the other. When the pain is excessive, it often
irradiates along the nervous filaments over the
same side of the cranium, or of the face, or both,
the eyes sometimes becoming red and watery ;
but it seldom or ever occasions delirium or convul-
sions (Itard), unless it be connected with inflam-
mation of the internal ear, or is produced by in-
sects or foreign bodies in the meatus. When,
however, the pain proceeds from this latter cause

— an occurrence which is not unfrequent, parti-
cularly in children, anil of which I have seen
several instances amongst the poor and squalid —
dangerous and repeated convulsions often super-
vene. Noises in the ear, and often a slight deaf-
ness, accompany otalgia; indicating the coinci-
dence of extreme exaltation of sensibility in the
parts composing the ear, with a diminished power
of perceiving sounds; and evincing that the
acoustic nerves are not the seat of the exquisite
pain that is felt. Like all nervous affections, it is
never constant in its course : it may be continued
or intermittent ; may recur several times, after
irregular intervals ; or it may appear once and
never return.

8. ii. The Causes of earache are those of all

EAR — Acute Inflammation of — PATHotocY.

737

other nervous affections. Otalgia is much more
common in females than in males; and it some-
times attends the early periods of pregnaticj'. It
is often symptomatic of disorder in tliu prima via,
and is frequently connected with rheumatism, par-
ticularly of the face, head, or neck; as well as
with facial neuralgia and tootiiach. M. Andual
treated a case in wiiich it alternated with sciatic
neuralgia. INI. Fauciiard records an instance
where it long resisted all treatment, until a C!u-ious
molar tooth on the same side as the affected ear
was extracted ; and Mr. Pettigrew, in the case
of a lady suffering excruciating agony from this
affection, directed the wisdom tooth to be drawn,
which he correctly inferred to be its cause, and
the pain was instantly abated. \'arious writers
have seen otalgia consequent upon the disappear-
ance of rheumatism and gout. A case following
rheumatism occurred in my own practice ; and
another, produced by a current of cold air falling
on the ear. This last is, perhaps, one of its most
frequent causes. Earache may exist for some time,
and either excite, or be merely contingently fol-
lowed by, otitis, which, however, may have com-
menced long before its usual signs were fully
developed.

9. iii. Treatment. — If this affection be symp-
tomatic, the means of cure must be directed to the
primary disease. (See Ear — Injiammatinn of.)
If it arise from a foreign body, this should be ex-
tracted without greatly increasing the irritation ;
but if that cannot be accomplished, it will be
better to wait its spontaneous discharge by means
of the increased secretion which will be occa-
sioned. Insects may be dislodged by injecting a
sufficient quantity of an emollient oil into the
meatus ; or by introducing a small piece of sponge
or cotton, with oil, by means of a probe. Infu-
sion of tobacco, various other narcotics, and even
acrid substances, have been directed to be em-
ployed for this purpose ; but I believe that they
may sometimes prove injurious, — an opinion also
entertained by M. Itard. For the more obvi-
ously nervous or idiopathic otalgia, the ancients
recommend the injections of warm emollient or
stimulating oils ; or these conjoined wit'u ano-
dynes. C^ELius AuRELiANus adviscs tepid oil to
be dropped into the ear, and wool to be stuffed
into it ; he also directs fomentations, poultices,
scarifications, and leeches, — remedies often ser-
viceable, and generally safe. ]M. Itard states,
that he has seen opiates introduced into the meatus
for this affection followed by cerebral symptoms;
he therefore prescribes the injection of tepid emol-
lients, such as milk, the decoction of marslimal-
lows, &:c. ; means but little different from those
mentioned by the authority just referred to. In
addition to these he recommends the mouth of a
phial containing three drachms of Hoffjiann's
anodyne, and half an ounce of water, to be directed
to the meatus, the phial being kept immersed in
warm water ; and an abundant transpiration from
the surface of the head to be excited, by sponging
il with warm water for a quarter of an hour, after-
wards rubbing it for some time with warm flannel,
and lastly covering it by an impermeable or
gummed silk cap. Blisters behind the ear, or on
the temple, and medicines to promote the alvine
secretions and excretions are also suitable. Dr.
Lehman directs a mild purgative, and the intro-
duction of cotton into the meatus, charged witli
Vol. I.

tincture of digitalis. Dr. Kennedy prescribes an
emetic as early as possible in this affection ; and
after vascular depletion, if inflammatory actioa
seem to be present. I found an active emetic
almost immediately abate the excruciating pain,
in the case of the wile of a celebrated author.
After free vomiting, which may in some cases be
promoted by the warm infusion of chamomile
flowers, a dose of calomel, either with, or fol-
lowed by, a purgative ; and gentle diaphoretics ;
will be of much service. In every case, the state
of the gums and teeth should be examined. Where
the head is free from congestion, warm baths,
vapour or fumigating baths, and narcotics with
antispasmodics internally, may be tried. Tonics,
especially the sulphate of quinine, the prepara-
tions of iron in large doses ; valerian, or serpen-
taria with cinchona ; or an infusion of valerian
with the compound tincture of colchicum ; may
also be prescribed, more particularly if the otalgia
be of an intermittent type, or of a rheumatic cha-
racter, and if morbid secretions have been evacu-
ated by an emetic and purgatives. In the rheu-
matic or gouty state of the complaint, the decoc-
tion or infusion of cinchona with valerian, the
carbonate of soda, and the compound tincture of
colchicum, will be most efficacious. On the first
indication of inflammatory action in the ear, or
within the head, the jugular vein on the affected
side should be opened, or other modes of deple-
tion instituted, and active cathartics administered.

BiBLioG. and JlEfEH. — Celsus, 1. vi. c. 7. — Cislius
Aurclianus, Morb. Chron. 1. ii. cap. 3. — Hoffmann. De
Colore Otalgico, ol^s. 2, 3. ; Opera, vol. ii. p. 338. —

I'olckainar, De Otalgia. Alt. 1733. — Kaltsclnnid, De
Otalgia. JeiiiE, 17-19. —Detius, Amoenit. Acad. dec. iv,
n. 10. — Itard, in Diet, des Sciences Medicales, t. xxxviii,
p. 5U7., et op. cit. — Andral, Diet, de Med. t, xvi. p. 5S. —

Kenned//, in Lond. Med. Repos. vol. xxv. p. 244 G. F.

LcJiman, in the Amer. Journ. of Med. Sciences, vol. v.
p. 31. — (See also the Rejerences to art. on Inflammation
of the Ear.)

EAR — Inflammation OF THE. Syn. — Otitis ;
Empresma Otitis, Good. Ohrenentzundung,
Germ. Otite, Fr.

Classif. — 3. Class, Diseases of the Sangui-
neous Function ; 2. Order, Inflammations
(Good). III. Class, I. Order (Author').

10. Defin. — Ingravescent pai)i in the ear, tvith
tenderness on pressure, or on movitig the lower jaw ;
with inflammatory fever, and frequently impaired
or confused hearing.

11 . Inflammation may affect both the external
and internal ear at the same time ; and it may com-
mence in either, and be thus confined, or extend
to both. It assumes various grades of severity ;
its duration being equally indefinite. The more
acute states of the disease will be first considered:
and next, those which are chronic, and which, from
being characterised hy a discharge from the ex-
ternal meatus, have been called Otorrha-a.

12. I. Acute Inflammation of the Ear —
Otitis Acntus — has been accurately observed only
in modern times ; and more especially by J. P.
Frank, Itard, and Lai.lemand. — (a) Some-
times the external conduit or meatus is the chief
seaH. of inflammation — External acute otitis. —
(h) Frequently the cavity of the drum, with its
dependencies, the membrane of the tympanum.
Eustachian tube, anrl mastoid cells ; or the in-
ternal ear, strictly speaking — as the vestibule,
the semiciicular canals, and the cochlea ; either
separately or conjointly, is the seat of the disease,

3 B

738 EAR — Acute Inflammation of— Symptoms.

— Internal acute otitis. These will be described
separately, but with reference to their mutual
relations.

13. i. SvMPTOJis. — A. 0{ External Otitis. —
Inflammation of the external conduit frequently
commences with slight pain, or a sense of heat,
or of intense itching or irritation, gradually in-
creasing to an acute or distressing degree. It is
sometimes lancinating, or is increased at intervals ;
and it occasionally gives rise to various nervous
symptoms. In other cases, the disease runs its
course without being attended by much pain.
But pain is always augmented upon pressure; by
the motions of the lower jaw ; and by the contact
of cold air, and too warm fluids. Hearing is also
impaired or confused ; and noises are heard in
the ear. Upon examining carefully the meatus,
several of the changes about to be noticed
(§ 17.) are observable. From a few hours to
three or four days after the commencement of
the symptoms, a fluid begins to be discharged from
the meatus, that is generally at first thin, limpid,
or sanguinolent ; but gradually becomes thicker,
and assumes puriform characters; being whitish,
yellowish, or greenish ; inodorous, or fcxitid ; and
sometimes so acrid as to irritate the part with
which it remains for some time in contact. With
the increase of the discharge, the pain usually
abates, unless inflammation extends to the inner
ear. Afterwards, as inflammation declines, the
fluid passes into a consistent or caseous matter,
that accumulates in the meatus, and requires to
be removed ; and is followed by a more abundant
secretion of wax than usual. Occasionally, as
the discharge from the interior of the meatus de-
creases, a serous exudation from behind the ear
supervenes.

14. B. Internal Otitis is sometimes attended
merely by local symptoms: but whenever the
inflammation is very acute, and the pain great,
more or less fever is present, with headach, watch-
fulness, and disorder of the natural functions.
The chief diflPerence between the course of this
and external otitis is contingent upon the parts of
the internal or middle ear chiefly aflTected. Thus,
the matters secreted by the inflamed surface of
the cavity of the tympanum can be discharged
externally only with great difficulty, owing to the
extension of inflammation to the adjoining por-
tion of the Eustachian tube, and its consequent
obstruction ; their retention giving rise to a most
distressing sense of distension, with painful throb-
bing, febrile reaction, and nervous disturbance.

— a. Internal otitis often co»i»)e?(ces with severe
headach or hemicrania ; and an intense, acute,
continued, and deep-seated pain, with clanging,
loud, or beating noises in the ear. These symp-
toms become more severe, and are generally
attended by heaviness in the head, and often with
a sense of bursting or distension in the ear. The
eyes are now injected and watery ; the face anxious
or red; the skin soraewiiat hot; the pulse fre-
quent, but not full ; the tongue loaded or white ;
and all the natural functions disordered. In
some ciisc's, particularly when the more interior
parts arc inflairied, it requires attention to (connect
the cerebral symptoms with their origin ; but the
pain is generally referred more especially to the
mternal ear ; is attended by severe tinnitus ; and is
increased on mastication, and on moving the
head, and on the least noise. In other instances,

the pain is felt at the bottom of the meatus, which
is seen, on examination, exempt from lesion ; or
in the mastoid process. Delirium, especially at
night, often attends the complaint at its acme ; or
convulsions in children. The fever often assumes
a nervous or typhoid character, if the inflamma-
tion do not readily terminate in resolution. The
above may be called l\ie Jirst stage, in the most
severe cases ; but those which are less violent, or
sub-acute, or actively treated at the outset, subside
partially in from twenty-four to forty-eight hours;
and afterwards more slowly ; the functions of
the organ still remaining more or less im-
paired for some time, but without passing into
the next stage.

15. b. When the disease does not thus ter-
minate in resolution, the products of inflammation
accumulate in the cavity of the drum and de-
pendencies, and force their way externally, their
appearance commencing the second stage. These
matters may be discharged — a. through a spon-
taneous perforation of the membrane of the drum;
— 0. along the Eustacliian tube ; and, y. through
a fistulous opening in the mastoid apophysis. The
first of these is the most common — its frequency
being to that of the second in the proportion of
six to one (Itaiid) ; and the third comparatively
rare. The discharge by perforation of the tym-
panum generally takes place suddenly ; a large
quantity of matter being voided, as if an abscess
had burst ; and the patient experiences relief,
which increases with the continuance of the evacu-
ation. Sometimes the great consistence of the
secretion prevents its passage through the opening
in the membrane, and causes its reaccumulation
in the cavity ; and occasionally the iriitation and
inflammation produced by it in the meatus, or the
incrustation of it on this passage, obstructs this
outlet, and has the effect now stated, with the
consequences of prolonging or augmenting both
the local and general symptoms. It is necessary,
therefore, to ascertain the permeability of the
meatus, as well as that of the Eustachian tube,
which most frequently is obstructed in these
cases. This is to be done both by inspection of
the external conduit, and by causing the patient
to expire forcibly whilst the mouth and nose are
shut. If the Eustachian tube be permeable,
bubbles of air mixed with the fluid will escape
at the meatus. In the much less fiequent cases
of the discharge of the accumulated fluid along
the Eustachian tube, a sensation is felt in the pos-
terior fauces or throat, as if an abscess in one of
the tonsils had burst ; a sudden expectoration of
a muco-puriform, sanioiis, or purulent matter
taking place, and continuing, in smaller quantity,
for some time afterwards, or returning after inde-
finite intervals.

16. C. From what has been stated, it is evi-
dent that tlie inflammation may extend from the
external to the internal ear ; but rarely from the
latter to the former ; unless matter finds its way
through the tympanum. 'I'he duration of the dis-
ease varies from two to thirty, or even forty, days;
but the symptoms lose their severity before a
month is elapsed, and become chronic, generally
in the form of otorrliwa, which may, however,
follow a sub-acute or an originally slight or
chronic affection. After acute otitis has termi-
nated, as above (§ 14.) in I'esolution, or by the
discharge of matter externally ( § 15.), hear-

EAR — Cunoxic Inflammation of — Pathology.

739

irig often remains impaired, owing to the lesions I is much more serious, as being generally depend-

ent upon caries of tiie bone. Otorrhoea is often a
termination of acute otitis ; but it is frequently a

consequent upon it ; and is either recovered after
some time, or permanently diminished. These
lesions are tiiickening of the cartilaginous parts of ] primary disease, and not preceded by any acute

the conduit; permanent thickening of tlie skin
or dermis of the meatus, and narrowing of its
canal ; thickening, opacity, or perforation of the
membrane of the drum ; loss of one or more of
the small bones ; and obstruction of the tube of
EusTACHius. Caries of the mastoid apophysis,
and of the petrous portion of the temporal bone,
with destruction of tlie internal organisation of
the ear, and disease of the adjoining membranes
and portions of tiie brain, may also be caused by
internal otitis ; sometimes at a period very remote
from the first manifestation of disease in this organ.
17. ii. The Structural Changes produced by
acute otitis are, injection of the delicate dermis
lining the auditory conduit, with more or less
tumefaction, and entire or partial obliteration
of the canal. Pustular formations, at first red,
afterwards whitish and filled with pus, are seen in
the surface of this tissue, varying in size and num-
ber ; sometimes transparent vesicles are met with
instead of these. The fluid contained in these
pustules or vesicles either is absorbed, or escapes
through their parietes, giving rise to ulcerations
of variable depth and size. The lining of the
meatus, when inflamed, presents a striking resem-
blance to an inflamed mucous membrane; and
the fluid which it secretes undergoes the same
changes as that proceeding from an inflamed
mucous tissue. Thus, in the slighter grades of
inflammation, a mucous fluid fills the meatus ; in
an advanced stage and grade, purulent matter is
formed; and occasionally, in children, a mem-
branous or albuminous exudation forms' upon the
surface of the canal. The osseous parts of the
internal ear are seldom afl^ected excepting in
otorrhoea ; but the cartilaginous portion is not
infrequently softened, or even perforated, in the
acute disease. In rare instances, the perforation
takes place from without, owing to an abscess
formed between the mastoid apophysis, the angle
of the jaw, and the conduit. The inflammation
may be limited to the mucous membrane of the
tympanum, and give rise to the collection of a
mucous, serous, sanguinolent, purulent, or curd-
like fluid in tlie cavity. From the mucous sur-
face of this cavity, inflammation may extend — a.,
to the surface of the Eustachian tube, causing
obstruction of it, either by the diseased secretion,
or bv the temporary swelling of the inflamed

symptom, not even by pain; the disciiarge being
the only phenomenon. — a. Mucous otorrh(xa may
be confined to the external ear, the lining mem-
brane being either scarcely altered, or red, tu-
mefied, covered with vegetations ; or partially ad-
herent, and the canal partially or altogether
obstructed or obliterated. This species of otor-
rhoea is most common among children of a
delicate, lymphatic, or scrofulous constitution ;
frequently resisting treatment for years, and yet
subsiding spontaneously, or disappearing at pu-
berty. Serious symptoms seldom accompany it;
but sometimes hearing is somewhat impaired.
The discharge varies greatly in colour, odour, and
quantity ; but little importance need be attached
to these variations. It is often scanty at one
time, and copious at another ; or even disappears
for a while, and returns in greater or less abun-
dance. The obstructions already noticed (§ 15.)
in respect of the discharge in acute otitis, also
occasion this change. In some cases, the sudden
interruption of the discharge may be followed by
pathological phenomena in some other quarters.
jM. Itard has seen engorgements of the lymphatic
glands of the neck, tumefaction of the testes,
affections of the eyes, porriginous eruptions on
the scalp, and dangerous diseases of the brain,
follow its disappearance. I have likewise seen
the same results, as well as partial paralysis of
the nerves of the same side of the face, in three
instances, two of which were referred to Sir
C. Bell, in illustration of the discoveries of this
eminent physiologist. ]M. Lallemand has re-
marked the alternation of otorrhoea with an attack
of rheumatism, with catarrhus vesica;, and with
leucorrhoea. SIucous otorrhoea may also be seated
in the cavity of the drum : in this case, the mem-
brane is perforated, and the symptoms are nearly
the same as now described.

19. b. Purulent otorrha'a may, like the pre-
ceding, but much more rarely, be the result of a
porriginous inflammation of the lining membrane
of the meatus ; or the matter may, in the first
instance, proceed, as stated above (§ 15.), from
acute otitis, the tympanum having been spon-
taneously perforated ; and, owing to the access
of air whilst it lodges in the cavity of the drum,
mastoid cells, and other parts, become more and
more acid ; inducing ulceration in the membrane

part ; — ^. to the mastoid cells, producing tume- ; lining these parts, and ultimately inflammation

faction of the mastoid apophysis, and occasionally
a fistulous opening through it ; — y. to tlie mem-
brane of the tympanum, which often in a very
short time, is softened and perforated, allowing
the discharge of the matters collected in the
cavity, sometimes with one or more of the de-
stroyed small bones.

II. Chronic Inflammation of the Ear — Chro-
nic Otitis ; Otorrhaa (from oS;, iro;, the ear, and
piai, I Jiow); Olirenjius, Germ. ; Otorrhee, Fr.
18. i. History, &c. — A discharge from the
ears may be seated in the external, or in the inter-
nal, ear, or in both ; or may proceed from an ab-
scess opening into the ear. It has been distinguished
into — a. Mucous, or Catarrhal otorrhoea ; and, /).
Puruleiit oiorrhceu, from the appearance of the d

and caries of the osseous structure itself. As
soon as these changes take place, the discharge
is more sanious than purulent — or of a greyish
tint, mixed with red ; exhales a peculiar odour,
and stains a silver probe of a bronze colour ; ca-
rious portions of bone being sometimes also de-
tached at an advanced stage. The patient, in
these cases, generally complains of a dull pain in
the ear, extending over the side of the head ; of
iijipai red hearing ; with dulness, and a heaviness
of expression. The caries is, in most instances,
as here stated, the consequence of the disease of
the mucous membrane lining the several auditory
canals ; but it is also, although much more rarely,
the primary disease. In both cases, the otorrhoea
is idiopathic. Abscess formed in the brain may

charge; the former often preceding the latter, which form a passage through the petrous bone, which

3 B2

740

EAR — Inflammation of — Pathology.

had become secondarily affected and destroyed ;
the caries being, in this case, si/mptumatic, Tliis
occurrence, however, seldom takes place.

20. The mastoid process is more frequently
the seat of caries than any other part ; and is,
consequently, the source of purulent otorrhcea in
most instances ; disorganisation proceeding also
most rapidly in this situation, which is painful
and tender on pressure, the external parts being-
swollen and oedematous. After some time, the
mastoid cells are perforated ; the skin reddened ;
and an abscess forms, bursts, and becomes fis-
tulous. On injecting a fluid through the external
opening, which is generally close behind the ear,
it frequently escapes by the meatus, or the Eus-
tachian tube. Instead of an opening in this
situation, the pus sometimes penetrates between
the muscles attached to this process, and the
abscess opens low in the side of the neck. The
diagnosis is then more difficult. In some in-
stances, the carious mastoid apophysis is not per-
forated, but the pus collected in its cells is
evacuated through the cavity of the tympanum
and the external meatus. Occasionally the ca-
rious part of the process is gradually melted
away in the sanio-puriform discharge, without
any disease of the soft parts covering it ; the
gradual destruction of it causing the disappear-
ance of the prominence it occasions. M. Lalle-
mand, therefore, directs the comparative state of
both mastoid regions to be examined in cases of
purulent otorrhcea. The bony parietes of the
external auditory conduit is sometimes the seat
of caries; but much more rarely than the pre-
ceding. The part of the petrous portion of the
temporal bone, which contains the semicircular
canals, is, according to Itadd and Lallemand,
that which is most frequently diseased after the
mastoid process. In other cases, caries is seated
in the parts forming the aqueduct of the cochlea,
or the aqueduct of Fallopius ; or lastly, and
more rarely, the internal auditory canal. But, if
in some instances, the disease is thus limited, it is
not so in others ; various portions of the osseous
structure, being either simultaneously or succes-
sively attacked. The prtrous portion may be
altogether destroyed, and the adjoining bones also
invaded, and more or less injured. JM. Lalle-
mand has seen, in the same case, caries of difler-
ent parts of the temporal and of the occipital
bones, and even of the first vertebra also.

21. a. Caries of the petrous portion of the tem-
poral bone, in some one of the states now noticed,
necessarily induces disease of the membranes, and
frequently also of the brain. — (a) It sometimes
happens, that acute cerebral disease suddenly su-
pervenes during otorrhcea, and death quickly
follows; the petrous bone being found carious
uj)on dissection, and the membranes adjoining
extensively inflamed ; but the biain itself sound.
— (6) In other cases, the cerebral symptoms
take place more slowly, or assume the cha-
racters of chronic meningitis or cerebritis (see
15«AiN, § 160. et seij.); cither partial separation
of the duia mater, with or witliout adiiesion of tiie
two lamella; of the aracimoid, or softening of the
brain, or abscess seated in the cerebral structure,
or both these alterations of the membranes and
brain, being found after death. I'hese lesions
arc ol)served more fiefpiently at the anterior, than
at the posterior, aspect of the petrous bone. Son;e-

times instead of this portion of the temporal bone>
a large collection of pus communicating with the
middle ear is only found. The abscess formed
around, or in the vicinity of, the petrous bone,
consecutively upon disease of this part, often
makes its way externally to the meatus ; a similar
channel of evacuation also being formed, but
much more rarely when caries of this bone fol-
lows the formation of cerebral abscess ( Andkal).

22. /3. The Symptoms which indicate the exten-
sion of disease from tiie ear to the brain, or its
membranes, are nearly the same as characterise
the idiopathic states of inflammation of these struc-
tures (Brain, § 146. et seq.) according to the
acute and chronic states they may assume. Whilst
the ear only is diseased, the pain in the head ap-
pears to proceed from the ear as its source ; but
when the parts within the head become affected, the
cerebral symptoms are most prominent, and often
obscure or altogether mask the disease of the ear.
If, at an advanced stage of chronic otitis, the dis-
charge be suppressed, or even much diminished,
these symptoms are very liable to come on in a
very severe form ; andif some time elapse between
the disappearance of the one, and the supervention
of the other, and if the history of the case be
not attentively investigated, the disease of the
ear may be altogether overlooked ; and what is
strictly a symptomatic affection of the brain, or
its membranes, treated inappropriately as an idio-
pathic seizure. — When inflammation extends to
the parts within the head, the patient complains
of a deep-seated, and often throbbing pain, to-
wards one side, with heaviness of the eyes, stupor,
and slight delirium. The pulse is small, sharp,
and quick ; the tongue furred ; and the febrile
symptoms, which are usually slight, increased in
the evening. There are also tenderness of the scalp
near the affected ear, so that the patient prefi^rs
to lie on the opposite side, thereby favouring the
lodgment of the morbid secretion in the ear ;
and sometimes convulsions with paralysis. Dur-
ing tiie progress of caries of the bony structure
even before the disease has extended to the mem-
branes and biain, more especially when the pari-
etes of the aqueduct of Fali.omus are implicated,
neuralgic pains in the face, inflammation of the
conjunctiva of the eye, convulsive motions, and
ultimately paralysis, of tiie muscles of that side
of the face, &c. take place, owing to lesion of
the trunk of the facial nerve. Since attention
was directed to these associations by Sir C. Bell,
numerous cases illustrative of them have been ob-
served by Lallemand, and others, and several
have been seen by myself.

23. y. The duratum of otorrhcea is most indefi-
nite. It may continue for several weeks or many
years; and may resist all means. Sometimes it dis-
appears either spontaneously, or during medical
treatment. In other cases it presents a somewhat
intermittent form, continues long to do so, and
ultimately terminates either favourably or fatally,
as stated above. In two instances which termi-
nated in this latter manner, — at upwards of forty
years of age in the one, and about thirty in the
other, — J ascertained that otorrhcea conmienced
in early childhood, and had continued, with vari-
ous remissions and intermissions, to that age, when
cerebial symptoms came on. In these prolonged
cases, the discharge vai ics much in quantity. When
the Eustachian tube is not obstructed, it often

EAU — Inflammation of — Theatmext.

741

passes into the throat, and discolours the sputum ;
or is at one time evacuated by tliis route, at an-
other by the meatus. During catarrh or sore-
throat, the symptoms are generally aggravated,
chiefly in consequence of obstruction to the dis-
chai ge of matter.

24. ii. The Prognosis of otorrhcea depends —
1st, on its cause, — thus the syphilitic is much
less dangerous than the scrofulous disease ; — 2d,
on the nature of the discharge, — the puriform
being much more unfavourable than the mucous ;
— 3il, on the age, — it being much less serious in
childhood, than at or after puberty ; — 4th, and
most especially on the presumed extent of disor-
ganisation, and curies; the occurrence of local
paralysis, but particularly of the cerebral symp-
toms alluded to (§ 22.), being very unfavourable.
All chronic discliarges from the ear, however
slight they may seem, should be viewed in a seri-
ous light, not merely as they generally lead to
deafness, but as they are also liable to be followed
by fatal cerebral disorganisation.

25. iii. Causes. — ^4. TIte predisposing ca^tses
nf otitis and otorrhcea are, delicacy and susceptibi-
lity of frame ; the scrofulous diathesis ; the peiiods
of dentition and childhood ; the syphilitic poison ;
and disorders of the prima via and digestive organs
generally. — B. The exciting causes are chiefly a
current of cold air ; exposure to cold air after the
removal of the hair ; the introduction of foreign
bodies into the meatus; accumulations of wax in
this part, or the use of irritating injections ; her-
petic eruptions on other parts of the body, or
porriginous eruptions on the scalp, and the sup-
pression of either; inflammatory aflections of the
throat, tonsils, and fauces ; and determinations of
blood to the head. Either the acute, sub-acute,
or chronic states of the disease may supervene in
the course, or after the subsidence, of any of the
exanthemata, or even of continued fever, but more
especially scarlet fever, small-pox, and erysipelas.
Difficult dentition, the irruption of the wisdom-
teeth, caries of tlie teeth, and injuries of the head,
are more rarely exciting causes. iNLIxAito tliinks
that falls upon the head may occasion otitis with-
out producing disease of the brain. It may follow
even slight attacks of catarrh in children ; and in
some instances its cause is by no means evident.

2G. III. Treatment. — The means of cure dif-
fer according to the acuteness, the seat, the stage,
and the particular characteristics of the inflamma-
tion ; and the results to which it has given rise.

27. i. Of the Acute.- — A. Acute eiternal Otitis,
whilst the pain is moderate, and febrile symptoms
are absent, recjuires chiefly the removal of all
sources of irritation, the injection of tepid and
simply emollient fluids, and the application of
poultices. AVhen the pain is severe, and febrile
commotion is present, general or local bleeding —
the former in patients who are more than a few
years of age, either from the arm, or from the
jugular vein — should be prescribed ; and, if there
be not much fulness of blood in the head present,
an emetic, as recommended by Dr. Kennedy, ex-
hibited. After its operation, a full dose of calomel
with James's powder ought to be given, and fol-
lowed in a few hours by an active cathartic draught.
If the symptoms be not greatly relieved by these,
a number of leeclies should be placed behind the
ear, or cupping performed on the nape of the neck,
a blister being subsequently applied in this situa-

tion. In this stage and state of the disease, the
introduction of any substance into the meatus be-
yond simple emollient injections occasionally, is
more injurious than beneficial. Some writers re-
commend the use of narcotics ; but unless the
harmless decoction of poppy-heads, they arc as
well abstained from. AI. Itaud advises two or
three grains of camphor, rolled in cotton, to be
placed in the meatus, if there be no discharge ;
but this appears more suitable in sub-acute and
slight cases, than in those that are very acute.
Dr. Lehman directs the tincture of digitalis to be
dropped into the ear, or cotton impregnated vvith
it to be introduced. When a discharge takes
place, the simplest tepid injections only should be
employed ; and, during the course of treatment, a
free action on the bowels kept up. The blister on
the nape of the neck should also be preserved
open ; and leeches again applied behind the ear.
AV'hen the pain has subsided, a mucous discharge
only remaining, M. Andkal prescribes slightly
astringent injections, and particularly those con-
sisting of the waters of Barreges. I believe that
the less they are employed the better ; attention
to the functions of the stomach and bowels, and
change of air, with such means as may promote the
general health, being the safest and best means.

28. B. Acute internal Otitis, demands the
prompt and decided use of the above remedies.
After general depletion, the repeated application
of leeches behind the ear, at short intervals, is
often requisite, with external deriration, &i.c. If
the exhibition of an emetic after these fails of re-
moving the acute symptoms, antimonials should
be given, so as to produce nausea and keep down
vascular action ; the bowels being also freely acted
on. For this purpose, calomel with small doses of
James's powder, or of the potassio-tartrale, or of the
compound powder of anlimonii should be prescribed
every three or four hours. These means will ge-
nerally be followed by resolution of the inflamma-
tion, and subsidence of the symptoms, if resorted
to at an early period. But if the disease pass on
to suppuration, the patient will complain of a
throbbing pain, with a bursting sensation in the
ear, and persistence, or even aggravation of Ids
sufiierings. In this case, an additional indication
must be fulfilled, viz. the speedy evacuation of the
matter, collected in the cavity of the drum, as its
retention will materially aggravate the disease, and
endanger the bony structure of the car. Several
authors have advised, in such circumstances, the
apj)lication of fomentations and poultices, to acce-
lerate the ulcerative perforation of the tympanum
and the external evacuation of the matter. These
are, however, often inefficient. In order to re-
move obstruction of the Eustachian tube usually
existing in such cnsc^, gargles with a solution of
the biborate of soda, or of nitre and it, may be em-
ployed. Some writers recommend the smoke of
tobacco to be forced into the tube whilst the mouth
and nose are shut. But these means do not often
succeed. Instead of waiting for the spontaneous
evacuation of the pent up matter, which insinuates
it*elf under such circumstances into the various
sinuosities of the ear, IM. Itard advises, and has in
many instances practised with benefit, perforation
of the membrane of the drum. Having performed
tliis operation, it is generally requi-^ite to inject
mild tepid fluids in order to procure the full eva-
cuation of the matter, which has often become
3 B 3

742

ECTHYMA.

more or less consistent. If inflammatory symp-
toms either continue or return, after the perforation
of the tympanum, antiphlogistic measures should
be directed ; but if the discharge continue, the pa-
tient should sleep on the side on which the ear is
affected, diluent and emoUtent injections being oc-
casionally employed, so as to prevent any clogging
of the meatus, and accumulation of matter in the
middle ear. M. Itard directs, with this view, an
injection formed of a drachm of caustic potash to
the pint of rose-water. Light tonics and mild
laxatives, with change of air, ought also to be pre-
scribed, so as to prevent the disease from degener-
ating into the ulcerative and chronic states.

29. ii. Of Chronic Otitis. — When otorrhoea
becomes established after acute otitis, as above,
or follows a slight or imperceptible state of in-
flammatory irritation, the treatment may be divided
into the local, and general, — the latter more
especially being directed against the state of con-
stitutional disorder. Local depletion is required
only early in those cases which present more of a
sub-acute character, or when this, or even acute
symptoms supervene from obstruction to the
discharge, or any other cause. Blisters behind
the ear, stretching to the occiput, or on the nape
of the neck, and either kept discharging or re-
peated, are often very serviceable. M. Amdral
notices setons, or cautery of the nucha, or issues
in the extremities. M. Itard directs, in addition,
the head to be shaved, rubbed assiduously with
stimulating substances, and kept constantly co-
vered with a gummed silk cap. He very judici-
ously forbids the use of any other than simply
diluent or emollient injections. Even gently as-
tringent fluids ought not to be resorted to until the
discharge begins to diminish ; if its diminution be
not attended by any aggravation of the local or
constitutional symptoms. In this case, the mildest
asiringents may be commenced with, and those
which are more and more active successively em-
ployed. A weak infusion of roses, or of chamo-
mile flowers, may be first prescribed, and subse-
quently a weak solution of the sulphate of zinc, or
of creasote in distilled water. Oily injections, in
cases of otorrhoea, should not be used, as the oil
speedily becomes rancid when any part of it re-
mains in the ear. Whenever the discharge is sud-
denly suppressed, means should be taken to re-
store it. Warm bread and water pouliices orj'o-
mentaiions, frequently renewed, may be resorted
to with this intention. M. Jtard directs bread
warm from the oven, and deprived of its crust, to
be applied every three hours, and an injection of a
.solution consisting of three grains of bichloride of
mercury, in eight ounces of water. Care should
also be taken to remove any obstruction that may
present itself in the meatus. If the suppression be
attended by the accession of acute .symptoms,
leeches must be applied ; but the powers of life
ought not to be much reduced by tliosc or any
other means. INIercury in this state of disease is
injurious. If matter form in the vicinity of the
njastoid process, an early outlet should be given
to it by a free incision down to the carious bone,
and the powers of life supported by gentle tonics,
light nutritious diet, and change to a healthy air.
When caries is obviously present, and there is no
increase of sensibility, or any other symptom of
acute inflammatory action, M.Anijual advises
injections of a strong solution of potash to be fre-

quently thrown into the ear. When, however,
there is evidence of the caries having induced dis-
ease within the head, the simply diluent injections
should only be used, in order to prevent any inter-
ruption to the discharge.

30. By the constant use of simple diluent or
emollient injections — of warm water, or milk and
water merely — and careful attention to the gene-
ral health, the disease may be kept stationary,
from youth to old age, although it may not be
cured. In scrofulous and lymphatic subjects, the
bitter tonics; the infusion or decoction of bark;
the creasote internally ; the preparations of iodine
in gentle doses ; the ioduret of iron, or the ammonio-
chloride or the potassio-tartrate of iron ; and mild
purgatives, once or twice a week ; will be extremely
serviceable, if there be no acute symptoms, or
febrile action. I have also seen much benefit ac-
crue from sulphur given daily in sufficient quantity
to keep the bowels freely open. If the disease
seems connected with a syphilitic taint, or has
come on after syphilitic sore-throat, or an ineffi-
cient course of mercury, the bichloride of mercury
should be given in gentle tonics, or with a course
o( sarsaparilla. Where there is fever, with a loaded
tongue, or pain in the head and ear ; in addition
to those appropriate local means above stated
(§ 28.), a course of mild and cooling purgatives
or aperients, external derivatives, diaphoretics, and
a mild farinaceous diet, should be employed.
Change of air, and such mineral waters as may
suit the peculiarities of the case — the chalybeate,
aerated, and sulphureous, in cases devoid of fever
and other acute symptoms ; the aperient and re-
frigerant in those thus accompanied — will be
very powerful adjuvants. (See Art. Hearing.)

BiBLiOG. AND Refer. — Oribashis, De Loc. Affect.
1. iv. — Aetius, 1. iv. c. 74. — Actiiarius, \. y\. c. 3. —

Alexander Trail, 1. i. c. 2-1 Paulus Mj^ineta, 1. iii. c. 23.

— Brotheck, De Inflam. Auiium. Tub. 1667. — Forestiis,

1. vii. obs. 19., et 1. xii. obs. 7. — Schcnck, 1. i. obs. 351

Buverney, Traite de I'Organe de I'Ouie. Par. 1683. —
Bonet, Seinilcliret. 1. i. sect. 19. obs. 1. — Sclmlze, Ue Aur.
Mancntibus et Ulccratis. Hal. 1743. — A. Bergen, De
Morb. Amis Interna;. Fr. 1754. — Morgagm', De Caus.
et .Scd. Morb. epist. xiv. 3. 5. 7. 11. 13. Kc—A. Duncan,

Med. Comment, vol. ii. p. 286 IVeickard, Verm. Schrif-

ten. b. i. p. 78. — Heberden, Comment, in Morb. Hist, et
Curat, cap. 12. — Frixc, Diss, sistens pra^cipuas Aur.
Morbos. Fr. 1789. — Bourienne, in Journ. de Med. t. xli.
p. 342. — J. P. Frank, De Cur. Hom. Mori). 1. ii. p. 90. ;
et Interp. Clin. vol. i. p. 141. — Tliicle, in Bust's Magazin

f. d. Ges. Heilk. b. ii. par. i. p. 164 Starke, in Ibid.

b. ii. par. ii. p. 311. ; ot Ibid. b. iv. par. i. p. 197 J. C.

Saunders, The Anat. and Dis. of the Hum. Ear. Lond.
1806. — J/ard, Sur le Catarrhe de I'Oreille, 8vo. Par.

1808 Earle, in Trans, of Med.-Chir. See. vol. x. p. 410.

— Sloan, in Ibid. vol. xi. p. 330 Duncan, in Edin. Med.

and Surg. Journ. vol.xvii. p. 331. — Swan, in Ibid. vol. xvii.
p. 401. — Itard, Traite des Malad. de I'Oreille, et de I'Au-
dition, t. i. p. 160. etscij. — Andral,'m Diet, de Med.t.xvi.
p. 60. — Lallen/and, Hecherches Anat. Pathol, sur I'En-
ceph. et scs Dependances. Let. 6. Paris, 1830, 8vo. — J. II.
Curt/'.f, Trait, on thePhys. and Pathol, of the Ear, 5th cd.
Lond. 1831. — Buchaunan, Op. cit. passwi.

ECLAMPSIA. See Convulsions {§ 24, 27.),
ICCSTASV. See Cataleptic Ecstasy, &c.
ECTIIYIMA. Syn.— "E^Sy^a (from IxWaj, I
break forth), Willan. Tip^wivSo?, tcrebinlhus of
the Greeks, according toHotrmann ; or 'Eps/3(y9of,
Cicer., as it is read by others with more reason,
Turner ; also 'Ettivukti? (from km and vh^),
owing to its appearing or being aggravated at
night, according to Celsus, Galen, I'aulus, and
Ai'tius. 'J'erniinlhus, Wiseman, 'J'urner, &c.
I'lilifsis Kclliyma, Young. Ecpyesis Ecthyma,
Good. I'sydracia, J. 1'. I'rank, Chiarurgi,
and J. Frank. Phlyzacion, Paget, Dartre Crus-

ECTHYMA — Acute — CunoKrc — Pathology,

743

tac^e, Furoncle Atoiiique, Fr. Erbsenblatteyn,
Eilernde Flechte, Germ. FapuLoiis Scall,

Classif. — 5. Order, Pustular Eruptions
(Willan). 6, Class, Dis. of Excernent
Eunctions ; 3. Order, Affecting- the Skin
(Good). Ill, Class, I. Order (Author in
Preface),
1. Devi>:, — An eruption of large, round, and
distinct pustules, seated on a hard, elevated, red
base, and terminating in a thick, hard, and dark-
coloured scab, leaving a livid spot or superficial
cicatrix ; not contagious.

2. 1. Description. — These pustules are always
discrete, scattered sparingly, and appear succes-
sively in difterent parts of the body ; and rarely
terminate in ulceration or tuberculous induration.
They may appear in any part of the body ; but
they are most frequently observed on the limbs,
abdomen, shoulders, breast, and neck — rarely in
the face or scalp. They present modified states,
according to the causes, the age of the patient, and
the severity of the eruption. These Willan has
arranged into Ecthyma Vulgare, E. Infantilis,
E, luridum, and E. Cachecticum. To these may
be added the Ecthyma Syphiliticum (Frank,
BiETT, Cazenave, Scheuel, Todd, &c.), the
syphilitic affection sometimes assuming the ecthy-
matous form. M. Rayer has adopted a simpler
and more correct division, viz. into the Acute and
Chronic, which I shall here follow.

3. i. Acute Ecthyma ; E. Vulgare, Willan.
— In its simpler and rarer form, ecthyma appears
in some one part of the body, most frequently on
the neck and shoulders, in the form of circunx-
scribed reddish elevations, firm to the touch, and
distant from each other. Pus soon is formed at the
summit of these elevations ; and the pustules are
completely developed in three or four days ; their
basis being much inflamed, elevated, large, hard,
and circular, — of a bright red in young persons,
and of a livid red in the aged. Their suppurating
summits generally break in one or two days after
their formation ; the purulent matter giving rise to
a brownish or greenish, and very adherent scab.
After one or two weeks, the scabs are detached,
and leave a livid red mark, or occasionally very
superficial cicatrices, of the size of those of small-
pox, but much less deep. The eruption of the
pustules is attended with stinging pains in them ;
sometimes with tumefaction of the adjoining lym-
phatic glands, and is often preceded or accom-
panied by chronic inflammation of the digestive
mucous surface, which may continue after the
healing of the pustules. This variety is seldom
attended by fever.

4. ii. Chronic Ecthyjia is much more fre-
quent than the preceding, and always consists of
several successive eruptions on the limbs, neck,
breast, &c., at periods more or less distant. The
pustules present the same characters, and follow
individually and independently of each other, the
same course as above described ; some making
their appearance whilst others are suppurating,
or even healing. During several months, divers
eruptions are thus formed. Besides the successive
eruptions, the pustules themselves may be more
chronic, their bases assuming large dimensions,
approaching those of boils, and being tense and
prominent. In these cases, the subjacent cellular
tissue is inflamed, their areola) becoming hard and
violet-coloured. — Ecthyma luridum ol Willan.

Their summits break in eight or ten days, and dis-
charge a little sanious or bloody matter, sometimes
ulcerate slightly, and are covered by hard and
black crusts or scabs, which adhere firmly, and are
surrounded by livid red arcolai, which sometimes
remain after the crusts have fallen off; this taking
place in the course of a few weeks; leaving dark
red spots, or livid cicatrices, after them. If the
scabs are torn away before the period at which they
usually fall oflT, small indolent ulcers, with callous
borders, giving issue to a sanious fluid, are often
produced. When the pustules remain long sta-
tionary without ulcerating, they are occasionally
followed by violet-coloured tubercles, which may
ultimately suppurate or ulcerate, and more deeply
mark the skin. A symptomatic form of this erup-
tion, which is often tedious and severe, sometimes
attends the cachexia consequent on measles and
other eruptive fevers ; but it differs in nothing
from the disease now described, excepting in the
number of the pustules, and the marked constitu-
tional disorder.

5. The successive eruptions characterising this
variety are observed chiefly in feeble and ill fed
children — (Ecthy)na Infantile of Willan).-—
When the number of pustules is small, and the suc-
cessive eruptions are distant from each other, there
is generally little or no fever. But when the pus-
tules are numerous, their bases very large and
much Inflamed, or if they ulcerate, there is usually
present a co-ordinate degree of fever — Ecthyma
Febrile, E. Cacheclicum. — The febrile symptoms
sometimes precede, and at other times accompany
the severer forms of the eruption, particularly in
unhealthy and aged persons ; and are also
attended by gastric and intestinal disorder, — by
anorexia, pain at the epigastrium, irregularity or
constipation of the bowels, a morbid appearance
of the tongue, gums, and fauces, and of the eva-
cuations, headach, pains in the limbs, lassitude,
and by great depression of spirits, — with heat,
stinging, tingling, or itching in the pustules. In
such cases, as well as in other chronic states, this
eruption is often complicated with swellings of
the lymphatic glands, with inflammation of the
conjunctiva, or of the fauces, or of the pharynx ;
with oedema of the lower extremities ; and with
other cutaneous eruptions, especially with rupia
and furunculus. It is also frequently associated
with, or rather symptomatic of, chronic inflam-
mation of the digestive or respiratory mucous
surfaces and biliary derangement. The duration
of chronic ecthyma is always subordinate to the
successive eruptions of pustules, to the habit and
constitution of the patient, and the treatment
employed. It is usually from two to four
months ; but it may be longer or shorter.

6. When syphilitic disease gives rise to erup-
tions with the characters of ecthyma — E. Sy-
philiticum ; Psydracia Venerea, J.Frank; Sy-
philide pustuleuse, Phlyzacie, Biett, Rayer,
&c. ; Pustular Venereal Disease, Carmichael
— the pustules are always surrounded by broad,
dark, copper-coloured areolas, and are very •
4arge, indolent, and inclined to ulcerate. The
ulcerations, when the scabs are detached, are
deep, greyish or pale, unhealthy, with abrupt and
violet-coloured edges; but they seldom extend,
the scabs gradually reforming over them, and
being successively detached, until they heal
under appropriate treatment, leaving permanent,

3 B 4

744 ECTHYMA — Diagnosis

round, copper-coloured cicatrices. This form |
of tlie syphilitic eruption is most common in
children born with the infection, the pustules
being numerous, flat, and sometimes oval, fol-
lowed by ulcerations ; the skin foul and dingy ;
and the body emaciated (Cazenave and
Schedel).

7. II. Diagnosis. — The pustules of ecthyma
are easily recognised, by their form, their size,
their inflamed base, and mode of developement ;
and distinguished from those of acne, of impetigo,
mentagra, or porrigo. — a. However, when the
pustules of mentagra or of acne present, as they
occasionally do, hardened led bases, they may be
mistaken for the phlyzacious pustules of ecthyma,
if the induration, rather than the inflammation,
were attended to; but the specific characters of
these eruptions are suflrciently distinct. — b. The
umbilicated pustules of smalt-pox, themultilocular
pustules of vaccinia, independently of their con-
tagious properties, cannot be mistaken for those
of ecthyma. — c. The inflammation mfurnnculus
begins in the sub-cutaneous cellular tissue, and
extends outwards ; in ecthyma, it commences in
the skin, and proceeds inwards ; the former
being either single, or much less numerous, and
much larger. — d, Rnpia sometimes is coetaneous
with ecthyma in its chronic form — E. luridum
and Cachecticnm ; the latter seeming to be con-
verted into, or appearing to be an earlier stage or
less severe grade of, the former, more especially
in cachectic children, as correctly alluded to by
Mr. Dendy, whose experience in cutaneous dis-
eases, as my colleague at the Infirmary for Chil-
dren, has been most extensive. But the early
stages of both will sufficiently distinguish them
from each other, independently of the prominent
and thick crusts with the deep ulcerations, charac-
terising rupia. — e. The itch presents only a few
analogies with ecthyma, when it is complicated
with, or when its vesicles are accidentally trans-
formed into, pustules. In ecthyma, the pustules
are rarely numerous ; they appear successively,
the course of each being independent of the
rest. But in itch, the accidental pustules form
on the most inflamed points ; are always inter-
mixed with the small vesicles, by which it is
characterised ; are more agglomerated than in
ecthyma; are seated chiefly on the hands, be-
tween the fingers, especially between the thumb
and forefinger ; and are attended by itching ;
whilst the pustules of ecthyma produce a sting-
ing pain : the itch, moreover, being vesicular and
contagious.

8. III. Causes. — Ecthyma attacks all ages
and constitutions ; but it is most common in adults
of a sanguineous temperament and bad habit of
body ; or in persons who have prematurely ex-
hausted the powers of the digestive organs, and
vital energies of the system generally. It occurs
at all seasons ; but is most fre(|uent in spring and
summer. Unwholesome and insuflficient nourisii-
inent; cold and moist habitations; want of per-
sonal cleanliness, especially among those who
wear foul woollen next the skin, or who are scantily
clothed ; and the irritation of various mineral and
pulverulent substances ; are its most common
causes. Hence it is pnivalent chiefly among the
poor, and mechanics ( I'siidracia Arlijicnm, J.
I'uank), whose occupations subject them to
those contingencies. Great fatigue, j)rolongcd

• — Causes — Treatment.

watching, anxiety or distress of mind, inattention
to the states of the stomach and bowels, and what-
ever lowers the digestive and assimilating powers,
and energies of lite, inducing general cachexia,
will occasion this form of eruption. The chronic
states of the eruption are most frequent in the in-
digent ; in persons living on stale smoked or salted
provisions ; or whose constitutions are broken
down by imprudence, misfortune, drunkenness,
age, and irregularities; or in ill-nourished arid de-
bilitated children, living in low, damp, dark, and
close cellars, &c. Ecthyma often also follows
small-pox, the itch, scarlatina, measles, the bites
of leeches, and the application of irritating plas-
ters, or unguents. The tartarised antimonial
ointment produces pustules of this kind. It may
be symptomatic of pregnancy, and of several dis-
eases of internal organs, especially of the prima
via. Indeed, it may be in most instances con-
sidered as one of those infinitely diversified ex-
pressions of morbid action on the external surface,
attendant upon prolonged disorder of the digestive
and assimilative organs. Hence it cannot be a
matter of surprise to find it sometimes associated
with other chronic diseases of the skin. From the
foregoing it follows that this eruption is dependent
upon the general state of the system, to which'
our treatment should be chiefly directed in all its
forms. This state is evidently one of debility,
accompanied frequently with erethism, or mor-
bid irritability, and essentially with altered
sensibility and deficient tone of the vascular
ramifications in the cuticular and sub-cuticular
tissues.

9. IV. Treatment ^. In the Acute form,

when the pustules are few, little more is requisite
than a mild diet, tepid baths, cooling aperients,
and two or three grains of hydrarg. cum creta with
dried carbonate of soda or potash, at bed-time.
Whey is the best beverage ; and if the patient be
robust and the pustules numerous, a small bleed-
ing, or leeches to the anus (Cazenave, &c.),may
be resorted to. If the stools be morbid, the potas-
sio-lartrate of soda, or the soluble tartar, should be
given with infusion of senna, and afterwards the
compound infusion of roses may be taken with
small doses of either of the sulphates ; or these
latter may be taken in tonic infusions, with the
addition of a little dilute sulphuric acid.

10. B. The Chronic slates generally require
gentle tonics, with alteratives, and light nourish-
ing diet. — a. When they occur in infants, the
nurse should either be changed, or the treatment
directed chiefly to her. Where this cannot be
done, asses' or goats' milk should be substituted or
given in addition ; and the regimen strictly regu-
lated. Change of air, warm sidt water bathing or
sponging, and gentle alteratives, will also greatly
assist the cure. Hydrarg. cum creta, and the
carbonate of soda or potassa at night ; the liquor
potassai in tonic infusions twice a day, and an
occasional purgative in the morning; small doses
of the chlorate of potash, or of the iodide of
potassium ; warm salt-water bathing, and after-
wards the potassio-tarlrate of iron; have been the
most cflicacioiis remedies, in these states, in my
practice among c/u7(ire»i. The chlorate of potassa,
and the other chlorates, were first employed by
mc, in this disease, many years ago, at the In-
firmary for Children.

11. h. In grown up or aged persons, we should

ECZEMA — Pathology

always suspect disorder of the digestive and assi-
milating functions ; and if tliere be little or no
fever, have recourse to deobstruent alteratives, as
Plumjieii's pill, with soap, or taraxacum, at
night ; a stomachic purgative every second or
third morning, and tlie decoction of sarsaparilla ;
or mild tonic infusions with soda or potash, in the
course of the day. If we suspect congestion of
the liver, or find tenderness of the stomach on
pressure, small local depictions should be cm-
ployed, and repeated according to circumstances,
whilst the above depurating and mildly tonic re-
medies are continued. ]Mercurials should not be
given in large doses. PLUMniEn's pill, blue pill, or
liydrarg. cum creta, with taraxacum, inspissated
ox-gall, guaiacum, and sarsaparilla, are the most
beneficial. The occasional exhibition of purg-
atives, or the association of them with tonics, is
also necessary, especially if the stools be morbid,
and the abdominal viscera require to be excited.
In such cases, a prolonged course of tonic or sto-
machic purgatives is often necessarj'.

12. c. '\^4ren the cachectic state is complicated
with some degree of febrile action {§ 5.), the
mild mercurials now particularised should be con-
joined with James's or Dover's powder ; and sa-
line diaphoretics exhibited at short intervals ; the
morbid secretions and fajcal accumulations being
evacuated from time to time, by cooling purg-
atives. If there be tenderness at the epigastrium,
a few leeches applied there will materially assist
these remedies. After these, the infusion or de-
coction of cinchona with liquor ammonire acetatis,
or with the pyroligneous acid, or with nitrate of
potash and carbonate of soda ; a course of
tonic infusions, with alkalies and the extract of
taraxacum ; tepid or warm bathing ; the mi-
neral acids with anodynes ; and the other means
particularised in the last paragraph ; may severally
be exhibited. Having removed fever, and eva-
cuated morbid matters, more active tonics, as the
quinine in the compound infusion of roses, with
tinctura o])ii ; the decoctum cinchonae with the
mineral acids, or with camphor and ammonia;
chalybeate preparations, sarsaparilla and guaia-
cum, the balsams and terebinthinates with mag-
nesia, common tar made into pills with this ab-
sorbent, the bark of the madar root, &c., may be
prescribed.

13. (/. The syphylitic form of ecthyma should
be treated in the manner described in the article
Acne (§ 30.). Mr. CAnMiciiAEL does not con-
sider this eruption as being truly syphilitic, and
therefore confides chiefly in sarsapardla with an-
timonials and guaiacum. In a case of this form
of syphilitic eruption, lately attended by my
friend Mr. C. Ilt'rcHiNSON and myself, bichloride
of mercury, given in sarsaparilla, was required
for its cure, milder means not having succeeded.
Dr. A. T. Thomson advises this preparation in
minute doses to be given in the decoction of elm-
bark, or in the emulsion of bitter almonds. In
the cases of infants, some French physicians re-
commend the milk of a goat on whicli mercurial
ointment has been rubbed. When tlie child is at
the breast, the nurse should enter upon a gentle
course of the bichloride in the decoction of sar-
sapaiilla, or in almond emulsion.

14. e. E.xternal means are sometimes required
to remove the irritation attending the eruption,
and to heal such as ulcerate. With these inten-

547

tions, tepid alkaline baths ; fomentations with a de-
coction of poppy-heads; a weak solution of the
.chlorinated lime or soda, especially when there is
ulceration ; or solutions of chlorine, or of sulphate
of zinc with hydrocyanic acid, or of the nitro-
hydrochloric acids,' or of nitrate of silver, &c. ;
may severally be employed. Dr. A.T. Thomson
recommends the following : —

No. 209. B Plumbi Acetatis 3 ss. ; Acidi Hydrocyanic!
3 iij. ; Unguciiti Cctacci 3 iij- M. Fiat Unfueiitum
partibus cutis nudis applicandum.

15. y. The diet in the acute form ought to
be bland and farinaceous, whey and emollient
fluids, or water with a little vinegar, being the
chief beverages. — In the chronic states, light
and nourishing food, if there be no fever, or
after fever is removed, is always requisite. In
the more cachectic cases, a small quantity of
wine should also be allowed. The patient will
always derive benefit from the internal use of tar-
water, which may be taken as the common drink
in these cases. This medicine, which was for-
merly so inordinately praised, and, owing to this
circumstance, now so undeservedly neglected, is
most serviceable in this and many other chronic
afl^ections of the skin. In addition to these, fre-
quent tepid and warm baths, and sub.-equenily
salt-water bathing, exercise in the open air, change
of air, mental recreation, warm and suitable
clothing ; regularity in eating, drinking, and sleep-
ing ; early rising, and a rcgularstate of the bowels,
are important adjuvants.

BniLiOG. AND Kefer. — Cftsus, lib. v. cap. 28.— Pmiliis
Mgincta, 1. iv. cap. 9.—0ribasms, Synops. ). vii. c. 37 —
Avicenna, 1. iv. ten. iii. t. i. c. i., et fen. vii. t. iii. c. i. —
i/(i/fmrt«»,; Institut. Sled. 1. iii. cap. 151.— Z). Turner,
Treat, of Dis. incident to the Skin, 5th edit. Lond. ITSli.
p. \\i. — Lorry, Tract, de Morb. Cutaneis, -ito. 1777,

p. 250. J. P. Frank, Dc Cur. Horn. Morb. vol. iv. p. 180.

—J. Frank, Praxoos Med. Univ. Praecepta, partis primiE
vol. secund. p. 432. — Willan, On Ecthyma, 4to.— R.
Carmicliad, Essay onlVen. Dis. confounded witli Syijhiiis,

part i. Dub. 1814. ; and on Venereal Diseases, 1825

IV. C. Bendy, On the Cutaneous Dis. incidental to Child-
hood, Svo. Lond. 18'27, p. 134. — T. Bateman, Pract.

Synop. of Cutaneous Dis. 7lh ed. by Thomson, \}. 2-57

Jlcirson, North American Med. and Surg. Jour. 1826. —
Phanbc, Diseases of the Skin, 2d edit. p. 440. ~ C. E.
Assclin, Essai sur I'Ecthyma. Paris, 1827. — /'. Rayer,
Traite Thcorique et Pratique des Maladies do la Peau,
vol. i. p. 4.;o. — Caxcnavc et Schedel, Abr^ge Prat, des
Mai. de la Peau. 8; o. Par. 1828, p. 187. — J. Paget, On
Classification as applied to Dis. of the Skin, &c. Svo.
Edin. 1833.

ECZEMA. Syn. — Eczemata (from bkI^im, I
effervesce). Ecscsmata, Blancard. Hidroa,
Sauvages, Vogel. Ecphlysis Eczema, Good.
Ci/tisma Eczema, Young. Hydrargyria, Alley,
Mercurial Lepra, Mercurial Disease, Moriarty
and Malliias. Hitzhldlterchen, Germ. Dartre
Sqnamcuse hiimide. Dartre Vive, Hydrargyrie,
Ft. Heat Eruption.

Ci.ASSiF. — 6. Order, Vesicular Eruptions
(Willan). 1. Group, Eczematu (Alibert).
6. Class, 3. Order {Good). III. CL.iss,
1. OnoER (Author).

1. Defin. — An eruption of minute vesicles,
tincontagious, crouded together, and terminating
in the absorption of the Jinid they contain, or in
superficial ejcoriations, with more or less serous
Exudation, concreting into thin fakes or crusts.

2. I. DEScnii'TioN. — This eruption may be
confined to a single part of the body, or it may
attack several parts, or even the whole surface.
It most frequently appears in the axilla, the in-
sides of the thighs, the groins, hams, &c. When
it is more general, it often extends over the backs

7 46

ECZEMA — Acute — Chronic — Pathology,

of the hands, the face, scalp, neck, and fore-
arms. It often occurs on the scrotum and verge
of the anus, on and around the nipples, and in
the vulva. Eczema presents various mo(/i/jcafw«s,
distinguished by Dr. \Villan into the £. si)Za)-e, £.
impeliginodes, and E. rubntm. jMiNI. Uiett and
Raver have, I think more correctly, divided it
into the Acute and Chkonic — a division which
I shall partially adopt.

3. i. Acute Eczema. — The eruption of the
vesicles of this form is preceded and accompanied
by a sensation of heat and tingling of the affected
parts, aggravated to smarting on being exposed to
heat — A. In its most simple form — Eczema sim-
plex— the skin still preserves its natural colour;
and the vesicles are very small, very crowded, and
hardly inflamed at their bases. The serum which
Ihey contain is at first limpid, afterwards opaque,
milky, or turbid ; and is ultimately absorbed, or
dried on the summit of the vesicles after their
rupture. In this latter case, which is not frequent,
small epidermic flakes, and minute crusts of the
size of a pin's head, are observed. These are
soon detached ; and often, in the space of one or
two weeks, no traces of the eruption remain.
Such is the usual course of the slightest state of
eczema, as when it follows the action of the sun's
rays, or of topical irritants, &c. It occurs most
commonly in young persons, particularly females ;
is attended by no fever ; but is sometimes compli-
cated with lichen, and with psora.

4. B. When the inflammation is more acute,
the skin becomes red and shining, as in erythema
or erysipelas, at the same time that it is covered by
minute vesicles — Eczema ruhrum, Wii.lan. — It
commonly appears about the parts provided with
hair, as the organs of generation, the margin of
the anus, bends of the arms, wrists, and neck ;
and is more frequent and much more severe than
the foregoing. The vesicles are small, crowded,
or confluent, transparent, slightly shining, sur-
rounded by red areolag, especially in young, ple-
thoric, and strong persons. They remain limpid
until they burst, — about the fifth or sixth day, —
frequently giving issue to a milky or reddish serum ;
and are replaced by small, yellowish lamellae or
flakes. In the slighter grades of this variety, the
fluid is often absorbed, and the cuticle forming the
vesicle exfoliates; but in the severer grades, the
contents of the vesicles, when they burst, irritate
the already inflamed surface, occasioning super-
ficial excoriations, with a more or less abundant
exudation of serum, which ultimately lessens,
becomes thicker, and at last concretes, form-
ing, with the detached cuticle, thin lamella! or
crusts.

5. C. The vesicles of eczema may be associ-
ated with small psydracious pustules ^ E. n«pe-
liginodes of Willan. — The inflammation is tiien
carried to its highest degree, is preceded by a
sensation of tension in the affected part, of burn-
ing heat, or attended by smarting, and intense itcii-
ing, and considerable tumefaction. The vesicles
are confluent or agglomerated, — at first trans-
parent, assuming, in tiiree or four days, an opaline
hue, and passing into a sero-puriform state, being
moreover interspersed with psydracious pustules.
They all discharge a fluid having a faint unpleasant
odour, !ind irritating the parts with which it comes
in contact.

'»• IJ. — a. In the simple acute Eczema there is

usually at first not much disorder beyond that of
the affected part. But in the £. ruhrum and £.
impeliginodes, there is generally febrile action, the
intensity of which is proportionate to the local irri-
tation. Not infrequently the eruption is preceded
by gastro-intestinal irritation or disorder, the symp-
toms of which are often very manifest both before
and at the time of the eruption. The lymphatic
glands in the vicinity of the eruption are often
swelled and painful. This form of the disease is
almost always consequent upon appreciable ex-
ternal causes (§ 15.). — b. hs duration is com-
monly from two to three weeks. But the simplest
variety may be a week less, and the severest form
a week longer ; the affected parts not losing their
red colour for a considerable time longer.

7. ii. Chronic Eczema — niay present the
three grades of acute eczema particularised above,
-—the E. simplex, E. ruhrum, and E. impetigi'
nodes, whatever may be the causes which produce
them. — a. When the inflammation is aggravated
after the breaking of the vesicles, it may be ex-
tended to the deeper layers of the skin, and even
to the sub-cutaneous tissue. The skin becomes
very painful, is excoriated, its cuticle fissured ;
and, when it is very much irritated, resembles a
blistered surface in a stale of suppuration — the
Dartre Squameuse hiunide of Alibert — and con-
stantly exudes an ichorous fluid, which resembles
drops of dew, and is often so abundant as to pene-
trate all the linen wrapped around the part. It
is chiefly when the eruption has reached this
height, that it is attended with the most insup-
portable itchings. The skin is then so acutely
inflamed as to be as red as carmine in some parts,
llepose at night is impossible, unless at intervals,
when the smarting, stinging, or itching subsides ;
but this symptom suddenly returns without any
obvious cause ; when scratching of the part, some-
times until blood is poured forth with the exuded
serum, cannot be longer forborne.

8. b. After a time, varying from a few weeks
to many months, the inflammation subsides. The
exuded serum becomes less abundant, thickens,
and forms into thin, soft, yellowish brown, and
semitransparent crusts, but little adherent, often
very large, leaving beneath them, when detached,
an inflamed and a slightly moistened surface.
These crusts form more slowly, become drier, &c. j
and then, without any obvious cause, the inflam-
mation and the serous exudation resume their
former intensity ; or, when the healing process
has proceeded further, the surface again becomes
red, vesicles reform, break, and the affection fol-
lows the same course. Lastly, in some cases, no
further exudation takes place : the crusts become
drier, less yellow, and more adherent ; often
thickened, fissured, or chopped, and easily de-
tached, leaving the surface but little inflamed.
Sometimes, however, in the more extensively dif-
fused state of the disease, the skin remains, even
for several months, of a bright red ; is covered in
parts by dry and thin scales or flakes ; and is in
some places cracked, but without any perceptible
exhalation. In this case, the eczema resembles
certain scaly affections, especially psoriasis, — the
more, as these scales arise, not as heretofore, from
an exhalation and concretion of lymph, but are,
as in the scaly eruptions, the lamellae formed of
diseased epidermis. In some cases, especially
on the limbs, there remain but two or three small

ECZEMA — SpEcinc — Diagnosis,

747

})laces, the skin of which seems thin, stretched, <
sliining, and smooth ; its surface being covered
by whitish and extremely thin scales, as if formed
of epidermis, but without the least appearance
of vesicles ; the diagnosis being difficult, if the
previous history, or the appearance of vesicles j
about the circumference of the excoriated part did
not render the nature of the eruption evident. :

9. c. Clironic Eczema, although generally at i
first very limited, may extend over a wide surface,
so as even to cover a whole limb, or the greater
part of the body. — a. When it attacks the face,
the redness and swelling, with oedema of the eye-
lids, are considerable ; and sometimes associated
with inflammation of the conjunctiva. — S. It
occasionally is seen in the ears, especially when
it affects the scalp, and is then often mistaken for
a variety of porrigo, and it is sometimes associated
with otorrhoea. — y. When it attacks the scalp,
it exudes a viscous fluid having a faint and nau-
seous odour. As it subsequently diminishes, it
concretes into lamellated or furfuraceous crusts,
which are easily detached. At last the secretion
entirely subsides, the skin passing into a scaly
state, and becoming the seat of an abundant and
constant desquamation, the removal of the scales
leaving the skin red, shining, and irritated. Eczema
of the scalp may continue many months. It is
generally attended by swelling of the posterior
cervical lymphatic glands ; and it occasions change
or loss of the hair. — J. Wlien it is seated in the
upper parts of the tliighs, it often spreads to the
anus, the scrotum, and to the vulva, occasioning,
as indeed in its other severe forms, the most in-
supportable stinging and itching. If it extend to
the penis, the prepuce is often fissured ; painful
itching, irritation, and erections, being caused by
it. — e. Eczema may be complicated with lichen,
with scabies, with impetigo, and with ecthyma.

10. iii. Specific Eczema — Mercurial Eczema,
Mercurial Disease, Schreiber, Moriarty ;
Hydrargyria, Alley; Exanthema Mercuriale,
J. Frank — is, in its slighter grades, and as re-
spects the characters of the eruption, in every re-
spect the same as the acute and chronic Eczema
rubrum. But the constitutional symptoms are
much more severe, and the disturbance of the
nervous system much greater, in the former than
the latter ; whilst the eruption is much more ge-
nerally and more frequently dift'used over the
surface. Both in these lesser grades, and in the
severer states about to be described, it is ushered
in by much constitutional disturbance — espe-
cially furred tongue, accelerated circulation, and
increased sensibility and irritability.

11. The more severe states of this affection
were first described by Benjamin Bell, Spens,
Moriarty, Pearson, INI'JMulliv, Chisholm,
and Alley. Besides being preceded by a well-
marked febrile paroxysm, these grades are often
accompanied by difficult respiration, tightness
across the chest, and dry cough, the skin being
very hot, and the seat of a smarting and stinging
sensation. When the disease is consequent on
mercurial inunction — for it may also follow the'
internal use of mercurials — a diffused redness,
with numerous crowded vesicles, supervenes in
one or two days, generally on the thighs, scrotum,
fore-arms, ficc. In some cases, the eruption pro-
ceeds no further than the parts where frictions
have been applied, and, after one or two weeks,

subsides. But in the severer grades, the skin is
extensively studded with vesicles, which soon
break, discharging an irritating and offensive
fluid, which concretes into large incrustations of
a dark colour. At the same time the fauces, and
fretjuently the conjunctiva, are greatly inflamed ;
and the face itself covered with incrustations, fis-
sured in different directions. The eruption ex-
tends over a large space, and spreads in succes-
sion over most of the body ; the excoriated sur-
face being the seat of constant irritation, which is
increased by the pressure of the body, and by
the substances which imbibe the exuded fluid.
The incrustations crack, and expose the raw sur-
face in several places, upon change of posture.
If the disease increase in severity, or be still more
intense from the commencement, the attendant
fever assumes a more adynamic form ; diarrhoea is
readily induced ; the pain in the chest, and diffi-
culty of breathing, increase, and are attended by
anxiety at the pra;cordia ; a dirty, bloody expec-
toration, indicating an analogous affection of the
respiratory mucous surface, is observed ; and ul-
timately, if relief be not obtained, the tongue and
fauces become dry and dark, and the pulse
frequent, small, feeble, and irregular. Sometimes
sphacelation of the skin, with delirium or con-
vulsions, takes place, and death ensues. — Sucli
are the intense states of this disease, according
to the physicians now referred to ; but it more fre-
quently assumes the milder grade described by
Dr. Bate5ian ; and which is characterised chiefly
by a less severe and less extensive eruption and
excoriation ; by less remarkable constitutional dis-
turbance, and by the entire absence, or the slight
nature, of the pectoral symptoms.

12. The duration of this particular variety is
very uncertain. When a limited part is affected,
it may terminate in ten or twelve days ; but when
it is more universal and more severe, recovery
seldom takes place in less than as many weeks, or
even longer. The whole epidermis is destroyed by
the more intense grades of the inflammation ; and
when the discharge ceases, it lies loose, and, with
the concreted matter, assumes a pale brown
colour, changing to black, before it falls off in
large flakes. The red cuticle afterwards formed
is liable, as in some other diseases, to desquamate
again and again, even for a third or fourth time,
but in smaller branny scales, of a light colour, a
roughness long remaining like slight psoriasis.
After the intenser forms, the nails and hair fall
off; the former, when renewed, being thickened,
furrowed, and incurvated.

13. II. Diagnosis. — a. Eczema simplex may
be mistaken for soub/es,.especially when affecting
the wrist, and the sides of the fingers, or attended
by much itching. But the vesicles of the former
are flattened and agglomerated ; those of the latter
acuminated and isolated. The irritation or pru-
ritus of eczema is rather a smarting or stinging;
whilst that of scabies is rather agreeable than
painful. Moreover, the latter is essentially con-
tagious, the former is non-contagious. — b. Eczema

1 rubrum may be mistaken for miliaria ; but the
vesicles of the latter are never confluent, as in the
former; and are symptomatic of much constitu-
tional disturbance, of which the eruption is a less
important symptom than in eczema. — c. E. im-
petiginodes differs from impetigo in alwaj's occu-
pying a large space, the latter being much more

748 ECZEMA— Prognosis

confined. The pustules of impetigo have a larger
base, and contain a thicker fluid, than this variety
of eczema, which is always vesicular at its com-
mencement, its secretion never consisting of true
pus. Impetigo also gives rise to thicker, rouglier,
and more unequal crusts than it ; and is never
surrounded by the vesicles of eczema rubrum, as
the E. impetiglnodes always is. — d. Eczema, in
its chronic state, may be confounded with lichen
agrhis ; but the crusts formed by the latter are not
so large, nor so thin, as the scales of the former ;
and when they fall off, they leave not a red,
smooth, and shining surface ; but a certain rough-
ness, owingto the small prominent papulse, which
are generally evident to the eye, and always to
the touch. Also, when lichen becomes dry and
scaly, the skin is thicker, and more rugose, than
in eczema ; and there are commonly some papula;
scattered about, whicli, by their peculiar charac-
ters, further distinguish lichen. — e. The vesicles
of the early stages, and their presence around the
patches of excoriation in the latter periods, as
well as the less dry and less friable scales of
chronic eczema, will generally distinguish it from
psoriasis ; in which also the skin is more elevated
or thickened, and more fissured in parts not in-
fluenced by the motions of the joints, tlian in any
of the states of chronic eczema.

14. III. PnoGNOsis. — In its acute form, this
affection is generally of no great importance :
but in many of its chronic states it often becomes
most distressing ; and sometimes even embitters
existence ; opposing, for many montiis, every
known means of cure ; and often returning after
having been apparently altogether removed.
When occasioned by mercury, especially if this
mineral have been employed in large quantity, it
may assume, as shown above, a most dangerous
form ; it therefore requires a guarded, and in some
instances an unfavourable, prognosis, particularly
when pectoral and nervous symptoms are present.

15. IV. Causes. — «. Eczema is most common
in adults ; is somewhat more frequent in females
than in males ; and oftener occurs in spring and
summer, than in winter. Susceptibility of frame
seems to dispose to it ; and there appears to be a
predisposition in some constitutions, generally
connected with vascular plethora, favouring its
passage into a severe and chronic form. — /*. It is
most frequently excited by solar or artificial heat;
by the contact of either mineral, vegetable, or ani-
mal irritants, — especially the oxides of the
metals ; by mineral or other powders ; by lime,
alkalies, dust, and want of cleanliness; by sugar,
&c. I have seen it produced on theinsides of tiie
thighs and parts adjoining, liy tiie contact of the
leucorrhceal discharge, and by the catamenial
fluid. Draughts of cold water when the body is
overheated, acid, acid fruits, pickles, and shell-
fish will also occasion it, especially in some con-
stitutions. ]51isters and plasters, and rancid oils
or grease applied to the surface, are also among
its usual causes. It sometimes, however, appears
without any obvious reason ; at other tin)es, it
seems attributable to indigestible and unwhole-
some food, to spirituous lieiuors and similar errors
indict ; it being in such cases most obstinate. It
is not contagious: but M. 1$iktt supposes that
it may be communicated in some cases, as when
llie exudation continues in contact with a healthy
surface. He states, that he has .seen it transmitted

— Causes — Treatment.

from, and to the organs of generation, by sexual
intercourse. The specific form is always caused
by the use of mercurials — internal or external

— but most frequently the latter; and by expo-
sure to cold during their influence. Whether or
not the eruption, in such cases, may be in some
measure produced by a change in the fatty sub-
stance used in oxidizing the metal, is very difl^cult
to determine.

16. V. Treatment. — The remedies recom-
mended by WiLLAN and Bateman, viz. heating
tonics and acids, I have found more generally in-
jurious than beneficial. The treatment directed
by Biett in his clinical lectures at the " Hopital
Saint Louis," and by his pupils Rayer, Cazenavjs
and ScnEDEL, in their works, is decidedly more
rational and successful. — ^. The slighter grades
of the acute disease are readily removed by simple
refrigerants and emollient diluents, with cooling
aperients, and tepid bathing. But when the
eruption is more extended, is accompanied by
smarting, or assumes tlie 'form of the Eczema
rubmun or E. iinpetiginodes, tepid alkaline or sul-
phuretted baths — made by adding from four to
eight ounces of the carbonate of soda or of potash
to the water of a whole bath, for an adult; or
four ounces of the sulphuret of potassium ; — an
antiphlogistic regimen ; general blood-letting in
young plethoric or robust persons; local bleedings
in the vicinity of the excoriations ; and small
doses of the »((ra(e (i/' /)i)tos/i, with S()(/a, in muci-
laginous diluents ; will^be required in addition to
the above more gentle means. I^mollient and
soothing applications should also be resorted to. I
agree with JMr. Pi.ujibe, in avoiding all greasy
applications; and with Sir. Biett, in forbidding
the use of sulphur, or repeated doses of mercury,
in this state of the disease ; an antiphlogistic and
soothing treatment being in every respect the
most appropriate. I have prescribed with much
benefit the biborate of soda, with or without the
nitrate of potash, in emollients in the acute form ;
and after the bowels have been evacuated, the
nitrate of soda in similar veh.icles. In all cases,
the exciting causes should be ascertained and re-
moved.

17. B. In the chronic states of this eruption,
the antiphlogistic treatment recommended above
sliould be employed, where it has been either
neglected, or insufficiently tried. Pvrgatives
also ought to be frequently resorted to, where the
tongue is loaded ,and the evacuations unnatural,
and repeated daily until they assume a healthy
hue. For this purpose, a mercurial preparation
may be exhibited at night, and a purgative
draught in the morning. If there be signs of
asthenia and a cachectic state of the frame, the
purgative should be of a tonic and stomachic
kind; the bark o( the ma dar root, or tonic infu-
sions, with the nitrate of potash, or with the
mineral acids, being taken through the day,
but not until mercurial medicines have been
relinquished. Dr. Elt.iotson advises, in addi-
tion to bleeding and a low diet, the exhibition
of mercury until the moutl) is affected ; but the
latter part of this practice does not agree with
my experience ; the former I have always di-
rected. It is chiefly when the excoriations arc
extensive, and the exudation co])ious, and after
depletions have been employed, that acids seem
to be indicated ; morbid secretions having been

EDUCATION,

evacuated from the prima via. The infusion of |
roses, with sulphuric acid and small doses of tiie
sulphate of potash, or of quinine, or tlie infusion
of cinchona with nitrate of potash, nitric acid,
and tlie spiritus ajtheris nitrici, is most conform-
able to the treatment advised by other- writers ;
but I have seen more benefit accrue from the de-
coction or infusion of bark, with nitrate of potash
and carbonate of soda ; from the compound
decoction of sarsaparilla Cthe mezereon having j
been omitted in its preparation) with liquor potas- i
sai ; and from the decoction of dulcamara, or of
elm bark, with very minute quantities of the bi-
chloride of mercury, tlian from mineral acids. I
have found Fowi.En's arsenical solution of ser-
vice in some very chronic cases, but the afl'ection
often returned. It is requisite, in inveterate cases,
that the diet should be strictly regulated, and
confined chiefly to farinaceous food, and broth
with emollient diluents, in order to derive lasting
advantage from any plan of treatment.

18. a. External means are especially requisite
in most clironic states of the complaint. In addi-
tion to those directed above, poultices or cold
cream with a solution of the acetate of lead, or
lint moistened in a dilute solution of this sub-
stance, may be applied to the excoriated parts.
When smarting and stinging are great, Dr. A. T.
Thomson recommends them to be washed with a
mixture of a drachm cf iiydrocyanic acid in
eight ounces of the emulsion of bitter almonds.
M. GuiLLEMiNEAU adviscs the application of a
solution of the nitrate of silver. When the ex-
coriations are extensive, and the exudation copi-
ous, the linimentum calcis, either alone or with
a little of the linimentuni caniphorai, will be very
serviceable. The external use of camphor, in all
such cases is productive of advantage. Much
benefit will often accrue from vapour baths, from
tepid and warm alkaline, or sulphuretted baths;
and, in the more chronic cases, from sulphureous
fumigating baths : but this result will seldom be
obtained — more particularly in plethoric and
robust persons — until after moibid secretions
have been fully evacuated, and bloodletting has
been carried as far as ciicumstances will permit.
Indeed, any of the numerous applications or
combinations of moist heat, in the treatment of
acute or sub-acute eruptive diseases, is more or
less injurious, un'ess preceded by these measures.
— When the eruption passes into a scaly and in-
dolent state, some writers have prescribed blisters,
or an ointment with the red precipitate, witii the
view of exciting a new action in the part ; but
these and similar means are inferior to the baths
mentioned above. Ointments v/ith the protiodide
(9j. t0 3J.) or the biniodidc (gr. x. to ^j.) of
iuercurji, promise however greater benefit. When
the disease has been of long duration, the arrest
of it should not be risked, unless with the 'pre-
cautions of occasional vascular depletions, al-
vine evacuations, and the insertion of either an
issue or seton^ otherwise internal disorder may
supervene, or the eruption return, — illustrations
of both these results having come before me in ]
practice.

19. b. Mercurial eczema requires, according to
the grade it assumes, a nearly similar treatment
to the above, Biett judiciously prescribes blood-
letting at ihe outset ; Pe.\i{so>i, diaplioretics; and
Baxema.v, frequent ivarm baths, with diaphoretics

PHYSICAL,

749

and opiates ; and subsequently tonics and mineral
acids. Dr. MoniAnTY, however, found opium to
be a somewhat doubtful remedy. Rlercury
ought to be immediately relinquished, and a re-
turn lo it either avoided, or ventured on with
caution. When the symptoms are severe, and
the attendant fever of an adynamic kind, cam-
phor, ammonia, the liquor ammonice acetatis, or
piiroligttenus acid, or the chlorates are the most
appropriate remedies. Either of these should be
associated with such other substances as may be
appropriate to the circumstances of the case ;
and, when the discharge from the excoriated sur-
face is either abundant or offensive, employed
externallii as well as internally ; the strength of
the patient being supported by appropriate means,

20. c. When convalescence fcom either of the
states of the complaint is advanced, change of air,
regular exercise, avoiding the ingestion of cold
fluids when the surface is warm ; a spare, light,
and regular diet, with the occasional use of deob-
struent or sulphuretted mineral waters; will
generally tend to confirm the recovery.

BniLioG. AND Refer Aetius, Tetrab. iv. s. i. c. 128.

— Paiilus JEgineta, I. iv. cap. 10. — Acluarius, I. vi. caj). 8.

— Sennert, Pract. Med. 1. v. par. i. cap. 2 Brendel. De

Ino])inatis ex Mercurio dulei noxis, Opusc. vol. i. p. 69.
— Scln-eiber, DeMorbo Mercurali. Erf. 1792. — B. Bell,
On Gon. Vir. and Lues Venerea, vol. ii. p. 25i8. — Pear-
son, On the EHects of var. Articles of the Mat. Med. in

Lues Venerea, 2d edit. cap. 13 Butter, Treat, on the

Venereal Rose, 1799. — iloriarfi/, A Descrip. of Mercu-
rial Lepra, 8vo. 1804. — Spetis, in Edin. Med. and Surgi

Jourii. vol. i. p. 7 M'Mul/ms, in Ibid. vol. ii. p. 37

Butter, in Ibid. vol. v. p. 143.^ — C/ii's/wbn, in Ibid. vol. viii.
p. '2'J6.— J. Frank, Acta Clinica, vol. iii. p. 22. ; et Praxeog
Med. Univ. Pra;c. pars i. vol. ii. p. 177. — Marcel, in Med.

and Cliirurg. Soc. Trans, vol. ii. art. 9 Allei/, On the

Hydrargyria, or that Vesicular Disease caused by Mer-
cury, &c. Lond. 1810. — Mathias, On the Mercurial
Disease, 8vo. 1811. — Horn, Arehiv. f. Med. Erfahr.

Jahrg. 1812, p. 115 Guille?}ieneau,'De I'Einploi du Nit.

dWrgent, fondu dans le Traitera. externe de quclr|ue
Mai. &c. 4to. Paris, 1826.— Bai/rr, Traite des Mal. de la

Peaii, vol. i. p. 272 Cazenavc et Sc/icdel, Abrcge Prat.

lies Mal. de la Peau, p. 74. — Bateman, Syn. of Cut. Dis.
by Thomson, \>. 353. — S. Plnmbe, Tract. Treat, on Dis. of
the Skin, 3d ed. 1S32, p. 3S0.— W. C. Demly, Treatise ou
the Cut. Diseases of Childliood, &c. Lond. 1827, p. I6S.

EDUCATION, PHYSICAL. This sub-
ject is fully treated of in the article Age, where
measures for the healthy developement of the
organs and tissues, and for strengthening the
constitution, are succinctly stated in connection
with the epochs of early life in which they should
be adopted (see Age, § 5 — 28.). In the ar-
ticle Disease, the numerous causes which im-
pede, counteract, or entirely subvert, physical
developement and strength are described, and
their mode of operation explained (see Disease,
§ 11 — 62.); and in the article on Infants, va-
rious observations not comprised under the fore*
going heads are adduced.

BiBUOG. AND Rr.FER. — Andry, OTtho\mCi\e,Svo. Beil.
1774. — Wilrzer, Leber die Pliys^ische Erziehung. 8vo.

Bonn. 1797 M'illich, On Physical Education, 8vo. Lond.

\m\.— Duncan's Annals, 1801, p. 290. Fothernitl, Med.

Observ. andlnq. vol. v. p. 160 Underwood, On the Dis. of

Cliildren, with Directions for the Management of Infants,
Sec, by Merrininn, 8vo. Sth edit. — Si/er, Treatise on the
Management of Inlants, &c. 8vo. 1811. — J. B. Davis,
Annals of the Universal Dispensary for Children, with
Rules for the Bodily Management of Infants, &c. 8vo.
Lond. 1821. — Iladcn, Pract. Observat. on the Manage-
ment and Dis. of Children, with addit. Observ. by T.
Alcnck, 8vo. 1827. — J. Kennedy, On the Management of
Children in Health and Disease, &c. 12mo. 1825. — Baticr,

Sur I'Educatio:! Physique des Enfans, 8vo. Paris, 1820 .

Bullicr, in Diet, de Med. t. i. p. 231 Lachaise, in Ar.

chives Gener.de Mt'd. t. ix. p. ISO. — 7)?(i9;«, The In.
fluence of Physical Education in producing Deformity of
tlie Spine, &c'. 8vo, Lond. 182y. — lioberton, Observat.

750

ELEPHANTIA — Causes — Symptoms and Progress — Pathology.

en the Mortality and Physical Management of Children,
12mo. Lond. 1827.— i. Stewart, On the Tendency to
Disease in Refined Life, &c. 12mo. Lond. 1828. — J.
Darwall, Instructions for the Management of Infants,
&c. Lond. 12mo. 1830. — A/. liyan. Lectures on the Ma-
nagement of Infants, iSrc, in Med. and Surgical Journ.
vols. iv. and v. passim. —See also the Bib/iog. and Re-
ferences to the articles Age, Disease, and Infants.

ELEPHANTIASIS OF THE ARABIANS.

Syn. — Elephantia, Elephantiasis Arabum,
Auct. Var. Heniia Carnosa, Prosper Alpinus.
Glandular Disease of Barbadoes, Hendy. Bar-
badoes Leg. Cochin Leg. Egiiptian Sarcocele,
Larrey. Bucnemia Tropica, Good. Elephan-
tiasis tuberosa, and Scrotalis, Alibert. Oel-
schenkel, Drusenkrankheit, Germ. Lepre tu-
berculeuse elephantine, Fr. Dal Fil, Arab.
Elephant Leg, Elephant Disease.

Classif. — 7. Order, Tubercular afFections
(^Bateman). 6. Group, Leprous affections
{Alibert), 3. Class. 2. Order {Good).
IV. Class, IV. Order {Author).
"[.DEFin.-— Hardness, lividity, and great tume-
faction of one or both li7nbs, or of the scrotum, S;c.,
with an irregular glabrous, or scaly state of the
skin; endemic chiefy in warm countries.

2. Although this disease was first described by
RiiAZEs, it has been very generally confounded
in modern times with the elephantiasis of the
Greeks, from which it is quite distinct. Its re-
semblance, even, to the latter affection, does not
sufficiently justify M. Alibert in arranging it
under the same genus. It is seated most fre-
quently in the lower extremities, but is also met
with in the upper extremities, in the scrotum, the
vulva, the breasts, and more rarely in other parts
of the body. The countries in which it is most
common are, Barbadoes, and all the West India
Islands; various partsof South America ; Egypt,
and several parts of inter-tropical Africa ; Ceylon,
the neighbourhood of Cochin, on the coast of
Malabar, and other parts of Hindostan; Japan,
and some districts of China ; the Polynesian isles ;
and the provinces of Asturias and Castile, in
Spain. Cases, however, occasionally occur in
all the countries of Europe. According to Dr.
Graves and Dr. Evanson, a variety of it is com-
mon in Ireland. I have seen one case in the
Infirmary at Edinburgh ; five in London, one of
them very recently under the care of ]\Ir. Morlev,
and several, many years ago, in Africa, and on the
Continent of Europe.

3. I. Causes. — a. The ^^^'edisposing causes are
not sufficiently known. It appears not to have
been a very old disease in the West Indies, where
it seldom occurs in Europeans. It is most fre-
quent in Creoles and in imported Africans, and
in places near the sea-coast. In the East Indies,
it attacks only the natives. It seems in some
instances hereditary, and in others derived from
the habits or circumstances of the individual. —
b. The exciting causes are also obscure. Hil-
lary and Henuy attribute it to sudden vicissi-
tudes of temperature. It has been considered
that the use of fermented beverages, especially
those prepared in warm climates from tiie sap of
several s])ecies of ))alm, occasions it, as acid wines
^ive rise to gout, with swelling of the extremities,
in this country. The remarkable case of it in both
lower extremities, under the care of Mr. Moim.ey,
IS tliiit of a man in good circumstances, who has
lived well, and resided constantly in London.

4. II. Symptoms and Progress. — The dis-
ease often commences without any premonitory
signs ; the patient experiencing rigors or chills,
with nausea, headache, and intense fever, followed
or attended by acute and burning pain, extending
in the course of the lymphatics. Subsequently a
tense, knotted, and hard chord, very painful to
the touch, may be traced to enlarged glands in
the groin or armpits. The surface of the part is
soon affected by an erysipelatous inffammation, at-
tended by a burning and smarting sensation, and
by great tumefaction ; the cellular tissue being
implicated as well as the skin, which presents no
appearance of vesication. These local symptoms
are accompanied by fever, ardent thirst, burning
heat of surface, &c., alternating with copious per-
spirations. All these symptoms are diminished in
the course of two or three days, and, excepting
the tumefaction, disappear in a short time ; but
they return again after irregular intervals, each
successive attack leaving the limb more tumefied
and hard, until the disease reaches that pitch to
which the term elephantiasis has generally been
applied. After each of these seizures, the redness
of the surface, and particularly that in the course
of the absorbents, disappears ; but the part at last
becomes irregular, altered in colour, sometimes
fissured or cracked, hard and elastic, pressure
leaving no impressions after it. The progress of
alteration varies extremely — from a few months
to many years. Sometimes the disease remains
stationary for several years, and without any re-
turn of the attacks now described. The cutaneous
surface is occasionally pale, rriore frequently yel-
lowish, of a dirty hue or livic^ It is often also
scaly, resembling icthyosis, rugose, or fissured ;
is in some instances covered with soft vegetations ;
or with hard horny excrescences ; and is more
rarely ulcerated. In other cases, the surface is
traversed by enlarged veins ; and very frequently
enlarged or varicose veins are seen ramifying from
the seat of enlargement, — a circumstance which
evidently induced the Arabian physicians to notice
this affection in connection with, and indeed as de-
pending upon, a varicose state of these vessels. At
a far advanced period, the hard and engorged
glands sometimes sujipurate, or even sphacelate ;
and more rarely, indolent abscesses, or deep-
seated suppuration, with offensive discharges, su-
pervene in the midst of the enlarged mass. When
the disease is seated in the soroduH, this part often
becomes very remarkably enlarged. In Egypt and
the East, tumours of this description are not infre-
quent, and sometimes weigh from 30 to 801bs.
Several of these have been removed in Egypt by
Clot-bey. One of enormous size was lately
operated upon in London, but unsuccessfully.
M. DupuYTREN met with an instance of this al-
teration in the labia majora vulva;.

5. III. Paihoi.oov. — i. On dissection, the
integuments of the part are found thickened and
hardened : — 1st. The epidermis is veiy thick, ad-
herent, and fissured; — 2d. The mucous layer is
very distinct ; — 3d. Tiie papillary body is greatly
developed, and readily distinguished from the cutis
vera or dermis, the papillae being elongated, en-
larged, and prominent (Andral, Chevalier); —
4th. 'i'hc cutis v6ra is much thickened, it some-
times being half an incii in thickness; — 5th. 'i'he
sub-cutaneous cellular tissue is either thickened,
the cellular areola; containing a semiliquid, gcla-

ELEPHANTIA — Diagnosis.

751

tlnous matter ; or it is hardened, presenting an
intermediate state between a lardaceous and a
scirrhous structure, and is more and more dense
as it approaches the skin. The muscles under-
neath are pale, thin, or softened. The lymphatic
glands and vessels present evidence of disease, but
not uniformly ; and one or more of the principal
veins are generally obstructed or obliterated, as
observed in the cases inspected by MM. Bouil-
LAUD and Gaide.

6. ii. Nature, &;c, — The structural alterations
to which elephantiasis is strictly applicable, are
evidently remote effects of various states of mor-
bid action, which have either repeatedly returned,
or have long continued in the diseased part. From
the history of cases, and the changes observed on
dissection, the skin, subjacent cellular tissue, the
absorbents, and the veins, are evidently more or
less implicated ; but it is very difficult to ascertain
which of these is primarily or chiefly affected.
Tiie principal characteristics of elephantiasis
have manifestly resulted, in several instances,
from disease of the absorbents, or veins, or both.
They have also followed, within the scope of my
own observation, a chronic affection of the skin,
•which has extended to the subjacent tissues,
and, sooner or later, to either the veins or the
absorbents, or perhaps to both. I was lately
consulted by a female of middle age, who,
during convalescence from a dangerous attack of
continued fever, more than ten years previously,
experienced hard and painful swelling of one of
the lower extremities, depending on disease of the
absorbents or veins, or both, according to the ac-
count she gave. When I saw her, the limb,
below the knee, was very hard, and enormously
swollen ; and had all the characters of elephant
leg ; the skin being irregular, scabrous, livid, and
fissured. I directed bandages, and the internal
use of iodine ; but after two or three visits, I saw
no more of her, and consequently know nothing
of the result. Some time previously, a similar
case, as respects its origin and history, although
not so severe, came before me. It had been of
several years' duration ; and had increased gradu-
ally after the acute attack in which it originated.
The limb was hard, dark red, and livid in parts,
somewhat irregular, slightly scaly, and the veins
above the tumefied part enlarged. The affection
of the skin was here consecutive. Considerable
advantage was procured from bandaging, and the
internal use of iodine ; but the enlargement is not
entirely removed. The patient is still under my
occasional observation. More than one of the
cases I saw in Africa, seemed, on the other hand,
to originate in a very manifest alteration of the
cutaneous surface.

7. M, Alard considers elephantiasis essenti-
ally to depend upon inflammation of the cutane-
ous and sub-cutaneous absorbing vessels and
lymphatics. Dr. Musgrave also views it, as it
occurs in the West Indies, as a consequence of
inflammation of the lymphatics, the inflammation
being accompanied with pungent heat, and with
redness of the skin, and characterised by great
tendency to metastasis. He states, that it usually
betrays itself in the scrotum, the mammae, or in
some part of the extremities, most frequently about
the ancle, or high up the thigh ; and, although at
first circumscribed, it often difl'uses itself over the
limb. When the glands are uot involved, painful

and indurated chords can be traced to the nearest
cluster ; but, whatever may be its original seat,
the patient is never secure, while the constitutional
disturbance subsists, from a sudden retrocession to
some vital organ. He has seen it translated from
the scrotum to the head ; from thence, after a few
hours, descend rapidly to the abdomen ; again
migrate to the chest; and return, perhaps, to the
encephalon, and prove fatal there; or resume its
more harmless situation, and there run its course.
While occupying an internal viscus, it gives rise
to the usual symptoms of acute inflammation.
Dr. Hillary and Dr. JMusgravf, view the local
affection as a consequence of fever, which com-
monly precedes it for two days. Dr. Hendy,
however, contends that the fever is symptomatic
of the inflammation of the lymphatic vessels and
glands. During the acute stage of the disease,
either, perhaps, may precede the other ; but it is
most conformable with just views in pathology, to
consider the local change as a consequence of the
constitutional disorder ; the advanced or chronic
state being the result of repeated attacks of in-
flammation of the lymphatics or veins, and of the
integuments, generally existing together, but often
originating in, and continuing more or less con-
fined to, either.

8. Inferences. — According to the descriptions
furnished by Towne, Hillary', Hendy, Mus-
grave, Bouillaud, and Gaide, and to my own
observations, this disease should be viewed — (a)
as consisting of certain acute, as well as far ad-
vanced OT chronic, states, generally connected with
a bad habit of body, and each requiring an appro-
priate method of cure ; and, (fc) as arising — a.
most frequently from inflammation of the lympha-
tic system and skin, particularly in warm climates ;
B. from inflammation and obstruction of the veins,
in some instances, with irritation of the skin in
various grades at an advanced period ; and y.
from the extension of inflammation from the skin
to the veins or lymphatics, in other cases. The
tumefaction and hardness are necessary conse-
quences of thickening of the cutis vera and sub-
cutaneous tissue, with deposition of inspissated
lymph in the areola of the latter, whether arising
from chronic inflammation of these structures or
from inflammation and obstruction of the lym-
phatics or veins, or from both these species of
alteration.

9. IV. a. The Diagnosis of elephantiasis is
very easy in the chronic and far advanced state.
In the earlier stages, when commencing in either
of the parts noticed above, it should be viewed as
inflammation of that part, which, in countries
where the disease is endemic, may be followed, if
not properly treated, by the organic changes con-
stituting its fully formed condition. A\'hen this
takes place, the great tumefaction and hardness,
and especially the circumstance of pressure not
being followed by pitting, with the alterations
already described (§ 4.), will sufficiently mark
the nature of the disease. — h. The Prognosis is
unfavourable, as respects tlie removal of the dis-
ease, when it is fully formed, although relief may
be obtained, and persons may live very many-
years with it. But it tends generally to shorten
life, and always to render it much less comfortable.
AVhen it is not far advanced, it may be nearly or
altogether removed by treatment. The result,
however, will very much depend upon the

752

ElMPHYSEMA — Pathology.

habit of body, and vigour of constitution, of the
patient.

10. V. Treatment. — i. Rhazes and others
of the Arabian physicians recommended, in the
Acute stage of elephantiasis, general bleeding,
emetics, aperients, confinement to the horizontal
posture, and spare diet, with cooling epithenis to
the part, and subsequently bandages. A similar
treatment is very generally adopted in the East;
and I believe that it cannot be much improved
upon. Dr. Musguave advises, in addition to the
local application of warmth, and to febrifuge and
purgative medicines, the exhibition of mercury
until the mouth is affected, in order to prevent
the metastasis of the disease, which, in the West
Indies, is so common and dangerous ; as well as
the deposition of lymph, to which the hardness
and swelling are chiefly owing. The employment
of a number oi leeclies, or incisions, asrecommeded
by Mr. Copland Hutchison in erysipelas, fol-
lowed by poultices, or other emollient applications,
may also be resorted to with advantage at this
period.

1 1. ii. In the Chronic Uage, the above treatment
will seldom be productive of benefit. JM. Raver,
however, states, that general bleeding will be of
service when the constitutional powers are not
much impaired ; and J\I. Lisfuanc advises scari-

Jicutions, local bleedings, and compression. Band-
ages, and frictions witli various resolvent sub-
stances, are more to be depended upon in the
most clironic cases, and where the vital energies
are too far depressed to admit of depletions. ]3ut
even in these,'active purging is indispensable. M.
Alabd records a case of twelve years' duration,
that was cured by the repeated exhibition of ca-
thartics. When the skin is in a state of irritation
— is fissured, erythematous, or exudes a fluid
concreting into scales or crusts — frictions, or even
bandages, are not endured by the patient, and are
not appropriate. In these, scarifications and
blisters may be employed with the view of giving
issue to the fluid infiltrated into the sub-cutaneous
tissues. Cauteries and moras have also been di-
rected witii this intention. Several writers advise
douches of vapour — simple or medicated; and
fumigating baths — either local or general. From
my experience of iodine, I am inclined to think
favourably of it in this disease. In one of the
two cases, in which I employed it, manifest bene-
fit was derived. It should be prescribed chiefly
internally, as its external application is apt to in-
crease the local irritation ; and the bowels ought
to be freely and frequently acted upon by deob-
struent and stomachic purgatives. The limb
should be kept as much as possible in the hori-
zontal position. Amputation of the affected part
has been advised, and practised in a few instances
with success.

I!iui.i0(;. AND Rei'f.r. — Alliinus, De Elephantia Java'
Ndva. Vr. lV»i. — Furcstus, 1. xxix. obs. Siii. — Toiune,
On the Dis. most frequent in Karbaitoes and West In-
tlics, Kvo. I,oncl. MICt. — I'lillcnrij, in Philos. 'J'raiis.
vol. Ixii. — Kiinnefru'sser, Dc Kleph. Morlio India' Orien.
CJidoniio. Kil. ilbi. — Hi-iisclhr, h) //r/Z/cj-'s D.sputat.
(Jhirurg. vol. v. p. 403.— /////«/»/, On tlie Kpidcmical
Diseases of JJarbadoes, &c. 8vo. Lond. 17fil. — Itapport
(Ie» Cominissairea de la .Soc. Uoy. des Medec. sur la
Mai. Kouge, ou Eleph. &c. Paris, )7K.O. — Conradi,
in Arncmann's Masazin, b. i. p. a"). — llcndy. On the
fUandular Dis. of IJarb.artcics, &c. 8vo. Lond. 1781. —
llrvolat, in 15nl. de la .Soc. dc Medecine, 1810, No. 1. —
Atciril, Nonvcllcs Observat sur TElephant. des Arabcs,
«vii. Pari*, IHU. ; et de InHamm. des Vaissoaux Al).
•orb. Lymph. &c. 8vo. Sid ed. I'aiis, IWi.— C/icvalicr,

in Trans, of Med. -Chirurg. Soc. vol. ii. p. 71. — Good,
Study of Med. by Cooper, vol. ii. p. 640. — Miisgrave, in
Edin. Med. and Surg. Journ. vol. xxviii. p. 46 — Keji-

nrdy, in llnd. vol. xiii. p. .54 Graves, in Dub. Hosp.

Reports and Comraun. voL iv. p. .M. — Caxciiave, in Journ.
Hebdomad, t. iii. p. 146. — Martini et Horack, in Ibid,
t. iii. p. 'ilO. — Bateman, Syn. of Cut. Dis., by Thomson,
p. 427 — Hoi/illavd, in Archives Goner, de Med. t. vi.
p. B(i7. — Guide, in Ibid. t. xvii. p. .533. — Andral, in
Ibid. Mars, 1827. — iiavc)-, Des Mai. de la Peau, &c.
vol. ii. p. 424. — Caxena've et Scliedel, Abrege Prat, des
Mai. de la Peau, p. 476 — Pierquin, Journ. des Progres
des Scien. Med. vol. xi. p. 140.

EMPHYSEMA. Svn. — 'i.[x<^(,a-nixa (from ly.-

tpoa-ao), comp. Iv, in, into, and (pua-am, I blow),

'Ef-iTrvivfxdriDcrig, Gr. Pnemnatosis, Lat. ]Vi}id-

geschwulst. Germ. Einphi/sime, Boursoujlure,

Ft. Enfisema, Ital. Injiation, Wind Dropsy.

Classif. — 3. Class, 2. Order (Cullen).

6. Class, 2. Order (Good). IV. Class,

II. Order (Author).

1. Defin. — Soft, elastic tumefaction, occa-
sioned by the presence of air, or of any other gas-
eous fluid, introduced or developed in cellular
parts.

2. Although the sub-cutaneous cellular tissue
is the most frequent seat of emphysema, yet other
parts of the cellular structure maybe also affected,
either separately and independently, or in con-
nection with it. Those parts of this tissue, which
are the most lax and the least loaded with fat, are
most frequently and extensively inflated ; and
parts pressed upon by unyielding structures, or
by the action of muscles, although they may give
passage to the air, admit not of its accumulation.
J. P. Frank thinks that lean persons are most
liable to emphysema : this may or may not be
the case ; but there can be no doubt of these
persons being more generally and extensively
affected than those who are fat. When air is
infiltrated into the cellular tissue, it may be dif-
fused or conveyed, by the motion of contractile
parts, to places remote from that at which it was
introduced.

3. Emphysema maybe divided, according to its
seat, into — (a) External, or of the sub-cutaneous
cellular tissue ; and, (b) Internal, or of in-
ternal viscera. The former may be more or less
general, as regards that situation ; the latter is
commonly limited in respect of these viscera, but
is often the source in which the former origin-
ates ; the admission of air into the cellular tissue
of the respiratory passages, by a solution of con-
tinuity in the lining membrane, or by rupture of
tlie air cells, being the cause of the great majo-
rity of cases of external emphysema. It may
also be considered, in connection with the modes
in which it is produced — with reference, a. to its
spontaneous evolution ; and, b. to its origin in a
solution of continuity in some part of a surface
communicating with the external air — to its /«-
trinsic, and extrinsic forins. The division into
symptomalic or traumatic, and idiopathic or spon-
taneous, is faulty ; inasmuch as the spontaneous
secretion of air from the blood into the cellular
tissue, is merely a rare phenomenon contingent
on far advancetl states of disease ; and as the in-
troduction of air from without into liiis texture is
not a symptom, but an accidental occurrence —
is not a necessary or even a frecpient conBe([uence
of a wound or injury, but dependent only upon
certain circumstances or changes connected with
such injury, — I shall, therefore, consider, y/cs(/_v,
the Inirinsic, or spontaneously contingent form

EMPHYSEMA — I

of emp]iysema'; and, secondl}^, the Extrinsic, or
the accidental traumatic conditions.

4. I. The Intrinsic, or Spontanemis Contingent
Emphysema, is evidently dependent upon a more
advanced state of the same general condition of
the frame which gives rise to collections of air in
other parts, and which, in its slightest grades,
often occasions similar accumulations in the
bowels and uterus; the air in such cases being
secreted from the blood, and consisting, most
probably, of certain combinations of hydrogen
and azote, or of carbonic acid. Dead bodies be-
come emphysematous from the gases disengaged
during the process of decomposition ; and a part
which is gangrenous, is often also emphysematous
from this change. But in these, the colour and
cohesion of the parts are remarkably altered,
and other proofs of decomposition are also pre-
sent. In all diseases affecting the circulating
fluid, as typhoid or adynamic fevers, esj)ecially
those usually called malignant, and where the
blood is coataminated by the absorption or intro-
duction of morbid secretions or fluids, the exha-
lation of air into the cellular tissue and hollow
viscera often takes place immediately after death ;
and, in some instances, it is observed in parts be-
fore life is extinct. Moroagni remarked it in
an advanced stage of fever following the repul-
sion of a chronic eruption (Epist. xxxvii. sect.22.) ;
Fabricius Hildanus noticed its supervention
after small-pox ; and Wilmer, from the absorp-
tion of putrid matters. 1 saw lately an iastance
of its appearance under the integuments in the
vicinity of carious dorsal vertebras, in a young
lady. It was limited in extent, but elastic and
crepitating. It is most frequently met with in
warm and unhealthy countries, and in certain
epidemics. I have seen it in the malignant fevers
of warm climates ; it has occasionally been no-
ticed in epidemic yellow fever. Dr. W. Hunter
(^Med. Observ, and Inquiries, vol. ii.) and .T. P.
Frank (De Cur. Horn. Mnrbis, 1. vi. p. 38.)
observed it very generally in an epidemic affect-
ing horned cattle : the latter physician refers to
its frequency in the last stage of an epidemic
fever that raged in some parts of Germany in
1772, and of a similar fever that prevailed in
Italy in 1789; the emphysema appearing about
the neck and face, and sometimes extending to
other parts of the body. Huxhaji (illerf. Ob-
serv. and Inquiries, vol. iii. p. 33.) remarks its
connection with putrid fever and sore throat, as
well as with scurvy ; and records a case where it
occurred, the patient recovering nevertheless.
I saw it in a case of scarlet fever that terminated
fatally, and in another that recovered ; and I agree
with HuxiiAM in considering its appearance about
the neck and upper part of the breast as not rare
in this and similar diseases. The only question
as to these cases was, whether or not the air was
evolved or secreted from the blood, or was intro-
duced from without at some part of the respiratory
passages in the manner about to be explained.
Frank and some other writers likewise notice its
supervention upon erysipelas, when the latter is
prevalent in crowded hospitals. IMiNI. Rullier and
Delarociie have seen it occasioned by poisoning.

5. The intrinsic or spontaneous appearance of
emphysema in such cases may be imputed to the
partial decomposition or alteration of the circu-
lating fluids consequent upon failure of vital

Vol. I.

NTRiNsic — Extrinsic.

753

power. This is evidently the case in some in-
stances, especially when the swollen parts aje
discoloured, and when it comes on near the
period of dissolution. But cases sometimes occur
where no evidence of decomposition can be
traced, depression only of vital power being pre-
sent. J. Hunter, Frank, Baillie, Home,
Davy, and others, have adduced evidence of
the evolution of air from the blood-vessels in-
dependently of such change. The experiments
of Dr. Edwards prove that azote, and the other
constituent gases of the atmosphere, are more
or less absorbed into the circulation, and at'ter-
wards discharged from it, chiefly by the mucous
surface of the respiratory organs and digestive
canal ; and that these actions are regulated by
the state of the vital energies of the system. It
therefore cannot appear surprising that air should
be extricated into the areolaj of parts of the cel-
lular tissue, as well as from mucous surfaces, in
certain states of morbid vascular action connected
with depressed vital power. Besides, we know
that air is secreted into the sound or air-bladder
of numerous species of fish. As to the chemical
constitution of the air, which is spontaneously
evolved in cellular parts, we have very imperfect
inibrmation. It is very probably nearly the same
as that found in the digestive canal, and which
consists chiefly of azote, carbonic acid, hydrogen,
and certain of its combinations. In a case re-
corded by M. Bally {Land. Med. and Phys.
Jflurn. for .Tune 1831.), in which general emphy-
sema occurred immediately after death, with
signs of dissolution of the blood, the air was evi-
dently of the last description; it having taken fire
from the flame of a taper, and burnt with a blue
and white flame; and the edges of the aperture
through which it, escaped having been consumed.
Gaseous fluids may be evolved also in the cavities
of the peritoneum and pleura : but generally in
consequence of the decomposition of fluids, &c.
previously aflTused in these situations; although
they may likewise be secreted by these surfaces;
or common air may accumulate in the pleural
cavities, owing to a communication with the
vesicular structure of the lungs. (See Perito-
neum, and Pleura.)

6. II. Extrinsic, or Accidental Traumatic
Emphysema, sometimes appears in the course of
various diseases, and from external injuries — of
those maladies in which the respiratory functions
become especially affected, more particularly the
expiratory actions; and from laceration, rather
than from puncture or incision, of parts con-
cerned in these functions. It always proceeds,
unless in a remarkably rare form of this species,
from the passage of common air into the cellular
tissue, through a breach of continuity in some
part of the respiratory apparatus. — («) It may
take place from rupture of the membrane lining
the nasal fossce, oT from wounds communicating
with the lachrymal sac or duct; the air passing
into the cellular tissue, upon forcibly blowing the
nose. jNI. JMeniere instances two cases of this
description. J. P. Frank mentions its occur-
rence from playing on wind instruments, whilst
the insides of the cheeks are abraded or lacerat-
ed. M. RuLLiER states that the prisoners in the
Bicetre at Paris produced it by puncturing the
inside of the cheek, and forcing the breath into
the puncture.

3 C

754

EMPHYSEMA — Extrinsic.

7. (b) Emphysema is not infrequently occa-
sioned by injuries of the larynx ov trachea, espe-
cially when the parts are lacerated by wounds
perforating them, particularly when the external
outlet is partially obstructed; and by surgical
operations on the neck (A. Burns). Rupture
of the rings of the trachea will also produce it.
ScHREGER adduces an instance of it from fracture
of the thyroid cartilage. Ulceration in these
situations, with sthenic vascular action, can
hardly be followed by this contingency, as the
lymph effused in the areola; of the surrounding
cellular tissue quickly coagulates, and prevents
the introduction of air. But when ulceration
occurs in connection with asthenic action, em-
physema may supervene ; as the lymph thrown
out in this state of the system is not coagulable,
and consequently cannot prevent the air from
being forced into the cellular structure.

8. (c) Emphysema often proceeds from rj/p-
ture of the air-cells, and interlobular cellular
tissue, the air escaping into the latter, and passing
along it to the superficial parts of the body, owing
to the entire state of the pleura. When the
rupture is confined to the air-cells, the air passes
no further than the lobule in which the lacerated
cells are situated ; but when the connecting tissue
is also torn, the air escapes into it, and along its
areola;, by the root of the lungs and mediastinum,
until it reaches the cellular tissue of the throat,
producing a crepitating and an elastic swelling
above the clavicles, which is soon diffused over
the face, chest, and trunk. This form of em-
physema is occasioned chiefly by violent efforts,
and straining, as lifting heavy weights (Hicks,
Meniere), and child-labour (Hamilton, Hal-
LiDAY, Blagden, Bland, Simmons, &c.), and
by obstacles to respiration, as in hooping cough,
pneumonia, bronchitis (Desbois, Ireland, &c.),
hysteria, &c., and in cases where a foreign body
has fallen into the trachea (Louis, &c.). I have
seen it occur in the advanced stage of measles
complicated with severe pulmonary affection. I
lately attended a case of this description with Mr.
Austin, in which the only matter of doubt was
as to its having arisen spontaneously, or from the
interruptions to respiration in the way now ex-
plained. But the great difficulty of breathing that
was present in consequence of infiltration of air
into the interlobular tissue and mediastinum,
readily pointed out its origin in this case, as it
will in all others of the same kind. Dr. Druim-
breck has recorded a similar instance, in which
he could find no appearance of rupture in the
bronchial lining ; but it is in the vesicular struc-
ture where it should have been looked for ; and
there it is manifested chiefly by the effects in ques-
tion. The emphysema that is rarely observed in
the course of diseases of the lungs characterised
by dyspnoea, and of rabies, hysteria, &c., is evi-
dently of the kind now described.

9. (f/) Lareratic7}S or perforations of the pleura",
costalis and pulmonalis, and /»»?":, by fracture of
the ribs, and penetrating wounds, are the most
frequent causes of emphysema. When the frac-
tured end of n bone lacerates both pleura;, and
the superficial porlion of lung, the inspired air
sometimes passes from the vesicular structure of
tlie latter, accumulates in the pleural cavity, and
is forced, by efforts at expiration, through the
breach in the costal pleura, into the cellular

tissue. Frequently, in consequence of the effu-
sion of blood or lymph, the wound in the lung is
in a short time so far closed as to prevent the
further escape of air into this cavity ; that which
was effused being absorbed, and respiration be-
coming less laborious. In this case, the emphy-
sema soon subsides, owing to the absorption of
the infiltrated air. But it occasionally happens
that the wound in the lung continues open ; and,
upon each dilatation of the chest, air is drawn
into the pleural cavity, and forced by each expir-
ation into the cellular tissue of the thoracic parietes,
until the inflation becomes enormous. When this
occurs, respiration is remarkably laborious ; in-
spiration is very rapid ; expiration is slower, and,
more forced, and is quickly succeeded by inspira-
tion ; the whole process being short, and apparently
attended by an effort to expand the lungs, which
are compressed by the air accumulated in the
pleura. Emphysema is less frequently occasioned
by penetrating wounds of the thorax and lungs,
than by lacerations from fractured ribs ; owing to
the more constant effusion of blood or lymph
from the wound in the lung after the former
than after the latter, as shown by the experiments
of Hewson ; and to the escape of the air from
the pleural cavity by the external outlet in the
thoracic parietes. It sometimes, however, arises
from this cause ; closure of the wound in the in-
teguments, or some other obstruction in its more
external part, occasionally allowing the air ac-
cumulated in the chest to be forced into the cel-
lular tissue during expiration. Penetrating wounds
of the chest very seldom produce emphysema,
unless the lungs be wounded, and then the reason
of its occurrence is obvious. But they may oc-
casion it without any injury of the lungs, owing
to the air being more readily drawn into the pleural
cavity during inspiration, than expelled from it
during expiration.

10. (e) Ulceration of the pleura costalis and
pulmonalis, and of the lung, has in rare instances
produced emphysema, chiefly as a consequence
of circumscribed empyema, that has opened into
the bronchi. In this case, a communication is
formed by ulceration between the cellular tissue
of the thoracic parietes and the vesicular structure
of the lung, the surrounding pleura; being gene-
rally adherent. An abscess in the parietes of the
chest likewise may point internally, and, having
produced adhesion of the pleuree, burst into the
lungs, and be followed by emphysema. But this
last result will not occur in either of the above
cases, unless the surrounding tissue is permeable
by air, owing to coagulable lymph not having
been formed in it. If this tissue be impermeable,
then the air will only replace the matter that is
evacuated, and give rise to circumscribed em-
physematous swelling or swellings, as in a case
recorded by Dr. Duncan (Trans, of Med. and
Chirurg. Soc. of Edin. vol. i. p. 455.). A still
more rare form is that following empyema which
has opened externally through tlie thoracic pa-
rietes. Ulceration may also take place in the
lungs, and through the investing membrane, either
from a vomica or tubercles, and the air be drawn
into the cavity of the pleura; and, having accu-
mulated there, forming pneuma-thorax, be forced
through an ulcerated opening in some part of the
costal pleura, into the cellular tissue of the tho-
racic parietes, and be thence dift'used to a greater

EMPHYSEMA — Diagnosis

or less extent over the body. Cases of this kind
have been described by Kelly and Halliday.

11. (/) The rarest form of extrinsic emphy-
sema is tliat consequent upon the escape of air,
through a rupture or ulcer of the internal coats of
some portion of the alimentary canal, into the
sub-serous cellular tissue, and the diffusion of it
through this tissue. Haller (Opusc. Pathol.
vol. iii. obs. 31. p. 309.), met with a case of this
kind in a female ; and JM. jMarjolin (Archives
G6n6r.de M£d. t. xi. p. 112.) records an instance
of it after a contusion of the abdomen which had
ruptured the small intestines. MM. Chabert
and HuzARD (Observ.svr les Animaux Domest.S^c.
8vo. Paris, 1792.) state that this form is not rare
in ruminating animals.

12. III. Diagnosis. — Emphysema of the sub-
cutaneous cellular tissue is readily recognised by
the uniform, light, elastic, and crepitating swelling
constituting it. But it is often by no means so
easy to determine the manner in which it has
arisen. What has been adduced above on this
subject will generally enable the inexperienced
practitioner to recognise the different forms of its
origin.

13. IV. Prognosis. — Our opinion of the tei-
mination of emphysema will necessarily depend
upon the causes that have produced it, and the
state of the respiratory functions. The inflation
is, in itself, but of little consequence, as air may
be introduced to a great extent into the sub-cuta-
neous tissue without giving rise to any serious re-
sults,— unless, indeed, in a cachectic and asthe-
nic state of frame, when puncture or laceration
of this tissue, or of the integuments, is very liable
to be followed by gangrene of the part, as in the
case recorded by M. Meniere. Aristotle and
Pliny allude to a practice of inflating the sub-
cutaneous tissue of animals, with the intention of
rendering them speedily fat. Schulze states, that
this process makes them first dull ; and that the
emphysema generally disappears in two or three
days, after which they recover their spirits, ac-
quire a voracious appetite, and, in a few weeks,
become very fat. Haller, Gallandat, and
SoEiiMERRiNG, adduce similar facts in proof of
the introduction of air into the cellular tissue being
in itself perfectly innocuous ; and Achard con-
tends that the insufflation of carbonic acid gas
into this tissue is the best mode of administering
this fluid in the treatment of disease. Fabricius
HiLDANus (Cent. iii. observ. 18. p. 369.), Dionis,
Ambrose Pare, and Keraudren (Bullet, des
Scienc. Mtd. t. iii. p. 422.), mention instances of
the insufflation of air into the sub-cutaneous cel-
lular tissue of children, with the iutention of ex-
citing compassion, or of showing them as curio-
sities. Sauvages states, that a soldier was simi-
larly inflated during sleep, to an enormous ex-
tent, without any further inconvenience than the
impediment it occasioned to the respiratory ac-
tions. I therefore infer, with M. Bresciiet ( Diet,
des Scienc. Mtd. t. xii. p. 20.), that the prognosis
in emphysema is altogether dependent upon the
disease or injury on which it is contingent, and
not upon itself, or even upon its extent ; the de-
gree to which the respiratory functions are disor-
dered being the chief indications of danger, as
evincing the effusion of air either into the sac
of the pleura, or into the interlobular cellular
tissue of the lungs. Spontaneous intrinsic em-

•— Prognosis-^ Treatment. 755'

physema may be viewed as generally a fatal
occurrence.

14. V. Treatment. — i. Of Intrinsic JUmphy-
sema. — Tliis species can be remedied only by re-
storing the depressed vital power, and removing
the morbid condition of the local and general cir-
culation on which it depends ( § 4, 5). The
means most appropriate to these ends have been
described in the articles Blood (§ 157.), and
Debility (§ 38.), to which the reader is re-
ferred. Scarifieations and punctures have been
recommended when the inflation is considerable ;
but there is great danger, in this state of disease,
of gangrene following puncture of the skin, es-
pecially if it be resorted to in hospitals, or in con-
fined or ill-ventilated habitations. More benefit
will follow gently stimulating and astringent lini-
ments and epithems applied to the emphysematous
surface and vicinity, and active stimulants, tonics,
and antiseptics employed internally.

15. ii. Contingent Extrinsic Emphysema must be
treated with strict reference to the nature of the
injury that has occasioned it, and the state of the
respiration. — When it has arisen from penetrating
wounds of any part of the respiratory apparatus,
enlargement of the external wound will generally
be requisite, in order that the air may have a
direct external outlet. If it proceed from frac-
ture of a rib, the application of a bandage may
be serviceable, if the breathing be not materially
oppressed; but when respiration is difficult, and
pneuma-thorax is present, a bandiige is generally
injurious, by preventing that degree of dilatation
of the lungs which is absolutely requisite to the
continuance of life. If the pneuma-thorax from
this species of injury, in addition to the external
emphysema, be so great as to threaten suffocation,
it will be necessary to m.ake an opening directly
into the pleural cavity as much as possible in the
situation of the lacerated pleura costalis. If the
inflation be so extensive as to prove, of itself, an
impediment to the respiratory actions, and if the
vital powers be not greatly depressed, and the
frame not cachectic, several punctures, at a con-
siderable distance from each other, may be re-
sorted to. When the emphysema is more obvi-
ously dependent upon rupture of the air-cells,
and the escape of air into the interlobular tissue,
&c., anndunes should be administered in order to
lower the force of the respiratory action ; and
bloodletting practised, to lessen the quantity of
blood to be acted on by the inspired air.' In most
instances of traumatic emphysema, the abstrac-
tion of blood is requisite, unless the patient is
sufficiently reduced by heemorrhage consequent
on the accident. If inflation take place to a very
great extent, punctures sufficiently deep to reach
the cellular tissue may also be practised in this
class of cases, but only in the circumstances and
with the precautions now stated. M. Desbois
advises, in preference to scarifications or punc-
tures, the surface to be enveloped in cloths moist-
ened with camphorated spirit, or a slightly as-
tringent lotion. Unless the inflation by its extent
greatly embarrass respiration, little need be at-
tempted beyond the means now mentioned. In
cases, however, characterised by great difficulty
of breathing consequent upon penetrating wounds
of the chest, or fractures of the ribs, or on ul-
ceration, and which are generally preceded by
pneuma-thorax, paracentesis of the chest som.e-

3C 2

756

times cannot be dispensed witli. But it is neces-
sary, previously to performing tliis operation, to
observe and determine early and accurately, by
auscultation and percussion before the inflation
becomes extensive, in which pleural cavity the air
has accumulated ; because an opening made on
the sound side, by causing collapse of the lung,
•would have a fatal result, as in a case recorded by
Dr. Halliday. The seat of the injury, and the
part at which the emphysema first appeared will
generally indicate the situation where it should be
performed. (For Emphysema of the Lungs, see
Lungs — Emphysema of.)

BiBLioo. AND Refer. — Aettus, Tetrabibl. iv. ser. iii.
c. 2. Oribasius, Syiiops. 1. vii. c. 50. — Pauius jEgineta,

I. iv. c. 28. Plater, Observ. 1. iii. p. 632. — Fabricitis

Hildanus, Cent. v. observ. 70. — Riverius, Observ. cent. ii.

II. 69. — Tlmitlier, Observ. Med. Pract. Paris, 8vo. 1732.

— Schulxc, De Emphysemate. Hal. 1733, in Holler's Coll.

Diss. Chir. vol. ii. n. 56 D. Hoffman, De Aere Micro.

cosmi Factitio. Tub. 1737, in Halter's Coll. Dis. Med.
Pract. vol. iii. n. 81. — Morgagni, De Cans, et Sed. Morb.
ep. liv. 37. — iV. Hunter, in Med. Observ. and Inquiries,
vol. ii. n. 2. — Leake, in Ibid. vol. iii. n. 4. — Mussel, in
Ibid. vol. iii. n. 36. — Hewson, in Ibid, vol. iii. n. S5.—-
Lloyd in Ibid. vol. vi. n. 19. — Tiimnermann, De Em-
physemate. Rint. 1765. — J. Hunter, On the Anim.
Oiconomy, p. 207. — Hicks, in Med. Communicat. vol. i.
n. 13. — Simmons, in Ibid, vol. i. n. 14. — Bland, in Ibid,
vol. i. n. 14. — Tondu, in Journ. de Med. t. xxv. p. 464.

— Herbin, in Ibid. t. 1. p. 465. -r Barriere, in Ibid. t. liv.
p. 246. — Kelli/, in Edin. Med. Comment, vol. ii. p. 427.

— Koelpin, in Acta Soc. Med. Hafn. vol. i. n. 23. — Tho-
inann, Annales Wirceburg. vol. i. p. 176. — Baillie, in
Trans, of a Society lor Improv. of Med. Knowledge, vol. i.
n. 11. — Hebenstreit, De Emphysemate. Lips. 1803. —
J. P. Frank, De Cur. Horn. Morb. 1. vi. pars i. p. 46. — Hal-
liday, in Med. and Surg. Journ. vol. iv. p. 351. — Verheyen,
Essai sur I'Emphyseme, &c. Paris, 1809. — Schreger, in
Horn's Archiv. Jan. 1810, p. 65. — Murat, in Diet, de
Medecine, t. vii. p. 395. — Ireland, in Trans, of Coll. of

Phys. of Ireland, vol. iii. p. 112 Dumbreck, in Trans, of

Med. and Chirurg. Soc. of Edin. vol. iii. p. 566. — Me.
niere, in Archives Gen. de Med. t. xix. p. 341. — J. Davy,
in Philos. Trans. 1823, — Bouillaud, Diet, de Med. et
Chiiurg. Pract. t. vii. p. 112 ; Lond. Med. Gazette, vol. iii.
p. 300. — Piedagnel, Journ. Hebdomad, de Med. t. iii.
p. 512.

EMPYEMA. See Pleura — Diseases of.
ENDEMIC INFLUENCE AND DIS-
EASES.

Ci.AssiF. — General Pathology. — .Eti-
ology.
1. This subject is considered in many of its
r.iore general relations, in the articles Cluiate,
and Disease; but there remain a few observ-
ations, which do not fall under these heads, to be
made at this place. The word endemic has usu-
ally been applied to that influence exerted by the
geology, soil, water, and air of a particular dis-
trict or country, and by occupations and modes
of living, upon the constitution and health of its
inhabitants ; and the more common and uniform
results, or the consequent forms of morbid action,
have been denominated endemic diseases. Al-
I.. ough IIippocrati s directed attention to en-
demic influences in hi? Treatise on Airs, ]Vfiters,
and Localities, but little notice was taken of the
subject by medical writers until about the end
of the seventeenth and commencement of the
eighteenth century, when several works on the
maladies prevalent in particular districts, and a
few on endemic diseases generally, made their
appearance. 15efore this period, iiowever, Caius
had offered some observations connected with en-
demic influence in his work on the Sweating Sick-
iiess. A few remarks of the same kind are to be
found in An drew Boroe's Dietani of Health;
and in Hamesey's Origination of W(n-nis, &c.
The earliest work that treated of the general en-

endemic influences.

demic diseases of England was published in Lon-
don in 1672, by Claromontius, a native of Lor-
raine, and dedicated to James Duke of Ormond,
to whom he was probably domestic physician.
In an address to the London College of Phy-
sicians, he apologises to that learned body for
having encroached, he being a foreigner, upon a
province which peculiarly belonged to them.
The apology, as remarked by Dr. Duncan, was
a tacit rebuke, and the severest he could have
given, to a body which, even to the present day,
has hardly interested itself in the advancement of
medical science. In his enquiry, he enters upon
the consideration of the extent to which venas-
section is required by the nature of the endemic
diseases of this country ; and concludes that,
although well-timed bloodletting is a judicious
practice, yet purging is, upon the whole, oftener
required, and better adapted to their cure. After
the treatise of this enhghtened writer, others ap-
peared, which comprised subjects connected with
endemic influences and diseases, either incident-
ally or specially. But sufficient reference will
be made to. them at the end of this article.

2. A reference to the topics treated of in the
articles Cli.mate, and the Causation of Disease,
will show that endemic influences are recognised
rather by their effects than by positive characters,
or manifest and demonstrative properties ; and
that they are results of several coincidences of
physical phenomena and moral conditions, which
often vary, and consequently give rise to modified
effects. When we reflect that they are con-
sequences of the geology, soil, elevation, temper-
ature, prevailing winds, vegetation, and the vici-
nity of wood and water ; and not of these merely
in their various states and associations, but of
these in connection with the avocations, the
modes of life, and the quality of the food of the
inhabitants, modified by moral agencies ; we can-
not be surprised at the diversity and importance
of the resulting effects, and at the general uni-
formity they frequently present, in certain cir-
cumstances or combinations of these causes. In
estimating endemic influences in relation to the
resulting maladies, there are other agents, besides
those now enumerated, that should be taken into
consideration. The indolence or activity of the
inhabitants ; their privations and comforts ; their
states of filth or cleanliness ; their habits of life,
and employments ; their ignorance and mental
improvement ; and their social, moral, religious,
and political conditions ; are most material ele-
ments in the general amount of endemic caus-
ation. It should not, however, be overlooked,
tiiat these diversified agencies act and react in
developing, counteracting, or entirely removing
each other ; that the circumstances of locality
will modify the moral and social conditions of its
inhabitants ; these latter, in their turn, giving
rise to numerous collateral changes, and to im-
portant alterations even in the conditions of sur-
rounding nature, as demonstrated by the march
of civilisation and social improvement in both the
old and new worlds. A casual view of the in-
fluence of elevated and mountainous situations
upon the physical and moral condition of its in-
habitants, in relation to those of the plains, or of
low, confined, and miasmatous localities, espe-
cially witliin tiie tropics, and in some of the more
southern countries of Europe, will sufficiently

ENDEMIC INFLUENCES.

757

prove the importance of this suLject ; and if we
take a closer view, so that the individual effects
upon the frame and on the mind become appa-
rent, the propriety of studying it in its practical
bearings must be evident.

3. It was stated in the article Climate, that
the constitutions of the natives of a particular
country should be considered in many respects
as products of the soil and climate, more espe-
cially vvhen its physical circumstances are differ-
ent from those which most generally obtain on
the face of this globe, and are productive of dis-
ease in the more civilised racesof our species. In
such a country the human frame has become
adapted to the climate to so great a degree as to
render it a distinct variety from the rest of the
species. We observe this in most low and
swampy districts within tlie tropics, and emi-
nently in Africa, many places of which could
not be long habitable to others of tlie species
constituted in any respect differently from the
negro. The native frame, being thus assimilated
to the climate, and modified by, and suited to, its
endemic influences, is not injuriously impressed
by them. But when persons whose constitutions
are formed by influences of a different, or even of
a modified, character, migrate to a country differ-
ently circumstanced, disease will sooner or later
ensue. This susceptibility to endemic influences
different from those to which the constitution has
been accustomed, and by which it has been most
remarkably modified, is evident in all the races of
man, and is evinced more or less in all changes
of climate ; — by the inhabitant of elevated situ-
ations, when he visits the low grounds and plains,
even under the same latitude ; by the native of
northern Europe, when he visits the shores of the
INIediierranean — still more manifestly when he
migrates to hot climates — and much more remark-
ably when he resides in low and marshy inter-
tropical districts ; by the negro, the JMalay, and
the Hindoo, when they pass from the warm, moist,
and low plains, on which they have been reared,
to more elevated situations, or to temperate or
cold countries; and so on, as respects all classes of
our species, when the change involves a change
also of the physical conditions of surrounding
nature. This susceptibility is most remarkable in
youth and early manhood, and diminishes gra-
dually until age advances, and then the powers
of life more readily sink when the change is made
to a more unhealthy locality.

4. As endemic influences are frequently the
result of certain conditions of locality, inde-
pendently of difference of latitude, or even of tem-
perature, and often depend upon one or two
circumstances connected with wood and water,
or with the nature of the soil, or with elevation
merely above the level of the sea, a change of
situation apparently slight, may be essentially
great, owing to these or other circumstances, and
be followed by an injurious impression of the
resulting influences upon persons not accustomed
to them. The waters of large towns, that are, to
a certain extent, impregnated by decomposed <
animal matters, seldom materially disorder the
bowels of those accustomed to them, unless their
impurity be very great, although they may other-
wise affect the health ; but they will seriously de-
range the bowels of persons, even in the vicinitj',
who have not been in the habit of using them, as

shown by the different effects of the water of the
Seine, at Paris, upon the inhabitants, and upon
strangers in that city. Impurity of the water is,
in all climates, an important source of endemic
diseases, particularly of those seated in the digestive
canal and circulation, as dysentery, diarrhoea,
and fever; but the soil and vegetation, in con-
nection with the extent to which they are watered,
witii high ranges of temperature, and with situ-
ation particularly in respect of elevation, adjoin-
ing acclivities, woods, &c., are the chief sources
of these and all others of this class of maladies.
The inhabitant of the high lands in the interior
of Mexico is seldom affected by fever ; but if he
remain any time in the low grounds on the coast,
in the same latitude, as at A'era Cruz, he is as
liable to be seized by the malignant remittent
endemic in that place, as the person who has
migrated from Europe.

5. i. Of the chief Sources of T^ndemic Influence.
— Low marshy places, and grounds subject
to inundations, or saturated with moisture, and
abounding with the exuvia? of organic substances ;
thick woods and jungles, particularly in warm
climates; argillaceous soils, and the deep alluvial
earth in the bottom of valleys, on the banks of
rivers, or near the level and shores of the sea or
of large lakes, or the embouchures of rivers, es-
pecially if subjected to a high temperature ; are
most productive of endemic diseases, which vary
in character with the range of temperature, in
connection with the degree of humidity, the ex-
tent to which the soil is exposed to the direct rays
of the sun, and the prevailing states of the at-
mosphere. It may be inferred from the writings
of the ancients, particularly those of Hippo-
crates, LivY, Tacitus, Plutarch, and Diony-
sius of Halicarnassus, that the insalubrity of
these places was well known to them, and that
the means of removing and counteracting it were
as well understood then as at the present day.
Hippocrates, in his Epidemics, states that the
city of Abydos had been several times depopu-
lated by fever ; but the adjoining marshes having
been drained by his advice, it became healthy.
The lake Averna, mentioned by Virgil, is,
probably, a poetical exaggeration of the effects
arising from marshes ; and the deeds of Hercules,
the metaphorical record of his success in removing
these sources of disease.

6. Pools and ditches containing stagnant water,
or nearly or altogether dry, after warm weather ;
and grounds used for the cultivation of rice ; are
also important sources of endemic influence. The
former, in tlie vicinity of villages, frequently re-
ceive animal exuviae, which render the exhal-
ations from them much more noxious ; and the
latter are especially injurious to white cultivators.
The extent of disease proceeding from this source
has been shown by Lancisi, Bailly, Mont-
falcon, Irvine, Tarc;ioni, Grottanelli, and
others, to be, in many places of Italy, Sicily, and
Greece, so great, as to occasion more than two
thirds of the average mortality. The exposure
of a rich, wet, and low soil, abounding with
vegetable matters undergoing decay, after repeat-
ed irrigations and inundations, to a powerful sun,
is the circumstance to which the insalubrity or
rice-grounds, and many other places, chiefly is
owing. In all intertropical regions, where the
nature of the locality admits only of a rice culti-

3 C 3

758

ENDEMIC INFLUENCES.

vation, Europeans are more or less subject to
endemic disease ; and although the dark races
are much less liable to it, owing to the adaptation
of their organisation and functions to this parti-
cular soil and climate, yet they are occasionally
affected by it in a slighter degree, and in a
modified manner. Inundations, whether from
the sea, or from the swelling of rivers, or from
an admixture of sea with river water, render low
grounds particularly insalubrious upon their be-
ing exposed to the action of the sun's rays. Sea
water, owing to the quantity of animal matter it
contains, soon becomes offensive when it stagnates
on a soil abounding with vegetable substances ;
and the inundated grounds and islets in the
course, or at the mouths, of rivers, are generally
left covered, when the waters subside, by mud
and slime, which become an additional source
of miasmata. The inundations by the sea, wliich
have occurred in many places in Holland, have
been the cause of mucli disease, upon the ex-
posure of the soil to the sun during the following
summer and autumn.

7. When low and moist grounds, and deep or
rich soils, which have been covered by large trees
or by water, are cleared, or exposed to the action
of a warm sun, especially in a hot country, they
emit more noxious emanations than in their un-
reclaimed states ; and they generally continue so
to do, particularly during moist and warm wea-
ther, and after long continued droughts following
heavy rains, until they are completely brought
under cultivation, and even for ages afterwards,
in warm countries, near the level of the ocean,
or the seashore, — circumstances which com-
bine to make so many places in the West and
East Indies productive of disease. Rich soils
covered by large trees, and other bulky vege-
table productions, are thereby protected from the
action of the sun ; and the exhalations which
are given off from them, during warm and moist
states of the air, are confined by these produc-
tions to the situations which produce them. Dr.
Rush states, that the endemic disorders of Penn-
sylvania were converted, by clearing the soil,
from intermittents and mild remittents, to bilious
and malignant remittents, and destructive epi-
demics; and that it was not until t!ie soil had
been subjected to cultivation for a number of
years, that a tolerable degree of healthiness was
procured. The district of Bresse, in the Lyon-
nais, when well wooded, was comparatively
healthy ; but now, deprived of its woods, the low
and wet soils being exposed more to the action of
the sun, the exhalations from these, and from its
numerous marshes and stagnant pools, are no
longer confined by surrounding forest trees ; and,
consequently, endemic diseases of a severe cha-
racter are very prevalent. Similar instances are
to be found in the works of Deveze, Montfalcon,
and lUiLLY.

8. There are various circumstances connected
with the production and diffusion of exhalations
given out from the soil, that require attention
from tiie medical practitioner. Some of them are
noticed at another place (see Disease, § 55, 56.) ;
but it seems fully established, that dead animal
matter and exuvia; in situations producing these
exhalations, contribute most remarkably to their
noxious effects. In warm countries, or in liot
seasons in temperate climates, the places which

are most productive of malaria, generally, also,
abound the most in animal substances undergoing
decomposition. The circumstances whicii render
vegetation quick and luxuriant, generate immense
swarms of insects and reptiles, the exuviaa and
dead bodies of which mingle with vegetable mat-
ter in a state of decay, and give rise to miasms,
particularly during moist states of the air, much
more noxious than those resulting from vegetable
matter alone. I have always considered the
number of insects and reptiles, with which a place
abounds, as more indicative of its insalubrity,
than almost any other circumstance. Malaria
may be conveyed a considerable distance from its
source, and be condensed in the exhaled vapour,
when attracted by hills or acclivities in the vici-
nity, and when there are no high trees or woods
to confine it, or to intercept it in its passage.
Owing to this circumstance, high grounds, near
exposed marshes, are often more unhealthy than
the places immediately adjoining, that are on a
level with them.

9. There are no circumstances that tend more
to increase the sources of endemic influence, than
high ranges of temperature, and calm states of the
air. The effects of these vary remarkably with
the quantity of humidity exhaled, and with the
conditions of the air, in respect of horizontal and
vertical currents, and of electricity. However
productive the sources of malaria may be, and
however rapid the evaporation from them, the
effects will be comparatively slight, if there be a
quick renewal of the atmosphere passing over
tlieir surfaces, preventing the stagnation and
concentration of the effluvia emitted by them.
A high temperature, particularly with exposure
of the soil to the sun's rays, penetrates to the
lower alluvial strata; and, if it be attended by
protracted dryness, occasions wide fissures in the
upper strata, through which the moisture of the
lower passes in the form of vapour, which is often
more noxious than the emanations fi'om a wet
or marshy situation, especially when the soil is
argillaceous or absorbent. It is also indirectly
owing to temperature, and the greater capacity
it gives the air for moisture, that the marshes of
warm, or even of temperate, climates are infinitely
more unhealthy than tlie bogs and peat mosses of
northern countries. High temperature and hu-
midity, together with richness of soil, generate
succulent plants which contain saccharine and
oleaginous principles, and carbonaceous and hy-
drogenous elements, with a portion of azote ; and
which rapidly pass, either altogether or partially,
throujih the alternate processes of growth and
decay. The vegetable productions, also, of hot
countries, especially those which are most abun-
dant, possess much less of the antiseptic princi-
ples, with which those of cold climates abound,
particularly tannin, creosote, the terebinthinates
and their associated resins, the gallates, &c., which
are found largely in the plants contributing to the
bogs and peat mosses of the latter. i?esides, the
marshy places, and the surfaces of alluvial soils,
in warm countries, contain more animal matters
undergoing decomposition, than in cold and tem-
perate regions ; and are subject, in alternate suc-
cession, to periodical rains and long droughts —
are alternately inundated, and exposed to the
direct action of the sun. Stillness of the atmo-
sphere, by favouring the accumulation of malaria

ENDEMIC INFLUENCES AND DISEASES. 759

in the lower strata, and in circumscribed limits,
increases the injurious influence of tliis agent upon
tlie human economy. Hence the danger of ex-
posure to its sources during still and humid states
of the air, at the close of the day, when it is con-
densed in the descending moisture ; or at night,
or approaching dawn, when it is un rarefied by the
solar heat, and not yet carried to the higher
regions by the ascending or vertical currents
of the atmosphere, and when the system is most
exposed to its impression. During moist states
of a warm atmosphere, also, the equilibrium of
its electrical conditions is disturbed ; the relative
electrical states of this fluid, and of the body, is
also considerably modified ; and the changes pro-
duced upon the blood in the lungs, by respiration,
are somewhat retarded. These effects are mate-
rially influenced by the situations and circum-
stances now adduced, and the respiratory func-
rions remarkably impeded by them.

10. The good effects of a quick renewal of the
air, in unhealthy places — of high winds, hurri-
canes, and thunderstorms — in dispersing and al-
together sweeping off the exhalations from the
soil, and from decayed animal and vegetable
matters, must be apparent. The more violent
commotions of the air are the means employed
by Providence to dilute, or entirely dissipate,
those noxious agents, and to prevent their pesti-
lential accumulation in the situations which have
been described. It has been observed, especially
in warm climates, and in hot seasons in temper-
ate countries, that, when the air has been long
undisturbed by high winds or thunderstorms, and
at the same time hot and moist, endemic diseases
have assumed a very severe, and even epidemic,
character. Numerous facts illustrative of this
have been adduced by Rusii, Webster, Chis-
HOLM, Clark, Deveze, Bakcroft, and others.
It is generally in hot miasmatous countries, and
after prolonged seasons of drought and still states
of the air, that tornadoes occur in hot climates, and
thunderstorms in temperate countries, purifying
and refreshing all the objects exposed to them, and
preventing the occurrence of these severer forms
of disease which would otherwise supervene.

11. Although the localities and related condi-
tions described above are sources of diseases,
chiefly in warm climates, and in temperate regions
d rring hot seasons, they are not entirely destitute
ot influence in cold countries ; their ill effects
Ijeing generally in proportion to the height and
duration of the summer temperature, and to co-
incident circumstances. In northern temperate
latitudes, and inland situations, the dryness of
tiie air, especially during low ranges of the ther-
mometer, and when the surface of the earth is
sealed by an icy congelation, not only does the
human frame enjoy a perfect immunity from ter-
restrial emanations, but it experiences an accu-
mulation of positive electricity, and increased
activity of all the functions. The changes pro-
duced by respiration are most complete ; the
nervous and circulating systems evince increased
tone ; animal heat is rapidly generated to replace,
that carried oft' by the surfaces, the body acquires
the phlogistic diathesis, and diseases present the
sthenic forms.

12. ii. Effects of Endemic Influence. — A. The
exhalations from the situations now described, at
the commencement, during, and after heavy rains

and moist states of the air, generally occasioa
agues, dysentery, scurvy, scorbutic dysentery,
enlargements of the liver and spleen, cretinism,
scrofula, rickets, &c.; and if the temperature be
high, the various forms of remittent and conti-
nued fevers, in addition to these. The same lo-
calities during warm and dry seasons, and after
protracted drought, produce bilious and malig-
nant fevers, of a remittent and continued type,
cholera, diseases of the liver, and inflammations
of the alimentary canal ; the intermittent and
remittent fevers prevalent during the colder sea-
sons, passing into a more continued type, and bili-
ous or malignant form, after great or continued
heat. This change in the character of the en-
demic with the temperature and seasons, was
well illustrated by the history furnished by M.
KiRciioFF (^Journ. Complement, des Scien. Med.
Jan. 1827.), of the diseases following the partial
inundations by the sea of some parts of Holland, in
the winters of 1825 and 1826. He states that the
waters used for domestic purposes were brackish ;
and the ponds and ditches, which were usually
limpid during the spring, became greenish on the
surface, and offensive. At this time, agues pre-
vailed amongst workmen exposed to the exhal-
ations from these sources. As the summer ad-
vanced, and the waters were more completely
drained off, the effluvia were more concentrated,
and fevers assumed a remittent type. In the
months of August and September, fever presented
more of the continued character, with periodical
exacerbations, particularly of the pains in the
head and back, and closely resembled tiie endemic
of low and moist situations within the tropics, —
the circumstances occasioning it having been ia
every respect similar. In the majority of cases,
the liver was affected. It has been shown by
writers on the fevers endemic in Hungary, that
agues are most prevalent during spring ; and that
remittents, continued fevers, and dysentery, be-
come more common during summer and autumn.
Indeed, endemic fevers are modified, from the
more simple form of ague to the most malignant
remittent or continued type, by the particular
circumstances in which they originate, — as the
miasms become more concentrated, or consist
more of the eflluvia of decayed animal substances,
— by the warmth of the season and climate, —
by the humidity and dryness of the air, — and
by the constitution and predisposition of the
patient. As these vary, so does the particular
character of the disease. Intermittents present
every type, and various complications ; and re-
mittents, numeroTis grades and forms — the bilious
or gastric, the inflammatory, the bilious inflam-
matory, and the asthenic or malignant. Con-
tinued fevers, also, assume a mild, an inflamma-
tory, a gastric, or an adynamic form. Not infre-
quently, the intermittent passes into the remittent,
and this latter into the continued type ; and either
may be followed by dysentery. Each of these
states of fever may be simple or complicated ;
the principal local affection being different, as well
as diversified in kind, in diiferent cases, and ap-
pearing sometimes so early as to seem the primary
disease, frequently in the advanced progress of
the fever, and occasionally not until its latter
periods. Either of these forms of fever may com-
mence mildly and insidiously, and yet soon pass
into dangerous local derangement and disor^anis-
3 C 4

760

ENDEMIC INFLUENCES AND DISEASES.

ation ; others may begin with great excitement,
rapidly terminating in exhaustion and depravation
of the circulating and secreted fluids; some pre-
sent great depression from tlie beginning, the
powers of life never rallying throughout, or very
imperfectly, with an unnatural state of all the
secretions and soft solids, and a tendency to dis-
solution of their cohesion, which rapidly advances,
especially in warm countries, as soon as respir-
ation ceases. In certain circumstances, particu-
larly when great vicissitudes of temperature and
weather cooperate with the strictly endemic causes,
or with improper living, impure water, &c., dy-
sentery becomes as prevalent as fever, or entirely
usurps its place ; or the fever assumes a dysen-
teric character, or passes completely into dysen-
tery ; this latter malady producing even a greater
rate of mortality than fever itself. (See art. Dys-
entery.)

13. B. Whilst rich soils, and warm, low, moist,
and marshy situations, are productive of disefise
affecting chiefly the circulating and secreted fluids,
and the abdominal viscera, by lowering vital
power, especially as manifested in the nervous
systems ; elevated, cool, or temperate and dry dis-
tricts favour the developement of vital energy,
especially as expressed in the nervous, muscular,
and circulating systems, and in the thoracic vis-
cera ; and produce diseases of a phlogistic cha-
racter, as sthenic inflammations of the lungs and
circulating organs, of the membranes of the brain,
and of the other serous and fibrous structures,
hsemorrhages, rheumatism, and fevers of an in-
flammatory type. — These diseases, however, al-
though the most prevalent, can scarcely be said
to be endemic in these latter localities, they being
much less frequent than the maladies of the former
situations. It should, however, be recollected
that the respective endemic influences of districts
are not so deleteriously exerted on the native in-
habitants, as upon those who have lately removed
to them ; and that, though they may affect the
constitutions of the former class, and give rise to
certain diseases in preference to others, yet those
diseases are not so acute or violent in them, as in
the latter. This circumstance is well illustrated
by what is constantly observed in warm countries
productive of terrestrial emanations. There, the
native inhabitants are either scarcely affected by
them, or are liable only to agues, bowel com-
plaints, enlargements of the spleen, or slight ail-
ments referrible to the large secreting organs,
excepting on occasions of tliese exhalations be-
coming more concentrated or energetic than usual.
But persons who have removed thitlier from healthy
localities, in cold or temperate climates, sooner or
later are seized by fever, generally of a remittent,
or continued type, often assuming an inflamma-
tory or malignant form, and frequently associated
with violent local determinations ; and it is not
until after the frame has been assimilated to the
climate by such attacks — usually called the sea-
soning fever — that agues, dysentery, and the
milder forms of disease, appear in such persons.
On the other hand, the inhabitants of low or miiis-
matous situations, who have removed to elevated
and mountainous districts, arc much more liable
to diseases of the lungs, to rheumatism, and to
inflammations of a sub-acute or chronic form,
than the natives of these latter places ; and if the
change at the same time involves a ciiangc from

a high to a low temperature, the liability to pec-
toral maladies is still further increased.

14. C, When persons have migrated to a country
abounding with the sources of endemic diseases,
a peiiod of longer or shorter duration, according
to the activity and concentration of the malaria,
and the predisposition of the individual, usually
elapses before they are attacked by these maladies.
In Rome, and other malaria districts in the south
of Europe, as well as in many of those in the
eastern and western hemispheres, where the ex-
halations are not very active, several months, or
even a year or two, pass before the unaccli-
mated are seized by fever, unless the exposure
and predisposition (see Disease — Predisposing
Causes of) be great. Whilst in many situations,
where the emanations are more concentrated, or
consist of an admixture of those given off both
by vegetable and by animal matters in a state of
decomposition, particularly in warm climates and
seasons, the first exposure to them is often pro-
ductive of the most active forms of fever, and in
a very short time after the exposure occurs. This
is commonly observed in respect of young un-
seasoned sailors and soldiers, who, coming from
a pure air, in a state of high predisposition, are
often subjected to these emanations in their most
active states. Persons arriving in warm mias-
matous districts, from temperate and healthy
places, are affected with a celerity and severity
generally in proportion to the fulness of their
vascular systems, to the rigidity of their, fibres,
and to their nearness to the epoch of early man-
hood ; but various exceptions to this occur, arising
out of the habits of individuals, the susceptibi-
lity of their nervous systems, the extent of their
exposures, and the States of their minds and
moral emotions.

15. D. Although the white races of the species
will live to an advanced age in warm districts
productive of endemic disease, especially if they
have removed thither after the constitution has
been fully developed ; yet their offspring will very
seldom reach maturity, or survive the epoch of
childhood, if they continue to reside in such
situations ; or, if they arrive at manhood, they
will very rarely reach an advanced age. Dr.
Jackson states, that white persons, born and
residing in the more unhealthy districts of Lower
Georgia, seldom live to forty ; and that, at Pe-
tersburgh, in Virginia, they rarely reach twenty-
five. He saw, at this latter place, a person who
was only twenty-one ; and although he had never
been confined by severe sickness, yet he was
weak and decrepit : so injuriously does endemic
influence operate upon the constitutions of the
white variety, even when it fails of inducing
acute disease. Buuce records similar instances
among the white natives of the banks of the Nile,
in Abyssinia ; and other illustrations have been ob-
served by myself in some parts of Africa. Children
born of European ])arents in India require to be sent
to Europe to acquire due maturity and strength ;
for they very seldom arrive at puberty in India, 'i'he
case, however, is different when one of the parents
belongs to the indigenous inhabitants; but there
can be no doubt, that, were a colony of the white
races conveyed to the low miasmatous localities
within the tropics or in more temperate regions
liable to very hot seasons, it would, in a very few
gcDcrations, become extinct, if intermarriage did

ENDEMIC INFLUENCES AND DISEASES,

761

not take place with the natives, or if it were not
supplied from time to time from more salubrious
places. Whilst a change to a more unliealtliy
climate is best endured by those who have arrived
at full maturity, change to an equally or a more
healthy climate is especially beneficial to very
young persons, unless in the case of removal of
individuals belonging to the dark races to a tem-
perate country, from the hot climate iu which they
are indigenous.

16. E. Besides fevers, dysentery, and the slow
blight of the constitutional powers, the localities
above described induce, in the white races, dis-
eases of the spleen, liver, and pancreas, both in
unassociated forms, and as complications with
fevers and dysentery. Among their less obvious
effects may be enumerated scurvy, and foul ulcers
of the lower extremities. The great prevalence
and obstinacy of these latter in miasm atous situ-
ations have not been sufficiently attended to, al-
though Baglivi had noticed the circumstance in
Rome, and Cleghorn in Minorca. Indeed, in
all low places productive of malaria, injuries
and sores of the legs heal with great difficulty,
whilst those of the head recover rapidly., Hippo-
crates and Cei.sus seem to have been aware of
this fact. They both notice the frequent association
of indolent ulcers of the legs with enlargement of
the spleen, — which is remarkably common among
the cultivators of rice-grounds, both in the soutli
of Europe, and in otiier quarters of the globe.

17. There are some situations, which do not
fall within the description given above, produc-
tive of diseases almost proper to them, or which
are comparatively rare elsewhere ; as cretinism,
hronchocele, plica or matted hair, Guinea uorm,
tarantulism, pellagra, &;c. These depend in great
measure on the water, in conjunction with modes
of living, and various other circumstances. —
(a) Cretinism (see this article) is endemic in the
deep ill-ventilated valleys of the Alps and Py-
renees, in Carinthiaand the Vallais, in tlie moun-
tainous parts of Tartary and Cliina, in some parts
of the south of France, and in Salzbourg. It
seems not to have been unknown in this country,
two or three centuries ago, in the situations where
hronchocele and rickets — very nearly allied
diseases — have continued to be common. — [b)
Hronchocele is very frequent in the situations
now particularised, especially in the valleys of
the Alps, where it was equally prevalent m the
times of Pliny and Juvenal; in Derbyshire;
in Behar, and some other mountainous districts of
northern India; in similar situations in Java (S.
Raffles) and Sumatra ; in Bambara, in the
course of the Niger (M. Park) ; and in IMexico,
and some other parts of South America (Hum-
boldt). It is most prevalent in females after pu-
berty ; and is, in my opinion, often connected with
interrupted or irregular catamenia. — (c) Plica, or
matted hair, is not noticed by the ancients, and it
is doubtful when it first appeared — probably
some time between the thirteenth and fifteenth
centuries. It is most common in Poland and
Lithuania ; but it is met with occasionally in
Transylvania, Hungary, the southern parts of
Russia and Tartary, and more rarely in Switzer-
land, Belgium, and Prussia : but it is not so fre-
quent, even in Poland, as it was a century ago. It
proceeds chiefly from want of cleanliness, especi-
ally in respect of the hair, and to wearing too warm

coverings on the head(KERCKiioFFs, Laruy, Ali-
BERT, &c.). There appears to be frequently an
hereditary predisposition to it ; but the cause now
assigned is evidently the most influential in pro-
ducing it, assisted by tiie use of unwholesome
water (Vicat). It is most common amongst the
poorest classes. According to Dr. L. Kerck-
HOFFs (Mc(/. Trans, of Coll. of Phys. vol. vi,
p. 27.), it is not infectious (see art. Hair). —
(d) Tarantulism (see Chorea, § 18.) was for-
merly endemic in Apulia, but is now by no means
so frequent (Laurent and Merat). This species
of irregular convulsive or hysterical affection, in
which the moral emotions seem more disordered
than the physical powers, was imputed by Sir T.
Browne, Boyle, Kircher, Baglivi, Mead,
and Sauvages, entirely to the bite of the taran-
tula spider, which probably is an exciting cause,
in certain states of the nervous system, although
neither the only nor the chief cause. Cornelio,
Serao, and Cirillo, physicians in Naples, and
M. Nollet, have taken juster views of its origin;
and refer it rather to the state of the nervous
system, in connection with the moral emotions,
than to this insect. Indeed, it is extremely pro-
bable that it is often feigned, or frequently occurs,
without any such accident as that to which it is
so commonly imputed ; for very nervous and fan-
cilul females may persuade themselves that tliey
are stung by this insect, in order to account for
their ailments, conformably with the vulgar opi-
nion, and may thereby induce that form "of irre-
gular chorea or hysterical affection to which the
term tarantulism or taranlismus has been applied.
M. Merat (Diet, des Sciences Med. t. liv. p. 345.)
infers that the inhabitants of Apulia, ovvino- to
situation and climate, are liable to nervous and
spasmodic affections ; and that, among others,
this is apt to supervene, — from their ardent and
choleric dispositions, and their love of dancing
and music. In Calabria and the Apennines, where
chorea and convulsive affections are common
tarantulism also occurs (Ferrus). — (e) The
Guinea irorm (Dracunculus^, the lono- thin
worm which is sometimes found in the inhabitants
of certain localities, generally under the inteo-u-
ments, and so named from the circumstance of its
having been first accurately observed in the natives
of Guinea, is now seen in other countries. It
appears from Plutarch to have been met with
in the inhabitants near the Red Sea. It occurs
among the negroes in most of the low marshy
situations of intertropical Africa (Welch, Bruce,
Park, &c.) ; in the slaves, and sometimes in the
whites, in the West India islands (Ciiisholm,
Thomas, &c.) ; in Bombay, and along a oreat
part of that coast, as well as in some other mari-
time districts of India (M'Grigor, Milne, H.
Scott, Grant, &c.) ; and in the islands of the
Persian Gulf (K^f.mpfer). — It is observed chiefly
during the months of November, December, Jan-
uary, and February, in both the East and West
Indies. M. Dubois found, in parts of the Car-
natic and JMadura, more than one half of the
inhabitants of some villages affected by it. Dr.
Ciiisholm (Edin. Med. and Surg. Jonrn. vol. xi.
p. 145.), Dr. Smyttam (Ti-ans. of Med. and
Phjis. Soc. of Calcutta, vol. i. p. 179.), Dr.
Anderson, and several others, state that it is met
with chiefly in those who use wells made in argil-
laceous soils, impregnated with salt or percolated

762

ENDEMIC DISEASES — Prevention of.

by sea water. M. Dubois adds, that the inha-
bitants of villages who take water from one well
are subject to this worm, whilst those at the dis-
tance of only half a mile, who resort to a different
well, are not affected by it. Other writers, in
addition to those named above, agree in ascribing
it to brackish waters containing the ova or embryo
of this worm. The circumstance of this animal
having been rarely found out of the human body
has induced Dr. Milne (Edin, Med. and Surg.
Journ. No. 106. p. 1 12.) to suppose that the sub-
stance taken for it has been a diseased lymphatic
vessel ; but the evidence of its independent exist-
ence furnished by Dr. H. Scott {Med. Chir.Rev.
vol. iv. p. 182.) and Dr. R. Grant {Edin. Med.
and Surg. Journ. No. 106. p. 114.) has set the
matter at rest. As to the manner in which this
worm becomes lodged in the sub-cutaneous cel-
lular tissue, much doubt exists. It must eitlier
insinuate itself through the skin from without, or
its ova escape the action of the alimentary juices,
and pass along with the chyle into the circulation,
and thence into the cellular tissue, where, having
attained a certain growth, it excites the irritation
preceding its expulsion. But, if it pass by this
latter route, how is it that it is never found in the
cellular or other parts of internal organs, where
it may be expected to produce dangerous, if not
fatal, effects!

18. -F. In low, moist, and cold districts, liable to
frequent vicissitudes of weather and temperature,
catarrhal and rheumatic affections, croup, bron-
chitis, scrofula, rickets, and tubercular diseases,
are more or less prevalent ; and in those similarly
situated on the sea-coast, where the inhabitants live
chiefly on fish — particularly on stale or dried fish,
or the grey kinds — chronic eruptions on the skin
are common. In large towns and cities, where a
confined and impure air co-operate with the anxie-
ties of business, the exhaustion of mental exer-
tion or of dissipation, the luxuries of refinement,
the conflict of the passions, and the excitement
of the different moral emotions, disorders of the
nervous system, frequently implicating the mani-
festations of mind, are more common than in the
country, and much more so than in imperfectly
civilised states of society. — My limits will admit
only of a simple reference to other endemic dis-
eases — to the prevalence of trismus and tetanus
in the West Indies; of elephantiasis in these
islands, and in the East, as well as in Africa ; of
the yaws in the negro racej of the pellagra in
Lombardy and the Milanese ; of the beriberi in the
East Indies; of hepatic colic (see Colic, ^ 20.)
in Spain and the West Indies ; and of ophthalmia
in Egypt. Some of these may be imputed to
obvious physical causes ; as the ophthalmia of
Egypt to the reflected heat, and the dust in the
air; or pellagra, and some cutaneous diseases, to
dirty habits and unwholesome food : but there are
others that cannot be explained without ascribing
them to the co-operation of a variety of circum-
stances, as shown in the articles on these maladies.
In illustration of the influence of occupations in
producing a certain train of morbid actions in
those similarly circumstanced, it may be staled,
that amongst the children and young persons
employed in cotton mills, more especially in
Manchester, chorea, wliich is comparatively a
rare disease, is one of the most common ; scrofula,
tubercles, and debility in all its slates, being

likewise very prevalent ; and that, in the some-
what older work-people, chronic rheumatism,
in all its forms, is remarkably frequent. The
protracted periods of occupation in a very hot
and moist air, and generally in a standing pos-
ture ; the sudden exposure to a cold atmosphere
on every occasion of leaving the factory ; and the
want of due sleep, of exercise in the open air,
and often of sufficient nourishment, independently
of various moral causes ; sufficiently explain the
endemic prevalence of these diseases in the large
manufacturing town now mentioned. (See Arts
AND Employments — as Causes of Disease.^

19. iii. Of the Mode of Operation of Endemic
Influence on the Economy. — The endemic causes
productive of the more acute and malignant dis-
eases were supposed by Cullen to be direct se-
datives, not merely lowering vital power, but also
inducing spasm of the extreme capillaries ; and
that, if the vital energy of the system is not en-
tirely overpowered by them, reaction supervenes, ia
order to overcome this spasm, and thus fever be-
comes developed. Other pathologists suppose that
marsh effluvium acts as a stimulant or irritant ;
and that the debility which it obviously occasions
is either consecutive, or a state of exhaustion.
Neither of these hypotheses accounts for the whole
phenomena which diseases, arising from this cause,
evince throughout their course, although either
explains many of their symptoms. That malaria
depresses vital power, contaminates the circulat-
ing and the secreted fluids, and weakens the vital
affinity or cohesion of the soft solids, is shown by
its more immediate, as well as by its consecutive,
effects upon the living body, and by the fact of
dead animal matter running faster into putrefac-
tion in situations where it abounds. Its septic
operation on sores and wounds is often evinced
during life. It has been repeatedly proved, that
substances fabricated of silk, woollen, and even
of cotton and flax, exposed to marsh exhalations,
very rapidly undergo decay ; silk and woollen
becoming putrid, and cotton and linen assuming
a dingy or yellow hue, and afterwards losing
their cohesion. These effects are generally rapid
and complete, in proportion to the moisture and
warmth of the air, and the concentration of mal-
aria in it ; and so well are they known, M.Mon-
FALCON states, that they are generally recognised,
by the more intelligent inhabitants of Italy and
the south of France, as indications of the insalu-
brity of particular places and seasons.

20. iv. Of preventing the Production of Endemic
Causes, and of counteracting their Effects. — A, Of
preventing tlie generation of malaria. — (a) Drain-
itig marsh grounds is one of the most efficient
modes of pieventing the formation of malaria ;
but it should be recollected that uncovered drains
and ditches are fruitful sources of endemic in-
fluence.— {h) Embankments thrown up against in-
undations from rivers and the sea are also im-
portant means of prevention ; but, if they be not
quite adequate to the purpose, they may aggra-
vate the evil, by preventing the water from re-
tiring with sufficient rapidity. — (c) In situations
admitting of neither of these means beingemployed,
then advantage will often be derived from cover-
ing them entirelii iviili water ; for lakes do not ex-
hale miasmata until after the mud and soil of
their bottoms and sides have appeared above the
surface. Senac stales, that liie outskirts of a

ENDEMIC DISEASES — Prevention of.

763

large town became unhealthy as soon as tlie mud
at the bottom of some adjoining morasses was ex-
posed to the sun and air; but that disease dis-
appeared when they were completely inundated.
l)r. RoLLO mentions, that mild intermittents pre-
vailed in St. Lucie during the rains, when the
pools and marshes were filled ; and that danger-
ous fevers appeared after their slimy surfaces be-
came exposed and completely dry. JMr.ANNEs-
LEY records similar facts in relation to various
places in the East Indies. The ditch round the
ramparts of Geneva was once drained, and sick-
ness prevailed in the vicinity, but disappeared
when it was again filled. And the water-courses
and beds of rivers that are dried up in summer, par-
ticularly in warm countries, and thereby become
sources of malignant fevers, are quite innocuous
when filled (Ferguson, &c.). — {d) Clearing the
$oil from its more bulky vegetation will be benefi-
cial only when an assiduous cultivation is adopted,
without the necessity of having recourse to a very
abundant irrigation. In many circumstances,
however, this measure will greatly aggravate the
insalubrity of adistrict, as shown above, especially
in respect of low swampy places within the tropics,
or near the sea. Facts illustrative of this have
been often observed in both the old and new
worlds. — (e) Protecting the soil in w hich large
cities are built, particularly when situate near the
embouchures of rivers, &c., fronr the action of the
sun, by a closely laid pavement; intersecting the
strata of earth by large deep sewers, conveying
the exuviae and other impurities beyond the reach
of the inhabitants, and in such a way as to pre-
vent the escape of emanations from them, in the
midst of a dense population ; and removing places
of sepulture beyond the outskirts of cities and
towns ; are measures of the utmost importance to
the health of the community.

21. It is established beyond a doubt, that the
narrow winding streets of towns built in low situa-
tions, or in the vicinity of marshes, are, especially
when the houses are high, actually conducive
to health ; inasmuch as the exhalations trans-
ported from thence have a less ready access to
all parts of them, the horizontal currents of air
being more completely intercepted by the nearest
buildings; also, when the streets are narrow, and
the houses high, the sun cannot act upon the soil,
which necessarily becomes saturated with animal
exuviae, unless deeply intersected and purified by
drains and sewers. The importance of this con-
sideration was not overlooked by the ancients, as
appears from the remark of Tacitus, on the re-
building of Rome after its destruction by Nero.
" Erant tamen, qui crederent, veterem illam for-
mam salubritati magis conduvisse, quoniam an-
gustiae itinerum, et altitudo tectorum non perinde
solis vapore perrumperentur. At nunc patulam
latitudinem, et nulla umbra defensam, graviore
aestu ardescere." (Ann. 1. xv. 43.)

22. B. Whilst the above measures have refer-
ence chiefly to the prevention of the formation of
terrestrial exhalations, there are others that may
be employed to confine them to the sources whence
they issue, when the former means are ineffectual!'
or cannot be put in practice. It is very proba-
ble that many places, the insalubrity of which
was recognised and guarded against by the an-
cients, have actually become more unhealthy in
modern times, owing to the accession of alluvial

soil washed down from the higher grounds in the
vicinity ; to the accumulation of decayed or-
ganised matter and mineral detritus at the mouths
of rivers, and in the bottoms of lakes, which have
been thereby converted into marshes ; to the
neglect of the drainage and cultivation which a
former crowded population was enabled to pre-
serve; and to the removal of those screens of
trees which confined the exhalations to the place,
that generated them. The importance of these
considerations has been insisted on by Lancisi and
Brocchi, in respect of Italy ; by JMonfalcon,
with reference to France ; by Annesley and my-
self, in regard to warm climates; and by M'Cul-
LocH, as respects this country. It was remarked
by Pliny, and some others among the ancients,
that trees absorb the exhalations which prove in-
jurious to man ; and the observation is perhaps
just ; but whether trees simply obstruct the
transit of malaria from its source, and confine it
there, or actually absorb it along with the mois-
ture in the air, and dew which rests on their
leaves ; or whether they act in both ways, in ad-
dition to their shading the soil from the action of
the sun ; the power they possess, in low and marshy
situations, of moderating the generation of mala-
ria, and confining it to its source, is indisputable.
It is, therefore, important to plant trees around,
and more especially to leeward of, unhealthy
places (§ 5.), in order to screen persons living
in their immediate vicinity from their influence.
Owing to the extent to which trees, high houses
and walls, and intervening water, not liable to
become stagnant, protect places near the sources
of malaria from its effects, is to be explained the
fact of the inhabitants of one side of a street, or
road, often escaping ague, whilst many of those
living on the other side are affected ; and of the
crew of one ship being seized with fever, while
those of another, somewhat further removed from
the shore, escaped.

23. C. There are other means, besides those
enumerated, which both destroy and counteract , or
othenuise remove, the causes of endemic mutadies.
— (a) In the case of impure water, filtering it,
especially through charcoal ; boiling it before it is
used, or passing it through lime ; preserving it in
iron tanks on board ships ; and adding to it a
small quantity of either of the chlorurets, when it
cannot be otherwise deprived of a portion of
animal matter ; are very important precautions.
When sewers, drains, ditches, and other confined
sources of impure air cannot be removed, or
covered so as to prevent the emission of effluvia,
the chloruret of lime should be thrown into them
from time to time. A solution of the same sub-
stance, or either of the other chlorurets, outjht
also to be liberally employed in the wards of
crowded hospitals, whenever the air becomes
close and foul, in order to prevent the prevalence
of fever, dysentery, erysipelas, and gangrene ;
and should also be poured down the privies.
Similar precautions ought also to be employed in
crowded transports and ships of war, as well as in
camps and besieged towns, more especially if dis-
ease appears. But this means is only subsidiary
to free ventilation, and is most to be confided
in when the' latter cannot be established. By
having recourse to these disinfectants, the sickness
that sometimes arises from the leakage of sugar,
or the decomposition of vegetable matter collected

764

in the hold or between the timbers of ships,
and from the action of bilge-waler on chips or
sliavings, as recorded by Sir W.Burnett and
other able observers, and the ill effects contingent
on the steeping of flax and hemp, may be entirely
prevented.

24. (6) Whatever progress is made in civilis-
ation, in the cultivation of the soil, and in the
useful arts of life, tends to diminish the prevalence
of endemic diseases. Improved modes of culture
introduce a greater abundance of wholesome
nourishment, and, together with a more extensive
commerce, render subsistence much less pre-
carious than in the ruder slates of society. It is
chiefly pwing lo these circumstances that scurvy,
dysentery, and diseases of the skin, are much less
common now than formerly. These, also, aided
by personal and domestic cleanliness, much better
clothing, and a freer ventilation of houses, hos-
pitals, prisons, &c., have tended greatly to dimin-
ish the general amount of mortality. As respects
prisons, the diminution of disease, chiefly result-
ing from stricter attention to cleanliness, ventila-
tion, and diet, shown to have taken place in those
of France, by M. Villerme, is most striking.
At Lyons, from 1800 to 1806, the annual mor-
tality in the prisons was 1 in 19 ; from 1806 to
1812, it was 1 in 31 ; from 1812 to 1819, it was
1 in 34; and from 1820 to 1826, 1 in 43. A
similar amelioration has also been remarked in
the prisons of Rouen, and some otlier large towns
in that kingdom. Alti:ough other diseases may
appear, there can be no doubt that those that are
more strictly endemic diminish before the pro-
gress of civilisation, and the increase of the com-
forts of life.

25, (c) The healthiness of the inhabitants de-
pends much upon the choice of residences. This
obtains, especially in warm climates, in respect
of both casual and permanent residents. Where
the winds blow from particular quarters, at certain
seasons and hours of the day, buildings or en-
campments should be placed so as to be, during
the night especially, to windward of the principal
sources of endemic disease. Ships, also, should
be anchored, as much as possible, with a regard
to this precaution, or at a distance from an un-
healthy coast sufficiently great to admit of the
dilution of the malaria, or of its absorption by
the water, before the winds conveying it reach
them. When a temporary residence must be to
leeward of a swamp, then some advantage may
accrue from lighting fires between it and tiiis
source of disease, particularly during night, and
from double tents, withm which gauze or fine
net curtains are kept spread. Buildings either
near or to leeward of any source of malaria, or
standing on a deep, moist, or argillaceous soil,
should be very iiigh ; the ground floor should be
left unoccupied, and be open on every side to
permit complete perflation ; and that side ought
to be always shut on which the prevailing night
or land winds blow, or towards the place from
which unhealthy exhalations proceed. The in-
habitants should also sleep near the tops of the
houses, where, if built high, they will generally
be placed above the more concentrated vapour
and miasms, anrl, in great measure, beyond their
influence ; for, although gentle acclivities or hills
in tlie vicinity will often attract malaria, or be
swept by currents of air conveying it, yet pre-

ENDEMIC DISEASES — Prevention of.

cipitous elevations and high houses, even near i(3
sources, will frequently escape, as, from its spe-
cific gravity, it is confined chiefly near the surface
of the earth.

26. (d) The diet of persons exposed to noxious
exhalations should be easy of digestion, and nou-
rishing, but not heating. Animal food should be
taken sparingly, and spirituous liquors and strong
wines laid aside. The lighter and thinner wines
may be used in moderation. In hot climates or
seasons, exercise in the heat of the day, or while
exposed to the sun's rays, ought to be avoided ;
but it should be regularly taken without causing
fatigue. Such medicines as will promote the
secretions and excretions, particularly those of
the liver and bowels, may be resorted to when
these functions recjuire aid. For this purpose,
two or three grains of blue pill, with the aloesand
myrrh pill, may be taken at night, and equal parts
of the compound infusions of gentian and senna in
the morning. When exposure to malaria, either
at night or early in the morning, is to be dreaded,
a moderate dose of bark or sulphate of quinine,
with camphor or some warm spice, as Cayenne
pepper, maybe taken previously to such exposure.
A fire should be lighted in the apartment or near
it ; and care be taken to exclude the raw night
air, especially in the direction of the sources of
miasmata. On occasions of this kind warm coffee or
smoking cigars will be serviceable. The tenour
of the mind should also be duly regulated. The de-
pressing passions and ideas, and all undue excite-
ment, as being liable to be followed by depres-
sion, ought to be avoided. A calm, confident,
and well-employed mind — • moderately occupied,
and interested with its pursuit — unruffled by
gusts of temper or passion — not weakened by
inordinate indulgence of the desires — with a suf-
ficient gratification of the wants and wishes to
give a foretaste of more perfect enjoyment, and
to leave still more to aspire after, so that the ca-
pacity of gratification be not exiiansted — is that
state which most successfully opposes the impres-
sion of endemic influence, which, assisted by the
sensual indulgences of some, the ill-regulated
passions and dispositions of otiiers, and the care-
lessness of many, proves so destructive to human
hfe.

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in Lond. Med. Repos. vol. i. p. 367. — T. Bateman, Re-
ports on the Dis. of London, and State of the Weather,
&c. from 1804 to 1816. Lond. 1819, 8vo.— J. Douglas, Me-
dical Topography of Upper Canada, 8vo. Lond. 1819. —
J. Copland, Medical Topography of the West Coast of

Africa, in Journ. of For. Med. vol. ii. p. 1 J. Dcvii.e,

Traite de la Fievre Jaune, 8vo. Paris, 1820. — G. Brocchi,
Considerazioni suU' Agro Romano Antico e sul Sito di
Roma Antica, 4to. Rom. 1826. ; et Del Stato Fisico de
Suolo di Roma, 4to. Rom. 1820. — W. Ferguson, The
Nature and History of Marsh Poison, Trans, of the Roy.
Soc. of Edin. 1821.— H. Marshall, Med. Topography of

Ceylon, &c. 8vo. Lond. 1822 J. B. Monfalcon, Histoire

Medicaledes Marais, &c. 8vo. Paris, 1824. — Speer, On
the Dis. of Lower Orders in Dublin, in Dub. Hosp. Rep.
vol.iii. p. \G\. — E. M. Bailly, TruitO Anatomico-Pa-
thologique des Fi&vres Intermittentes, &c. 8vo. Paris,
1825. — J. Anncsley, Researches into the Causes,
Nature, and Treatment of Diseases of India and of Warm
Climates, imp. 4to. vol. i. p. 47. et seq. — M. Dollcmann,
DIsquisitiones Histor. de plerisque apud Belgas Septen-
trionales Endemicis Morb. 4to. Amst. 1824. — J. Maccul-
loch,On the Product and Propagation of Malaria, &c. 8vo.
Limd. 1827. ; and On Remittent and Intermittent Dis-
eases, &c. 2 vols. 8vo. Lond. 1828. — Villerme, des Pri-
sons &c. 8vo. Paris, 1829 Rai/er, in Archives Gen. de

Med. t. iv. p. 477., et t. v. p. 269." (Dis. of Paris.) — Fer-
rus, in Diet, de Med. t. viii. p. 66. — J. Hennen, Sketches
of Med. Topography of Gibraltar, Ionian Islands, Malta,

&c. 8vo. Lond. 18;i0 H. Bellinaye, The Sources of

Health and Disease in Communities, &c. r2mo. Lond.

1831 — Andral, in Diet, de Med. et Chir. Prat. t. vii. p.

279.

ENTERITIS. See Intestines — L(/?nnima-

tion of.
ENURESIS. See Xinn^^ — Incontinence of.
EPHELIS. Syn. — 'E<^)iiXi? (from lirl, and
rixioc, the sun). Macules Fusccc, Plenck. Epi-
chrosis Ephelis et Lenticula, Good. Ephelides,

Alibert. Ephelide, Fr. Spotted Discolouration

of the Skin.

Cl.^ssif. — 10. Gen. 3. Order, 6. Class,
(Good). 1. Gen. 8. Order, Maculee
(Bateinaii). I. Class, V. Order,
(Author).

1. Defin. — Discolourations of the skin, varying
from a yellowish grey to a dark brown, and from

minute points to large patches, and either scattered,
confluent, or corymbose.

2. I. Forms and History. — Hippocrates
applied the term ephelis to the freckles produced
by the sun ; but he also extended it to the spots
sometimes seen in the faces of pregnant females.
This extension of the term was adopted by Ori-
basius, AJETius, AcTUARius, and Gorr^t.us ; and
carried even much further by Plater, Sauvages,
and Alieert. Other words have been employed
by modern writers as a designation either for
ephelis generically, or for certain of its varieties,
as will be stated hereafter ; but, as this appears
to have been the original one, I shall adopt it
here. The change of colour characterising it is
not seated in the cuticle, but in the pigmentum
whicli gives the hue to the skin. It seems, in
some instances, connected with a deficient tone of
the extreme vessels ; and is very variable in its
progress, occasionally coining on slowly, some-
times rapidly and extensively. It is often of long
duration, or even permanent ; and in other cases
it soon disappears, either spontaneously or after
the application of some lotion. In itself, it can-
not be considered to require medical interference ;
but certain of its forms are important as symptoms
of internal disorder. It may be divided into two
species — the lenticular and diffused.

i. Lenticular Ephelis. Syn. — Ephelis Len-
ticularis ; Lentigo, Lenticula, Auct. Lat. ;
Ephelis Lentigo, Sauvages and Todd ; Lentigo
Ephelis, Frank; Pannus le)iticularis, Paget;
Ephelide lentiforme, Alibert ; Freckles.

3. This species is characterised by its fawn or
brown colour, the spots being generally very
small, and always under the size of a lentil, dis-
seminated or in clusters; and without any eleva-
tion of the cuticle, or attendant irritation. Dr.
Todd has very properly divided it into two varie-
ties — viz. that which is congenital or dependent
upon the complexion, and consequently sometimes
hereditary ; and that which is caused by the sun.

4. A. Congenite Ephelis; Oa^to?, Gr. ; Taches
de Rousseur, Fr. ; Ephelis Lentigo materna, Todd ;
Congenite Freckles. — This variety occurs most
frequently in persons of a very fair complexion,
with a delicate skin, and yellowish or reddish
hair; and sometimes in those with a very white
skin, and dark hair and eyes. The spots are len-
ticular, persistent, and not confined to tlie parts
exposed to the light; but are in some cases disse-
minated over the body. They frequently do not
become very apparent until some time after birth,
or even not until the child is five or six years old.
The darkness of the discolouration varies as above
(§ 1.), with the colour of the hair or eyes, and

' usually remains till old age.

5. B. Solar lenticular Ephelis ; Lenticulte So-
lares ; Macuhe Solares, Plenck ; Ephelis a Sole,
Sauvages; Lentigo (estiva, J. Frank; Su7nmer-

Jiecken , Sonnensprossen , Ger. ; Evanescent Freckles,
— This is a common lenticular discolouration,
occurring in young persons, especially females.

766

EPHELIS — Diffused — Treatment.

during spring and summer, and disappearing in
winter; and limited to parts exposed to the sun.
Those who live in cities, or keep much within
doors, are very liable to it when exposed to the
sun and fresh air. The deepness of the discolour-
ation generally varies with the colour of the hair ;
and the spots are most numerous in the face, par-
ticularly of those who go bareheaded, or insuffici-
ently shaded from the sun's rays.
ii. Diffused Ephelis. — Ephelis diffusa, Todd.

6. This species is characterised by the irregular,
diffused, and large patches, which vary more
widely in colour than the foregoing species ; and
are sometimes distinct, sometimes confluent. It
has been made to comprise certain discolourations,
arising from various causes, and presenting very
different appearances. Some of these proceed
from the direct action of heat and light, and others
are symptomatic of an internal affection.

7. A. Idiopathic diffused Ephelis — Ephelis dif-
fusa Idiopathica (T'oud) — presents two very dis-
tinct forms ; that caused by the heat of fires, and
that by the sun and air. — (a) The blotches pro-
duced by artificial heat — Ephelis ignealis (Sau-
VAGEs), Ephelis spuria (J. P. Frank), Lentigo al>
IgHe{J. Thank), Tdches de BriUure, i'r. — are
generally seen on the legs, arms, and thighs of
persons who sit near the fire, without any cover-
ing intervening between these parts and it. They
are usually of a mottled character, and often as-
sume a livid, or purple, or purplish red, colour,
especially when the surface is exposed to cold.
They are met with chiefly in females. — (b) Sun-
burn, or the diffused and general discolouration —
Nigredo a Sole (Sennert), Fuscedo Cutis
(Plenck), Ephelis umbrosa (J . Frank) — is merely
the dark colour acquired by the skin after the pro-
tracted action of a high range of solar heat and at-
mospheric temperature, aided by the influence of
the air, more especially sea air, and salt water.

8. -B. Symptumatic diffused Ephelis, Ilepatizon,
MaciiliE Hepaticte (Sennert), Vitiligo Hepatica
(Sauvages), Kelis fulvescens (Swediaur), Chlo-
asma (the Franks), Ephelis diffusa Symptomatica
(Todd), Punnus Hepaticus (Paget), Ephelides
Hepatiques (Ai.iJiTinr), Tdches Hepatiques (Fr.),
Leberjtecken {Germ.). — I'his form of discolour-
ation varies much in shade, and in the size of the
patches. It is usually of a pale dirty yellow, or
of a yellowish brown, or a light tawny shade ; or
it passes from a saffron to a rhubarb hue. The
patches are occasionally preceded by itching,
are sometimes very slightly elevated, and then
terminate in desquamation of the cuticle. They
appear most fretjuently on tlie neck, over the
regions of tiie liver and kidneys, on the groins,
on the forehead, and sometimes about the mouth,
and are generally distinct ; but they usually run
into each other as they extend, and often form
groups or wide blotches. When slightly elevated,
and followed by desquamation of the cuticle,
they nearly approach the Pityriasis versicolor
of liATEMAN J and in this slate are very dry and
unperspirable, while the surrounding skin is soft
and moist. They are either persistent, or of
short duration. The transient form of this dis-
colouration is very common in delicate females,
particularly those whose uterine functions are dis-
ordered, and at the period of the catamcnia.
'Jliey occasionally appear suddenly, and disap-
pear as speedily after a few hours ; but they often

remain a very considerable time, especially when
they are connected with suppression of the menses
(the Chloasma Amenorrhaiim of J. Frank), or
with conception (the Epl^elis Gravidarum of
Plenck, and the Chloasma Gravidarum of F^rank).
— This form of ephelis is also sometimes connected
with chronic disorders of the liver ; but more fre-
quently with those of the stomach and large,
bowels, and with those of the uterine organs. It
is occasionally attendant upon haemorrhoids ; and
is very readily excited in those liable to it by
vexation and anxiety of mind. It is also very
generally connected with a state of the digestive
organs, characterised by a craving appetite, and
imperfect digestion and assimilation.

9. II. Treatment. — The Lenticular Ephelis
is frequently a matter of serious consideration to
the fair sex ; and ingenuity has been often tor-
tured for means of removing it. — (a) In respect
of the congenite variety (§ 4.), the remark of
Celsus, as to. the folly of those who attempt to
remove it, is perfectly just. — (h) That variety,
which is caused by the summer heat — the solar
lenticular ephelis (§ 5.) ■ — • may be prevented by
the use of veils and wide-brimmed hats ; which
will frequently assist its removal when already
produced. The articles — nostrums, cosmetics,
&c. — which have been recommended for it, are
beyond the possibility of enumeration ; every
perfumer, &c. being possessed of a panacea.
Gently astringent and discutient lotions and poul-
tices have been most commonly employed. From
the time of Hippocrates to the present, lotions
and liniments with bitter almonds have been re-
commended. Celsus advised a liniment of resin
with a little fossil salt and honey ; Actuarius,
one with vinegar, honey, and bitter almonds ;
and Geoffrey, ox-gall, either alone, or with
liquor potassae. Dr. Thomson mentions a weak
solution of bichloride of mercury, in the emulsion
of bitter almonds ; and Dr. Bateman, a drachm
of either sulphuric or hydrochloric acid, in half a
pint of water, in the form of lotion. Dr. J.
Frank prescribes the chloric acid in rose-water
(ni xij. — XX. to 5 vj.) ; and Dr. Withering,
an infusion of horseradish in milk. Sour butter-
milk is frequently employed in country places
as a cosmetic wash. Besides these, a decoction
of powdered lupines or tares, or of the narcissus
root, or of the seeds of the garden cucumber,
also poultices prepared from these, and from a
great variety of roots, have been recommended.
The balsam of Mecca, with super-acetate of
lead, in the form of pomatum ; washes with
the juice of sorrel, or with lime-juice and cam-
phor mixture ; also this last, with nitrate of
potash, or with milk of sulphur, or with Vene-
tian soap dissolved in lemon-juice; rubbing the
parts with a slice of lemon or sour-npple ; solu-
tions of zinci sulphas, in emollient vehicles ; and
of the biborate of soda in rose-water or orange-
flower water (F. 334.) ; have also been em-
ployed, and frequently with success. JNIost of
these are best applied at night, and washed off in
the morning.

10. ii. The Diffused Ephelis, when preceeding
directly from artificial or solar heat {§ 7.), dis-
appears gradually upon tlie removal of the cause ;
and requires no further consideration. The symp-
tomatic stales arc important only as symptoms
of internal disorder ; and, as being generally

EPIDEMICS -

connected with imperfect secretion, excretion, and
assimilation, these functions should be assisted
by mild, cooling, and alterative purgatives, light
diet, and moderate exercise. Very small and
frequent doses of blue pill orhydrarg. cum creta,
may be given with Castile soap and taraxacum,
or with the aloes and myrrh pill, if the catamenia
are scanty ; or with ox-gall in addition. The
internal use of the creosote may also be tried. I
have prescribed it, in one case of this kind, with
great benefit. Sulphurous mineral waters may
also be taken ; and lotions with the sulphuret of
potassium, or with nitre and camphor julap; or
sulphureted fumigating baths resorted to.

BiBLiOG. AND Refer. — Hippocrates, Prjenot. 1. ii.
xxxi. 9. ; De Aliniento, iv. 18. ; De Morb. Mulier, 1. ii.
Ixvii. 6. — Celsus, De Med. 1. vi. c. 5. — Aetius, Tetrabib.

ii. ser. iv. c. 11 Oribasius, Synop. 1. viii. c. 33. ; De

Loc. Affect. Cur. 1. iv. c. 52. ; et De Virtute Simp. 1. ii.
c. 1. {Bitter almonds.) — Actuarius, Meth. Med. 1. iv.

c. 13. — Sentierttis, De Cutis Vitiis, 1. v. pars 3 Gor-

r«EMS, Defin. ad Vocem 'EfriXi'v. — Plater, De Superfic.
Corp. Dolore, cap. 17. — Bender, Yie Cosmeticis. Arg.

8vo. 1764 Lorry, De Morb. Cutaneis, art. Lentigo

Sauvages, Nosol. Mt'thod. Class i. Gen. 3. — Plenck, De
Morb. Cut. Class i. Sp. 2. — Alibert, Plate 26. and 27. —
Bateman, Synopsis of Cut. Dis. by yl. T. Thomson, p.441.
—J. P. Frank, De Cur. Horn. Morbis, 1. iv. p. 82. etseq.
— J. Frank, Praxeos Medicae Universae Praecepta, pars
prima, vol. ii. p. 331. et 337. — Bayer, Traite Theor. et
Prat, des Mai. de la Peau, t. ii. p. 206. ; et Diet, de Med.
et Chir. Prat. t. vii. p. 3G9. — Cazenavc et Sc/iedel, Abrege

Prat, des Mai. de la Peau, 8vo. p. 370 Todd, Cyclop, of

Pract. Med. vol. ii. p. 69. — J. Paget, On the Classification
of Diseases of the Skin, 8vo. p. -51.

EPIDEIMICS. — Epidemic Diseases ; 'E7ri^riy,ia,
'EOTS'?/uioj,'E7nW|aoc (from Itti among, and JS^oj,
people). Epidemia, Epideinius, Epidemicus,
Morbi Epidemici, Morbi Pitblici, Morbi Popu-
lares, Auct. Lat. Epidemie, Fr. Volkskraiik-
heit, Germ. Epidemia, Ital. Epidemy, Epi-
demic Influence. Epidemic Constitutions,
Classif. — General Pathology.

1. EpiDEMics are such diseases as occasionalli)
prevail more or less generally in a community
at the same time or season, and depend upon a
common cause. — They recur at uncertain periods ;
and continue to prevail for a time varying from
two, three, or four months, to as many years, or
even longer. When their spread is most exten-
sive, or throughout countries differently cir-
cumstanced as to climate, &c., or when they
are universal in their attack, they have often re-
ceived the appellation of Pandemic (TravStijCuo; or
7ravS'»i(U.oc, from 7ra?, all, and S'>i|«.oc, people). When,
together with their very genera! prevalence, they
occasion a very great mortality, they have usually
been denominated pestilential (see art. Pesti-
lence.). They are commonly acute and febrile,
and often rapidly run their course. They appear
at any season of the year ; but most frequently
in autumn, summer, and spring. They are dis-
tinguished from endemic maladies by the circum-
stance of these latter being occasioned by pecu-
liarity of situation. But it should be recollected,
that endemic diseases may be converted into
epidemics of a very fatal kind by those injluences,
either obvious or inferred, to which attention will
be directed in this article ; and which, acting
either separately or in combination, modify the
character, whilst they cause the prevalence, of
disease.

2. I. Causes, &c. — The Injluences whence
epidemics proceed may be traced in many in-
stances ; and in others, particularly those that are
pestilential, they cannot be inferred with the same

Causes, etc. 757

degree of probability. Certain epidemics have
manifestly arisen out of combinations of circum-
stances, the nature and operation of which admit
not of dispute, whilst some have presented only
certain elements of their causation, others beint^
wanting to explain fully all the phenomena ob°
served. — A. Amongst the most important ele-
ments of epidemic injluences, are those endemic
sources which are amply described in the articles
Climate (§ 3 — 32.); Disease — Causation of ;
and Endemic Influence (§ 5.). These sources
often perform very important parts in the causation
of epidemics, upon the addition of some other
cause, either manifest or concealed; endemics
being sometimes the parent stock upon which epi-
demics are engrafted ; the latter varying in cha-
racter with the nature of the superadded cause
or causes, especially those which are about to be
noticed. Several of these additional causes may
consist merely of certain changes, from the usual
course of the seasons, which obtain in these local-
ities ; as prolonged drought, or protracted rains •
and, still more, the former following the latter •
and particularly if conjoined with increased tem-
perature. As long as the temperature continues
low, very material changes in the state of the
seasons may not be productive of any increase of
disease in unhealthy situations, unless other causes
come into operation, as infection, deficient or
unwholesome food, Sec. Hufeland states that,
in 1815 and 1816, in the north of Germany,
the seasons were remarkably wet, and the temper-
ature low, and yet the public health was very
good ; that intermittents and low fevers were
rare, even in marshy localities ; inflammations
and rheumatism being the predominating mala-
dies. In warm countries, however, protracted
and heavy rains generally occasion epidemic dis-
ease, especially in low and marshy places, during
the subsequent hot or dry season, or when great
numbers of persons are crowded in a small space ;
and, moreover, impart to it an asthenic and in-
fectious character. Of diseases originating in
local sources, becoming infectious and epidemic,
I could adduce several instances in modern times,
Livv (1. XXV. 26.) states that, during the siege
of Syracuse by JMarcellus, 213 years B. C, a
pestilence broke out in both armies ; and that it
occurred in autumn, and in a situation naturally
unhealthy. " At first," he observes, " persons
sickened and died, owing to the unwholesomeness
of the place; afterwards the disease spread by
infection, so that those who were seized were
neglected, or abandoned, and died, or their atten-
dants contracted the disease." lie further adds,
that the dead affected the sick, and the sick those
in health, with terror and pestiferous stench ;
that the disease was more fatal to the Carthagi-
nians than to the Romans, who, in this long
siege, had become accustomed to the air and
water ; and that, in the same year, an epidemic
visited Rome and the adjoining country, which was
remarkable rather for parsing into chronic afTec-
tions, than for the mortality it occasioned. Al-
though some of the sources of endemic disease
may, by the aid of concurrent causes, as in the
instance now quoted, give rise to epidemics, yet
pestilential epidemics otherwise originating, as in
infection, have sometimes spared places which
have seemed to abound the most in certain causes
of insalubrity J but this has occurred only when

768 EPIDEMICS

those places have emitted a powerful stench and \
ammoniacal vapours, or other strong odours,
which have either counteracted or neutralised
the exhalations or miasms which have spread the
infection.

3. B. The seasons have a very remarkable influ-
ence upon certain epidemics, as those of yellow
fever and plague ; and but little on others, as pesti-
lential cholera, influenza, &c. As respects those
epidemics which are less universal and fatal, the
influence of the seasons is more or less manifest. —
In spring, various forms of angina, croup, bron-
chial afl'ections, inflammations of the lungs and
pleura, catarrhs, rheumatism, hooping cough, ter-
tian or quotidian agues, and the febrile exanthema-
ta, as measles, &c., are usually most prevalent. —
In sijmmer, certain of the above diseases will often
remain, with continued fevers of various forms,
erysipelas, smallpox, stomach and bowel com-
plaints, &c. — In autumn, the diseases of summer
either continue or become more prevalent, espe-
cially cholera, dysentery, and colicky att"eclions ;
and quartan or irregular agues, remittents, sore
throat, scarlatina, inflammations, or obstructions
of the abdominal viscera, &c. are also frequent.
' — In ivinter, inflammations of the thoracic and
respiratory organs, rheumatism, and low or typhoid
fevers are 'most common ; and, inclose or crowded
places, infectious eflluvia, either from the sick or
from accumulated filth, are readily generated,
■when the air in heated apartments becomes stag-
nant. IIippocnATEs had remarked that, when the
seasons are regular, diseases are also more regular
in their course; and, unless during the prevalence
of epidemics, the observation appears just.

4. C, The weather has a considerable influence
on the prevalence of the more common diseases.
Protracted droughts are unfavourable to pul-
monary diseases, with the exception of bronchor-
rhoea, and frequently excite inflammations and
inflammatory fevers. During, and soon after,
very wet seasons, gastric, remittent, and inter-
mittent fevers, catarrhal and rheumatic affec-
tions, dysentery, diarrhoea, and sore throat, are
often epidemic. The frequent recurrence, or the
continuance, of high and cold winds, occasion
catarrhal, pectoral, inflammatory, and rheumatic
diseases; and warm or hot winds induce remittent
and bilious fevers, cholera, ophthalmia, &c. Calm
humid states of the air promote the spread of con-
tinued fevers, and all infectious and contagious ma-
ladies ; and similar conditions of the atmosphere,
conjoined with great heat, favour the prevalence
of adynamic and malignant fevers of a continued
or remittent type ; whilst very hot and dry seasons
give rise to synochol and ardent fevers, to bilious
remittents, cholera, and inflammations of the liver,
stomach, and bowels.

5. Although the states of the atmosphere here
enumerated very frequently ])roduce the eflfects
ascribed to them respectively, yet other causes aid
their operation. Writers, from Hippocrates down-
wards, have attributed too much to irregularities
and sudden vicissitudes of season in the production
of epidemics, more especially of those which are
very general or pestilential. I believe that this
cause is instrumental chiefly in augmenting the
number of cases of the diseases common to a coun-
try ; and that it is very seldom the only, or even
the chief, 8ou.ice of wide-spreading or pestilential
niuladies, although it may aid their generation

— Causes, etc.

and diffusion. On this point I cannot agree with
Dr. Hancock, M. Fodere, and some other mo-
dern authors. That this dictum of Hippocrates
was not altogether believed, even in ancient
times, may be inferred from the frequent excep-
tions to it adduced by historians and medical
writers. Tacitus (Annalium, ]. xvi. 13.), when
noticing the epidemic that raged at Rome in the
year 68, states, that there was no irregularity
of season or weather to account for it. Tiie
plague that prevailed so long, and spread so gene-
rally, between the middle and end of the sixth
century, and which has been fully described by
Procopii'S and Evagriiis, who were witnesses
of it, was in no way dependent upon irregularity
of season, but was evidently propagated by in-
fection. The following remarks of Evagrius
are, according to the _experience of every candid
observer, perfectly cliaracteristic of an infectious
pestilential epidemic : — " Some perished by once
entering into, or remaining in, the infected houses ;
some by touching the sick. Some contracted the
disease in open market ; others, who fled from
infected places, remained safe, while they com-
municated the disease to others, who died. Many
who remained with the sick, and freely handled
the dead bodies, did not contract the disease. "
(Eccles. Hist. 1. iv. cap. 29.). The pestilence
called the Black Death, which visited nearly all
the then known world in 1347, 1348, 1349, and
1350, was equally independent of irregularity of
season or deficiency of food. Parker (^Antiq.
Brit. p. 360.) states, that it first appeared in
the south of England about Christmas, '1348,
and amidst the greatest abundance of provisions.
TnuANus and Riverius, when noticing the epi-
demic that broke out in France in 1580, re-
marked that the crops that year were plentiful,
and the sky serene ; so that it was thought that
the disease was produced rather by the influence
of the stars than by the malignity of a corrupt
air. Webster (On Epidemic Diseases, vol. i.
p. 323.) admits that the summer in 1665, in
England, when the plague commenced in Lon-
don, was very temperate, the weather fine, and
the fruits good. All the writers of the day agree
that no cause of pestilence could be observed in
the states of the seasons. The epidemics of our
own days also prove that, although irregularities
of seasons and weather may aid the ende-
mic sources of disease, or increase the pre-
valence of the common diseases, they are by no
means amongst the chief causes of pestilential
maladies.

6. D. In connection with, and often resulting:
from, irregularity and inclemency of seasons, un-
loholesnme and deficient food sometimes performs
an important part in the production of epidemics,
— a fact which seems to have been well known and
guarded against by the inspired lawgiver, Moses.
In Devteronomy (ch. xxviii.) the Israelites are
warned against transgressing his laws ; and are
threatened, as a consequence of disobedience,
with the diseases of ]'>gypt — the botch, the scab,
and the emcrods ; maladies known at present, by
the names of elephantiasis, leprosy, and plague,
respectively to prevail in that country ; and in
A'umhers (ch. xi.), they are stated to have been
seized by pestilence from eating a great quantity of
the flesh of (juails, which had fallen in surprising
numbers around tiieir camp, after having been

EPIDEMICS — Causes, etc.

769

long destitute of animal food, — a consequence of
the circumstances in which they were placed,
and of the unwiiolesome nature of their food,
FoDERE states, that during 1815, 1816, and 1817,
in several parts of Italy and France, the inhabit-
ants were obliged to have recourse to such roots
and herbs as they could procure, the grain havin

in those who partake of it, notwithstanding^
the eflect of cookery in counteracting its noxious
tendency.

8. (c.) The agency of unripe, stale, or other-
wise unwholesome fruit, and of stale and diseased
fisii of any kind, in the production of certain epi-
demics, is fully shownin tiie article Disk.vse (§ 40.),

been remarkably scarce, and of bad quality ; and and in tiie sequel. — {d) The operation of un-

that, in consequence, scurvy, diseases of the skin,
and malignant and infectious fevers, became very
prevalent anjong the lower classes. A similar
circumstance was observed at Marseilles in 1812
and 1813 ; and in Ireland, on several occasions
since the commencement of the present century ;
typhoid and low fevers, and dysentery, being the

wholesome water, although especially manifested
in the causation of endemic distempers, is also
productive of those that are epidemic, particularly
on occasions of inundation of the sea; as observed
on several occasions in Holland, Italy, and
many places within the tropics. — (e) j\I. Fodekk
states, that during a tour lately made in the Low

most prevalent results. Diseased or unripe grain, ] Countries and French Flanders, he learnt that
or alterations which it may have undergone in functional and organic affections of the stomach
granaries, and the admixture of seeds which are i were sometimes epidemic there, from the use of
injurious with it, are also very inHuential agents ; spiced spirits and cordials, and the practice of

of disease. In years of scarcity, both gram
and roots are often prepared for food before
they have acquired due maturity ; and in that
state derange not merely the alimentary canal,
but also the nervous and circulating systems, at a
period when want and debility have rendered them
more than usually susceptible of disorder. Ma-
lignant fevers, dysentery, convulsive affections,
scurvy, ergotism, raphania, &c. have, in numer-
ous instances, proceeded chiefly from diseased
or altered grain. M. Fodehe mentions, in ad-
dition to the more speciHc effects of ergoled rye
(see Ergotism), its causing abortions to become
epidemic.

7. (fc) Flesh of animals, and fish, when dis-
eased, or tainted, are not infrequently productive
of most dangerous maladies. Epidemics often
commence among the lower animals ; especially
horned cattle and sheep ; and the use of the dis-
eased flesh may occasion malignant diseases
among the human species. Whetheror not infec-
tion may be conveyed from these animals whilst
alive, to man, during epizootics, has not been as-
certained, nor, indeed, has the question been fully

adding lime and alkaline substances to the bter to
prevent it from becoming acid. The well-known
exclamation which SaiKSPEAUE puts in the mouth
of Falstaff would lead to the inference that lime
was very generally used, in the sixteenth century,
to remove or prevent acidity in the white wines
then drunk. This, however, is a cause rather of
endemic than of epidemic diseases. The ill effects
of adding deleterious narcotics to beer — even to
the small-beer — in this country, although satis-
factorily shown in the production of a great
variety of disorders, chiefly of the digestive organs
and nervous systems, seldom manifest themselves
in a form so specific as to be recognised as epi-
demic or even endemic.

9. E. a. Several writers on the epidemic ap-
pearance of certain diseases, finding that neither of
the foregoing description of causes could account
for them, have had recourse to various sup-
positious agents, of the nature of which they are
entirely ignorant, and even the existence of which
they have not been able to demonstrate. These
agents have been supposed by some to be a
malaria, or principle of a peculiar kind, generated

entertained. That it can be thus conveyed in by the prolonged action of the sun, or by heat.

respect of some maladies, has been proved in mo-
dern times. FoDEiii: adduces a very convincing
proof of the ill effects of diseased flesh in the pro-
duction of dysentery and typhoid or adynamic
fevers. At a period when the French troops, in
the late war, were in want of provisions, over-
driven cattle, some of them diseased chiefly from

upon low absorbent soils, and exerting a very-
noxious operation on the human constitution ;
and by others, to be a peculiar aura, or fluid,
which has escaped from more deep-seated parts of
Ihe earth ; and, although altogether incognisable
to the sense>, yet most destructive to human life.
The former opinion is maintained by many, espe-

this circumstance, were killed before time was ; cially by Jacksox, P'erguson, Deveze, O'Hal-
allowed them to recover their fatigue. Their flesh ' loran, Dickson, Robertson, &c. ; the latter,
was remarkably red, and passed quickly into de- { also, by a numerous body of physicians. Noah
composition. Most of those who partook of it Webster endeavoured by most laborious research
were seized with febi'ile and malignant dysentery, i to connect the appearance of epidemics with vol-
During the French war in Prussia, Germany, ' canoes, earthquakes and comets, — supposing that
and Italy, the sound meat and grain were often j they ail depend upon the same cause, or that the
carried off by the victorious armies, leaving the I changes produced by the latter give rise to the
unhealthy animals, &c. to the inhabitants, who . former, either directly by their action on the
became, from the nature of their food, the prey , human frame, or indirectly by blighting the pro-
of epidemic fever and dysentery. The blood 1 ductions of the earth, and thereby deteriorating
and viscera of these animals are generally most the chief articles of food. In struggling througli
noxious from being especially affected ; and it is a dry and meagre enumeration of epidemics — •

fully established that these parts become princi-
pally diseased in the persons who are seized by
these maladies from this cause. The muscular

silight as well as pestilential — furnished by this
writer, the reader is often amused by the attempts
to connect an influenza, or some other epidemic, in

flesh of cattle attacked by anepizooty much sooner Europe, with an earthquake in America or in Asia,
presents appearances of alteration afler death, than ! or with acometthat had appeared twoorthreeyears
that belonging to such as are healthy. It cannot, either previously or subsequently, or with some
therefore, fail of being productive of disease I such phenomenon, as the fall of meteoric stones,
Vol. I. 3D

770 EPIDEMICS — Causes, etc.

10. b. Other authors have ascribed an unusual i records of history extend

prevalence of disease, or the appearance of pes-
tilential epidemics, chiefly to the states of elec-
tricity in the air, and on the earth's surface. Tiiat
certain conditions of this agent should affect the
animal economy, and either predispose it to be
infected by the exciting causes, or of itself be a
principal cause, of disease, is probable ; but we
have no direct proof of any connection between
epidemics and known changes in the electrical
states, either of the air, or of objects on the earth's
surface ; and even granting that such connection
exists, tliere is no evidence that this agent can
produce the morbid effects ascribed to it. It is
impossible to reconcile the modes in which epi-
demics are observed to diffuse themselves, or the
peculiar and novel characters they often assume,
or the very opposite physical circumstances in
which they occur, merely vvitii changes in the
electric fluids, often of inappreciable and in-
sensible kinds. Indeed, experience rather shows
that the body may be made ihe medium of a very
energetic, electrical, or electro-motive, action,
without any injury being inflicted on it ; and it is
only when a very powerful and very manifest
current of either the negative or positive electrici-
ties strikes, or passes through it, that life is thereby
in any way affected.

11. c. Numerous instances have occurred of
the lower animals participating in the fatal effects
of an epidemic constitution, and they have been
adduced by modern authors as proofs of the exist-
ence of a noxious effluvium in the air, however it
rnay have been generated. Thus it has been ob-
served, that epizootics have preceded the preva-
lence of fevers ; that catarrhal affections in horses
have been followed by influenza ; that birds have
either forsaken the vicinity of a town ravaged by
a pestilence, or have fallen dead when flying over
it ; and that numerous species of animals, particu-
larly domestic animals, have died in houses visited
by pestilential maladies. These phenomena have
been adduced as proofs nf the existence of some
one of the agencies placed under this head.
Without disputing their actual occurrence, or
attempting to reduce them to their exact dimen-
sions, from which they had been exaggerated for
the purposes of argument, I will receive them
as they have been described by those who have
adduced them in support of their views. — 1st.
As respects epizootics in connection with epidemic
fevers, Lancisi, Ramazzini, and still more
modern writers, have furnished much information.
It has very frequently been observed, when the
prevailing fevers have been an exaggerated form
of tlie endemic of the country, or when endemic
sources have been manifestly concerned in their
causation, that the lower animals, especially horned
cattle and sheep, which derive their sustenance
chiefly in places productive of malaria, are the
first to experience its efiects, when it is more than
usually active or concentrated. This is nothing
more than what might be inferred a priori. We
know that remittent and continued fevers, in
various forms, are frequently epidemic, especially
in marshy countries in the south of I'.urope; are
chiefly dependent ujion local sources, aided by
heat, crowding, imperfect ventilation, neglect of
cleanliness, and the state of society ; and are
often cither j)receded or accompanied by epi-
zootics. Such occurrences are as old as the

and have been ad-
verted to in the Books of Moses, as well as in
those of the Prophets. Homer has signalised the
connection, and Eustathius and Spondanus
have explained it, in their commentaries on the
Iliad, as satisfactorily as any philosopher of the
present day. Eustathius, the celebrated critic
of the twelfth century, ascribes the disease that
broke out in the Grecian camp, in the tenth year
of the siege of Troy, to immoderate heat and gross
exhalations: and De Sponde, or Spondanus, as
he is commonly called, conceived the circum-
stance of the mules and dogs having been affected
before man, to have been owing to their natural
quickness of smell, rendering the exhalations
sooner perceivable and operative ; and to their
feeding on the earth with prone heads, whereby
effluvia are more readily inhaled, and before they
rise so as to affect man, or become diffused in
the air.

12. A connection similar to the above, and evi-
dently proceeding from tlie same sources, especially
in warm or dry seasons, consequent upon the
inundations of low grounds or marshes, is men- '
tioned in various places by Livv. Tliat the epi-
demics, which were thus consequent upon or
attended by epizootics, were of the nature I have
contended for, may be inferred from the following
notice he has recorded of an epidemic fever which
was remarkably destructive in the year of Rome,
576: — " Pestilentia, c[uae priore anno in boves
ingrueiat, eo verterat in hominum morbos. Qui
inciderant hand facile septimum diem superabant :
qui supeiaverant longinquo, maxime quartanae
implicabantur morbo. Servitia maxime morie-
bantur ; eorum strages per omnes vias insepul-
torum erat. Ne hberonim quidem funeribus
Libilina subficiebat. Cadavera intacta a canibus
ac vulturibus, tabes absumebat; satisque con-
stabat nee illo, nee priore anno, in tanta strage
bourn hominumque, vulturium usquam visum."
(L. xli. 21.) Here the commencement of the
disease amongst tlie cattle, its subsidence into the
intermittent type, its greater prevalence in the
lowest classes, and the absence of birds of prey
from the infected atmosphere, are proofs — 1st, of
its having originated in malaria, and possessed the
characters distinguishing this class of fevers ; and,
2d, of the effect of the contaminated air and dis-
eased bodies on animals of prey. The destructive
epidemic that ravaged Rome in the year A. D.
187, and many parts of Italy, was attended, rather
than preceded, by a disease in cattle. Herodian
(L. i.) ascribes it to the great concourse of people,
assembled from all parts of the earth, and to an
unfruitful year, and consequent famine, — causes
most likely to generate infection, particularly when
aided by others which are seldom absent under
sucii circumstances. Although this connt'ction
of epizootics and epidemics may be explained
as was attempted by J'justatiiius and Spondanus,
yet it is not improbable, that cattle confined to-
gether in a state of disease will generate an efflu-
vium, remarkably injurious to man ; that the use
of the flesli of diseased animals, as may be
inferred to have been the case in the epidemic
last noticed, will have a similar effect ; and that,
when aided by other noxious agents, both these
causes will occasion an infectious malady,
which will spread with great rapidity and
mortality under the circumstances in which

EPIDEMICS

tliese epidemics were observed. The facts
already adduced (§, 7.), support this infer-
ence ; the following further tend to confirm
it: — LivY, DioNYsius of Haliearnassus, and
Orosics mention a destructive pestilence which
Rome and its territory experienced 464 years B. C.
It seems to have occurred in autumn, and to have
arisen from the crowds of countrymen and herds
of cattle received within the walls of the city.
" Ea coHuvio," Livv remaiks, " mixtorum omnis
generis animantium, et odore iiisolito urbanos,
et agrestem, confertum in arcta tecta, asstu ac
vigiliis angebat, ministeriaque in vicem ac con-
tagio ipsa vulgabant niorbos." (L. iii. 6.) The
circumstance here so very explicitly stated, the
vicinity of the Pontine marshes, and the state of
the surrounding country admitting of inundations
from any unusual rise of the Tyber, fully explain
the occurrence of this epidemic. About ten years
afterwards, another epidemic ravaged liome, and
was connected with famine and disease among
cattle. In the year of this city 325, or twenty-
five years subsequently, a remarkable drouglit and
famine visited the lloman territory, the springs of
water even having been dried up. Livy states,
that " multitudes of cattle thronged round the
arid fountains, and perished with thirst. Diseases
followed, first invading cattle, and infecting the
rustics and the lower classes of people, and then
extending to the city." (L. iv. 30.) Dr. Hodges
states, that the plague of London in 1665 was
preceded by sickness among cattle, and that bad
meat was consequently sold to the poor so cheap
that they fed upon it to excess, — a circumstance
that could not fail of predisposing them to be
affected by its principal causes. — During the epi-
demic of New Orleans in 1819, cattle, sheep,
and horses were affected, evidently ov.'ing to the
concentrated malaria concerned in causing the
disease.

13. 2d. It has been supposed that the death or
absence of birds during an epidemic is evidence
of the dependence of such epidemic upon terres-
trial exhalations. But it should first be ascer-
tained at what period this phenomenon occurs ;
for if it precede the disease in the human species,
then it "may be inferred that these exhalations are
concerned more or less in causing that disease.
But if it take place during the course of the epi-
demic, then it may arise from the infection of the
atmosphere by the exhalations from the sick ; the
feathered creation, owing to the extent of their
respiratory organs, and to their relatively large
consumption of air, being very susceptible to
changes in this fluid. I believe, that the pheno-
menon in question has occurred only during pes-
tilentUd epidemics, where the sickness and mor-
tality have been very great ; and that it has pro-
ceeded from tiiis latter cause. This is proved by
the circumstances in which it has been observed.
Thucydides states, that, during the plague of
Athens, birds that prey on human flesh entirely
disappeared. Analogous facts were noticed by
DiEMERBROECK during the plague of Nimeguen ;
by Sir J. Fellowes, during the epidemic 'of
Cadiz ; and at Dantzic in 1709, according to
Shout. It has likewise been remarked that do-
mestic animals have died, during these epidemics,
similarly aflTected to man. In these cases, the
infection has manifestly extended from t'le latter

— Cjwses, ETC. nt

to tiie former ; the air having been contaminated
by the effluvium exhaled from the sick.*

14. F. Tiie putrefaction of animal substances
has been supposed by many to occasion disease
in those who come within the sphere of the ex-
halations thus produced, and even to generate a
malady which has become infectious, and has,
partly thereby, and partly from other concurring
causes, prevailed to an epidemic, or even pesti-
lential, extent. It is not, however, merely dead
animal bodies, or considerable collections of putrid
matter, but also heaps of filth exposed in the
streets, or animal excretions and exuvia;, subjected
to a warm and stagnant air, and neglect of do-
mestic and personal cleanness, that are thus inju-
rious. Tiiese latter may be less energetic agents
than the foregoing ; but they more frequently
exist, and are more common concurrent causes.
The injurious effects, however, of putrefying ani-
mal substances have been, denied by Dr. Ban-
croft and others, by a species of argumentation
more specious than solid — by a kind of medical
special pleading, of which we have had more,
since the commencement of this century, than
is consistent either with facts, or with the ad-
vanced state of general science. Animal sub-
stances in a state of decay will produce effects,
varying with the temperature and humidity of
the air, with the concentration of the exhalations
proceeding therefrom, and with the state of in-
dividuals, or of the community, exposed to them.
A candid appreciation of the facts which have
occurred to most experienced observers, in con-
nection with those recorded by creditable writers,
will, I believe, warrant the following inferences :
— 1st. That in low ranges of temperature, the
emanations from putrid animal substances will
seldom be productive of marked eftects, unless
tiiey accumulate or become concentrated in a
stagnant atmosphere — unless they be assisted by

* The above occurrences were common in the pesti-
lential epidemics that have visited the south of Spain
since the commencement of the present century. The
foUowingillustrative facts have been observed by myself:
— Some years ago, malignaut puerperal fever, proceeding
from a contaminated state of the air in the wards of a
then crowded and ill-ventilated lying-in-hospital, had
attacked nearly all the patients, 'l^he cat kept in the
house died at that time, soon after having had kittens,
with all the characteristic symptoms of that malady.
During the prevalence of cholera in London, in 1832, a
parrot, in the apartment of a person who had this dis-
ease, died with all the symptoms of it. Due precautiong
having been used to pr'event'its extension to the rest of
the family, no one eisy Wit^.'affected by it. Some other
birds, in different parts of the house, escaped. That a
very sensible effluviuTi is given oif from the sick, and long
adheres to the clothes of the attendants, is proved by the
following occurrence: — During the summer of 1833, I
was .called, by Mr. Faxon, to a patient violently attacked
by pestilential cholera, at a considerable distance from
my house. I took occasion, directly after one of my visits
to this patient, to call upon two relatives of my own,
residing about a mile and a half from the house of the
patient ; and, although I walked that distHnce, they
both, upon entering the room, enquired respecting the
peculiarly unpleasant odour I had brought in my clothes.
I I professed perfect ignorance of its existence and of any
cause for it. They had no idea.nor do they even now know.
I that I had been visiting a person in cholera. They were
i both seized with this disease on the following day, but
recovered. No one else in the house was affected by
it ; and no other cases occurred in the vicinity, or within
a mile of them in every direction, for long afterwards.
This fact will, of itself, explain several important cir-
cumstances connected with the spread of infectious epi-
demics, and show the difliculty of accounting for the source
or manner of infection; although infection, either direct or
mediate, has, as in these cases, undoubtedly taken place.
3 D 2

772

EPIDEMICS

imperfect ventilation ; — 2d. That the combin-
ation of these exhalations v.ith those emitted
by decayed vegetable matter, and by deep ab-
sorbent soils, gives rise to eflects of greater seve-
rity than those occasioned by either operating
separately ; and that the intensity of these effects
will depend upon the temperature, humidity, and
stillness of the air, and other concurrent circum-
stances ; — 3d. That emanations from dead animal
matter, in the various states in which it is met
with, are capable of causing, even of them-
selves, serious effects, as shown in the article
DvsENTERY (§ 23.) ; and that, when aided by
hich ranges of temperature and humidity, they
are often productive of extensive disease, which
usually assumes, especially in a crowded popu-
lation, and calm atmosphere, infectious proper-
ties ; — 4th. That even when they have not been
the chief element or cause of the epidemic con-
stitution, they have been, not unfrequently, con-
curring agents.

15. It is recorded in the Magdeburgh History,
that, in the year 394 or 395, swarms of locusts
covered Judea ; and were driven by tlie wind into
the sea, and washed on the shore of Palestine ;
they filled the air with foetid effluvia, which occa-
sioned pestilence among men and cattle. In this
case, the high temperature of the country, very
probably famine — the frequent consequence of
swarms of these insects — and other causes, con-
curred in the production of this epidemic. It is
likewise stated in the same history, that swarms of
locusts covered a great part of France in 874, and
were driven by the winds into the British Chan-
nel ; and, having been washed on shore, caused
such a stencil and sickness, aided by a famine, as
to destroy about a third of the inhabitants of the
French coast. I have stated that the dysenteries
(see that article), which have been very gene-
rally epidemic immediately after very destruc-
tive pestilences, have been occasioned chiefly
by the exhalations proceeding from the immense
number of dead bodies, and by the presence of
animal matter in the water. It is more, even,
than probable, that pestilences are perpetuated
in large cities from this circumstance ; and that
the prolonged epidemics, of which Home, in
her rise, in her acme, and in her decay, was so
frequently the seat, were partly owing to this
cause, wiiich neither burning nor burying the
dead bodies could prevent. During the very
prolonged pestilence that ravaged Home in 262
and 263. the air is described by Eusedius to have
been so corrupt, as to form on the surface of
objects a mould or tabid dew, such as proceeds
from putrid bodies : — " Kos quidam tabidus e
cadaveribus putridis;" — or, as Ceduenus ex-
presses if, "Kos saniei mortuorum similis ap-
parebat."

16. G. Infection and contagion are amongst the
most important agents in the spread of certain
epidemics ; but great misappreiiension has existed,
as to the extent of their influence, tiie exact parts
they perform, and their mutual connection. Many
writeis have erred remarkably in viewing epi-
demic diseases as being necessarily infectious, and
even contagious ; and others, in considering
them entirely devoid of infectious and contagious
properties. The importance of determining in
how far they possess either property, and are dif-
Juscd in couse(]uence ; and the great interest of

— Causes, etc.

the subject, in medical, commercial, and political
points of view ; have given occasion to much and
to warm discussion — a great part of which has
not been calculated to advance the cause of
science, or to elevate the medical character in
public estimation. The subject of contagion, in
all its relations, is fully discussed in tiie article
Infection. I can, therefore, only allude briefly
to a few of its connections with epidemic ma-
ladies.

17. 1st. A foul air maybe generated by the
crowding of many into a small space, even in
health, but more especially in a state of disease,
as in hospitals, &c. ; or by the presence of only
a very few in the same apartment, if their ail-
ments be attended by copious discharges, as in
puerperal and dysenteric cases, &c. ; and this air
may infect those who breathe it in a state of pre-
disposition, with fever, dysentery, &c.; persons-
thus infected, communicating the disease to others
similarly predisposed, and under the circumstances
about to be stated (§ 18. 2d.). Thus I have
seen puerperal fever generated in the wards of
a lying-in-hospital, from the air having become
vitiated by the discharges; and nearly all the
females, who have been exposed to the action of
the contaminated air soon after delivery, affected
by it; the disease being, moreover, conveyed
from one patient to another by means of the
accoucheur. Foul and phagedenic ulceration,
hospital gangrene, erysipelas, dysentery, inflam-
mation of veins, &c. may also be produced, and
become even epidemic to a certain extent, in this
way.

18. 2d. Disease may take place sporadically,
or from local causes, and, owing to various cir-
cumstances, acting either in close succession or
coetaneously, the circulating and secreted fluids,
and even the soft solids, may be so changed dur-
ing its course, as to emit an effluvium, contamin-
ating the surrounding air, and thereby infectino-
many of those vvlio breathe this air in a sufficiently
contaminated state; and thus it will bepropagated
to several, and from those to others — especially
under favourable circumstances of temperature,
humifiity, electrical conditions, and stillness of
the air, and of predisposition on the part of those
who come within the focus of infei-tion. Thus
disease may become infectious and epidemic, aided
by the constitution of the air and other circum-
stances ; and, after a time, cease and entirely dis-
appear, with the circumstances which combined
to propagate it.

19. 3d. A person may be either infected in the
manner now stated, or seized by a malady which
always evinces infectious properties under circum-
stances favourable to their developement, as
typhoid or adynamic fevers ; or by one obviously
contaf^ious, and propagated by a palpable virus,
as small pox, &c. ; and be removed to a district
where the physical conditions, aerial and terres-
trial, as well as the states and manners of the in-
habitants, favour its spread to others ; or the mor-
bid miasm or matter may be conveyed, by means
of some inanimate substance eihbucd with it, to a
distant place thus circumstanced, and the dis-
ease 1)0 there propagated for a time, then subside,
entirely disappear, or again break out, according
to the concurrence or disa])pearance of one or
more of the causes aiding in its diffusion. In
these cases, the disease becomes e]>idc?nic from in-

EPIDEMICS — Causes

fection, and generally disseminates itself gradually
at first, but with rapidly increased celerity as its
victims accumulate, until either it exhausts the
numbers of those predisposed, or the circum-
stances favouring it disappear, and others occur
counteracting its diffusion.

20. 4th. The same disease may appear simul-
taneously in a number of persons distant from
each other, and between wiiom no communica-
tion has taken place ; and affect a great part of a
community — those who are secluded, as well as
those who mix with the rest of their species ; and
it may disappear after a time, without sufficient
evidence being furnished of its possessing either
infectious or contagious properties. Disorders
thus appearing may be termed simply epidemic.

21. 5th. Disease may first appear as now stated
(§ 20) ; but, in certain situations and circum-
stances, as in low, filthy places ; in crowded and
ill-ventilated streets and houses ; in stagnant,
moist, impure, or other states of the air; from
the confinement of a number of sick in small
space ; want of cleanliness, or bad habit of body ;
in states of physical and mental depression, &c. ;
may assume a more malignant character, and
emit an effluvium, which will become either a
superadded cause concurrent with apparent or
concealed antecedent causes, in diffusing the
malady, or a principal agent of infection, or
possibly even of contagion, to which the others
are entirely subsidiary. In this case, the epi-
demic is consecutively infectious ; and a person
who, being infected, removes into a district
which the disease has not yet reached, may,
under the circumstances, and in the way stated
above (§ 18, 19.), propagate it there : but if these
circumstances do not exist, this occurrence will
not take place ; and thus the epidemic will be
limited to the place where the constitution of the
air, and the conditions, physical, social, and
moral, of the inhabitants, combine to favour the
operation of such infectious effluvia as may be
generated and accumulated around the sick.

22. 6th. Certain diseases may appear, either in
a sporadic or endemic form, or in a simply epi-
demic state (§ 20.) ; and, owing to the manners
and circumstances of the community, be propa-
gated only to members of the same family, or to
tliose in very intimate communication with the
affected ; for although commonly observed in the
above forms, and, in ordinary circumstances,
without evincing any infectious property, they
have sometimes been transmitted to those who
either sleep with, or inhale tlie breath of, the
person affected, as in croup, and in some
other diseases of the respiratory organs ; or
live in the same apartment with him, as occa-
sionally remarked in respect of erysipelas, dy-
sentery, &c.

23. Epidemics present themselves in one or
other of these modes according to the combin-
ation of the elements or agents co-operating in
their production ; and to the influence of these
elements, either in predisposing the system to, o^
in directly exciting, certain trains of morbid ac-
tion. Thus it "will be seen that epidemics are
either — (a), not manifestly infectious (§20.) ; (6)
or conditionally infectious, owing to the co-
operation of certain circumstances (§ 18.) ; (r)
or primarily infectious and contagious, — the epi-
demic constitution, or state of the atmosphere,

Conclusions,

773
This last

&c. favouring their general diffusion
class, or that primarily and generally infectious,
is characterised — a. by the specific forms which
the (Hseases comprised in it assume ; B. by their
nearly determinate duration ; y. by their propa-
gation under very different circumstances, al-
though favoured by various atmospheric condi-
tions; J. by their little disposition to relapse or
return ; £. and by their affecting, with few excep-
tions, the system only once. From the foregoing,
also, the fact may be explained, that the same
disease, when occuiring sporadically, often pre-
sents no infectious properties ; but, when prevail-
ing epidemically, generally evinces them more or
less remarkably ; the slates of the air, the circum-
stances of the community, physical, social, and
moral, and various other agents contributing either
to the development of new properties, or to the
manifestation of those which would have been
otiierwise latent or concealed.

24. //. The last element in the causation of
epidemics, to which I shall briefly allude, is
mental depression, in every form it can present
itself. This, although a source of predisposition,
rather than an element of the epidemic constitu-
tion, is one of the most influential causes in the
spread of disease, particularly those that are pes-
tilential. An army, during the success of a cam-
paign, seldom presents moie than sporadic cases
of disease, unless they are subject to great priva-
tions, and even then, little illness may occur.
But, during reverses, panic, disappointment, &c.,
particularly if such reverses be attended by their
usual concomitants — by crowding, privations of
all kinds, inattention to cleanliness, exposure to
night air and malaria, &c. — epidemic sickness is a
common result. The fear of the disease, amount-
ing often to panic, which is very generally expe-
rienced upon the approach or breaking out of an
epidemic, is not only one of the causes of its rapid
diffusion, but also of the suddenness and fatality
of the attack, usually remarked at its accession.
The mental distress so generally diffused in the
seats of war, is a very powerful concurrent cause
of the diseases which are commonly attendant
upon it ; and this, as well as other contingencies,
will, at least partly, explain the prevalence of
sickness after earthquakes, in places where they
have been most severely felt.

25. Conclusions. — a. It may be inferred from
the foregoing, that, although any individual ele-
ment of epidemic causation will of itself be in-
sufficient for the production of the effects observed,
more especially of wide-spreading or pestilential
diseases, a concurrence of several, in various grades
and forms, aided by a number of incidental ciicum-
stances, must, in the present state of our know-
ledge, be viewed as their true sources; — that
neither infection, although the most influential
agent, perhaps; nor terrestrial malaria, nor mineral
vapours — the favourite agent of Sydenham, and
of many recent writers ; nor exhalations from
dead animal matter ; nor intemperature of season
or weather ; nor famine, scarcity, or unwhole-
some food; nor crowding of the living — the
healthy, or the sick ; nor filth ; nor stillness, hu-
midity, warmth, or other conditions of the air ;
nor depressing motions and passions ; nor any
physical, social, or moral vicissitude ; will, singly,
account for epidemics : but that the association of
several, or of two or more, of these causes, in

3 D 3

774

EPIDEMICS — PnEcunsons of.

various grades of predominance, is necessary to
;their occurrence, diffusion, and continuance.

26. b. That miasms generated by the sick in
.one or other of the modes stated above (§ 17, 18.
■21.), and accumulated in a close air, or trans-
.mitted by means of fomes, or contagion by a pal-
pable virus, are either primarily or consecutively

■ (§ 19.) concerned in the production, or in the pro-
pagation, of all fatal, malignant, wide-spreading,
or pestilential epidemics.

27. c. That the appearance of epidemics is
owing to the rare concurrence of the elementsjust
enumerated, and probably of others of less im-
portance, whether acting as specific, exciting, or
predisposing causes ; and that infection, in any of
its forms, will seldom or never give rise to the epi-
demic prevalence of a malady, unless it be aided
by one or more of the above elements of an
epidemic constitution, more especially such as oc-
casion a stagnant and impure state of air, and
depress the spirits of, or otherwise predispose, the
community.

28. rf. That the specific form which an epi-
demic assumes, depends upon the association of
-the causes in which it originates, and which favours
its diffusion, but more especially upon the infec-
tious miasm concerned either primarily or conse-
cutively in producing it, and that its character
may change, and become either move virulent
upon the addition of a new cause or element, or
Jess so on the abstraction of one or more. Thus,
small-pox, scarlet fever, true yellow fever, pesti-
lential cholera, plague, typhoid fevers, the ady-
namic forms of dysentery and measles, require a
concurrence of causes to their epidemic appear-
ance, that will actccliiefly in predisposing the
community to be impressed or affected by their
respective infectious miasms ; these miasms being
their specific exciting causes, without which they
could not continue to present the same forms, or
each one could no longer generate its like. When
the predisposition to be affected by the specific
miasm — whether such predisposition be inherent
in the frame or intrinsic, or temporarily induced
by external agents, as the state of the air or other
extrinsic influences — -is limited to a very few of
those coming within the sphere of its operation,
then sporadic cases only of the malady will pre-
sent themselves : but when, in consequence of the
combined action of several causes, or of a peculiar
but unknown state of air,, the predisposition is more
or less general, the disease will become epidemic ;
the nature, severity, and number of these causes,
whether extrinsic or intrinsic — whether physical,
social, or moral -^ determining the intensity of its
character, as well as promoting its diffusion and
^continuance, until it exhausts itself, by affecting
all those predisposed, or some change takes place
which abstracts, or otherwise changes, the princi-
pal concurrent and predisposing agents. The
salutary results sometimes observed during epi-
demics, from a violent storm, are obviously
occasioneil ciiiefly l)y the dissipation of an infected
atmosphere ; and those, as yellow fever, which
require a higii temperature as a principal con-
curient cause, subside upon the setting in of cold
weather.

29. fi. The history of epi<lcmic diseases, more
e=»pecially smull-pox, ])lagiK', yellow fever, pesti-
lential cholera, ho(i])ing cough, and exanthematous
fevers, show that, although the concunence of

the causes enumerated above, are commonly
concerned in their production as epidemics, they,
nevertheless, som-Ctimes rage violently without
such concurrence having been observed. This
can be explained only by inferring either the
presence of tliese causes in a slight grade, or
the existence of some quality in the atmosphere,
independently of them, favouring the propagation
of disease, or predisposing the community to in-
fection : for, although measles become epidemic
usually in winter and spring ; and scarlet fever in
summer and autumn, as observed by Sydenham ;
yet the same association of circumstances, at these
respective seasons, does not always give rise to
them ; and they sometimes appear at other
times, and even prevail very extensively. It is
notorious, also, that small-pox, before either
inoculation or vaccination was introduced, was
often propagated with difificulty at one time, and
with remarkable readiness at another, and yet the
concurrent circumstances were sometimes ap-
parently the same; and, although the usual epi-
demic agencies geneifilly favoured its spread, yet
it occasionally became extremely prevalent with-
out their apparent aid. It must, therefore, be in-
ferred, that there is a state of air either arising out
of some of those changes insisted upon above, in
peculiar but not manifest states of association, or
consisting of an entirely unknown quality, that is
sometimes instrumental in spreading infectious or
epidemic maladies. The history of the progress
of pestilential cholera fully illustrates this in-
ference.

30. f. As the association of causes and circum-
stances, already specified, and a peculiar or un-
known state of the air, are mainly concerned in
the rapid diffusion of disease ; and, as it is evident
that these are but occasionally, although often
suddenly, formed, the epidemic spreading with a
rapidity in proportion to the suddenness and the
degree of the change ; so it may be inferred, that
the return to the natural or healthy state of
things may be equally sudden with the departure
from it, and the epidemic abate with proportionate
celerity. ]Much, however, should be attributed
to the circumstance, that, when an infectious
epidemic occurs, it speedily seizes the most sus-
ceptible, and spreads rapidly until they are ex-
hausted : it then subsides, and entirely disappears,
either from this circumstance, as in the yellow
fever at Gibraltar in 1813; or from a change in
the concurrent circumstances and state of the air,
as on several occasions in the south of Spain ; or
from the infectious miasm becomingless malignant
in its passage through numerous persons, or
from the circumstances influencing the disease in
its progress.

31. g. That the germs of infection may lie
dormant for a time, whilst either the concurrence
of manifest causes, or the concealed constitution
of the atmosphere, is unfavourable to their deve-
lopment, liut as soon as the one or the other,
or both become favourable, and predispose the
frame, the infection assumes activity, and the dis-
temper spreads accordingly.

32. II. a. Of the PnECURsons of Epidemics.
— It is obvious that the true and only precursors
of epidemics are their Causes. The phenomena
preceding the more pestilential diseases have been
too often magnified or misinterpreted, either from
ignorance, or for the purposes of argument. One

EPIDEMICS — PnEcunsons or.

775

of the precursors most insisted on by writers, is
intemperature of the seasons ; but it has been
shown above, that although this may be a princi-
pal cause of the prevalence and aggravation of
the endemic diseases of a country, it has only a
concurrent influence in producing malignant or
wide-spreading epidemics — some of the most pes-
tilential not having been thus preceded ; and, even
where it has been remarked in its most intense
forms, it has operated chiefly in favouring the
generation of infection, and in predisposing the
community to be impressed by the infectious
miasm. The circumstance of nearly all epidemics
commencing among the poor, and being most
destructive to them, is a manifest consequence of
their earlier and much greater exposure to, and
predisposition to be affected by, the exciting
causes — more especially such as are specific and
energetic — tlran persons in good circumstances ;
and of the concurrence of causes occasioning
epidemics, taking place chiefly in the former
class, and very rarely in tlie higher grades of
society.

33. b. Another precursor, on which much
stress has been laid, viz. disease and mortality in
the lower animals, is one which has likewise been
shown, even when it precedes an epidemic, which
is only occasionally the case, to be the necessary
consequence of their earlier or greater exposure
to its chief causes. In some unhealthy climates
I have visited within the tropics, where malignant
remittent fever, agues, and dysentery, in various
forms, according to the habit, constitution, &c.
of those who arrive, or are resident in it, are
constantly prevalent, the more perfect animals,
as horses, cattle, sheep, dogs, &c., soon die,
evidently from the concentrated exhalations al-
most constantly evolved from a humid soil, and
other endemic sources. This circumstance proves
that the epidemic which is thus preceded is mere-
ly an aggravated form of the endemic of the
place, more generally diffused through the com-
munity, owing to the concurrence of additional
causes, than is commonly observed ; and not a
new or different distemper, unless either infectious
miasms have been evolved by those first affected,
and, having become a superadded cause of great
activity, have thereby changed the character of
the epidemic, or infection has been introduced
originally, and favoured in its operation by the
terrestrial exhalations, state of the air, &c., which
occasioned at first the mortality in the lower ani-
mals, and the aggravation of the endemic disease.
But in this latter case, the mortality in animals,
as insisted upon above, vvill have been posterior
to the commencement of the epidemic ; as fully
shown in the accounts furnished by the aggra-
vated plague, or " black death," which extended
over Europe during 1348, 1349, and 1350; and
in the progress of pestilential cholera. Both
Barnes and Wood expressly state that the fatal
murrain among cattle, that accompanied the
black plague in England, in 1349, was several
months subsequent to the appearance of this^
plague ; and Hecker remarks, — " Of what nature
this murrain may have been, can no more be
determined, than whether it originated from com-
munication with the plague patients, or from
other causes ; but this much is certain, that it
did not break out until after the commencement
of the black death." (p. 70.)

34. c. Some authors have viewed the aggra-
vation of the sporadic and endemic diseases of a
country as forerunners of pestilential epidemics,
and have considered an occasional occurrence, or
a mere coincidence, as an intimately connected
phenomenon. JNIuch misapprehension, also, of a
different kind, as will appear hereafter, has arisen
on the subject. Dr. SIead and Dr. Heberden
have too easily admitted that malignant or putrid
fevers often precede plague ; and various writers
have contended that yellow fever commences as
the bilious remittent of the country, — the latter
passing into the former by such insensible grades,
that a difference between them cannot be assign-
ed. This last assertion, although made by some
of the ablest of the non-infectionists, and insisted
upon by all of them, is very properly denied by
those who consider yellow fever to be distinct
from even the worst forms of endemic fever.
The diagnosis between them, the establishing of
which is of so much importance in the contro-
versy, is given in another place. But that there
is a wide difference in the causes, the symptoms,
the duration, the mortality, the morbid changes,
the contaminating effects, &c. of both, I am
morally convinced. One of the most recent,
ablest, and most moderate writers on this subject,
Dr. Hancock; believes in the gradual and imper-
ceptible change of malignant fever into plague,
and of remittent into yellow fever. But I cannot
agree with this opinion. There is, doubtless,
much difficulty sometimes in distinguishing a very
violent case of bilious remittent, from yellow
fever ; or a severe one of adynamic continued
fever, from a certain form of plague ; and the
difficulty is greatly increased by the fact, that the
infections of yellow fever, and of plague, are
propagated chiefly by the concurring aid of those
causes and circumstances which respectively give
rise to, and favour the prevalence of, bilious re-
mittents and adynamic fevers; and that, without
such aid, these infections cannot occasion their
respective distempers in a pestilential or epidemic
form. Great stress has been laid upon the pre-
valence of fevers in London, at the time of the
appearance of the great plague. But fevers were
necessarily more or less prevalent in the tiien
circumstances of the city ; and it does not actu-
ally appear that they were more so at the time,
when the first cases of plague occurred, than on
other occasions. The imputed prevalence of a
malignant fever, which Sydenham mentions (see
Works, p. 105—107. and 123. of Leydeii edit, of
1726.), occurred during the spring of 1665, —
some months after the first cases of plague — and
was considered by him,forreasonswliich heassigns,
especially its difterence from all other fevers that
he had ever seen, as a variety of that pestilence.
How could it, then, be the forerunner? Did the
writers who lived subsequently know more of the
matter than Sydenham and others, who saw the
commencement of that plague, as well as its
decline ; at which latter time, this milder form of
the plague — this malignant, spotted, or putrid
fever, as it was called for the purposes of decep-
tion, as shown hereafter — began to predominate,
owing either to th.e change in the temperature of
the air, or some other alteration in the epidemic
constitution. But, even admitting that fevers were
actually prevalent before, and during the com-
mencement of that pestilence, the association of
3 D 4

776

EPIDEMICS — PRECURSORS of.

causes giving rise to their prevalence was, at that
epoch, exactly such as would favour the action
and propagation of the infection of plague, pro-
vided it had been introduced either by an infected
person, or by fomites. That sucti introduction
took place, and tliat the pestilence spread in con-
sequence of the concurrence of causes produc-
tive of fever, is more probable, independently of
the strong evidence of the fact, than that the
circumstances usually occasioning fevers should
have trenerated a progressively malignant distem-
per, until plague was at last produced. Our
knowledge of pathological phenomena does not
warrant tliis latter inference ; for if such pro-
gression without any specific difference existed in
respect of these maladies, v/e should surely see,
on some occasions, the infection of plague give
rise to fever, just as the confluent often produces
the distinct small-pox ; or the malignant, the
mild, scarlatina ; — or, without reference to cause,
■we should sometimes observe plague subside into
common fever; as we often see nialignant remit-
tents lapse into ague.* The same reasoning
equally applies to the supposed passage of remit-
tents into true yellow fever — an error which is
fully exposed at other places (see § 43., and
Fever, Yellow).

35. d. Several writers have insisted upon the
appearance of malignant fevers, during and after
the decline of plague, as a proof of the converti-
bility of the one disease into the other ; and have
referred to Sydenham's account of the plague of
1665, in suppoit of their argument. Jiut he
distinctly infers that the malignant, or spotted
fever, as it was named in the bills of mortality,
was a variety of that pestilence, which continued
during 1666, chiefly in that form, when it ceased
to be epidemic. It is not improbable, however,
that though many of the cases of the malignant

* Upon a careful examination of Sydenham, Baynard,
Hodges, De Foe, &c., it is manifest that tlie malignant
spotted fever, said to have been prevalent at the com-
mencement and decline of the plague, was actually this
distemper, reported as fever for the purposes of conceal-
ing its existence ; and that, where this fever actually
existed, it was one of the forms that plague very com-
m.only assumes, especially during low ranges of tem-
perature, as at that season. De Foe (whom I consider
especially deserving notice as to this point, as he had
no medical doctrine to support) states, after describing
the introduction and commencement of plague in St.
Giles's, in December, 1G64, tliat, early in May, ICG."!,
" it had gotten into several streets, and several favrilies
lay all sick together ; and, accordingly, in the next
weekly bill, the thing began to show itself ; there was,
indeed, but fourteen set down of the pl.igue, but this was
all knavery and collusion ; for St. Giles'.'-; parish buried
forty in all — most of whom, it was certain, died of the
plague." In the next week's bill, but nine were sctdown
to the plague ; " but, on examination more strictly by
the justices of the peace, it was found there were twenty
more, who were really dead of the plague in that parish ;
but had been set down of the spotted lever, or other dis-
tempers, besides others concealed." — " Now the weather
not in hot ; and, from the first week in .June, the infec-
tion spread in a dreadful manner; and the bills rose
high, and the articles fever, spotted fever, &c. began to
swell ; for all that could conceal their distemjiers did it,
to prevent authority shutting up their houses, Sec. (Hist,
of Great Plague, p. 0. and 7.) A reforence to the bills of
mortality will show, that, at the time the jilague first
appeareil in London, there was no particular jirevalence
of diseaso. 'I'lie attempts thus made to conceal the exist-
ence of plague have been equalled in the present day,
(luring the prevalence of a difl'erent malady ; and inmon;
places than London. The rcimteil predominance of
putrid and spotted fevers, therefore, hclievcil in by Mead
and Hekekdin, who wrote long alt(ruard,s, was alto-
gether a mistake ; which originated as I have now shown,
and was actually gubsequent to the appearance of the first
Ciiii'jj of undoubted plague.

fever seen after the decline of the plague, were
milder cases of this distemper ; yet some may
have been — especially at a later period — actually
cases of adynamic fever, occasioned by the con-
tamination of the air, by the exhalations arising
from so many thousand bodies scarcely covered
by earth in the crowded churchyards of the city,
and pits in which they were thrown, within
the short period of a few weeks, and during a
warm season; fever and dysentery affecting,
owing to this very obvious cause, many of those
whom the infection of plague had spared, or who
returned to London after the epidemic had ceased.
The circumstance, also, so much relied upon by
ScHENK, IIoRST, Shout, IJancock, and others, of
continued fevers, dysenteries, small-pox, and mea-
sles, when raging epidemically, being frequently
forerunners of plague, and sometimes reappearing
upon, or following, its decline, is certainly no
proof of the convertibility of either of these ma-
ladies into pestilence : but merely shows that,
during epidemic constitutions, in which other
diseases usually propagated by infection had be-
come very prevalent, plague likewise spread
rapidly owing to its infectious property — its con-
tingent appearance after these maladies com-
menced, having depended upon the introduction
of the pestilential infection, which was but little
guarded against at the lime when Schenk and
HoRST wrote, and not at all in the Mahomedan
countries where this occurrence has been noticed
by Jackson and others.*

* The non-infectionists insist upon four things ; the
truth of which they take for granted, and make the bases
of their arguments in proof of their doctrine. The first
is, the ])assage of fever into plague, and of remittents
into yellow fever. I have shown, particularly, in other
articles, that no such transition takes place ; and that it
did not take place in the great plague, to which especial
reference has incorrectly been made in proof of it. That
pestilential infection spreads most readily in circum-
stances productive of continued and remittent fevers,
is fully admitted ; but the difficulty of distinguishing be-
tween these fevers and the pestilential epidemics is not
so great as the non-infectionists are desirous of showing
as an argument in favour of the opinion that the latter
are only liigher grades of the former, and devoid of spe-
cific differences.

The second is, that prevailing diseases are banished
while epi;iemic pestilence rages. This only occasionally
and partially obtains ; and, when observed, is owing
chiefly to the circumstance of a great part of those per-
sons, who, from exposure and predisposition, would
probably have been atlected by the usual endemic dis-
eases of the place, being actually such as are most ob-
noxious to the attack of pestilence. Pestilential cholera
did not banish other diseases during jts prevalence; or,
at most, did so very partially : and similar facts have been
remarked in respect of other pestilences — both plague
and yellow fever. The great plague furnishes no grounds
for the statement, that I can lind in the writers on it the
most deserving of conlidence, more particularly as there
actually apiieared to be no prevailing disease at the time
when the lirst cases of plague occurred. Facts should be
duly investigated, before they are made the bases of im-
portant iiircrcn<-es. How many " false facts," furnished
by (111' i,L;i>(irant, the prejudiced, and the emissaries of in-
terested traders and chartered companies, have been ad-
dtuHid in support of this and other parts of the doctrine,
are best known to those who have devoted long and pa-
tient study to the sul->ject.

The third statement is, the reappearance, upon the
decline of pestilence, of the prevailing diseases which
preceded it, — a circumstance of only occasional or even
rare occurrence : 1st, because pestilences are only occa-
sionally so preceded : and 2dly, when they are so pre-
ceded, these diseases do not always disappear; nor when
they disappear, do they always return. I ap|ieal to facts.
Let them be scrutiiii.scd ; and, when diseases, w Inch pre-
vailed at the breaking out of pestdcMce, rcliirn alter it
has ceased, the occurrence is to be explained eiWier as
hinted at above, or by referring to the influence of exist-
ing endemic irourccs, and the causes usu;illy concurring

EPIDEMICS — Constitutions of Authors.

777

36. e. The appearance of swarms of insects has
been likewise considered as a forerunner of epi-
demics. After mild and open winters, when the
cold has tiot been sufficient to destroy the eggs
and larvffi of insects; and during moist and warm
springs and summers, when warmth, moisture,
and animal decay have contributed to tlieir ex-
traordinary generation ; various species of both
insects and reptiles have sometimes become so
numerous, especially in low and humid districts,
as to destroy the vegetable productions, to occa-

with them or increasing their activity. Those " prevailing
or minor epidemic diseases," which these writers (see
Dr. Hancock, in Cycl. of Pract. Med. vol. ii. p. 82.) have
viewed, not merely as the forerunners of pestilence, hut
as convertible into it, must be either epidemic or ende-
mic, otherwise they cannot be said to prevail. If the
former, which the writer just referred to admits, where
are the facts ? — Can they bear scrutiny ? None have
been adduced that can stand the test. If the latter, the
circumstance might be expected, a priori, occasionally to
occur, and is no proof either of the convertibility of the ,
endemic into an epidemic pestilence, or of the absence of I
infection. The distemper to which this statement is most
applicable, and regarding which it has been especially
made, is yellow fever, as it requires a certain concurrence
of causes for its development, especially in temperate cli.
mates, which causes are chiefly and commonly productive
of endemic fevers. Those causes are also tlie principal
predisposing and concurrent agents in the diffusion of the
infection of yellow fever, whicli thereby attacks a large
proportion of those who might otherwise have been seized
by the endemic maladies — the predisposition to infection,
occasioned by those causes, favouring an attack of the
pestilential epidemic, which thereby takes the place of
the endemic disease. Can it be a matter of surprise, or
should it not rather be expected — {a) upon the breaking
out of epidemic yellow fever, which requires a high range
of atmospheric warmth for its existence, and which,
therefore, can occur beyond the tropics only at parti-
cular seasons, which are also those of remittents, that
these latter or other endemic diseases sliould prevail ? — !

(b) or, after great numbers have left the place where it
has appeared, and the population is thereby greatly re- i
duced ; and when three fourths, or even more, of those
who remained are attacked by it, as in the epidemics in
the south of Spain ; that the endemic diseases that pre-
vailed, and which generally do prevail, at these seasons,
should then not be heard of, or entirely disappear ? —

(c) or that, when the inhabitants who had departed have
returned, and seeing that an attack of one disease does
not necessarily preclude an attack of a different disease,
remittents and other endemic disorders should reappear
to a greater or less extent, according to the intensity and
combination of causes producing them, after the pesti-
lential epidemic has ceased ? A careful investigation
shows that the phenomena connected with this and other
pestilences are actually such as may be inferred a priori,
conformably with the doctrine which imputes them, viz. '
plague, yellow fever, and pestilential cholera — the chief i
pestilential epidemics with which we are acquainted — to
infection. i

Tihejourth andlast statement of the non-infectionists, i
to which 1 shall here allude, is, that " no pestilential |
epidemic is one form of disease" (Op. cit. p. 82.), or of I
unvarying type ; and they adduce tliis as an argument of 1
such epidemic being an aggravated form of the diseases
endemic to the place in which it breaks out. But what
is the foundation for this statement ? Actually none : i
for however much the pestilences ju':t enumerated may j
vary in grade and severity, they present, individually, ]
such speciality of features, wherever they are observed,
as readily enables the well-educated, the careful, or the
candid observer, to distinguish them from diseases which
approach them the nearest in character ; and are as un-
varyingas small-pox, measles, or scarlet fever — if, indeed, [
they be not much more so. We see these latter maladies j
vary in severity, but they still preserve the same specific
features ; so do the pestilences in question. We, more- !
over, see the infections of those familiar and domestic [
diseases very limited, or scarcely at all diffusing them- |
selves, at certain times and seasons ; and, at others^
spreading rapidly, generally, and in severe forms ; — the
same is also observed in respect of plague, yellow fever,
and pestilential cholera. The principal difference between
the epidemic manifestations of these two classes of dis-
tempers is in the frequency and the seasons of their
appearance ; and this is owing to the nature of the causes
concurring to aid the diffusion of their respective infec-
tions ; and without which aid they could not jircvail
generally, or become epidemic.

sion scarcity, and, by the decay of their exuviaj
and dead bodies, to increase the local sources of
diseases. They have thus contributed to the
causation of an epidemic constitution, and, per-
haps, in some instances, have directly produced
disease. In such cases, they have either preceded
or attended the commencement of the epidemic.
The common insects of a country have been said
to have disappeared during the prevalence of
pestilence. If this have occurred, it may be
referred to the operation of the same cause to
which the disappearance of, or death of, birds
was imputed ((^ 13.). But the non-infectionists,
who have endeavoured to torture an argu-
ment in favour of tlieir views out of the latter
circumstance, have not ventured to affinn, as
they did in respect of the disappearance of birds,
than an unusual absence of insects or reptiles
has been ever remarked as a forerunner of
pestilence.

37. f. As to the influence of comets, meteors,
earthquakes, the breaking out of volcanoes, &c.
in causing epidemics, or even in indicating their
approach, there is not the least evidence, notwith-
standing Noah Webster's labours to demonstrate
it. Coincidence may have been sometimes re-
marked : but it would require a tolerably uniform
antecedence of the former in respect of the latter,
to show any relation between them, either as
cause and efl'ect, or as concurrent results of one
general or pervading cause.

38. III. JNOTICES OF SOME EpiDEMIC CONSTI-
TUTIONS OF Authors. — In illustration of what
has been already advanced, I will take a brief
view of some epidemics, and the causes to which
they have been chiefly imputed by those who have
recorded them. Epidemics and pestilences of
recent occurrence, as well as some of very early
date, are referred to in other and more appropriate
places. Ramazzini records, that the years from
1689 to 1694 were wet, the winters mild, and
inundations frequent ; and that periodic fevers of
an unfavourable kind, and diseases of the bowels,
were epidemic ; which he attributes chiefly to the
irregularity of the seasons, and to the failure of
the crops. But these were manifestly only a
part of the elements which contributed to the
causation of these maladies ; the warmth of the
climate, the great quantity of rain, and the fre-
quent inundations, with their more direct results,
being equally, if not much more, powerful
agents. Baglivi describes the epidemic consti-
tution of 1703 to 1705, and imputes it chiefly
to the seasons, which were mild and rainy in
winter and spring, and dry in summer and au-
tumn. Earthquakes were frequently felt during
these three years, in the States of the Church ;
and caused great alarm in the minds of the inha-
bitants, contributing thereby to the prevalence of
disease. He states, that apoplexies and sudden
deaths were very frequent ; and that they had
been also prevalent during 1694 and 1695,
throughout Italy. Although he attributes them
chiefly to irregularity of the seasons, it is more
than probable that the wars, and the attendant
evils, which devastated that country during these
years, were equally concerned in their produc-
tion. CoTUGNo and Sarcone have described an
epidemic, which was very fatal in Naples in
1764, which followed irregularity of seasons,
and a scarcity of grain; and which appeared

778

EPIDEMICS — Constitutions of Authors.

first among the poor, presenting the various ma-
lignant forms of continued ancl remittent fever.
Bleeding, emetics, purgatives, bark, opium, &c.
■were principally resorted to, but the mortality
amounted to nearly one half of those affected.
The intermittent, and subsequently the remittent,
character which the epidemic assumed during its
early progress, proved that the state of the sea-
sons, and the abundant sources of malaria, which
existed at the time, were concerned in its produc-
tion : but the great malignity, with tendency to
dissolution, in the fluids and soft solids, which
characterised its advanced progress, evinced the
operation of additional agents ; and these were
sufficiently apparent in the wretchedness of the
lower classes, the bad quality of the grain, in the
want of cleanliness and the general inattention to
infection, excepting in the religious houses, which
escaped.

39. M. FoDERE refers to the transactions of
the physicians of Berlin, Augsbourg, Breslau,
Presbourg, and Laybach, to show that the sea-
sons were not the chief causes of the epidemic
constitutions they describe. Indeed, at numer-
ous periods, as well as at these, the seasons have
been remarkably irregular, without disease be-
coming epidemic, unless where endemic sources
have been very much increased by such irregu-
larity, or where the evils of war, or scarcity, or
some other element of au epidemic constitution,
have been superadded. When diseases have pre-
vailed, they have not always been influenced by
the state of the weather and seasons alone, more
especially when they have possessed infectious
properties. Sydenham, although he once con-
ceived that the epidemics of this climate could be
accounted for by means of the sensible states of
the air, subsequently confessed that they depended
less upon these states than upon something in this
fluid that could not be ascertained ; a more
extensive observation having proved the inaccu-
racy of his former opinion, and confirmed the
inference at which Hippocrates had arrived.
Geoffroy and others attribute the adynamic and
infectious fevers, dysentery, and scurvy, which
became epidemic in Paris and the surrounding
districts in 1709, to the very severe winter and
spring of that year. But a stricter examination
has shown that much more was owing to the
scarcity of provisions, to their increased price
from the imposts of a disastrous war, to the op-
pression and poverty of the lower classes, to the
want of cleanliness, and more particularly to in-
fection favoured by these circumstances, by the
state of society and manners, and by inattention to
ventilation, &c., than to the severity of the seasons,
to which they had been imputed ; this co-oper-
ation of the elements of an epidemic constitution
protracting as well as extending the prevalence of
these maladies, as might have been expected, a
7>rio»J, during three years, and for some time after
certain of these elements had begun to disappear.
In proof of the accuracy of this view of the mat-
ter, I may add, that the early months of 1716
were equally severe in Paris, and yet no epidemic
occurred; for the principal causes which came
into operation in !7()9 did not then exist. In
1720, the winter and spring, in the same part of
France, were very cold and wet, and grain some-
what scarce ; but there was little increase of dis-
ease, — scurvy being, as it always was daring the

preceding century and the early part of the last,
one of the most common maladies of that country.
But in 1740, a similar severity of these seasons
existed, and was aided by the evils of war, by a
much greater scarcity, amounting to famine in
many places, and by infection, with the rest of
the causes just enumerated ; and the results were
such as the well-informed pathologist might have
inferred from this combination of agents, more
especially when acting upon a population phy-
sically and morally constituted and circumstanced
as the French of that period were : these results
being infectious, adynamic, and malignant fevers ;
dysentery, diarrhoea, and scurvy. Cold and wet
seasons, thick fogs, and winds that have passed
over marshy and woody countries, are often pro-
ductive of epidemic catarrh, hooping cough, sore
throat, bronchitis, rheumatism, &c., especially
among children, aged persons, and females ; and,
as additional agents come into operation— as
scarcity, emanations from animal bodies, infec-
tion, or whatever depresses the powers of life —
so the character of the epidemic changes, and the
maladies above enumerated, or the exanthemata,
supervene, and spread widely.

40. The malignant remittent fevers that raged
in the summer and autumn of 1652, in Copen-
hagen (Bartholin); of 1657, in London (VVil-
Lis) ; of 1669, in Leyden (Sylvius de la Bok) ;
of 1691, in various parts of Holland (Dekkers) ;
of 1684, in Helmstadt (Sciieliiammer) ; of 1695,
in Rome (Lancisi) ; and of 1737, in Breslau
(Hann); and which presented somewhat modified
characters, viith the variation in the circum-
stances producing them, were very generally
imputed to the epidemic constitution of these
seasons, by the authors just named. But the
evidence they have themselves furnished of the
state of the antecedent seasons, and of the great
heat and protracted drought following inunda-
tions, and the exposing of places generally covered
by water, together with various concurrent and
subordiaate circumstances, satisfactorily accounts
for these epidemics. These cities were, for a
time, owing to these causes, similarly circum-
stanced to places within the tropics surrounded
by the sources of endemic diseases ; and con-
sequently the prevailing maladies were, in their
most prominent features, the same as those which
are common to such places, or which attack un-
seasoned Europeans visiting them. This was
manifestly the case, on these occasions, as regards
Copenhagen, Leyden, and other parts of Holland,
and Rome. London, in the middle of the seven-
teenth century, was still surrounded by marshes
and low grounds on nearly three of its sides.
These endemic sources, during very hot summers
and autumns, particularly when these followed
immediately upon wet seasons or inundations, al-
ways occasioned periodical and continued fevers,
dysentery, &;c. ; and, aided by a crowded popu-
lation, want of cleanliness and ventilation, the
manners of the lower classes, by moist and calm
stales of the air, and possibly by certain electrical
conditions, favoured not oidy the generation of the
more common infectious feveis, but also the de-
velopment and propagation of foreign infection,
as that of plague, when introduced.

41. The fever characterised by disorganipation
of the digestive mucous surface, — the Mvcous
Fever, of FonERE and others; the Febrh Stoma-

EPIDEMICS

chaU-epedemica, of Arnold ; the Adetwmr.tiingeal
Fever, of Pinel; and the Gastric, the Catarrhal,
the Mesenteric, &c., of various authors, — liad
been observed in an epidemic form, on various
occasions, somewhat similar to that in which it
occurred in Gottingen in 1760 and 1761, when
it was accurately observed and described by Koe-
DERER and Wagler. It then assumed a very
severe form, modified into the remittent, dysen-
teric, nervous, adynamic, and infectious states by
the circumstances which concurred in producing
it. 7 hese years, as well as those immediately
preceding them, were very wet, and, moreover,
the epoch of scarcity and war, during which the
city was besieged. Hence it cannot be a matter of
surprise that agues, remittents, dysentery, scurvy ;
gastric, adynamic, and typhoid fevers, &c. ;
should have successively appeared ; or that either
should have successively predominated ; or that a
fever of a mixed or complicated character, and
very severe form, should have prevailed during
the co-operation of these energetic elements or
agents of an epidemic constitution. My limits
will not permit me to take a further view of the
epidemic constitutions of authors. Those described
more recently by Huxham, Heberden, Sijis, &c.
are of easy access to most physicians, and furnish
merely illustrations of what has been already ad-
vanced. The epidemics which have occurred
during the last half century in America and the
south of Spain are particularly reviewed in the
article on Yellow Fever. I shall, therefore,
only advert to certain topics connected with them,
and state such inferences as observation and study
suggest.

42. Many of the writers who have either seen
or given an account of the epidemic occurrences
of yellow fever, as Deveze, Jackson, Ferguson,
&c. have insisted particularly upon the agency of
miasms extricated, by a powerful sun, from the
soil, and of the electrical states of the atmosphere,
in their causation. It is very probable that such
miasms emanate from rich deep soils abounding
with the elements of vegetable and animal organis-
ation and life, during very hot seasons, and when
they are fully exposed to the sun's rays ; it is
also probable that vicissitudes in the electrical
conditions both of the air and of the bodies
placed on the earth's surface occasionally take
place ; and it is possible that both these agencies
may be occasionally coincident, or co-operate in
certain localities. IBut we possess no evidence,
even granting their existence, that they are capa-
ble of producing the effects ascribed to them.
Their existence, however, is only a matter of
inference from certain phenomena which cannot
sometimes be otherwise satisfactorily explained,
and not of demonstration ; and altliougli the
proofs of the injurious operation of the former of
these are more convincing than those yet fur-
nished in respect of the latter, yet facts are still
wanting to render the evidence in support of it
complete. After a personal examination of many
of the localities both within and without the
tropics, to which certain pestilential epidemics
have been altogether ascribed by many writers, I
cannot come to the conclufion, that, under cir-
cumstances of the kind just stated, these localities
could ever, of themselves, produce the very
general and fatal effects characterising these pes-
tilences; that even the warmest sun, the stillest

Constitutions of Authors. 779

atmosphere, and the longest absence of thunder-
storms, which observation has ever shown to have
occurred — the conditions' so strongly insisted
upon by these writers, — could generate from
them miasms of so noxious a nature as to occa-
sion, by their unaided action, such pestilential
epidemics as have occurred in various parts of
America, and the south of Spain. That endemic
sources of disease, especially the situations alluded
to, give out miasms when long acted on by a hot
sun ; that these miasms often become concentrated
in a humid and calm atmosphere, or after au-
tumnal showers ; and occasionally are aided in
their operation upon the human frame by the
electrical states of the air; may be admitted ; for
an increased prevalence, and a more severe form,
of fever are often observed in these situations, on
such occasions. But after the most careful con-
sideration long bestowed on the subject, and after
a patient enquiry into the facts recorded, I cannot
believe that these exhalations are the only, or al-
ways the chief, cause of these epidemics. That
infection is a primary agent in the propagation of
the disease, and that an infectious miasm is gene-
rated by the sick, cannot, I think, be denied by
the candid enquirer into all the facts connected
with the subject. But I believe that, without the
physical changes and the consequent emanations
alluded to, or some other concurrent causes, the
infection would not extend through the commu-
nity, as these emanations, floating in the air, dis-
pose the system to be impressed by the infectious
principle, or otherwise aid its operation ; or, in
circumstances where the terrestrial exhalations
have already produced much disease, the miasms
from the sick become a superadded cause, in-
creasing the severity of the epidemic as well as
the rapidity and universality of its spread. That
an infectious principle is concerned thus primarily
or consecutively in the production and propaga-
tion of pestilential epidemics, according as it may
be introduced from some other quarter, or gene-
rated by those first affected, appears fully estab-
lished by numerous circumstances independently
of various considerations derived from the nature
of the particular epidemic, and of the antecedent
and consecutive disorders, especially those en-
demic to the place in which it breaks out. Of
these considerations, the following seem not the
least important.

43. a. The localities to which certain epi-
demics, as yellow fever, are chiefly confined, have
been, for many successive years, circumstanced,
in respect of season and weather, similarly to the
periods in which that disease has been most de-
structive ; and yet the common endemic of the
country only has been observed, in the form it
usually puts on in that particular season.— b. True,
or epidemic yellow fever, differs not merely in de-
gree, but also most essentially and in kind, from
the endemic fever of these localities ; consequently
the former is not merely an aggravated state
of the latter, — the one disease is as different from
'■the other as small-pox is from measles. — c. On
all occasions on which the non-infectious proper-
ties of yellow fever have been argued for, the
bilious remittent or severer forms of endemic fever
of low situations in warm countries, and the ardent
or seasoning fever of Europeans who have lately
arrived within the tropics, have been assumed as
identical with that malady. This error has arisen

780 EPIDEMICS

from the occasionally yellow appearance of tiie
skin in the bilious remittent, and the dark or coffee
ground vomiting sometimes seen before death in
it and in the ardent fever. But these changes
are not the same, even in the cases where they
are most prominent, as those in the true yellow
fever; and, as shown in another place, are
owing to very different pathological states. —
d. That the very essential difference between these
diseases indicates their diff"erent origins; and a
speciality of form in the various quarters where the
epidemic malady has been observed, equally de-
notes its source in a specific cause. — e. That
diseases which arise from terrestrial exhalations
present numerous modifications, forms, and types ;
have all a tendency to relapse, or to return in some
form or other, upon exposure to the exciting-
cause ; and always occasion marked derange-
ment, and ultimately organic change, of the liver,
spleen, or pancreas, or one, or all : whereas the
true or epidemic yellow fever, independently of
the most irrefragable proofs of infection, possesses
all the attributes of infectious diseases ; attacks
the frame only once, as shown by the most un-
questionable evidence, British and foreign, derived
from the epidemics of Spain and America ; and
leaves no organic changes of these viscera as
sequela;, even of its most malignant state. —
The manner in which the very different diseases
now referred to have been confounded the one
with the other, by those espousing the non-infec-
tious nature of yellow fever, whether from igno-
rance or unfairness, has led to the most serious
consequences to the community ; has misled the
inexperienced, mystified the subjects in dispute,
furnished grounds for a special pleading sort of
argumentation, and, as will be seen in the articles
Fever and Infection, endangered the safety of
fleets and armies, and even of kingdoms.

44. IV. General Inferences.- — a. Civilis-
ation exerts a most decided influence in diminish-
ing the frequency and mortality of epidemics,
especially those that are fatal or pestilential,
as shown by their history at different epochs,
and in different countries holding various grades
in the scale of civilisation, — an amelioration evi-
dently due — a. to a better cultivation of the soil ;
to more extensive commerce, and, consequently,
to the less frequent occurrence of great scarcity,
and to the improved diet and circumstances of the
lower classes in most European countries, in
modern times ; — (3. to a favourable change in the
manners and habits of the middle and lower
classes, particularly in regard to cleanliness,
social intercourse, and domestic arrangements;
and to better ventilated and improved dwellings ;
y. — to superior care in the separation and treat-
ment of the aflTectcd ; and to stricter measures
for the prevention and counteraction of infec-
tion. Owing chiefly to neglect of these circum-
stances, the lowest classes, and the most
wretched amongst these classes, are ftiost fre-
<|uently attacked — the mortality being also the
greatest among them in proportion to the number
affected.

45. b. Different ages are not equally affected
by epidemics. 'J'he exuiithematous fevers and
hooping cough are most prevalent among, and
fatal to, infants and children; influen/.a, to the
aged and debilitated. Continued fevers, in ady-
namic and malignant forms, attack chiefly per-

General Inferences.

sons from fifteen to fifty ; but are less fatal to
them, than to those of earlier or later ages. I'lague
most frequently seizes adult persons of early or
middle life, and generally males in somewhat
greater numbers than females, — probably owing,
in part, to more exposure, at this age, and of the
male sex, to the predisposing causes and to infec-
tion. Yellow fever attacks chiefly the young and
middle-aged ; but spares only those who have
passed through it in former epidemics. Pestilen-
tial cholera, on the other hand, does not so often
attack persons about puberty and the meridian of
life, as those that are aged and exhausted; and it
is usually more fatal in the latter than the
former. When an increased activity of endemic
causes produces epidemic fevers, young chil-
dren often suffer very remarkably ; and the malady
assumes in them, gastric, choleric, or dysenteric
forms.

46. c. The mortality from diseases, when they
first appear in an epidemic form, is usually very
great; but diminishes with the frequency of their
recurrence, especially those which have sprung
up since the early history of our science, and
which are of a contagious or infectious nature.
This has been the case with hooping cough,
measles, syphilis, small-pox, and may probably
be so with pestilential cholera. It is not so
manifest with regard to pestilences appearing
after long intervals : but these are usually much
more fatal at their commencement, or during their
early course, and less so at their decline. The
first introduction of small-pox, syphilis, &c.
among savage tribes, has been as destructive as
the pestilences that occurred in the middle ages.
This can be explained only as briefly stated above
(§30.).

47. d. As to the infiuence oj epidemics on popu-
lation, it may be inferred, that the diminished pre-
valence of certain maladies, which formerly raged
epidemically, is in some respects compensated
by the greater frequency of other diseases, for-
merly of rarer occurrence ; or the appearance of
some previously but little or not at all known. — a,.
Since the introduction of vaccination, small-pox
has rarely prevailed to a great or fatal extent ;
but scarlatina, measles, croup, inflammations of
the bronchi and lungs, and cerebral affections
have evidently increased. The benefits, therefore,
of vaccination may be said to be somewhat over-
rated. It is remarked by M. Say (Cotn-s complet
de Economie Politique, t. iv. p. 385.), " When we
hear it said, that by saving a hundred thousand
lives, vaccination has added a hundred thousand
souls to the population, we may smile at the error,
whilst we applaud the discovery." M.Vil-
i.ERME has deduced from his researches, that,
in populous countries, and particularly in
large towns and cities, and in the lower classes,
small-pox is fully replaced by an increase
of other dangerous diseases ; but in districts fur-
nishing sufficient subsistence and scope for in-
creased population, and in the higher classes,
this compensation is hardly or but slightly
observed. Indeed, all preservative measures
against the diseases of infancy act simi-
larly, — in suppressing one cause of death
we more or less increase the activity of the
rest.

48. 0. In civilised countries, epidemics, nl-
ihough attended by a very great mortality, only

EPIDEMICS — General Inferences.

781

temporarily diminish the population ; for it is
uniformly observeil, that the void is filled up,
during tlie next few years, by a mucli greater
annual average of marriages and birilis, and by
an influx of strangers from other parts, the mor-
tality leaving more abundant means of subsist-
ence for tliose vvho have escaped. Destructive
epidemics are most frequent in low situations
and crowded cities ; and epidemics of a slighter
kind and commoner form often occur in these
and other districts abounding with malaria ; and,
whether they be aggravated forms of the usual
endemics, or infectious fevers, &c., they all in-
directly tend to augment the number of marriages
and births, whilst tlicy increase the deaths and
diminish the mean duration of life. These re-
sults are evidently owing to the more abundant
means of sustenance and employment furnished
by these places, than by mounlainous and barren
districts ; and to the influx from moie healthy
parts ; the excess of deaths over births being sup-
plied from the latter source. The following statistic
return, furnished by JM. Bossi, prefect ot the de-
partment of the Ain, in France, and which he
has divided into four zones, according to the na-
ture of the locality, illustrates this statement, and
shows —

1 Death

1 Marr.

1 Birth

annually

animallv

annually

to Inhab.

to Inliab.

to Inhab.

In the hilly districts

38-3

179

34-8

Along banks of rivers, &c.

26-6

145

28.8

In cultivated grounds -

24-6

133

27-5

In marshy places, &c. -

so-s

107

2fi-l

(For the Prevention of Epidemics, see art. En-
demic Influence (§ 20.) and Infection.)

BiBLioG. AND Refer. — Hippocrates, Ui^) ^uc-io; 'Av-
B^iiTdv, sect. xii. et seq., vol. i. p. 270. ; et 'Et/5,j^;wv,

vol. i. p. 653. edit. Vander Linden. Luu'ri. Bat. 1G65.

Oribasiiis, Synop. 1. vi. c. 24. — Joann. Cantacuzen, His.
tor. 1. iv. c. 8. edit. Paris, p. 730. — Gentilis de Fiilgineo,

Consilia, De Peste, consil. i. ii. pp. 76,77. Venet. U")14.

Ga.'eazxo di Santo Sofia, Liber de Febribus, fol. Venet.
1514. (He first dist?ng?/is/ie(/ epidemics from endemics,
pointed out the origin of the latter in local telluric changes ;
and referred thefoimer, with pestilences, to an tink7iown
change or corruption of the air.) — Chalin de Vinario, De
Peste I.iber, i)iira Latinitate donatus, a J. Dalechampio.
Lugd. 1552. (Asserts boldly and truly '•'■ that all epidemic
diseases may become contagious, and all fevers epidemic")
p. 149. — Guidon de C/iaul/aco, Tract, xi. c. 5. p. 113. ed.

I.ugd. 1572. — Muratori, Script. Rer. Ital.vol. iii. p.556

M. A. Florio, Delia Natura de Mali Epidemici, e Mododi
Curargli, 8vo. Ferrar. l.')K7 — Ferneliiis, De Abditis Re-
rum Caiisis, cap. 13. — T. Farina, Ortiis et Oecasus Morb.
Epidem. 12nio. Rom. 1672. — F. Gouet, Ergo in Acutis
Morbis Epidemicis Constitutionis maximehabenda Ratio

est, 4to. Paris. 1692 Sydenham, Opera, et I.egd. Bat.

8vo. \~'2G, passim. — De Hcredia, Comment, in Libros
Hippocratis de Morb. Popul. fol. 168S.— jl/fxoo^, His.

toire de France, fol. Paris, 1685. t. ii. p. 418 Barnes,

History of F^dward III. C.imbr. 1688, fol. p. 4.'^2.— Man-
gold, De Morbis Epid. Malignis. Bas. \'H)\.'—Ra)naz%nii,
Opera omnia, 4to. p. 120. 155. 187. — Torftens, Histor.
llerum Norvegicarum. Hafn. 1711, 1. ix. c. 8. p. 478. —
Basnage, Histoire dcs Juifs. A la Have, 1716, 8vo. —
J. Rogers, Essay on Epidemic Diseases. Diibl. 1734, 8vo.
— Berger, De Aeris Potentia in Kpidem. Morb. CJenera-
tione, 4to. Hala% 1727.— 7". Short, On the Air, Weather,
Seasons, See. 2 vols. 8vo. Lond, 1749. — Pohlius, De

Morb. Epid. ab Aere Atraosph. Lips. 1749. J. J. Hu-

ber, Observat. circa Morbos Epidem. per reciprocum
Aeris Humani et Atmosph.Commercium illustratos,4to.
Cassel, 1755. — A. Nunn, Diss, de variis Spec. Morb.
Epid. atque eorum Causa, &c. 4to. Erfur. 1758. — J.
Augi<stini, Obscrv. Epidemiorum qui 1740 — 57 grassati
sunt, 8vo. Vien. 17.'J8. — Huxham, Opera, vol. \. passim ;
vel Observ. de Aereet Morbis Epidem. ab 1728 ad 1737,
8vo. Lond. 1739. ; et ab 1738 ad 174H, in 8vo. Lond.
1752. — G. Cleghorn, On the Epidemic Diseases in Mi-
norca, from 1744 to 1749, 8vo. Lond. 17ii2. — Boyer, Le
Traitement des differons Epid. qui regnent dans la Ge-
neralUe de Paris, 8vo. 1762. — ^i. Wood, Hist, et Anti-

quit. Universit. Oxonicns. fol. Oxon. 1764, 1. i. p. 172.
— M. Sarcone, Istoria de Mali Osservati in Napoli nell' in-
tera Corso dell' Anno 1764. 2 vols. 8vo. Napoli, 1765. —
Q. H. Reipenhausen, Murbi Epid. ab Anno 1757 usque ad
1762, Goet. et circa earn, grassati. Halae, 1766. — A. E.
Biichner, De Differcntiis Morb. quae Constitut. Epid.
debciitur, 4to. Hala;, 1768. — J. Si/ns, Observ. on Epid.

Disorders and Contin. Fevers, 8vo. Lond. 1773 E.

Roscnbind, De Causis Morb. Epidemic, generatim, 8vo.
Lond. 1775. — Eichelberg, De Causis Phsenora. qua; ob-
servantur in Progressione Morb. Epidem. &c. 8vo. Ni-

meg. 1776 CapJKUH/^, Compendio Historico y Chrono-

logico de las Reste.s, Contagios y Epidemias, &c. t. iv. de
las Memor. Hist. No. 7. p. 66. — Lepecq de la Cloture,
Obscrv. sur les Malad. Epidem. &c. 4to. Paris, 1776. ;
et Collect. d'Observat. sur les Malad. et Constitut. Epid.
&c. 2 torn. 4to. Paris, 1778. — Saitlant, Tableau Hist, et
Kais. des Epid. Catarrhales, vulgairement dites la Grippe,

depuis 1510, &c. 12mo. Paris, 1780 L. L. Finke, De

Morbis Biliosis Anoraalis, ab Anno 1776 ad 17*0, &c.
121T10. Westph. 1780. — G. Vari. Swieten, Constitut. Epi.
dem. et Morbi potissimum Lugd. Bat. Ob^ervati, &c.
cdid. M. Stoll, 2 vols. 8vo. Lips. 1782. — W. Coley, Ac-
count of the late Epidemic Ague in Shropshire, 1784.
Lond. 8vo. 1785. — M. Stoll, Rat. Med. passim, et vol. iv.
pp. 6). 82. 88. Sec— J. RocdererctC. G. ll'agler,TTact.de
Morb. Mucoso denuo recusus, &c. 12mo.' Goet. 1783. ;
Description des Epidemics qui ontregne depuis quelques
Annies dans la Gencr. de Paris, avec la Tojiograph. &c.
publiee par Ordre de M. I'lntendant de Paris, 8vo. 1783. ;
et Journ. de Med. t. Ix. p. 289 — Lebrun, Sur les Mai.

Epid. et de les Prevcnir, 12mo. Paris, 1784 Retz,

Precis sur les Mai. Epidemiqiies, I2mo. Paris, 1787

Raymond, Sur lea Epidemics, et quels sont les Rapports
de Mai. Epid. avec celles qui surviennent au meme Temps
et qu'on appelle liiteicurrentes, &c. in Mem. de la Soc.
Royale de Med. t. iv. p. 36. Paris, 1785 — Can ere, in
Ibid. t. iv. p. 215. — I'an der Myc, De Morb. Popular.

Bredanis, Temi)ore Obsidionis, etc. 8vo. Jenaj, 1792.

Hopfengiirtner, Beytr. zur Allgemeinen und Bcsondern
Theorie der Epid. Krankh. ivc. Frank. 8vo. 1795. —
Priestley, in N. Y. Med. Repos. vol. v. art. 8. — F. Fer-
nandez, Tratadode las Epidemias, 4to. Madrid, 1794

A. F. Hecker, De Constitut. Epid. ex Mutat. Corpor.
Humani, &c. 4to. Erf. 1791. — Burdack, Comment, in

Hippocratem, de Morb. Epidemicis. Lips. 1798 Auten-

reith, Versuche fiir die Pratische Heilk. st. i. p. 86.

H. LvdoljT, De Morb. Epidem. Generationo ab Aere
Vitiate, 4to. Erf 1791. — ll'eise, De Causis Epid. Gene-
ralioribus, 4to. Hala?, 1797. — Kramer, De Constitut.
Epidem. Aerisque in Morbor. Diagnosin, &c. 4to. Jens,
1799. — F. Schraud, De eo quod est in Morb. Epid. 4to.
Pest. 1803. — Noah liebster, A Brief History of E|)idemic
and Pestilential Diseases, with Princip. Phenom. in Uie
Physical World which precede and accompany them,
2 vols. 8vo. Lond. 1800 — J. De J'illalba, Ei)idemiologia
Espafiola, o Historia Cronologia delas Pestes, Contagios,
Epidemias, y Epizootias que han acaecido en Espafia
desde la Venida de los Cartagineses hasta el Aiio 1801.
Madrid, 1803 — R. Hooper, Observat. on the Epidem.
Diseases now prevailing in Lond. &c. 8vo. Lond. 1803.

— F. Schnurer, Mater, zu einer Allgemeinen Naturlehre
der Epid. und Coiitagionen, 8vo. 'J'ubing. 1810.— Horn,

Archiv. May, 1809, p. 94 I'enada, Saggio d'Osserva-

zioni, vol. iv. et v. — J, Adatns, An Inquiry into the

Laws of Ei>ideraic.>;, 8vo. 1809 Willan, Reports on the

Dis. of Lond. from 1796 to 18Ui) ; and Bateman, Reports on
the Dis of Lond. and the .State of the Weather, from 1804
to 1816, 8vo. Lond.lnl9. ; also art. Epidonie, in Rees's
Cyclopsedia. — G. Blane, in Trans, of Med. and Chirurg.
Soc. vol. iv. pp. 89. 145. — Noquart, in Diet, des Sciences

Med. t. xii. p. 467 T. A. F. Ozana7n, Hist MecL des Ma-

ladies Epidemiques,&c.S tcm. 8vo. Paris, 1817 Finke,

in Journ. Univers. des Sciences Med. t. xiii. p. 58 De

Peyrelongue, in Ibid. t. xxvii. p. 47. — Fourcault, in
Ibid. t. XXV. p. 257., et t. xxvi. pp. 5. 129 — T. Hancock,
Researches into the Laws of Pestilence, &c. 8vo. Lond.
1821. — Lassis, Causes des Malad. Epidemiques, Moyens
d'y remeiher et de les pri'venir, &c. 8vo. Paris, 1822.

— F. E. Foderi, Lemons sur les Epldeinies et I'Hygiene
Publique, &c. 8vo. 4 tomes. Paris, 1822-1824. (Avery good
work.) — Speer, in Dublin Hosp. Reports, vol. iii. p. 161.

— Maclean, On Epidemic and Pestilential Diseases, 8vo.
1817, 2 vols. ; and Evils of (Quarantine Laws, and Non-
existence of Pestilential Contagion, &c. 8vo. Lond. 1824.
( Il'or/'S on which little reliance can be placed, as respects
either the statements they contain, or the medical knowledge

t/iey betray.) — C. Ferrus, in Dict.de Med. t. viii. p. 185.

Smith, Elements of the /Etiology and Philosophy of Epi-
demics, 8vo. New York, 1824. — Dollemann, bisquisi-
tiones Historica; de Plerisque apiid Belgas Septentrionales
Epid. Morbis, 4to. Amst. I82i. — Andral, in Diet, de

Jli'd. et Chir. Prat. t. vii. p. 382 Rayer, in Archives

Gencr. de Med. t. iv. p. 477., t. v. p. 6-9. — Auctor. Va-
rii, in Ibid. t. xii. pp. 026. 632., t. xiv. p. 446., t. xv.
p. 276., t. xvii. pp. 76. 131. 248. 4.53., t. xviii. pp. 122. 232.
310. 455. 596. — F. G. Mansa, De Epidemiis maxima

782

EPIGASTUIUM — Examination of its States.

Memorab. quae in Dauia grassats sunt, 8vo. Haunise,
1831. — i. K Gaste, Sur les Epid. cie 17e et ]S<^ Siccles,

in Journ. Hebdom. de Medecine, t. iv. N. S. p. ">S5

Huan, in Trans, of Med. and Chirurg. Soc. of Edui.
vol. iii. p. 459. — Fricke, in Archives Gen. de Med.
t. xvii. p. 76. — Genest, in Ibid. t. xviii. p. 232.. et t. xix.

pp. 63. 357 Alibert, Sur les Causes Secretes des EpidiS-

mies, in Rev. Medicale, &c. t. i. et iv. 1833.— J. F. C.
Hecker, The Black Death of the Fourteenth Century,
by B. G. Babington, Syo. Lond. 1833.— L. R. J illerini,
Des Epid<;mies dans les Rap. de 1' Hygiene Pubhque, de
la Statisque Medicale, &c., in Annales d'HygiOiie Pub-
liqueetde Mod. Legale. Jan. 1833. — See also the Bib-
LiOGUAPHV ANu REFERENCES of the Articles Fever, &c..
Infection, Pestilence.

EPIGASTRIUM. Syn. — 'ETnyacrrpiov (from
Itti, upon, and ycta-rh^, the stomach). Regio
Epigastrica. L'Epigasti-e, Fr. Der Ober-
bauch, Ober-Schmeerbauch, Germ. Epigas-
trio, Ital. Pit of the Stomach.

Classif. — General Pathology, &c. Se-
me'wlogy, &i;c. Special Pathology.

1. I. Examination of its States. — A care-
ful investigation of this region, and accurate in-
terpretation of the phenomena it may present,
are of the utmost importance in practice. The
symptoms of disorder referrible to this part, must
not, however, be estimated by themselves, but
in conjunction with others furnished by the ad-
joining regions, by the general surface, by the
pulse, by the stale of the tongue, by the excre-
tions, &c. — Attention was directed to this part
in the diagnosis and prognosis of disease, from the
earliest history of medicine. Hippocrates re-
marks, that it is a favourable symptom in fevers,
when the epigastrium is supple, soft, equal, and
free from pain.

2. i. Altered or augmented sensibilitl^ of this
region, in any degree or kind, is an important
indication of the seat, the nature, and the result
of disease. In order to ascertain these points
more accurately than can possibly be otherwise
done, not only should the patient's account of his
sensations be attended to, but the bared region
should be carefully examined, when it can be
done with propriety (§ 3, 4.). The sensibility of
this region is greater than that of any other,
more especially in thin delicate persons, and
females — in tlie hysterical and hypochondriacal

sensation is aggravated, and is attended by great
anxiety and vital depression. A sense of heat or
burning at this part often precedes an attack of
haimatemesis ; and the same feeling, with acute,
lacerating pain, anxiety, depression, remarkable
tenderness, tension, and continued, or repeated
vomiting., characterise acute sthenic gastritis.
When a fixed, deep-seated, occasionally lanci-
nating pain, is felt at the upper part of this re-
gion, sometimes extending under the sternum, or
between the left shoulders, or under the shoulder-
blade, and is increased during or directly after
eating, or is accompanied by difficult deglutition,
or rumination, or by palpitations and irregular
action of the heart, then organic lesions of the
cardiac orifice of the stomach may be inferred.
Similarly characterised pain at the lower part of
this region and to the right, increased an hour
or two after a meal, and sometimes attended by-
sickness, indicates the commencement of chronic
disease of the pylorus; but in its advanced
stages, these symptoms are felt much lower down
in the abdomen, or to ihe right of this part. — Pain
of this region is a symptom also of acute and chronic
pericarditis, particularly at the upper and left por-
tion of it ; and is frequently complained of, espe-
cially after a meal, by females who wear tightly
laced corsets, and during the latter periods of preg-
nancy. A sensation of gnawing, erosion, &c. fre-
quently accompanies worms in the prima via, and
in some cases, the first months of utero-gestation,
3. ii. Distension, tumefaction, or distinct tumour
of the epigastrium is seen in various diseases.
Unusual fulness, or elastic distension, is generally
occasioned by flatulence of the stomach, or by
collections of air in the colon. In these cases,
external pressure, if it be not prevented by in-
creased sensibility, which is usually also present,
often partially expels the flatus; and a tympanitic
sound is emitted on percussion. Borborygmi are
also troublesome, particularly when this symptom
is observed in hysterical and hypochondriacal
cases, or in flatulent colic. It also attends upon
accumulations of bile in the biliary ducts and
gall-bladder, and upon congestion of the liver;
but in such cases, the fulness is partly owing to

It is increased in many acute diseases — frequent- | the disease of these parts, and partly to a contin

ly in fevers, of every type and form, very re-
markably in gastritis, generally in hepatitis and
diaphragmitis, particularly on pressure, and in in-
flammatory dyspepsia. Morbid sensibility amounts
to acute pain, characterised by anxiety and a

gent distension of the stomach by air. — Tumefac-
tion of this region is frequently seen in hydro-
thorax, and in chronic pericarditis, with effusion
into the pericardium ; but most remarkably when
tiie patient sits up. In the recumbent posture, it is

sense of vital depression or sinking, in inflammations less evident. — Either swelling, or distinct tumour,

of the stomach, of the tendinous part and peri
toneal surface of the diaphragm of the upper
portions of the peritoneum and omentum, and of
the gall-bladder and ducts ; and in spasm of,
or impaction of gall-stones in, the latter. In all
these, tenderness is often extreme, and pressure is
followed by sickness and desire to vomit. Pain
is commonly dull, heavy, gnawing, or but little
felt except on pressure, and deep-seated, in
chronic inflammation of the liver, particularly of
its substance ; in hepatic abscess ; in chronic dis-
ease of the gall-bladder and ducts, of the pan-
creas, and of the orifices of the stomach. It is
burning and attended by nidorous, acrid, and
acid eructations, in cardialgia, and otiier dys-
peptic affections, particularly in the gouty dia.-
thesis, or before a paroxysm of this complaint ;
or upon its retrocession, on which occasion this

is sometimes observed in enlargement of the liver,
particularly of its left lobe, and in abscess of this
organ. When the abscess points upon the dia-
phragm and rises into the right tiiorax, swelling
is occasionally not observed, but the patient ge-
nerally comphiins of a duller heavy pain, or sore-
ness, with tenderness on pressure, in tiiis part. In
two cases of hepatic abscesses, in which I was
very recently consulted by the practitioners at-
tending them, there was very great, but diffused,
swelling in the epigastrium, with pain and ten-
derness, in one ; and no swelling, but deep-seated
pain and soreness, in the other. The nature of
the disease was recognised in both instances, and
confirmed shoitly afterwards by the sudden and
profuse expectoration of the contents of the ab-
scesses, which in both cases had opened into the
lungs. The patients are still under treatment ;

EPIGASTRIUM —

and, in one at least, there are hopes of recovery.
Tumour in this region may be occasioned by
great distension of the gall-bladder with bile,
from obstruction of the common duct ; but, in
this case, it is more circumscribed and distinct
than in abscess of tlie liver, is unattended by any
appearance of inflammation of the external parie-
tes, is often pyriform, and situated at the lower
part of the region, and to the right, tlucluates ob-
scurely, and often disappears after appropriate
purgatives. Swelling of this part, in lean per-
sons, may also be occasioned by enlarged or
scirrhous pancreas, more rarely by distension
of the duodenum, and not so often as is supposed
by tumours about tlie pylorus, because, when
they are sufficiently large to distend this region,
they generally draw this extremity of the stomach
below, and to the right of it. Fulness of the
epigastrium is seldom occasioned by distension of
the colon with flatus, or accumulated fajces, or by
enlarged spleen, or by the effusion of fluid, until
after the swelling has appeared to a very consider-
able extent in the adjoining regions ; and then it
is greatest at the lower part.

4. lii. Pulsation in the Epigastrium arises from
the following causes: — a. JVervous susceptibility
and irritation; — -&. Inflammation of the aorta;
^c. Aneurism of the aorta, cceliac, or superior
mesenteric artery; — d. Adhesion of the pericar-
dium to the heart ; — e. Tumours at the root of
the mesentery ; — f. Tumours of the stomach, and
scirrhus of the pylorus ; — g. Enlargement of the
pancreas ; — h. Hypertrophy of the heart, parti-
cularly of its right side ; — i. Enlargement of tlie
vena cava inferior; — k. Hepatisation of the
lower portion of the lungs ; — /. Enlargement of,
or abscess in, the liver. On the chief of these I
shall oft'er a few remarks.

5. a. Nervous pulsation of the aorta and cce-
liac arteries is not infrequent. It comes on sud-
denly ; and often continues long, chiefly in hyste-
rical females, and hypochondriacal men, whose
nervous system and digestive organs have been
long debilitated or otherwise disordered. It is
generally stronger in the morning than in the
evening. Dr. Baillie met with a case that re-
mained for many years. Dr. Valentine Mott
states that of a lady, in whom it occurred as a
certain sign of pregnancy ; but usually left her
after the third month. I have seen it so violent
that the pulsation could be observed through the
dress, and the patient insisted it could be heatd
at some distance. (See AonjA, § 2. et seq.)

6. b. Aneurisms of the aorta and large arteries
may occasion pulsation in this region ; but they
frequently have proved fatal without this symp-
tom being noticed; and, where it has been re-
marked, the pulsation has not been strong. ]\Ir.
A. Burns states, that aneurism of the coeliac ar-
tery is rarely a cause of this pulsation ; and that,
in about twenty cases of pulsating tumours in the
region of this artery, not one of them turned out,
upon dissection, to be disease of this or any other
artery. (See Aorta, § 44.)

7. c. Adhesion of the pericardium to the heart,^
is sometimes a cause of pulsation ; and that it
should be, is obvious. Dr. jNIott thinks it one of
the most frequent causes. Dr. Hope describes
the pulsation as peculiar, and distinguishes it by
the epithets jogging or trembling ; it is synchronous
with the sounds of the heart. (SeePERiCABDiuM.)

Pulsation in the. 733

8. d, Tumotirs, from enlargement of the
glands at the root, or in the duplicatures, of the
mesentery, are productive of pulsation when they
become considerable and press upon the aorta, or
coeliac or superior mesenteric artery. A case of
this description is described by Dr. Albers. In
a person whom I attended some time ago, and who
had become very emaciated, a distinct pulsation
in the umbilical region arose from this cause. In-
deed, the pulsation, when thus produced, is rarely
so high up as the epigastrium, and is sometimes
fell in both regions.

9. e. Tumours developed in the stomach, or at-
tached to its villous coat, and scirrhus of the
pylorus, have been noticed, by Baillie, Burns,
INIoNRo, Francis, and V, Mott, as occasionally
attended by pulsation. I cannot, however, agree
with the last writer, in thinking that"" the obstruc-
tion to the free passage of blood through the
hardened" and enlarged parts occasions this
symptom ; but believe that, when they press upon
or come in contact with, the large arteries, especi-
ally the aorta, the pulsation is necessarily propa-
gated to the external situation in which it is felt.

10. J. Enlargement of the pancreas, or of the
liver, is probably more frequently a cause of epi-
gastric pulsation, than tumours connected with
the stomach ; the enlarged and indurated viscus
transmitting the pulsation of the aorta, as just
stated. This cause has been noticed by Burns,
Warren, V. Mott, Portal, and myself. Dr.
Sewell considers that an enlarged pancreas is
always accompanied with pulsation at the epigas-
trium. I think that such is not the case ; and
that, generally, the disease must be far advanced
before this symptom attends it.

11. g. Of the other causes of pulsation at the
epigastrium, I need only remark, that cases, in
which it has been occasioned by enlargement of
the vena cava, are mentioned by Senac and A.
Burns. Dr. Pemberton thinks that the flutter-
ing, sometimes felt at this region, is produced by
congestion of the vena portarum, and the undula-
tion communicated to it. Pulsation from hepa-
tisation of the lower margin of the lungs, has been
observed by A. Burns and others. Bertin,
Bouillaud, and myself have noticed this as a
symptom of inflammation of the aorta. (See art.
Aorta- — Injiam. of.) Its connection with hy-
pertrophy of the heart, particularly of its right side,
requires no remark.

12. iv. In cramining the epigastric region,
pressure should at first be very gentle, gradually
increased, and be made in various directions.
^Vhen the heart is diseased, it should be directed
under the anterior cartilages of the upper false
ribs ; and, according to the situation of other or-
gans or parts suspected of disorder, the pressure
ought to be directed. When the patient almost
involuntarily throws the muscles underneath into
action, upon commencing the examination, acute
disease of some part or other may be suspected.
The state of the surface, in respect of moisture,
temperature, softness, colour, &C. ; and the sensi-
bility, the elasticity, the degree of depression, ful-
ness, pulsation, &c. of this region ; are equally
deserving of notice. In difficult or doubtful cases,
percussion, particularly if aided by Pigrrv's plexi-
meter, will be of service in giving information as
to the presence of air, or of efl^used fluids, or of
enlargement of the subjacent viscera.

EPIGASTRIUM — Contusions, etc. — Symptoms— Treatment.

784

BiBLioG. AND Refer. — Portal, Cours d'Anat. Medj-
cale, t. V. p. 193. et seq.- BaiUie, Trans, of Roy. coll.
of Phys. Lond. vol. iv. p. 271. — A. Burns, On the Dis-
eases of the Heart, &c. 8%o p. 59. — ./. Monro Morbid
Anatomy, &c. 2d edit. p. ibn.-Albers, m Kdin. Med
and .Surg. Journ. vol. ni— Hodgson, On Diseases of the
Arteries and Veins, &c. p. 8S. _ Francis Trans, ot Lit.
and Philosoph. Soe. of New York vol. i. — ' • j)^"".
Trans, of tlie Physico-Medical Society ot New "iork,
vol. i. ; and Lond. Med. and Physical Journ. vol. xl.
p. b-H.-Rcnauldin, in Diet, des Sciences Medicale, t. xii.
D 505 —J. Hone, Treat, on the Dis. of the Heart, &c.
8;o. 1832, p. nG:-BcrUneX B«„/«a«d, Traite des Ma-
lad, du Cffiur et des Gios Vaisseaux, p. 6G. et 6bi.

II. EPIGASTRIUM — Contusions and Con-
cussions OF. , A -I X
Classif. — I. Class, I. Order (yiut/ior).
13. Blows on the epigastrium, or falls, and
concussions of the trunk, may give vise to
the most serious consequences, and even to
immediate death. The manner in which these
effects are produced has not always been cor-
rectly estimated, although they are amongst the
most familiar phenomena which present them-
selves. A blow on the epigastrium may seriously
affect the frame from its effect — Isl, upon the
stomach ; 2d, upon the liver, gall-bladder, or
spleen, either of which it may rupture, particu-
larly when congested, or in a state of disease;
3d, upon the digestive canal, some part of which
may be ruptured by it ; 4th, upon the diaphragm
and respiratory organs ; 5th, upon the actions of
the heart; 6th, and lastly, upon the great
ganglia and ganglia! nerves. In a person in
previous health, I believe, from an attentive ex-
amination of the phenomena consequent upon the
injury, that the immediate effect is produced
upon these ganglia, and is analogous to that
occasioned by concussion of the brain. In some
cases, the stomach or other parts enumerated, may
suffer, according to the nature and the direction of
the blow ; as in a case recorded by Duponcii at.,
in which the jejunum was ruptured ; and in one
seen by myself, many years since, in which the
spleen, which had been much enlarged, was rup-
tured. A distended gall-bladder is, however,
most obnoxious to this contingency, if it be dis-
tended with bile on the receipt of the injury.

14. i. Sy.mptoms. — a. The patient generally
falls to the ground, pale and motionless, with the
most distressing death-like sensation. The skin
is cool, damp, and pale ; the breathing is feeble,
often scarcely perceptible, and slow. The eyes
are fixed, the countenance collapsed, the lips
pale, and the pulse at tiie wrist scarcely percepti-
ble, or irregular and intermitting, or not to be
felt! The surface and extremities become quickly
cold ; the muscles are flaccid, the joints pliable ;
and, in some instances, the sphincters are relaxed.
If tiie powers of life be not rallied at this time,
all these phenomena increase, until the action of
the heart and respiration entirely cease. If death
follow, the blood generally continues fluid, the
limbs flaccid, and cadaveric changes quickly
supervene. The changes, in the most severe
cat-es, somewhat resemble those produced by
lio-htriing. In some instances, one or more of the
organs, above enumerated, arc injured, either in
conjunction with these changes, or independently
of them.

15. h. These are the more direct effects, which
may terminate rapidly in death when the injury
has been severe. I'ut when slighter, or wlien a
judicious treatment has rallied vital power, a

different train of .symptoms appear. The patient
is enabled to speak ; he complains of pain and
anxiety at the epigastrium, with remarkable ten-
derness ; the pulse returns, and the surface reco-
vers its temperature. At last, symptoms of intense
reaction supervene; the pulse becomes full,
strong, and quick ; the epigastrium and abdomen
tumid or tense ; the eyes sunk and red ; the face
sharpened, pale, and anxious; the tongue and
mouth dry, with great thirst, but generally without
either sickness or vomiting ; and pains are felt in
the limbs, and different parts of the body, with
restlessness. Such are the usual phenomena cha-
racterising the reaction, when no particular organ
is seriously injured, or inflained. The stomach,
or the liver, or even the peritoneum, or one or
more of them, often becomes inflamed in the course
of the reaction, owing to the injury it had re-
ceived. In this case, the particular signs of such
lesion will be superadded ; as constant vomiting
upon taking matters into the stomach, and pain
in the region of this viscus, when it is inflamed ;
tenderness and pain in the right hypochondrium
and epigastrium, when the liver is affected ; and
so on as respects the other organs.

16. ii. Treatment. — The means of cure are
very different at the difterent periods distinguished
above. — a. In the J7 est period, remedies should
be promptly employed, but with caution. Inter-
nal stimuli are dangerous, from their liability to
induce fatal inflammation, particulaily of the
stomach. External warmth, and hot stimulating
baths, are generally beneficial, especially when
aided by irritating frictions. In plethoric and
robust subjects, cupping over the hypochondria,
notwithstanding the depression, and abstracting a
moderate quantity of blood, so as to give greater
freedom of action to the heart and blood-vessels,
will be of service. But experience has shown,
not merely in one country, but in all, that animal
warmth, derived from a recently killed animal, is
the most effectual means of rallying the depressed
powers of life in cases of this kind. Ambrose
Pare advises the skin stripped fiom a sheep
as soon as it is killed, to be wrapt round a person
whose life is menaced by the first shock of a con-
tusion. M. Larrev has resorted to it, in several
cases, with instant benefit, one of which is de-
tailed by M. DupoNcnAL. M. Larrey states,
that some sailors, shipwrecked on the coast of
Labrador, were found by Esquimaux Indians
almost dead with cold and fatigue; and that they
were recovered by these kind savages, who en-
veloped their bodies in the warm hides of newly
killed animals, and chafed their limbs with hot
aromatic liquors, — a proof of the frequent supe-
riority of even rude observation, to fine-drawn
inferences from theory, the grounds of which
have either been assumed without investigation,
or received as the dictum of current but worth-
less authoiity. The inhabitants of Upper Egypt,
according to M. Pugnet, resort to similar appli-
cations, to severe injuries ; and analogous means,
particularly warm eviscerated animals, applied
over the trunk, and the almost living flesh of
pithed quadru])cds, are in common use among the
vulgar in northern countries, in cases of contu-
sion, &c.

17. /». In the second period, or that of reac-
tion, general and local depletions, the tepid bath
and fomentations, camphorated and stimulating

embrocations or liniments, blisters over the epi-
gastrium or abdomen, emollient and gently refri-
a;erant drinks, and aperient eneniata, are the
•rincipal remedies. Great caution should be ex-
ercised during convalescence, as to the patient's
food and drink ; the former of which ought to be
chiefly farinaceous, and in small quantity at a
time ; the latter bland, and between the tempera-
ture of 70° and 90° of Fahrenheit's scale. If
symptoms of inflammation of the stomach, or of
any other part, appear during reaction, the treat-
ment should be directed accordingly.

BiBLioG. AND Refer Ambrose I' are, CEavres^de,

fol. Paris, 1628, 1. xii. cap. 3., p. 107 Larrey, Mem.

et Campagnes de Chir. Militaire, t. i Pugnet, Apercju

du Sayd, p. 74. — Duponc/iel, in Rt'v. Medicale, t. v.
p. 418. ; et Medico-Chirurg. Review, vol. ii. p. 662.

EPILEPSY. Syn. — 'E7rl^?^|.«i, 'ETriA^^ic (from
iTTiXa/xSavai, I seize, I attack). i\hn-bus Sacer,
Hippocrates. Morbus Major, Celsus. Morbus
Herculeus, Aristotle. Morbus Comitialis, Pliny
et Seneca. Morbus Couvivalis-, Plautus. Mor-
bus Lunalicus, Aretffius. Anulepsia, Riverius.
, Apoplexia parva ; Caduca Pussio ; Morbus Son-
ticus, Caducus, Astralis, Sideratus, Scelestns,
D<£moniacus, Deijicus, Divinus, Sancli Johan-
ids,f(xdus,pueriUs, insputatus ; Pediiio ; Epi-
leptica Passio ; Cataptosis, var. Auct. Lat.
• Epilepsie, Mal-Caduc, Mai de St. Jean, Fr.
Fallsucht, Die Fallende Sucht, Germ. Mul
Caduco, Ital. Falling Sickness, 6)C.

Classif. — 4. Class, 3. Order (Culten).
4. Class, 4. Order (^Good). II. Class,
III. Order (^Author, in Preface). See
Convulsions.

1. Defin. — Sudden loss of sensation and con-
sciousness, with spasmodic cojjtraction of the vohui-
tari/ muscles, quicklii passing into violent convulsire
distortions, attended and followed h\i sopor, recur-
ring in paroxysms often more or less regular.

2. Epilepsy has been noticed by all the ancient
writers; but by none so fully and accurately as
by Aret.eus. The sudden and frightful seizure
of which it consists, induced them to refer it to
supernatural causes ; and hence originated seve-
ral of the names whicii have been applied to it.
I*fotwilhstanding the very numerous results of ob-
servation accumulated by the ancients, and still
more remarkably by the moderns, its nature and
treatment are very imperfectly known. There is,
perhaps, no other malady of which the treatment
has been more empirical than of it ; and this
opprobrium must necessarily continue until our
knowledge of its pathological relations is much
lurther advanced than at present. In the descrip-
tion I am about to give of this disease, its more
distinctly marked states will be frst considered,
and afterwards the varieties into which it has been
divided, according to the modifications and com-
plications it usually presents in practice. It will
appear in the sequel how very nearly it is related
to apopleiii on the one hand, and to convulsions on
the other, — in its more idiopathic staples, to the
former, to mania, maniacal delirium, and idiotcy ;
and in its siimptomatic states, to the latter, to hys-
teria, ecstacii, and some other nervous affections.
But the relations and complications of epilepsy,
and the transitions of it into these maladies,
as well as of those into it, will be noticed here-
after ; and the disease will be treated of as it
actually presents itself to the practitioner, and
not as it is usually described by systematic writers,

Vol. I,

EPl LEPS Y — Pathology — Description. 7 85

who have viewed it (and, indeed, all other dis-
eases) as a distinct species, and not as it com-
monly occurs — as a concatenation or group of
morbid phenomena, which varies infinitely in
form, intensity, and combination, and conse-
quently approximates more or less nearly to other
morbid actions, particularly of the same system or
organ, and which may either pass into them, or
appear in their course.

3. I. Description, &c. — In order to enter-
tain satisfactory ideas of the nature and morbid
relations of epilepsy, it should be studied as to —
1st, the phenomena which precede its evolution;
2dly, the signs indicating the approach of the
paroxysm ; 3dly, the paroxysm itself, and the
phenomena immediately consequent upon it; and,
4thly, the intervals between the seizures. M.
Andral has adopted a nearly similar arrange-
ment, which, however, is merely a modification
of that of J. Frank, the latter, upon the whole,
being the preferable of the two. Having de-
scribed the more regular states of the malady, I
shall take a brief view of its varieties and compli-
cations.

4. A. The phenomena preceding the eiolution of
tlie disease. — J.Frank remarks that, of three
hundred cases, the early history of which he had
the opportunity of investigating, very few oc-
curred in persons vvho had been perfectly healthy
previously to the accession of the disease. This,
however, had not escaped Hiverius and Tissot,
the latter of whom has treated specifically " On
the Diseases which precede Epilepsy." This
malady attacks chiefly those persons who had
been subject to convulsions during their first den-
tition ; to tinea capitis, or other chronic eruptions
in early life ; to diseases of the head, violent
affections of temper, or to disorders of mind ;
to an unbridled indulgence of the passions ; to
diseases of the ear ; to affections of the glandular
and lymphatic system ; to worms, to chorea,
or to hysteria, at* any period previously to the
epileptic seizure. INlany of these antecedent
disorders may be viewed either as predisposing
or exciting causes ; or as indications of those
early disturbances of the nervous systems, and
of the circulation of the cerebro-spinal centres,
that lead on to further changes, when left to
themselves, until the fully formed epileptic seizure
is the result. Thus, it is not infrequently re-
marked that epileptic patients have, long before
the accession of the disease, complained of tre-
mors, cramps, vertigo, partial paralysis, disorders
of sensation, chorea, stammering, palpitations,
epistaxis, &c.; or have received injuries on the
head. The relations of these with the seizure,
as well as of those noticed above, must be obvi-
ous to all. There are also other disorders which
precede the disease ; but which, being more
intimately related to its causes, will be noticed
hereafter.

5. B. Phenomena premonitory of the seizure.
— As this disease rarely attacks a sound consti-
tution, or person previously in good health, so
each paroxysiTi frequently is preceded by some
indication or other of its approach. Instances,
however, are common, of persons being seized
without any intimation, and even in the day-
time, as suddenly as if struck by lightning.
Wedel, IIenke, and J. Frank refer to several
such. The last writer thinks it a rare occur-
3E

786

EPILEPSY — Description of.

rence ; but I agree with EsQuiROi-.in considering
it by no means uncommon, particularly in the
idiopathic foTm ; the symptomatict'oTm being gene-
rally preceded by some indication. In two cases
at present under my care, the seizures are instan-
taneous and unexpected : and I have met with se-
veral such, chiefly in those idiopathically affected,
or who have inherited the disease.

6. The premonitorii signs of the fit are, gene-
rally, increased sensibility, or a sense of formi-
cation of the surface, or of some particular part,
as the arm, back, breast, &c. ; cramps; turgidity
of the vessels of the head; redness of the counte-
nance ; a peculiar, anxious, or fixed look ; heavi-
ness or obtuse pain of the head ; vertigo, or par-
ticular sensibility, or a feeling of emptiness or
coldness in the head ; a great paleness of the face,
and paleness or blueness of the lips and gums; a
deeper sleep than usual ; sleeplessness, or sleep
attended by startings or peculiar succussions of
various parts of the body, or disturbed by singu-
lar dreams and visions, or by the nightmare ; a
sensation of sinking, or leipothymia, when falling
asleep ; unusual states of temper ; irritability, or
marked disposition to anger; various hallucina-
ions, or spectral illusions ; great timidity, or un-
usual depression or serenity of mind ; anxious de-
portment ; great hilarity or mental excitation : an
uncommon feeling of strength, or of robust health ;
sudden loss of recollection, confusion of ideas,
or forgetfulness ; unsteady gait ; a desire of mo-
tion, or an irresistible impulse to run forwards ;
shivering of the limbs; dimness of sight; red or
black objects, or coruscations or scintillations,
before the eyes ; trembling of the iris, or alternate
contractions and dilatations of the pupils ; tempo-
rary loss of sight, double or partial vision, or
strabismus; a rush of tears ; deafness, or a sense
of humming, roaring, or other noises in the ears ;
a morbid perception of colours, of odours, or of
flavours ; a sense of sweetness in the mouth ; a
flow of saliva ; violent sneezing, hiccup, frequent
yawning, attended by a feeling of anxiety at the
praecordia ; pandiculation ; difficulty of articula-
tion, or stammering ; distortion of the counte-
nance ; spasmodic affections of the larynx ; faint-
ing, or leipothymia ; palpitations ; borbor) gmi ;
a sense of constriction in the fauces, throat,
thorax, or abdomen; cramps in the stomach;
great voracity, or unusual craving of the appe-
tite ; a copious discharge of watery or offensive
urine, or haematuria ; a peculiar foetor of the
faeces ; more frequently eructations, nausea, and
vomiting, or other dyspeptic symptoms ; and still
more commonly the aura epileptica. J. Fkank
saw the paroxysm preceded by an eruption, over
the whole body, excepting tiie face, of the vitiligo
alba. He states, that in twenty-one epileptics
treated in the clinical wards of the hospital at
Wilna, vomiting announced the paroxysm in
seven.

7. More than two or three of the foregoing
symptoms seldom exist at the same time ; but
they sometimes precede one another. Thus, in
a case which I lately attemled, the patient was
unusually excited in tiie morning, was restless,
could not sit in one place any time, and desired
me not to call again, as lie never felt better in
health and spirits than he did at that time. As I
had Ijecn seeing liim from lime to time, on ac-
count of an indifferent state of healtli, I requested

his friends to watch him. In the afternoon, h^
turned pale, felt very cold, complained of pain
in one eye-ball, became sick, vomited, and in-
stantly was severely seized. Another patient felt
an unusual craving for food, with faintness, sunk
and pallid features, most distressing sense of sink-
ing, followed by violent palpitations ; and directly
afterwards, experienced a severe paroxysm : the
pulse becoming irregular and intermitting during its
continuance. The sensation of a cold or warm aura
proceeding from some part, and ascending to the
head, but very rarely descending from the head
to another part, is one of the most common pre-
cursors of the fit. In some cases, the aura has
been felt to terminate at the epigastrium. The
places whence it most frequently proceeds, are
various parts of the upper and lower extremities,
the groins, hypochondria, abdomen, loins, uterine
regions or vulva, along the vertebral column,
and from the vertex to the occiput. Fehne-
Lius mentions its occurrence at the vertex ;
and ScHELHAMMER, a case in which it com-
menced at this part, and proceeded to the arm.
From whatever place the aura may arise, as
soon as it reaches the head, or ceases, the patient
loses all consciousness, and the fit is fully de-
clared,

8. C. Phenomena characterising and directly
following the Jit. — It is only during the paroxysm

that the characterised symptoms are observed.
These may be so violent as to appear most fright-
ful, or so slight or momentary as to be hardly
observed, with every intermediate grade. This
has led to the arbitrary distinction adopted by
EsQuiROL, FoviLi.E, Calmiel, and Andral, into
the Grand and Petit Mai, The former, or fully
developed paroxysm, may be divided into three
stages. — (a) In the Jirst, or that of tetanic rigid-
ity, the patient, either without any premonition,
or after having felt one or more of the precursory
signs above enumerated, generally utters a
scream or exclamation, of which he has no
recollection afterwards, and instantly falls back-
wards, if standing. Sometimes he runs some
steps forward, or turns so as to describe a semi-
circle or circle, and then falls to the ground.
Rarely he turns rapidly around, more than once,
as remarked by Kriegal, VVedel, Bang, Va-
lentin, LcJBENSTEiN-LoBEL, EsQuiROL, and J,
Frank; or is thrown into a sort of dancing
motion, — a circumstance which led Fabricius to
describe a variety of the disease by the name of
Epilepsia Saltator. Directly afterwards the whole
body assumes an almost tetanic stiffness ; the
head is drawn backwards ; the eyes are generally
open, and directed froiti the usual axis of vision;
the limbs are thrown out forcibly, and become
rigid ; and the muscles of the thorax and abdo-
men firmly contracted. The pulse is either ir-
regular, or natural, or slower than usual. The
face is very pale, unless cerebral congestion pre-
cede the attack ; and the respiration is impeded
by the spastic contraction of the thoracic muscles,
()ccasionally, one half of the body is more affected
than the other ; and erection generally occurs ia
the male, with retraction of the testes. This stage
is usually of very short duration, passing in some
seconds, or almost instantaneously, into the next.

9. (li) In the second stage, or that of convul-
sion, the ])henomena diffur in no respect from
those characterising the tonic form of Convulsion

EPILEPSY— Description of.

787

( § 12.), excepting in the more profound insensi-
bility attending it, which is so great tliat the
patient may be subjected to the most painful
applications without sensation being excited.
The whole body is generally thrown into the
most violent convulsions, so that, as Ahet^us
has remarked, the spectators dread the iinme-
diate extinction of life. The head is violently
rotated, or tossed in every direction ; the vessels
of the head and neclc are enormously swollen ;
tiie eye-brows, forehead, and scalp are much
agitated or coatracted ; tiie hair is erect ; the
eyelids are either open, half-shut, or convulsed ;
the eyes fixed, prominent, vacant, rolled about,
or turned upwards, or out of their axis ; and the
pupils are either dilated, contracted, or natural ;
but the motions of the iris are very slow, or entirely
abolished. This varying state of the pupils ac-
counts for the different descriptions given by

HeNKE, SpRENCEL, MeTZGER, ScHlIIDTMiJLLEn,

ScHMALz, Dressig, and others. The face, which
was generally at first pale, now becomes in-
jected, tumid, and livid ; the forehead con-
tracted and wrinkled ; the lips are at one time
contracted, elongated, and pushed forwards, and
at another drawn forcibly backwards ; the teeth
are gnashed ; and the jaws so forcibly moved as
to produce a remarkable stridor, or even to break
the teeth. Van Swieten saw dislocation of the
jaws, owing to their violent action. The tongue
is generally swollen, livid, forcibly protruded
between the teeth, and more or less injured in
consequence. The arms are tossed about vio-
lently or struck against the chest ; and the hands
and fingers rapidly perform the motions of flexion,
extension, &c. The lower extremities are simi-
larly convulsed. The thumbs aredrriwn inwards,
and the toes incurvated. The convulsions are often
more violent on one side than another. In some
cases, much fulness of the abdomen and hypo-
chondria is observed, often with borborygmi or
singultus.

10. Respiration, which was at first interrupted
by the spasm of the thoracic muscles, and per-
formed as if the chest were placed under a load, or
as in the act of stran;;ulation or suffocation, until a
state of partial asphyxy was produced, now be-
comes quick, short, irregular, and sonorous. The
patient sometimes screams, or utters the most un-
natural and prolonged sounds, or the most extra-
>agant expressions, but more frequently moans
piteously ; and the forcible expirations throw out
a white tenacious froth, sometimes coloured with
blood, over the lips. Tissox lias observed the
saliva sometimes to possess a cadaverous odour ;
and Macbride and others have remarked, in rare
instances, blood to escape from the ears : epistaxis
is more common. The pulse is often quick and
small, but it is felt with difficulty ; and is usually
irregular, becoming more distinct, slower, and
more languid towards the close of this stage. The
action of the heart is loud, vehement, or tumul-
tuous ; and that of the carotids much increased.
I'latus is often expelled involuntarily, sometimes
with the fffices and urine ; and the erection is
occasionally followed by a discharge of semen, or
of the prostatic secretion. At last the convulsions
subside ; foetid perspirations break out about the
head, neck, and breast; the interrupted and con-
vulsive respiration is followed by deep sighs ; and
the spasms of the muscles, by subsultus; voniiting

or eructations sometimes occur, and the patient
passes into the next stage. The duration of the
first and second stages varies from less than one
to fifteen or twenty minutes. If they be prolonged
beyond this, death is generally the consequence ;
which, in the most violent cases may also occur
in the first stage, from the asphyxy occasioned by
the spasm of the respiratory muscles ; or in the
second, from the degree of cerebral congestion
and its more direct effects.

11. (c) The (/(i'rrf stage, or that of collapse, is
the most prolonged, and is characterised by a con-
tinuance of tiie loss of consciousness, by the dis-
appearance of the convulsions, by the deep and
often snoring sleep into which the patient falls,
and by the gradual return of the sensibility, which
may be now momentarily roused by powerful ex-
citants. The perspiration which had broken out
at the close of the last stage becomes more copious
and general, aad continues for about an hour ;
the pulse is now fuller, softer, and sometimes
slower; the respiration freer and easier; and after
a while the patient awakes as from a deep sleep,
and is restored to perfect consciousness ; but is
stunned, or wearied and exhausted, and complains
of headach, or pain in the neck, or occiput.
Sometimes the eyes remain, for a considerable
time, fixed, dull, or squinting, and the pupil en-
larged. The patient has no recollection of what
has passed. His speech often falters, and he
occasionally feels greater weakness in some one
limb or other. These symptoms gradually dis-
appear, but disinclination to exertion reinains.

12. The duration of the whole paroxysm is ge-
nerally from five or ten minutes, in the slight and
imperfect cases, to three or four hours. M. Es-
QuiROL has seen it continue five hours. I have
seen it last more than four — in one case seven hours,
the seizure consisting of two fits, with an indistinct
interval of soporose exhaustion ; and in another,
ten hours, the attack consisting of several fits,
without any remission attended by restored sen-
sibility. The long attacks generally consist of two
or more short fits, a slight remission taking place
between each. The return of the fits is extremely
various in different cases. Several years may
elapse between the seizures, as in a case in which
I was recently consulted ; or one, two, or three
years may intervene. In a few cases, they have
appeared every year at the same period, or even
day. When they occur monthly, a stated day
is more frequently observed, which often coincides
with the new dr full moon, — a coincidence
much insisted on by Galen, Aret^us, Arnold
of Villanova, Gehler, Hoffjiann, Mead, and
others. The interval of a lunar month is mere
commonly noticed among females, from the
connection of the disease with the uterine func-
tions. In some instances, the paroxysms occur
every week, on the same day ; and occasionally
every day, or night, at the same hour ; but
they most frequently come on when first falling
asleep, and are often, for a tiinc, unsuspected

' or overlooked. Sometimes seveval slight sei-
zures take place in one day ; but their recur-
rence is often extremely irregular. When
they are neglected, they usually either become
more and more severe, or occur after shorter
intervals. Consciousness and sensation being
aljolished, pain cannot be felt, during the fit.

13. The slialit or imperfect seizures — thQ Petit

3 E 2

788

Mai of French writers — are very varied in cha-
racter. They often precede, for months or years,
the full evolution of the severe form of the dis-
ease. Generally they consist of loss of conscious-
ness, and slight rigidity, spasm, or convulsions of
a few muscles, or of one or more limbs, which
continue only one or two minutes. In still
slighter cases, the patient is seized with vertigo,
loss of consciousness and sensation, and muscular
collapse or slight spasm of a few muscles, and is,
after some seconds, completely restored. In some
instances, the eyes of the patient become fixed
and vacant ; he attempts to articulate, but is un-
able ; loses consciousness for a very few seconds ;
and, upon recovering it, takes up the thread of
discourse which the seizure may have interrupted,
and endeavours to conceal the occurrence. Occa-
sionally the slight seizures very nearly approxi-
mate those of hysteria, or are associated with se-
veral hysterical symptoms. In many instances, the
patient does not fall to the ground, although he
may have been standing at the time of attack ; and
in others, consciousness is not entirely abolished,
the patient retaining a vague recollection of what
passed in the seizure, upon recovery from it, as
after temporary delirium or dreaming. These
slighter fits may recur eitiier frequently or very
rarely, but they commonly return after short inter-
vals, and sometimes as often as several times a day.
14. D. Of the intervals between the ■paroxifsms.
— After the fit, the patient complains of lassitude,
of soreness of the limbs and of parts that have
been injured, and is pale, sad, and fearful of its
return. In some severe cases, the face is studded,
particularly about the eyes and temples, with
numerous small ecchymoses arising from minute
extravasations from the extreme capillaries of the
rete mucosum duiing the congestion to which they
had been subjected in the paroxysm. In rare
cases vomiting or purging of blood is observed,
owing most probably to sanguineous exhalation
from the congested capillaries of the digestive mu-
cous surface. Sometimes paralysis of a limb,
more or less complete, or strabismus, or even ir-
regular movements or convulsions, or various jhal-
lucinations follow tlie severer attacks, and continue
several hours, or even days. In a case to which
I was very recently called, paralysis of the left
arm, and severe pain in the right eye-ball and
temple, continued after the fit — the former for
some hours, the latter for several days. Deaf-
ness, watchfulness, terrifying dreams, slight or
passing delirium, occasional convulsive move-
ments (Aret.'eus, &c.), and fits of absence
or forge tfulness, often afflict the patient, either
for some time after an attack, or during the
■whole interval. Between tlie complete parox-
ysms, as well as before their evolution, the slight
seizures described above (§. 13.) in one or other
of their forms — sometimes so slight as to amount
merely to vertigo with momentary loss of con-
.sciousness, or spasm of some part — the Verlige
J^/jt/e/j/iVyKe of French writers, are very common.
Various signs of mental alienation often appear,
■which generally become more and more remark-
able after successive, more frequent, or severer
attacks, until insanity is the result. Epileptics
commonly experience, during the intervals, vari-
ous dyspeptic disorders ; but their appetites are
usually very keen, and seldom duly restrained.
J. f RANK states, that he has seen persons suffer

EPILEPSY — Consequences and Terminations.

little disturbance after a fit, and others display
increased activity of both mind and body, until its
approaching return ; but this is a rare exception ;
the great majority, even of those who suffer the
least, being incapable of devoting themselves to
any undertaking with attention and perseverance.

15. II. Consequences AND Terminations. —
Persons long afflicted by the disease, gradually
acquire a peculiar physiognomy, owing lo the re-
peated distension of the vessels of the head, and
to the frequent spastic and convulsive actions of
the muscles of the face during the paroxysms.
This is particularly the case in such as are ad-
dicted to masturbation — a baneful practice which
is common among epileptics, and, indeed a prin-
cipal cause of their malady. This alteration of
the features has been noticed by Aret^eus, who
mentions their pale or leaden complexion, and their
languid dejected look : but Dumas and Esquirol
have described it most accurately. The individual
features become coarse ; the lips thick ; the lower
eyelids swollen ; the eyes unsteady, full, and pro-
minent ; the look vacant ; the pupils dilated ; the
cheeks pale.; the finest countenances plain; the
muscles of the face subject to twitchines, or slight
convulsive movements ; the arms and limbs thinner
than the rest of the body ; and the gait peculiar.
The functions of organic life likewise languish,
obesity or emaciation being a common result.
When the disease appears or continues after
puberty, or the fits return frequently, the mental
as well as the bodily powers become greatly im-
paired. These consequences are, however, in
some respects connected with the states of nervous
function, and the circulation within the head
directly producing the seizures ; the pathological
conditions, which, at their commencement, and in
slighter degrees, occasion the epileptic seizures,
giving rise, in their advanced course and height-
ened grades, to various associated maladies.
After the continuance of the disease, the patient
is at first listless, incapable of energetic ex-
ertion, and sometimes hypochondriacal. He is
liable to attacks of stupor, and complains of
lassitude, flatulency ; of various forms of in-
digestion, generally attended by a craving appe-
tite ; of great torpor of the bowels ; of vertigo
and tremors, &:c. He is subject to deafness,
amaurosis, and, in prolonged cases, to irregular
muscular contractions, or paralytic tremors, to
partial paralysis or complete hemiplegia, to im-
perfections or even loss of speech, to apoplexy,
to melancholy, to partial or complete, or to inter-
mittent or continued insanity, and to mania and
idiotcy.

16. Notwithstanding that epilepsy seldom
passes into the apoplectic state, until after re-
peated fits, yet both maladies may be associated
in the very first seizure. (See § 40.) Insanity
and mania, although not generally appearing
until after several or many attacks, are by far
the most frequent consequences of epilepsy ; but
I believe much more so on the Continent than
in this country ; whilst apoplexy and paralysis
oftener supervene here than there. Van Swie-
TKN states, that persons who have become insane
at an early age, have been generally first epileptic.
EsQuiuoi. has come to a similar conclusion ; and
my experience confirms it ; the seizures, how-
ever, having been sometimes of an irregular con-
vulsive kind, rather than those of true epilepsy. In

I

this fretjueCit class of cases, the mental faculties
are gradually impaired; sensation and memory
are weakened, the former being often acute ;
perception and imagination perverted ; various
hallucinations generated ; and the patient lapses
into a state of incurable insanity or imbecility, or
passes from the former into the latter. The more
severe the fits, the more is tiiis result to be
dreaded. Sometimes violent attacks of mania
follow the paroxysms. Of 289 epileptics in flie
Saltpetriere, in 1813, 80 were maniacal, and 56
in various states of mental alienation and imbe-
cility. In 1822, out of 339 cases in the same
hospital there were two monomaniacs, 30 maniacs,
34 furious maniacs, 129 insane for some time
after the paroxysms, 16 constantly insane, 8
idiotic ; 50 upon the whole reasonable, but with
impaired memories, and liable to occasional slight
delirium, and tendency to insanity ; and 60 with-
out aberration of intellect, but susceptible, iras-
cible, capricious, obstinate, and presenting some-
thing singular in their characters. As this
institution receives chiefly old and severe cases of
epilepsy, it furnishes sufficient illustrations of the
consequences of this disease. Occasionally the
epileptic mania alternates with melancholia and a
desire to commit suicide ; the mania often preced-
ing the paroxysm. Dr. Cheyne states that he
has known epileptics preserve their intellects to a
very old age ; but this is only the exception to
the general rule, for tliey seldom live to a
great age, or retain their fiiculties when they
reach it.

17. The duration of the disease is most uncer-
tain and various, and depends upon numerous cir-
cumstances connected with the regimen, habits,
and treatment of the patient. Epileptics are most
injuriously addicted to the indulgence of the an-
petites for food, and for the sex, — practices which
should as much as possible be guarded against,
as tending not merely to counteract the good
effects of treatment, but also to induce the un-
favourable consequences of the seizures enu-
merated above. A favourable termination is
indicated by the fits being slighter, shorter, and
more distant. Sometimes a marked crisis occurs
— as the return of a suppressed evacuation, par-
ticularly tiie menstrual and hfemorrhoidal fluxes,
epistaxis, &;c., the reappearance of a repelled
eruption, &:c. An attack of continued fever has
removed the disease, — but very rarely when it
has become confirmed. M. Esquirol states that
in 1814, when typhus fever raged in the Salpetriere,
although upwards of fifty epileptics were attacked
by it, and but few died, little or no amelioration
was observed in any.

18. A person subject to epileptic fits may die
of other diseases, or of a malady proceeding from
an increased grade of the same changes, which,
in a less degree, occasioned the fits ; or of the
direct or indirect effects of the repeated seizures ;
death taking place sometimes in the intervals,
but more frequently during the paroxysm or soon
afterwards. When it takes place in the interval,
it is occasioned by the remote effects of the fits,
in connection with the pathological states inducing
them — by some one of the diseases consecjuent
upon them (§ 38. et seq.). If it occur during or
soon after the paroxysms, it is generally owing to
an augmented degree of the same changes
usually producing them, or to some further alter-

EPILEPSY— Causes. 789

ation directly proceeding from tliese changes J
either upoplcxif caused by excessive congestion
within the head, or by extravasation of blood in
some situation, or by effusion of serum in the
ventricles or between the membranes of the
brain ; or asphi/xy occasioned by similar lesions
affecting the medulla oblongata and upper part
of the spinal chord, being the immediate cause
of dissolution. It has been supposed, that suffo-
cation often occurs in the paroxysm, owing to the
position of the patient, or of the clothes around
him when in bed. But this, 1 believe, rarely
takes place ; and when suffocation, or rather
asphyxy, is met with, itis caused chiefly, if not
altogether, by some one of the changes just
stated.

19. III. Caiises.' — i. Fredisponeiit. — Heredi-
tary disposition is a remarkable predisposing cause
of epilepsy, notwithstanding this kind of influence
has been disputed in respect of it. But although
the father or mother of the patient may never have
had an attack, either of the grand-parents, or
uncles, or aunts, may have been subject to it.
Zacutus LusiTAMis(Pra.r. ad Mir. 1. i. obs, 36.)
mentions the case of an epileptic man who had
eight children and three grandchildren afflicted
by the disease. Stahl (Be Hered. Dispos, ad
var. Affect. Halas, 1706, p. 48.) and Reimnger
adduce instances of the whole of the members of
a family being attacked by it at the period of pu-
berty. BoERHAAVE (Aphorisms, 1075.) remarks,
that, like several other hereditary maladies, it
often passes over alternate generations; and he
adduces an instance (Pra.r. ilierf. t. v. p. 30.) in
which all the children of an epileptic father died
of it. I had, in 1820, a brother and sister some
time under my care, who inherited the disease
from their father, and they had two other brothers
and one sister also subject to it — in all five. The
fits appeared in all of them about the period of
puberty ; and one of the brothers died about the
age of forty from apoplexy, complicated with the
seizure. IM]M. Boucher and Casauvieilh slate
that in 110 patients, respecting whom they had
made the enquiry, 31 were hereditary cases; and
M. Esquirol found, that in 321 cases of epileptic
insanity, 105 were descendedTrom either epileptic
or insane parents. Predisposition is often con-
nected with congenital Jormation. 1 have seen
the disease iu several children, whose heads were
of an oblique or diamond shape, or otherwise ill-
formed ; one side being more elevated than the
other, and either side advancing or receding.
Peculiarity of constitution, or idiosyncrasy, seems
to predispose to it, as well as the epochs of child-
hood and puberty, at which periods the nervous
and muscular systems are endowed with their
greatest sum of sensibility and irritability, and
the whole frame with great susceptibility. Cases,
however, often occur, in which these properties
are rather diminished than increased. After pu-
berty is fully attained, the disposition to the disease
is greatly lessened.

,. 20. The influence of sex is not remarkable ; and
is not manifested until after the second den-
tition. According to Esquirol and Foville,
females are more subject to the disease after this
epoch than males. At the end of 1813, 162
male epileptics were in the BaVne, and 289 female
cases iu the Salpetriere. J.Frank found, that
of 75 patients, 40 were females ; but he agrtcij
3E3

790

EPILEPSY — Causes,

with Celsus, Heberden, and Soemmereixg, in
believing, that if a strict diagnosis were established
between this and other convulsive diseases to
which females are very liable, particularly several
of those seizures described in the article Convul-
sions, the predominance would be found on the
side of the males; and Drs, Cooke, Eliiotson,
and CnEVNE are of the same opinion. IMJ\I.
BoucHET, and Casauvieilh ascertained, that of
66 female epileptics, 38 were seized before their
first menstruation, and 28 subsequently to that
epoch. I agree with M. Foville in thinking the
disease more prevalent in the Imcer than the upper
classes. M. EsQUiROL states, that the melancholic
temperament is more disposed to it than any other.
Dr. PmcHARD seems nearer the truth, in saying
that it is common to all temperaments and hahiis ;
but it is not equallii common to all. Dr. Cooke
remarks, that almost every case he has seen lias
occurred in sanguine temperaments and plethoric
habits. This does not agree with my experience,
which leads me to infer that it is most frequent in
persons who are eitiier very plethoric or very
much the reverse. Its greater prevalence in per-
sons of a, scrofulous and rickety diatlicsis, than m
any other, has been shown by Hufeland and
Portal, and is undoubted. J. Frank remarks,
that more than half the cases in his practice were
strumous. Dr. Cheyne would make t!ie pro-
portion even larger. De la Fontaine and Frank
found epilepsy extremely common amongst those
born of parents aflected by the Plica Pulonica.
An exhausted state of frame occasioned by what-
ever means, a cachectic habit of body, tlie syphi-
litic and mercurial poisons, and scorbutus, also
dispose to the disease. Great activity of tlie
mental faculties, and an exalted or excited state
of mind, may predispose to it; and in proof of
this, the circumstance of Julius Caesar, Maho-
met, Petrarch, Columna, Francis Rhedi,
Housseau, and Napoleon, having been subject
to it, has been adduced by authors. But in men
of strong minds and powerful talents, the disease
has seldom or ever occurred, until the nervous
energy has been exhausted by exertion, or by the
excitements and anxieties of life. Suetonius
(1. i. cap. 45.) states, that it was only in the last
part of his life, that C/tsar was seized with epi-
lepsy ; and that he had two attacks while he was
engaged in business. It seems more prevalent in
some countries than in others. This has been
referred to peculiarity of climate, especially to
cold and moisture. It is more evidently de-
pendent upon moral causes, particularly to ex-
cessive and ])remiiturc venereal indulgences,
which are more common in some countries than
in others ; the disease being very prevalent in tlie
south of Russia and Germany, in Poland, in Italy,
and France — certainly much more so than in
this country and the United States. Hippocrates
and TissoT tliink it most frequent and severe in
spring, but this is not remarkably the case, and
has been denied by seveial writers.

21. It has been asked. Whether or no this
disease is more common now than formerly? '['lie
dissolute habits of the ancient Greeks and Romans
lead me to infer that it was at least as prevalent
among them as with u^. Panaroli states, that
it was very frequent among the rich and noble
Romans, particularly during the acme and de-
cline of their greatness, when the utmost luxury.

dissipation, and debauchery prevailed among the
higher classes under the emperors,

22. ii. The occasional Exciting Causes are re-
markably numerous and diversified. Various
circumstances may concur in exciting the first
seizure ; and where no marked predisposition to
it exists, a concurrence of several causes is requi-
site to its production; but, when once produced,
a single, and even a slight, cause may occasion
subsequent attacks. This class of causes acts
variously : — 1st, Many directly change the phy-
sical condition and circulation of the encephalon ;

— 2dly, Others aflTect the organic nervous influ-
ence and circulation of the brain, through the
mediun\ of the sensations, perceptions, and other
operations of the mind ; — and 3dly, Some act
upon various remote organs or parts; the brain
and nervous system being only consecutively and
indirectly aflected. — (a) Injuries of the head;
fractures, depressions of a portion of one of the
bones of the cranium, concussions of the brain
or spinal chord ; tumours, and the numerous
pathological changes in the brain, its vessels, and
its membranes, or in the cranium, described in
the articles Brain, and Cranium; partial or
general inflammation of the brain, or of its mem-
branes ; diseases of parts immediately adjoining,
as of the cranial bones, the scalp, the medulla
oblongata, and spinal chord, the ear, eye, &c,,
or of the vertebras, &c. ; excessive haemorrhage
and discharges; hypocatharsis, or blood-letting
carried too far ; omitting accustomed and requi-
site evacuations; insolation; the suppression of
otorrhoea, of porrigo, and other eruptions; pro-
longed sleep ; and the metastasis of gout or rheu-
matism to tlie encephalon ; are the principal
causes which act in the first mode pointed out.

— (b) All inordinate affections of the mind may
induce a seizure in persons predisposed to it,
either by "exciting the nervous influence, and
cerebral circulation too far above the natural
pitch, as joy, anger, fits of indignation, coition,
&c. ; or by depressing the one or retarding the
other to a degree incompatible with the con-
tinuance of the vitjfil functions — as terror, sudden
alarm, grief, protracted anxiety, a sense of disgust,
the impression of various odours, excessive mental
application or exertion, &c., nostalgia, disappoint-
ments, unrequited, or forbidden affection, long-
ings after objects of desire, or love, &c. Pro-
longed want of sleep; very great or enduring
pain ; diflScult dentition ; great surprise; fright-
ful dreams ; appalling and distressing sights ; seeing
others in the paroxysm ; nervous irritation ; titil-
lation, whirling rapidly round ; excessive sexual
intercourse and masturbation ; ill-controlled states
or flights of imagination, &c.; are also very
common and powerful causes. M. Esquirol,
whose experience in this disease has been un-
equalled, truly states that fits of passion, distress
of mind, and venereal excesses, iiold the next
rank to terror, &c. in exciting the disease. — (c)
Tlie causes which act in the third mode are ex-
ti'cmely numerous; persons who have become
subject to the disease often experiencing a
seizure from very slight occurrences. The most
common are, however, the indulgence in too
much, or in improper food ; a heavy meal taken
shortly before retiring to rest ; the use of spirit-
uous and ferfliented licjuors, or of coffee, in
excess, very high teinperalurc, impure air, and

EPILEPSY— Varieties

791

crowded assemblies ; exposure to great cold ; irri-
tation of worms or morbid matters in the prima
via ; various acrid, narcotic, and aero-narcotic
poisons, the injudicious use of strychnine, &c.
There are several causes, the operation of which is
either not well known, or connected with the dia-
thesis and peculiar pre-disposition of the patient ;
and others — as, indeed, many of tiiose justenume-
rated — which manifestly act in more than one of
the ways pointed out above. The most remarkable
of these are disorders of other organs or parts, par-
ticularly functional or structural diseases of tiie
heart, of the digestive canal, of the liver, and of the
generative or urinary organs ; the presence of a cuL-
culus in either the kidney, the ureter, or bladder
(Bartholin, De LA JMoTTE, Brendal,Sauvages,
&c.), or of a, gall stone in the ducts (Jens, Beames,
&c.) ; the irritation or lesions of remote nerves ; the
syphilitic and mercurial poisons, &;c.(LAr!REY).

23. Dr. Hebreard ascertained that, of 162
male epileptics in the Bicetre at Paris, 119 were
unmarried, 33 married, and 7 widowers. Ac-
cording to Locher (Observ. Pract. in Vien. 1736,
p. 36.), out of 80 cases, 60 were occasioned by
frights of various kinds and degrees : but, of 69
cases, MM. Bouchet and Casauvieilh found
only 21 that could be referred to this cause.
The excitation of the feelings or passions pro-
duced by dramatic performances has also brought
on an attack. J. Frank states that, before epi-
leptics were separated from the other patients in
the wards of the Civil Hospital in Vienna, it was
not uncommon for some of tiie other patients to
be seized with the disease from sympathy or
imitation upon seeing the epileptic paroxysm.
This has been observed by Baglivi {Opera, 1. i.
cap. 14.), Lettsom {Mem. of filed. Soc. of Lond.
vol. iii. p. 383.), Duncan (Med. Cases, Edin.
1778.), Aaskow (Coll. Soc. Med. Hatin. vol. ii.
p. 14. 22.), Meza (Comp. Med. Pract. fasc. v.
p. 15.), and Hardy (Lond. Med. Gazette,
vol. xi. p. 247.). I have seen it occur in one
instance ; but I believe that the form of con-
vulsion described in § 17,18. of that article is
more frequently produced by this circumstance
than true epilepsy, unless in persons liable to this
malady. Various writers, particularly Galen
(De Diebus Criticis, 1. iii. c. 2.), Ahet^us (De
Caus, et Sig. Morb. 1. i. c. 4.), Alexander
Trallianus (1. i. c. 15. 21.), Camera rius (Me-
morah. cent. ii. n. 38.), Riverii's, F. Hoffmann
(Institut. i. iii. c. 88.), Stahl, INIead (De Imp.
Solis et Lume iSjc, Lond. 1704.), Wedel (Ephem.
Germ, An. ii. decur. 2. obs. 148.), IIumpelt,
BuRMESTER_(£)e Morfeo Spastico,S)C. Goet. p. 21.),
Otto (De Planet, in Corp, Hum. Influxu,
Franc. 1805.), have insisted upon the more
frequent occurrence of the paroxysm at the
periods of new and full moon than at any other.
Indeed, lunar influence on this disease seems to
have been generally believed in by the ancients;
and hence one of the names given to it by them.
The supervention of epilepsy during the early
stages of the exanthemata, or upon the disap-
pearance of the eruption, is much more rare'
than stated by many writers ; for the seizures
that sometimes take place in such circum-
stances are more strictly symptomatic convul-
sions, and seldom return afterwards, unless in
those much predisposed to this disease. A simi-
lar remark also applies to the violent convulsive

attacks, which occur duilng, or about the period
of, parturition ; and which, although they possess
most of the characters of epilepsy, particularly
of the uterine variety, do not necessarily return
at any other period, or even on a subsequent
confinement, unless in females who are really
epileptic, who are very liable to dangerous
seizures at this particular time.

24. Various nervous diseases sometimes pass
into epilepsy, either of a simple or complicated
form, — most frequently the latter. Hysteria,
chorea, catalepsy, cataleptic ecstasy, somnambulism,
and symptomatic attacks of convulsion, when neg«
lected or improperly treated, occasionally ter-
minate in confirmed epilepsy, with various asso-
ciated disorders, and not infrequently in some
one of the complicated states hereafter to be
noticed. Numerous affections of the digestive
organs have been assigned by writers as exciting
causes. But I consider them, with the exception
of worms in the prima via, which are a frequent
cause, particularly in children, as coexistent
with, or contingent upon, the commencement of
that state of organic nervous power and circula-
tion in the brain producing the disease, and that
the disorders of the digestive organs, as well as
this early state of cerebral affection, equally
depend upon deranged vital manifestation
throughout the organic nervous system.

25. IV. Varieties of Epilepsy. — Various di-
visions have been proposed with the view of fixing
with greater precision the treatment which is most
appropriate to the different phases of the com-
plaint. Aret.eus and other ancient writers dis-
tinguished it by the terms acute and chronic.
One of the most commonly adopted divisions is
that into idiopathic or cerebral, and sympathetic
or originating in disorder of some other organ.
Piso long ago doubted the existence of the sym-
pathetic disease, and MM. Georget and Bos-
QuiLLON have adopted his opinion. These writers
contend, that the sensations, or disordered feel-
ings manifested in remote organs, may actually
have their seat in the brain ; and that the aura
felt in a distant part may depend upon an original
cerebral affection. Those who believe in the
sympathetic forms admit that the seat of the
paroxysm is always the encephalon ; its cause,
or the disorder which excites the cerebral affec-
tion, on which the seizure depends, being often in
other organs. Hence they subdivide the sympa-
thetic species into as many varieties as there is
disorder manifested in other organs — into the
spinal, the cardiac, the gastric, hepatic, intes-
tinal, nephritic, genital or uterine, the nervous,
&c. Sauvages and Sagar (Systema Morborum,
8^c, p. 442.) make as many varieties as there
are principal exciting causes. Vogel (De Cog-
nosc, et Curand. Corp. Hiimani Ajfectibus,
p. 404.) notices the cerebral, that depending
upon disorder of the digestive organs, and that
arising from irritation of other parts. Dr. Cullen
admits two species, the idiopathic and symptomatic
— and distinguishes the former into the cerebral,
the sympathetic, or that attended by a«ra, and the
occasional, or that arising from son\<i irritation ;
the latter into as many varieties as there are
organs occasionally originating the disease. Dr.
Good mentions three species — the cerebral, the
catenating, and complicate. Dr. J. Frank views
epilepsy in connection, both with the organs from

3 E 4

792

EPILEPSY-

which it seems to derive its origin, and with the
states of action it manifests : these states he
divides as follows — the atonic, traumatic, in-
Jiammatory , rheumatic, metastatic, arthritic, car-
cinomatous, gastric, scrophulous, si/philitic, and
complicated. These distinctions are too compli-
cated and unavailable in practice — are, in truth,
as respects several of them, distinctions without
differences. The arrangement adopted by Dr.
Prichard is deserving of attention, as it com-
.prises several of the most important sympathetic
associations and complications of the disease ;
■that, followed by Dr. Ciieyne, presents nothing
■novel or retiuiring remark. The division which
•seems to me most accordant with the states it com-
monly presents in practice, is that into — 1st, its
Simple forms ; 2dly, its Sympathetic varieties ; and
3dly, its Complications.

26. i. Simple Epilepsy, Epilepsia Simplex —
Primary Epilepsy ; E. Cerebralis, Idiopathica, Es-
sentialis, Legitima, Primaria, Enceplialica , Auct.
varior. — may present itself in various forms, as
respects nervous susceptibility and vascular ful-
ness and action. — It may occur in emaciated
persons, whose nervous energy has been ex-
hausted, and whose blood is deficient in quantity
and quality, or in those who are plethoric and
apparently robust. It may present symptoms of
imperfect or sub-action, in connection either with
deficiency, or with too great fulness of blood ; or
of increased action, especially as respects parts
about the base of the encephalon. It is very im-
portant in practice to ascertain these states of the
-vascular system, as upon them must necessarily
be founded the chief indications of cure.

27. A. Simple Nervous or Asthenic Epilepsy —
E. Simplex nervosa, or Epilepsy with defective
power and action — is not so common in this, as
in other countries; yet it is not infrequent in
London and large manufacturing towns. — It is
observed in weak constitutions ; in thin habits,
presenting a deficiency rather than fulness of
blood; in young persons employed in factories;
and in those who are endowed with great suscep-
tibility, and who have been addicted to venereal
excesses, especially to onanism. In this form,
the face is pale or sallow ; tiie vtins small ; the
pulse weak, small, and , accelerated, or readily
excited ; the seizures are frequently ushered in by
leipothymia or fainting; and the countenance is
neither full nor livid, until the convulsive stage of
the fit, and often not even tlien. It is probable
that, at the accession of the attack, the due sup-
ply of blood to the brain is witlilield, or the cir-
culation of it interrupted ; although it must be ad-
.mitted that there may be evident want of nerv-
ous power, and general deficiency of blood, and
yet vascular action may be increased witiiin the
head, relatively to the rest of the body. It is very
important in practice, to ascertain which of tliese
states exists on the accession of the fit ; and this
can be done only by examining the circulation in
the carotids, the temperature of the head, and the
action of the heart, at tliis and at other periods.
This state of the disease may ultimately become
complicated with insanity, imbecility, or paralysis.

28. B. Simple Sanguineous Epilepsii — E.
. Simplex Sanguinea ; Acute Epilepsy, Lobkn-

STiiiN-LiJiiEL and IIiciitek ; Epilepsy with Pie-
, thora ; E. Plelhoricu, Poktal and others ; E.

Piith excited or sthenic action; E. with deter-

SiMPLE — Sympathetic.

mination of blood — appears to be the most
common form of cerebral epilepsy, especially
in this country. — It is usually observed in san-
guine and ^plethoric habits, and is consequent
upon too high living, great exertion, the suppres-
sion of accustomed evacuations and discharges,
the disappearance of eruptions, or the translation
of morbid action from other structures to the
brain, exposure to the sun, and violent fits of
passion. In these, as in other cases betraying
increased vital action, the disease has been sup-
posed by several writers to possess an inflamma-
tory character — E. Injiammatoria, J. Frank,
I'oRTAL, and others. — There is every reason to
suppose that this form is caused by an impeded
return of blood from the head, as well as by in-
creased determination to it ; and that it is more
frequently associated with disordered action of
the heart and congestion of the liver, than is
generally supposed. Although simple plethora,
or determination of blood to the encephalon,
may alone be sufficient to the production of the
fits, yet these states will ultimately be followed,
if the disease be not arrested, by partial or
slow forms, of inflammatory action ; and, con-
sequently, in protracted cases, the malady will
often pass into, or be complicated with, mania,
phrenitis, apoplexy, or paralysis. In other
cases, owing to the constitution of the patient
and the nature of the exciting causes, the disease
is obviously connected, from the commencement,
with chronic inflammation of a partial or limited
kind, inducing alterations chiefly in the medul-
lary substance of the brain. The distinction,
made by Sauva&es, Sa-gar, J. Frank, and others,
between the inflammatory , the rheumatic, the me-
tastatic, and arthritic states of the disease, are
not to be discovered in practice ; as they all
present signs of determination of blood to the
encephalon, and of excited action : but it is of
importance to keep these morbid relations in re-
collection, as they should very materially influ-
ence the treatment. The countenance in the fit
is generally red, tumid or livid, and is, with the
head, covered by perspiration ; respiration is at
first interrupted, and afterwards sonorous and
laboured ; the convulsions are not very violent,
nor of long duration ; and the subsequent stupor is
profound and prolonged. In the intervals, the
patient is subject to vertigo, or temporary loss of
consciousness. The Syphilitic, Scorbutic, Ca-
chectic, Humoral, Febrile, &c. of Bonet, Hoff-
mann, Sauvages, &c. are merely occasional
symptomatic or comjilicated states of the disease,
the paroxysms often closely resembling those of
simple convulsions.

29. ii. Sympathetic Epilepsy ; E. Sympathica ;
Epilepsy with associated disorder of other organs.
— This form is much more vaiied than the fore-
going, not only as particular organs may betray
disorder antecedent to, or coexistent with, or
consecjuent upon, the explosion of the epileptic
attacks; but also as it may present more or less
of the features of either of the two states just
particulaiised ; epilepsy associated with especial
disorder of some important organ, being, in re-
spect of nervous power and vascular fulness, also
either nervous or sanguineous, as described above
(§27,28.) — being oltener further characterised
byjdefective tone and energy, and deficient fulness
of blood or by plethora and excited action. 1'liis

EPILEPSY — Sympathetic.

79 3

very important connection of morbid states,
.altliough appearing complex to the superficial
.observer, will not seem so to those who are in
the habit of pathological analysis. It is chiefly
■owing 1o the circumstance of this species of in-
vestigation having been neglected as respects
•epilepsy, and to our consequent ignorance of the
.actual state of the circulation within the head,
.and of the heart's action, about the accession of
4he paroxysm, that our knowledge of the nature
and treatment of the disease has advanced so
little since the days of Aret;f.us.

30. A. Epilepsu from affection of the spinal
choj-d — E. Spinalis of J. Frank — has been ela-
borately described by Hahles (Opera Min. ac
Med. t. i. 1825.). It generally arises from
■injuries and concussions of the spine ; from caries
of the bodies of the vertebra;, or inflammation
of the intervertebral substances ; and from inflam-
mation of the membranes of the chord, or eftusion
of fluid within the sheath, from the metastasis of
rheumatism, or the disappearance of eruptions,
&c. ; and is sometimes preceded by great sensi-
tility, formication, or irritation of the skin. The
fits are generally characterised by severe convul-
sions, seminal emissions, and relaxation of the
sphincters. The head is seldom so much affected
as in cerebral epilepsy, and the seizures often ap-
proach nearly, or altogether, to simple convul-
sions. One or other of the limbs is frequently
weak, and sensation in them occasionally di-
minished, or otherwise altered, during the inter-
vals. Mr. Austin and myself lately attended a
young lady, in whom the catamema returned
every fortnight in large quantity ■; and who after-
wards had slight epileptic seizures. We found
the spinous processes of the three upper lumbar
vertebrae projecting, and that part of the spine
painful, and tender upon firm pressure and per-
cussion. The case terminated favourably from
the treatment advised in tliis state. I believe
that disease of the spine, associated with disorder
of the uterine functions, and epilepsy or convul-
sions, is not rare. This form of epilepsy may be
attended by great nervous susceptibility and de-
ficiency of blood, as in the case now referred to;
or by sanguineous plethora or excited action ;
either of tlie two pathological states character-
ising the simple malady also subsisting in this.

31. Very intimately connected with this va-
jiety, is the supervention of the seizures upon
pressure, irritation, laceration, or other injury of
■nerves. As in the spinal variety, so in this, the
paroxysm, generally, is rather one of convulsions
than of complete epilepsy. I do not believe
that this and the spinal variety are more fre-
quently preceded by an aiira than the other
forms ; as this sensation may not depend upon
any change in the part in which it seems to
-originate, but upon tiie condition of that portion
of the brain or chord with which its situation is
especially related. I have even met with cases
in which the auia shifted from one limb to an-
other in the course of treatment.

32. JB. With especial disorder of the circutatiitg
-and respiratory actions. — (a) I believe that the
paroxysm is more commonly connected with dis-
ordered function of the heart, than is generally
-stated by writers. In many of the cases where
I have had an opportunity of examining the state
•of the circulation, just before, or at the com-

mencement of, the fit, the action of the heart has
been either suspended for a few seconds, or re-
markably slow or irregular. This connection has
not been overlooked by some authors, Querce-
TANus (Tetrad, de Affect. Capitis, c3.-p. 8.), in-
deed, assigns to this organ the seat of the disease •
and instances have been adduced by JMoiiGAONr
(Epist. Ix'w. art. 5, 6.), Lancisi (De Mortib. Su-
bitaneis, p. 113.), Gould (Philosoph. Trans.
vol. xiv. p. 537.), SpiiENGEL,and Brera (Krank.
d. Herzeiis. <Sfc.), in which the seizures com-
menced with fainting, followed by palpita-
tions ; and, after death, the cavities of the
heart were found dilated, and containing fibrinous
concretions. The numerous dissections of Gre-
niNG also show the frequent connection of the
disease with lesions of this viscus. (See §47.)
Dr. Reid has drawn attention to the subject in
a more especial manner than any other writer,
but in too general terras. "It will be found,"
he states, "that the first symptom of an attack
is the suspension of the action of the heart ; and,
consequently, an intermission of the pulse, which
may continue from a few seconds to about three
minutes ; which was the longest period of inter-
mission I have yet seen." I noticed the affection
of the heart in a young man, whom I attended in
1820 ; and in several cases since that time. But
opportunities are comparatively rare in which the
physician can examine the patient at or shortly
before the accession of a fit. That the heart's action
is interrupted at this period, in many cases, appears
evident, on observingthe symptoms, and tracing the
connection between the exciting causes and their
more immediate effects. When we consider that
the most common and energetic causes, as fright,
surprise, grief, anxiety, &c., are those which, al-
though primarily aflfecting the cerebral functions,
most remarkably disorder the actions of the heart,
the importance of more frequently directing our
attention to this organ, in our researches respecting
the nature and treatment of epilepsy, will be evi-
dent.— (/;) The disease can hardly be said ever
to depend upon disorders of the lungs; althouo-li
the function of respiration is very often remark-
ably afl^ected, or even altogether arrested, owing
to the sudden spastic contraction of the respina-
tory muscles in the first period of the paroxvsm •
and cases sometimes occur in which the frequent
congestions of the lungs, from this cause, are
productive of inflammation, or hepalisation, or
even of effusions into the pleurae. But such asso-
ciations are merely consecutive ; and are chiefly
met with in prolonged and complicated cases, as
shown by the researches of Greding. (§ 47.)

33. C. With disorder of the digestive oro-aiis.
— (a) When the stomach is the organ chiefly dis-
ordered— the Epilepsia Stomachica ofSAuvACEs
Cheyne, &c. ; the E. Gastrica of Frank and
others — there are generally a loaded tonoue
heavy or disagreeable breath and perspiration
unpleasant taste, acrid or acid eructations, car-
dialgia, a sense of distension at the epigastrium
and hypochondria, and morbidly increased or
even ravenous appetite ; digestion being at the
same time very slow and imperfect, especially
just before the paroxysm. In some instances
the appetite is crapricious or defective ; and, occa-
sionally, nausea and even vomiting occur. Not
infrequently, large quantities of undigested food,
some of which was taken two or three days pre-

794

EPILEPSY -~ Sympathetic.

viously, are vomited shortly after the fit. The
bowels are usually torpid. This form, particularly
irj the paroxysm, generally assumes the character
of the sangumeous or plethoric variety (§ 28.).

34. (6) Where the biliary organs, especially
betray disorder — the Epilepsia Hepatica of BuR-
SERius, Prichard, and several nosologists —
pain, fulness, or tenderness in the right hypo-
chondrium, or towards the epigastrium, with
flatulence, occasional hiccup, or quickened re-
spiration, and a sallow or icteric countenance, are
complained of, generally some time before the
explosion of the paroxysm, Buhserius has seen
the disease follow the formation of biliary cal-
culi. It seems, from my own experience, to be
connected more frequently with jaundice than
with any other form of biliary disorder ; and to
possess more of the plethoric, or sub-inflammatory
form, than of the nervous (§ 27, 28.).

35. (c) Epilepsy arising from, or associated
with disorders of the bowels — the E. Etiierica of
Prichard — more especially with worms in the
intestines — the E. Verminosa of nosologists — is
very common, particularly in children. It may
commence in the form of convulsions, and be-
come fully developed after several seizures ; or it
may be complete from the first attack, especially
in the scrofulous diathesis. Although it most
frequently depends upon worms, it may be con-
nected only with an accumulation of morbid se-
cretions, or fajcal and undigested substances, in
the intestinal canal. The tape and lumbricoid
worms are those which oftenest induce it; and,
where this cause exists, the symptoms of worms
are usually observed. When it occurs about the
period of second dentition, or about that of pu-
berty, it is often a most severe and obstinate dis-
ease. It is very frequent among the poor and
ill-fed. AuTENREiTH states, that more boys than
girls are affected by it. It is with difficulty dis-
tinguished from convulsions, into which it almost
insensibly passes; but, according to my expe-
rience, which, especially as respects children,
has been very extensive, it is not so common
as the different forms of Convulsions. (See
that article, § 24.) Monschein (De Epilepsia.
Franc. 1700, p. 9.) and J.Frank consider true
epilepsy from worms comparatively rare. The
paroxysms, in thin and weak patients, generally
commence as in the cardiac variety ; or with
vertigo and leiopothymia, the action of the heart
apparently being momentarily suspended, and the
countenance pale and collapsed. In some in-
stances, where the habit is more plethoric, the
face becomes tumid, livid, or injected. The at-
tack is often preceded by pain in the abdomen,
or by nausea or vomiting ; and occasionally by
an aura ascending from the umbilicus. The
bowels are generally constipated ; but sometimes
the constipation alternates with diarrhoea, the
evacuations being unhealthy, crude, and offensive,
and often containing little or no bile. The appetite
is also craving, ravenous, and unnatural ; and
the skin is foul, or the seat of chronic eruptions.

36. (d) In these varieties, the disorders of the
digestive organs may be more or less concerned
in producing the disease ; or both the one and
the other may be coexistent, or the associated
consequences of impaired vital energy, mani-
fested in the organic nervous and vascular sys-
tems, particularly of those organs which evince

most disturbance (§ 47.). In some cases, as
in those related by Morgagni (Epist. ix. art. 7.,
et Ep. Ixiv. art. 5.), and by Sir W. Burnett,
it is difficult to determine whether the heart, the
liver, the stomach, or the bowels, present great-
est functional disturbance. But, besides these,
othes parts concerned in the functions of diges-
tion and assimilation may also betray disorder j
as the spleen, pancreas, and mesenteric glands.
These affections, whether they be viewed as con-
current exciting causes, or as associated effects
of impaired health, are deserving of attention ia
practice, as their increase or diminution will very
materially affect the disease ; treatment being of
little service, unless directed with strict reference
to them.

37. D. With disorder of the generative or
urinary organs. — (a) Epilepsy is most frequently
either excited by, or associated with, disorderof the
female organs, especially the uterus — the Epilepsia
Uterina of Eickmeyer, GRiJGER, Sauvages,
Prichard, and Cheyne — or with irritation ^of
the adjoining parts, as of the ovaria, vulva, &c.
It may be further associated with hysteric symp-
toms — the E. Hysterica of Wedel, Schulze,
&c. ; and the E. Ne>-iwsa of Dr. Cheyne. But
these are merely phases of the same variety ;
and not different species, as described by some
recent writers. Uterine epilepsy sometimes pro-
ceeds from delayed, or difficult, or obstructed
catamenia, and generally returns about the men-
strual period. Frequently, the same causes which
disorder the uterine functions, also induce this
disease ; as sudden alarms, terror, anxiety of
mind, manustupratio, disappointed love, nostalgia,
great fatigue, cold applied to the lower parts of
the body, &c. This variety is most common
about, or soon after, the period of puberty ; and
in young females of a sanguine temperament,
light eyes, ruddy complexion, and plethoric habit
of body ; and is associated not only with dif-
ficult or suppressed menstruation, but with va-
rious symptoms of irritation of the uterine organs,
or with too frequent or excessive menstruation.
I have remarked that the paroxysm oftener
occurs after the subsidence of the menstrual
evacuation than either before it or during its
continuance ; and that the fit commonly com-
mences in the leipothymiac or cardiac form.
Although hysterical symptoms are observed in
other varieties of the disease affecting females,
yet they are most common in this, especially in
nervous and delicate constitutions. These symp-
toms are, vertigo, faintings, palpitations, the
globus or clavis hystericus ; pain about the sa-
crum, under the left breast, or in the left side,
or in either mammae ; large evacuations of pale
urine; borborygmi ; and occasionally hysteric de-
lirium.— (6) The irritation of calculi in the
kidneys or urinary bladder may likewise be con-
nected with epilepsy ; but I agree with Frank
in thinking that this disorder induces convulsions
more frequently than genuine epilepsy. This
latter is more commonly associated with great
irritability of the male oi'gans, both affections
having been brought on by masturbation ; in-
ordinate excitement, whether mental or physical,
occasioning a paroxysm. There are few states
of the disease which oftener present extreme ful-
ness, or deficiency of blood than this.

38. iii. Complicated Ejnlepfy — E. Complicata.

EPILEPSY — Complicated

— Besides the association of diseases of distant
parts with epilepsy, various important complica-

795

tions of other maladies of the nervous system with
it, very frequently present themselves in practice.
In most cases, the complications are of the kind
above noticed (§ 15, 16.) — are merely conse-
quences of an advanced grade of the same
changes upon which the epileptic paroxysms
seem to depend, or these heightened by the effects
of the repeated seizures. But in others, different
affections of the nervous system long precede the
occurrence of an attack ; and in some instances
the complication is manifested from the com-
mencement; and occasionally, even the first or
second seizure is of a mixed kind.

39. (a) The most frequent complication is that
with mania and other forms of mental alienation.
Much attention has been paid to this state of
disease by Continental writers, particularly by

EsQUIROL, GrEDING, GuISLAIN, FrANK, CaL-
MIEL, BOUCHET, CaSAUVIEILH, and BOUILLA'JD,

and by Dr. Prichard. The mental disorder
generally appears in the course of prolonged
cases, and at first immediately after the seizures,
in an intermitting form, and as stated above
(§ 15, 16.) ; but it is occasionally the original
affection, the epileptic paroxysms supervening in
the most protracted and hopeless cases of insanity,
imbecility, or idiotcy. ^\ hen it occurs early in
epilepsy, the fits usually pass into a maniacal
state of delirium, remaming longer or shorter
after each, until continued and confirmed insanity
is the result. This complication is sometimes con-
genital, and is then often connected with mal-
formation of the cranium. It very frequently
seems to depend upon chronic or sub-infiamma-
tory vascular excitement in the encephalon,
affecting chiefly the cortical and medullary struc-
tures of a part, or parts only ; and is often fur-
ther associated with diseases of either the heart,
the digestive canal, the biliary organs, or the uterine
functions, as shown by the instructive researches
of Greding, Prichard, Bright, Bouchet, and
Casauvieilh. — This state of disease may even
ultimately pass into apoplexy or paralysis, before
it terminates fatally.

40. (/;) The apoplectic complication may
occur as stated above (§ 16. 18.), or the very
first seizure may be a combination of apoplexy
with epilepsy. Of this latter, I have seen two
cases within six months of writing this ; — one,
that of a female of middle age, attended by Mr.
Byam ; the other, that of a corpulent man of
sixty-three years. The former of these recovered,
the latter died. When the apoplectic and epileptic
seizures are thus associated, the distinctive features
of either may precede those of the other. In the
two cases now alluded to, the seizure was apo-
plectic at its commencement, the true epileptic
convulsions not appearing until after some time ;
but more frequently the apoplectic phenomena
supervene upon the epileptic fit. Partial or gene-
ral convulsions are not infrequent in the course
of an apoplectic attack. But these do not consti-
tute the complication now being considered; for
in it, the stages of the epileptic fit, as described
above, with the characteristic phenomena — injury
of the tongue, priapism, &c. — are clearly defined.
In this kind of seizure, one or more limbs, or one
half the body, may be paralysed ; but as often,
this additional affection is not observed. The se-

vere forms of convulsions which occur in the puer-
peral states sometimes very clearly approach, or
are altogether identical with, this complication.
But they are rarely connected with paralysis.
Notwithstanding the obvious relation betweea
epilepsy and apoplexy, and their frequent com-
plication, the subject has been unaccountably
overlooked, even by practical writers ; it having
been incidentally noticed only by a few, until Dr.
Bright directed attention to it (Med. Reports,
vol. ii. pp. 198. 519.). Hippocrates (nep; 'aJevcov,
^ ix. v. 103.) seems, however, to allude to it ; and
his commentator, Martianus (A7inot. in Lib. Hip,
de Gland, v. 103.), Morgagni {De Sed, et Cans.
Morb. ep. iv. sect. 4. 5. et ep. ix.), and Dr.
Prichard (On Nerv. Dis. p. 59.) mention it
somewhat more explicitly.

41. Nearly allied to this complication, especi-
ally to the slighter of those seiziires which com-
mence as apoplexy, is that form of attack men-
tioned by Dr. Prichard (p. 86.) as intermediate
between apoplexy and epilepsy. In these fits, the
patient falls to the ground, and lies for some time
in a state of insensibility ; but without any rigid-
ity or convulsion of the muscular system. They
are sometimes preceded by vertigo; and seem —
at least, in the cases which I have seen — to be
slight forms of those attacks which I have as-
cribed to sudden congestion of blood on the brain
(see Brain, § 139.), probably with some degree
of affection of the Jnedii //a oblongata. They evi-
dently are connected with epilepsy, inasmuch as
they are occasioned by the same kind of causes as
produce it, and are often met with in persons at
other times subject to epileptic or convulsive
seizures; the one species of fit frequently passing
into or superseding the other. They are often
consequent upon disorder of the uterine functions,
and upon hysterical affections ; and they then
sometimes become convulsive as the attacks
subside.

42. (c) The complication of epilepsy with pa-
ralysis may appear in the same manner as the
foregoing; the latter occurring either during the
advanced progress of protracted cases of the
former, or almost contemporaneously with it, or
even long previously to it ; but I believe that pa-
ralysis is most frequently consequent upon the
epileptic seizures. Of this I have seen several
instances ; the paralytic affection consisting of
loss either of sensation, or of motion, or of both,
in one limb, or in half the body ; and occasionally
of loss of sensation in one limb, and of loss of
motion in another on the opposite side. Although
this association is most common after repeated
seizures, yet have I met with it after the first ;
the paralysis either disappearing some days or
weeks afterwards, and recurring after each fit, or
being from the first permanent, or ultimately be-
coming so. In some cases the paroxysm follows
the paralysis, and at last passes into coma or
apoplexy. Dr. Ferriah (Med. Hist, and Reflect,
vol. ii. p. 11.) ; Dr. Percival (Essays, Med. and
F.xperim. vol.i. p. 148.), and Dr. Prichard (On
Nerv. Dis. p. 60.), have recorded cases of this
kind. Occasionally the paralytic state entirely
supersedes the epileptic seizures ; this latter dis-
appearing, but the former being permanent. But
this complication may be further associated with
insanity or imbecility, or with amaurosis ; and
the seizure may, moreover, present a mixture of

793

EPILEPSY — Appea

epilepsy and paralysis, or a state intermediate
between botli, as remarked by Piso, Mead, Fer-
HiAR, Prichakd, and myself.

43. {d) Of the other complications, little be-
yond the mere mention is necessary. — Hysteria,
chorea, catalepsy, and somnambnlism, not infre-
quently pass iiito epilepsy; and the seizures are
sometimes intermediate between either of these
affections and this disease. In a very large pro-
portion of these cases, the uterine functions, or the
digestive organs, are more or less disordered at the
same time — such disorder proving the determin-
incr cause of ^the aggravated or epileptic character
of the attaeks. — Epilepsy may be also associated
with hifpochondriasis and melancholy , the digestive

'and biliary organs being generally remarkably
disordered in these cases. I have likewise seen it
alternate with delirium tremens, or this latter affec-
tion follow a regular paroxysm of epilepsy ; and
the same case, which has been thus associated,
may ultimately pass, after a recurrence of the fits,
into permanent mania or paralysis.*

44. V. Appearances after Death. — It has
already been stated (§ 22.), that epileptic seizures
may be connected with any of the organic lesions
described in the articles ISrain, and Cranium ;
but they sometimes are independent of any change
cognisable to the senses. Appearances, however,
vary much according as death has taken place in
the fit or in the interval, and as the disease has
been simple or complicated.

45. A. — (a) In the simple states of the disease
(§ 26.), when the patient has died of some other
malady unconnected with epilepsy, and has
evinced no disorder of the locomotive and intel-
lectual powers, either immediately after the fits,
or during the intervals, little or no alteration can
be detected in the nervous system. Occasionally,
small tubercles, increased vascularity in parts,
or bony deposits, and various other very slight
changes, which are frequently observed without
having produced any disorder of the nervous
functions, are detected ; but these may be viewed
as coincidences rather than as lesions connected
with this disease. — {b) When the patient dies
during the attack of simple epilepsy, the substance
and membranes of the brain and cerebellum are
generally loaded and injected with dark blood, as
observed in persons who have died from hanging
or asphyxy. 15ut this change is no further con-
nected with epilepsy than being contingent on the
form and mode of death in the paroxysm.

46. B. — (a) In the complicated states (§ 38.),
especially in that with mental disorder, lesions of
great diversity are generally found ; consisting
chiefly of induration of the medullary substance
of the brain, frequently with more or less injec-
tion; and of considerable dilatation of the blood-
vessels. In some cases accompanying the dila-
tation of the vessels, the medullary structure
is soft, flabby, or flaccid. These alterations are

• I was, whilst writing this, called to a man reduced in
circumstances, from habits of intoxication ; and who had
experienced two or more attacks of delirium tremens.
He was seized with an epileptic fit, brought on by the
fear of being run over by a carriage near his own house.
He had a return of the delirium tremens upon re-
covery from the paroxysm. A gentleman, given to oc-
casiimal Intoxii-.itioii, was lately under the care of
INIr. (;\iiri;u nml iny^cU. lie has had regular attacks
of epilepsy, followed \j\/ duliriuni tremens. The last pa-
roxysm has not been followed by this affection, but by
threatened paralysis.

RANCES AFTER DeATH.

generally limited in extent ; but are met vvitti in.
all the white portions of the encephalon. In ad-
dition to these, the grey substance often presents
inequalities of surface, alterations of colour and
consistence, and vascular injections — the usual
results of chronic inflammation; and, in some in-
stances, adhesions of a portion of the cortical sur-
face to the membranes, or accumulations of serum
in the ventricles. Greding states, that of sixteen
maniacal epileptics, the lateral ventricles of thir-
teen were filled with serum ; and the brain softer
than natural in nearly the same proportion of
cases. In rarer instances, partial or general atro-
phy or hypertrophy of the brain is met with. —
<^b) In epilepsy complicated with apoplexy, either
extreme injection of the vessels with dark blood,
or the appearances presented by the different states
of that disease, or great effusion of serum ihto the
ventricles (Richter, Mills, &c.), are met with.
In those accompanied by paralysis, tumours and
various other adventitious formations, cysts, soft-
ening, extravasation of blood, abscesses, and the
other lesions described in the articles Apoplexy,
I3rain, and Paralysis, are usually observed.

47. C. In the sympathetic states, aherations of
the medulla oblongata and spinal chord, similar to
those found in the encephalon, have been re-
marked by MoRGAGNi, Harles, Frank, Gre-
ding, and others. Water in the pericardium,;
enlargement and dilatation of the cavities ; thin-
ning and softening of the walls of the heart ; and
diminution of its entire bulk ; have been noticed
by Lieutaud, Greding, and Pew. — Hepatisa-
tion and congestion of the lungs, and purulent
collections in them, have been recorded by Bonet,
Baader, and the writers just mentioned. — En-
largement and other lesions of the liver have
been observed by Prichard, Dr. Ciieyne, and
myself. — In a case of abscess of the liver, lately
under my care, and seen also by Mr. Copland
Hutchison, an epileptic fit occurred at a time
when the diaphragm was much affected. — Cal-
culi in the kidneys have been met with by Bar-
TiioLiN, La Motte, and Brendel ; and disease
of its secreting structure, by Dr. Bright.

48, D. The Wenzels, in their numerous dis-
sections, directed attention to the state of the
pituitary and pineal glands; but the result of
their researches, until the mistake was pointed
out by Dr. Siais (Lond. Med. Guz. vol. vii.
p. 374,), was referred to the cerebellum, by
nearly all subsequent writers, excepting Esqui-
ROL. These able pathologists found iha pituitary
gland and inj'undihulum variously altered in
colour, consistence, size, and structure, in nearly
all the cases of epilepsy they examined ; and
the spinous processes of the os frontis, the crista-
galii of the ethmoid, and the clynoid processes
of the sphenoid bone, more or less prominent,
or otherwise changed in position and shape, in
most of them. The pineal gland was also more
or less altered in colour, and softer than usual,
in the larger proportion of cases. — Caries,
thickening, internal exostoses, spiculi, malform-
ations, and malpositions, of the bones at the base
of the skull, with various changes of tl>e mem-
branes, were met with in several instances. In
fifteen cases out of twenty, the cerebrum and
cerebellum were (piite sound. Alterations in the
sphenoid bone and pituitary gland have been
found likewise by Greding, Neumann, Sims, and

EPILEPSY — Nature of.

797

myself. Gredino has also observed changes of] some continuance ; or to sudden loss of power?
the pineal gland, and fibrinous concretions ad- j or to an interruption of the return of blood to
hering to the inner surface of the sinuses, — appear- ! either side of the heart ? It is obvious that, until
ances likewise noticed by Wagner and myself. ' these and other points are fully ascertained, no
Nearly all the lesions described in § 29. et seq. of | satisfactory conclusion can be come to respecting
the article on the Brain and its Membranes have ; the nature of the disease. Numerous opinions

been occasionally detected, but not so frequently
as the foregoing, nor so often in this as in some
other diseases of the nervous system, as insanity,
paralysis, (Sec. Indeed, the most important ma-
ladies seated in this system, as somnambulism,
chorea, hysteria, catalepsy, ecstacy, convulsions,
epilepsy, mania, apoplexy, and paralysis, are
merely modifications, with exaltations of grade, of
nearly the same pathological conditions.

49. VI. Nature of Epilepsy. — There are
certain circumstances connected with the patho-
logy of epilepsy, fully ascertained, and which
should be kept in recollection in our speculations
as to its nature and treatment : — 1st. That it may
remotely depend upon inanition, losses of blood,
or a deficient quantity or quality of this fluid. —
2d. That it may be owing to a totally opposite
state as respects either the system generally, or
the brain especially. — 3d. That it seldom occurs
in persons whose digestive, assimilating, and cir-
culating organs perform their functions regularly.
— 4th. That, in the simple and early disease, it
is not dependent upon any lesion cognisable by
our unassisted senses, unless such lesion be seated
in the medulla oblongata or pittiitary and pineal
glands, — parts not yet sufficiently examined
in this malady, and which may be dangerously
affected without manifesting any material change.
5th. — That the appearances found in old or
complicated cases are to be referred rather to the
repeated derangements the circulation of the brain
has suffered in the paroxysm, and to the nature of
the associated disease, than to the lesions detected
in fatal cases ; such lesions, however, when in-
duced in the course of other disorders, being
occasionally exciting or concurrent causes of the
epileptic attacks. — 6th. That general congestion
of the encephalic vessels evidently exists in the
second or convulsive stage of the fit ; but it is not
so manifest that this state is present from the com-
mencement of the seizure, as cases have presented,
at this period, symptoms of a very opposite con-
dition.— 7th. This congestion is only a passing
phenomenon, evidently caused by interruption to
the respiratory actions, impeded circulation
through the heart, and to the spasmodic action of
the muscular system ; and is not the cause of the
seizure, the principal phenomena of the fit even
ceasing at the very moment when the congestion is
at its height. — 8th. The paroxysms of epilepsy
cannot, therefore, be imputed to the congestion,
which is evidently an advanced or consecutive

have been offered, but very few of them require
any notice. The ancients supposed tiiat the dis-
order is caused by a pituitous humour in the ven-
tricles of the brain, the symptoms arising from
an effort of nature to relieve herself from it,
Boerhaave and Van Swieten imputed it to a
morbid action of the brain exciting the nerves of
motion, and obscuring those of sensation. Dr.
CuLLEN considered that it may proceed in some
cases from too great excitement of the brain, and
in others from collapse. Numerous modern'
writers have referred it to a change in the struc-
ture of parts within the cranium. But opposed
to this opinion, are the facts, that in the simple
disease lesions are seldom observed ; and that,
when observed in either the simple or complicated
states, they are not uniform, or even of the same
kind, and are as frequently seen in other diseases
of the brain, unattended by convulsions, as in epi-
lepsy. Dr. J. Johnson has remarked that the
immediate cause of the attack seems to be a tem-
porary local turgescence of the cerebral vessels,
determined by a temporary super-excitement of
the nervous structure of the parts thus affected.
This opinion is very generally adopted in connec-
tion with the inferences, that local turgescence or
plethora causes pressure; and that pressure, when
general, produces apoplexy ; when partial, para-
lysis ; and when slight, epileptic convulsions, —
phenomena which, doubtless, frequently arise
from these conditions, but not from them alone,
but likewise from others ; symptoms of pressure
being very often altogether wanting at the com-
mencement of the fit. Mr. jMansford, proceed-
ing on the supposition that the nervous and electro-
motive fluids are identical, has contended that the
brain is constantly generating them, and that, in
health, they are controlled by the will, in opposition
to their natural tendencies; their formation, reten-
tion, and discharge thereby being duly regulated ;
but, when weakened by disease, this control is
irregularly or imperfectly exercised, and their ac-
cumulation is favoured, until it reaches its maxi-
mum, when it explodes in an epileptic seizure. It
is obvious that this opinion is entirely founded on a
postulatum — the identity of nervous influence
with the electricities — to which few will sub-
scribe. Sauvages had long ago ascertained by
experiment that the hemispheres of the denuded
brain may be punctured wtthout exciting sensibi-
lity ; but that, as soon as the instrument reaches
the origin of the nerves, or the medulla oblongata.

phenomenon produced as now stated ; but must j epileptic convulsions are produced (Xosol. Me-
be referred to the parts on which sensibility de- \thod,\ol.i. p. 782.), and hence, concluded that
pends, and which actuate the respiratory and , whatever especially affects those parts, may induce
muscular organs. the disease. The opinion has been adopted by

50. Although these positions seem not to admit several pathologists, and probably approximates

of being controverted, yet there are other points
necessary to a knowledge of the nature of the
disease that still require to be ascertained : — (a)
What are the states of the heart's action, and of
the circulation, particularly in the head, just i

'as nearly to the truth as can be expected in the
present state of our knowledge. — The researches
of the Wenzels have led them to imagine that
the proximate cause is to be referred chiefly to
the pituitary and pineal glands, especially the
before and at the time of seizure ? — (b) Is the sus- ' former ; and it is not improbable that impairment
pension of the heart's action, sometimes observed, ■ or other disorder of the function I have attributed
at this time, owing to a spasmodic contraction of at another place to these parts (see Apoplexy

798

EPILEPSY

4 103, 104.), may be concerned in some way or
other in deranging the circulation of the encephalic
organs, and in predisposing, or giving rise, to the
disease. Dr. Reid, msisting on the suspension
of the heart's action at the commencement of the
fit, and on the tetanic rigidity of the muscles
in the first stage of it, has referred these changes to
" irritation or accumulation of blood in the spinal
nervous mass," particularly the cervical portion.
Dr. Shearman has contended, with much justice,
that simple epilepsy often owes its origin to defi-
ciency of nervous energy, or irregular distribution
of it, independently of vascular excitement or any
primary disorder of the circulation.

51. It is unnecessary to offer any further opin-
ion of the foregoing views. From a survey of the
predisposing and exciting causes, and of their
mode of operation, as well as of tlie connection
frequently subsisting between other diseases and
this, it seems probable, that changes in the organic
nervous influence of the encephalon, or alterations
of structure of any part within the cranium, may
so affect those parts at the base of the brain, con-
nected with the origin of the nerves, especially
the medulla oblongata, as to suppress sensibility,
derange the functions of respiration and circula-
tion, and occasion inordinate action of the mus-
cles, under the influence of the cerebro-spinal
axis — in short, to disorder especially the func-
tions depending upon these parts, in the manner
constituting the disease. It may be urged that,
if this affection arise from irritation or any other
change in the parts now named, wherefore is it
paroxysmal, or of occasional occurrence and
short continuance ? To this I can only answer,
that nervous excitement, not depending upon, or
kept up by inflammatory action, is usually mani-
fested in this form ; that any other than functional
affection of the parts about the origin of the
nerves of respiration cannot produce tlie disease,
as any remarkable change of structure of these
parts is quickly followed by death ; and that, pre-
suming the change, therefore, to be functional, or
at most very slightly structural, the successive
phenomena constituting the difl'trent stages of
the paroxysm, most probably remove for a longer
or shorter time, according to the duration of the
interval, the particular condition which excited
the attack. According to this view, irritations or
other alterations of function or structure in re-
mote but related organs or structures may affect
the medulla oblongata or adjoining parts, so as to
induce a paroxysm of the disease, especially in
persons predisposed to disorder of tiiese parts, the
predisposition arising from the state of organic
nervous influence and of circulation within the
head. In such cases, the irritation is propagated
by nervous connections to the situation referred
to, the chief phenomena of the seizure being one
of the numerous forms of morbid action depending
upon 1-pJlex sympatliy,*

* The aura epilrplica is also, in many cases, notliiiig
else than a manifestation of this kind of sympatliy —
the irritation of some internal jiart aflectin;.; somc^ portion
of the encephalic organs, tlic all'(( tion licinf; rcllected in
the course of some nerve liclonKlng to tlie ciTcliro-sjiiiial
system. In cases where this sensation ni.ay ilcjieiKl npon
gome change in the part where it originates, the paroxysm
i» still more evidently .an expression of reflex syiiijiathy.
Till- nailer may refer to mv remarks on tlu' Si//>ip,il/iirs,
ill tlie Ciri-t anil seronil cdftions of mv notes to M. Hl-
c:iii i;\M)N I'lii/sivlufi,, (pill). iH'j-laiid IH'ji)), where he will
fl.uUheiii divi.kd into the direct and reflex — " (//Vrr/

— Diagnosis.

52. VII. Diagnosis. — The intimate relation-
subsisting between the diseases of the nervous
system just alluded to, might lead to the inference
that the diagnosis of epilepsy would be sometimes
a matter of diflSculty. But in the regular and un-
complicated form of the disease, no difficulty will
be experienced. It is only when insensibility
precedes the convulsions ; or when there are no
convulsions, or merely slight or partial convul-
sions ; or when there is violent delirium in the
paroxysm ; or when there are convulsions with
some degree of consciousness ; or when one half
the body is only affected — all which modifica-
tions may occasionally present themselves in both
the simple and associated forms of the disease ; —
that the practitioner can doubt as to the exact
nature of the attack. The intermediate seizures,
also . between epilepsy and apoplexy (§ 41.),
which frequently attack aged persons, and are,
as respects the course of the affection, merely a
variety of epilepsy without the convulsions —
the Leipothiimia of Sauvages — may also be mis-
taken, especially for apoplexy, or (or syncope ; but,
by attending to the history of the disease, in all its
forms, and to the slate of the pulse in the fit, its
nature will become apparent. When the par-
oxysms exhibit the regular course described above,
as they usually do, there can be no difficulty in the
diagnosis.

53. (a) If the fit be complicated with apoplexy,
it may be mistaken for the simple form of that
tnalady ; but convulsions will sufficiently show
the mixed nature of the attack. In the inter-
mediate «ta<es (§ 41.), or the paroxysms without
convulsions, greater difficulty will be experienced.
The nature of the seizure, will, however, be
evinced upon tickling the soles ; for, if it be epi-
leptic, no sensibility will be evinced, particularly
in the first and second stages of the fit ; whereas,
in apoplexy, the patient draws away his feet,unless
there be paralysis, but still one foot will retain
its sensibility. Eesides, this form of fit is seldom
above half an hour, or an hour in duration, unless
it be aggravated by improper treatment. — {h) Hys-
teria may be mistaken for epilepsy, particularly
when the paroxysms of tlie former are severe; but
the borborygmi and globus hystericus, the dis-
charge of limpid urine, followed by laughing,
crying, sobbing, &c. will indicate their nature.
INIoreover, sensibility is only obscured, but never
altogether lost, in hysteria, until it has assumed
the epileptic character; and the convulsions come
on first, even when the insensibility is greatest ;
the restoration of sensibility being often followed
by a renewal of the convulsions, the patient at last
recovering without any sopor, and with little or
no fatigue .— (c.) The convulsions of clnldreii
arc often confounded with epilepsy, although both
afl"ections are very distinct. The former are more

sympathy" sympathy depending upon the organic ner-
vous functions ; " reflex sj/mpiilhi/," upon the cerchro.
spinal. See, also, a paper in the I'liihtSDphical Transac-
tions for 1833, on the latter class of sympathies — the
reflex, which the author has dignified by the name of
" reflex J'lnulion.'^ The reader will then see in what this
7tcir " reflex, function," of thenervous system differs from
the old" reflex sympathy" of the nervous system ; or
whether it differsat all ; also whether or not the pheno-
mena usually designated hy the term sympathetic are
more correctly named by substituting for it the word
function ; function, in iihysiolui^y, being the office any
jiart espeiially performs, and not such phenomena as only
accidentally or occasionally dejiend upon it.

EPILEPSY — Prognosis — Treatment.

799

continued or recurrent ; are more irregular in
their course ; and are accompanied with more or
less fever, loss of appetite, and often with thirst ;
whilst the latter is less frequent, more periodic,
and attended by much less disorder of the digestive,
circulating, and assimilating functions; the one
being ata acute, the other a chronic, malady. —
(d) In fine, epileptic seizures may be readily dis-
tinguished from all others by — Istj their com-
mencing with a scream, and sudden and com-
plete loss of sensibility ; 2d, the spastic rigidity
of the affected muscles in the first stage ; 3d,
the convulsions being more tetanic than clonic,
unless in severe cases complicated with apoplexy ;
4th, the foaming at the mouth, distortion of the
features, and lividity of the countenance ; 5th,
the priapism and unconscious discharges ; 6th, the
injury sustained by the tongue ; and 7th, the con-
sequent sopor, or mental aberration. The diagnosis
of real from feigned epilepsy is considered in the
article on Feigning Disease.

54. VIII. Prognosis. — An opinion of the dis-
ease should have reference — 1st, to the recurrence
of the paroxysms ; 2d, to their severity, duration,
and the danger to be apprehended ; and, 3d, to
the nature of the disorder complicated with them.
Of epilepsy generally it may be said, even when the
simple form, and not very frequent recurrence,
of the fits indicate no immediate danger, that few
disorders are more intractable, or more liable to
contingent complications of a very serious kind.
The danger varies materially in the different
varieties and states of the disease, and increases
as the fits return more frequently, as they become
more severe or of longer duration, and as addi-
tional disorder of the nervous system associates
itself with them. — (a) In the simple forms, the
cerebral symptoms, preceding and following the
fits, are the chief guides in forming a prognosis ;
but what is known of the causes must also be
taken into account. The presence of intense

fiain, vigilance, delirium, mania, amaurosis, para-
ytic symptoms, &c., either before or after the
seizure, indicate organic lesions of the brain, and
an unfavourable form of the disease, usually
passing into some one of the complications de-
scribed above. In cases of this kind, considerable
danger is to be apprehended from the paroxysm,
especially when there is evident plethora. Here-
ditary predisposition, severe injuries of the head,
and the scrofulous diathesis, although not neces-
sarily indicating immediate danger, are also very
unfavourable circumstances.

55. (ft) The sympathetic states, or those associ-
ated with or arising from disease in related organs,
are generally less dangerous than the cerebral
varieties. Of these forms, the most serious are
the spinal and cardiac ; and the least so, the
uterine, enteric, and stomachic or dyspeptic, but
much will depend upon the amount of disorder
in the respective organs, and the habits of the
patient, particularly as to indulgence of the ap-
petites. When these are under due control, the
latter three varieties often terminate favourably.
The iiterine variety sometimes disappears after
marriage ; but if an attack occurs in the puerperal
states, it is attended by much danger.

56. (c) The complicated varieties present few
chances of complete recovery, especially the
paralntic and the insane. When, however, the
paralytic symptoms are slight, or pass away soon

after the fit, recovery should not be despaired of ;
and the same may be said of the form attended
by temporary delirium, or by delirium tremens,
or by temporary mania, or intermitting insanity.
M. EsQuiROL states, that epilepsy complicated
with continued insanity is never cured. I have
seen complete recovery from the apoplectic variety ;
but this is a complication also of great, and often
immediate, danger. The intermediate form is
much less dangerous.

57. (d) The fits usually recur most frequently
in the cerebral and complicated forms ; and next
in the spinal and cardiac. They are most rare in
the uterine and the nephritic, and in the gastric
and hepatic. Dr. Cheyne thinks that the disease
is most inveterate when it is accompanied with
chronic cutaneous affections. Addiction to mas-
turbation aggravates and prolongs it, and often
causes it to pass into the paralytic and maniacal
or insane complications ; but, when it has arisen
from this most baneful and disgusting practice,
and the patient has had resolution enougii entirely
to relinquish it, a complete cure will often be ac-
complished. Epileptic seizures from the meta-
stasis of gout or rheumatism, or in persons of the
gouty or rheumatic diathesis, may not return, if
these diseases fix themselves in the extremities.
When the fits arise from the syphilitic infection, a
mercurial course will generally remove them per-
manently. M. CuLLERiER has recorded several
instances of this.

58. IX. Treatment. — i. Of the Paroxysm. —
The intention is to shorten the fit, or render it less
severe: but this is not easily accomplished ; and
the means usually recommended for the purpose,
if inappropriately used, may have a very opposite
effect; and either render the next seizure more
severe, and the interval shorter : or convert wliat
would have been a simple, and by no means
serious, paroxysm into a recurring and prolonged
seizure, followed by various unfavourable symp-
toms.— Bleeding has been advised in the par-
oxysm ; but, unless in the epileptic convulsions
of the puerperal states, or when the fits are
attended by very marked plethora, or cerebral
congestion, or in a first attack, especially when
consequent upon the suppression of some san-
guineous evacuation, it should be deferred. Be-
sides, it cannot easily be performed in the con-
vulsive stage of the paroxysm, at which time it is
most appropriate. In the just mentioned excepted
circumstances, however, I have directed it with
great advantage. But in the soporose period of
the fit, it should not be resorted to, unless apo-
plectic symptoms be present. I have seen it, at
this stage, cause a return of the paroxysm as
soon as sensibility had been partially restored.*

* A gentleman, residing near Portman Square, Iiad
been under my care, in the spring of 1833, for articular
rheumatism. He soon recovered, and went out of town.
Towards the close of the year, whilst in Scotland, he had
an epileptic attack ; and was blooded in the arm, and
cupped soon afterwards. This was the second seizure
rtie first having occurred two or three years before. He
returned to town immediately after this second attack ;
and, when I saw him, there appeared no occasion for
further vascular depletion ; a course of alteratives and
stomachic purgatives was therefore directed. Three or
four days afterwards, he had a third seizure, and was
brought home in the soporose stage of the fit. I did no
see him until about two hours afterwards ; and then a
physician, who had been called in whilst I ivas sent for,
had had him cupped largely! But, soon after the de-
pletion, and as sensibility was returning, the paroxysm

800

EPILEPSY

■ — The cold affusion on the head and. occiput is
sometimes useful, particularly where there is
much heat of the head, and when the disease has
been consequent upon or connected with hysteria,
or associated with uterine disorder ; but in other
circumstances I have not seen so much advantage
from it as I had anticipated. Brera (Giorn. di
Med. Prat. t. iii. c. 3.), however, speaks of it
very favourably. It requires, however, discrimi-
nation as to the time and manner of employing it ;
for it may be even injurious, if resorted to in the
soporose stage, or continued too long, especially
when the head is cool, and the pulsation of the
carotids is weak : in these, the tepid or warm
affusion is much more appropriate. — Antispas-
modic aiid purgative enemata are, upon the whole,
as safe and efficacious means as can be employed
in the fit. When there is but little determination
to the head, the assafoetida injection, with or with-
out a small quantity of camphor, and some castor
oil, may be preferred. But when this symptom
is present, the terebinthinated enema (F. 150.) is
more efficient. In some cases it will be advis-
able to combine these substances, or to add
others.

59. Under every circumstance, all ligatures
and cinctures should be instantly removed ; and
the patient placed in bed, in a large and very airy
apartment, with the head and shoulders much
elevated. A cork or wedge-shaped piece of soft
wood ought to be introduced between the teeth,
and the struggles gently but not forcibly re-
strained, so as to prevent the patient from in-
juring himself by their violence. Certain popular
remedies have been noticed by writers. Dr.
F. Hawkins thinks that filling the patient's
mouth with common salt is not without use; and
J. Frank entertains a similar opinion of placing
a piece of cold metal in the hands. I have seen
apparent benefit from a similar application to the
nape of the neck and occiput ; and probably ice,
or the cold affusion, in this situation, would be

recurred. The obvious course in this case was, to have
caused the patient to be removed to bed, and to have
stated that nothing further was requisite in that stage of
the lit, until the patient had partly slept ofl' the exhaus-
tion ; when the physician in attendance would pursue
that course w hich his knowledge of the antecedent disor-
ders and state of the patient w ould warrant.

Aman of middle size, apparently about forty, consulted
me ; and stated that he had been seized with the first pa-
roxysm of the disease immediately pust coitura quinquies
rejietitum duabus cum puellis inter horas perpaucas ; that
he had been blooded to about a pint soon afterwards, and
experienced a still more severe fit about a month after
the first ; that the third seizure occurred about a fortnight
after the second, during whicli he fell down and cut
his head, the cut part having bled a pint at least ;
that his usual medical attendant, upon arriving soon
after the termination cjf this fit, bled him largely from
the arm ; but tliat, as soon as tlie vein was closed, the fit
recurred ; and that, during the struggles, the vein broke
out, and the blood was allowed to How until two or three
pints were taken in addition to the quantities lost just
beVore. The person who accompanied him to my house,
on account of his weak state, and who witnessed the
paroxysms, stated that this last was most severe ; and
that the fit which occurred during the depletion, and
which was attempted to be put a stop to by contlnuuig
the abstraction of blood until a very unusual quantity was
lost (about five pints in all), was remarkably prolonged
and violent. The patient was pale and weak, with a
waxy ajiiiearance of the surface ; completely exhausted,
physically and mentally; and constantly dreading a re-
currence of the paroxysms. This case furnishes a very
remarkable instance, not only of tlie lailure of large
blood-letting in arresting or shortening the fits, but also
of Its influence in rendering Ihcin moie frequent and
violent, when injudiciously prescribed. He iierfectly re-
covered under the treatment about to be recommended
Ci 1)1 . ct scrj.), aided by strict attention to diet.

— Treatment.

equally useful. Upon the whole, excepting th*
precautions recommended above, it will be as
well to adopt the advice of Celsus, and to do but
little in the paroxysm, unless under the circum-
stances now stated. Where the fits are moderate
and uncomplicated, and especially when the prac-
titioner is either in doubt, or insufficiently informed
as to the state or variety of the disease, this is cer-
tainly the safest plan ; for in the simple forms of
epilepsy^ I have seen more harm than advantage!
from the " nimia diligentia medici " during the
paroxysm.

60. ii. Treatment in the Intervals. — Upon
visiting an epileptic patient, the physician should
enquire into his general health, disposition, avoca-
tions, habits, modes of living, and former attacks
of this or of other diseases; and ascertain the
causes of the first seizure. The information thus
obtained, viewed in connection with his present
state, will generally enable the physician to ascer-
tain the following things, which are of the utmost
practical importance : — (o) The existence of
plethora, of asthenia, or of inanition, and the pro-
bable extent of either, in the simple, the sympa-
thetic,[diTiA complicated forms of the malady ; — (6)
The states of the digestive, assimilating, circulating,
depurative, and generative functions, and of the
organs chiefly concerned in them — or the st/?n-
pathetic forms of the disease ; — (c) The existence
of other disorders of the nervous system, and espe-
cially with reference to chronic inflammation, or
its effects in parts within the cranium — or the
complicated states ; — (rf) The evidence of im-
pending or of more remote danger. Having,
thus analysed the case, the particular variety
to which it should be referred will be determined
with greater ease. Proceeding thus, in order
to the due appropriation of the means of cure,
the physician should direct them calmly and
decidedly, with reference to the disposition, the
feelings, the weaknesses, and the irresolution of
the patient, and in a manner calculated to gain
his confidence, and to inspire hope. In this,
as well as in all nervous diseases, the con-^
munications of the physician should be brief,
clear, and forcible, without descending to any
explanation whatever, either as to the cause or
intimate nature of the disease, and the operation
of the remedies he recommends, or as to his
reasons for adopting them in preference to others ;
for these are matters respecting which no one but
a well-educated medical man can think aright,
or should even attempt to think. All endeavours
to explain abstract matters connected with disease,
and the means of removing it, to unprofessional
persons, however well informed they may be,
is to place ourselves at the mercy of the prag-
matical objector, oi self-sufficient volunteer
in the professed cause of humanitj. That igno-
rant empirics are sometimes apparently more
successful in the cure of nervous diseases, than
scientific ])ractitioners, chiefly arises from the
circumstance of the former being incapable of
stating their views, or assigning reasons for their
procedures ; whilst the latter, as justly remarked
by Dr. Ciievne, are generally very much too
ready, as respects both their own reputation, and
the confidence of their patients, to explain every
thing. The em])iric is fully convinced of the
justice of the apothegm — " Omne ignoium pro
viagnijico," ■ — and acts conformably with it :

EPILEPSY — Simple Ci-rebral — Treatment of.

gOl

the man of science is candid, and ready to im-
part to others the views he entertains. I'he
silence of the one, although generally the cloak
of ignorance, imposes more on the public than
the open deductions of the other, however con-
firmed by science and enligiitened experience.

61-. iii. Treatment of Simple Cerebral Epilepsy. —
A, This form of the disease, when depending upon
dejicieiit power, fini\ iiiaiiilion (^27.), being occa-
sioned chiefly by exhausting discharges, vicious
habits, or imperfect nuirition, obviously requires
the removal of these causes, and means to in-
vigorate the nervous system, and to equalise the
circulation, which, even when the blood is most
deficient in quantity, is generally inordinately
determined to particular organs, and especially
to the brain during the convulsive stage of the
fit. In this and the other form (§ 63.) of the
cerebral disease, the moral means just hinted at
are especially required, with the regimen here-
after to be described ; and, whilst the mind is
confirmed thereby, these intentions may be simul-
taneously fulfilled. With this view, a light and
nutritious diet, in very moderate quantity, and
chiefly farinaceous, may be allowed ; and the
preparations of iron exhibited in conjunction
with bitter tonics, or stomachic laxatives. The
feet should be kept warm, and the head cool,
whilst the circulation on the surface is promoted
by daily shampooing, or by frictions with coarse
flannels or the flesh-brush. If there be occa-
sional flushes, or increased heat of the scalp, the
hair should be cut close, and the head sponged
night and morning, or even oftener, with a cold
acetous lotion. INloxas or blisters may be applied
behind the ears, and repeated from time to time,
or a seton inserted in the nape of the neck. In
some cases, the latter may be found too irritating
or exhausting ; but, even in these, it may be of
service, if the rest of the treatment and regimen
be sufficiently invigorating; and the digestive and
assimilative functions be judiciously promoted.
As amendment proceeds, the cold sponging of
the scalp may be replaced by the dai^y use, in
the morning, of the shower-bath.

62. Where we have reason to suspect that the
disease has been induced by venereal excesses,
the carbonate of soda may be given with tonics,
and soda-water taken as a common beverage :
but neither of these ought to be continued too
long. In the scrofulous diathesis, and where
we suspect organic change, Bkandish's alkaline
solution may be prescribed, in any of the bitter
infusions ; or a solution of the iodide of iron, or of
the iodide of potassium. In a case very recently
under my care, three grains of blue pill, with
seven of the aloes and myrrh pill, were given
on alternate nights, and one of the above pre-
parations of iodine durlnsc the day, with very
remarkable advantage. When the functions of
the liver are impaired, as occasionally happens,
small but fr-ecjuent doses of the preparations of
mercury with taraxacum, taking care not to
afiect the mouth, will be of service. I have
found them, however, often fail of improving the
excretions, until tonics were also exhibited. In
a case of this kind, I prescribed very small doses
of the bichloride, with the compound tincture of
bark, and the preparations of sarsaparilla, with
great benefit. Equal proportions of the nitric and
hydrochloric acids, thrice daily, or oftener, or the

Vol. I.

addition of them to the warm foot-bath, may also
be useful. When the disease ].ioceeds from ex-
cessive sexual indulgences, late hours, and ad-
diction to intoxicating liquors ■ — a combination of
causes by no means infrequently inducing it —
the alkaline carbonates, or the liquor potassaj with
the infusion of valerian, or bitter tonics ; or very
sn)all doses of camjihor with the oxide of zinc,
and cinchona, or the tincture of the sesquichloride
of iron in the infusion of quassia, may be employed.
In this, as well as in the other varieties of the
disease, when depletions and depressing agents
have been carried too far, the preparations of
iodrne, or the extract of nux vomica, or strychnia,
or other tonic and antispasmodic remedies, here-
after to be noticed, may be prescribed, in foiins
or combinations which the peculiarities of the
case will suggest.

63. B. Simple cerebral epilepsy, connected with
pletliora or excited action in the head, is the most
common form of this variety in this country ;
and requires, according to the apparent degree of
either of these pathological states, hloodlctti)ig,
general or local, or both ; and, subsequently, the
affusion of cold water on, or cold sponging, the
head ; or the shower-bath ; derivatives, particu-
larly setons, moxas, or issues, or blisters behind
both ears, kept open some time, or often repeated ;
and purgatives every second or third night, with
low diet, and total abstinence from all spirituous
and fermented liquors. Unle^s plethora or vas-
cular action be very considerable, local blood-
letting once a month, in moderate or small quan-
tity, is preferable to large depletions ; and, if the
fits recur monthly, the patient may be cupped
just before the new or full moon, according to
the period at which the fits recur. Dry cupping
over the nucha and between the shoulders may
likewise be practised once 'or twice, or even
oftener, between the bleedings, as judiciously
advised by Dr. Ciieyxe. An issue or seton near
the nape of the neck, or an open blister, is
more serviceable in this than in the preceding
form of cerebral epilepsy. Where there is ma-
nifest determination to, or increased vascular
action in, the biain, anlimonials, and especially
.James's powders, are often beneficial. Dr.
CirEYNE {Dub. Hosp. Rep. vol. i. p. 315.) recom-
mends this powder to be taken at bedtime, com-
mencing with two or three grains, and increasing
the dose by half a grain each night, until a sensi-
ble effect is produced on the skin, stomach, or
bowels. If it occasion sickness, the dose should
be diminished one grain on the following night.
He states that, by adding a few grains of rhubarb
to it, a larger quantity of the James's powder
will be borne by the stomach than could other-
wise be taken. If it produce diaphoresis, the
same dose may be continued for three weeks, and
then it should be reduced half a grain each night ;
the course of this medicine thus usually extend-
ing to six weeks. In this manner the close may
be increased to fifteen or twenty grains, and con-
tinued for some weeks, without offending the sto-
mach. When we suspect the existence of a state
of chronic inflammatory action, the antimonial
liniment ( F. 301.") or ointment (F. 749.) may
be rubbed along the spine, or over the nape of
the neck and occiput; the latter application beino-
continued until a copious eruption of pirstules rs
procured, which should be kept out for some time.
3 F

802 EPILEPSY

64. Although cerebral or simple epilepsy fre-
quently appears connected with one or other of
the states of vascular fulness and action above
specified, yet cases will also often occur in which
the practitioner will be at a loss to determine the
presence of either ; the disease being dependent
upon deficient nervous power, with irregular cir-
culation or distribution of blood, rather than upon
any deficiency or excess of this fluid. In these
cases, the vital nervous system is primarily and
chiefly in fault ; congestion or irritation possibly
also existing in the medulla oblongata or adjoin-
ing parts of the encephalon. But little advantage
can be expected in such from depletions only,
especially when pushed far, as they will increase
these morbid states, and even favour determination
of blood to the heatl. I believe that most advan-
tage will accrue from such remedies as loitl pro-
mote an equable and free action of all the excreting
organs, and impart tone to the nervous system. Light
diet and very moderate use of animal food ; total
abstinence from fermented and spirituous liquors ;
careful avoidance of the predisposing and exciting
causes, and particularly of those in which the
case originated ; regular exercise in the open air,
taken often, and short of fatigue ; travelling,
or frequent change of air ; a due regulation or
moderation of all the passions and appetites ; the
daily use of the shower-bath ; external irritation
or derivation ; and anti-epileptic tonics and anti-
spasmodics ; or moderate local depletions; or dry
cupping, or both, as circumstances may indicate,
are the most rational resources. When the case
evinces an inclination to one or other of ihe states
above considered, the treatment pointed out with
reference to it should be enforced to an extent
co-ordinate to the amount of such disorder. If
there be any tendency to plethora or excited
action, animal food should be altogether re-
linquished,— a measure advi-ed also by Fother-
GiLi,, Hebeuden, Frank, Abercrombie, and
Cheyne.

65. iv. Treatment of the Sympathetic Varieties.
— A. From disease of the spinal chord or nerves
(§30, 31.). — This variety will necessarily require
either vascular depletions, or tonics, or even both,
according to the degree in whicli plethora, in-
creased action, or deficient power, is inferred to
be present. — (a) Where increased fulness or
action exists, cupping, the application of leeches,
and dry-cupping in the course of the spine ; the
insertion of setons or issues a little below the seat
of pain ; frictions with the mercurial and com-
pound camphor liniments, or the repeated ap-
plication of moxas, are the most efficient means,
aided by purgatives, the usual antiplilogistic re-
medies, and by rest. — (h) Increased vascular
action in the spinal chord, or its surrounding parts,
is, however, often associated wit!', deficient power,
and sometimes even with inanition. In such
cases, whilst moderate local depletion, dry cup-
ping, exteinal derivation, &c. aie resorted to, tlie
more antispasmodic tonics, as valerian, myrrh,
castor, &c. and even the preparations of iron,
cinchona, camplior, ammonia, &c., should be pre-
scribed.— (c) Thi-i state of disease is not infre-
quently induced by masturbation. In this case,
cold aspersion of the genitals, nigiitand morning;
sponging the spine with cold salt water, or with
vinegar and water ; or the effusion or aspersion
of these along the back ; and the interaal use of

Sympathetic — Treatment or.

the tincture of the sesquichloride of iron, or of the
sesquioxide of iron with soda, or of Brandisii's
alkahne solution in tonic infusions, will prove of
the greatest benefit. Due regulation of all the
secretions and excretions ; early rising ; and, as the
strength increases, a shower-bath every morning ;
will also be powerful adjuvants. When cold
sponging, &c. are not resorted to, tonic plasters
(F. 111. 117, 118.) may be applied along the
spine. — (rf) If pressure from the eflTusion of lymph,
or serum, or from the thickening of some portion
of the sheath of the cord, be inferred after a
careful examination, the preparations of iodine
may be tried both internally and externally, par-
ticularly the iodide of potassium, or the ioduret
of mercury ; or the hnimentum hydrargyri and
the Hnimentum terebinthinaj maybe rubbed along
the spine night and morning. — (e) If the fits be
preceded by an aura, a ligature should be in-
stantly applied above the place at which it com-
mences, if this be practicable; or a seton or issue
inserted in the part, and kept freely discharging;
or a blister applied before the expected return of
the paroxysm, and either preserved open, or often
repeated. — (f) Sometimes this variety is connected
witli uterine irritation or disorder ; it being almost
impossible to determine whether the spinal or the
uterine affection is primary, or which of them is
most instrumental in causing the epileptic seizures.
Cases of this kind are met with chiefly in large
or manufacturing towns, and in females who have
become addicted to sexual excitement; and appear
to me to be most benefited by counter-irritation
in the course of the spine ; by the application
of an antispasmodic liniment (F. 297. 311.) in
this situation ; and by the alkaline carbonates,
or Brandism's solution with hyoscyamus, in
tonic infusions or decoctions. Subsequently, the
remedies enumerated above (c) may be pre-
scribed.

66. B. ]Vith especial disorder of the heart or
lungs ( § 32.). — It is by no means easy to deter-
mine what is the most appropriate and successful
treatment in these states of the disease. Local
depletions, antispasmodic tonics, or chalybeates,
according as the case may present excess or de-
ficiency of blood, aided by purgatives or laxatives,
and regulated diet, are generally required. Ex-
ternal derivation, chiefly by means of one or two
setons or issues, should not be omitted. It has
been supposed that the circumstances especially
indicating the propriety of resorting to setons or
issues contra-indicate the exhibition of tonics.
But such is certainly not generally, nor even
frequently, the case in this disease. I believe
that, in many instances in which these external
means fail of affording relief, the failure has been
partly owing to their having been employed, either
at a time when the system has been too far re-
duced by depletions, or in conjunction with those
and other depressing agents, in cases wherein
such treatment was inappropriate, or carried too
far. Where the function, or even the organis-
ation, of the heart is aftected in epilepsy, it will
be found that greater benefit will accrue from a
judicious exhibition of tonics and antispasmodics,
aided by external derivation, than from other
reinedies. In many cases, tlic disorder near the
centre of tlie circulation depends, either upon
deficient or irregularly distributed nervous power,
or upon some affection of the medulla oblongata.

EPILEPSY — Sympathetic — Tueatment of.

803

and is merely a varied manifestation of the pri-
mary form of the disease. In these, the treatment
already advised for that form, according: to the
states of vascular fulness and action, will be ap-
propriate. Where signs of pulmonary congestion
or inflammation appear, after repeated seizures,
vascular depletions, external derivation, and low
diet, must be chiefly depended upon. Wlien the
fits are preceded by a feeling or any otiier symptom
of cardiac disturbance, an antispasmodic medicine
should be in readiness for the patient to resort to.
The following; have been recommended ; and either
of them, or F. 423. or 424?, may betaken, in any
of the forms of the disease, when premonition of
the fit is felt.

No. 210. R Aquse Amnion. Sesqui -carbon. 3j.; Tinct
Succini, 3iij.i Tinct. Castorei, Tinct. AsssefoetidJe, aa
5 vjss. Capiat a>ger coclileare unum minimum, vel duo,
in aquK cyatho. (De Haen.)

No. 211. B I'ol- Kecent. Lauri-Cerasi .5 vij. ; tcre cum
Sacchari Albi 3 xiv ; Pulv. Fol. Aurantiijj-; Syrupi
Ross et Syrupi Viola;, aa 3 ij- Fiat Electuarium, cujus
capiat coclileare unum medium ante paruxysnii acces-
sionera. (Van Mons.)

No. 212. B Tinct. .■\mnionia? Compos. 5iij.; Tinct.
Castorei, Tinct. Valerianae, aa 5 ijss. ; Mist. Cainjitiora!
3 vij. M. Capiat cocli. ij. vel. iij. magna, adveniente
paroxysmo.

67. C. With disorder of the digestive organs.
— (a) In the gastric association, it may often be
requisite to commence with an emetic, consisting
chiefly of the sulphate of zinc. But the frequent
repetition of it is very rarely of the least advantage.
Altliough the appetite is often ravenous, yet di-
gestion is slow and imperfect, and needs the aid
of tonics associated with laxatives. The com-
pound galbanum pill may be given through the
day, conjoined witii equal quantities of inspissated
ox-gall and Castile soap, or with the extract of
gentian and quinine; and, when the bowels are
sluggish, three or four grains of the gall may be
taken on alternate nights with an equal quantity
of aloes. If the biliary secretion be deficient, a
full dose of calomel once a week, followed by a
purgative draught (F. 181, 182.), will be requisite.
If there be deficient action or fulness of the
vascular system, or general asthenia, the mistura
ferri composita, or the mistura ferri aromatica
(^Dublin Pharmacop.'), may be exhibited ; or the
sulphate of iron, or of zinc, or of copper, or of
quinine may be prescribed with some tonic or
antispasmodic extract, or with the compound
galbanum pill. In cases eviiicing great depres-
sion of nervous power, with deficient tone of the
vascular and muscular systems, these latter re-
medies, or the ammonio-sulphate of copper, the
extract of nux vomica, or strychnia, or the nitrate
of silver, may also be tried, and in similar forms
of prescription. It is in this variety that travel-
ling, and change of air, of domicile, or of habits,
as advised by De Haen, is most likely to be of
service, as Dr. Cheyne remarks. In many cases
it will be necessary to assist the digestive organs
either shortly before, at the time of, or soon after
a full meal. With this view, the aloes and myrrh
pill, or aloes with mastich, or wiih the addition
of capsicum, has been generally recommended.
Either of the digestive pills in the Appendix
(F. 558. et seq.) may be directed in this manner.
The ox-gall with extract of gentian, or of hop,
and a grain or two of aloes, is the most beneficial ;
a small portion of the aloes acting fully on the
bowels, when combined with these bitter tonics,
or with the sulphate i)f quinine. These will

seldom or never fail of preserving the bowels very
freely open ; but, if irritation in the rtctuni be
excited by them, they may be relinquished for a
time, and injections substituted ; or they may ba
prescribed, in a more purgative form, every second
or third night.

68. {!>) Cases manifesting /(cputic disorder (§ 34.)
should be treated with reference to the nature of
that disorder. If symptoms of excited action be
present, general or local depletions, an"limonials
and cooling diaphoretics, and a seton or issue
near the region of the liver, will be necessary.
If there be enlargement, chronic obstruction, tor-
por, or accumulation of bile in the ducts, deob-
strueiit purgatives, especially the preparations of
mercury, the taraxacum in large doses, and sub-
sequently a course of alteratives (see especially
F. 503 — 511.) ; the repeated application of blis-
ters over the hypochondrium ; and the dilute
nitro-hydrochloric acid, internally or externally,
or both, will be productive of more or less benefit.
As, in these cases, the functions of both the sto-
mach and intestines are also impaired, these
means should be conjoined with so much of the
treatment directed with reference to disorder of
these organs (§ 67. 69.) as the peculiarities of
the case may warrant.

69. (c) Epilepsy from loorms or other disorders
of the intestines (^ 35.) should at once be treated
by the purgative anthelmintics ; for, even where
no worms may exist, these medicines frequently
remove morbid matters which have accumulated
in the prima via in this variety. Having ex-
pelled thtse sources of irritation, antispasmodic
tonics — especially valerian, assafoetida, camphor,
galbanum, the preparations of iron, &c. — will
gent^rully be of great service, in preventing both a
recurrence of the paroxysms and the regeneration
of worms. It is in this variety that an occasional
full dose of the oil of turpentine, either with cas-
tor oil, or followed, in two or three hours, by this
or some other purgative, is most beneficial. A
full dose of calomel should al^o sometimes pre-
cede the exhibition of the turpentine ; and their
action may be further assisted by enemata with
equal quantities of these oils. When the symp-
toms described towards the conclusion of para-
graph 35. are present, purgatives and purgative
enemata every second and third day, and tonics
or chalybeates, with warm cardiacs and anti-
spasmodics, should be prescribed for a considerable
period. Frictions of the surface, particularly of
the abdomen, loins, and thighs, ought also to be
employed daily, occasionally aided by warm em-
brocations or liniments. Subsequently, the shower
bath may be directed, and steadily persevered in,
with such other of the remedies already recom-
mended as the circumstances of the case may
require. Where associated disorder of ihe spleen,
pancreas, or mesenteric glands is present (4 36.),
purgatives, deobstruenls, and tonics, variously
combined, and the preparations of iodine, with
external derivation, are chiefly to be relied upon.

tin this variety, the following stomachic purgative.^,
taken alternately, at bedtime, will frequently be
very serviceable : —

No. 213. B Pilul. Hydrarg. (vel Kydrarg. cum Cre!a),
Pil. Galbani Comp., E\tr. Oolocyntfi. Conip.,aa gr. iv. ;
Fellis Bovini inspissati gr. ij M. Fiant Pilulje iij. pro
dosi.

No. 214. R Soda; Carbon. 3 j. ; Soda; Sulph. 3ss.—
3j. ; Infusi Senna?, Intusi Calumba;, Aquoe Pimentse, aa
3 V. ; Tinct. Cardamom. Comp. 3j. M. Fjat Haustus.
3 F 2

EPILEPSY — Complicated — Treatment of.

804'

70. D, From disorder of the generative and
urinary organs. — The causes {§ 37.) of this va-
riety should be ascertained and ivnioved, otherwise
medicine will be of little service. The treatment
should depend chiefly upon the degree of vascular
fulness and action, in connection with the state
of nervous power. When it has arisen from sup-
pressed catamenia, or from amenorrhoea, without
any chlorotic appearance, bloodletting may be
safely prescribed and repeated ; and the usual
means of restoring this evacuation resorted to.
But, when the fits appear before the catamenia
are established, the period of puberty having
arrived, bloodletting must be more cautiously
employed, unless there be evident plethora, when
it may be prescribed much more freely ; and it
should be aided by such emmenagogues and purg-
atives as the habit of body, diathesis, and strength
of the patient will warrant. If the disease be
attended by signs of irritation of the uterus or
ovaria, or by hysterical symptoms (§ 37.), heating
and stimulating emmenagogues and antispasmodics
should be laid aside, and those of a cooling and
sedative kind prescribed, such as nitre, with the
carbonate of soda or of potash, with hyoscyamus
or the preparations of hop. When the fits
follow the subsidence of regular and free uterine
evacuations, vascular depletion is veiy seldom
Leneficial ; the antispasmodic tonics, as valerian,
the compound tincture of valerian, assafoetida,
the metallic sulphates, &c., occasional purga-
tives, and strict attention to the digestive func-
tions, being much more appropriate. If the fits
Le connected with dysmenorrhcea, or scanty men-
struation, vascular depletions, especially from the
feet immersed in warm water, are generally of
service, when the habit is full, or the strength
unimpaired. After the necessary evacuations,
large doses of camphor combined with opium or
liyoscyamus, also in large quantities, will gene-
rally relieve the more urgent symptoms. This
practice has been pursued by me for several years,
and has very recently been recommended by Dr.
Cheynk. Semicupium, or the iiip-bath, the in-
ternal use of the bi-borate of soda, and frictions
of the lumbar region, abdomen, hips, and thighs,
night and morning, and, after coming out of the
l)ath, by a hard flesh-brush, orby flannel, will also
be useful adjuvants. If the attacks occur about
the commencement of the menstrual period, the ap-
plication of a number of leeches near tiie groins,
or on the insides of the thighs, shortly before tiie
expected time, will often render the attacks more
and more slight, and increase the discharge. Se-
tons or issues m the latter situation will sometimes
have a similar eflect. If tiie catamenia be too
abundant, or too frocjuent, or if symptoms of in-
anition or asthenia be manifest, the invigorating
measures already advised ought not to be neg-
lected. The connection of this form of the dis-
ease with manustui)ratio, or with great irritability
of the sexual organs, should be kept in recol-
lection ; and where either the one or the other is
detected, or even suspected, a strict mental and
moral discipline, with the means recommended
above (§ fj2.), ought to be instituted. An oc-
casional full dose of turpentine, eitlier conjoined
with some otiier purgative, or preceded by a dose
of calomel, or followed by a lirisk cathartic, and
turpentine enemata, are sometimes of great ser-
vice, particularly when the fits j^rocced from

suppressed, obstructed, or difficult menstruation."
Dr. Priciiatid advices the turpentine, in this
state of the disease, to be given in an emulsion,
in doses of from half a drachm to two drachms
three times a day, or two drachms every night ;
but in this mocle of exhibition it is generally
nauseated, and is often productive of disagreeable
effects, unless it be conjoined with some other
purgative. If the fits be connected with disease
of the ^lrinary organs (§ 37. 6.) the alkaline car-
bonates, with hyoscyanms, and oily purgatives,
or other remedies suited to the disorder of these
organs, will often prevent or relieve them.

71. V. Treatment of Complicated Epitepsii. —
'i"he complicated states, being evidently, in a
large majority of cases, caused by advanced
grades of the same pathological conditions as
produced at first the simple epileptic paroxysms
(§28. 51.), generally demand similar measures
to those directed in the cerebral forms, but
in a more energetic and persevering manner,
especially when occurring early in the disease,
and in young or robust persons. — A.thccom-
plicaiion with mania or insanity will require,
according to the history, the stage, and the exist-
ing circumstances, of the case, either copious
depletions and evacuations, or an invigorating
treatment, conformably with the principles already
stated. Ciironic inflammation of the brain or of
its membianes should always be dreaded in this
unfavourable form of the disease; and wherever
the state of the circulation, and the symptoms
referable to the head and organs of sense, espe-
cially the pulse in the carotids, and the temper-
ature of the scalp, evince its existence, general or
local bleeding ; the cold affusion on, and sponging,
the head ; purgatives ; mercurials with anti-
monials, particularly calomel and James's pow-
der; external derivation; irritating liniments,
setons, or issues, &c., should be employed, ac-
cording to the habit of body, and degree of vas-
cular action and vital power. When the com-
plication is of a maniacal kmd, and vital pov\'er
is not much impaired, these means may generally
be energetically prescribed ; repeated local de-
pletions, the spirits of turpentine in purgative
doses, and calomel with antimony pushed so far
as to affect the mouth, being often of great
service, especially if it occur in young robust
persons, or from the suppression or disappearance
of some other disorder, or of accustomed evacu-
ations, liut when the mental disturbance has
slowly supervened, or attended an asthenic state
of the disease (§ 27.), or has arisen from causes
proluctive of exhaustion or inanition, consisting
more or less of the low forms of insanity, or of
mental weakness, the treatment advised witii
reference to the nervous or asthenic form of cere-
bral epile])sy (§61,62.), must be pursued ; ex-
ternal derivatives, and free alvine evacuations,
being also directed. In this complication, the
functions of the heart, digestive canal, liver, and
uterine organs, simuld be duly regulated, as al-
ready recommended in the sympathetic varieties,
whenever they present any manifest disorder.

72. B. The apoplectic complication (§ 40.)
must be treated conformably with the principles
explained in the article Apopi.ixv. Hut my
experience enables me to state that bloodletting
can seldom be safely carried so far in it as in true
apoplexy ; and tiiat cupping on the nape of the

EPILEPSY — Remarks on Rejiedies nECOMMEXDED by AuTiiorts.

805

neck, leeches behind the ears and to the temples,
purgatives frequently repeated, brisk catl)iirtic
enemata, and external derivatives, are chiefly to
be confided in. After recovery from the seizure,
the measures appropriate to the habit of body
and other circumstances of the case, as described
with reference to the sanguineous form of cerebral
epilepsy (§ 63.), should be resorted to. The
intermediate slates between apoplexy and epi-
lepsy (§ 41.) will require local depletion, alvme
evacuations, and restorative medicines, according
to the evidence furnished of vascular fulness, or
of vital and nervous depression. In the intervals,
stomachic purgatives, and antispasmodic tonics,
with regulated diet, change of air, &c., will gene-
rally be necessary. When these states are con-
nected with disorder of the uterine functions, the
measures directed in the uterine form of epilepsy
should be prescribed.

73. C. The cvmplication ^lith paralysis (§42.)
will seldom be treated with any success, unless
the palsy be partial, and pass off soon after the
fit; when we may infer that it has been owing to
the congestion attending the convulsion. When
the patient is young, of a full habit, or of unim-
paired powers, bloodletting, general or local, or re-
petitions of the latter, will be requisite; aided by
purgatives, setons, and the other means advised
in the apoplectic complication. But in persons
presenting evidence of asthenia or inanition, the
preparations of iodine, especially the iodide of po-
tassium and ioduret of iron; the extract of (H(.r

the Varieties and Circumstances in which titev are
most appropriate. — A. Bloodletting, general and
local, has been recommended by most writers ;
but the extent to which it may be carried has
rarely been understood, and never attempted to
be assigned. At the present day, it is more fre-
quently carried too far than neglected when it
ought to be directed. Of modern writers. Dr.
Ci'LLEN and Dr. Bright have estimated it in a
manner which a])proaches the nearest to the
results of my own experience. If carried too
far, or performed in such a manner as to induce
full syncope, it is apt to bring on a paroxysm;
and if it be not followed by purgatives, restricted
diet, and regular exercise, it will only increase the
tendency to plethora. The circumstances in which
it should be prescribed, as well as those in which
it ought not to be resoited to, have been explicitly
stated ; but the extent to which it should be
carried, the particular situation and manner of
performing it, and the repetitions of it, can be
regulated only by the existing circumstances of
the case* — by the habit of body, the state of the
pulse, the modes of living, the strength of the
patient, and the causes producing and tending
to perpetuate the malady. Dr. Hebebden ex-
presses himself strongly against bloodletting; but
the class of persons amongst whom he practised,
and the inhabitants of large towns subject to
this disease, certainly are not so much bene-
fited by this evacuation as those otherwise circum-
stanced; and yet, even in them, very small and

vomica with aloes, or the aloes and myrrh pill, or often-repeated local depletion is frequently of great

struchnia, in any of the forms given in the Appen
dix (F. 542. 565. 907.); and the metallic sul-
phates, with the antispasmodic tonics, especially
valerian, serpentaria, assafalida, camphor, am-
monia, &c., will be most beneficial. But even
in these cases, purgatives should not be neglected ;
such as are of a warm stomachic kind being se-
lected, and exhibited regularly every second or

service.

76. B. Pwgatives, and purgative enemata,
have nearly all writers in their favour ; and 1 be-
lieve that there is no class of medicines which is
less capable of abuse in this disease than they.
But the success of the practitioner will depend
chiefly upon the selection and combination of them
appropriately to the peculiarities of the case; and

third day, so as fully to evacuate the bowels. In 1 upon his firmness in per.-isting in them, when they
"' -'•-'■ - •-■ ' ■ ' are clearly indicated, although little apparent

benefit at first results from them. The more
drastic purgatives, as elaterium, croton oil, and the
hellebores, have been presciibed ; and are most
suitable in the plethoric states, and apoplectic,
paralytic, and maniacal complications of the dis-
ease. The foetid, black, and even the white
hellebores have been recommended from Hippo-
crates to the present day ; and are often very
serviceable in the verminous and uterine varieties,
and in the maniacal complication, in which they
have been prescribed byCELSvs, Aret.iits, Alex-
ander Trallianus, Schuez, Starke, Smyth,
G REDING, and Prichard. Pliny states that the
tribune Drusus was cured of epilepsy by the
black hellebore. The powder of the root, or the
extract, may be given in doses of ten grains, in-
creased to thirty ; or the decoction of the leaves
or root may be employed. In the apoplectic and
paralytic complications, the extract or decoction
are advantageously given in enemata. The oil of
turpentine, especially conjoined with castor oil.

the n.ore sthenic states of this variety, complete
recovery from the paralytic symptoms is some-
times witnessed after free evacuations ; but the
patient is not secure from a return of the paroxysm
in some one of its most dangerous states of com-
plication, although his health may appear quite
re-established. In a case to which I was lately
called, these symptoms disappeared after a full
bleeding from the arm, copious purging, &c. ;
and the patient was able to pursue his occupation,
and expressed himself cjuite well : but in a few
days he was seized with another fit, of which he
died in a few minutes. The bloodletting which
I directed in this case was laige; but the habit
of the patient, the state of the pulse, and of the
blood drawn, and the effect produced by it, indi-
cated the propriety of having recourse to it in a
decided manner.

74. IJ. Of the other complications (§ 43.) of
this malady, little further need be adduced. They
retjuire more especially a persevering use of sto-
machic and dtiobstrueiit purgatives, with anlit

spasmodics, external derivatives, and due attention in order to insure its cathartic operation, is a very
to diet and regimen, varied and associated with efficacious medicine, exhibited either tiy the mouth
other means according to the particular nature of , or in clysters. It is, in the latter mode of admi-
the complication, or sympathetic disorder, and the ; nistration, the safest and most active of antispas-
habit of body and other circumstances of the case. J modics that can be given during the paroxysm •
75. vi. Remarks on the Remedies and Means of j and, when presciibed in energetic doses, and suil-
Cure recommended by Aulhora, tvith reference tn I ably combined, it produces a very remarkable

3F 3

806 EPILEPSY

derivative action from the head, whilst it fully
evacuates the intestinal canal, and stimulates the
abdominal organs. Hence it is especially ser-
viceable in the enteric, verminous, uterine, apo-
plectic, maniacal, and paralytic states of the dis-
ease. It has been employed successfully by
Latham, Young {Trans. of Coll. of Phys. vol. v.
p. 52.), Percival (Edin. Med. and Surg. Journ.
vol. ix. p. 271.), LiTHGOw (i;;id. vol. xi. p. 301.)
PniCHARD, and by myself (see Med. and Phys.
Journ. for May and July, 1821.) The an-
cients, as well as the moderns, have depended
also upon scammony, colocynth, and aloes ; but
ofthe.se, as well as of calomel, it is unnecessary
to make further mention. Ur. IIebilRden was
averse from the use of purgatives, excepting
in the enteric variety, owing, probably, to the
reason assigned above (§ 75.); and, certainly, in
the more asthenic states of the disease, and when
the circulating fluids are deficient in quantity and
qizality, if trusted to mainly, they will be produc-
tive of mischief rather than benefit. In such cases,
they should be given only on alternate -^lays, or
every thiid day, — should be of a warm and
stomacliic kind, or combined with tonics, and
associated with the means recommended above
(§ G7.). Thom, J. Frank, Kinneir, Mangold,
&c., prefer rhubarb, the neutral salts, and the
bi-turtrate of potash. This last, given in large
doses, is most serviceable, when persisted in, if
the vascular system be plethoric, and the biliary
secretion in a morbid state. Galen and many re-
cent writers have preferred aloes. In some one or
other of its preparations and combinations, it is the
most generally appropriate purgative that can be
prescribed. With stomachic, chalybeate, and car-
diac medicines, it is suitable in tlie asthenic cases;
and combined with ox-gall, or with sulphate of
quinine, or with bitter extracts, &c., it will act with
very remarkable energy, and without depressing
vital power, — a circumstance of peculiar import-
ance in the treatment of epilepsy.

77. C. Emetics have been recommended by
Aret-eus, ALtxAxuER of Tralles, Zacutus Lxj-
ciTANUs, Ettmuller, Roncalli, Werlhoff,
Lettsom, J. Clarke, and others. Van Svvieten
and J. Prank assign, with much propriety, the
circumstances in which they should be given, in
prescribing them only when the fits appear to
proceed from disorder of, or the irritation of mor-
biil oi' noxious matters in, the stomach. De
Haen directs them when the paroxysm is preceded
by nausea ; Tissot, when a sense of weight, or a
ravenous appetite, is felt; and RicnxER, shortly
before the expected return of the fit. RIayer is
favourable to the use of them, particularly of
ipecacuanha, exhibited in doses short of producing
full vomiting, and INIarhvat prefers those con-
taining the sulphate if copper. Heberdkn con-
siders them injurious; and Frank remarks, tiiat
he has never known an instance of a cure having
been effected by them, although he believes that
they have cleared the way for the action of other
medicines. I agree with Meihom in restricting
them to the stomachic form of the disease, and in
considering that they may be injurious in most
other states, especially when there is much vas-
cular fulness or cerebral congestion.

78. D. iJi(//)//07e(ies are much praised by TisbOT
and l.KNTiN, who consider it of much importance
to promote; a free and equable perspiration, which

Remarks on Remedies recommended by Authors.

is seldom observed in epileptics. James's powder'
as prescribed above, or the other preparations of
antimony, may be selected, particularly in ple-
thoric persons ; or the vinicm ipecacuanhie may be
given with liquor ammonia acetatis, and the spi-
ritus (Blheris nitrici. These are, however, most
serviceable after other evacuations have been em-
ployed, and when the skin is dry ; and then their
operation may be aided by the tepid bath, as ad-
vised by TissoT and Marcard. Dr. Abercrom-
BiE, according to Dr. Cooke, has seen benefit from
Wiepotassio-tartrate oj untimoni), given four times a
day, in such doses as the stomach could bear. I
had recently a patient under my care, who expe-
rienced a very severe attack whilst he was under
the influence of this medicine.

79. E, Emmenagogues are required in those states
of the uterine form of the disease that are con-
nected with delayed, suppressed, or difficult men-
struation. The oil of turpentine is one of the
most efficient of this class of medicines that can
be given in such cases, as fully shown by Dr.
Prichard, more especially after bloodletting from
the feet, or leeches to the groins and tops of the
thighs, and the hip-bath, or semicupium, have
been prescribed. The bi-borate of soda is also
sometnnes of service, either given alone, in doses
of ten or fifteen grains, or in conjunction with
other emmenagogues and antispasmodics, — more
especially with cauiphor, or valerian, castor,
an-.monia, galbanum, assafoetida,' aloes, &c.
(F. 268. 368.). Rut, as M. Maisonneuve
justly remarks, the restoration of the uterine
functions to their healthy state is not always fol-
lowed by a cure or even alleviation of the disease.
When this is the case, the treatment must pro-
ceed according to the principles already explained.
Marriage has occasionally removed the seizures,
especially in the female, as remarked by Stahl
(Jje Dispos. Hered.ad Var. Morh. p. 48,), Hoff-
mann {Ue L';j(7ep. 0pp. vol. iii. obs. 9. p. 20.),
Krijnitz (De Iilalrimonio ]\Iultor. Morb. Uemedio.
Franc. 1749.), ]\1oreau (]\Um. de la Soc. Med.
d'' Emulation, t. ii. p. 189. — in the male), and
Prichard (Op. cit.), A young lady, whom I
long attended on account of slight epileptic
seizures, connected with irregularity of the uterine
functions and of the bowels, experienced, after
marriage, a gradual amendment for some time ;
but had a very severe attack of puerperal mania
after her first child. She is now in good health.

80. F, Tonics and antispasmodics. — In the
asthenic states of the disease, and in the other
varieties, after bloodletting and the foregoing
evacuations have been actively prescribed, re-
medies possessing a tonic and antispasmodic
action aie chiefly to be depended upon. Rut
these should be selected with reference to the
results of experience as to their operation, to the
form of the disease, and to the particular fea-
tures of the case, especially the states of sen-
sibility and irritability, and of vascular fulness
and action, generally and locally. Rut even
when such remedies are most necessary, purga-
tives should be so conjoined, or so alternated,
with them as to j)rcserve a regular action of the
bowels, or to occasion a brisker operation once or
twice a week, according to the strength of the
patient. In many cases, also, it will be requisite
to adniiiiislcr tonics, and, still more frequently,
antispasmodics, even conlempoiuneou^ly with

EPILEPSY

local depletions, more especially wlicn general or
local plethora is associated with defective power
and increased susceptibility.

81. a. OC mineral tonics and antispiismndics, the
most active are the metallic sulphates and nitrates.
— a. The preparations of copper, particularly the
cupri ammonio-sulphiis, or the simple sitlphus
cupri, have been recommended by Aret/eus,

EOERHAAVE, Van SwIETEN, WLlZENBnEYEIt,

Duncan, Baumes, Tiiilemus, Thei'ssink, I\Ii-
CHAELis, Cullen, Stone, Greding, Bi.and,
Vogel, VVillan, Bathe, and Reil ; and em-
ployed by them successfully in many cases. Urs.
Home, Hook, and Magennis, however, state
that they have found it to fail in most instances.
Dr. F. Hawkins expresses himself much in favour
of the sulphate, in doses of a fourth of a grain,
conjoined with sulphate of quinine, or cinchona.
In the asthenic states, and in the more plethoric
forms, after depletions and evacuations have been
prescribed, this combination, and the amnioniated
preparation, frecjuently produce very great bene-
fit, and sometimes entirely cure the disease. Dr.
Urban (Hufeland, Journ. d. Pr. Heilk. 1827.)
prefers the animoniacal sulphate in the simpler
states of the affection ; and prescribes eight grains
of it in forty-eight pills, of which three are to be
taken night and morning, increasing the dose by
one pill each second day.

82. $. The sulphate and oxide of zinc have been
prescribed by IIart, Martini, Hartmann,
Crell, Aasheim, Bell, Percival, Guthrie,
Haygarth, Rush, Arnaud, Richter, and Ra-
nge. OsiANDER directs the zinc with valerian
and orange leaves. The oxide has been preferred
by most of these writers; and Dr. F. Hawkins
advises it to be given with extract of conium. I
have combined it advantageously with the am-
moniated copper (F. 459. 593.), with camphor
(F. 615.), and with valerian (F. 582. 665.) ; but
I believe that the sulpliate is more efficacious,
especially when conjoined with camphor, musk,
or other antispasmodics (F. 584 — 587.). Upon
the whole, zinc appears to be less useful than
copper in this disease, although 1 do not rank it
so low as Dr. Cullen and Dr. Cooke, have done,
who employed chiefly the oxide, which is fre-
quently inert, unless it be exhibited in large
doses.

83. y. The nitrate of silver seems, from a pas-
sage in Staiii. (^Theoria Med. Vera, p. 1019.), to
have been given in this disease as the principal
ingredient of a secret medicine much employed
in some parts of Austria at the time when he
wrote; having been probably adopted from the
preparation described by Angelis Sala, v/hich
consisted of a solution of the salt in wine ; and
which he directed in so large doses as to act as
a cathartic. Schroeder, however, had already
recommended it in epilepsy and other diseases of
the head. Both Sala and GEOFrROV prescribed
it as a purgative in dropsies ; but; although
ScROEDER and Boerhaave had mentioned it as
a cure for epilepsy, it was scarcely used until Dr.
Wilson noticed (Duncan's Annals of Med.
vol. ii. p. 405.) its good effects. It was afterwards
adopted by Dr. Sims, Dr. Cappe, Dr. Powell,
and many others, who published proofs of its
efficacy. Subsequently, Dr. Baillie, Dr. Ro-
get. Dr. R. Harrison, Dr. J. Johnson, Dr.
Cooke, Dr. Semenitni, I\I. Valeniin, Dr. Heisi,

Remarks on Remedies recommended by Authors. 807

and others, have prescribed this medicine with
advantage ; and the more numerous observations
of M. Lombard have also proved its success in a
very large proportion of cases. The discoloura-
tion of the skin by it, noticed by Albers, Roget,
J. Johnson, Vetch, and others, is so frequent,
and so permanent when it does occur, as to be
a serious objection to it. In some of the cases
in which this effect was produced, the disease
was not removed ; but in others the recovery
was complete. It does not seem to depend so
mucli upon the largeness of the dose, as upon
the long continuance of its use. Sementini
(Giornale di Fisica, t. xi. p. 355.) recommends
this salt to be triturated with some vegetable
extract, and given in tiie form of pill ; in this state
the dose may be gradually increased to six or
eight grains, or even more, in the day. I have
prescribed it thus in several cases of epilepsy,
and other diseases; and frequently with great
benefit. It should not be continued very long,
without intermitting it for a while. An eruption
of minute pustules over the surface of the body,
sometimes is proiluced by it, as first lemarked
by Sementini, and observed by myself; but
this should be viewed as a favourable circum-
stance. The nitrate of silver appears to me most
beneficial in the asthenic states of the disease ;
or after evacuations have been practised in the
other forms; also in the stomachic and enteric
varieties, and in the complica'ion with paralysis.
I have generally combined it with hyoscyamus,
or camphor (F. 473.), extract of belladonna
(F. 472.), musk, opium (F. 475.), or gentian
(F. 474.). The following is the mode of admin-
istering it adopted by Heim, an eminent physician
in Berlin : —

No. 215. R Argenti NitratisinPuIv. gr.xij. ; Opii Puri
gr.vj.; Extr. Conii IVtaculati 5ij.; Extr. Glycyrrh 5j.
Tere bene, et divide in Pilulas ponderis granorum duo-
rum. Blane et vespere iij. — v. pil. capiat.

84. S'. The preparations of iron, especially the
sulphate, and the tincture of the sesqui-chloride, are
often beneficial in the asthenic forms of the disease,
or when depletions have been carried too far, and
morbid matters have been evacuated. They have
been much praised by Tissot, and by Quarin,
who combined them with hellebore. I have
directed them with valerian (F. 40.); with ex-
tract of hop ; or with ox-gall, aloes, and myrrh,
— £. Arsoiic, particularly Fowler's solution, has
been employed by Pearson, Brugnatelli,
Prichard, and A. T. Thomson. It requires
much caution ; as too large doses, or a too pro-
tracted use of it, may produce injurious effects,
especially on the heart and arterial system. —
^. The trisnitrate of bismuth has been tried by
me in two or three cases, both alone, and with
other tonics and antispasmodics, the bowels hav-
ing been kept freely open ; and has appeared
quite as beneficial as the preparations of zinc. —
n. The chloride of barium has been recommended
by Hufeland and Gebel (Hufeland, Journ. d.
Pr. Heilk. h. vii. st. 3. p. 177.), especially when
the disease is connected with the scrofulous dia-
thesis ; the aqua calcis, by Tissot ; and the snl-
jihuric acid, by Ruland (Curat Empir, cent. vi.
obs. 96.), Rosenberg (Rosa Jatrica, cap. 30.),
HiHsciiEL, Feuerstein, and Hildebuand. 'i"he
nitro-hiidrochloric acids, in equal proportion, have
been prescribed by me in tonic and astringent
infu-ion.s, in only one instance, connected v^ith
■ 3 F 4

808

EPILEPSY — Remarks on Remedies recommekded by Authors.

torpid function of the liver, and with some bene-
fit ; but the ultimate result is unknown to me.

85. b. Numerous vegetable tonics have been
employed, in circumstances similar to those in
which the foregoing are prescribed. — a. Cinchona
and its preparations have been preferred, espe-
cially when the paroxysms were periodic, by
Bang (Acta Ueg. Soc. Med. Hann. vol. i.
p. 106.), BuciiHAVE {Act. Med. Soc. Ha/n. vol. i.
p. 224.), Frank, Chkvalier, Comparetti (Oc-
cursus Medici, 'i^'c. p. 303.), De Haen, Cullen,
Home {Clinical Experiments, &;c. p. 194.), Pinel,
&c. ; and by Tode {Med. Chirurg. Bihliolh. b.ii.
p. 160.), with the ammoniacal salts. — (3. Orange
leaves, and the bark of the tree, have been praised
by Tnii.ENius {Med. Chir. Bemerk. p. 129.),
IIannes, Fischer, Gesner {Beobacht. h. i.
No. 19.), De Haen, IIenning, Tissot, Locher
{Observ. Pract. p. 44. 47.), Oberteuffer, Hlte-
LAND, &c. Quarin {Animadvers. &;c, p. 23.),
however, and Home, consider them inert. —
■y. Tlie misletoe, or viscum album, was formerly
much employed against tliis disease ; and is evi-
dently a medicine of great power. But the
misletoe of the oak is procured with difficulty.
It has been prescribed in epilepsy, probably from
the time of the Druids. Gerarde {Herbal,
p. 1351.) mentions it as a popular remedy. Par-
kinson * {The Theatre of Plants, p. 1394.) is
much more copious respecting it ; and Colbatcii,
in his treatise on its virtues, thinks it almost spe-
cific. The evidence of Borelli, Cole, Boer-
iiaave, Van Swieten, Buchwald, Andree,
Haller, De Haen, Quarin, and others, is also
very much in favour of it. Dr. Frazer states,
that out of eleven cases which he treated with it
in the years 1802, 1803, and 1804, nine were
completely cured. He prescribed it in powder,
in the dose of from two scruples to two drachms,
twice a day, in camphorated emulsions. Dr. Fo-
TiiERGiLL, Dr. G. i'liOMPsoN, INlr. Haynes, and
Dr. Willan, have also employed it successfully.
On the other hand, Tissot, Culi.en, Hojie,
Good, and Cooke place no confidence in it ; and
at the present day it is almost wholly, and, per-
haps, undeservedly, neglected, unless by empi-
rics, whose success in this, as in other diseases,
often depends upon the adoption of a once popu-
lar and efficacious remedy which had fallen into
undeserved disuse. — J'. Valerian is mentioned
by DioscoRiDEs and Arftkus as a remedy
in epilepsy. F^arius Calumna cured himself
and others bv it (Phytobasanos, Nap. 1592. 4to.
p. 97.). Willis {De Morb. Convul. c. 24.),
Panarolli (Jatralogism. Pentecost, i. obs. 33.),
Cannengifsser, Marcard, Brisbane, Lin-
naeus, Quarin, Haller, Fotiiergill, Sprem-
GEL, Unzer, and many others, have insisted on
its efficacy when exhibited in sufficiently large

• He states — " The Missellto it selfe of the Oke is the
best (or of the Chesnuttree.as Matthiolus saith to boas
good), made into pouther, .ind given in drlnl<e unto
those that have the falling sicknesse : but it is fit to use
it forty days together : and with this caution, that the
wood, after it is broken from the tree, doe not touch
the ground ; which is in my miuilo too superstitious. "
— " (Jf.ntilis I''iii,(;iNAS, and others, have so liiglily
esteemed of the vcrtues hereof, that they have railed it
Lignum sanclie Cruets ; bcleeving it to heipe the
falling sicknesse, ai)o])lcxy, and palsic very speedily. " —
" Divcrrs doe esteeine of the Missellto that groweth on
llassell nuts, or Peares, as effectual as that on the Oke,
BO It touch not the ground, for the falling sicknesse, to hv.
taken in wine. "

doses. TiiiLENius (Med. Chir. Bemerk. p. 1 13-r-
131.) and other German authors, prefer its essen-
tial oil ; and M. Gi'iBERT (iiei). Medicate, Dec.
1827, p. 376.) gives the e.itract in large doses.
A powder, consisting of valerian and puff-balls,
the hycopcrdon Bovista, is a popular remedy for
the disease in Germany ; and several writers con-
tend that this latter substance is almost a specific
for those fits which proceed from terror (Cooke).

— M. Tissot placed great confidence in the effi-
cacy of valerian, not only in epilepsy, but in all
nervous affections requiring a gentle tonic and
antispasmodic. Cullen, Home, Frazer, VVood-
viLLE, Heberden, Tode, and Cooke, however,
consider it a medicine of very little power — an
inference much at variance with my experience
of its effects when appropriately exhibited, and
depletions and evacuations have been premised,
in plethoric cases. The powder of the root soon
loses its activity by keeping; and, even when
recent, often requires to be given in large doses.
The ammoniated or camphorated tinctures, the ex-
tract, and the essential oil, are useful preparations
of it. The formulae in the Appendix, particularly
F. 81. 101. 269. 368. 582. 665. and 863., illus-
trate the mode of prescribing it ; but in most
cases of this disease its quantity should be much
increased. It may also be exhibited in enemata.

— e. The root of the Artemisia vulgaris, or mug-
wort, has been recommended by Burdacii, Hufe-
LAND, and LoEwENiiARD, in the dose of from 50
to 80 grains, on alternate days, or a few hours
before the expected return of the fit, the patient
being kept warm in bed. Hufeland prescribed it
in ten cases, of which three were completely cured,
three much relieved, and four received no benefit
(Reu. Med. 1824.1. iv. p. 447.). Its operation,
in the above dose, is tonic, diaphoretic, and diure-
tic. In plethoric cases it should be preceded by
depletions and cathartics (see F. 224.).

86. ^. Assafa'tida has been much employed,
but seldom in sufficiently large doses, and not
always in appropriate circumstances. It is advan-
tageously combmed with purgatives, and other
tonics and antispasmodics (F.367. 423. 480.).
Lange (Miscel. Verit. p. 59.), Berger (De
Uemed. Specif, in 'Epilep. p. 13.), and Tissot,
give it with valerian. With either castor, cam-
phor, t;albanum, myrrh, aloes, ox-gall, &c.
(¥. 368. 481, 482.), or any two of these, it is ser-
viceable in the asthenic, dyspeptic, and enteric
forms, and in the uterine variety after evacuations
have been prescribed. It is one of the best medi-
cines that can be given in enemata during either
the fit or interval (F. 135, 136.). — >i. Calbanum
and myrrh are useful chiefly as adjuncts in these
varieties ; but they are less efficacious singly
than assafcEtida and the other substances just
named. — S'. Camphor may be employed in every
form of the disease, but in very different doses and
combinations : in the plethoric s'ates, in small
quantity with diaphoretics and refrigerants (F.24.);
in the astlicnic, enteric, and uterine varieties, in
full doses with Ionics and other antispasmodics
(F.-35. 615.). LociiER (Observ. Pract. No. 40.)
prescribed it with bark : and Tlssot, Pinfl, and
most modern writers have employed it, either as
the chief agent, or as an adjuvant of other sub-
stances. When an immediate effect is required,
it should bo given in the form of draught or mix-
ture, with the preparations of ammonia or of the

EPILEPSY — PvFsiAnKS on Remedifs eecomjiended ny Author?

809

aethers (F. 186.212. 423. 845.). It often shortens
the fit, or prevents it altogether, when exhibited
in enemuta stiortly before tlie usual period of ac-
cession, as in Formulre 130. 135 — 138. 151.

87. c. Of a)iimal substances, castor, mask, and
ox-galt are most deserving of notice. — a. Castor
is recommended by Aret^eus, Celsus, Pliny,
Serapion (apud Ccel. Aurel. p. 352.), K. Dicby
{Experimen. Med. p. 332.), ]\Ioor ( Pathol. Cerebri,
p. 211.), Thouvenel (Sur les Vertus des Subst.
Anim. Medicain. p. 3o7 .), TissoT,and Fotheiigill.
When unadulterated, and given in full or large
doses, it is often of much service ; especially in the
asthenic, dyspeptic, and uterine varieties; and in
the combinations advised in respect of assafoetida
and camphor, with which (as well as valerian and
musk) it may be conjoined (F. 480. 497. 905.).
— B. Musk is also beneficial in these varieties, or
in the other forms, after evacuations have been
prescribed, and in similar combinations to those
mentioned with reference to the preceding sub-
stance. It is favourably mentioned by Feuerstein,
Van Swieten, Quarin, Culi.en, Ackermann,
and others. Hannes made a full ami s iccessful
trial of its efficacy on his own son (See A'^ova Acta
Nat. Curios, vol. v. p. 244.). It shouh!, unless
intended merely as an adjuvant of other means,
be given in much larger doses than usually di-
rected. It may be conjoined with camphor, sul-
phate of zinc, &c. — y. The bile of various animals,
particularly of the ox, bear, and dog, has been
noticed by Bartholin, Unzer, Quarin, and
others. Of inspissated ox gall I have had some
experience in this complaint ; but have usually
directed it in combination chiefly with assafoetida,
galbanum, myrrh, aloes, &c. (F. 558. et seq.)
It is of much service in the states just particular-
ised, and after depletions have been carried far,
or to an injurious extent. In a case of this latter
description, I am now employing it with very
marked advantage.

88. d. Cold or salt water bathing has been
advised by Celsus, C/elius Aurelianus, Flover,
Eextin, Tissot, and Hufeland ; but it requires
caution, and attention to its effects. In young
persons and delicate females, who have not been
accustomed to a plunge bath, the fear or shock
of immersion may bring on the seizure : indeed,
Wiekard {Observ. Med. Franc. 1775.) and
ToDE (Med. Chir. Bibl. b. i. p. 117.) adduce in-
stances of such an occurrence. The shower-bath,
used daily, commencing with tepid water, and
gradually reducing the temperature, in cases
where the shock may be dreaded, is of much less
equivocal benefit ; and is, in all the varieties, but
in the simple or cerebral forms especially, a very
excellent remedy. When it cannot be employed,
the patient should daily efluse water from a large
sponge over the whole head and occiput.

89. G. Numerous substances evincing more
of stimulating, than of tonic and antispasmodic,
properties have been prescribed, with occasional
success; but, in general, in combination with one
another, or with medicines producing- an astringenl^
or tonic efl^ect. — a. — a. The oil o( hartshorn, or
Dippel's animal oil, was very generally used, both
internally and externally, especially during the last
century, owing to the recommendations chiefly of
Dippei. (Disqiiisit. de Vit(c Animalis ]\lor/io et
Med. &:c. p. 89.), Alberti (De Med. in Motlhns
Nat. Exacerbatis. Halae, 1718.), Vatfr (De

Specijicor. Epilep. Sigillatiyn Olei Animal. Vir-
tutibus. Vitel. 1725.), Mauchart (De Oleo
Animal. Dippeltii. Frib. 1745.), Juch,Kortum,
Bang, Thouvenel, Cullen, jNIoranu, and Por-
tal. Feuerstein believes that, when it is pure,
and not altered by the action of the air, it is often
beneficial. Ackermann considers it possessed of
no small efficacy in the asthenic forms of the
disease, particularly those connected with anemia,
and languor; but hurtful in the irritable and ple-
thoric states. Quarin advises it in the uterine
variety. Tissot, however, thinks it possesses but
little power. — B. Cajuput oil was prescribed with
benefit by Goetz (in Commerc. Lit. Noric. 1731,
p. 5.), in doses of from two to ten drops on sugar ;
and by Werlhof (Oper. Med. p. 711.), with
cinchona. — y. The oiV and other preparations of
amber have been found sometimes useful by Ri-
VERius (Pia.r. Med. p. 32.), Beattie (De Cogno-
scend. et Cvr. Morb. S^c. Halaj, 1780.), Cullen
(Mat. Medica, vol. ii. p. 361.), and others. The
oils of hartshorn, cajuput, valerian, and amber, are
serviceable chiefly in the simply nervous and as-
thenic states of the disease; and are useful adju-
vants of other medicines, and are often beneficially
conjoined with narcotics (§97.). Besides these,
other oils, both simple and medicated, have been
prescribed ; but they hardly deserve enumeration.

90. b. Phosphorus was, I believe, used for
epilepsy first by Kramer (in Commerc. Lit.
Noric. 1733, p. 137.) ; and more, recently by
Feuerstein, Quarin, and others. Weikard,
Autenrieth, and Hufeland justly view it as a
doubtful and dangerous remedy. Haartmann
(De Noxio Phospb. in Med. Usu, &jc. Aboee,
1773.) gave it in four cases without benefit. — /3,
Caiitharides has been tried internally, by AIer-
curialis (De Morb. Pueror. 1. i. c. 3.), Zacutus
LusiTANus (Prax. Admirab. 1. i. obs. 35.), Stoc-
KAH (De Usn Canth. Interna. Goet. 1784.
p. 34.), and D v. 5. 3 on^so^ (On Derangements
of the Liver, &;c. p. 105.), with occasionafadvan-
tage. Its external use is, however, more com-
mon, if not more beneficial, in this complaint.

91. c. Guaiacum, either in decoction or sub-
stance, has been employed by Vesalius ( Haller's
Bibl. Med. Pract. vol. ii. p. 32.), Willis (De
Morb. Convuls. p. 460.), Sennert (Prax. Med.
I. i. c. 31.), Mercurialis (liespons. et Consult.
I. ii. c. 3.), FoRESTUS (Observ. Med. 1. x. obs. 58.
63.), F. Hoffmann (J^led. Rat. Syst. t. iv. p. iii.
c. i. p. 21.), and others, who considered it pos-
sessed of much efficacy in this complaint, espe-
cially if connected with a syphilitic taint ; but it
has been neglected by more modern writers. —
y. The flowers of the Cardamine pratensis were
found beneficial by Berger and Nagel (De Usu
Med. Card. Prat. &ic. Franc. 1793. p. 13,) ;
but Baker (Trans, of Coll. of Phys. vol. i.
p. 443.), Lysons (Pract. Essai/s, S\c.~p. 173.),
and Gredino, state it to be inefficacious. The
saturated infusion of the flowers and leaves pro-
duced a copious and foetid perspiration in the
experiments made with it by Berger. (De Itemed.
Spec, in Ep. S^c. Fianc. 1795. p. 11.)- ^. The
Arnica montaiia has likewise been noticed by
Stoerck, and the Serpentaria, by Gruelmann
when the attack has been occasioned by fright.

92. d. The extract of tmx vomica was praised by
SiDREN (in Acta Med. Suec. t. i. Upsala?, 1783,
p. 367.), Rese (De Nuce Vomica. Jena?, 1788.

BIO EPILEPSY

p. 20.). HuFELAND (Journ. d. Pr. Arsneyh. b. i.
p. 109.), and Vieweo (in Annal. der Heilkunst,
Mai, 1811. p. 426.); and its active principle,
strx^chnia, was prescribed by Dr. Brofferio
(Revue Med. t. iv. 1825, p. 488.) in this disease.
I have tried the former preparation in two or three
cases, and conjoined it with aloes (F, 541, 542.
907.). It is a powerful remedy in the asthenic
forms of the disease, and in the paralytic compli-
cation, connected with inanition, or consequent
upon excessive evacuations. When the fits follow
tlie disappearance of the menstrual discharge, it is
of especial service. Lobenstein-Loeel recom-
mends the tinclure of nux vomica, beginning with
sixteen drops every three hours, and gradually
increasing the dose to thirty or even to forty. This
medicine is most injurious in the plethoric, inflam-
matory, and irritaijje states ; and, if carried too far,
is liable to excite inflammation of the membranes
of the brain and spinal cord. These remarks apply
equally to strychnia, which should be given in
very small doses, and with strict attention to its
eft'eets (F.'565.). I know of an instance of its
having caused an attack of the disease in a person
who had not had it before. The Strycknos Sancti
lo-natii, or the Igriatia amara, has been prescribed
by Stein and Valentin. It operates similarly to
the foregoing, and requires equal caution in its use.
The secret remedy for epilepsy employed by Witz,
father and son, is said by Dr. Haase to have con-
sisted chiefly of the powder of this bean. It was
found most useful against the fits following ex-
cessive fear ; and was given in doses of two or
three grains twice or thrice daily (Bullet, des Sc,
Med. de Ferussac, t. xi. p. 74.).

93. e. The ■pttony (Fcconia officinalis) entered,
in conjunction with various vegetable antispas-
modics and tonics, into many of the empirical
remedies so much employed in epilepsy. The
dried root, seeds, and flowers, and the recent ex-
pressed juice of the root, were chiefly used ; and,
with other writers, old Parkinson (Theatre of
Plaiits, p. 1382.) directs the male plant to be
selected. The root was formerly hung around
the neck as a charm against a return of the fits.
Although praised by Berger, Forestus, Willis,
RiVERius, Apvni.{De Epilepsia. Alt.1713. p. 39.),
ScHACHT (Iiistit. Med. Pract. p. 64.), Murray
(Appar. Medicam. t. iii. p. 40.), De Haen (Rat.
Med. par. vi. p. 317.), and Vogel (Hist. Mat.
Med. p. 206.), no confidence is placed in it by
Sylvius (Op. Med. p. 427.), Herrmann (Cttnos.
Mat. Merf. Argen. 1726. p. 176.). Moor (Path.
Cereh. &c.), IIai.i.f.r, and Tissot. The im-
perfect trials made of it by Home (Clin. Experim.
2d ed. p. 209.) showed it was not without efi^ect,
This contradictory evidence is easily explained by
the empirical mode of prescribing it ; like the
other medicines classed under the present head, it
being appropriate only in the asthenic cases, and
in the uterine variety after evacuations have been
practised. — The Scdurn acre, or wall-pepper, was
used in Germany, as a popular anti-epileptic,
before it was noticed as such by medical writers.
L/iuiiENDKii, of Saxony, first prescribed it, and
gave from ten to fifteen grains of the dried plant
for a dose. Isciiorn (IIufelam), Journ. d. Pr.
Jleillt. h. xiii. p. 167.) afterwards resorted to it
with success. Petfus (liihlioth. Med. t. vii.
p. IHi.) tried it with five patients, one of whom
was cured, and the others relieved. M. Fauverce

Remarks on Remedies recommended by Authors.

(Journ. Gener. de Med. t. xcvii. p. 152.) em-
ployed it in four cases, three of which were cured.
In these, bleeding was premised and vegetable
diet directed : and very recently, M. Godier
(Ibid. t. cviii. p. 141.) has given it in three cases,
but with benefit in two only.

94. /. Rue (Rata graveolens), and its distilled
water, decoction, infusion, expressed juice, and
oil, were formerly much employed in epilepsy,
especially by Forestus (De Capitis et Ventris
Mortis. 1590, 8vo.), Mayerne (Prax. Med. p.
20.), Moor, Riedlin (Lin. Med. Ann. iv. 1698,
obs. 25.), and Stenzel (De Rata Medicam. et
Venen. Viteb. 1735). Pliny (I. xx. cap. 13.)
mentions the use of the decoction before the ex-
pected return of the paroxysm ; and IJoerhaave
(Consult. Med. Goet. 1752, p. 28.) frequently
confided in the distilled water and infusion. It,
as well as the sedum acre, should be prescribed
only in those cases to which I have restricted the
pa;ony. — The extract, infusion, and powder of the
flowers of the Narcissus pseudo-narcissus have been
recommended by Lauremberg (Appar. Plant.
1. i. cap. 18.), and Du Fresno y (Des Propriet.
du Narcisse de Pres. Paris, 1788), in such doses
as will not irritate the stomach. The Viola odor-
ata, and V. tricolor, also, have been noticed by
DioscoRiDES, Pliny, Matthioli, and Haase, as
anti-epileptic medicines.

95. g. The frequent dependence of epilepsy on
the scrofulous taint, or upon morbid structure,
induced me several years since to employ iodine*
in the treatment of it ; but the utmost discrimi-
nation and caution are required in the use of this
substance; for it maybe injurious in the inflam-
matory and plethoric states of the complaint, or if
given in too large doses, or even for too long a
period. It is indicated chiefly in the asthenic
conditions, and in the paralytic complication, if
independent of inflammatory action. The iodide
of potassium, or the iodurctted solution of it, or the
iodide if iron, may he preferred. But the iodides
are often uncertain as to the relative proportion of
the metal and iodine. The iodide of mercury,
although a promising combination in this disorder,
was prescribed by Dr. Roots until the gums were
affected, but without permanent relief. — I have
found the ioduretted solution of the iodide of potas-
sium most serviceable, given in very small doses
three or four times a day : blue pill, and the aloes
and myrrh pill, or any other gentle stomachic
aperient, having been taken at bedtime, A patient
at present under my care is pursuing this treat-
ment with great benefit.

96. /(. Petroleum, tninernl oils, and naphtha,
especially the former, have been recommended
by DioscoRiDts (I. i. cap. 85.), Wedel (De
Epilepsia. .Tenas, 1676.), and Gmelin (Appar.
Medicam. vol. i. p. 185.). Ramazzini (Opera,
p. 320.) has published a curious tract, written
about the middle of the fifteenth century by
Francis Ariosto, in which petroleum is said to
have been employed successfully against this
disease." — Theffitherial preparation from caoutchouc
seems deserving of a trial in the sim))le or nerv-
ous states of the disease. — Of the ])reparations
of ammonia and of tether, little further need be

* Ihml, a carpenter, aged i'orty, for many years subject
to epilepsy, was treated with l)lue an<l aloes and myrrh
I)ill on .•ilternatc niijhts, .and with twelve ilrops of (he
tinct. of iodine thrice d.iily. lie has now Ijeen three
years w ithout a fit.

EPILEPSY — Remarks on Remedies recommended by Authors.

811

stated. They are useful adjuncts — especially the
spir. amnion, foetid., tlie tinct. amnion, comp., and
the tinct. valeriantE composita — to tonic or other
agents, in the nervous or asthenic conditions of
the complaint ; and are sometimes serviceable
when the accession of the paroxysm is indicated
by failure or irregularity of the heart's action, or
by other symptoms depending upon deficient nerv-
ous power. In such cases, the patient should be
provided with a medicine into the composition of
which these preparations very largely enter (F.
210. 423. 424.), and liave immediate recourse to
it upon the recurrence of these symptoms.

97. H. Tlie propriety of giving Narcntia and
Anodynes in epilepsy is sometimes questionable.
Yet cases frequently occur in which they may be
prescribed, not only with safety, but with advan-
tage, in judicious combinations, and after plethora,
general or local, lias been removed, and morbid
secretions evacuated. — a. Opiates were employed
by Aetius {Tetmh. iv. ser. i. c. 96.), Avicenxa,
JMillars, IMoRCAGNi, De Haen, Trali.es (i)e
Usu Opii, sect. iii. p. 16.),Tissot, Murray ( Ap-
par. Med. t. ii. p. 272.), Ciili.en (Mat. Med.\o].
ii. p.247.),FoTHERGiLi. (Med. Observ.and Inquir.
vol. vi. p. 80.), Rehfield (Doering's Tracts, vo\.
i. p. 160.), and Cooke. They should not be ex-
hibited in the plethoric or inflammatory states, until
evacuations have been carried to the utmost ex-
tent ; nor in any form of the disease, until tlie
bowels have been fully and frequently purged,
and the secretions have assumed a natural cha-
racter. In these circumstances, and in the asthenic
conditions of the complaint, they are often valu-
able remedies ; more especially if the attacks have
proceeded from fright, or other affections of the
mind, or are connected with an irritable or suscep-
tible state of the nervous system. Aetius and
AvicENNA gave opium, with various stimulating
antispasmodics ; Sh^itiERT (Medicime Pract, vol. i.
p. 370.), with camphor ; Duchesne with aro-
matics ; Aaskow, with assafcetida ; Huxby, with
musk; and Ferhiar (Med. Hist, and Reflect.
vol. i. p. 34.), with musk and camphor. De Haen
and Darwin prescribed it alone, at bed time, suc-
cessfully, in cases in which the fits came on during
sleep. Ward and Portal applied it with benefit,
externally to the part which appeared to be the
seat of irritation. Panzani (Giornaie di Med.
t. xiii. ^'en. 1776.) exhibited as much as four
grains with advantage in a case compl'cated with
maniacal delirium. It is seldom of any use in
the hereditary disease, or in that occasioned by
the suppression of accustomed evacuations, — in-
deed, it may be injurious in the latter ; and as
Quarin (Aninutd. Pructica,Y>. 20.) justly remarks,
it may induce a state of apoplectic torpor, when
given during the paroxysm. The preparations of
7norpliia, especially the acetate, in the liquor
ammonias acetatis and camphor julep, or with an
aromatic spirit, are frequently preferable to the
pure opium, and less likely to aflect the head in-
juriously. I have found the following draught
to agree even with those who could not take opium
in any of the more usual forms : —

No. 210.1^ Morphiffi Acetatis gr. J ; solve in Liq. Am-
moniae Acetatis 3jss.,et addeWist. Camphoras (vel Aq.
Distillata;) 3 j. ; Spirit. Caryoph. 5j. ; Olei Anisi Uliij.
M.- Fiat Haustus.

98. b. Stramoninm, principally its extract, has
been much employed in epilepsy by Continental
writers. Stoerck (Liliellits, quo dentonstralur

Stramonium, d;c. Vindob. 1762), who first pre-
scribed it in this complaint, gave from half a
grain to a grain of the extract, three, four, or six
times a day, for several weeks or months. It af-
terwards was approved of by AVahlin, Spa-
LOWSKY, DuRANDE (Gardane's Gazette de Sante,
1773 et 1774, p. 143.), Sidren (De Usu Stramonii
in Convuts. Ups. 1772), Razouz (De Cicuta,
Stramonio, &;c. Neni. 1780, 8vo.), and others.
Odhelius (Coram. Acad. Suec. Stuck, vol. xxvii.
p. 277.) prescribed it in fourteen cases of epilepsy
and convulsions, eight of which, he says, were
cured, and live relieved. G reding (Sammtl.
i'c/i)'j7t, th. i. p. r02.), however, states, that of
twenty-eight epileptics, it cured only two, per-
manently relieved tour, and temporarily relieved
eleven. He remarks, that aperients, tonics, and
antispasmodics should also be exhibited. Arne-
mann (Pract. Arzneimitiellehre, th. i. p. 279.)
advises it to be given in the form of a pill, with
camphor and bitter extracts.

99. c. Hynscyamus, as well as stramonium, is
indicated only in the circumstances and states of
the disease pointed out when remarking on the use
of opium and morphia ( § 97.), and in similar
combinations to them. Mayerne (Synt. Prax.
Med. Lond. 1690, p. 23.) prescribed' the seeds,
commencing with six or eight grains, gradually
increasing, in the course of forty days, the dose to
twenty-four grains : and directed them to be taken
in theexpressedjuiceofthesem/;er(;iri<»!. Stoerck
employed the extract, the preparation adopted also
by Sauvages, Lentin, Bang, Greding, and
Oiserteuffer, who derived from it only slight
or temporary advantage. — Conium has likewise
been employed by Stoerck and some other wri-
ters, chiefly with liquor potassas, when the disease
is connected with the scyofulous taint.

100. d. The powdered root and leaves of bella-
donna, and the extract, are recommended by
MiJNCH, fatherand son. Stole, and Bottcher. —

RiCIITER, LOBENSTEIN-LOEEL, and HuFELAND

(Journ. d. Pr. Arzn. b. ix. p. 100.) prescribe
either of these, with tonics, antispasmodics, and
aperients, according to the nature of the case.
Greding (Ludwig's Adversaria, b. i. par. 4.)
considers this plant to possess but little efficacy.
Kaufer and jMtJNCH, the son (De Usu Bella-
donnce in Melanchol. et Epileps. Goet. 1783),
however, contend that it is especfelly beneficial
when the fits are followed by maniacal alienation
or tremors. It is most suited to the atonic states,
conjoined either with ammonio-sulphate of copper,
or with nitrate of silver {F. 472.), or with musk,
castor, camphor, &c. — Tobacco is stated by Sen-
NERT, Zacutus Lusitanus, and Dupau (in Jow,
de Med. Sept. 1789), to have been used success-
fully in the form of clyster, in the stomachic and
verminous associations of the complaint. Currie
directed epithems of the infusion over the epigas-
trium, before the accession of the fit, with benefit.

101. /. There are many other substances which
have been employed internally in this disease. —

'((. Digitalis is one of the most important of these.
Parkinson (Theatre of Plants, p. 654.) remarks,
respecting it, that "divers have been cured of the
falling sicknesse thereby ; for after taking of the de-
coction of two handfulls thereof, with four ounces
of the potlipody of the oake bruised, in ale, they
that have been troubled with that disease twenty-six
years, and have ftdlen once a week, or two or

812

EPILEPSY — Remarks on Remedies recommended by Authors.

three times a moneth, have not fallen once in
fourteen or fifteen moneths." Salmon and With-
ering also praise it ; but Currie {Mem. ()/' the
Med. Society of Land. vol. iv. p. 18.) gave it in
three cases with only temporary benefit. Dr.
PERCiVAL(E(/i«. Med. and Surg. Jour».\o]. ix.
p. 271.) also tried it unsuccessfully, but in an un-
satisfactory manner ; for it is not by the empirical
exhibition of one or two large doses of this medi-
cine that good effects can be obtained from it in
a chronic complaint. Its efficacy in small doses
has been shown in two cases (Atner. Med. Recor-
der, No. 2.) ; and in one that came under my
own observation. It has been favourably noticed
also by Dr. Br iocs and ]Mr. Scott (Edin. Med.
Joiirn. Jan. 1827), and by Knight, who has
found much benefit from it in epileptic insanity.
Dr. Sharkey recommends an infusion of it in
porter to be given until vomiting supervenes. It
is advantageously exhibited also in conjunction
with tonics, antispasmodics, and anodynes (F. 456.
469. 514. 537.) ; and is most serviceable when
the disease has been caused by fright, or is con-
nected with disorder of the heart.

102. b. The preparations of mercurxj have been
used in epilepsy for their alterative effect, and in
combination with various antispasmodics, or with
antimonials. Of the propriety of these in the ve-
nereal and hepatic associations of the complaint,
no doubt can be entertained. But in other cir-
cumstances they require discrimination. In the
inflammatory or congestive states, and either
alone or with James's Powder, they are often bene-
ficial, although they be carried so far as to affect
the mouth. Piso, Roi.finck, Scardona, Wal-
ther, M. Hoffmann (Eph. Ac. N. C. cent. 1. et
2. p. 272., et Ibid. cent. 3. et 4. p. 231.) and
Rahn, have adduced proofs of the good effects of
salivation in some instances. When we reflect on
the frequency of serous effusion in the cavities,
and of alterations of the coverings of the brain in
fatal cases, a judiciously conducted course of mer-
cury, independently of the evidence of Willis,
Riedlin, Ettmuller, LocnER,TissoT, Burseri.
Lysons, Frank, Sporry (Ueb. die Wurk. des
Quiclisilhers in der Ejiil., in Mus. der Heilk. b. i.
No. 35.) and others in its favour, promises some be-
nefit. It is chiefly, however; in the moreactive con-
ditinna, or when the malady presents the apoplec-
tic, inflammatory, maniacal, or paralytic compli-
cations ; or follows some acute cerebral disease,
and the pulse retains considerable firmness ; that
mercury, given so as to affect the mouth, is most
likely to be serviceable. In these, calomel or
blue pill, with antimonials or mercurial inunction,
may be employed ; but in the more astlienic and
chronic cnsf.s, either these preparations should be
conjoined with antispasmodics, as camphor, castor,
or musk, as directed by Bang ; or the bichloride
should be given dissolved in sulphuric tether (J.
Frank), or in tincture of bark ; or hydrarg. cum
creta, or Pi.uMMKit's pill, with .James's powder,
Castile soap, or any other substance that the pecu-
liarities of the case will suggest.

103. c. The elutriated oxide of tin has been re-
commended by ]3r. Shearman, in the dose of two
scruples to a drachm to an adult, night and morn-
ing, continued for four or five days, an active ca-
thartic l)cing exliihiled on the fifth day, and the tin
again resumed, nccnnlitr^' to its (•ffe<;l. — J'he ace-
tate of (end has been prescribeil by Mavehni;,

Saxtorth {Acta Reg. Soc. Med. Ilaun. vol. iii*
p. 90.), Rush {Philad. Med. Mus. vol. i. p. 60.),
and Ei;erle {Lond. Med. Repos. vol. viii. p.
178.) ; and the hydrochloric acid, by Larrey,
chiefly in the syphilitic and cachectic states.

104. d. The Agaricus muscarius has been
found serviceable in doses of from ten to twenty
grains, by Whistling {De Virtut. Agar, Mas.
c*^'c. Jenffi, 1773, p. 13.) ; the Boletus suaceoleiis,
in doses of a scruple four times a day, by Enslin
(De Bol. Suav. ^c. Erling. 1784, p. 77.) ; the
Aconitum panictilatum, by Durande ; the root of
the Dictamus albus*, by Stoerck ; the seeds and
root of the Ilcraclium spondylium, in doses of two
or three drachms of the latter, by Pliny {Hist.
A^at. 1. xxiv. cap. 6.) and Orne ; the root of the
Tussilago petasites, by Cranz {Nat. Med. par. ii.
p. 162.); the colchicum, by Alderson {Land.
Med. and Phys. Journ. vol. xxxvii. p, 17.) ; the
Hyssopus officinalis, by Forestus, Ruland, and
Sennert ; the flowers of pimpernel {Anagullis
arvensis), in doses of twenty grains, three or
four limes a day, by Dioscorides and Gasser ;
the expressed juice of the Galium luteum, in doses
of two or three ounces in the morning, by Chomel
{Plant. Usuelles, &^c. t. ii. p. 24.), Gardane
{Gaz.de Sante, 1773. p. 19.), and Wendt {Klin.
Annal. p. 146.) ; the seed of the Lycopodium
clavatum, by Schroeder and Kuhn ; the Lnnaria
rediciva by J. Frank ; the watery extract of
the leaves of i/eiu (Taans baccatus), in from one
to ten grains in the day, by Loder {De Tato
Bacchato. Jena, 1794, p. 17.) and HuFELAND,in
uterine epilepsy ; the Cocos micij'era, by Thun-
BFRG ; the flowers of the Anchusa officinalis, by
Brutz and Baldinger ; the Bryonia alba, by
Reusner ; the essential oil of the Buxus semper-
vivens, by Schroeder and Vogel ; the flowers
of the Lilium convalliwm, by Senkenberg, Bal-
dinger, and Langhan, in doses of a scruple to a
drachm, in the periodic type of the complaint;
the powdered leaves, the decoction, and the es-
sential oil of the Origanum majorana, by Dios-
corides, Schroeder, and Fonseca ; the berries
oi xhaSambucus nigra, by Dufour ; the decoc-
tion of the Solanum dulcamara , by Boerhaave,
in epilepsy from metastasis ; the flowers and root
of the Tilia Europea, by Hoffmann, Ruland,
andTiLEMANN (De Mat.' Med. p. 308.) the Ver-
bena officinalis, by Sebitz and Rosenstein ; and
the distilled water of the Prnnus laurocerasus, by
J. Frank. Neither of these require any remark,
excepting this last, which, from the quantity of
hydrocyanic acid it contains, is sometimes not with-
out eflficacy. Its active constituent, liydrocyanic
acid, is occasionally beneficial in the simple states
of the complaint, after plethora has been removed,
and the bowels fully evacuated, or when the dis-
ease is connected with great susceptibility and irri-
tability, or is dependent on pain, local irritation,
or gastric disorder. — Of internal treatment, gene-
rally, it may be added, that every medicine will
fail, or afford merely temporary advantage, as
long as plethora exists, or active determination
to the head is unrestrained, and the appetites arc
indulged. And I must subscribe to the justice

* Baron Sloet, of the Hague, praises the following: —
R Pulv. Cort. Had. ])irtamni albi Crc/rnxis (Frn.ri-
«(•//«) 'It), j. ; I'ulv. /('iloiiriac 5jss.; Caiiiat 3 ij., in
aqua I'lor. 'I'ilia', l)is ad qiiator in die. The bowels to
'In- kept freely open ; and leeches to be applied occasioii-
allv I" the anus.

EPILEPSY — Remarks on Remedies recommexded uy Authors.

813

of Heberden's remark — " Etenim nulla sunt re-
media, quae non toties spes nostras fefelleruut, ut
incertum sit quantum illis dubeatiir, ubi visa
sunt profuisse," (Commeiil . t^c. p. 143.) It is
chiefly by a judicious sequence, and combination
of remedies ; and by a well-devised plan, having
strict reference to the circumstances of the case ;
that we can hope to treat this malady with
success.* <«

105. K. Electricity was formerly much em-
ployed, but is now seldom tried, in epilepsy.
Deshais, ]M.vxgix (Hist, de I'Eteclr. par. iii.
Paris, 1752), IMorris (Gent. Mag. 1753, p.
379), LiNNSus (Co/isect. Electrico-Medica. Ups.
1754), Franklin, and Lovet (Elect, rendered
vseful in Med. Intentions, Lond. 1760), furnished
the earliest notices of its use ; but these were un-
satisfactory, and almost contradictory. The more
extensive experience, however, of Feller (De
Therapia per Eteclrum. Leips. 1785), Feuer-
STEIN, Deimann, and Kuhn (Geschichte der
Med. u. r/ivs. Elect. &;c. Leips. 1785, 8vo.), de-
monstrated — what indeed might have bten in-
ferred a priori — that it is occasionally successful
in cases characterised by debility, inanition, or tor-
por of the vital functions, and in those occasioned
by frights; but that it is seldom beneficial, and
may even be injurious, in the acute, plethoric, in-
flammatory, and hereditary states of the complaint.
In cases caused by suppressed di-charge, it is not
always a safe remedy : for, although the experi-
ments of Spengler and KiJiiN have furnished in-
stances of itssuccess in such ; yet those of LiNN^us,
Feller, and QuiiRiN, show that it was either in-
efficacious or hurtful, unless evacuations had been
premised. Of the effects of galnDtic e'ectricitii, the
evidence is but little different from the foregoing.
Mr. Whitlam {Land. Med. Fhys. Journ. vol.xiv.
p. 527.), Ur. Duncan (Ann. of Med. vol. viii.
p. 339.), and Mr. Mansford, have detailed cases
where this agent proved of service ; but the last-
named writer admits, notwithstanding his views as
to the nature of the disease (§ 50.), that galvanism
can often rank only as an auxiliary means.
His plan of employing this agent is peculiar ;
and, although it may be the most rational and
efficacious, it is seldom possible to have recourse
to it ; for, granting that the physician may
manage, in the way Mr. i\lA>sFORD directs, con-
stantly to inclose the body of his patient within
the circle of a galvanic battery, yet it may not

* M. BoKiE's' plan of treating epilepsy, which is in
great repute in Paris, is as follows : — Having premised
a small blood-letting from the feet, exhibited an emetic,
and acted on the bowels by means of four grains of calo.
mel, and an ounce of castor oil, he dim ts, every morn-
ing, fasting, twenty drops of the distilled laurel water in
a glassful of sugared water ; increasing the dose one drop
daily until it reaches sixty, when that quantity is con-
tinued ; and, every night, two drachms of the leaves of
the urtcmisia, in powder, in the infusion of the tilia
Europea. He applies, every fortnight, moxas — not ex-
ceeding six — along the spine, from the occiput down-
wards ; causes the lower extremities to be well rul)bed,
with somea-therial preparation, twice daily ; and leaves a
bracelet on the left arm, which is to be drawn very tight
upon the approach of the fit. He allows the patient only
water for his drink, and restricts him to vegetable diet.
He further directs sea-bathing — the head being first
immersed — or the shower-bath, and exercise in the open
air, avoiding exposure to the sun : and, lastly, he enjoins
him — " Eviter les I'motions vives, les emportemens de
rolere, les occupations serieuses, les tensions de I'esprit,
les lectures obscencs, la frequentation des spectacles, les
contrarietes, les habitudes extenuantes, Tonanisme, les
plaisirs vcneriens," ^:c. (Journ. dcs I'rogris des Scicn.
MM. t.ii. D. S. p. 226.)

prove successful, or the benefit derived may cease
with the discontinuance of its use. Of electricity
and galvanism, it may be said generally that
they have occasionally been found successful ;
that, when resorted to shortly before the seizure,
they have sometimes suppressed it, or rendered it
more mild ; that, when applied during the par-
oxysm, they have often mitigated its violence and
duration ; and that the safest mode of employing-
electricity is to place the patient on the insulating
stool, and subject him to the electric hath ; and to
diaw sparks from diflferent parts, when thus insu-
lated, and placed in connection with tiie prime
conductor.

106. L, Of external means, the most de-
serving notice are selons, issues, moxas, open
blisters, and artificial pustulation. — a. The ac-
tual cautery, applied to the nape of the neck, the
occiput, and even to the vertex, is recommended
by Aret;eus, Celsus, C.t.lius, Aurelianus,
AvicENNA, and several writers of the sixteenth
and seventeenth centuries. At the present time,
moxas have nearly superseded the cautery, and
have received the sanction of the most expe-
rienced writers, especially Esquirol and Larrey ;
the former of whom directs them along the cervix
and spine, he having observed disease of the
medulla oblongata and spinal cord in several
instances.

107. h. Setons and issues have been directed
by nearly every writer on the disease. In the
cerebral variety, with determination to the head,
they are often serviceable ; but in the asthenic
forms, or when evacuations have been carried
too far, and when susceptibility and irritability
are augmented, they often either fail, or increase
the disorder, unless tonics and antispasmodics be
administered. The nucha is the place usually
selected for their insertion, but the insides of the
arm or thigh are often preferable situations.
Zacutus Lusitanus (Prax. Admir. 1. i. obs.
22.), Ab-Heers, RocHARD, and Lociier, direct
either them, or the actual or potential canterif,
to the seat of the aura. JM.Andral prefers the
latter means, and advises their application to a
limb in preference to the nucha or occiput. An
accidental burn of the limb, followed by ulcer-
ation, has not infrequently effected a cure, as in
the case detailed by Dr. Bona (Hufeland's
Journ. 1827).

108. c. Artificial pustulation by tartarised an-
timonial ointment, applied to the nucha, occiput,
or vertex, has been found serviceable by Dr.
Carter (Lond. Med. Eepos. vol. xix. p. 382.,
and vol. xxi. p. 369.), Mr. Crfigtiton, and Dr.
IVIn.Ls ; but it has, like all other agents, also
failed. Horx (Archie. \B12, May, p. 573.)
directs this ointment to be rubbed on the part
where the aura commences. — d. The propriety
of exciting irritation in the scalp itself is ques-
tionable in the inflammatory, plethoric, and
acute cases ; although Arf.t.eus recommends it,
and Alexander Trallianus advises mezereon
bark to be applied to this part. Where the dis-
ease has followed the suppression of an eruption
in this situation, the antiirjonial ointment, or
the mezereon bark, or blisters, are very appro-
priate applications. In the more obstinate and
chronic cases, and after free evacuations in the
more acute, blisters kept freely open, on the oc-
ciput, behind theears, or on other parts of the scalp.

814

EPILEPSY — Remarks on Remedies recommended by Authors.

are prescribed by Rxverius, Piso, Hoffmann,
jMeaDjPercival, and others. — e. ijcarijications of
the scalp, particularly on the occiput, are directed
by Celsus and C.elius Auuelianus, and are de-
serving of adoption in modern practice. — f. Dry
cupping on the neck and between tiie shoulders,
shortly before the expected return of the fit, has
been prescribed by me, with slight benefit, in some
cases in which depletion had been carried as far as
was judged prudent.

109. M. — a. Oi«imeH/s, containing the active
principles of various medicines, as strychnia, vera-
tria, acetate of inorpliia, &c., have very recently
been tried in epilepsy, and are calculated to prove
serviceable in some of its states ; but, as yet, the
results have not been such as to admit of further
remarks. — ft. Variously medicated epithems have
likewise been resorted to, applied chiefly on the
epigastrium, or along the spine. 1 have directed
them in a few instances with advantage, particu-
larly in children, and have generally employed
modifications of F. 311. 313. and 770. in this
manner. — c. The endermic method, or the applica-
tion of various active substances to the skin de-
nuded of its cuticle, has recently been tried on the
Continent in this disease. It possesses this ad-
advantage, that it combines tiie operation of
medicinal agents on the nerves of the part, and on
the circulation, with external iiritalion ; and it
therefore deserves a cautious adoption, and more
extended trials than have hitherto been made
of it.

110. N. Immediate ligalure of a limb or part,
above the situation in which the aura ccm-
mences, has been favourably noticed by Galen,
Alexander Trallianus, Rhazes, Avicenna,
ScHENCK, Gredixg, Lysons, Pew, Cullen, 6cc.,
and is generally recommended when the fit is pre-
ceded by an aura. It sometimes wards off the
seizure ; but it fails of doing so as often as it suc-
ceeds, although it may have been sufficiently early
employed.

111. 0. — a. Arf.t.=eus 15 the earliest author who
has noticed trephining the cranium in epilepsy,
and the circumstances in which it may be per-
formed. C.KLius Aurelianus was opposed to the
practice, although he states Tiiemison to have
been in favour of it. Instances have, however,
been recorded by AnERNiTnE (Qiuent. Mediccp
Monspel, 6;c. Monsp. 1617), Riiodius {Ohserv,
cent. i. obs. 66.), Van der VViel (Observ.
Med. cent. i. obs. 8.), Marchettis {Ohserv. Chi-
rurg. Patav. 1664.), La Moite (^Chirurgie,
t. ii. p. 40.'J.), LvsoNs (Essays, ^c. p. 111.),
KriE, TissOT, and others, where external injury,
and circumscribed disease of the bone or sculp,
have furnished indications to warrant the perform-
ance of this operation ; and where it was resorti;d
to with success. It has also been practised re-
cently with benefit. Dr. Ei.i.ioison refers to a
case in St. Thomas's Hospital, where the trephine
removed a piece of bone with a sjjicula from its
inner surface, and cured the disease. Otiier suc-
cessful instances are recorded by Dr. Guild (JUc(^.
and Chirurg. Review, \o\.x'n. p. 504.), and Dr.
IJlake (Lond. Med. and I'hys. Jonrn.Jnn. 1826).
— /;. The much less feasible experiment of lying
the common carotid, in order to cure the disease,
has been suggested by Mr. Eaui.e, and actually
practised by Mr. Piuston (Trans, (fllie l\led. and
I'hys. .'ioc. of Calcutta, vol. v.) ; but its ultimate

success is not apparent. — c. Pressure on the ca-
rotids has been advised by Mr. Earle; but it is
probable, that the obstruction it must occasion to
the return of blood from the head will be as in-
jurious as the diminution of the supply may be
beneficial.

1 12. P. Travelling, and change of air and, of
residence, are sometimes serviceable ; and are re-
commended by Hippocrates and Hoffmann.
In the cases of children, change to a dry situation,
or to the sea-side, is especially beneficial. Van
SwiETEN (CommeHf. vol. iii. p. 436.) states, that
several epileptics were cured by emigrating from
Holland to the East Indies, and that, upon their
returning to Europe, some experienced a relapse,
but that others had recovered permanently. It
is chiefly, however, in the asthenic and sympathetic
forms of the disease that change of air and travel-
ling prove serviceable.

113. Q. Regimen. — In addition to what has
been already advanced on this subject, the prac-
titioner should bear in mind, that as much may
be done by a regimen suited to the peculiarities of
the case as by medicinal agents. — a. The meals
should be light, very moderate in quantity, at re-
gular and not too long intervals between each. In
the plethoric and more acute states, animal food
should be altogether or nearly relincjuished ; but
in the asthenic conditions, or when there ap-
pears to be a deficiency of blood, the more diges-
tible kinds of animal food may be allowed once,
and occasionally twice, a day. Even in these
latter cases, a spare, but nutritious and digestible,
diet ought to be adopted, as a liberal allowance
will seldom be duly assimilated, and will only
embarrass the digestive organs. The principal
meal should be taken early, and a light supper,
consisting of a biscuit and half a pint of milk,
about an hour before retiring to rest. The only
drink, in plethoric habits, should be water, or
toast-water, or imperial ; but in the opposite states,
and in asthenic cases. Seltzer vvater, or even Pyr-
mont or Spa waters, with milk, may be allowed.
Chocolate and cocoa are unsuited to the former
class of cases ; and coffee and green tea should
be avoided, especially where active determina-
tion to the head is observed. Black tea once
a day, and milk and water, are the best suited to
the ordinary states of t!ie disease. Not more
than half a pint of any liquid should be taken
at one time.

114. b. Epileptics should noi sleep longer than
seven hours. l hey ought to lie in an airy cham-
ber, without curtains to the bed, and without
nightcaps; upon a hair mattress, with the head
and shoulders somewhat raised. U'lie hair ought
to be worn closely cut, and in the severe sthenic
cases should be shaved entirely off. The tepid or
cold afi'usion on the head, or shower-bath, should
be used every morning, the scalp being afterwards
well rubbed. In all an^cs, early rising, and ?'ew-?t-
/(/)■ exercise in the open air, should be enjoined.
i5ut the exercise should not be at one time, but
twice or thrice daily, vvith intervals of repose. It
shotdd be taken on foot, and not sooner than
two hours after a full meal. The patient should
be as much as possible in the open air, but
should not venture on horseback. Flannel ought
to be worn next the skin, and the lowercxtremities
constantly kept warm. During warm weather,
a light-coloured hat should be worn ; and expo-

EPILEPSY BlBLIOOnAPIIY and IlEFEnENCES.

815

sure to tlie sun's rays always avoided. When
the attacks are at all fioqacnf, the patient
ought never to be without an attendant, and lie
should be guarded from the fire, from precipices,
and water. He ought not to frequent crowded
assemblies, nor even the bustling and crowded
streets of great cities, nor should he look down
from precipitous places. — There is no disease that
requires a more strict dominance of liie passions
and desires than this. The concluding injunc-
tions of RI. Borie's judicious treatment (see note
to § 104.) especialies require observance, as the
habits there referred to have a powerful influence
both in inducing and perpetuating tlie malady,
and in destroying the constitutional and intellec-
tual powers.

BiBLioG. AND Refer. — Herodotus, \. vi. cap. 81. —
Hippocrates, De Morbo Sacro, edit. Van der Linden,
vol. ii. p. 324. ; et De Aiire Locis, et Aquis, vol. 1.

p. 327 Aristotle, Probl. sect. xxx. qucest. i. — Aulas

Gelliies, Noct. Attic. 1. xx. cap. 1 — AretteusfGe Caus.
et Sign. Morb. Acut. 1. i. cap. 4. et 5. ; et Chron. 1. i.
cap. 4. ( The best writer on epilepsy among the ancients.)

— Celsiis, 1. ii. cap. 8., et 1. iii. cap. 23. — Galen, Com-
ment, in lib. vi. Epidem. ; et Charter, t. ix. p. 550. —
CiBlius Arirelianus, Chron. Morb. 1. i. cap.iv — Oribasius,
Synopsis, 1. viii. cap. 3, 4. — A'elius, Tetrab. ii. serm. 2. —
Alexander Trallianus, l.i. c.21. — Paulus ^,gineta,\.m.

cap. 13 Avicenna, canon. 1. iii. fen. i. tr. 5. cap. 8, 9. —

Arnaldus De Villa Nova, Opera, fol. 310. — Roth, De Ortu
et Cura Morbi Comitialis. Lips. 1548. — Mercurialis,
Consil. vol. i. No. 26. .')4.77., vol.ii. No.8.5., vol.iv. No. 30.
hG. — Gnbuccini,'Oe Morbo Comitiali. Venet. 1.5fi8.—
Liebault, Ergo Ingeniosi et Lilndinosi Epilep. Obnoxiosi
sunt, 4to. Paris, 1580. — Bartliolin, Hist. Anat. cent. iii.

No. 80 Dealers, De Epil. Adultorum, 4to. 1611. — Fer-

nelii/s, Consilia. vii. et seg. ; et Patholog. 1. v. cap. 3. —
A Collection of English Medicines experienced against
the Jaundice, Dropsy, Falling Sickness, and Pestilence.

Lond. 1615 Forestus, Observat. 1. x. No. .58. — Salmuth,

Observ.-cent.i. obs. 90. — Panarolus, Pentecost, iv. ob-
serv. 42. 47., et v. obs. 3.5. — Riveriiis, Prax. Med. cap. 7. ;
et Obser. cent. ii. No. 93. — Rulfinclc, De Epil.4to. Jena;,

1640. — Schellinmmer, De Epilepsia. Jena;, 1644 Willis,

Pathologia Cerebri. Oxon. 1664. ; et De Morbis Convul-

sivis, cap. 3 Piso, De Morbis ex Serosa CoUuvie, &c.

p. 100. 150. — Horstiiis, Opera, iii. p. 32 Langlois, Ergo

Epil. de Melanch. Ha?morrhoides SaUitares. Paris, 1640.
— Ettmiiller, Opera, vol. ii. par. ii. p. 779. — Senncrt, l.i.

— ScI.enk, Obscrv. Med. Rarior. &c. 1. i.— Wedel, De
Epil. Hysterica. Jenee, 1676. — Ramnxzini, Opera, p. .339.
— r^Vf/nVjjjre, Do Epil. Hypochondriaca, 4to. Lugd. Bat.
1677. — Richard, Ergo Epil. Venarura Jugular. Sectio,4to.

I^aris, 16-i9 T. Mai/erne, Prax. Med. &c. p. 52— A. Bra,

^.italiigus Medicam. adversus Epd. Aruh. 1690. — Gould,
in Pliilosoph. Trans. 1684, p. 537 — Eickmeyer , De Epil.
Uterina, 4to. Ultraj. 1698. — F. Hoffmann, Diss, sistens
Affectus Hsreditavios. HaliE, 1699. ; et De Vera Mali
E[)il. Causa. Halse, 1732; et De Peregrinationibus, &c.
Hala;, 1701, p.22. — AVieg^rf, De Epil. Rotatoria. Lugd.
Bat. 1722. — ilarchard, in Mem. de I'Acad. des Scien.
17oO, p. 3.5.5. — Co/e, Consil. iEtiolog. de Casu quodam
Epil. &c. Svo. Lond. 1702. — Clossy, Observations taken
of Morbid Bodies, sect. i. obs. 9. — Bonet, Sepulchretum,

L i. sect. yi\\.—Alberli, De Epil. 4to. Halx, 1718 Boer-

haavc, De Morbis Nervorum, p. 770. — Van der Wiel, De
Eiiil. Lugd. Bat. 1719. — ./. Co/irt/cA, Diss, ccracerning
Miseltoe, a most wonderful Specilick Remedy for Convul-
sive Distempers, 8vo. Lond. 1723. — l-'.tahl, De Morbo
Caduco. Erf. 1730.— Mead, De Impcrio Soils et Lunae,

cap. 2. — Morgagni, De Sed. et Caus. Morb. ep. ix

Millars, De Medicara Antepilepticis. Argent. 1737. —

Monro, in Edin. Med. Es.says,&c. vol. v. part ii. p. 561

Meibom, De Epil.. Stomachica, 4to. Helmst. 1740 J.

Junckcr, De Cur.»Epil. sine Specificis, 4to. Halee, 1740.
— Roncalli, Histor. Morborum, &c. p. 21. et seq. — Buch-
wald. Analysis Visci ejusque in Divers. Morbis Usus.
Hafn. 1753. — JVeisnumn, in Nova Acta Nat. Cur. vol.i.
p. 276. — Linnteus, Amoenit. Acad, vol.ii. p. 135 — Kiemp-
■*;•(•, .^moen. Exot. fasc. iii. p. 595. {Moj'as along the co-
ronal suture.) — Delius, De Cranii Ustionc in Eidl. Erl.

1763 Locher, Observ. Pract. Circa Luem Ven. Epileps.

et Maniam, Svo. Vind. 1763. — Hannes, De Epil. Foliis
Aurantiorum Cur. &c. Leip. 1766. — Gesner, Beobacht.
b. i. No. 19. — Andree, Cases of Epil. Hysteric Fits, &c.
Svo. Lond. 1764. — Van Swieten, Comment. &c. t. iii.
p. 404. — Stoerck, Libel, de Stramonio, Hyoscyamo, &c.
8vo. Vindob. 1762 — Mangold, De Epil. Speciebus non-

nuUis, in Opusc. Med. Phys. Alt. 1769 Sauvages,

Nosol. McHhod. t ii. par. ii. p. 97 — Tralles,V)i; Usu ()pii,
sect, iii.— Tissot, Traite de I'Epilepsie, Svo. Lausanne,

1770 Fothergill, in Med. Observ. and Inquiries, vol. vi.

p. 79. — Johnston, in Ibid. vol. ii. No. 6. — Stull, Prielcct.

vol. ii. p. 1. — Hallcr, Opusciila Pathol, obs.74 Werlhof,

Opera Med. pars i. p. iiii.— Baker, Med. Trans, of Coll.of
Phys. vol.ii. p. 442. — D. Lysons, Pract. Essays on Inter-
mit. Fevers, Dropsy, Epilepsy, &c. Svo. liath, 1772 .

■SVrfrf«,DeUsu Stramouii in Convuls. Ups. 1772 — Brom-
field. Observations and Cases, vol. i. Lond. 1773. — W.

Threlfiil, Essay on Epilepsy, &c. Svo. Lond. 1772 De

Hiien, Rat. Med. par. v. cap. iv. — Lieutaiid, Hist. Anat.
Med. 1. iii. obs. IS. bO.— Tkilenius, Med. u. Chir. Bemerk.

p. 124 Reiningcr, Diss, de Prole Parentura Culpas

luente. Lips. 1772. — Kinneir, New Essays on the Nerves,

p. 117 Crell, De Zinco Medico. Helms. 1780. — (iuarin,

Aninjadvers. Practicfe in Divers. Morbos. Vindojj. 1780.

— Weizenbreyer,\)e Cupro Medicato. Erf. 1783. — Starke,
Klin. Institut. p. 176. — IV. Perfect, Cases of Insanity,
Epilepsy, &c. Svo. Lond. 1781. — Hartmanji, Diss.isis-

tens varias Epil. Med. Methodos. Franc. 1787 Greding,

Vermischte Schriften, th. i. p. iS9. et seq.; et Siimmtl.
.Schrift. i. p. 294. etseq. ; et in Ludwig's Adversaria, t.ii.
ett. iii. — J. H. Munch, Observ. Prat, de Usu Belladonnas
in Melancholia, Mania, et Epil. Svo. Goet. 1783.— Hir-
sc/iel, Gedanken von der Fallcnden Sucht, p.35. — Feucr-
stein, De Epil. 4to. Goet. l7'.>2.~M>elia(-tis, Med. Pract.
Biblioth. b. i. st.3. — Oberteiijfer, in Museum d. Heilk.

b. iv. p. 172. — Theussink, in Ibid. b. iii. p. 147 Wagner,

Epist. de Morb. Insanabilium Curatione. Lips. 1792 .

Burserivs, Institut. Med. Pract. vol. iii. p. 258 T/iomas,

Journ. de Medecine, t. xxvii. p. 238 Rochard, in Ibid.

t. XXV. p. 46. — Chevalier, in Ibid. t. xii. p. 329 Wien-

mann, in Ibid. t. xi. p. 277. — Buuteillc, in Ibid. t. xlviii.
p. 544. — Lemonier, in Ibid. t. lix. p. 421. — Arnaud, in

Ibid. t. Ixxvi. p. 246. — Beaumes, in Ibid. t. Ixx.p. 290.

Morand,m Ibid. t. xxxv. p. 565 Dela Roche, in Ibid.

t. xlii. p. bin.— Dumas, in Ibid. Dec. 1810, p. 385.— Lnd-

wig, De Vi Terroris in Corp. Human. &c. Lips. 170!>.

Osiander, Denkwiirdigkeiten,&c. b. ii.p. 188 Ferriar,

Med. Hist, and Reflect, vol. ii. p. 48. — Burmelster, De
Morbo Spastico. Goet. 1791. — Pideril, Practische An-
nalen, st. i. p. 91. — Collingivood, in Edin. Med. Comment.

vol. xviii. p. 390 Heysham, in Ibid. vol. vii. p. 349 .

T. Bland, in Ibid. vol. vii. p. 301 —B. Bell, in Ibid. vol. i.
p. 204._i;t' la Roche, in Ibid. vol. i. p. 200.— T. Percival,

in Ibid. vol. ii. p. 309., vol. v. p. 166 Walker, in Ibid.

vol. X. p. 288 Guthrie, in Annals of Med. vol. iv. p. 473.

— Mossmann, in Ibid, vol.ii. p. 413 Cappe, in Ibid.

vol. iii. p. 455.— Hull, in Ibid. vol. v. p. 245 Handel, ya.

Ibid, vol, iv. p. 273.— W. Batty, in Ibid. vol. vi. p. 377.' —
Richter, Med. u. Chirurg. Bemerk. Sec. p. 137. — Maissoti-
neuve, Rechercheset oijserv. sur I'Epil.Svo. Paris, 1800.

— Currie, Mem. of Med. Soc. of Lond. vol. iv. art. 2

S«»i, in Ibid. vol. ir. art. 24., et vol. vi. art. 29. — Store,
De Faba Sancti Ignatii. Erl. 1793 — A. F. Ueeker, Diss.de
Epil. Svo. Erf. ISCO. — /'oj-^rt/, Mem. sur la Nat. et le
Traitement de plus. Mai. t. ii. p. 229. ; et Observations
sur la Nat. et le Traitem. de I'Epil. Svo. Par. 1827. —
Pinel, Nosographie Philosoph. vol. ii. p. 70. — Bostock,
Med. and Phys. Journ. 1800, vol. i. p. IW.—Magennis, in
Ibid. vol. iv. p. 417. — Arnemann, in Ibid. vol. xiv. p. 430.

— Willich, in Ibid. vol. i. p. 183. (Rev. of Med. successfully

employed in epil.)— White, in Ibid. vol. ii, p. 173 Rush,

in Ibid. vol. xiv. p. 10. — Spence, in Ibid. vol. xviii. p. 355.

— Fraser, Treatise on Epil. and the Use of the Viscus

Quercinus, &c. Svo. Lond. 1806 Lentin, in Hvf eland's

Journ. der Pr. Heilk. b. xiv. st. i. p. 44. — Hildenbrand, in
Ibid, b. ix. st.iv. p. 34., b. xiii. st.i. p. 140 — Joerdens, in

Ibid. b. xiii. st. iv. p. 143 Fischer, in Ibid. b. xii. st. i.

p. 169. — Gebel, in Ibid. b. vii. st.iii. p. 177. — Mliller, in
Ibid. b. XX. St. i. p. 173 — Bischoff, in Ibid. b. xxx. st. ii.
p. 126 — Hufeland,m Ibid. June, 1811, p. 14. — Remer,m

Ibid. b. xvii. st.i. p.ll3 Autenrielh, Physiologic, § 1041.

(The medulla oblongata diseased.) — Baldingcr, Magazin

fiir Aerzte, St. iii. p. 745 Viciveg, Annalen der Heil-

kunst. May, 1811, p. 426.— Pros/, Med. Eclairee par I'Ob-
servat.etrOuvert de Corps. Svo. vol.ii. p. 379. Paris,1804.
— Joseph Frank, Acta Institut. Clin. Universit. Vilnens.
&c. Lips. 1808. ; et Praxeos Med. Universa Prascepta,
pars ii. vol. i. sec. ii. p. 277.— J. Wenzel, Beobacht. iiber
den Hernauhang FallsiichtigerPersonen, &c.8vo. Mainz.
ISIO. — Esquirol, in Diet, des Sciences Mi'dicales, t. xii.
p. 510. — Powell, Med. Trans, of Coll. of Phys. vol. iv.
art. 8. — Badeley, in Trans of Med. and Chirurg. Soc.
vol. ix. p.l. — Valentin, Ann. de la Soc. de Med. de

Montp. t. viii par. ii. p. 301. (Acetate of lead in epil.)

I.obenstein-Lobel , V.'esen u. lleilung der Epilepsic, Svo.
Leip. 1818. — Aibers, in Med. Chirurg. Soc. Trans, vol. vii.
par. i. — Roget, in Ibid. vol. vii. p. 290. — Halle, in Nouv.
Journ. de Med. t. v. p. \83.—Rudolphi, Diss, sistens Ca-
sum Epil. per Terebrationem Cranii Sanata;, Svo. Berol.

1811 Moreau, Recueil Periodique, &c. t. vi. p. 226

Ciillerier, in Ibid. t. xiv. p. 271 J. C. Prirhard, Treat.

on Dis. of the Nervous System, Svo. Lond. 1822, p. 85.
el seq. — ,1/. Georget, La Physiol, du Syst. Nerveux, et
Recherches sur les Mai. Nerveuses, t.ii. p. 365. Paris,
1821.; ct Diction, de Mi'd. t. viii. p.20(). _,/. Cooke,
Hist, of the Method of Cure of the various Species of

816

ERECTILE TISSU

Epil. 8vo. l.ond.lH23. — Larrey, Rev. Medicale, Jul.
1822. {The si/p/iiliiic.) — Me7iarcl, in Ibid. Mars, 1825.—
Z). A. G. Tt/c/iter, Die Specielle Therapie, &c. b. vii.
p. 5rt'2. — Mii/s, The Morb. Appearances in Dis. of the
Brain, &c. Dub. 1S2G, 8vo. p. 213.— Cliishulm, in I>ond.
Med. Repos. vol. xxi. p. 102.— Carter, in Ibid. p. 369. —
Surdach, Archives Gener. de Med. t. vii. p. 588. (Cases
treated by the artcmisia.) — Iloileaii. in Ibid. t. vlii. p. 45.
(Case xrhere /igature af carulhlfur a irounddid not ejfecl a
permanent ein-e.) — Masseau,\\\ liiid. t.viii. p. 603. (Case
in tnhich the heart teas remarkabli/ small.) — Pei/ssuti, in
Ibid. vol. xi. p. 4G2. — W. Shearman, Lond. Med. and
Phys. Journ. vol. xxiii. p. 314. ; and Lond. Med. Repos.
vol. xviii. p. 181. — J. Smith, ini,ond. Med. Repos. vol.'iv.
p. I'Jl. — Siveetmg, in Ibid. vol. v. p. 175. — R. Rcid, in

Transact, of College of Phys. in Ireland, vol. iv. p. 354

Creighton, in Ibid. vol. iv. p. 3.32. — Giinn, in Edin. Med.

and Surg. Journ. No. BO. p. 78 Scott, in Ibid. No. 90.

p. 19. — lVidia?ns, in Ibid. No. 85. p. 297 Coates, in

Ibid. vol. 1. p. 428 — Clarke, in Ibid. vol. v. p. 272. — Lith-
gow, in Ibid, vol.xi. p. 300. — Prichard, in Ibid. vol. xi.
p. 458. — E. Percival, in Ibid. vol. ix. p. 271. ; and Dub.
Hosp. Rep. &c. vol.i. — Lombard, Gazette Medicale, No.
66. vol.iii. — W. Burnett, Trans, of Med. and (Jhirurg.
Soc. vol. xiii. p. 202. — Tacheron, Recherches Anat.
Pathol, sur la Med. Prat. t. iii. p. 5^6. Paris, 1823. —
Rogers, New York Med. and Phys. Journ. 1826. — L. F.
Caimiel, L'Epilepsie etudiie ecus la Rapport de son
Seige, 8vo. Paris, 1826 Baillie, Lectures and Observ-
ations on Medicine, 8vo. Lond. 1825. — Revue Medicale,
t. iii. \S27 .—Menard, in Ibid. t. i. 1825, p. 3m.—Brqfferio,
in Ibid. t. iv. 1825, p. 488. —Larrey, m Ibid. July, 1822;
ot Med. Chir. Rev. vol. iv. p. 465. — Kolotviich, Journ. des

Progres des Sciences Med. t. xii. p. 257 Bouchet et Ca-

zauveilh. Archives Generalos de Med. t. ix. p. 510., et
t.x. p. 5. {Belaliuns of epil.tptth insanity.) — Loewenhard,

in Ibid. vol. xvi. p. 605. — Urban, in Ibid. t. xvi. p. 273

Stengel, in Ibid. t. xvi. p. 597 Rcn7ies, in Ibid. t. xvii.

p. 63. — F. Hatin, De I'Epil. consid. dans sa Nat. et dans
ses Causes et des Moyens prop, a les querir, 8vo. Paris,
l»iO.— Elliotson,\n Lancet, vol. xviii. p. 116. 231. 539. ;
and in Lond. Med. Gazette, vol. vii. p. 423.798., vol. viii.
p. 278., and vol. xi. p. 577. 609. — Sims, in Ibid. vol. vii.

p. 374 — A. T. Thomson, in Ibid. vol. ix. p. 241. 387 F.

.HattfA/ns, in Ibid. vol. viii. \^.\9'i. — Davidson, in Ibid,
vol. ix. p. 664. 707. 819 — Roots, in Lond. Med. and Surg.
Journ. vol. iii. p. 12. 171 — Boisseau, Nosographie Orga-
nique, t. iv. p. 782. — Fovil/e, Diet, de Mid. et Chirurg.

Prat. t. vii. p. 412 Cheyiie, in Cyclop, of Pract. Med.

vol.ii. p. 85. — Bartels, Encyclop. Wiirterb. de Medicin
Wissenchaften, b. xi. p. 357. — A?idral, Lectures on Epil.
in Lancet, No. 502., p. 65., and No. 503. p. 102.

EPISTAXIS, See Haemorrhages.
EllECTILE TISSUE.— Syn. Vasa Erigentia ;

Tela Erectilii. Tissue Erectile, Fi'. Erectiles

Gewebe, Ger.

Cl \ssii-. — Pathology — Morbid Struc-
tures.

1. This structure, which is eminently vascular,
and copiously supplied with organic or ganglial
nerves, possesses, beyond all others, that vital pro-
perty which is obscurely evinced by several other
textures, and which was denoLninated the turgor
vitalis, or vital turgescence, by Hebenstriet,
Sciii.ossER, Reil, and Ackermann. This pro-
perty, whether denominated as above, or called
vital expansion, or any other name, is more ge-
nerally diffused, and presents more important
relations, both in health and in disease, than have
usually been acknowledged.- The reader will find
it more fully discussed under the article Turges-
cence. i have merely to notice in this place,
very briefly, the morbid states which the parts
allowedly erectile present. 'These parts are — the
cavernous and spongy body of the penis, as well
as its bulb and gland ; the clitoiis and nvmphoB ;
and the nij)ple of the female. There are other
j)arts more obscurely (owing to their situation),
but undoubtedly, endowed with this property :
these are — the uterus, especially its neck; the
Eallopian tubes, particularly tiie fimbriated ex-
tremities ; the spleen ; and the lips of ijoth sexes ;
but these are not comprised in tlie following ob-
servations. The morbid structure called Nirims
malernus, Aneurimn by Anastomosis (JJkll and

E. — ERETHISM.

Freer), Angiectasia, or vasorum dilatatio (RIeck-
el), Telangiectasis, orvasorum iiltimorumdistensio,
by some German authors, appears to be merely
an accessory or morbid form of the erectile tissue ;
and I agree with Dr. Craigie in considering that
such is the case, and that the throbbing vascular
tumour first noticed by Pearson, and subse(iuently
minutely described by Scarpa, is an adventitious
formation of the same kind.

2. The erectile tissue may evince its charac-
teristic property in a very marked manner, and
to an extent that is truly morbid, without any
appreciable change in its organisation. This is
shown in priapism, in which the vascular turges-
cence is the result merely of nervous excitement
or irritation. Chordee is a modification of this
state, caused chiefly by inflammation of an ad-
joining structure ; the erectile tissue of the penis
being excited, whilst the submucous tissue of the
urethra is inflamed, and unyielding, owing to its
moibid state, and to spasm of the ischiocavernosus
muscle.

3. Haemorrhage rarely takes place sponta-
neously in erectile tissues. I have, however,
met with it in the corpus cavernosum of the penis,
occasioning a state nearly resembling that of
priapism, but unattended by nervous or mental
excitement. In tiiis case, the morbid state was
removed by a small incision made into the
cavernous structure, when grumous dark blood
escaped. An interesting instance of this kind
is recorded by INIr. Callaway. Similar changes
are r)ot so infrequent from external violence, par-
ticularly in the erectile tissue of the female organs,
owing to difficult or instrumental labours. This
tissue may be the seat of excrescences, of scir-
rhus, and, like others, be involved in specific
inflammation, malignant ulcerations, and adventi-
tious formations ; but such of these as belong
to the province of the physician are noticed in
the articles on the Spleen and Uterus.

BiBLiOG. and Refer. — J. Bell, Principles of Surgery,
&c. vol. i. disc. xi. p. 456. 1801. — Freer, On Aneurism and
some Diseases of the Arterial System, &c. Birm. 1807.

— Peanon, in Medical Cominunications, vol. ii. p. 95

Scarpa, On the Pathology and Treatment of Aneurism.
— Callaway, in Lond. Med. Repos. vol. xxi. p. 286. —

Craigie, General and Patliological Anatomy, p. 192

Meckel, Anat. Pathol, t. iii. p. 792. — Begin, in Diet, de
INIed. et Chir. Prat. t. vii. \> iW. — MUller, Encyclop.
Wiirtetb. der Med. Wissenchaft. b. xi. p. 460.

ERETHISM, AND MERCURIAL ERE-
THISM. Erethismus (EpEfltcrjuo;, from Epsfli^o),
I excite or irritate).

1. I. Erethism, in Pa//ii)/o^'3/, has been gene-
rally understood, since the time of 1I(i>pocrates,
as implying a state of irritation, or excitement of
a part, differeut from, or short of, the inflam-
matory oondiiion, although often passing into it.
Ilipi'OCRATEs and Auet;eus viewed it as irrita-
tion, accompanied with some degree of debility.
Galkn applied the term to irritafion of the sto-
mach and intestines by acrimonious fluids; and
Uiost of the ancients believed that, where it ex-
isted, it prevented the accession of salutary cri-
tical evacuations. Many modern pathologists
employ it as synonymous with orgasm, or simply
an exalted state of the vital actions of a pan ;
and others attribute to it more of a morbid im-
port, viewing it as an early sl.nge, and lesser
grade, of many acute disea.ses, especially tiiose
tiiat are febrile or inflammatory. 'J he most
familiar illustration of this state, according to tiie

ERETHISM, MERCURIAL. — ERGOTISM.

817

former class, is the act of blushing. According
to the latter class, the ravenous appetite attend-
ant sometimes upon debility and various aflec-
tions of tiie digestive organs, proceeds from
erethism of these parts, or, in other words, from
an excited state of the nerves of tlie organ, with
increased circulation and secretion or exhalation
from the villous surface. It is very probable
that this state, either prolonged, or frequently ex-
cited, will give rise to acute or chronic inflam-
mation, and even to changes of structure, and to
effusion from mucous or serous surfaces. That
it prevents the accession of critical changes, is
also probable.

2. This condition should be viewed as morbid,
and treated according to its seat and grade. It
requires, generall}', refrigerants, ligiit or low
diet, soothing and mucdaginous drinks, tepid or
warm bathing, cooling diaphoretics and diuretics,
and mild laxatives and enemata. When ne-
glected, it is apt to extend the sphere of its
morbid influence, more especially when sealed in
the digestive mucous surfaces; the functions of
digestion, sanguifaction, and assimilation becom-
ing disordered, and irritation supervening in the
cutaneous surface, in the liver, and even in
various remote parts. (See art. Disease, § 72. et
seq. and 78. et seq.)

3. II. Erethism, Mercurial — Erethisnnis
Mercurialis — was the name given by Mr.PEARsoN
to that extreme state of irritability and exhaus-
tion which sometimes is occasioned by mercury.
Before this state was described by this surgeon,
its nature and cause had been entirely over-
looked, although it must have often occurred,
and even proved fatal. It evidently arises from
the poisonous action of the preparations of mer-
cury upon the organic nervous system and heart.
The preparations which most commonly produce
it, are, the blue pill and the ointment, paiticu-
larly the latter ; and it is not improbable that
some change may take place in these from the
action of the air, when they have been long kept,
that will give rise to this affection, although pre-
scribed in the quantities safely administered in the
more recent state. A mercurial atmosphere, as in
confined syphilitic wards, has also, very probably,
a considerable share in its causation, 'i'he erethis-
mal symptoms usually come on early in a mercurial
course, but they may occur at .any period. When
once produced, they very readily return upon
resuming the mercury, in the same form that
first occasioned them. Pre-existing debility, the
action of malaria, the scrofulous diathesis, constitu-
tional susceptibility and irritability, and previous
mental excitement and anxiety, seem to be, as
far as is yet known, the chief predisposing
causes.

4. i. This affection usually conunenees with
slight trembling of the limbs and tongue, sense of
fluttering in the chest, irregularity of the heart's
action, and palpitations on the least exertion.
The pulse is feeble, small, quick, compressible,
irregular, or intermitting. The strength is ex-
tremely depressed, the countenance is pale and
contracted ; and great anxiety at the prfecordia,
with frequent sighing and a feeling of sinking, is
complained of. If the mercury be still con-
tinued, the tremblings, the frequency, irregularity,
and intermissions of the pulse, increase rapidly,
and are attended by a sense of coldness, and

Vol. I.

sometimes by vomitings. At this period, sudden
or great exertion may extinguish life.

5. ii. The Treatment, early in the affection, is
generally easy and effectual. Upon the first in-
dication of it, the patient should be removed to,
and remain as much as possible in, the open air;
and mercury, in every form, relinquished; even a
mercurial atmosphere should be avoided. The pre-
parations of ammonia and camphor ought to be
given in full doses, and the surface of the body
cleansed from all impurities, especially from the
remains of mercurial ointment. Having thereby re-
stored thestateof the circulation, a courseof nitric
acid with sarsaparilla should be entered upon,
and the bowels kept gently open by a sufficient
dose of the precipitated sulphur taken at bedtime
on alternate nights. If it should be still necessary
to resume the use of mercury, as sometimes
proves to be the case, the utmost circumspection
is requisite. The bichloride in the tincture of
cinchona, or in the form of pill with the pulvis
glycyrrhizaj and camphor, and taken with the
meals, will often produce a sufficient salivation.
After a most severe case of this affection which
came under my care, where it was determined,
in consultation, to have recourse to mercurial
salivation as a last resource, for tiie cure of most
dangerous secondary syphilis, the preparation pre-
scribed in the manner now mentioned had the
desired effect.

BiBLioG. AND Refer. — Hippocrates, Aphorism, xx.
sect, i — Arelieiis, De Cur. Morb. Acut. 1. i. cap. I.—
J. Pearson, On the Lues Venerea, 2il edit. p. 156. — Vaidj/,
in Diet, des Scien. Med. t. xiii. p. 161. — Batemnn, Trans.

of Med. and Cfiirurg. Soc. vol. ix. p. 2'20 T.H. Burder,

in Cyclop, of Pract. Med. vol. ii. p. 101.

ERGOTISM.— (Classif.— Pathology, —
/Etiotogi).') Diseased, unripe, or damaged grain of
any kind, is injurious to the animal economy,
according to the quantity consumed. The specif s
of grain, the nature of its alteration from the
wholesome state, and the proportion of it enter-
ing into the food of man and the lower animals,
are the chief circumstances modifying the morbid
results. Kite is most frequently productive of
injurious effects in the northern countries of Eu-
rope, the disease in it giving rise to the ergot, or
spur, being the chief cause. Rut wheat, rice, or
any other grain, either similarly diseased, or pre-
maturely cut down, or damaged by the mode of
keeping, or by age, or mixed with the seeds of
poisonous plants, as those of the Jlaphania ra-
jihanistrum and the Lntinm temnlentum, will
occasion dangerous diseases. The noxious effects
of spurred rye (Secale cnrmitum) have been most
frequently observed, and are especially noticed
in connection with the affections of which it is
one of the chief causes. (See arts. Gangrene,
and Spasm — Cachectic). But the disorders pro-
duced by other kinds of diseased or unwholesome
grain, are in many respects similar to those con-
sequent upon the use of spurred rye. Sufficient
allusion has been made, in the article Epi-
DEMics, to the influence of unripe, blighted,
deficient, or damaged crops, upon the health
of the community ; the epidemics thereby oc
casioned, varying in character with the particular
state on which the unwholesomeness of the grain
depended, and the concomitance of other causes.
The particular unwholesome condition of grain
has not, however, been hitherto viewed suf-
ficiently in connection with its specific effects
3 G

818

upon the economy, in any one instance ; and
it is only in respect of spurred rye that we
have any kind of data that will admit of the
special consideration of the subject. From some
circumstances that have come before me, I should
infer that unripe grain is productive chiefly of
diarrhoea and dysentery; that diseased, impure,
or bhghted grain, most frequently occasions af-
fections of the nervous and vascular systems,
with disorder of the digestive organs, and con-
tamination of the circulating fluids ; and that
damaged and old grain gives rise principally to
fevers of a malignant or adynamic kind, with
predominance of some one or more of the pre-
ceding affections, according to concurrent causes
and circumstances. (See Disease — Causation
of; Gangrene, and Spasm,)
ERYSIPELAS. Syn. — 'E7^■:<^^Xo>ta■/^a, Hip-
pocrates; Ipuo-iVeXaf, Gr. (from Trapa, to
Sfvc!r9a.i twi to TrtAaf, that it extends to adjoin-
ing parts; or rather, from spuoo, I draw, and
TriXfflf, adjoining ; or from Ipufifo?, red, and
tteXoc, brown, livid) Ignis -Sacer, Lat. Fehris
Erysipelalosa, Sydenham, Schroeder, &c. Fe-
hris Erysipelacea, Hoffmann, Vogel, &c. Rosa,
Serinert. Jgnis Sancti Antonii, Auct, Var.
Emphlysis Erysipelas, Good. Erysipite, Fr.
Die Rose, der Rothlauf, Germ. Erisipela, Risi-
pola, Ital. The Rose, St. Anthony's Fire,
Classif. — 1. Class, Febrile Diseases; 3.
Order, Eruptive Diseases (Cullen). 3.
Class, Sanguineous Diseases ; 3. Order,
Eruptive Fevers (Good). 4. Orrfer, Vesi-
cular Eruptions (Willan). III. Class,
III. Order (Author, in Preface).

1. Defin. — Asthenic infiammation of the in-
teguments, affecting them more or less deeply and
extensively, with diffused tumefaction, and a dis-
position to spread, depending upon constitutional
disorder,

2. I. General Description. — A. Erysi-
pelas* usually commences with either the local or
the constitutional symptoms more prominently
marked ; but I believe that the local symptoms
never manifest themselves before some disorder
referrible to the vital sources and centres has
been present, altiiough frequently in too slight a
degree to alarm the patient or come before the
physician. Previous to, or accompanying, a
sense of tension, itching, heat, weight, and un-
easiness, with diffused redness and swelling of the
skin, the patient experiences chills, rigors, dis-
turbance of the functions of the stomach and
bowels, and a quickened circulation. On the
second and third days, the swelling, which was
either slight, or scarcely noticed, increases ra-
pidly, extends superficially, and is warm, shining,
of a yellowish red colour, disappearing moment-
arily during pressure, wiiii a tensive burning pain,
exacerbation of fever towards evening, and remis-
sions in the morning. In addition to these, the
patient complains of frontal headach, drowsiness.

• Some confusion has arisen from the m;inner in which
this disease a\iiirri/thc7na liavc been viewed in relation to
each other, and ill which both liave boon classed. l'"or,
while I admit, with Dr. fioon, that the term erysijjelas
has been loosely employed in medical writings, yet I con.
ceive that it will not add to the precision of our know-
ledge to remove certain of the varieties of erysipelas to
the genus erythema, where their local characters are
ehielly considered, and their more important constitu-
tional and vital relations arc overlooked.

ERYSIPELAS — General DEscnirTioN.

anxiety at the prarcordia, genera! lassitude, and
pain or aching of the limbs; anorexia, nausea, or
vomiting ; thirst, and heat or dryness of skin.
The tongue is generally loaded, and subsequently
dry ; the bowels are constipated, and the motions
offensive ; the urine is turbid or saffron-coloured ;
and the pulse full, soft, frequent, sometimes broad
and compressible, and often oppressed or irre-
gular. The disease generally runs its course, in
its more acute forms, between the seventh and .
fifteenth day. It is sometimes extended to the
twenty-first, but seldom beyond, unless in cases
of relapse or metastasis, or when it assumes
certain anomalous forms, or occasions organic
changes of subjacent or internal parts, which pro-
long the fever and increase the danger.

3. -B. Erysipelas presents phenomena which
are peculiar to it, and distinguish it from phleg-
monous inflammation, on the one hand, and from
the inflammatory action attendant on rheumatism
and catarrh, on the other. — a. The characters
of erysipelatous inflammation are as follows : — a.
The pain is peculiar — is tensive, burning, or
stinging ; is not severe, but is diflTused throughout
the "inflamed surface, and is occasionally remit-
ting.— ^. The rfdHfss is not intense, as in phleg-
mon ; but is either pale, rose-coloured, or of a
pale yellowish hue — arising, seemingly, from a
more copious and diflfuse deposition of serum,
slightly tinged with a little blood. The redness
always disappears on pressure, but quickly re-
turns when pressure is removed ^ it is of a deeper
red when the attendant febrile action is of a
sthenic kind; and of a more livid hue when the
vital powers are much reduced.— y. Tumefaction
is always present, and is sometimes very remark-
able, owing to the effusion of serum into the sub-
cutaneous cellular tissue. It is, however, diffused,
never acuminated or convex ; but sometimes
hard or brawny, as in the sthtenic or phlogistic va-
riety ; and occasionally soft and boggy, as in the
oedematous or asthenic variety, or when the ad-
jacent cellular tissue is affected or suppurating.

4. b. Erysipelas is seated chiefly in the integu-
ments ; but it presents various modifications,
according as the more superficial or more internal
tissues of the skin are especially diseased. Where
the cutis vera is the principal seat, the cellular
tissue underneath is also materially affected ; it
being usually infiltrated with serum, tumefied,
and sometimes inflamed to a very considerable
depth in some instances ; whilst the more super-
ficial ca'pillaries likewise partake in the disturb-
ance. \Vhere, on the other hand, the rete mu-
cosum and papillary tissue are the chief seat, the
disease is commonly accompanied with vesication.
When this occurs, or when a discharge from the
surface, or free exfoliation of the cuticle, takes
place, the severe affection of the subjacent cel-
lular tissue very rarely is observed.

5. c. I'^rysipelatous inflammation has always a
tendency to spread to adjoining, and occasionally
even to attack remote, parts. As long as the me-
tastasis, or vicarious affection of distant parts, is
confined to the integuments, the primitive form
and nature of erysipelas is retained ; but as soon
as it has a])parcntly attacked internal organs,
which is sometimes the case, owing to their pre-
existing disposition and morbid conditions, and to
the operation of superadded causes, then the
afTection of the skin disappears, and the super-

ERYSIPELAS — PAnricuLAn Description.

819

inJuced Intevrral disease occasions the symptoms
of an idiopathic malady, with more or less of the
constitutional disturbance characterising the erysi-
pelatous eruption, particularly those which relate
to the vital energies and powers of resistance.
'J'iius, inflammations of internal parts, as of the
serous or mucous surfaces, may displace, or be
vicarious of, the erysipelatous disease of the skin ;
but such inflammations will still retain peculiar
features, and differ from idiopathic or true phlo-
gosis of those parts ; the depression of the powers
of life, the morbid condition of the circulating fluids
and of the excretions, characterising erysipelas, at-
tending also upon them, often in increased grades.

6. d. Like other inflammations of membranous
parts, erysipelas generally assumes an acute

form ; and, in this respect, resembles phlegmon :
but difters from it very materially as regards
the nature of the constitutional disorder, especially
the morbid state of the circulating fluids and
of the excretions, and the manner of termination
• — particularly the slow convalescence ; the per-
sistence of congestion — especially of the venous
capillaries ; the desquamation of the cuticle, and
the tendency to relapse.

7. e. The characteristics of erysipelas arising
from the texture in which it is seated, are — the
dryness, the stinging heat, the peculiar shining
appearance of the surface, the burning and itch-
ing, and the frequent elevation of the cuticle into
vesicles, or its successive desquamation. Ail
these indicate — 1st, suppression of transpiration,
with increased circulation ; 2d, morbid sensi-
bility of the cutaneous nerves; 3d, a preternatural
secretion of serum beneath the cuticle ; and, 4th,
an altered state of the reproductive or plastic
function of the rete mucosum.

8. /'. When erysipelas has once attacked tlie
frame, there rejnains a certain morbid diatbeds,
disposing to renewed attacks at distant intervals.
The same property is also evinced by several non-
contagious affections of the skin ; and is most
probably owing to acquired constitutional dis-
position, or rather, to a weakened state of the
digestive and excreting or alimentary organs —
to a latent state of disorder arising out of the
remote causes of the disease, and heightened or
rendered more persistent by its attack.

9. fr. The causes of this malady are fre-
quently the same as those of low forms of fever,
catarrh, and rheumatism ; for, like them, it
generally proceeds from peculiar states and vicis-
situdes of weather and of the atmosphere ; espe-
cially cold, moist, miasmatous, and foul con-
ditions of the air, acting upon a system already
disposed to their influence by depression of vital
power, or by the accumulation of morbid or
effete matters in the circulation, owing to defective
action of the excreting organs, to unwholesome
diet and regimen, or to prolonged disorder of the
prima via.

10. h. Erysipelasis generally preceded and ac-
companied by more or \ess fever, according to the
situation of the part affected, the sensibility and
irritability of the system, and the character of the
prevailing epidemic constitution. It should never
be considered apart from theattendant state of con-
stitutional disturbance, — from the manifestations
of vital power, and the conditions of the cir-
culating fluius, and secretions, — of all which the
local affection is merely an extensive and im-

portant efl'ect ; but one which reacts upon these
states and conditions, whence it chiefly derived
its origin, or at least its peculiar characters. The
modifications of the attendant fever depend
chiefly upon the constitution and pre-existing
state of the assimilating and excreting organs,
upon the prevailing epidemic influence, and upon
the weather and season. Thus, the fever more com-
monly approaches the inflammatory type during
cold and dry seasons, or in winter and spring ;
whilst the more adynamic forms, with predomi-
nance either of the gastric, bilious, or nervous
states, are most frequent in summer and autumn.

11. II. Particular Description. — Erysipelas
presents various modifications, according — 1st,
to the part affected ; 2d, to the nature and form of
the local changes ; 3d, to the states of constitutional
disturbance with which these changes are asso-
ciated, and on which they are dependent ; and,
4th, to the causes which have produced it.

12. A. Madif cations as to the part affected. —
The sensibility of the part in health, and its vital
relations, especially modify the consentaneous
disturbances of the sensifeious and vital functions
generally characterising this malady. If it at-
tack iheface, commencing in one cheek, it gene-
rally soon extends to the other; and in a short
time to the forehead and scalp, producing more
tumefaction than almost in any other situation,
owing to the efl^usion of serum in the subcutaneous
cellular tissue. The eyes are closed or prominent ;
the no.-e is distended ; the ears are red, shining, and
burning. On the second or third day, the whole
head and face are often enormously distended,
presenting a yellowish or sub-livid redness. —
Also, when the disease commences in the scalp,
owing to punctures, bruises, or contused wounds,
the affection of the subcutaneous cellular tissue is
very great, frequently followed by dift'used sup-
puration, and disease of the fibrous tissues adjoin-
ing. But, whether originating in the face or in
the scalp, the greater the extent and intensity of
the affection of these parts, the more are the func-
tions of the brain, of the circulation, and of secre-
tion disturbed. Hence the violent headach,
tinnitus aurium, delirium, sopor, convulsions,
coma, &c. ; the parched and dark tongue ; the
morbid state of tlie evacuations ; and the dis-
turbance of respiration.

13. When erysipelas attacks the face, it some-
times affects the mouth and fauces, extending in
some instances to the pharynx and larynx, inter-
nally, and down the neck to the chest externally.
An interesting case of tlris kind was attended
lately by JNIr. Bvam and myself, where the enor-
mous tumefaction of the neck and throat, with
the affection of the larynx and trachea, increased
by the constriction produced by the integuments
suri'ounding the neck and throat, caused suffo-
cation in a few hours. This extension of the
disease to the fauces and tliroat, not infrequently
occasions a species of consecutive croup, as stated
in that article ( § 18. d.) : it may also occur, when
ths scalp is afl^ected ; but, in this case, the dis-
ease generally extends down the neck and back,
even to the loins. The disposition to spread thus
entensively, and to affect subjacent parts, is most
remarkable when the pulse is frequent, and vas-
cular action greatly excited, at the same time
that vital power is much depressed, the functions
of excretion impeded, and the blood morbid.

3 G 2

820

ERYSIPELAS — Particular Description.

14. In other parts of the body, the symptoms
are generally not so severe. The pain, however,
is very great when the disease attacks the wamm(e
during lactation, or when it extends to the organs
of generation. In these situations, it frequently
implicates the subcutaneous cellular tissue and
adjoining glands, and thus closely approximates in
seat and nature to the primary form of spreading
inflammation of the cellular tissue. When it
occurs in the latter situation, in children between
one and six years of age, it often proves fatal,
either from this circumstance, or from sloughing
ulceration. Where the extremities only are af-
fected, there are generally less pain and constitu-
tional disturbance than in other cases.

15. -B. Modifications of the local affection. —
The changes which take place in the external
seat of disease, may be classed under four
varieties : the glabrous, vesicular, crustaceous,
and deep-seated. — a. The glabrous local aflTec-
tion consists in a diffused or plane and smooth
tumefaction of the skin, of a rose or yellowish
redness, sometimes verging to a sub-livid hue. —
b. The vesicular form is attended with bulla?, or
blisters, in parts of the inflamed surface, resem-
bling the vesicles raised by cantharides. Some-
times they are numerous, small, and discrete p/i/i/c-
tena- ; at other times confluent, and forming very
large hulLe, containing a yellowish, sometimes
dark, sanguineous, acrid serum, effused between
the rete mucosum and cuticle, which it elevates.
These vesicles continue to appear during the
course of the disease ; are accompanied by an
unpleasant tension, itching, burning, or pain;
and, instead of diminishing, often increase, the in-
flammation and fever. — c.T\\e. crustaceous iovm
arises from an early rupture of the cuticle, and
escape of the lymphatic serum effused beneath it,
which exposure to tlie air forms into crusts, and
under which an acrid fluid collects, and irritates,
or even ulcerates the skin. — d. In the deep-seated
and tumefied, the cellular and other subcutaneous
tissues are affected, either by oedema, or by phleg-
monous or diffusive inflammation, tending to dis-
organisation. Whilst the supeificial parts of the
integuments are the chief seat of the affection, in
the preceding varieties, the tissues underneath are
principally diseased in this, particularly the cel-
lular and adipose ; and they present every shade
of morbid action, from simple passive oedema, to
inordinate vascular excitement— from the lowest
state of asthenia, to the highest degree of vital
action — either passing rapidly into suppuration,
or into disorganisation, or spreading extensively
in the course of the cellular tissue, and involving
other adjoining parts, as shown in the article on
Diffusive infiummation of this Tissue. It is gene-
rally observed in this associated or deep-seated
malady, that the skin is but slightly altered, or that
the morbid action in it diminishes, as that in the
subjacent parts increases, especially if the latter be
of a diffusive or septic kind.

16. C. Modifications connected with the con-
stitutional disturbance, — The forms which the
disease assumes, chiefly result from the states of
the nervous system of the assimihitiiig and ex-
creting organs, and of the circulating fluids, and
from the temperament and habit of body. 'J'hese
modify the febrile action, as well as the local
affection, aided by the existing grades of consti-
tutional power and vital resistance. Erysipelas

consequently presents every intermediate shade
between high vascular action with simply dimi-
nished vital power, and low vascular action with
great depression of the vital energies, as respects
both the part chiefly diseased, and the system in
general. — a. As soon as the morbid action in the
skin passes a certain height, it generally extends
to the subjacent cellular tissue ; and if it occur in
young, robust, or plethoric subjects, or if the
constitutional powers be not much reduced,
or the nervous system' not materially exhausted
or oppressed ; or if the functions of the digestive
and excreting organs be not altogether over-
powered ; then the- disease assumes more or less
of the sthenic or phlegmonous character, both as
to its local appearance and the attendant fever,
and has a marked tendency to pass into suppu-
ration, occasionally with destruction of the sub-
cutaneous cellular and adipose tissues. — b. When
the disease is attended by signs of accumulated
sordes in the prima via, with nausea and vomiting,
and a morbid state of the secretions, particularly
of the biliary secretion — characters which
it often presents, — it has received from Con-
tinental pathologists, the appellation of gastric or
bilious eri/sipelas. — c. If it present great depres-
sion or disturbance, especially of the cerebro-
spinal nervous functions, with a pale, evanescent,
and changeable state of the part aflJccted, and
imperfect secretion and excretion ; and if de-
lirium, coma, subsultus, &c. supervene; or if the
local affection spreads rapidly, or if it entirely
disappears, and is followed by internal disease ; it
has been called 7iervous eri/sipelas, or it may be
said to be complicated with febrile disturbance of
the nervous kind. — d. If, owing either to exces-
sive morbid action over vital power, or to a faulty
state of the system at the time of attack, or when
it supervenes upon remittent or continued fevers,
or upon any cachectic malady, or in aged or
broken-down constitutions, it extends to the sub-
cutaneous structures, and gives rise to oedema, or
terminates in softening or disorganisation of these
parts, it has received the name of a dematous, septic,
or gangrenous erysipelas. This state of the malady
is generally connected with defective assimilation
and excretion, with an impure state of the cir-
culating fluid, and with deficient vital power.

17. D. The causes which dispose to, or excite,
the disease, have also great influence in modifying
its characters, both local and general. When
propagated by infection, it is prone to assume a
complicated state, or to be associated with in-
flammation of the throat and pharynx of a most
dangerous character, owing to its disposition to
spread to the larynx and trachea ; and with dif-
fuse and gangrenous inflammation of the subcuta-
neous cellular tissue. A similar complication is
also observed during certain epidemic constitu-
tions, or when the disease has been occasioned by
the contact of animal matters in a state of decom-
position, or by other septic agents. In these cases,
the tumefaction is often great ; and, although vascu-
lar excitement may be very remarkable, vital power
is much depressed, and speedily overwhelmed ;
owing chiefly to the morbid state of the circulating
fluids, or to the contaminating and septic operation
of these causes.

18. III. Division of Erysipf.las. — This
disease has been divided by authors, according to
its various states, into febrile and non febrile ;

ERYSIPELAS — Simple — Complicated.

821

the stationary and the erratic ; the benign and
7naUgnaiit ; the acute and chronic; the periodic
or habitual, and the accidental ; the sporadic and
epidemic; the idiopathic and sywptomalic ; and
the primary and secondary ; to which may be
added, the internal and external. As to all these
general divisions, it is only necessary to remark
that, by Idiopathic erysipelas is understood that
condition of the disease whicli arises from the
direct impi-ession of the causus on the skin, as
from vicissitudes and epidemic states of the air,
chemical stimuli, morbid effluvia, poisonous mat-
ters, 6cc. ; and by Symptomatic, is meant the ex-
ternal manifestation of internal disorder, as of
impeded secretion and excretion, the accumu-
lation of morbid excretions in the prima via, and
an impure state of the circulating fluid, either
from interrupted elimination of effete matters, or
from the absorption of morbid secretions. As to the
existence of Internal erysipelas, I may observe,
that it cannot be allowed otherwise, than that
iuflammatory metastasis to internal organs, par-
ticularly the mucous and serous membranes, oc-
casionally occur ; the internal disease taking
place either in consequence of the suppression or
disappearance of the external affection ; or the
latter ceasing to exist, owing to the commence-
ment or progress of the former. But, although
the internal disease may retain the constitutional
peculiarities attendant on the primary afl'ection,
yet its distinctive characters can no longer exist
when it attacks a differently orgaiii-ed structure,
from that to which they are chiefly owing. It
is in such circumstances, and when internal
inflammations supervene in broken-down consti-
tutions, or from interrupted excretion and a morbid
condition of the circulating fluids, as in the course
of fevers, and in the puerperal state, that J. P.
Frank and many other writers contend for in-
ternal erysipelas; similiarity of morbid action,
local and constitutional, although affecting dif-
ferent structures, being considered by tliem as
sufficient to warrant the appellation.

19. The Division adopted by VVillan and
Bateman — viz. 1. Phlegmonous ; 2. (Ede-
matous ; 3. Gangrenous; and 4. Erratic — is
faulty, inasmuch as the termination in gangrene
is peculiar to no one state, but may occur in
either the first or second variety. — Dr. Good
associates certain varieties of erysipelas, with chil-
blain and intertrigo, under the generic term of
erijthema. — Biett, Cazenave, and Schedel
treat only of the True and Phlegmonoid. — One
of the best and simplest divisions is by MM. Ali-
liERT and Rayer, into (a) the Simple, (6) the
Phlegmonous, and (c) the (Edematous; but it is
defective, as it excludes certain states or com-
plications which should not be overlooked, wlien
treating of this disease. — Mt-Jamhs adopts a
nearly similar arrangement, substituting merely
the term superjicial, for that of simple, employed
by Rayer.*

* Synopsis qfthe Arrangement of different States of Ery-
sipelas adopted by the Author.

Species I Simple Erysipelas ; E. Simplex.

Var. A. — Benign or Superficial Erysipelas ; E. Sim-
plex Benignum.

Var. B. — Acute Erysipelas ; E. Simplex Acutum.
Species II. — Complicated Erysipelas; E. Coinpli-
catum.

Var. A With (Edema of the Subcutaneous Cellular

Tissue.
Var. B. — With Infiammation of the subjacent Parts.

i. Simple Erysii-elas — E. Simplex — E. Ex-
anlhemalicum (Rust). — Febris Erysipelatosa
(Sydenham, IIiedenbrand). — E.SnperJiciale
(James). — E. Verum seu Legilimum (Nau-
mann).

20. CnARACT. — Spreading inflammation of the
skin, with soft and slight tumefaction, redness,
stinging heat, fever, and frequently iiith vesication.

21. A. The mild, benign, or superficial form,
is attended by little constitutional disturbance, or
only by slight inflammatory fever, or disorder of
the digestive organs ; the surface of the skin is of
a pale or rose red ; vesication very seldom, or
sparingly, occurs ; and occasionally, after spread-
ing to, or affecting, adjoining parts of the surface,
and disappearing from those in which it first
commenced, it terminates in resolution in the
course of a few days, especially after the disorder
of the digestive and excreting organs, on which
it is usually dependent, has been removed.

22. B. The acute states are attended by more
severe local and constitutional symptoms (§2.).
They are preceded by marked disorder of the
secreting and excreting functions, and are accom-
panied by smart febrile action. The skin is ge-
nerally red, hot, diffusely tumefied, and covered
with small vesicles, and, in various parts, with
large bulls. These generally break soon after
their appearance, or about the fifth or sixth day
of the disease, the fluid drying into crusts of va-
rying colour and thickness ; the surface under*
neath either healing rapidly, or becoming exco-
riated by the acrid serum effused beneath 'them.
In this latter case, the duration of the disease
is longer, and the subsidence of the symptoms
more gradual, than in the former.

23. C. The termination, which is usually by
resolution, is preceded by a mitigation of the
symptoms, after having continued in full force
for three, four, or five days; and is attended by
exfoliation of the cuticle and of the crusts ; re-
solution generally taking place more rapidly in
this, than in any other, disease of the integuments.
But sometimes the sudden disappearance of the
inflammation is followed by its supervention in
some other part of the external surface — Erratic
Erysijielas ; and more rarely by asthenic inflamma-
tion of some internal part — Metastatic Erysipelas,
These occurrences are most frequent when the
local affection suddenly subsides, although the con-
stitutional disturbance continues, and effete or
morbid matters are still retained. The evacuation
of copious offensive stools, or of urine depositing
a large sediment, antecedently to, or about the
time of, the disappearance of the local affection,
is a sure indication of a salutary crisis.

ii. Complicated Erysipelas — E. Cojnplicatum,

24. Charact. — The inflammation of the inte-
guments of the kind above defined (^ 1. 15.), asso-
ciated ivith disease of the adjoining structures, or
ivith prominent disorder of internal organs,

25. This species is very varied, owing to cir-
cumstances already enumerated, but chiefly to
tjlie severity of the attack, to its situation, to the
states of the internal functions and of the con-
stitutional powers, and to the exciting causes.
Indeed, these latter circumstances mainly deter-
mine the character of the former. The morbid

J'ar. C. — '\\'UhInfla7iimatory Disease of the Throat,& c.

I'ar. D With Xeivous or Cephalic Affectio7i.

far. E. — With Gastric or Bilious Disorder.
30 3

822

ERYSIPELAS — Complicated.

associations, or more complicated states and
severe degrees, of erysipelas, are those in which
adjoining tissues suffer, or internal organs are
disordered, at the same time that the patho-
gnomonic phenomena — the inflammation of the
integuments — continue manifest. For, although
metastasis to internal viscera, or the inflammation
of other parts than of the skin, occurring in ca-
chectic habits, or in those who are subject to
this disease, may, vvith great propiiety, be viewed
as erysipelatous, as respects the nature of the
attendant constitutional affection, yet neither of
them can strictly be considered as such, as re-
gards the part affected. The erysipelatous cha-
racter, however, of the affection, under both
circumstances, should not be overlooked ; as
thereupon ought to depend, in a great measure,
the choice of remedies.

26. A. With OLdema, or Effusion into the Sub-
cutaneous Tissues — E. (Edemutodes of authors. —
a. This state of the disease may be consecutive of
the simple varieties, or it may accompany them
from the commencement, when they attack the
face, or the vicinity of the organs of generation ;
effusion, in these case?, always taking place in
the loose cellular tissue. It often, also, su-
pervenes in the progress of anasarcous swellings.
Its primary form occurs chiefly in old persons,
and broken-down constitutions, consecutively of
chronic visceral disease, and in the leucophleg-
matic and dropsical diathesis ; the affection of
the skin and subjacent cellular tissue being nearly
coetaheous. The external surface is of a pale
or yellowish red, inclining to brown ; generally
smooth and glossy ; and it is seldom tense. It
is but slightly hot or painful ; and sometimes
neither the one nor the other. 'J'he swelling in-
creases gradually, extends slowly, and pits sliglitly
on pressure. Vesications are not common ; and
the vesicles, which are small, numerous, and
flattened, usually appear from the third to the
fifth day ; they break in a day or two, and are
replaced by thin crusts. In the more active
states, a sero-puriform, or puriform, fluid infil-
trates the cellular tissue, or is discharged from
the vesicated surface. The genitals, the face and
scalp, the thighs and legs, are chiefly the seat of
this variety. Dropsical limbs, especially when
the cuticle is cracked or abraded, or after scari-
fications have been made in them, are often af-
fected by it : and, in these circumstances, there
is a marked disposition to gangrene.

27. /). CEdemutous erysipelas teimitiates—li^t,
in resolution, with absorption of the effused
fluid; 2d, in suppuration; and, 3d, in softening,
sloughing, and gangrenous destruction of the
part. — Suppuration occasionally takes place ;
but is generally of an irregular or diffusive kind,
extending in tlie couisc of the vessels, and be-
tween tendons and muscles ; is preceded by a
boggy state of the swelling ; and is often attended
by disorganisation of portions ot tiie cellular
membrane. — Gangrene is indicated by severe
pain ; and a red and glossy state of the surface,
j)assing into a livid or leaden hue.

29. 7i. With Injliimmatiim of the Subcutaneous
Structures — Er. Fhlecrmonosnm vel Phlegmn-
nodes, Auct. var. ; Diffuse Phlegmon, Dupuy-
TitEN ; Er. Spurium, Pseudo-Erysipelas, Rust. —
This is a most important and often dangerous
disease; especially when epidemic, or propa-

gated by infection. It is very varied in form
and seat ; and presents every grade of activity,
from the passive or cedematous state, just de-
scribed, to the most acute grades that rapidly
pass into gangrene (§31.). — When it occurs
sporadically, its local character is that of "dif-
fused phlegmon;" the attendant fever being of
an inflammatory kind, and preceded by rigors.
In this case, vascular action is more acute ; the
swelling is greater and more circumscribed ; the
pain and burning more remarkable, and more
pulsating ; the redness deeper ; tlie temperature
higher ; and the disposition to pass into suppu-
ration greater, but to change its situation less,
than in other circumstances. Where the symp-
toms are very acute, the subjacent cellular and
adipose tissue frequently are profoundly affected ;
the fasciae, the intermuscular substance, and even
the fibrous structures, becoming inflamed. In
such cases, disorganisation of the cellular and
adipose tissues often rapidly supervenes ; the
part passes from a brawny and tumefied, to a
flaccid and boggy, state; and the attendant fever
changes to a low or adynamic form. When
occurring epidemically, or from infection, the
local and constitutional symptoms are more
severe ; vital power and resistance are diminish-
ed; and the disease is often complicated with a very
dangerous affection of the throat and adjoining
parts. This variety may be divided, as suggested
by M. Rayek, into three grades,

29. a. In the Jirst, after rigors, and in con-
nection with the constitutional symptoms described
above (§2.), tingling, heat, and redness, fol-
lowed by hard tumefaction of the part, begin to
appear. A stingingpain, tension, and burning heat
are complained of in the seat of swelling ; which is
diffused, hnrd, and deep-sealed. After pressing the
surface with the finger, the redness returns more
slowly than in the superficial and simple disease.
The lymphatic glands often become inflamed or
enlarged ; and febrile action is fully developed.
If, about the fiftii or sixth day, the skin be less
red and tense, or covered by furfuraceous scales,
and the swelling subsides, resolution has com-
menced. (Edema of the cellular tissue, however,
sometimes remains for two or three days. But
if the pain, about this period, become puls-
ating, suppuration in one or more parts is in-
evitable. The abscesses thus formed generally
give issue to well-digested pus, and heal in a few
days.

30. /). In the second grade of this variety, in-
flammation is more extensive ; and the redness,
heat, pain, and fever are greater. If the disease
be not arrested, abscesses form, very insidiously,
from the sixth to the ninth day, or even earlier;
or a sero-puriforni fluid infiltrates the cellular
tissue, extending between the muscles and under
the integuments ; and, upon free openings being
made, di-sorganiscd portions of this tissue are
discharged with the puriform or ichorous matter.
Fistulous cavities fietpiently are formed, giving
issue to a foetid and ichorous pus. — Sometimes
tlie skin is tiiinned or detached, and falls within
the margin of the ulceration (Rayer). In these
cases, the stomacii and bovvels frequently become
inilable ; and the patient dies, either from the
exhaustion occasioned by diarrhoea, or by the ex-
tensive suppuration and disorganisation of the cel-
'ulav tissue ; or from the absorption of the morbid

ERYSIPELAS —Complicated.

823

secretion of the part, and the consequent conta- j infiltrated, and tumefied. Most commonly, the
mination of the circulating fluids ; or from those inflammation commences, with or after rigors in

causes combined ; severe nervous symptoms
(§ 35.) being either superadded, or taking the
place of this disorder of the prima via.

31. c. The third grade presents a still more
acute series of symptoms. In two or three days,
the inflammation of both skin and subjacent
parts reaches its acme. The skin is tense, smooth,
and shining; and of a deep or dusky red, wliich
is hardly a moment dissipated by the pressure
of the finger. The swelling is profound, very
painful, intolerant of pressure, and dittused. In
this grade, and sometimes also in the preceding,
the inflammation extends to, and beneath, apo-
neurotic expansions ; and occasionally even to
the periosteum, especially when the head is af-
fected. The pulse is sharp and frequent : the |
tongue is loaded and furred ; and the excretions
are offensive. There are, also, great thirst, restless-
ness, sleeplessness, increased fever towards night,
and delirium. About the fifth or sixth day, the
inflamed integuments assume a violet hue, lose
their sensibility, are softened, and covered by
phlyctenai filled with a reddish serum. Soon
afterwards ecchymoses and sloughs form ; and
at the same time, an ichorous suppuration, with
destruction of the cellular tissue, is established in
the subjacent parts : — Gangrenous Erysi/pelas.
In favourable circumstances, the sloughs are de-
tached, and the parts beneath assume a healthy
character ; but more frequently the patient sinks,
from the absorption of morbid matter causing con-
tamination of the fluids, or inflammation of veins ;
with affections of the brain, of the stomach, and
of the bowels, as in the more severe forms of ady-
namic fever.

32. d. The Jirst and second grades of this variety
often occur in the scalp, face, and neck ; and are
frequently farther complicated with ceiebral af-
fection, especially delirium, coma, &c. : or with
gastric and bilious disorder ; and with inflammalion
of the fauces and throat. The third grade, as well
as the first and second, is met with chiefly in the
extremities, particularly after contusions, fractures,
and punctured wounds, and is seldom preceded
or attended by rigors. When occurring epidemi-
cally, as from infection, the constitutional distur-
bance is greater and more dangerous ; the pulse
weaker and more frequent ; the inflammation of
the skin generally less, and thatof the cellular tissue
more remarkable, and more nearly approaching,
if not altogether identical v/'ilh, diffusive inflamma-
tion of that tissue (see this article), than in other
circumstances.

33. C. With severe injiammatory Affection of
the Throat and Larynx. — This afteclion may ac-
company any of the forms of erysipelas attacking
the face ; but it is most frequent in the phlegmo-
nous variety, particularly when it appears epi-
demically, or from infection. Of this, the papers
of Dr. Stevenson, Mr. Arnott, Dr. Gibson, and
Dr. M'Dowel, furnish interesting illustrations.
In some cases, the extension of the disease over
the nostrils and lips, to the fauces and pharynx,
may be traced. In others the afl^ections of tlie
throat and face are almost coetaneous ; and in
the more severe cases, the face, throat, and integu-
ments, down to the chest, with the cellular sub-
stance underneath, and surrounding the phurynx,
trachea, and glands, are more or less inflamed,

the fauces or pharynx ; is of a dusky hue ; ex-
tends along the nasal surfaces, and afl^ects the
face, scalp, &c. A sero-albuminous exudation
is either partially or rarely seen ; the croupy
symptoms, which sometimes supervene upon this
complication, being owing rather to the exten-
sion of the inflammation to the mucous surface
of the larynx and trachea, and the infiltration of
the subjacent and surrounding cellular substance,
than to the exudation of lymph. In a few cases
of the complication — one of them in the prac-
tice of my friend, Mr. Byam, at the time of writ-
ing this — the cellular tissue of the throat, and
of the whole neck, was so distended, that the in-
teguments appeared girt around them with the
utmost tension ; and, in this instance especially,
the respiration and cough were as distinctly
croupal as in idiopathic croup. I have seen, in
some cases of this kind, the constriction of the
integuments so great, that incisions of them — as
first recommended by Mr. Copland Hutciiison
— were required, to arrest fatal cerebral conges-
tion or immediate strangulation. The constitu-
tional disturbance in this state of disease is most
acute; and, at the commencement, attended by
high action with deficient power. As the dis-
ease proceeds, the pulse becomes more and more
frequent, unequal, irregular, soft, or small ;
deglutition difficult or impossible ; respiration
sometimes suffocative, wheezing, or sonorous and
croupal, with strangulating cough ; and the ex-
cretions are always foul, morbid, and offensive.
Delirium, coma, or sinking, preceded by rest-
lessness or anxiety, or disorder of the alimentary
canal, are also generally observed.

34. This complication may terminate, in the
most acute cases, in the course of three or four
days — 1st, in suffocation, from the extension of
the disease to the larynx and trachea, or from the
inflammation, infiltration, and tumefaction of the
cellular tissue surrounding these parts ; — 2d, in
sphacelation; — 3d, from the severity of the
superinduced cerebral affection, in connection,
sometimes, with congestion of the lungs; — and,
4th, the symptoms may abate under very de-
cided treatment ; and, as in the less severe cases,
may pass on to resolution, or to the formation
of purulent collections, either near the eyes, or
about the angle of the lower jaw, or side of the
neck. The formation of matter is generally in-
sidious ; this fluid being diffused throughout the
cellular tissue, and frequently deep-seated. When
this is the case, the result is usually fatal ; owing
to the partial absorption of the matter, and to the
effects caused by it on important parts in the
vicinity.

35. D. With Nervous or Cephalic Affection —
Erysipelas Nervosum, of authors. — This is a
common complication, wh.ere the disease affects
the face or scalp, particularly the cellular sub-
stance surrounding the eyes (Piorry) ; occurring
generally between the third and sixth days ;
and in the course of other varieties, attacking
persons of weak constitutions and susceptible
nervous systems, especially when about to pass
into dangerous exhaustion, or gangrene, or pre-
vailing epidemically. In the former circumstance,
there is evidently superinduced inflammatory
irritation, or excited vnscular action, in the mem-
3 G 4

824

ERYSIPELAS — Lesions in Fatal Cases — Diagnosis.

branes of the brain, analogous to the vascular
excitement of the skin, often occasioning an in-
creased exhalation of serum : hence the delirium,
passing frequently into coma. In the latter cir-
cumstance, the cerebral disturbance is the result
rather of depressed vital power, manifested espe-
cially in the cerebral functions, and of the morbid
changes in the blood, than of inflammatory action.
The pulse is frequent, but variable as to fulness
and power. The tongue is at first loaded, red at
the point and edges, and afterwards dry in the
middle, and of a brown or dusky hue. The
excretions are suppressed or impeded ; and, in
the worst cases, particularly towards the close,
are passed unconsciously. Tremors, subsultus
of the tendons, floccitation, &c. are then also
observed. A fatal termination occurs generally
from the seventh to the fourteenth day, or later.
A bilious diarrhoea, or copious faaculent and
offensive stools ; a free discharge of urine de-
positing a copious sediment ; and a general,
warm, and copious perspiration ; are favourable
occurrences.

36. E. With Gastric and Bilious Disorder. —
The bilious nature of erysipelas was strenuously
insisted on by Stoll, Dessault, aud others.
Antecedent disorder of the digestive and assi-
milating organs is more or less evident in all the
varieties, but especially in this, wliich is of com-
mon occurrence during summer and autumn,
when the digestive mucous surface and biliary
apparatus are most liable to be diseased. It is
generally attended by manifest signs of accu-
mulated sordes and morbid secretions in the pri-
ma via, and of an increased secretion of acrid bile,
especially when the disease is epidemic at the
seasons just mentioned.

37. F. Erysipelas may, moreover, be com-
plicated with inflammatory action of the mucous
surfaces, analogous to that of the skin, giving
rise to a form of bronchitis or gastritis. Where
it is connected with inflammatory sore throat, it
sometimes extends along either the trachea, or
the oesophagus, or even both, until the lungs, or
the stomach and bowels, are aflPected ; and, oc-
casionally, along the Eustachian tube, to the
ear ; it thus becoming complicated with one, or
even more, of these affections. This connection, first
distinctly pointed out by J. P. Frank, has more
recently been insisted upon by Beoussais, El-
i-ioTSON, and others. Fkan'k alludes to instances
in which erysipelatous inflammation extended
from the pudenda, along thevaj;ina, to the uteru«,
and even to the bladder. Erysipelas may be
further complicated witii injlanvnuiion of tlie lipn-
phntics, particularly when caused by breach of
Hurface ; or with phlebitis, when consequent upon
injury, or when it has proceeded to suppuration.

38. G. Erysipelas may occur in the course of
continued and remittent fevers ; and it may
appear during convalescence from any of the
exanttiemata. — In the first of these associations,
it generally presents an adynamic character, with
nervous or with maiignant symptoms ; frctjucntly
attacks the face, throat, and scalp ; or the parts
j)ressed upon in bed, or irritateil by the evacu-
ations ; and is especially dis])osed to gangrene.
When it sujjervenes upon remittents, it often
assumes a bilious or gastric form; and in these,
as well as in exanthematous fevers, it may prove
a salutary crisis, if the pulse do not rise in fre-

quency ; and if the cerebral functions remain
undisturbed. In crowded sick wards, and in
lying-in hospitals, it often occurs in the progress
of other diseases, with whicli it consequently
becomes complicated. But it is a most danger-
ous circumstance ; as it is, in those cases, caused
by an infected or impure air, which, favoured by
the depressed state of vital power, or by imper-
fect excretion, has contaminated the circulating
and secreted fluids.

39. IV. Lesions in Fatal Cases. — When the
cellular tissue has not been severely affected, the
injection of the integuments subsides considerably
after death ; and hence the redness of the exter-
nal surface, as well as that of the throat, has
often nearly or altogether disappeared. In addi-
tion to infiltration of the subcutaneous tissues
with serum, or a sero-puriform matter, and occa-
sional disorganisation or gangrene of these and of
the integuments, various internal lesions are com-
monly observed. The blood in the large vessels
and cavities of the heart is frequently semifluid;
and the veins proceeding from the part chiefly
affected, are often inflamed, or contain pus; as
first observed by M. Ribes, and confirmed by M M.
Dance, Arnott, and by my own observations,
especially when the disease has been complicated
with diffuse suppuration of adjoining cellular
parts. In cases that have been attended by
cephalic affection, the membranes of the brain
are sometimes injected, or inflamed, and the
arachnoid opaque, with serum effused between
them, and in the ventricles; but, as M. Piorry
has shown, these lesions are often not observed
in this complication. Where the throat has been
affected, the fauces, pharynx, and asophagus
are of a dark or dusky red, or of a livid or
brown tint; much softened, sometimes with small
patches of dark lymph on their surfaces ; and the
subjacent tissues infiltrated with a bloody serum,
or with a sero-puriform matter. These appear-
ances occasionally extend to the larynx and
trachea, the submucous tissues being cedema-
tous, or infiltrated with similar fluids. — In cases
that have been associated with bronchial or pul-
monary disorder, the lungs are congested with
a dark semifluid blood ; the bronchi are of a dark
red or brown colour, are injected, and often con-
tain a frothy and bloody fluid ; portions of the
lungs being oedematous, and otiiers partially
hepatised. — ^ The mucous surface of the stomach
and intestines is generally injected, of a deep or
dark colour, often softened, and, where the bowels
had been much afl^ected, abraded, or inflamed,
especially in the cajcum and rectum. The liver
and spleen are seldom found in a healthy state,
particularly in persons advanced in age ; but
they present no lesions peculiar to this complaint,
excepting that those usually resulting from intem-
perance are most frequently observed.

39. \'. Diagnosis. — The antecedent consti-
tutional disturbance, with excited vascular action
and drowsiness ; — the dull or yellowish red, or
rose-colour, of tiie integuments, terminating in an
irregular, but well defined margin, and disappear-
ing, momentarily, on pressure; — the pricking,
stinging, and burning heat and pain of the part,
sometimes with irreguhir vesications ; — the slight,
plane, and diffused tumefaction, or the greater
swelling and diffused affection of the cellular
tissue in connection with the inflammation of the

ERYSIPELAS — Prognosis — Causes.

825

skin; — its rapid extension, or delitescence, or
change of situation ; — its almost uniformly acute
or subacute character, as respects both the local
and constitutional symptoms; — its manifest as-
sociation with disorder of internal organs, par-
ticularly of the digestive, assimilative, and excret-
ing viscera, and of tiie brain and membranes ; and
its dependence upon a change in the circulating
fluids; — its indispostion, owing to the states of
vascular action and of the fluids, to confine or
limit itself; and the inability of forming coagu-
lable lymph, owing to these causes; — its infec-
tious character under circumstances favourable
to the manifestation of this property, more espe-
cially when the constitutional affection is of an
adynamic kind, or when attended by sore throat ;

— the readiness with which it is repelled, and
thrown in upon vital or important viscera ; — its
rapid termination in, or transition to, resolution
and desquamation, or suppuration, or gangrene;

— and, finally, the insidious and diffused manner
in which purulent matter forms in the cellular
tissue, when suppuration takes place ; are suf-
ficient to distinguish the disease from erythema on
the one hand, and from phlegmon on the other.

40. VI. Prognosis. — -There are various circum-
stances which should influence our opinion as to
theresults, in this disease ; and determine us to give
a guarded prognosis on all occasions : — 1st, Its
tendency to relapse or to recur, from slight or un-
appreciable causes, or from errors in diet, &c. ; —
2d, Its disposition to become o^socia fed with severe
or dangerous internal aflPections ; to disappear sud-
denly ; and to be succeeded by them, especially
diseases of the brain and its membranes, of the air-
passages and lungs, of the digestive canal and
peritoneum, and of the veins; — 3d, The age,
habits, and previous health of the patient ; — 4th,
I'he causes which produce it, and the character of
the prevailing epidemic ; — 5th, The parts which
it attacks, its particular form and complication,
and the state of constitutional disorder accompany-
ing it.

41. a. Recollecting that erysipelas is the ex-
ternal expression of an internal or constitutional
disease, we should consider the free manifestation
of it on the external surface, with little or no af-
fection of the subjacent or internal parts, and
without any remarkable depression of vital power,
as a. favourable circumstance, and not to be im-
peded by external means. As long as it remains
thus simple and superficial, and of neither a deep,
fiery, nor purple colour, although it may be ex-
tensive, and attended by vesication, it is not dan-
gerous ; unless it affect the face and head, and be
accompanied with cerebral disorder. If it follow
the stings of insects, the application of acrid sub-
stances to the skin, or external injuries, it is seldom
attended by danger, unless in cachectic or aged
persons, or those addicted to the use of spirituous
liquors. Stationary superficial erysipelas is less to
be dreaded than the erratic ; for, in the latter,
there is greater risk of internal metastasis ; and
the erratic character is often connected with
serious changes in the nervous and vascular func-
tions, or with latent internal disorder.

42. b. The risk of an imfavoiirahlc issue is
generally great in proportion to the severity of the
constitutional afifection, — to the adynamic or
nervous character of the attendant fever, — to
the depravation of the circulating and excreted

fluids,— to the deepness and darkness of the
colour of the afli"ected part, — to tiie severity of
the cephalic disturbance, — to the extent and
diffusive form of the inflammation and suppur-
ation in the subcutaneous tissues, — and to the
vital importance of the parts prominently asso-
ciated in the malady. Great tumefaction of the
throat, scalp, or face, with prominence of the eye-
balls ; attendant disease of the fauces and pha-
rynx, or of the respiratory passages and lungs,
or of the stomach, intestines, &c.; tenderness at
the cpigastiium, or over the nbdomen ; the disap-
pearance of the external inflammation, and su-
pervention of either of these, or of some other
malady; and coma, jactitation, unconscious eva-
cuations, &c. ; are dangerous occurrences. 'I'he
frequent or habitual recurrence of erysipelas,
particularly in persons advanced in life, indicates
organic change in the liver ; and its appearance
about the organs of generation, in them, and in
ciiildren, and around the umbilicus of infants,
or in cedematous and dropsical limbs, especially
after scarifications, is very unfavourable. A
similar inference may be drawn when it attacks
the face and scalp, particularly of delicate, aged,
or broken-down subjects; or follows severe in-
juries or surgical operations; or appears during
convalescence from dangerous maladies, and when
it is not preceded nor attended by shivering. Epi-
demic erysipelas, particularly in the crowded
wards of hospitals, and during cold and humid
states of the air, is attended by greater risk than
sporadic cases.

43. VII. Causes. — A. There frequently exists
a peculiar predisposition, or an erysipelatous dia-
thesis, the nature of which has not been fully
ascertained. It seems, however, to be connected
with great irritability, or tenderness of the cuta-
neous surface, and defective power of the capillary
vessels and secreting surfaces and viscera. Females
are much more predisposed than males, particu-
larly at the period of menstruation, and after the
epoch of its termination. The irritable, bilious,
and piilogistic temperaments ; feeble, leucophleg-
matic, and plethoric habits ; the gouty diathesis ;
the autumnal, winter, and spring seasons; torpor
or interruption of the biliary functions ; an habi-
tually acrid and foetid perspiration ; unwholesome
and low diet; addiction to spirituous liquors ; pre-
existing visceral disease, general cachexia, and ex-
haustion of vital or constitutional power; are the
chief predisposing causes. J. Frank supposes
that young persons and females are most subject
to erysipelas of the face and head ; and the aged,
to that of the extremities. Certain parts are more
predisposed than others ; as the face, sexual
organs, and lower limbs ; owing to the greater
sensibility and vascularity of the former, and the
liability of the latter to injury and external
irritation.

44. -B. The exciting catises are — a. Those
whichact locally, as injuries of the head and face ;
contusions, wounds, and fractures ; surgical oper-
iftions, particularly when performed on cachectic
habits : the scarification or puncture of anasarcous
limbs; venaesection, and the bites of leeches;
punctures of the skin, and the inoculation of
morbid, putrid, acrid, or septic matters ; the stings
and bites of insects ; abrasions of the cuticle ;
irritation caused by coarse articles of clothing, or
by morbid secretions or excretions ; the appli-

826

ERYSIPELAS — Causes.

cation of stimulating or acrid substances to the
surface, particularly rancid oils and unguents ;
and the want of personal cleanliness. — b. The
more genera/ and internal causes are — exposure
to cold and moisture ; atmospheric vicissitudes ;
suppression of the cutaneous excretion ; a fish
diet, and especially the use of shell-fish, or of
dried, stale, or rancid fish ; or of rich, oily, fat, or
smoked meats ; the suppression of accustomed
secretions, excretions, and discharges — as the
menses, hemorrhoids, &c. ; violent mental per-
turbation ; an impure state of the air, particularly
a stagnant and moist air, loaded with animal
effluvia ; the miasm from persons affected by the
disease, when confined in a close atmosphere ;
and certain constitutions of the air which are re-
cognised only by their effects.

45. In persons strongly predisposed, and par-
ticularly in those wiio have experienced an
attack, very slight errors in diet, and indigestible
meats, especially such as are apt to induce a
rancid, acrid, or acid change in the chyme ; or
spirituous or malt liquors in excess; very fre-
quently induce a relapse or return of the disease.
Indeed, whatever has the effect of altering the
chyme and chyle from their healthy stales, or of
interrupting the functions of depurating organs,
and thereby of changing the circulating fluids,
either by the introduction of morbid and conta-
minating matters, or by tlie diminished elimina-
tion of hurtful or irritating elements, will excite
this malady.

46. The influence of infection in causing ery-
sipelas was first, pointed out, and indeed proved,
by Dr. Wells, the most original observer of
disease in this country at the termination of the
last and the commencement of the present century,
when the state of medical science was by no means
flourishing ; and is fully confirmed by the ob-
servations of Pitcairn, Paris, Baillie, Dickson,
Weatherhead, Stevenson, Arnott, Gibson,
Bury, and Lawrence, referred to in the Biblio-
graphic ; and by evidence that has occurred to
myself on more than one occasion. — When thus
caused, erysipelas is very prone to attack the face
and throat, and assume dangerous or even malig-
nant characters ; more especially if it also be
epidemic.

47. C. Epidemic Ertisipchis. — JVlost writers on
the disease, from Hippocrates to the present
time, have mentioned its occasional appearance
in an epidemic form, and the circumstance of its
characters partaking of the prevailing epidemic
constitution. On most of the occasions of my
seeing it, from 1814 to 1824 or 1825, it possessed
more or less of a sthenic or phlogistic type ; and
depletions early in the attack, v.'ere then better
borne than more recently ; it having, for the last
few years (till 1834), presented chiefly adynamic
forms. Its appearance in hospitals as a circum-
scribed epidemic is very common ; and is gene-
rally owing to impure air, particularly during the
cold, raw, and foggy east winds that prevail
about the months of November and March ;
when the external air is in some measure ex-
cluded, and the air of the wards becomes loaded
with animal miasms ; or with the effluvium of one
or more persons affected by it. In these circum-
stances, the constitutional disturbance presents,
or passes speedily into, the adynamic or nervous
states; the secretions, excretions, and circulating

fluids being more or less morbid. I'hus, accord-
ing to the particular epidemic constitution, the
habit of body, the age and strength, and the
modes of living, of those affected ; the season in
which it prevails; the contingent generation of an
infectious effluvium, or of an impure and confined
air ; and the pre-existing state of the assimilating
and excreting functions; epidemic erysipelas will
appear with a predominance either of inflamma-
tory, or bilious, or adynamic, or nervous
symptoms — on some occasions, with an inflam-
matory appearance of the blood ; on others with
a loose, dissolved, and otherwise morbid state of
this fluid ; and always with the excreting functions
more or less disordered. In some instances, the
integuments are chiefly affected ; in others, and
those the most dangerous, the subjacent parts are
principally and often insidiously, diseased. It
occasionally does not confine itself to the situation
it first attacked ; and frequently it seizes on the
face, neck, and scalp ; and is sometimes compli-
cated with a similar form of inflammation of the
fauces, pharynx, and surrounding parts, or of
the digestive or respiratory mucous surface. An
abrasion, or some palpable irritation of the cu-
ticle, or external injury, is sometimes required to
originate an attack ; but much more frequently
It is the external expression of a morbid state of
the frame, especially of the assimilating and ex-
creting functions, and of the circulating fluids.
On all occasions of its epidemic prevalence, the
constitutional disturbance, ushered in either by
rigors, or by irregular chills, precedes the local
affection : sometimes in a very evident manner ;
at others, more slightly or obscurely ; and, gene-
rally, the formation of matter, and effusion of
fluid into the cellular tissue, are not attended by
the well-marked symptoms usually indicating
them in more healthy states of the body.*

* Hippocrates {Epid. 1. iii.) states, that erysipelas, epi-
demic in the spring,sometiines continues through the sum-
mer and autumn. — Bartholin and Sylvius describe an
epidemic which was frequently complicated with inflam-
mation of the stomach and bowels. — Tozzi (Comment, in
Hippoc. Aphorism. 1. vii. \ 20.) remarks, that a fatal form
of the disease was prevalent,during the autuinn and winter
of 1700, in Naples; and afTected chiefly the face ; delirium,
cpistaxis, and malignant symptoms rapidly supervening.
When erysipelas is epidemic about the autumnal equinox,
it sometimes abates during the winter, as remarked by
Sydenham, and becomes again more prevalent in the
spring. RiciiTER states, that such was the case in respect
of tlie epidemic of 1720-21, in Turin. It attacked any
part of the body ; but most frequently the face, neck, and
limbs. Epistaxis and a lax state of the bowels were fa-
vourable oecurrences. Bloodletting, in the more phlo-
gistic cases, and medicines to aid the depurative proce.sses,
were found most beneficial. — In the epidemic of 1750,
described by Darluc, the diso:ise commenced with cir-
cumscribed redness in somepai t of the face, which spread
over the head and face, and was attended by great tume-
faction, a hard and frequent pulse, great thirst, anxiety,
&c. In many cases, the adection extended over the
throat, was accompanied with " difiiculty of deglutition,
lioarseness, a feeling of sutlbcation, and swelling of the ex-
ternal parts of the throat and neck," with delirium, thick
and turbid urine, subsultus tcndinum, Ac. ; and occa-
sionally terminated in sphacelation. Offen.sivo sweats,
and free, copious, and foetid alvino evacuations, were
salutary. Bleeding at the commencement, followed by
emetics, purgatives, and diaphoretic tisanes, was generally
employed. If these were neglected, the affection of the
throat often proved fatal. — Brompield mentions the epi-
demic prevalence of the disease for two years ; the head
being adected. In it, the antiphlogistic treatment was
generally fata! : bark and cordials were most serviceable.
— Dr. Fekro, of Vienna, and Dr. IlAtiCi, of Pavia, de-
scribed an epidemic in these cities, during the years 1780
and Hf^S, which was freciuently either associated with, or
pissed into, peripneumonia, culic, and diarrhoea. And,
in all these cimiplications, liloodlctting, antimonials, dilu-
ent.'?, and laxatives, were the most successful remedies.

ERYSIPELAS — OF Infaxts.

827

48. D. Nature of Erysipelas. — Dr. Cullen
considered erysipelas to arise from the irritation
of a morbid matter generated within the body,
and thrown out, by the fever, upon the cutaneous
surface. This is substantially the opinion of the
ancients; and, with u very few slight modifica-
tions, of the best writers among the moderns also,
especially the Franks, Selt,e, Richtf.r, &c. —
Sir A. Carlisle says, that " it is a humoral and
constitutional inflammation occasioned by aliment-
ary crudities," and attended by an excess of acid
in the fluids. That it is a humoral and constitu-
tional inflammation, is very generally admitted ;
and that alimentary crudities often precede and
attend it, is also evident : I conceive, however,
that not only a vitiateil state of the chyme and
chyle, proceeding from weak digestive power, or
unwholesome and indigestible food, and vitiating
the circulating fluids, but also the absorption of
morbid effluvia, and the r(;tention of effete matters
in the blood, owing to impeded excretion, either
by the skin, the liver, the kidneys, the mucous
surfaces, or the uterus, — in short, that a morbid
condition of the fluids, arising either from the
passage into them of contaminating materials, or
the retention in them of effete elements, that are
constantly being excreted by the various emunc-
tories, — are the principal changes productive of
this disease.

49. These changes most probably depend upon
deficient power of the digestive, assimilative, and
excreting viscera — upon depression of the or-
ganic nervous influence. But, as soon as the
change in the circulating fluid reaches a certain
pitch, febrile action is the consequence; and the
morbid matters in the blood are determined to
excreting surfaces and organs, which are thereby
excited either to eliminate them, or to assume a
morbid state of vascular action. The skin, being
one of the most important of these organs, thus
becomes irritated and inflamed, owing to its pe-
culiar functions and susceptibility, and to the
nature of the irritating matters contained in the
blood, or of the change this fluid may have ex-
perienced. If the febrile commotion be charac-
terised, owing to the state of vital power, by
much sthenic action, the local change will be
thereby fully developed, and thrown chiefly upon
the excreting surface ; but if, from deficient
power, the fever partake more of an adynamic
or asthenic form, the local expression of the dis-
ease will be made less fully on the external sur-
face, and will fall more fully upon subjacent
and internal parts. Hence the frequency of in-
ternal complications, and of aflPection of sub-
cutaneous tissues, in adynamic cases ; and of
the simple and superficial forms in the more
inflammatory and sthenic, unless when the dis-
ease is attended by a great excess of vascular
action above vital power, and then the local affec-
tion extends to adjoining parts from this circum-
stance, in connection with the morbid state of
the blood. The diflPusive character of the inflam-
mation, whatever tissue it may attack, is referrible
entirely to defective vital power, to the changes
in the circulating fluids, and to the imperfect
tone of the extreme vessels, — these conditions
being inadequate to the formation of coagulable
lymph ; the products of inflammatory action in
this state of vital power, and of vascular action
and impurity, being a turbid, puriform, ichorous,

or sanguineous serum, which produces a septic
effect, or poisons the adjoining parts, especially
the cellular tissue.

60. VIII. Erysipelas of Infants — Erysipelas
Neonatorum, Hildenbrand and Richter — may
bo either simple or complicated ; and it may
attack either the head, trunk, or extremities.
When it appears on the trunk, it generally com-
mence^ at the umbilicus ; the abdomen, trunk,
and lower extremities being its most frequent seat
in infants. It is generally accompanied with
phlyctenae or large bullae ; and it is sometimes com-
plicated with oedema or inflammation of the sub-
jacent tissues, and with inflammation or congestion
of internal organs. It is most common from
birth to a year old ; and is sometimes remarkably
prevalent in lying-in and foundling hospitals.
The occurrence of Bulle, in nearly all the
children born for many months in Queen Char-
lotte's Lying-in Hospital, alluded to in that
article (§4.), was evidently referrible to a more
than usually superficial, slight, and uniform kind
of erysipelas, which affected the whole surface
in many instances, and not any one part in pre-
ference to another.

51. When attacking infants, erysipelas presents
the following conditions and morbid relations : — •
1st, It is sometimes referrible to imperfect ablution
and removal, soon after birth, of the secretion
which covered the cuticle, and which becomes
acrid and irritating if left in contact with it; —
2d, It frequently proceeds, especially in hos-
pitals, from a foul air or other contaminating
agents, or irritants, acting either internally, or
on the uncicatrised umbilicus ; — 3d, The reten-
tion of excrementitious matters, as the meconium,
and morbid secretions, evidently dispose to it ; —
4th, Want of care and of due cleanliness, espe-
cially as to the immediate removal of the excre-
tions from the parts with which they come in
contact, is also a common cause; — 5th, It is
probably favoured, as M. Billard suggests, by
the great vascularity of the external tissue of the
integuments at this epoch; — 6th, It is not so
frequently complicated, or attended by great dis-
order of the circulating fluids, as in aged persons,
although it is generally accompanied with dis-
order of the excretions, and often with an inflam-
matory state of the digestive mucous surface, and
occasionally with disease of the throat and re-
spiratory organs ; — 7th, The attendant fever is
more commonly of an inflammatory kind, than in
adults and aged persons; — 8th, It terminates in
resolution, suppuration, and gangrene; this last
occurring frequently when the disease commences
about the urnbiHcus and genitals ; and occasion-
ally in Induration of the Cellular Tissue (see
that article); — 9th, The afl^ection of the pu-
dendum, and the complication with disease of
the throat, are rarer in infants than in children
from a year to five or six years of age ; — 10th, It
is generally attended by great danger, especially
when it prevails in lying-in and foundling hos-
pitals, owing to the frequency of its complication
with, or metastasis into, internal disease; — 11th,
Fatal cases usually present inflammatory appear-
ances in the digestive mucous surface, and less
frequently in the respiratory surfaces and mem-
branes of the brain, in connection with destruction
of the subcutaneous, cellular, and adipose tis-
sues; a turbid, puriform, or sanguineous serum

828

ERYSIPELAS — Treatment of the Simple Fonw.

being sometimes effused from the serous surfaces,
but never coagulable or albuminous lymph.

52. IX. Treatment. — So numerous are the
shades of difference, as to both nature and degree,
between the mildest and severest forms of erysi-
pelas, that no general plan of treatment can be
proposed, without modifications according to the
circumstances of particular cases. In some in-
stances, large depletions are required ; in others,
moderate or local depletion only is admissible ;
and, in many, depletion is most injurious, the
most energetic tonics being often indispensably
necessary. Whilst the disease thus requires,
from the veni commencement, most varied and
even opposite modes of cure, it frequently also
demands an almost equal diversity at different
stages of its progress. The following, as remarked
by Mr. James, is, perhaps, the most extensively
applicable precept, as to treatment, that can be
inculcated: — Where the skin is tense, deep-
coloured, and hot, with a high pulse, full and
flushed face, active delirium, and great heat of
the general surface, and the constitution not ma-
terially impaired, depletion is well borne, and is
required ; but where there is no tension, nor
much heat, nor great redness of tiie part ; the
pulse being soft, the countenance pale or sunk,
the general temperature but little elevated, and
the delirium quiet or comatose ; depletions are
injurious, and a restorative treatment is most
appropriate. In the former class of cases, the
reduction of the external inflammation, by local
as well as by general means, is most serviceable ;
but, in the latter, the external affection,is a small
part of the disease, relief to the system often
arising from encouraging it, and great injury
from repelling it. — Even in the most acute and
inflammatory cases, large depletions should be
employed with much circumspection ; for, how-
ever high, bounding, or hard the pulse, or great
the heat may be, there is always, owing to the
circumstances explained above (§ 16. 49.), a dis-
position to asthenic vascular action, and a defi-
ciency of vital power. Bloodletting, especially
venaesection, should, therefore, be resorted to
early in the attack, and should not be solely or
even chiefly relied upon ; the reduction of the
excited action forming only one of the intentions
of cure ; and bloodletting being only one of the
modes of fulfilling it.

63. i. Treatment of Simple or Superficial Ery-
sipeliis. — A, The mild or benign form requires
only simple measures. Purgulives with the alka-
line subcarbonates, warm diaphoretics, and diu-
retics, are most beneficial, if exhibited so as to
promote the depurating or secreting functions.
After the bowels have been fully evacuated, the
decoction of quince seed may be given frequently,
with mucilage, nitrate of potash, subcarbonate
of soda, and spirit of nitric a;ther. If this form
become erratic, a combination of tonics, especially
bark, with these, will generally remove all dis-
order. I have found the following remarkably
useful : —

No. 217. R Soda? Carbon. 5 j. ; Vini Ipecacuanha? 3 ij. ;
Spirit. Ammon. Arom. .3j. ; Infusi Senna.- Com]). ,? ij. ;
Decocti Cinchona; 3 iij. Tinct. Cardamom. Coinp. 3iij.
Miece. Capiat partem tcrtiam, tcr in die.

54. B. The slighter cases of the acute form
of superficial erysipelas are generally removed by
tiic above means. If, however, vas-cular action

be much excited, local depletions, or a small or
moderate bloodletting, followed by diaphoretics,
depurating purgatives, and abstinence, are al-
ways serviceable. When the head is unaffected,
particularly if the disease occur in autumn ; and
after depletions, if requisite, have been practised ;
an emetic, early in the attack, generally restores
the impeded functions of the liver and skin. A
dose of calomel and James's powder, with two or
three grains of camphor, should be exhibited at
bedtime, and a purgative early the following
morning ; this last being repeated every morning,
and diaphoretics, with diuretics, every three or
four hours during the day. If the disease be
caused by suppression of the perspiration, dia-
phoretics, as liicHTER very justly remarks, are
especially indicated ; the affected part being con-
stantly covered by oiled silk, to prevent evaporation
from it. The acetate of ammonia, antiinonials,
and camphor, are the most appropriate of this
class of medicines. If the head or face be af-
fected, a general bleeding — preferably from the
feet, whilst immersed in warm water— is requi-
site ; and the means just mentioned, with the
exception of the emetic, ought to be freely pre-
scribed, the action on the bowels being promoted
by purgative enemata (particularly F. 150. or
151.). Colchicum maybe tried in this and the
phlegmonoid varieties. It was much recom-
mended by Mr. Haden, and recently by Mr.
Bullock. It is most serviceable when givea
with the alkaline carbonates, or magnesia.

55. The choice ofpurgatives, and of the medicines
that should be combined with them, is a matter
of much greater consequence in this complaint,
than is usually supposed. I have most frequently
given the calomel in the above combination at
first; and afterwards, the compound infusions of
gentian and of senna, with a neutral salt. This
last may also be prescribed in camphor mixture,
with an alkaline bicarbonate, and taken whilst
effervescing with lemon juice, the alkali being in

excess Rjciiteu advises equal quantities of the

bitartrate of potash and magnesia. Sir A. Car-
lisle recommends the fixed alkaline bicarbonates
to be given with the purgatives ; and barley
water, with the carbonate of soda, to be used as
common drink ; on the supposition of the disease
arising from an acid in the blood. It is possible
that the change in this fluid may partake of an
acid character, but we have no proof of it ; nor
can it be the only, or even the chief, change. The
practice, however, has been long known to be ser-
viceable. I believe that the bicarbonate of potash
and sesquicarbonate of soda pass rapidly into the
circulation, and act beneficially on the blood. Yet
acids may be given not only without risk, but ap-
parently witli advantage. They have even been
recommended by Marcard, Panzani, and others.
In a case which I recently saw in consultation
witii Dr. RiDiNo, and which was complicated
with menorrhagia of a most atonic kind, and
with nervous symptoms, large doses of a mineral
acid were added to tonics, and yet the recovery
was rapid. The neutral salts, vvhich are most to
be depended upon, are — the sulphates of potash,
soda, and magnesia ; the tartrate of potash, or of
potash and soda ; and the phosphate of soda.
Either of these may be given in the infusion of
senna, or in equal parts of it and of the infusion
of gentian, or of bark. The association of purga-

ERYSIPELAS — Treatment

lives with tonic and bitter infusions is of the greatest
benefit at all periods, and particularly at an ad-
vanced stage of the complaint, F. 215. or the
following may be employed : —

No. 218. R Potassae Sulphatis 5 j. ; Soda; Carbon. 5 jss. ;
Infusl Senna; Comp., Infusi Gejitianie C'omp. aa, 3 iijss. ;
Tinct. Jalap. 3ijss. ; Tinct. Cardamom. Cump. .3iij. M.
Fiat Mist., cujiis capiat Coch. iij. larga.secunda veltertia
quaque horfl, donee plend dejecerit alvus.

56. After morbid secretions have been evacuated
by these means, and the functions of the skin
and kidneys promoted, the infusion or decoction
of cinchona, or the infusion of cascarilla, may be
taken with the alkaline carbonates, or witii
liquor potassas ; and if the urine be scanty,
the spirit of nitric a;ther, or of juniper, may be
added. If the skin still continue harsh or dry, '
the ligiiter infusions, or camphor mixture, may
be given with the solution of acetate of ammo-
monia, and the spirit of nitric aether, or ipeca-
cuanha wine. When excoriating secretions from
the vesications on the surface extend or increase
the irritation, defective function of the excreting
organs sliould be suspected, and deobstruent
and stomachic purgatives perseveringly pre-
scribed. The morbid action, also, of the part
ought to be corrected by washes containing a
solution of the chlorates of lime or of soda, or by
those consisting of lime water, or of Creasote
water ; or by applying the linimentum tere-
binthinaj. If dry incrustations form on the sur-
face, oiled silk should be constantly applied over
it. Hut in ordinary circumstances, especially of
the constitutional disease, it is advisable to abstain
from local applications, or to resort merely to
bathing or sponging the part with some tepid
fluid, as the decoction of quince seed, or of the
flowers of the lime {Tilia Europea) , if the heat,
pricking, &c. be troublesome. Where the vesica-
tions are nuinerous, the practice of dusting the
part with flour, or any other absorbent powder, is
warranted by the results of experience. Of inci-
sions and other local means, especial notice will
be taken hereafter.

57. Where a disposition to terminate in cedema
of the subjacent tissues becomes apparent, the
measures to be adopted must depend upon the
state of the constitution, and on the previous
treatment. If the former be not much impaired,
and if the latter have not been energetic, purga-
tives, as directed above, and warm diaphoretics,
should be frequently exhibited, and a blister ap-
plied to the part. But if the vital powers be
much impaired, the more restorative remedies,
and the local means, recommended in the next
section (§ 58.), should be resorted to. Where
the inflammation of tlie integuments extends to
the parts beneath, and the skin becomes tense,
local depletion by leeches, scarification, or inci-
sions, and the other measures directed in this
association of the disease (§ 60.), should be
adopted.

58. ii. Tveatment of Associated and Complicated
Eriisipelas. — A. In the association with cedema
of the subjacent cellular tissue, the utmost atten-
rion to the state of health, the age, and habits of
the patient, is necessary. When it occurs in
broken-down constitutions, and persons addicted
to spirituous liquors, not only should tonics, &c.,
particularly cinchona, quinine, cascarilla, with
soda or potash, camphor, the preparations of am-
monia, &c., be exhibited, but also wine, light

OF THE Complicated Forms.

829

nourishing diet, and occasionally small quantities
of the beverage to which the patient has become
habituated. But these remedies should be pre-
ceded by, or alternated, or even conjoined, with,
such purgatives as are most active in promoting
the secretions and excretions, which are generally
deficient in this state of disease. If the bile be
scanty or morbid, calomel, blue pill, Plummer's
pill, or the hydrargyrum cum creta, should be
given with camphor; and the mixture last pre-
scribed ought to be taken a few hours subse-
quently, and continued from time to time. Those
who have been addicted to spirituous liquors, are
most benefited by half an ounce each of the spirit
of turpentine and of castor oil, taken on the sur-
face of weak Hollands or common gin. This dose
may be repeated on alternate days .- it will be
found remarkably beneficial when the urinary se-
cretion is deficient; or when the affection of the
skin is consequent upon anasarca. In this latter
circumstance, the infusion or decoction of cin-
chona may be given with the chlorate of potash,
and the tincture of cinchona, more especially if
there be any tendency to gangrene, or if the tem-
perature of the surface be low, and the colour
deep or dark.* Either of the purgatives pre-
scribed above (§ 55.), should likewise be taken
occasionally. Fomentations with decoction of
chamomile flowers and camphorated spirit may
also be employed, early in the disease. It is in
this variety, as Mr. S. Cooper remarks, that pres-
sure by bandages, as recommended by MM.
Rayer, Bretonneau, and Velpeau, is most ap-
propriate. After morbid secretions have been eva-
cuated, and the use of tonics, with camphor in full
doses, or with the chlorate of potash, or vfith
both, has been commenced — the part being
greatly distended, and the surface irritable or dis-
posed to gangrene — I have seen immediate and
remarkable advantage accrue from the application
of a warm cloth, moistened either with the spirits
of turpentine, or with F.311., the bowels being
kept regularly open by the oily draught, or by
the stomachic purgatives directed above ; or by
enemata, particularly F. 135. 150. and 151., either
of which should be repeated according to its effect.
— When sphacelation has commenced, a poultice
of the powdered bark, or of carrots, and this
spirit; or a solution of the chloride of lime, or ap-
plications containing the Creasote; are the means
which promise the most advantage.

59. B. Treatment of Erysipelas associated with
inflammation of the subcutaneotis tissues. — This
most serious form requires, according to the grade
and kind of vascular action, local and consti-
tutional ; the age, strength, and habit of the
patient, and the stage of the disease, the most
varied, but still the most active, treatment — in
some cases general or local depletion, or both ;
and in others, as invigorating remedies as were
prescribed for the preceding variety; — in an
early stage the former means, and in a later pe-
riod the latter. The treatment of this variety
niay be divided — 1st, into that which should be
adopted before suppuration has taken place ;

* I have lately had an opportunity of trying the Cr^a.
sate, in doses of from one to three drops, four times a day,
in a case of this variety. It increased the urinary secre-
tion ; but it was not so beneficial as the chlorate of potash,
which I have been long in the habit of prescribing. I
have, however, found it useful in atonic dropsy, and ge-
neral cachexia.

830

ERYSIPELAS — Treatment of the Complicated Forms,

I where the disease approaclies the character of
diffusive inflammation of the cellular tissue. If

and, 2dly, into that v.'hich is required when sup-
puration or disorganisation has occurred.

60. a. Before suppuration or disorganisatio)i
takes place, the most varied, and even opposite,
measures are often necessary, according to the
age, strength, and habits of the patient, the pre-
vailing epidemic constitution, and the local and
constitutional symptoms. 'When the surface of
the inflamed part is of a deep or florid red, tense,
and very hot ; the pulse hard, full, or strong ;
the head much affected ; and the papilla; of the
tongue erect and excited ; both general and local
bloodlettings are requisite, especially in unbroken
constitutions, in persons not addicted to intoxica-
tion, and very early in the disease. When erysi-
pelas attacks the head, or face, and insufficient
epistaxis occurs, ventcseclion should be resorted to ;
but when it appears in other parts, a large num-
ber of leeches should be applied, or incisions made,
as recommended and practised by Ivlr. Copland
fluTciiisoN. This local mode of depletion will
often be sufficient, excepting in the most phlo-
gistic cases, when venajsection may also be neces-
sary. But in large towns, and in hospitals, this
latter will seldom be required, if the former have
been employed with decision. Besides, in these
circumstances especially, there is considerable
risk of inflammation attacking the vein. When
suflicient blood is not procured by leeches or
incisions, cupping around, or even over the part
if it can be borne, will frequently be preferable
to venffisection. In proportion as t!ie local and
constitutional symptoms approach to those de-
scribed under the head of Diffusive InflamnuUion
of the Cellular Tissue, is the necessity for
bleeding diminished — that which necessarily
attends the incisions of the part being often
suflficient, — and for the restorative and tonic
treatment there recommended (§ 34. et seq.) in-
creased, especially alter morbid secretions and
feecal matters have been evacuated. Where the
skin is but little affected ; the powers of life de-
pressed, from antecedent visceral disease or in-
temperance ; and the affection of the subjacent
parts extending rapidly ; the remedies advised in
that article should be prescribed energetically.
When the pulse is broad, open, and expansive, or
tumultuous, or easily compressed, although it be
quick, siiarp, or even bounding, general blood-
letting is injurious ; the local affection eitlier ex-
tending, or changing its place, and vital resistance
sinking from the evacuation. In the form of this
complication first described by Mr. Copland
Hutchison, wherein the inflammation extends to
the fascia;, to the intermuscular cellular sub-
stance, and to adjoining parts, incisions sufliciently
deep to divide the fascia;, as he directs (see Sur-
gical Observations, &;c. p. 110. 2d edit.), are most
indispensable, whatever may be the state of gene-
ral vascular action and constitutional power: for
if these be of a sthenic kind, the incisions come in
aid of the necessary depletions ; and if they be
asthenic, local congestion and effusion are thereby
removed, and the operation of restorative remedies
in no way impeded.

61. The observations made respecting other
evacuations in simple erysipelas,-very nearly apply
in this conq)lication. — Kinetics are recommended
by Ri.n,, IIeiz, and I'oux, and are most bene-
ficial in the more sthenic diathesis, where those
of antimony may be employed ; and least so

at all prescribed in the latter state, ipecacuanha,
conjoined with ammonia or camphor in full doses,
is preferable. The early and repeated exhibition
of purgatives is as requisite in this as in the simple
forms ; and the choice and combinations of them,
there directed (§ 55.), may be adopted. But, in
proportion as the characters of diffusive inflam-
mation of the subcutaneous tissues are assumed,
the more warm and stomachic should the purga-
tives be. Where this kind of complication pre-
dominates, the treatment described in that article
(§ 34. et seq.) should be followed. — Diaphoretics
also, as already recommended, are usually of
service ; but the selection of them should depend
much upon the state of the stomacii, and the
constitutional powers. Where the former is not
disturbed, and the latter are not much depressed,
small doses of antimony with other diapiioretics
are beneficial ; particularly if the febrile action
be great, and at an early stage of the disease :
but if the stomach be irritable, diaphoretics
ought to be given in effervescence, generally with
an excess of the alkali ; and, if vital power be
much depressed, those with the sesquicarbonate
of ammonia and camphor are preferable. If the
edges and point of the tongue be red, and the
epigastrium tender, a blister, or sinapism, or the
warm turpentine epithem, should be placed over
this region, and small doses of the nitrate of pot-
ash, with carbonate of soda, prescribed in the
decoction of quince seed, or of linseed, or of the
flowers or bark of the lime or linden. — Mercurials,
at the commencement, and occasionally after-
wards, are generally of service. Calomel is most
to be depended upon ; and, when conjoined with
camphor or am.monia, it may be taken in any
state of the disease, if the biliary and other se-
cretions require its exhibition. In low states of
vital power, it should be followed, in three or
four hours, by a stomachic purgative, the action
of which may be promoted by a cathartic enema
(§ 55. 58.).

62. Opiates or other anodynes are often neces-
snry, particularly when there are watchfulness,
general irritability, and much pain, which are
often the pre'cursors of, or even tend to induce,
delirium. But they should be given with great
caution. They are hazardous means, if pre-
scribed before morbid matters are evacuated, or
where there is any tendency to coma. The
acetate of morphia, in a full dose with an aromatic
spirit, nt bedtime, is most to be depended upon,
— Bark and other tonics are necessary from the
commencement, when the disease presents more
of the diffusive, than of the phlegmonoid, charac-
ters. At first, the bark may be given in decoc-
tion or infusion, particularly when the propriety
of exhibiting it is doubtful ; and with the alka-
line carbonates, or with the solution of the acetate
of ammonia. In cases of manifest asthenia, or
cachexia, and diffusive appearance, citiier the
sulphate of quinine, or the bark in substance, with
camphor and r.romatics, may be prescribed ; but
I have generally found the decoction, with the
chlorate of potash, and with cither the compound
tincture of bark, or the tincture of serpentaria, to
act beneficially, when alvine evacuations were
sufficiently promoted by suitable means.

63. In the three grades of the j)hlegmonoid

ERYSIPELAS — Treatmen

(^ 29. et seq.) complication, the same principles
as have been now stated are applicable. Deple-
tions and other evacuants should be prescribed
with a promptitude, and to an extent, co-ordinate
witli each, and with a due regard to the pecuhar
circumstances of the case ; always recollecting
that, in diseases like this, which are connected
more or less with imperfect excretion, and a mor-
bid state of the circulating fluids, vascular action
may be excessive, whilst nervous power and vilal
resistance are reduceil to the lowest states ; and,
therefore, that vascular depletion, in order to be
salutary, or even not to be injurious, sliould be
early employed, and with strict attention to its
effects both at the time and immediately after-
wards. Nor should it be overlooked, that, in cir-
cumstances where the propriety of general or even
local depletion appears doubtful, either one or
the other, or even both, may be practised, if ju-
dicious restorative means are also resorted to,
especially in conjunction wiih sucii remedies as
promote tlie excreting functions, and purify the
blood, or correct its morbid state.

64. /). When suppuration, of disorganisation,
has taken place, or when either is inevitable,
general bloodletting is no longer admissible,
although the vascular excitement may be great ;
and the only local depletion that can be ventured
upon, is that which will follow incisions, which
should now be made, if they have not already
been resorted to. In some cases, however, the
application of leeches, or cupping around the
part, may still be ventured on, if the local action
be high, and the changes now in question be only
commencing. But where matter has already
formed, or parts have sloughed, vencesection, or
emetics, or even lowering purgatives, will only
promote llie absorption of morbid matters from
the diseased part, and the consequent contamina-
tion of the circulating fluids, instead of throwing
them out upon tiie surface, and facilitating their
expulsion through the outlets which ought to be
made for them, by incisions down to tiieir seats.
In proportion as disorganisation is manifest, orad-
vances, so should restoratives and tonics be freely
administered ; and either those already mentioned,
or those prescribed in the article on Diff\isive
Injiammation of the Cellutau Tissue (^ >^4.),
ought to be liberally used ; with the aid of wine,
and such nourishment as the state of tiie digestive
organs will admit of. The stomachic purgatives
and evacuants directed above (§ 55. 58.), should
be given occasionally, in order to remove morbid
collections, and promote the depurating actions
of the abdoirinal viscera on the blood. In con-
stitutions broken down by intemperance, the be-
verage to which they have become habituated, is
the most serviceable, as Sir A.Coopeu has justly
remarked ; but, in other circumstances, wine may
be taken in soda water, or in spruce beer, to
which a little of the carbonate of soda or of potash
has been added. ^Vhen a free outlet has been
given to matter or sloughs, advantage will often
accrue from the injection of a weak solution of
any of the chlorurets, or of Kreosote water ; and
the use of compresses and bandages around or
above the seat of disorganisation, in order to pre-
vent its extension.

65. C. Erijsipelas with Nervous and Cephalic
Symptoms. — a. ^Vllen the nervous symptoms ap-
pear early, and the head or face is not the seat of

T OF THE Complicated Forms.

831

the disease, the attendant fever assuming this form,
gentle tonics and diaphoretics are serviceable,
especially the infusion of valerian, with the solu-
tion of the acetate, and the aromatic spirit of
ammonia ; or the infusion of bark or of cascarilla,
with the alkaline carbonates, and the prepa-
rations of camphor ; or either of these infusions,
with the tincture of serpentaria and the chlorate
of potash. RicHTKR remarks, that, when the
attendant fever is of the nervous kind, the local
affection is most prone to change its place, or
to recede from the surface, and attack internal
organs. I believe that there is much truth in
this ; and that these changes are less likely to
occur when the above remedies are lesorted to,
and a blister is applied over the affected part ; the
excreting functions being moderately promoted by
stomachic purgatives and enemata.

66. b. Where (ie/iri!i/7i supervenes, its treatment
must depend upon its form, the seat of the local
affection, and state of tiie system. When the
fever is of the nervous kind, delirium is an early
symptom, and the result chiefly of the febrile
action, and depiession of nervous power ; the
means now mentioned, especially if morbid ex-
cretions have been evacuated, being then bene-
ficial. If the tongue be, at the time, moist,
camphor and anodynes may also be prescribed.
But when delirium is connected with general vas-
cular excitement, depressed power, and manifest
disorder of the circulating and secreted fluids, the
alterative and stomachic purgatives, and ene-
mata prescribed above (§ 55. 58.), are most to be
depended on. When the disease attacks the
face and head, the delirium frequently proceeds
from inflammatory action in the membranes of
the lirain, and rapidly passes into coma, from
effusion and exhaustion of vital power. In this
case, early bleeding from the feet, or cupping on
the nape of the neck, or a number of leeches to
the occiput and behind the ears ; mustard pedi-
luvia ; cold applications to the head, if the heat
be excessive and the patient young or robust;
and active cathartics, both by the mouth and in
enemata; are to be prescribed. If great and deep-
seated tumefaction take place in the scalp, parti-
cularly about the occiput, incisions should not be
overlooked.

67. c. When profound coma comes on, the
excretions being voided involuntarily and uncon-
sciously, when the pulse is rapid, and the tongue
and gurns covered by a thick fuliginous coating,
what measures should be resorted to? This oc-
currence is frequent ; is attended by the utmost
danger; and is seldom satisfactorily treated. In
several cases, I have resorted to the following
means with success: — 1st, Unless calomel has
been already taken largely, a full dose of it, with
camphor, ought to be prescribed, in some thick
substance, and placed upon the back part of the
tongue, when it will gradually be swallowed ; ^
2d, Two or three hours afterwards, turpentine,
with an equal quantity, or with one half or two
tl^irds the quantity, of castor oil, with a little
liquor potassas, should be exhibited in the form of
an electuary, and as just directed, if the coma be
profound, or in any other form, if the patient can
be roused sufficiently to take it ; and repeated
frequently until the bowels begin to act ; when
itsoperation may be promoted by enemata (F. 150,
151.) J — 3d, If matter form in any part, incisions

ERYSIPELAS — Treatment of the Complicated Forms,

68. D. Treatment of Gastricaiul Bilious Eri/si-

832

should be made early, and through the aponeu-
rotic expansions, where there is the least risk of
matter forming beneatli them* ; and 4th, Blisters
to the insides of the thigh, or to the nape of the
neck, and between the shoulders, should also be
directed, if the symptoms be not soon ameliorated
by the preceding means ; and the calomel and
camphor repeated every five or six hours, until
the tongue and gums evince the specific operation
of the former ; when warm or stomachic purga-
tives, aided by the enemata already advised, and
gentle tonics, ought to be given from time to time,
to evacuate morbid secretions and support the
vital powers.

« The following case occurred, eleven years since, to a
very able practitioner, Mr. H. Cox, formerly House Sur-
geon to the Infirmary for Children ; and was soon after,
wards published by him. I quote it in an abridged form,
as it illustrates this complication, and the treatment re-
commended. It, moreover, is evidence of facts connected
with the treatment not only of this, but of other maladies :

" Jane Guest, aged 21, was seized, Jan. 22. 1824, with

rigors, and fits of hysteria, to wliich she was subject. On
the fourth day, her scalp had become red and swollen,
and the tongue tumid and red. Delirium and great rest-
lessness afterwards supervened, and the erysipelas ex-
tended over the face and neck to the sternum. The eyes
were now completely shut, and the features so swollen
that she could not be recognised. In two or three days
she passed into a state of coma and insensibility." — " The
pulse, which was formerly full, but easily compressed,
was now excessively quick ; the tongue was black and
crusted ; and she rolled towards the foot of the bed. The
treatment usually resorted to in similar cases had failed
to ameliorate any of the symptoms. The condition of
the patient was, on theSlst of January, the worst possible.
The pulse could not be counted ; she was profoundly
comatose ; the integuments of the head were distended
to the utmost ; and the tongue, teeth, and gums were
covered by a fuliginous coating. At this date, I stated
the case to Dr. Copland, as one for which there was no
room for hope. lie strongly advised me to exhibit the
oil of turpentine in large doses, as he had experienced
success from the use of it in several cases characterised by
similar symptoms to this." — " I had had many opportuni-
ties of witnessing the beneficial effects of this substance at
the Royal Dispensary for Children, where Dr. Copland
had introduced its frequent use. I, therefore, according
to his advice, prescribed as follows : —

" IV Olei Terebinthina; 3 ss. : Olei Ricini 3 ij. -, Mellis
3 ij. Misce. Fiat Etectuarium statim cajiiendum.

"R Olei TerebinthiniE 3 vj. ; Olei Olivfejj.; Aqua
5 X. Misce. Fiat Enema statim administrandum.

" Ft'4. 1st. — Several ofi'ensive evacuations. Pulse some-
what stronger, and not quite so quick. The coma is less
profound.

" li Olei Terebinth., Ol. Ricini, aa 3jss. ; Mellis q. s.
ut fiat Elect. Sumat, tertiis horis, partem quartam.

" 2a. The patient could be roused. Theraouth, teeth,

and gums were cleaner ; the pulse 130, and fuller. The
local symptoms were ameliorated. The oils have pro-
cured several bilious evacuations.

" R Olei Terebinth. 3 jss. ; Ol. Ricini 3 ss. ; Liq.Potassa;
3 j. ; Aq. Cinnamom. 3 iv. M. Capiat partem quartam,
quartis horis.

" 3d. Much better. Pulse 120, and more natural as to

strength. The ton^e .is beginning to become clean.
The bowels have acted copiously, and much yellow bile
has been voided. The patient now answers the questions
put to her," &c. From this time her recovery was unin.
terrupted. {I.ond. Med. Ilrpns. for April, 1825, p. 299.)
'I'here is much niisappruhcn.^ion as to the operation of
full doses of turpcntnif, given either by the mouth or in
enemata; many suppc snig that they increase vascular
action in the brain. 'I'he reader will perceive, upon pe-
rusing the account (published in the Lmid. Med. and
Phys. Journ. for May and July, 1821,) of the experiments
I performed — 1st, Ui)on myself; 2dly, upon the lower
animals; and, 3dly, in numerous cases nf disease — that
this substance, given so as to act upon the bowels, either
from the largeness of the dose, or by the aid of a purg-
ative conjoined with it, is a powerful derivative from
the brain, diminishes vascular action in serous mem-
branes, ami restores lost tone to the extreme capillaries,
especially in exhaling .surfaces. 'J"hc extensive experi-
ence I have since had iif this medicine, has confirmed
these inferences, but has shown that it may be injurious
in the hands of those who arc not well acquainted with
the exact circumstances in which it may be given with
advantage.

peias. — a. Where the yellowish coating of the
tongue, the appearance of the surface, or of the
excretions, and nausea or vomiting unattended
by much tenderness at the epigastrium, indicate
biliari) disorder, an emetic, given early in the dis-
ease, if the head be not seriously affected, is
usually of service. After its operation, a full
dose of calomel, purgatives, laxative enemata,
diaphoretics, and the other measures already re-
commended, according to the external character
of the disease, and the states of general and
local vascular action and of vital power, should
be prescribed, and repeated as circumstances may
require. Wherever tenderness of the epigastrium
or hypochondria exists in connection with the
nausea or vomiting, local depletions in the vi-
cinity, blisters, sinapisms, or warm terebin-
thinated epithems, placed over these regions,
will be of essential service. The last of the
should be applied until it produce redness,
and be repeated according to its effects upon
the disease. Whenever any part within the
abdominal or thoracic cavity is affected, either
coietaneously with, or consecutively upon, or even
after the disappearance of, erysipelas, these are the
most effectual remedies, especially when aided by
mercurials, prescribed either alone, or with cam-
phor and opium.

69. I). W here this specific form of inflammation
seems to affect tlie digestive mucous surface, small
and repeated doses of nitre, with the carbonate
of soda, in the decoction of quince seed, or of the
lime bark ; camphorated emulsions ; diaphoretics
in mucilaginous vehicles ; local depletion, and
the external means just specified, are most to be
depended upon. In both this and the hepatic
complication, calomel, blue pill, or hydrargyrum
cum creta, may also be given with opium and
small doses of camphor, until the gums are
afl'ected ; but it also will often be necessary to
evacuate morbid matters by stomachic and mild
purgatives, and to support the strength by light
tonics, especially at an advanced stage. In most
cases of internal erysipelas, particularly if parts
within the abdominal cavity be affected, calomel
with camphor and opium, lerebinthinated purga-
tives, and the epithems above mentioned (§ 68.),
are of the greatest benefit.

70. E. The association tviili Inflammation of the
Throat and Pliurijni, being often attended by much
danger, especially if the fever be of an adynamic
kind, or if the head and face be affected, requires
early and active treatment. Vena;section, or local
depletion, or both, are frequently necessary; but
the propriety of having recourse to them, and
the extent to which either of them may be
carried, must depend upon the state of general,
as well as of local, vascular action, and vital
power. Where there are great swelling of the
external throat, and tension of the integuments
(§ 33.), (JicisioHs should be made in the manner
about to be directed (§ 80.), and the internal
treatment conducted appropriately to the states
of the different functions, conformably with
the principles developed above. If the swelling
and tension be less, and the symptoms not so
urgent as to require incisions, a large blister may
be applied to the lower half of the neck, ex-
tendmg over a part of the sternal region. Active
cathartics, aided by the frequent exhibition of

ERYSIPELAS — Local Treatment.

833

enetnata (F. 135. 151.) ; gargles with a solution of
the chlorinated soda or lime ; or of the nitrate of
silver; and diaphoretics; are also very generally
appropriate and beneficial. Although depletions
are very often necessary in this complication,
yet venaesection is sometimes injurious, and
always in the adynamic forms, or at an advanced
stage. In two cases in which I was lately con-
sulted, an aggravation of both the local and
constitutional symptoms followed bloodletting,
though resorted to early, and in moderation. In
this, as in every other form of the disease, the
treatment should mainly depend upon the states
just mentioned ; and upon the various circum-
stances peculiar to the case.

71. F. Where tlie Eriisipelatous I iiflammation
extetids to the Larynx or Bronchi, or affects the
Lungs, venisection is frequently required, but
not always to a great amount : in some instances,
it has even appeared injurious. Local depletions,
however, are generally necessary. The chief de-
pendence should be placed upon dry-cupping and
the external applications mentioned above {§ 68.),
which ought to be repeated, sometimes oftener than
once ; and on purgatives, demulcents, andantinio-
nials, or other diaphoretics ; these being the chief
means of exciting the excreting functions, and
thereby of removing the constitutional derangement
upon which the local affection depends.

72. G. When erysipelas supervenes in the course
of fevers, venisection is inadmissible ; but the
early application of leeches to the part is often of
service. Internal inflammations appearing in
connection with external erysipelas, admit not of
vascular depletions nearly to the extent required
by true or idiopathic inflammation ; local deple-
tions, calomel, camphor and opium, terebin-
thinated purgatives and enemata, and the
external and other means just particularised,
being the most efficient remedies in such cases.
Whenever erysipelas attacks internal parts, it
may be referred either to insufficient power to
determine the morbid action to the surface, or to
pre-existing disorder of the part affected, or rather
to both. But as all such complications present
similar states of vital action to the more simple
forms of the disease — varying from the more phlo-
gistic to the most diffusive or adynamic, according
to the age, constitution, and habits of the patient,
the causes and stage of the disease, and the cha-
racters of the prevailing epidemic — so do they
require a treatment varying from the strictly
antiphlogistic, to the most energetically restora-
tive and tonic.

73. H. If Inflammation of the Lymvhaiics or
of the Veins appear in the course of the complaint,
or be associated with it — circumstances by no
means uncommon when the upper or lower limbs,
especially the former, are affected — general
bloodletting is always injurious, and even local
depletion is seldom beneficial. The liberal exhi-
bition of tonics and stimulants ; of stomachic and
mild aperients; and of warm diaphoretics; with
anodynes (§62.) if the pain and irritability be
great; and emollient and anodyne applications
to the part, particularly if the absorbents be in-
flamed ; are chiefly to be trusted to ; the intention
being, in all such cases, to arrest the extension
of disease, and prevent the contamination of the
circulating fluids.

74. The spurious forms of Erysipelas, which
Vol. I.

are often connected with inflammation of dcep'
seated parts, and which most frequently occur in
the extremities, should be treated according to
the principles developed above, and in the article
on the Cellular 'J'issue ; free incisions being
particularly requisite for them (§80.).

75. J. Depletions and other antiphlogistic reme-
dies are serviceable chiefly in a very early stage,
whether of the simple or of the complicated
disease, however high vascular action may seem j
and, although they have been most requisite at
that period, and energetically employed, a very
active recourse to stimulants and tonics will often
subsequently be necessary. Frequently, also,
where the propriety of resorting to moderate or
local depletions is unquestionable, the good
efl^ects of restoratives and tonics, exhibited even at
the same time, are equally manifest ; this com-
plaint, oftener perhaps than any other, requiring-
vital power to be restored by the latter means,
whilst vascular action and congestion are being
subdued by the former, and by medicines which
promote the secreting and excreting functions.
The stimulants most to be depended upon, are —
camphor and ammonia, or their preparations, given
in large doses, when the head is unaffected, or nerv-
ous power is exhausted ; and the tonics already
mentioned. Various substances, which are both
stimulant and tonic, as serpentaria, arnica, &:c.
are useful adjuncts to the barks ; and others,
which possess more of an antiseptic property,
as the chlorates of potash or of soda, or the
creasote, are often of essential service, especially
in advanced stages of the disease. Tlie frequent
and manifest dependence of the complaint upon
a morbid state of the circulating fluids, has in-
duced some writers to recommend the carbonates
of the fixed alkalies, and such other substances
as affect more immediately the state of the
blood ; but although these are often beneficial,
they ought not to be depended upon alone. The
morbid condition of the blood is the result of
imperfect action of the excreting organs, conse-
quent upon defective vital power. The chief
intention, therefore, should be to excite the func-
tions of these organs, by agents which operate
specifically and beneficially upon them, and by
those wiiich rouse the vital energies generally,
and resist the extension of morbid changes.

76. iii. Of tlie local Treatment. — A. a. Cold
applications have been recommended by several
writers, but they are not always safe, and ought
not to be prescribed when there is very evident
adynamia, or for aged persons, or broken-down
constitutions. In the more phlogistic states, at
an early stage, and especially when these states
occur in the face or head, they frequently afford
much relief. — b. Warm poultices and foment-
ations are objectionable in the phlegmonoid,
and, indeed, in the other varieties, unless under
some circumstances of the disease connected with
local injury. — c. In the strictly constitutional
complaint, neither of these are of much service ;
dustling the part with flour or any other absorbent
powder, when the vesicles break, or sponging it
with some tepid and soothing fluid, if the heat
and pricking paia be troublesome, being the
safest practice.

77. B.a. The application of the tiitrate of silver,
in substance or in strong solution, as recommended
by Mr, Higginbottom, is often of great benefit.

3H

834 ERYSIPELAS —

It should be applied either to the inflamed sur-
face and the adjoining integuments, or only to
the healthy skin surrounding the afl"ected part ;
and it should raise the cuticle, otherwise it will
be of little benefit, and fail of isolating the dis-
ease.— b, M. Larrey has advised the actual cau-
tery to be applied lightly to different points on
the inflamed surface, to the number of forty or
fifty, with the view of concentrating the morbid
action to the parts, and arresting its extension. —
c. Bli'iters v/ere employed first by i\I. Dupuytren
with this intention. I'hey are of great service in
stopping the progress of superficial spreading and
erratic erysipelas. But, even in such, when
the complaint is very acute, bloodletting should
precede, as Dr. ]M' Dowel justly slates, their ap-
plication. They are seldom of use in the phleg-
monoid form, and never when purulent depots are
likely to be formed. Tins writer concludes that
blistering succeeds best when the inflammation
is pale, or in patches, with but little tumefaction
or pain ; and when proper constitutional treat-
ment precedes and accompanies it. Tlie blister
should completely encircle the disease, covering
about two inches, from the margin, of the in-
flamed, and as much of the healthy, surface, or
it will extend at the unguarded point.

78. e. Mr. Reid and Dr. jNI'Dowel have given
extensive trial to mercurial inunction in tiiis com-
plaint, in two of the Dublin hospitals. They
concur in viewing it as a valuable remedy, espe-
cially in conjunction with such internal treat-
ment as the case may require, in both the
constitutional and the traumatic forms, whether
afFecting the head or the extremities. Two,
three, or four applications have generally suf-
ficed, and salivation has fre(|uently come on.
Where the ointment cannot be rubbed, it should
be dauljed upon the part. The recommendation
of M. llicoRD, who originated the practice, to
use only the recently prepared ointment, is very
deserving of attention.

79. I). iNIr. Jajies mentions in favourable terms
the application of spirits, and otlier stimulating
substances, to tiie part. Dr. Peart prescribed
a lotion, consisting of a drachm each of the sesqui-
carbonate of ammonia and the acetate of lead,
in a pint of rose-water. I have directed epithems
of spirits of turpentine with benefit ; but morbid
secretions should be evacuated, tiie excreting
functions restored, and stimulating diaphoretics
and tonics administered internally, before these
should be ventured on in the constitutional forms
of the malady. They are inadmissible where
suppuration appears inevitable, or when vital
power is much depressed, and vviiere a tendency
to affection of, or metastasis to, internal parts is
manifest. In such, the dirtusive stimuli are most
serviceable given internally.

80. E. 'J'he introduction of incisions into the
treatment of erysipelas and its allied aflections
is considered by all candid practitioners in this
country, and by the more recent Continental
writers, as one of the greatest improvements in
medical and surgical practice, and as sulelii due
to Mr. Coi'i.AND Hutchison. It has been
alleged, that the same means were previously
recommen<led by some -of the older of moilern
writers. I have looked into them, in order to
ascertain the fact ; and have founil that, by
two or three, superficial scarifications merely

Local Treatment.

have been directed for certain morbid slates, but
not for erysipelas ; these scarifications being
quite different from the incisions ])ractised by
this author, and such as have been adopted from
the earliest ages as a mode of local bloodletting,
among the inhabitants of both northern and in-
tertropical countries. Since the publication of
Mr. Hutchison's plan, modifications of it have
been devised by Dr. Dobson and Mr. Law-
rence— a number of minute punctures by the
former, and one or two incisions many inches in
length by the latter. There is now, I believe, but
little difl'erence of opinion among practical men,
as to which of the three modes should be adopted.
The extensive experience of Drs. Champtom,
Young, RIacfarlane, and M'Dowel, and others,
have decided the question. The last of these
remarks that, in phlegmonoid erysipelas, early
and free incisions, as advised by Rlr. Hutchison,
are of the greatest importance in immediately
relieving, and speedily arresting, the disease ; and
in preventing sloughing of the librous and other
tissues, and purulent mfiltration of the cellular
substance ; their depth and number being pro-
portioned to the extent of the inflammation.
The fasciaj should be divided if the disease ex-
tend beneath them. The bleeding from the
incisions ought to be watched, as it is some-
times profuse ; and it may, if uncontrolled, or
unaccompanied by a suflicienlly restorative treat-
ment, especially in old drunkards and broken-
down constitutions, be attended by dangerous
results. In these circumstances, and if the dis-
ease has been neglected till diffusion of pus in the
cellular tissue, or sloughing, has occurred, be-
fore incisions have been made, lint dipped in spirits
of turpentine, or in equal parts of it and Peru-
vian balsam, should be applied, and covered by
warm poultices. This practice has been pre-
scribed by me for several years ; and was resorted
to in a most dangerous case attended by Mr.
Hutchison, myself, and another practitioner,
in the summer of 1834. Applications with the
solution of the chlorinated lime, or soda, or
of creasote, will also be serviceable in cases
where sloughing has preceded the incisions or
where spreading ulceration attacks their edges,
as sometimes occurs in irritable and broken-down
constitutions. When phlegmonoid erysipelas
attacks the loose cellular substance about the
eyes, the rectum, and scrotum, early incisions
are requisite. Where the scalp is deeply aft'ect-
ed, they should pass through the aponeurotic
expansions and pericranium, the bleeding at-
tending them often rendering further depiction
unnecessary.

81. In erysipelas supervening in the advanced
stages of low or malignant fevers, incisions should
be made with great caution, and not unless im-
peratively required, as the bleeding attending
them, although moderate, may induce sudden or
even fatal collapse, notwithstanding the con-
temporaneous administration of restoratives. I
lately met with such an occurrence. When
suppuration has advanced or extended far, com-
jiression by bandages, as recommended by Gai.en,
Aiiiius, Heis'ier, and more circumstantially by
Dr. Dkwau, should follow the evacuation of the
matter by incision, in order to procure the
adhesion of the opposite surfaces of sinuous
cavities, liut the compression ought to Ve so

applied, as to give a free discharge to the secre-
tion by the outlet made for it,

82. iv. ' Treatment of Erysipelas in Infants
and Children, — A. a. In the early stage of tlie
complaint, the bowels ought to be kept freely
open ; calomel, or hydrargyrum cum creta, either
witli magnesia or the carbonate of soda, being
given at first : and, if the fever be high, James's
powder should be added, cooling diaphoretics
exhibited, and leeches applied behind the
ears, or over the sternum, especially if there be
associated affection of the bronchi or lungs.
The infant should be restricted to the mother's
milk, and even that ought to be given in di-
minished quantity. It will often be necessary
to administer a stomachic or mild purgative to
the nurse, and to attend to her digestive or-
gans, and her diet. — b. In the second stage of
the disease, when suppuration has commenced,
the various tonics and stimulants already men-
tioned— especially bark, quinine, ammonia, and
the chlorates — should be freely administered. 1
have for many years prescribed tiie chlorate of
potash with much benefit in this, and the allied
affections. The chloric acid, with decoction of
baik, and camplior, is also of great benefit.

83. e. Blisters have been favourably noticed by
Dewees, Physick, and others ; but they require
much more caution in this class of patients than
in adults. They ought to be applied only for a
few hours, or with very fine tissue paper inter-
posed between them and the skin, and be removed
as soon as their action commences ; when warm
bread and water poultices will complete their
effect. — d. Mercurial ointment is, however, a
much more generally appropriate application,
particularly in very young cliildren. If vesica-
tions cover the part, they should be broken pre-
viously to the application (Uf.wees) ; and if
incrustations have formed, or if suppuiation have
commenced, the ointment may be applied to
the inflamed margin, and a portion of the sound
skin. Dr. Dewees states, that Dr. Schott has
found a solu:ion of bichloride of mercury, \n the
proportion of a grain to the ounce of water,
equally beneficial with tlie ointment. In other
respects, the constitutional and local treatment
of erysipelas in infants should be conducted
according to the principles developed above.

84. B. The affection of tlie pudendum occurring
in children two or three years of age, and which
Mr. K. Wood considers distinct from erysipelas,
is certainly a severe form of this complaint, in
very delicate, ill-fed, or cachectic children, or in
those labouring under mesenteric oi' hepatic dis-
ease. It is not a rare affectioa in large or
manufacturing towns. JNIr. Dendy {On the Cu-
taneous Diseases incidental to Childhood, 8vo.
p. 199.), my respected colleague for many years,
and myself, have met with several cases, in both
sexes, at the Infirmary for Children. In lliese,
the weak and rapid pulse, the pale cachectic
countenance, and the appearance of the affected
parts, determined me to evacuate morbid matters
by stomachic and mild aperients ; to support vital
power, and thereby to prevent the extension of
the disease, by the decoction of bark, with the
chlorate of potash, or the medicines already men-
tioned; and to prescribe applications with the
solution of the chlorinated lime or soda, or with
Peruvian balsam.

ERYSIPELAS IN INFANTS — Treatment. 835

85. V. Regimen and Diet, — a. The rernoval of
patients to a pure atmosphere is of very great ad-
vantage in the treatment ; and fresh air should be
freely admitted into the apartment, all sources
of impurity, admitting of removal, being taken
away. — I'he <//«* should be antiphlogistic in the
early stage ; and in the more adynamic states of
the complaint, it should be light and nourishing,
and some agreeable and appropriate stimulant
given along with it, as old sherry, or spirits for
those who have been addicted to them. Chicken
broth, beef-tea, arrow-root, with old wine or
brandy, become necessary, where suppuration,
or desii'uction of the subjacent tissues, has super-
vened ; but in the early stages of the phleg-
monoid, or where there is plethora, abstinence
from food, and from drink, excepting as much
of the latter as is indispensable, should be en-
forced. Whatever is prone to becom.e acid or
acrid on the stomach, as rich broths and soups,
and all oily and fat matters, ought to be avoided.

86. b. During convalescence, change o( ViiT ; light
tonics, with alteratives and mild aperients ; warm
bathing followed by frictions of the surface, or
slightly alkaline baths ; due attention to all the
secretions and excretions, especially to the bil-
liary secretion ; a course of alkalies with small
doses of blue pill and taraxacum, whi.'n chronic
disease of the liver is suspected ; regulated diet
with a small proportion of lean animal food once
in the day ; the utmost temperance, and daily
exercise in the open air ; are the measures which
will most probably secure the patient from a
return of the disease, to which he is rendered
very liable by an attack. M. 'I'lssor justly ad-
vises those who have had the complaint, to avoid
the use of cream, milk, rich and viscid food,
baked and strong meats, aromatics ; warm spices,
and strong wines ; to shun a sendentary life, and
mental irritation ; to live on light cooling vegetable
diet, and to drink water with a little wine.

BiBLioG. AND TiETER.— Hippocrates, Aphor. vi. 28. ; et
Coac. 103. — Gnlett, Meth. Med. cap. xiv.; et Comment.

in Aphor. 20. lib. iv. — Aettus, Tetrab. iv. serm. ii. c. 59

Oribasn/s, Synopsis, 1. vii. c. 31. — Pardus JEgineta, 1. iv.
c. 21. — Avhtnini, Canon, 1. iv. fen. 3. tr. 1. c.4. — Schcnck,
Ordo et Alethodus Scrutandi et Curandi Febrim Erysipel.
Jena?, lOGG. — Sydenham, Opera Uiiiversa, cap. vi. p. 279.
(Bleeding and j'umcntaliuiis.) — Wiseman, Chirurgical
Treatises, vol. i. {Directs cupping and Jomentalions.) —

Heisier, Institutiones Chirurgica', part i. 1. ii. ch. 2.

F. Hoffmaiin, Opera, vol. ii. sect. v. iliijcmiile .) R.

Brocldesbury, Oiconomical and Medical Observations,
from 1758 to 17(J3. Lond. 17C4, p. 139. {Bloodletting and
nitre.) — Grant, On Fevers, p. 391. (Emetics.) — Lorry,

De Morb. Cutan. 4to. p. 192 Sauvages, Nosol. Method.

vol. i. p. 449. {Specifies an infeatious form.) — Schroedcr,
De Febribus Erysipelatosis. Goet. 1771. — JC. Broinjield,
Cliirurg. Observ. 2 vol. Lond. 1773. ; and Bled. Com-
munications, vol. ii. p. 322. — Colby, in Ibid. vol. ii. No. 3.
— Trommsdorf, Hist. Erysipelatiset Feb. Erysipel. Causa
Materiali, &c. Erf. Mm. — Lalta, System of Surgery,
vol. i. ch. 6. (J.eeches to the part.) — Stuil, Katio Med.
vol.ii. p. 80. 172. (Emetics.) — Cnllen, P'irst Lines, &c.
\ IG96. — Oehme, De Morbis Recens Natorum Chirurg.
p. 40. — Amman, De ?"rysip. ejusque Ab. Infl.immatione
Diversitate. Hard. 1790. — Garthshore, in Med. Com-
munications, &c. vol. ii. art. 5. (Infantile.) — I'ogel, in
Lodrr, Journ. f. d. Chirurg. b. ii. p. '254. (Leeches to the
paxt most inflamed.) — Feme, De Diversa Erysipelatis
Natura,4to. 1795. — Collingivood, Edin. Med. Comment,
vol. xvi.p. 58 ( The decoctum ulmi.) — Walshman, Me-
moirs of the Med. Society of Lond. vol. v. p. 18'.'. (In
children, complicated with gastritis.) — Peart, Prai.t. Ob-
servat. on Erysipelas, 8vo. Lond. 1802. — Dcsault,
Qluvres Chirurg. par. Bichat, t. ii. p. 581. — Undcrtrood,
On Dis. of Children, vol. i. p. 31. 5th edit.— I luf eland.
Die Rose ncugeborner Kinder. Journ. b. x. st. 4. No. 8.,
etb. xxii. St. 2.— %6rf, in Ibid. Nov. 1811, p. 91. (Ter-
mination in induration of cellular tissue.) — }lenke,\n
Hor?i's Archiv. b. vi. h. i — Mnrctis, Magazin. f. Spe-
3 H 2

836

ERYTHEMA —Primary.

cielle Therapie Klinik. b. ii. st. 2 Schtnalz, Versuch

einer Medic. Diagnostik. Leip. 1806. — K. Sprengel,
Handb. d. Pathol, th. ii. 3te Aufl. Leip. 1807— J. Pear-
son, Principles of Surgerj', &c. p. 191. — J. I'.'Hilden-
brand. Ratio Medendi in .Schola Practica Vindobon,
pars ii. 1809—13. ; et liistitutiones Practico- Medico, &c.
t. iii. p. 590.— Horn, Archiv. Nov. 1810, p. 395. (Emetics,
ti'hen commencing in the face.) — Vclsen, in Ibid. Nov.
1811, p. 450. (7«/n?jif(7c'.) — /"an-, Diet, of Medicine. In
verbo. (Infections.) —Lassus, Va.tho\og\e Chirurg. Par.
1809, t. i. p. 8.— J. P. Frank, De Curand. Horn. Morbis,
1. iii. Ord. i. Gen. 1. — J. Thomson, Lectures on Inflara-
mation, p. 512. — Richerand, Nosograph. Cliiriirgicale,
t. i. p. 118. — Dt'K'flr, in Trans, cf Med. and Chirurg.
Society, vol. vii. p. 477. — K. Wood, in Ibid. vol. vii. p.b'i.
J. A. F. Ozanam, Hist. Medicale des Maladies Epi-
demiques, t. v p. 223. (Notices the complication with an-
gina.)— J. Ilennen, Principles of Military Surgery, 2d
ed. Edin. 1820, p. 282. — (r. Fordyce, Trans, of Soc.
for Improv. Med and Chirurg. Knowledge, vol. i. p. 290.
{The throat affected — chiefly bark for the cure.) —
Wells, in Ibid. vol. ii. p. 213. (Infectious — treated by
bark.) — G. Blanc, On the Diseases of Seamen, 3d edit,
p. 600. — Boyer, Traite des Malad. Chirurg. t. ii. p. 6.

— A. C. Hutchison, Trans, of Med. and Chirurg. Soc.
vol. V. p. 278. ; and Practical Observat. in Surgery, 2d
edit. Lend. 1826, p. 110. —J. Frank, Praxeos Medics
Universa; PrEecepta, pars i. vol. ii. p. 116. — Patissicr,
Sur I'Erysipele Phlegmoneux, 4to. Paris, 181, "J. — P.
Bretonneau, De I'Utilit^ de la Compression, &c ; et
Diet, de.s Sciences Med. t. xii. — A. P. W. Philip, A
Treatise on Simple and Eruptive Fevers, 8vo. p. 267.
— i. G. Kichler, Specielle Therapie, b. i. Berl. 1817.—
J. Bedingti.ld, A Compendium of Med. Practice. Lond.
1816, p. 296. — S'rom, in Acta Nova Reg. Soc. Med.
Havn. vol. i. 1818. (Of the malignant state of erysip.) —
Wealherhead, Diagnosis between Erysipelas, Phlegmon,
&c. 8vo. 1819. — Dickson, in Med.-Chirurg. Rev. April,
1819, p 61.'3. — Haden, Pract. Observat. on Colchicum,
8vo. 18J1. (Colchicum in the phlegnionoid.) — Foderi!,
Lemons sur.les Epidemics, &c. t. in', p. 341. — J. N. Must,
Das Pseudo-Erysipelas, in Bust, Magazin b. viii. h. 3.
p. 498. — F. W. llemmer, D. Rose der Neugebornen, &c.
— Harless, Rhein. Jahrb. b. viii. st. 3. p. bo. — Larrey, in
Revue Med. t. i. 1826, p. 177. — .7. E. Vngewitier, De
Pseudo-Erysipel.ite. Berl. 1824. — Bateman, Synop. of
Cutaneous Diseases, edit, by Thomson, p. \lh. — W. H.
Burretl, Rdin. Med. and Surg. Journ. vol. xxiv. p. 287.
(Leeches and warm fomentations.) — A. Carlisle, Lond.
Med. Gazette, vol. i. p. 4(0.— W. P. Dewees, On the
Physical and Medical Treatment of Children. Lond.
1826, p. 308. _ W. Lawrence, Trans, of Med.-Chirurg.

Soc. of Lond. vol. xif. p. 3 Dob.wn,va Ibid. p. 206. —

A. Cooper, Surgical Lectures, vol. i. p. 249 Plunibc, Oxi

Dis. of the Skin, 2d ed. 1827. — Koux, Archives Geiier.
de Medecine, t. xiii. p. Ib9. (Emetics at the commence-
tnent.) — Guerin, in Ibid. t. xv. p. 27. (Compression 1>y
bandages.) — Schmidtmann, Summa Observat. Medicar.
&c. vol. iii. p. 371. — C. Billard, Traite des Maladies des
Enfans. Paris, 1828, p. 113. — Sahatier, Sur I'Erysip.
considere comme Moyen curatif dans Affect. Cutan.
Chron. 4to. Paris, 1831 ; et Bullet. Gener. de Th^rapeu-

tique, Juin, 1833 Cazenave et Schedel, Abrege Prat.

des Maladies de la Peau, Hvo. Par. 1828, p. <).— J.Aber-
nethy. Lectures on the Theorv and Practice of Surgery,
8vo. Lond. 1830, p. 67. —J. Stevenson, Trans, of Med.-
Chirurg Soc. of Edin. vol. ii. p. 127. — If-'. Gibson, in Ibid,
vol. iii. p. 94. — Labauche, Nouv. Biblioth. Med. t. vi.

p. 59 Travers, in Lond. Med. and Phys. Journ. vol. Ivi.

p. 439 Higginbottom, in Ibid, vol. Ivlii. p. 223 Slorer,

in Ibid. p. 227. — Earle, in Ibid. vol. lix. p. 22 Cases,

in Ibid. p. \7. —Lawrence, in Ibid. p. 225. — J. Arnott,
in Ibid. vol. Ivii. p. 193. ; and Lond. Med. Gazette, vol.
xiv. p. 218. — W. Young, Glasgow Med. Journ. vol. ii.
p. 241. — J. H. James, Oljserv. on the General Principles,
and on the Nat. and Treatni. of Inflammations, 2d ed.
p. 370. — /"/ojvy, (iazftte Medicale, No. 42. 1833. (On
cerebral iiffictions from) ; et Clinique Med.i'vc.Svo. Paris,
1832, p. 'A'M—Uicord, Lanccttc l-'ran<;aise, Wi'l, passim,
et No. 52. 1833. (Mercurial vintmcnt fur.]— Dnpnytrcii,
Lancet, No 543. p. 66.'). (On phlegmonoid erysip.) — Ali-

berl, Med. and Surg. Journ. vol. v. p. 174 Good, Study

of Med. by Cooper, vol. iii. p. 72. 3d edit llayer, in

Diet, de Med. et Chirurg. Prat. t. vii. p. 483. (Hecom-
mcnds incisions, and gives due ereilil In the originator of
the yractice.) — J. Jl-ulldcK. Mi.lical Quarterly Review,
vol.ii. p. 183. (Colchicuiuu'ilU t/u' all, iilinc sttbearlwtiates.)

— Crampton, Med. and Surg. Journ. vol. v. ji. 369. —

.S'. Cooper, in Ibid. vol. ii. p. 773 Bury, Med. Gazette,

vol. xii. p. .533. — Elliotson, in Ibid. vol. xi. p. 132.

./. Burns, Principles of .Surgery, vol. i. p. Is8 Thcden,

Bullttin Gener. de 'I h^rapeutique, May, 1834. (On com-
pression in'Jhc trealmcnt if phlegmonoid erysip.)

,S'. Coiiper, iJectures on Surgery, in Lond. Med. and Surg.
Journ. vol. il. p. 77.) — Macfarlanc, Clinicil Reports, &c.
<;i.ihKOW, 1H33. ; and Julmsun'f. Med. Cliir. Rev. July
1831 — £, A/'i^ott'f/, Dublin Journ. Of Med. and Chem.'

Science, vol. vi. p. 161.— Berndt, Encyclop. Worterbuch
d. Medicinischen Wissenschaften, t. xi. p. 478. — J. Arm-
strong, Lectures on the Nature and Treatment of Acute
and Chronic Diseases, edited by J. Bix,Svo. Lond. 1834.
( The account of erysipelas is imperfect, confused, and
interlarded with cant.)

ERYTHEMA. — Syn. 'EpLSo^a (from 'iftv-
Bo:;, red), Gr. Erysipelas, Celsus and Galen,
Erysipelas idiopathicum , Sauvages. Dartre
(rythimoide, Alibert. Die Rothe, Hautrothe,
Germ. Erytheme, Fr.

Classif. — 1. Class, Febrile Diseases ; 2.

Order, Inflammations (Ctti/e(i~). 3. Class,

Diseases ot the Sanguineous Function ; 2.

Order, Inflammations (Good).

III. Class, I. Order (Author).

1. Defin. — Superjicial redness, with burning
pain, of a part of the integuments, varying in ex-
tent and Jm-m, disappearing innmentarili/ on pres-
sure, usually of an acute character, and uiiinfec-
tious.

2. I. Description. — The varieties of frvS''ew!a
and of erijsipelas have been confounded together
by many writers, — a circumstance almost un-
avoidable, when it is considered, that several states
of the one are merely modifications of certain
forms of the other ; distinctions between them be-
ing rather conventional and artificial, than essen-
tial, distinct, and unvarying. Hippocrates used
the term erythema merely to signify simple red-
ness of a part. Callisen, Sauvages, and Rostan
employed it to designate the slightest grade of
ery.sipelas. J. P. Frank and J. Frank applied
it to several aflfections of a chronic kind, entirely
distinct from those to which it has been given by
recent British and French pathologists. Cullen
viewed it as a superficial inflammation of the in-
teguments, but little, or only symptomatically,
affecting the constitution ; and erysipelas as an
affection primarily, and chiefly of the whole
system. Willan, Bateman, and Rayer con-
sidered erythema as generally connected with
more or less constitutional disorder, — a circum-
stance that cannot be disputed, although such
disorder is frequently latent, or but little evident.
Dr. M. Good has detached two of the most
common forms of complex erysipelas, viz. the
phlegmonoid and cedematous, from that head,
and comprised them under this, — an arrange-
ment in so far improper, as intimately allied and
serious affeciions, depending upon veiy manifest
febrile disturbance of the system, are thereby
separated, and certain of them placed in con-
nection with others unattended by any marked
disorder, and of comparatively little importance. —
Erythema is either primary, and proceeding from
local causes ; or symptomatic of some other dis-
ease, or of constitutional disorder.

3. i. Pri.mary or Idiopathic Erythema pre-
sents various modifications, according to its causes
and seat. — A. Er. Intertrigo, Saw acvs, Willan
— E. ab Acri iuquilinn, Cullen — Ecirrchure, Fr.
— Fret, or Excoriation of the Skin — generally pro-
ceeds— (a) from the friction of two contiguous
surfaces, particularly in fat persons, as in the
upper parts of the thighs, arm-pits, &c. ; — (h) or
from the irritation of morbid secretions coming or
remaining in contact with parts, as of the perspir-
ation in the groins, and below the mammaj ; or of
the leucorrheal discharge, or catamenia, and of the
alviiie and urinary excretions, particularly in the
course of other diseases; — (c) or from chemical

ERYTHEMA— Symptomatic — Canosrc.

837

or mechanical irritants, and artificially from si-
napisms, or ammoniacal and terebinthinated lini-
ments, &c. ; — (rf) or from excessive heat, or
vicissitudes of heat and cold, or the rapid abstrac-
tion of heat — E. pernio, or chilblain ; — (e) or
from pressure, especially lying long in one posi-
tion— E. paratrima, Sauvagfs; — (_/') or from
the stings and bites of insects, &c. — £. punct ura
of Sauvages.

4. When the epidermis is partially removed in
this species of erythema, either by friction of the
surfaces, or by the excoriation produced by acrid
secretions, as in the intertrigo occurring in fe-
males and infants of a full habit from neglect of
due cleanliness, a serous or st-ro-puriform fluid
exudes from the inflamed surface during some
days ; but vesicles are not formed, nor is there
any manifest swelling of the part as in erysipelas.

5. ii. Symptomatic Erythema — I'Erutheme
Stjmptomatique, Biett, Rayer, Cazenave, &c.

— often accompanies other eruptions, especially
at their commencement and termination, as re-
marked by Billard; and is occasionally com-
plicated v\ith them. It most frequently is
dependent upon disorder of the digestive organs;
and is often observed in children about the pe-
riods of dentition, in plethoric or fat persons, and
at the critical periods of female life. It is most
commonly caused by the ingestion of irritating
substances, and by certain kinds of food, espe-
cially in irritable temperaments, feeble or deli-
cate constitutions, and individuals of a peculiar
diathesis.

6. A. Fugacious Erythema — E.fugax, Wil-
LAN, Bateman — the maculce vnlnticiE of various
writers — consists of irregular and evanescent
red patches, with increased heat of the part,
which appear successively on the arms, neck,
breast, and face, in vaiious febrile diseases, and
in bilious fevers and diarrhoea (Bateman) ; often
denoting, as Hippocrates has remarked, a tedious
and dangerous malady. This variety sometimes
attends derangements of the digestive organs,
and, more rarely, hysteria and hemicrania. It is
not usually followed by sensible desquamation
of the cuticle ; but exceptions to this occasionally
are observed.

7. B. Shining Erythema — E. Z<Et)e, Bateman

— is sometimes symptomatic of disorder of the
prima via, and occasionally attends the catamenia
in delicate and irritable females ; but it most fre-
quently accompanies anasarca, or cedematous
swellings. 'j"he inflamed surface is smooth and
shining. When it afl^ects young and sedentary
persons, it is often attended by slight fever, and
it generally terminates in extensive desquamation
as the anasarca subsides; butwheie it occurs in
aged persons, or in those addicted to intemperance,
it is liable to pass into spreading or sloughing
ulcers. It is merely a modification of cedematous
erysipelas.

8. C. Marginated Eriithema — E. marginatum

— occurs in patches bounded on one side by a
slightly elevated, tortuous, red border ; but the
redness has no boundary on the open side. It
appears on the extremities and loins of old per-
sons, produces little or no irritation, and remains
for an uncertain time. It is generally connected
with internal disorder of a serious or dangerous
tendency.

9. D, Papulated Erythema — E. papnlatum,

Bateman — appears chiefly on tlie arms, neck,
and breast, in irregular, extensive patches, and
most frequently in females and young persons.
The patches are of a bright red hue, ofien slightly
elevated ; and, for a day or two, before the co-
lour becomes vivid, they are rough or imperfectly
papulated. The redness afterwards continues for
several days; and, as it declines, assumes, in the
central parts, a bluish, or pale purple tinge. This
variety is generally attended by a tingling sensa-
tion, passing to soreness as the colour changes;
and sometimes with much constitutional disturb-
ance,— with a frequent small pulse, anorexia,
depression of strength and spirits, watchfulness,
and pains and tenderness of the limbs ; but the
general disorder is often trifling.

10. E. Tuherculated Erythema — E. tubercu-
latum — is merely a slight modification or an
advanced stage of the papulated. The patches
resemble those of this variety ; but there are
small, slightly elevated tumours interspersed
through them, subsiding in about a week ; the
erythema becoming livid and disappearing in
about a week more. It commences with fever ;
is attended by languor, irritability, and restless-
ness; and is succeeded by hectic. It is so rare,
that Bateman never met with it, and WiLLANsawr
only three cases ; and, in these, treatment did not
" alleviate the symptoms, nor prevent the sub-
sequent hectic" (Bateman).

1 1 . E. Nodose Erythema — E. nodosum — afl'ects
chiefly females, children, and young persons of a
lax and lymphatic constitution ; and rarely occurs
in boys. It is preceded by slight febrile symp-
toms for a week or more, which generally abate
upon its appearance. It shows itself on the fore
part of the leg, and rarely on the arm, and, in
large oval patches, the long diameter of which
is usually parallel with the tibia, and slowly
rises into hard and painful protuberances. In the
course of nine or ten days these soften and
subside, the red colour turning bluish or dusky
a day or two earlier. It is sometimes connected
with the approach of the catamenia ; and its pre-
mature disappearance is sometimes followed by
dangerous internal disease. Mr. Denuy saw
pneumonia suddenly supervene on its retroces-
sion.

12. iii. J. Frank and Rayer have described,
as a chronic f'or7n (if erythema, the redness affect-
ing parts of the face, and often associated with
Acne, particularly A. rosacea, which it sometimes
so nearly resembles, as to appear rather as a mo-
dification than as a complication of that eruption.*
It generally commences in the nose, extending to
the cheeks, and more rarely to the forehead and
chin ; is characterised by vascular arborisations
in the alas nasi and summits of the cheeks, with
shining redness disappearing momentarily from
pressure ; and is attended by a sensation of heat,
tension, and itching, which, with the redness, are
increased by external and internal stimulants, or
whatever determines the blood to the head ; and

* NicoLAUs NrcOLUS Florentinus took a tolerably
accurate view of tlicse complaints, in making them va-
rieties or degrees cf the same eruption. The one here
described, he.names, " liubedo simplex sen fades rubra ;"
the Acne rosacea, he calls " littbedu pustitlosa" {Serm. vii.
tr. vi.cap. 15.) : and T. Mayhrne was, u|ion tliewtiolej
right in connecting the former with disorder of the liver
[Opera Medica, p. 213.), and in prescribing for it, local
depletions from the nape of the neck, and behind the ears,
sctons, mercurial purgatives, antimonials, &c.
3 H3

838

ERYTHEMA — Causes — Diagnosis — Treatment.

at first, by slight exfoliations of the cuticle. Tiie
reddened skin," at much later periods, becomes
irregularly granulated, rough, thickened, and
occasionally tuberculated. It is dependent upon
protracted disorder of the digestive organs, usu-
ally resulting from a long course of indulgence or
intemperance, and seldom appears till after middle
age.

13. iv. M. Ai.iBERT describes two other spe-
cies of erythema, — the Epidemic and Endemic.
The former is characterised by burning itching,
with pricking in the hands and feet. In some
cases, the skin is red ; in others, it is black, as if
covered with a layer of soot. The epidermis ex-
foliates, or forms vesications ; and the constitu-
tional symptoms are very severe. Tliis disease
was epidemic in Paris in 1828. The endemic is
the chronic affection of the skin which attacks the
peasants of the north of Italy, and is better known
by the name of Pellagra (which see),

14. II. The Causes, particularly of primary
erythema, have been already noticed (§ 3.) ;
but, even when appearing in this manner, it is
favoured, if not in a great measure caused, by
disorder of the digestive and excreting organs.
It often accompanies dentition and diarrhoea in
children ; and, in them especially, is frequently
caused by particular kinds of food, or by errors
in diet. It sometimes appears in the course of
dysentery or fevers ; and is indicative of inflam-
mation or suppuration below fasciaj, or in deep-
seated parts ; it then generally assuming the
shining or smooth form. Vascular plethora ; the
cr-itical epochs in females; various irritating in-
gesta ; very warm spices ; disorder of the stomach,
liver, and bowels, or of the excreting or elimi-
nating functions ; are chi^y concerned in its
production.

15. III. Diagnosis. — A. The superficial red-
ness ; the absence of tumefaction and vesication ;
the more or less circumscribed patches ; the much
less, constant, severe and burning pain ; the
generally slight form, and favourable termination,
of both the local affection and the constitutional
disorder ; sufficiently distinguish erythema fcom
erysipelas. — B. Tlie redness is deeper in shade
and in situation, and the patches are larger, but
less numerous, in erythema than in Roseola : the
latter eruption often appearing simultaneously in
different parts of the body, which is never ob-
served in the former. These two afl'ections are,
however, often distinguished from one another with
difficulty ; and tliere can be as little doubt, that
they often insensibly pass into each other, as that
they are botii symptomatic of internal disorder ; as,
indeed, IMr. Plumbe has properly observed.

16. IV. Theatment. — A. The primciry or
idiopathic forms generally disappear readily upon
tlie removal of the causes which occasion them ;
aided by frequent tepid ablution, and by some
mild absorbent powder, as that of calamine or
of cerussa. When erythema occurs in infants,
from inattention to the removal of the urinary
and intestinal excretions, the tepid semicupium,
mild aperients, and saline diaphoretics, may also
be employed ; and if it be attended by a serous or
ffctid discharge, a lotion with a weak solution of
the chlorinated lime or soda, or of creasote,
will readily restore the parts to a healthy state.
If the part be very irritable, Dr. Hate.man directs
ii lotion consisting of ten "rains of bichloride of

mercury and six ounces of lime-water. A weak
solution of the nitrate of silver is also of great
service. — When it is produced by cold — E.
pernio — turpentine and the balsams, or the
former, and tincture of camphor, soon remove it. —
If it be caused by bites or stings of insects, ammo-
nia and the essential oils are generally beneficial.

— Erythema from pressure may be removed by the
use of air-pillows ; by spirituous, camphorated, or
terebinthinated applications ; and by suitable
means of protecting the surface.

17. B. The symptomatic states oj erythema
should be treated according to the indications of
internal disorder furnished by individual cases ;
and almost entirely by internal or constitutional
means. The principles advocated in erysipelas,
viz. that the excretions should be promoted and
the digestive and assimilating functions assisted,
ought also to be followed in these afl!ections.
Therefore, deobstruent and alterative purgatives ;
mild tonics, with the alkaline carbonates, and
diuretics ; diaphoretics with sedatives, particu-
larly at bedtime, as James's powder with small
doses of calomel and opium, or hyoscyamus, are
the most generally appropriate. In the populated
variety (§ 9.), gentle laxatives, mild tonics, and
light diet, are sufficient ; but, when local irritation,
or restlessness, is much complained of, antimonials
and anodynes may also be given at night. — The
nodose variety (§ 11.) is soon removed by rest;
small doses of mercurials, with James's powder, at
bedtime ; alterative mild purgatives given in the
morning; and light tonics in the course of the
day. Change of air and light diet are also of very
great benefit. External applications are seldom
useful, and may be hurtful. If this or any of the
other varieties be connected with suppression of
the catamenia, or of other discharges, blood-
letting should precede the means recommended
above ; and measures ought to be used to restore
the evacuation.

18. C. The chronic form of erythema (§ 12.)
should be treated in the manner advised in the
article Acne (see § 23 et seq.}, particularly for
the indurated and rosaceous varieties, with which
this form is often associated. Temperance;
light mild diet ; regular exercise ; avoidance of
stimulating and heating ingesta, especially hot
spices, spirituous liquors, acescent vegetables,
and fat meats ; mild tonics and laxatives, with
the alkaline carbonates; and frequent and very
small doses of blue pill, or hydrargyrum cum
cretri, with taraxacum, &c. ; constitute the most
appropriate remedies. Astringent or other repel-
lent washes are of use only at the commencement
of the eruption. When it has become more dif-
fused or chronic, it is not much affected by these
applications ; and if it were, the propriety of sup-
pressing it by such means would be very question-
able. When first ajipearing, the washes men-
tioned in the article Acne, an 1 a solution of
biborate of soda in weak pyroligneous acid, are
most useful, i'lie severer forms of erythema,
especially the shining, or (edematous, and the tu-
berculated, should be treated in the manner re-
commended for similar states of erysipelas ; and
the ren;imen and diet directed in that article ought
to be adopted in this disorder.

HinLioo. AND Refer. — Celsus, De Medicina, 1. v.
cap. V'H. ^ 4. — Calihrn, Sy.stema Cliirurg. Hodiern, 5 48.3.

— 1). Turner, A Trc,iti.?c on Diseases of the Skin, ,0th

EXANTHEMATOUS DISEASES— Pathology. 839

ed. nS6,x>.239.—Cullen, First Lines, &c. ^ 21i.—Lccourt-
Chantilly, Siir rErythemo et I'Erysipfele, 4to. Paris,
1804. — J. Frank, Prax. Meii. Universe Prajcepta, pars i.
vol. ii. p. 350. — Ba/etiian, Synopsis of Cut. Diseases, by
Thomson, p. \G1. — Uncicnroori, Dis. of Cliildren, 8th
edit. p. 116.— Plunibe, On Dis. of tliejSkin, 2d edit. p. 449.

— P. Rayer, Traite Theor. et Prat, des Malad. de la
Peau, t. ii. p. 221. , et Diet, de Med. et Chirurg. Prat,
t. vii. p. 490.— /r. C. Bfiidy, On Cut. Diseases of Child-
hood, yvo. p. IfiG. — Caxenave et Schedel, Abrt'ge Prat,
des Maladies de la Peau, p. 4. — C. Biilard, Traite des
Malad. des Enfans, &c. 8vo. 1828, p. 109. — M. Good,
Study of Medicine, 3d ed. vol. ii. p. 3G4. — lloclieet San-
son, Nouv. Elt'm. de Pathologic Med. Chirurg. t.i. p.3.51.

— J. Paget, Edin. Med. and Surg. Journ. vol. xl. p. 3

Ders, Encyclop. Werterb.der Medicin. Wissenschaf. &c.
vol. xi. p. 508.

EXANTHEMATOUS DISEASES. — Syn.
Exantliemata. " E^atdrifxa, (from l^avQiai, I
break forth, or efHoresce). Eruptive Fevers,
E.rciiithenis.

Cl.assif. — 1. Class, Febrile Diseases;

3. Order (Culleii). 3. Class, Dis. of

Sanguineous Functions; 3. Order (Good).

Tlie 3d Order, of Willun and Batemait.

III. Class, III. Order (Authm-, in

PreJ'ace).

1. Defin. — Diseases usually arising from
specijic causes, and capable of perpetuating their
kind ; evincing, at their commencement, diminished
vital pouer and function, followed by reaction
throughout the vascular system ; but expressed
chiefs in the mucous surfaces and skin, especially
in their earlier stages.

2. The term e^avOn/jia was employed by the
ancients to signify any cutaneous eruption, whe-
ther acute or chronic, febrile or non-febrile ; and
a similar extension of its signification is very ge-
nerally observable among medical writers until
the commencement of the last century. The no-
sologists who wrote about the middle, or towards
the close, of that century, either differed very
remarkably as to the diseases which should be
ranged under this order, or did not separate them
from otiier febrile or inflammatory complaints.
Sauvages, one of the earliest to make the distinc-
tion as to classification, placed the e.xanthemata
as the^'rst order of his third class, Inf animations ;
and comprised plague, small-pox, pemphigus,
measles, miliary fever, purpwa, erysipelas, scar-
latina, essera, and aphth<e. — Sagar arranged
the same diseases into one class, which he divided
into two orders, y\z. contagious and non-contagious
exanthemata ; miliary fever, erysipelas, essera,
and aphtha: constituting the latter order. — Mac-
BniDE made the e-xanthemata the fourth order
of the class. Fevers; and omitted purpura and
essera, on account of their non-feliriie charac-
ters.— CuLLEN added to the eruptive feveis of
Macbride's classification, c/nV/ce)i-7)ar and nettle-
rash. — Selle retained the more extended signi-
fication of the term, and distinguished iivo orders
— the Of i((e and chronic: the former embracing
the diseases enumerated above; the latter, vari-
ous chronic eruptions. — J. P. Frank formed
his third class of the exanthemata, and distin-
guished them into two orders : those with little
elevation of the cuticle, as erysipelas, scarlatina,
petechias, &c. ; and those in which the skin
is rendered scabrous, as variola, rubeola, &c. —
Parr arranged them as the first genus under his
third order. Eruptions; added strophulus and
achor to those already mentioned ; and made a
distinction between those appearing epidemically,
and those which never assume this form. — K.

Sprengel comprised them in his third book or
class; but, whilst he omitted plague, erysipelas,
miliary fever, and aphthte, he introduced scabies
and herpes.

3. Willan and Bateman, in their artificial
classification, restricted the term to 7neasles, scar-
latina, urticaria, roseola, purpura, and erythema ;
and Dr. Good extended it to the diseases admitted
by Sauvages, with the addition of urticaria,
vaccinia, and yaws. — Rayer, Cazlnave, and
Sciiedel have merely substituted erysipelas for
purpura, in modifying the arrangement of Wil-
i.AN. Alibert has enumerated in this, his second
group or order, variola, vaccinia, clavus, varicella,
nirlus, roseola, rubeola, scarlatina, and miliaria.
Two of tiiese he has introduced into this group
for the first time — viz. c/uri/s and nirlus. The
former is a febrile exanthema peculiar to sheep,
very contagious, and characterised by flat circu-
lar pustules, resembling nail-heads, which ap-
pear on the parts least covered with wool, and
wiiich, like variola and vaccinia, attacks only
once during life. Tiie nirlus — the nirles of
Scotland, consists of distinct prominent papulje,
of a dull red colour, appearing after ephemeral
fever, never suppurating, but terminating by ab-
sorption, or by desquamation. Tlie febrile ex-
anthemata formed the third order of the third
class, in the outline published by me in 1822. —
Lastly, Dr. WtAniERiiEAD admits only rubeola,
scarlatina, variola, vaccinia, varicella, and Frani-
bcesia, in his order of Exanthematici. — Other
systematists, as Vogel, Ploucquet, Pinel, and
Young, have not arranged the exanthems into a
distinct group ; but have classed them either with
fevers or with inflammations. I have divided
them into two sub-orders, viz. (a) tiiose which
attack the same person only once; and (6) those
which may occur oftener than once; and have
referred to a different order, such rashes, as ery-
thema, roseola, and urticaria, as are chiefly sym-
pathetic of disorder of the digestive organs.

4. There are various circumstances connected*
with all the diseases which I have classed as
exantliematic, requiring to be constantly kept in
mind by the practitioner: — ; 1st. They fre(|uently
prevail epidemically; — 2d. Diflferent epidemics
of the same malady often present very diflferent
or even opposite characters, chiefly as respects
the state cf vascular action, and of vital power
and resistance; — 3d. The sporadic occurrences
of the exanthemata are generally less severe or
dangerous than their epidemic prevalence, al-
though, occasionally, the latter is very mild ; —
4th. Like all other febrile diseases, the severity of
attack, the complications sometimes appearing in
their course, and their terminations, depend in
great measure upon the constitution and habit of
body, upon pre-existing disorder ; upon the occu-
pation of, and other circumstances peculiar to,
the individual ; and upon the season of the year,
and the treatment adopted at the invasion and in
tlie early stages of the disease; — 5th. As these
maladies, when *once formed, run a determined
coiyse, a too perturbative treatment, or the nimia
medici diligentia, particularly if misdirected or
otherwise injudicious, may be more injurious than
inactivity, or the unaided efforts of nature; —
6th. That we should protect vital organs from suf-
fering injury, cither from the reaction atleiiding
certain of their stages, or from the congestion

;•: ii -1

840

EXCRETIONS — Natural.

accompanying others of their periods ; and, by
eadeavouringto interpret the procession of morbid
phenomena aright, to follow where Nature points
the way, and in the manner she indicates, in par-
ticular cases ; in other words, that we should not
treat the disease as a substantive, or entity, to
which certain ideas are attached, but according to
the actions, changes, and states presented at the
commencement, and during the progress, of each
case ; — 7th. The advanced stages of, and con-
valescence from, the exanthemata require careful
supervision ; as, during the latter period, various
afiections are liable to supervene, that are some-
times more dangerous than the antecedent ma-
lady ; — 8lh. Opinions as to the result should ge-
nerally be given with reservation, as sudden and
unexpected changes may occur during their
course, and during recovery, owing to moral and
physical causes, over which the physician can
often exercise no control.

BiBUOG. AND Refer. — Saitvages, f^o'io]og\d Jlethodica,
class iii. order 1. — D. Macbridc, Methodical Introduc-
tion to the Theory and Practice of Physic, 4to. Lend.
3772, p. 3B2. — Sugar, Systema Morborum, &c. Vien.
1776, p 557. class x. — Ciillen, Synopsis, class i. order 3.
— C- T. Selle, Liber de Curaiidis Hominum Morbis, cura
C. Sprengel, 8vo. 1798, p. W2.— J. P. Frank, De Curand.
Horn. Morbis Epitome, 1. iii. vol. i. p. i. ^ B. Parr, The
JLond. Med. Dictionary, &c. 4to. Loud. 1809, vol. ii.
p. 2fi9. — K. Sprengel, Institutiones MedicEe, vol. iv. Pa-

thologia .Spec-ialis. Amstel, 1814, 8vo. p. .390 Author, in

Lond. Med. Repos. vol. xvii. 1822, p.S71.—Hat/e?;Ma\ai.l.
de la Peau, t. i. p. 12. — Cazenave et Scheriel, Abrege
des Mai. de la Peau, p. 1. — J. Paget, in Edin. Med. and
Surg. Journ. vol. xl. p. 7. — Weatherhead, Synopsis of
Nosology, &c. 12mo. 183+, p. 44.
EXCRETION AND EXCRETIONS.—
(Classif. Pathologv — /Etiology — Symp-
tomatology.)

1. Defin. — Excretioyj is the separation of
tubstancesfrom the liiing body ; and the secretions
or substances separated are the fcccal parts of the
ingesta, and the matters which Itave fulfilled their
destined purposes in the Jrame ; and which, being
no longer suited to, or susceptible of, vital alliances,
are eliminated from the blood in gaseous, vaporous,
or liquid states ; their discharge being necessary to
the continuance of health, and being performed
under the influence of life.

2. A knowledge of the various functions ex-
creting or eliminatmg effete mattersfrom the blood,
of the manner in which they are influenced by
foreign agents, and of their mutual actions and
reactions, is necessary to a philosophical and suc-
cessful exercise of the healing art. The continued
introduction of matters into the fiame, and their
temporary circulation and assimilation, is counter-
balanced by a corresponding discharge ; the sub-
stances received being, after indefinite periods,
excreted in very different states of elementary
combination. Matters are introduced into the
frame almost entirely by the digestive and respir-
atory surfaces ; they are discharged also by these
surfaces, and by otiier channels almost exclu-
sively a|)propriated to tiiis function. 1 shall take
a view, frst, of the several excreting functions ;
and, neit, of the manner in which their interrup-
tion or suppression affects each other, and disor-
ders the vital actions.

3. The ExciiKTioNs are either' — (a) The Na-
tural, or those which are ejected altogether
from the body, as the faices, urine, &:c. ; and
which may be divided into — a. exhaled, as the
transpirations from the skin and lungs ; 0. secreted,
as tho urine, iko. ; and, y, ficcal, consisting not

only of exhaled and secreted fluids, but also of
those parts of the ingesta which remain after the
process of digestion is completed; — (h) The
JNIonBiD, or those — a. which are imperfectly
ejected from the circulation, as tlie fatty matters
which accumulate in situations where they do
not materially interfere with the vital actions ;
and, B. tiie most remarkable alterations from the
healthy state presented by, or attending, the ex-
cretions discharged by natural channels.

4. /. The Natural Excretions, the excre-
tions proper, or those matters ivhich are ejected
altogether j'rom the body. — A. Exhaled Excretions,
— a. The cutaneous trajispiration, whether in its
more insensible states of aqueous vapour and
carbonic acid, or in the form of sweat, is a most
important evacuation. It consists chiefly of wa-
ter, with oily matter, mucus, osmazome, lactic or
acetic acid, and the salts usually found in the
blood (Thenard, Berzelius, Anselmino, Tie-
demann). When the large quantity of fluid
discharged fiom the blood by this channel is con-
sidered, interruption or suppression of the func-
tion will manifestly appear most injurious; and
calculated either to disorder other excreting
functions, or, if these do not perform a compens-
ating action, to induce febrile or inflammatory
affections. The causes which chiefly affect this
excretion are stated in the article Disease (§ 41.
101.).

5. The quantity of this evacuation may vary
remarkably ; and its quality may also change. —
It is suppressed or much diminished in the early
stages of febrile and inflammatory diseases, espe-
cially during the period of excitement ; and is
either restored or greatly increased as the excite-
ment passes into exhaustion. When it becomes
abundant, it is often a salutary crisis ; unless in
hectic fever, in haemorrhage, or in acute diseases
attended by sinking, and coldness of the surface.
Copious perspiration accompanies healthy action
and excitement, and then it is warm and general.
It is most profuse in the advanced stage of con-
sumption ; and in some malignant diseases, as
pestilential cholera, &c. It is sometimes foetid,
or contains more animal matters in solution than
usual ; and is at the same time more abundant,
paiticularly in persons who are habitually costive,
or who eat and drink largely or grossly ; and still
more so in the negro: in all whom, the suppres-
sion of the excretion is often followed by danger-
ous maladies. Profuse as well as offensive pers-
piration, particularly of the feet, also attends im-
perfect action of the liver or kidneys ; whilst
unusual heat and dryness of the feet, and of the
palms of the hands, accompany chronic inflam-
mation of these and otiier internal viscera. In
negroes and the dark-skinned races, the integu-
ments are a much more important organ of ex-
cretion than in the white variety — the perspir-
ation, both sensible and insensible, of the former
being very inucli more abundant, and containing
more carbonic acid and animal matter, than that
of the latter. I fully ascertained this fact by
experiments made in Africa, in 1817; the cuta-
neous transpirations of the negro being from one
fourth to nearly one half more abundant than that
of the European. — Besides the matters usually
found in it, the perspiration sometimes contains
the colouring matter of the bile, or bile itself,
especially in hepatic diseases and bilious fevers ;

EXCRETIONS — Natural.

and, occasionally, minute quantities of urea and
uric acid. It is very sensibly affected, particu-
larly in costive habits, by the ingesta, especially
some kinds of fish, and shellfish; the odour of
these, and of numerous other articles, being very
sensibly felt in this excretion.

6. b. The Pulmonarii Exhalation. — a. The
carbonic acid gas given out during respiration, is
one of the most important excretions that takes
place in the economy, whether this acid be
formed within the blood-vessels, or in the air-cells,
of the lungs ; the quantity of it produced being
an index of the extent to which the change from
venous to arterial blood is carried in this organ.
The evidence as to whether the carbonic acid is
formed icithin the blood-vessels, or ^^Hthout them,
is very contradictory. The experiments of Dr.
Edwards show that the former process takes
place to some extent ; and they are supported by
the fact observed by Behzei.ius, that blood, espe-
cially its colouring part, absorbs oxygen very
quickly, and retains some part of the carbonic
acid thereby produced. The passage of carbon
from the vessels, and its combination with oxygen
externally to them, is an inference from the ex-
periments of Mr. Ellis ; which, however, were
performed out of the body, and under circum-
stances which entirely excluded the operation of
the vital influence. The evidence, however, for
the absorption of oxygen through the capillary
parietes is nearly the same with that for the ex-
cretion of carbon ; for, if the tissue intervening
between the blood and the air will permit the
transmission of the one, it may also allow the
passage of the other. I am inclined to think that
both operations go on simultaneously : that, whilst
a portion of the carbonic acid gas is given out
from the blood, it is accompanied with a portion of
free carbon, or oxide or hydrate of carbon, which
combines with an additional quantity of oxygen
in the lungs, and thus forms the whole of the
carbonic acid in question ; and that, at the same
time, a portion of oxygen is absorbed, which
combines with a portion of carbon in the blood ;
and there forms the carbonic acid, or the oxide
of carbon, which is a part of the matters dis-
charged from the blood in the lungs. These
processes may vary, and either may predominate,
according to the state of vital influence at the
time, under whose control they are placed.
This view is supported by the experiments of Dr.
Edwards, which show that the carbonic acid is
not formed instantaneously in the lungs ; but is, to
a considerable extent, secreted from the blood in
the respiratory surfaces. Nor is it contradicted by
the experiments of INIM. Magendie and Orfila ;
who found that phosphorus, dissolved in oil, and
injected into the blood, was secreted by the lungs
in the form of phosphorous acid vapour.

7. However formed, it is obvious that the car-
bonic acid should be viewed as an excretion from
the blood, the combination of the carbon with the
oxygen being the principal source of animal heat.
The quantity of the gas thus excreted, neces-
sarily varies with the size of the thorax, the
activity of the circulation, the state of nervous
energy, and the condition of the excreting organ.
Dr. Crawford fir?t found the quantity of the
carbonic acid discharged, much diminisiied in a
high temperature; and Lavoisier, Seguin, Prout,
Fyfe, and myself confirmed the observation. In

841

an artificial high

the experiments I made

temperature in this country, and in nearly the
same temperature in a hot climate, the dimi-
nution was very remarkable, more especially in
the latter circumstances; the humid and miasma-
tous air of an unhealthy intertropical country
depressing vital and nervous power, and thereby
diminishing still further this important function.

8. /3, Other gases are exhaled from the lungs,
as shown by the experiments of Nysten and Ed-
wards. The former found that, when these are
injected into veins, tiiey pass out with the expired
air ; and the latter concludes that azote, absorbed
into the blood, is discharged from it by the lungs.
It is probable, however, that a considerable por-
tion of the azote which passes into the circulation
during respiration, combines with the chyle, and
contributes to its complete animalisation ; the
ultimate product being urea, which is excreted
by the kidneys. From experiments I performed
many years since (Lond, Med. and Physical
Journ. vol. xlvi. p. 107. 185.), I inferred that
numerous substances, as camphor, spirits of tur-
pentine, several essential oils, spirits, aethers, &c.,
when absorbed or otherwise introduced into the
circulation, are discharged from it chiefly by the
lungs. Spirituous liquors, taken largely, pass oflT
in great part through this channel — at least,
their more volatile portions.

9. y. The acjneous vapour constantly transpir-
ing from the lungs is often a most important
evacuation. It is slightly charged with aninjal
matter ; and proceeds chiefly from the blood in
the pulmonary artery. Its quantity varies very
much. Lavoisier, Seguin, and Thomson esti-
mate it at about twenty ounces in the twenty-four
hours : but it is increased much above this, by
the free use of diluents, and malt or spirituous
liquors, particularly the last ; or by whatever
increases vascular plethora. Diminished ex-
cretion by either the skin, kidneys, or intestines,
also augments it ; and in these circumstances, it
contains more animal or effete matters, to which,
chiefly, is owing the factor of the breath so often
remarked ; the lungs, in these cases, compensating
in some measure for the interruption of the other
excreting actions. The circumstance of various
substances, that are absorbed into the circulation,
being eliminated from it, along with the pulmonary
transpiration, explains their influence in diseases
of the air-passages, and their action in promoting
expectoration. The morbid conditions of these
passages, especially such as impede the functions
of transpiration — whether gaseous or vaporous —
must necessarily influence the other excreting
actions, particularly those of the skin, of the liver,
and the intestinal canal. Hence the advantages,
in such cases, resulting from the remedies which
promote those evacuations, and restore the pul-
monaiy functions.

10. e. The Catamenial or Menstrual Discharge
may be considered as an excretion, most salutary
in its effects in most instance?. It diminishes
both local and general plethora ; and it sometimes
seems to be the channel by which morbid states
of the circulating fluid are removed. In such
cases, the discharge is offensive, or altered in
colour ; and, occasionally, it induces irritation or
excoriation of the parts over which it passes, or
with which it remains a short time in contact ;
the cutaneous surface and countenance being

842

EXCRETIONS —Morbid.

clearer, and the health improved, after such eva-
cuations, particularly when copious, and when
the indications they furnish are properly followed.
The lochia is also a salutajy excretion, inasmuch
as vascular fulness and local determinations are
obviated by it, and the circulating fluid rendered
more pure. (See Puerpehal States.)

11. B. The Secreted Excretions. — a. The
biliurn secretion is excrement itial as well as recre-
mentitial ; the liver manifestly compensating for
the deficient excreting action of the lungs — as
was first shown by me in 1815 — and combining
a portion of tlie carbon, and other matters usually
discharged from the lungs, into bile, preliminary
to their excretion, as well as for the purposes of
digestion ; that portion of carbon, which does not
combine with oxygen to form carbonic acid, being
associated with the other constituents of bile in
the formation of this fluid. Hence the abundant
secretion of bile in circumstances which diminish
the activity of the respiratory functions, as in
warm moist states of tlie air, &c.

12. b. The Urinary Excretion. — JMM. Du-
mas, Prevost, and Segalas, found, on examin-
ing the blood of living animals whose kidneys
had been extirpated, that it contained tirea, the
quantity of which was increased according to the
duration of life after the operation ; and that this
substance could not be detected in the blood of
those animals in which the urinary secretion was
uninterrupted. Bl. Segaias, having injected an
aqueous solution of urea into the veins, observed
the secretion of urine rapidly increased by it,
and this substance so quickly eliminated in the
process, that, after twenty-four hours, it could
not be detected in the blood. It seems, therefore,
not improbable that the effete and more highly
animalised matters absorbed and carried into
the circulation, are converted, by the influence
of the vessels and organs through which they
circulate, into tiie substance called urea; and
that one of the functions of the kidneys is to
eliminate it from the circulation. These expe-
riments favour the conclusion that urea is not
formed, or at least altogetlier formed, in tlie
kidneys, by their appropriate actions ; but that
it, and probably other substances which are re-
moved by these organs, exist in tlie blood, either
already formed, or in certain stages of formation.

13. According to Berzelius's analysis, the
urine contains, in its healthy state, somewhat
more than 30 parts in 1000 of urea ; and Dr.
Prout has shown that nearly one half of
urea consists of azote. It consequently follows
that the injurious accumulation of azote in the
system, contingent either on assimilation or re-
si)iration, and the resulting putrefactive tendency
of the fluids, are prevented by the action of the
kidneys. Hence we observe the great ])roportion
of urea in the urine of those who eat much ani-
mal food, in which nitrogen abounds ; and we
may tlierefoie conclude, that the kidneys are tlie
great outlet for azote, as the lungs and liver arc
for carbon.

14. C. The Ftccal Excretions. — a. In their
course through the small intestines, the alimen-
tary matters are deprived of their chyle ; the
residue being poured into the caecum, where its
course is more slow, and where it assumes new
characters. The contents of the colon and rec-
tum evidently consist — 1st, of the residue of tiic

aliments ; and, 2d, of the excrementitial parts of
the secretions poured into the digestive canal.
These constitute the froces. It is, in some mea-
sure, owing to the quantity and properties of
these latter, especially the biliary and follicular
secretions, that the faeces present distinctive cha-
racters ; their consistence depending upon their
retention in tlie large bowel, and upon the quan-
tity of exhaled and secreted fluids poured out in
this, and the superior portions of the canal.
Their colour is owing — 1st, to the abundance
and properties of the bile, or to its suppression ;
2d, to tlie fluids poured into the digestive tube ;
3d, to acidity in some portion of the prima via ;
4th, to the food and drink ; and, 5th, to the pro-
perties of medicinal substances. A careful
consideration of each of these is necessary, in
estimating aright the indications furnished by the
ffflcal discharges. The odour of the faces de-
pends chiefly upon the secretion of the mucous
follicles, particularly those of the caecum, colon,
and rectum ; upon the states of constitutional and
vital power, in connection with vascular action,
and the conditions of the digestive canal ; and
upon their retention in the large bowels: an
offensive or unnatural odour of the fajces gene-
rally proceeding from depressed vital energy, or
long retention, and the extrication or secretion
of gases in the intestinal canal.

15. II. JMoRBiD Excretions. — A. The Fatty
Excretions consist of the secretion of fat —
1st, in cellular parts ; 2d, in the alimentary
canal; 3d, by the kidneys; and, 4th, by the
stomach. — a. 1 have stated in the article
Adipose Tissue (§ 3.), in how far the exces-
sive secretion of fat may be considered as a
salutary excretion, in the circumstances which
usually give rise to it; the excess of oily or fatty
matter in the blood, consequent upon imperfect
sanguifaction and assimilation, being deposited
principally in the areolaj of the cellular tissue,
whence it may be taken up by the absorbents
for the purposes of nutrition, when the supply of
food becomes deficient.

IG. b. In some states, chiefly of disease, fatty
substances are excreted /'mm the intestinal canal,
in a solid, semifluid, or liquid form. — 1st. In some
cases, the fat seems to be absorbed from the
adipose tissue, carried into the circulation, and
secreted or exhaled from the intestinal mucous
surface ; whence it is excreted of various con-
sistence, according to the preponderance of cer-
tain of its elements, or to its combination with
mucus or with an acid in t!ie bowels. — 2d. It may
also proceed from an undiij accumulaiion, owing
to imperfect assimilation, of oily matter in the
blood ; which is excreted in this situation, instead
of being secreted in the adipose cellular tissue:
and, 3d. In those instances, where tlie fatty sub-
stance consists of small solid pieces, and resem-
bles or appi'oachcs adipocire or cholestei ine, it may
lie secreted in the liver. Cases of this morbid
excretion are c()m])aratively rare ; but I am con-
vinced that they would be much more frequently
observed, if tlie alvine evacuations were more
attentively examined than they generally arc.
J have met with only two cases ; but several
have been lately observed by Dr. Ei.t.iotson,
iJr. liiu(;iii, and Mr. Lloyd. It should, how-
ever, be borne in mind, that olive and castor oils,
in ))asbing through the digestive canal, ai'e some-

EXCRETIONS — Morbid

times so altered by combining with mucus, or with
morbid secretions, as to assume a solid and fatty
appearance ; and that persons who eat largely of
fat meats, occasionally pass portions of undigested
fat, in either a fluid or consistent state. — In
the cases recorded by jMoeuius, jMoellenbhock
(Epiieni. Med. Phys. Germ. Curios, dec. i. cen. 2.
obs. 20.), and Fabricius IIildan'us (Obs. et
Curat. Med. Chirurg. cent. iv. obs. 47.),
emaciation appears to have been a prominent
symptom ; indicating the probable origin of the
discharge in the rapid absorption of fat from the
adipose tissue. Instances of fat voided from the
bowels in large quantities arc adduced also by
TuLPius (Observ. Med. Amst. 1685.), Arnot
(Edin. Med. Essays, vol. v. part ii. p. 652.),
Scott (Edbi. Med. Comment., vol. iv. p. 334.),
Babington (P/iitos. Trans, for 1813. part ii.
p. 150.), Mr. Howsiirp (Pract. Observat. in Sur-
gery and Morb. /Iwaf.p. 283.), Culleriek, East-
coTT(Med. Gaz. vol. xii. p. 49.), and Dr. Turner
(3Vans. of Med. and Chir. Soc. vol. xviii. p. 73.).
17. In the first case detaUed by Dr. Elliot-
son (Trans, af Med. and Cliir. Sue. vol. xviii.
p. 76.), the fatty matter discharged was flui<l,
of a yellow colour, concreted when cold, and
burnt with a large flame, like oil. It was gene-
rally evacuated with the faeces, in large quantity ;
and occasionally it ran from the patient involun-
tarily. The discharge was preceded by bloody
stools, was continued for several months, was
attended by great pain, and was associated with
phthisis and mellitic diabetes ; pus being thus
evacuated from the lungs, saccharine urine from
the kidneys, and fat from the bowels, at the same
time. On dissection, all the intestines appeared
greasy, as if soaked in oil, with numerous
black points in their mucous membrane ; but
there was no other lesion in them. Tlie liver
was healthy, and the giill-bladder full of thick
dark bile. The pancrealic duct, and large late-
ral branches, were filled with white calculi. The
kidneys were sound, the lungs tuberculated and
ulcerated. In the second case adduced by Dr.
Elliotson, the fat was discharged in both a solid
and fluid state. The patient died of this com-
plaint and phthisis. No disease was discernible
after death, in the alimentary canal or urinary
organs. The liver was large and pale, but
healthy in structure ; and, with the gall-bladder,
destitute of bile. Dr. Prout (Ibid. p. 79.)
saw a young lady, who voided, " for many
months before death, fatty matter in large quan-
tities, mixed with blood and other things." The
caicum was found tiiickened ; and the mucous
coat of it and of the colon was ulcerated. The
other abdominal viscera were healthy.

18. In the first of the cases detailed by Dr.
Bright (Trans, of Med. and Chirurg. Soc. vol.
xviii. p. 3.), the fatty matter was observed in the
stools, in the course of diabetes, on which jaun-
dice had supervened from obliteration of the com-
mon bile-duct, caused by disease of the pancreas,
with malignant ulceration of the duodenum. The
second instance of this kind of excretion recorded
by this physician was remarked during jaundice
caused also by obliteration of tiie common bile-
duct, owing to disease of the pancreas and ma-
lignant ulceration of the duodenum. In the third
case, a nearly similar association of morbid phe-
nomena, and of organic lesions, to those charac-

843

terising the second, was observed. In the case
detailed by Mr. Lloyd (Ibid. p. 57.), the ex-
cretion of fat in the stools was remarked in the
course of jaundice caused by enlarged pancreas ;
the gall-bladder and hepatic ducts being greatly
distended with bile, and the common and pan-
creatic ducts obliterated.

19. I was recently called Ui a married female
of about forty, who had never been pregnant, and
who compliiined of symptoms which I attributed
at first to the passage of gall-stones along the
ducf:, and afterwards to a concretion in the
bowels. Upon examining the evacuations, with
the expectation of detecting something of this
kind, two lumps were found, the largest of which
was above the size of a walnut. They were of a
whitisii colour, with a slight greyish green tinge,
were greasy to the touch, imparted a permanent
greasy stain to paper, resembled adipocire in con-
sistence, and burned with a whitish blue flame
and much smoke. After their evacuation, much
relief was procured, and the opportunities of ex-
amining the evacuations ceased ; but the patient
who occasionally calls at my house for advice,
still complains of disorder of the digestive organs,
particularly of the liver and bowels. In the
autumn of 1833, I saw, through the kindness of
Dr. O'DoNNEL, a most able physician in Liver-
pool, a lady who had long suffered chronic
disease of the bowels, particularly of the large
bowels. The evacuations, which were fluid, con-
tained a number of small lumps, varying from
the size of a split pea, to that of a bean : but
presenting all the characters just described.

20. b. The excretion of fatty matter by the
urinary organs is more rare. — Dr. Prout, in a
communication to Dr. Elliotson, states, that he
has seen, several times, a fatty or adipocirous
matter voided with the urine ; and that, in every
instance, malignant disease of the kidney or
bladder has supervened, and ultimately proved
fatal. TuLPius mentions a case of an old woman
who voided fat from both the bowels and bladder,
and died remarkably emaciated.* Mr. Pearson,
in Dr. Elliotson's interesting paper, details the
case of a lady of seventy-nine, who, after suf-
fering from gall-stones, observed in her stools,
which were without bile, a fatty substance, that
passed in the form of oil, but quickly concreted ;
and in her urine a similar oil, whit h floated on its
surface, and concreted like that passed from the in-
testines. The quantity excreted by the bowels aver-
aged an ounce and a half daily ; and by the urinary
organs, about the third of an ounce. The patient
died emaciated, but no inspection was allowed.

21. c. A case is given in the Medico Chiriir-
gical Review for July, 1826, from the Annali
Universali, of a m.an who, after irregularities of
diet, was seized with vomiting every week or
fortnight, for two years. During an unusually
severe attack, occasioned by great imprudence in
diet, a quantity of pure blood, and a thick oil, or
melted fat, were thrown up ; amounting in all
to thirty pounds in twenty-four hours. He
neafly sunk ; and his skin hung in folds, as
though all the fat had been absorbed. After
some time he was restored to health. It is
reasonably supposed that his fat had been rapidly
absorbed durino; the attack of vomiting, and

* See also J. Fletcher, The Differences, Causes, and
•ludgemcnts of the Urine, &-c. ISmo. Loud. 1641, p. tH. 92.
(. Verij rare.)

844

EXCRETIONS — MonBin.

poured into the stomacli. Diemerbuoecr (Ob-
serv. et Curat, Med. Cent. obs. 93.) minutely
details the case of a female of twenty-seven years
of age, who was long aiflicted by violent gastro-
dynia, and obstinate vomiting of a black fluid
containing lumps of fat of the colour and consist-
ence of butter. The bowels were costive ; but
the uterine, biliary, and urinary functions were
not deranged. She was ultimately cured by
cathartics, enemata, and cordial anodynes. In-
stances of the ejection of fatty matters from the
stomach, after prolonged or repeated vomiting,
and witiiout the possibility of a foreign origin,
are recorded also in the Philosophical Trans-
actions (for 1673, No. 96), and by Gesneh
(Beobachtungen, b. i. No. 10.), Gourrand
{Journ. de Med. t. Ixxxv. p. 366.), and J. P.
Frank (De Cur. Horn. Morb. 1. v.pars. ii. p. 370.)

22. From a consideration of the circumstances
attending the excretion of fatty matter from the
digestive and urinary organs, in the cases now
referred to, the inference that it takes place in
one or other of the three modes already stated
(§ 16.), according to the nature of the disease in
the course of which it supervenes, seems to be
well founded. The fact, that the milk-like stale
of the serum of the blood, so often observed, de-
pends upon the admixture of animal oil or fat in
it, remarkably favours the inference as to the first
and second of these sources of the fat found in
the excretions. The opinion entertained by Sir
E. Home {Philos. Trans. 1813, part ii. p. 150.),
and attempted to be proved by experiments, that
the fat is formed in the lower intestines by means
of bile, is disproved by the cases recorded by
Dr, Bright and Mr. Lloyd. The passage of
bile into the digestive canal was completely pre-
vented in all these. But the inference, that
imperfect digestion and assimilation, and the con-
sequent formation of oil in the blood, or the
absorption of it from the adipose tissue into the
circulation, and its excretion from the blood by
the bowels, are the true source of this pheno-
menon, is fully evinced by the history of these
as well as of the other cases. The presence of
oil in the urine, remarked in rare instances, is a
further proof of the origin now contended for.
There is strong reason to believe tliat the excre-
tion of superabundant oil in the blood takes place
ranch more frequently than is supposed, by this
latter ciiannel. IIii'i-ocuates, Galen, Prosper
Alpinus, and several other writers, noticed it as
an unfavourable occurrence, and not incorrectly
considered it as a symptom of colliquation.

23. B. The most remarkable changes presented by
the excretions through natural channels are de-
scribed in the articles Blood ('§ 115. et seq.),
and Disease (§ 99. et seq.), and in the numer-
ous articles on diseases in which the excre-
tions are early or principally aflfected. The more
isolated and prominent of them only will there-
fore be noticed at this place. — a. The ^"rfca/
excretions are either diminished or increased, or
otherwise changed ; alterations of these being
generally connected with disorder of the hepatic
organs. Obstructed or diminished discliarge of
bile, arising eitiier from torpor of the liver, from
congestion, or from obstruction of the ducts, &c.,
deranges not only the intestinal functions and
excretions, rendering the latter pale and offensive,
but also the digestive and assimilative actions,

the urinary and perspiratory functions, and the
conditions of the nervous system, occasionally
terminating in coma and death ; especially when
the bile has been taken into the circulation, and
has coloured the tissues and exhaled fluids. The
bile may be so altered in colour and consistence,
owing either to the superabundance of certain of
its elements in the blood, or to its remora in the
ducts and gall-bladder, and to the consequent
changes, as to impart to the fa;ces a very dark
green or almost black colour, even independently
of the exhalation of blood in the prima via. I
have remarked this uncommon state of the faecal
discharges chiefly in diseases impeding respiration,
as asthma, bronchitis, hydrothorax, and chronic
affections of the liver. A black appearance of
the alvine excretions is, however, more frequently
produced by the escape of blood into the upper
portions of the alimentary tube ; but upon dilut-
ing or mixing the evacuation with water, a
greenish hue will be assumed in the former case,
and a reddish or ochry tint in the latter. The
remarkably copious, rice-coloured, watery eva-
cuations, in pestilential cholera, are attended with
an albuminous coating of the intestinal mucous
surface ; the serum of the blood having exuded
from this surface, owing to deficient vital power
of this part, and of the frame generally, and to a
morbid state (dyscrasy) of the blood itself; its
albumen partially concreting on, and adhering to,
this surface, as proved by the examination of
bodies, in which treatment had not removed it
previously to dissolution. The fa?cal excretions
are more or less altered in most diseases ; but it
would lead to repetitions to pursue the subject
further at this place. The excretion of gaseous
matters from the alimentary canal is considered
in the article Flatulence.

24. b. The nrinarii excretion varies in quan-
tity, influenced by the interruption or abundance
— 1st, of the respiratory exhalation ; 2d, of
the cutaneous transpiration ; 3d, of the intes-
tinal exhalations : copious discharges from one or
more of these surfaces diminishing this excretion,
and opposite states increasing it. The urine may
also contain various foreign matters, or certain of
its usual constituents in excess ; but generally as
a consequence of disease. It contains much ge-
latine and urea, in typhoid or adynamic fevers ;
much albumen and phosphate of lime, in rickets;
much urea or lithic acid, in dyspeptic affections
and gout ; and much saccharine matter, in dia-
betes. In injiammatory fevers, the urine is red, deep
coloured, or even a deep brown, and transparent,
until a crisis occurs ; when it becomes more co-
pious, and deposits the lateritious sediment, which
is of a reddish colour, and consists of phosphate
of lime, lithic acid, sometimes lithate of ammonia,
and animal matter, with litiiate of soda, and pur-
puratcs of ammonia and soda, according to Dr.
Prout. In intermiltents, it varies with the stage
of tiie paroxysm ; but, after the seizure, it deposits
a red powder, consisting of rosacic acid. In gout
and rheumatism, it contains much lithic acid. lu
hysteria, h is copious, of a pale colour, is deficient
in urea and animal matter, and abounds with the
usual salts. In jaundice, and other diseases inter-
ru])ting the functions of the liver, the urine pre-
sents a brown or muddy appearance, or contains
bile ; the kidneys having to a certain extent as-
sumed an office vicarious of that of the liver. In

EXCRETIONS — Morbid.

845

hilious remittent fevers, it often possesses a similar
character. In dropsies, it is sometimes yellowish
green and extremely viscid. It generally depo-
sits a copious sediment of rosacic acid, lithic acid,
phosphate of lime, and animal matter; and in
acute dropsy is frequently so loaded with albumen
as to coagulate when heated, or when sulphuric
or nitric acid is added to it.

25. In all inflammalorii diseases, the urine is
small in quantity and high-coloured, and con-
tains acids in excess ; but in disorders of irritiitioii
or dehilitii, it is generally pale, in large quantity,
and abounds in neutral saline, or alkaline sub-
stances. Blood is sometimes found in the urine ;
and the inky or black colour it presents on rare
occasions, most probably is caused by the pas-
sage of the colouring matter of the blood along
with it from the kidneys, and by the action of the
salts contained in it. Dr. jNIarcet ascribed this
colour to a particular acid, wiiich he called the
melanic. In a few cases, tlie urine assumes an
almost gelatinous state shortly after it is voided.
I met with an instance of this kind in an ad-
vanced stage of pregnancy ; severe pains in the
loins and sickness being complained of. Anti-
phlogistic treatment removed it. Mucous and ));<-
riform matters are also seen in the urine, during
and after irritation, or inflammatory diseases, of
tlie kidneys, bladder, or prostate gland. (See
Kidneys, and Urine.)

26. c. Vicarious excretion is of frequent oc-
currence in several diseases ; and takes place to
a certain extent even in health ; causes which
merely diminish excretion in one part, increasing
it in others, without manifest disorder ensuing.
But no excretion can ever be long, or much
interrupted, without disease supervening ; the in-
creased function, which supplies its place for a
while, itself sooner or later passing into disorder
of a more or less acute kind and dangerous cha-
racter. The perspiratory and respiratory exha-
lations are seldom altogether suppressed ; but
when they are interrupted, one or two things
generally ensue: — 1st. When the vital powers
are not materially depressed, nor any organ dis-
posed to disease, the actions of the kidueys, of
the liver, and bowels, are individually or con-
jointly increased, so as to compensate for the
interruption of either of these exhalations ; —
2d. If such compensation does not take place,
or if some organ is disposed to disorder, the vas-
cular system is overloaded by the consequent
augmentation of the serous parts of the blood, or
iiritated by the retention of matters requiring to
be excreted ; and the predisposed organ becomes
congested or inflamed ; fevers, inflammations,
&c. supervening, according to individual pre-
disposition and concurrent causes.

27. d. Interruption or suppression of the urinary
function is one of the most serious occurrences
to which the frame is liable, and the least admits
of being replaced even for a time by other excre-
tions. Yet a compensation sometimes takes place
to an extent preservative of life, for several days,
or until suppression is removed. In such cases,
the exhalations from the lungs, the cutaneous
transpiration, and the actions of the alimentary
canal, are individually or conjointly increased,
so as to supply the deficiency ; and the urinous
or ammoniacal foetor of the breath and perspi-
ration often indicates that the excretion of urea

and other injurious matters is effected chiefly by
the cutaneous and pulmonary surfaces. In some
instances, an urinous fluid, or rather fluid con-
taining urea and the salts usually found in the
urine, is exhaled in considerable quantity during
the repeated or prolonged vomiting that often
attends disease of the kidneys with suppression
of urine ; and, in other instances, the intestinal
discharges become watery, urinous, and abun-
dant. When the suppression is complete, much
more serious results follow : an itrinous species of
fever supervenes, owing to the retention in the
blood of an excess of serum holding alkaline and
highly azotised salts in solution, and to the ac-
tions of other excreting organs being insuflicient
to compensate for the suppression. In such in-
stances, the pulse is accelerated, large, full, and
oppressed ; the perspiration copious and offen-
sive ; the soft solids and muscles flaccid ; the
bowels irregular or relaxed, and the stools mor-
bid and foetid ; the countenance and cutaneous
surface foul or lurid ; and the foetor of the pa-
tient's apartment often remarkable. These cases
generally terminate in coma, or sudden death,
with or without convulsions, owing to the influ-
ence of the impure blood on the brain ; and in
eft'usion into serous cavities : but similar ter-
minations of interrupted urinary excretion some-
times take place without antecedent urinous fever.
In a very hopeless case of this form of fever, in
the cook of a friend's family, the secretion of
urine, which had been suppressed entirely for
several days, was restored by cupping repeatedly
on the loins, and by diuretics, purgatives, and
deobslruents. The abundance and foetor of the
exhalations from the lungs and skin were very
great in this case.

28. e. Interruption of the biliary excretion may
continue for a long time without a fatal result ;
but whether the secretion be suppressed, or the
discharge of it into the Intestines prevented, se-
rious consequences usually ensue, although the
bile may not pass or be absorbed into the cir-
culation. If the secretion does not proceed, the
other excretions become morbid, particularly the
faecal and urinary ; the breath and perspiration
are offensive ; the skin sallow or lurid ; digestion
and assimilation are interrupted ; and, in the pro-
cess of eliminating those matters from the blood, by
which the organs are irritated, additional disease
is excited, and complications induced. Thus the
alimentary canal, lungs, kidneys, as well as the
liver, often become affected. Even when bile is
secreted, its discharge being prevented by ob-
struction of the ducts, the part of it which passes
into the circulation is frequently so far removed
by the kidneys and skin as to prevent, for a con-
siderable time, any change in the blood sufficient
to destroy life. (See Disease, § 162. 168.)

29. f. Protracted or frequent interruption of the
f cecal excretions are generally in some degree

compensated by an increase of the cutaneous and
pulmonary exhalations and of. tlie urine, and
sertous effects are thereby prevented for a time.
These vicarious excretions are generally very
offensive, owing to the quantity of effete animal
matter carried off in the exhaled vapour ; and
they not infreciuently excite dangerous disease of
the organs by which they are principally effected.
In a case of stricture of the transverse colon,
lately under my care, with nearly complete

846

obstruction of fajcal excretion, pulmonary dis- |
case was superinduced; the kidneys having be- j
come the chief excreting organs, and their ac- |
tions greatly increased. Of the other vicarious i
excretions, it is unnecessary to add any thing to
what is stated in the articles Disease {§162. et.
seq.), H;EMORiiHAGE, Menstruation, and Svmp-
TOMATOLOGY ; topics which have not been alluded
to at this place being considered in those articles
to which they more especially belong, and where
their practical importance is fully estimated.

30. g. The practical indications Jurmshed by the
excretions in their increase, diminution, and alter-
ation, as well as in their reciprocative relations,
are most important in the management of disease.
It is shown in various places, that one of the
earliest effects of the exciting causes of disorder
is the interruption or suppression of one or more
of the excreting actions ; it therefore follows,
that the restoration of the interrupted function
should be a principal indication of cure. The
diversified and ever-varying states of the several
excretions ought, in addition to the estimation of
quantity, to be made subjects of attentive and
daily examination ; as furnishing, when interpreted
ariglit, the surest proofs of existing disorder, and
of the operation of medicines, as well as the firm-
est basis of rational or philosophical practice.
The effects of impeded excretion on the blood
and on the nervous system should be carefully
watched and considered ; and such as most ob-
viously result, — although often unaccountably
overlooked bothby writers and by practitioners, —
especially vascular fulness, local or general, and
deterioration of the circulating fluids, ought to be
prevented or removed by means appropriate to the
peculiarities of the disease, and to the circum-
stances in which they are observed. (See Physic

— Practical Principles of.)
BiBLioG. AND Refer. — J. M. Savoranola, De Eges-

tionibus, App. ad Pract.de Feb. 8vo. Lugd. 1560

J. B. Montani, De Excrementis, 1. ii. Venet. 1566, 8vo.

Spacchius, De Expulsione et Retentions Excrement.

Arg. 1.597. — R. A. Fonseca, De Ilominis Excremenlis.
Pisis. 1613.— //o)-4/, De Causis Synip.Qualitalis mutatie et
Ketentorum atque Excretoruni prster Naturam. Witeb.
1687. — Boerhaave, De Utilitateinspiciendorum in iEgris
Excrementorum, &c. Lugd. 1693. — Junckcr, De Sa-
lutari Excretionum Promotione. Hala?, 1746. — Salz-
tnann, De Secretionis atque Excretionis Necessitate, Uti-
litate atque Noxis. Argent. 1737. — Gumbrecht, De
prsecipuis Morbis, qui ex Interceptis Excretionibus pro-
ficiscuntur. Helmst. 1769. — Ludwig, De Immoderatis
Excretionibus, Causa Debilitatis in Alorbis. Lips. 1763.

— Vogel, De Kegimine Secretionum et Excretionum.
Helmst. 1766. — IVahnschaft, De Excretionum qna-
rundam Compensatione. Arg. 1777. — Guldhngoi, De Va-
iore Eccrisium rite iEstimanda. Hal<e,1786. — Cart/ievser,
De Noxia Retinendorura Excretione, et Excernendorum
llctentione ; in Diss. .Select. No, 11. — Chaussicr ei Addon,
Diet, des Sciences Medicales, t. xiv. p. 3. — Proiit, On
the Diseases of the Urinary Organs, 8vo. Lond. 18S;6,
2d ed. — Author, in Apjiendix to Trans, of Richerand's
Elements of Physiology, 2d ed. p. 593. et 627. ct scq. —
Hostan, Midecine Clinique, ^c. t. i. p. ISO. — F. Ticde-
mann. Systematic Treatise of Couii)arative Physiology,
&c. translated by Gully and I.unc, 8vo. Lond. 1834,
]). 202. ct passim. — See also the IJiui.ioguaimiy and Re-
ferences (ii) under the articles Disease and Symftom-

ATOLOGY.

EXPECTORATION (from Ex and pectus).

— Ci.AssiF. 1'atiiology — Symptomatology.
1. This word, which signifies the act oj' discharg-
ing unif sulislance from the chest, K now usually
applied to the matter so discharged. Tiie secretion
which moistens the surface of the bronclii is a
colourless and somewhat viscid fluid, consisting
ciiiefly of the serum of the blood, and a modified,
peculiar, or slightly glutinous form of albumen.

EXPECTORATION — Muco-albuminous,

It is so scanty in health, as to be seldom or very
rarely excreted : but in disease, its quantity ys-ues
very much; it being commonly — occasionally,
remarkably — increased, excepting at the onset of
some inflammatory or exanthematous complaints,
when it is diminished, and then only for a short
time. Its quality or appearance is also extremely
difl^erent in difl^erent maladies, and even in dif-
ferent stages of the same malady, seated in or
implicating the respiratory or circulating organs ;
particularly as regards the quantity and condition
of the animal matter or albumen which it con-
tains. The saline substances found in the serum
of the blood also exist in it, but in various pro-
portions ; they being usually more abundant in
haemorrhagic and inflammatory diseases of these
organs.

2. A. The appearance and quantity of the ex-
pectorated matter are amongst the surest rational
signs of the progress and state of several diseases
of the chest, especially bronchitis and pneu-
monia ; and in many instances they alone furnish
suificient grounds of both diagnosis and progiiosis.
They should, theiefore, whenever the functions
of respiration are disturbed, or when the bron-
chial secretion is any way altered, be carefully
inspected. For this purpose the sputum ought
to be collected in two glass vessels ; one of which
should be previously nearly filled with clear
water, in order that it may be examined both
alone and on the surface of water. The periods
of expectoration should also be noted, with the
frequency and nature of the cough, and the
degree of difficulty attending the excretion.

3. a. The colour of the sputum varies, in pulmo-
nary diseases, from the colourless and transparent
or diaphanous, and viscid or glairy fluid of the
early stages of bronchitis, through every possible
shade, to the blackest hue exhibited in melanosis
or in gangrene of the lungs. The expectoration
is partly yellowish and opaque, and partly mucous,
pituitous, and serous, variously mixed, in chronic
bronchitis ; and it is yellowish, greenish, greenish
yellow, opaque, or slightly mixed with blood, red
or rusty, in pneumonia. Its colour is ash-grey
in phthisis, and blackish in the rare states of dis-
ease just mentioned. But healthy persons often
expectorate mucus so intimately mixed with the
carbonaceous particles usually floating in the air
of large towns and factories, as to resemble the
sputum in melanosis of the lungs.

4. b. The sarour of the expectoration is by no
means constant in the same disease. It is some-
times sweetish or saltish, or intermediate, in phthi-
sis and hicmoptysis. The odour of the sputum is
sometimes disagreeable in chronic bronchitis, and
in the ulcerated stages of phthisis ; in which latter
it is often foetid ; but it is much more so in gan-
grene of the lungs and pleura, and in the last
stage of abscess of the lungs. Increased warmth
of the sputum is not readily perceived, although
it may exist in inflammatory aftections of the
lungs. Diminished warmth indicates dangerous
or fatal sinking of the vital powers.

5. c. The form of the sputum is important ; and
is chiefly owing to the manner in which the mor-
bid secretion is excreted ; and to the quantity and
modification of the albumen existing in it. When
it is frothy, it may be inferred to have been ex-
pectorated with difficulty, and with severe cough :
itis then generally fluid, glairy, transjiarent, con-

EXPECTORATION —Bloody — Muco-puRULEXT, &c.

847

tains albumen, and runs into one mass in the con-
taining vessel, to the sides of which it adheres
slightly; as in catarrh, the early stages of bron-
chitis, &c. When it is viscid, opaque, somewhat
frothy, and thick, it is usually brought up with
much cough, contains niucli more albumen, ad-
heres closely to that previously expectoruted and
to the sides of the vessel, and results from acute
inflammation of the smaller bronchi and sub-
stance of the lungs. When it is rounded and
isolated, it is expectorated more easily, as in ad-
vanced stages of pneumonia ; and when it is
thick, opaque, rounded, distinct and muco-puri-
form, or purulent, it is also brought up with more
ease, and proceeils from organic change of the
substance of the lungs, as in certain states of
phthisis, Sec.

6. d. The couslstence of the sputum is of much
importance. When it is watery and serous, it
generally proceeds from simple increase of the
exhalation from the air-passagfS, witiiout inflam-
mation of, or merely with simple determination
to, the bronchial surface ; but this kind of expec-
toration may accompany plithisis, chronic pleu-
risy, and other thoracic diseases not seated in the
bronchi. A mucous and transparent fluid is ex-
pectorated in catarrh, and in slight affections of
the throat, but it also frequently attends the dis-
eases of the chest just mentioned. Viscid, thick,
and adhesive sputa, containing much albumen,
characterise acute inflammation of the lungs. A
membranous or tubular substance, with thin,
viscid, or puriform mucus, is often discharged in
croup, and consists chiefly of albumen, sometimes
approaching the fibrinous state. In rare in-
stances of sub-acute bronchitis, albuminous con-
cretions, solid or tubular, and of an arborescent
form, moulded in the ramifications of the bronchi
(Bi-onchial poliipi), are expectorated during the
decline of the disease. Cases of this description
are recorded by Tulpius, Dalbis, Consbruch,
EussuRES, Samber, De Haen, \VAnREN, Cal-
LisEN, Strack, Uixon, Aciiarius, Cheyne, and
Iliff.

7. e. The quantity of expectorated matters varies
extremely. At the commencement of inflamma-
tions it is but little increased ; but is augmented
with the progress of disease, and diminished as
disorder subsides. Suppression of the expec-
tora'ion, especially when sudden, the pulse con-
tinuing frequent, and the other symptoms uname-
liorated or exasperated, is a very dangerous
circumstance. The more watery or thin the
consistence, the more copious is the expectoration,
as in bronchitis and bronchorrhoea ; and the more
thick, opaque, or dense it is, and the smaller the
quantity compared with the severity of tiie other
symptoms, the more seriously is the substance of
the lungs diseased, as in pneumonia and phthisis.
In many cases of the worst states of these diseases,
the sputum is very scanty to the close.

8. /. Bloodii expectoration is a serious appear-
ance ; but it is of importance to asceitain its origin,
and to consider it connection with all the pheno-
mena. An exudation of blood from the nasal
fossai, from the posterior fauces or pharynx, or
even from the gums may take place, either so as
merely to tinge the surface of the sputa, or to the
extent of constituting a dangerours haemorrhage.
In these cases, the blood is not frothy, and is not
mixed with the matters brought up from the air.

passages. If the expectoration be thin, frothy,
ropy, and only streaked with blood, the fits of
coughing are generally the cause of the bloody
appearance. If the blood be mixed in a ropy,
opaque, or puriform mucus, very acute bronchial
inflammation is usually present ; and if it be seen
in spots in thick, opaque sputa, acute inflam-
mation of the smaller ramifications of the bronchi,
often extending to the substance of the lungs, may
be inferred. When the blood expectorated is
very abundant, or nearly pure (ha'moptysis), it
may proceed from simple exudation from the
bronchial surface, or from organic changes of the
lungs, heart, or large vessels. (See Hemorrhage
and Lungs.)

9. When the blood is simply exhaled from the
air cells of the lungs, it is florid and frothy, and
more or less abundant. If the sputa be only
tinged with blood, or reddish, and thick, viscid,
adhesive, or slightly frothy, pneumonia is certainly
present. If the expectoration become ochry,
rusty, reddish brown, livid, and rounded, purulent
infiltration, hepatisation in an advanced stage, or
some other most dangerous organic change of the
lungs, exists. Bloody sputa, but of no constant
form, also attend the efl'usion of blood in the pa-
renchyma of the lungs and phthisis. The appear-
ance of blood in the sputa, late in pulmonary dis-
eases, or in very minute quantity, is of much more
serious import, than in an early stage, or in large
quantity.

10. C. Purulent expectoration, of a pure and
unmixed kind, is much less frequent than is com-
monly supposed ; what is usually considered
purulent, being a mixture of puriform matter
with mucus, and a product of inflammatory
irritation in the bronchi. As a symptom of phthisis
it deserves little attention, as this disease may be
present, and even run its entire course, without
its appearance : and it may be most remarkable,
particularly in very young subjects, in the
slighter pulmonary affections, as in chronic bron-
chitis, in the decline of severe catarrh, and in
hooping-cough ; in which latter, the morbid
secretion in great part proceeds from the poste-
rior fattces, pharynx, and their vicinity. \Vhen
observed in phthisis, it is owing commonly to
associated chronic bronchitis, or to the com-
munication of a tubercular excavation with
the bronchi, the puiiform matter being secreted
by the irritated surface of these tubes. But pus
is seldom or never seen in a pure state, and
unmixed with mucus, unless when a large vomica,
or abscess, either formed in the parenchyma of
the lungs, or extendiug thither from the liver,
bursts into the bronchi. In this case, the matter,
variously tinged, is friable, often foetid, does not
retain air-bubbles, and sinks or dittuses itself in
water. When mixed with mucus, as in other
pulmonary diseases, it does not present these
characters, excepting in a very partial and vari-
ously modified form, as shown in the articles
Bronchi, and Lungs. When an abscess forms
in the lungs, which is a comparatively rare occur-
rence, and bursts into the bronchi, the pus ex-
pectorated is generally in very large quantity ;
the expectoration continuing until the abscess is
partially emptied ; when it frequently altogether
ceases, and agam returns in great abundance
when the cavity is refilled ; the intervals often
extending to several days. In these cases, the

848

EYE — Inflammation of — Causes.

matter is j'ellow, whitish yellow, yellowish green,
or reddish yellow ; presents all the characters of
pure pus, excepting in the intervals when the
more scanty sputa are generally mixed with mucus;
and ultimately becomes more offensive, and as-
sumes deeper shades of colour. I lately attended
a case where abscess formed in the substance of
the right lung presented these well-defined cha-
racters ; yet the patient never coughed during its
formation — althougii it was so large as to bulge
out the right side of the thorax — nor until the
time of its bursting into the bronchi.

11. D. The appearance of fine, white streaks ;
or the presence of ivhitish, or whitiah yellow, small
masses, like boiled rice, in mucous or muco-
puriform sputa, generally indicates the softening
of tubercles : but the earlier and more advanced
stages of phthisis are attended by the very vary-
ing state of the expectoration described in the
article on that malady. Sabulous, calcareous, or
earthy matters are sometimes expectorated in
certain states of pulmonary or phthisical disease ;
but these matters do not indicate the most danger-
ous forms ; for I have known several cases where
recovery took place after their discharge. The
presence of hydatids in the expectoration is very
rare. — Substances that are swallowed, are some-
times coughed up from the trachea, through an
ulcerated communication formed between it and
the oesophagus. Zeviani records a case of this
kind ; and one was, a few years since, attended
by JNIr. Byam and myself. The various modi-
fications of the expectoration, during the progress
of pulmonary diseases, are minutely described in
the articles Bronchi, Hemourhage, Lungs, and
Tubercular Consumfiion ; and the indications
derived from this source are there duly pointed
out.

BiBLioG. AND Refer Hippocrates, Aphorism.sect.vii.

15. — Blutn, De Sputo. Basil, 1622. — Bussiircs, in

Philos. Trans, n. 263. p. 545 Samher, in Ibid. n. 398.

p. '262. — Hebenstreit, De Sputo Critico. Lips. 1749. —
Rinck, De Sputo ut Signo in Morbis. Hard. VlfA. —
IVebel, De Sputis, in Doering'a Tract, vol. i. p. 70. —
Catlisen, in Acta Reg. Soc. Med. Haun. vol. i. p. 69. et
76. — ;Kfln-(7)i, Trans, of Coll. of Phys. vol. i. p.407.—
Portal, Meraoires de I'Acad. de Paris, 1780. — be Haen,
Ratio Med. pars ix. p. 4'J. — Consbruch, Observ. Med.
Stuttg. lin.— Dixon, Ed. Med. Comm. vol. ix. p. '25i. —
Dalbis, Journ. de Med. t.xi. p. 42. 370. — Zeviani, in Mem.

di Matematica e Fisica, t. vi. Verona, 1792 Strack, in

Hufeland's,iourx\.A. Pract. Arzneyk. b. vii. p.l6?. — Acha-
rius, Lond. Med. and Phys. Journ. vol. viii. p. 201. — C.
Darwin, in Ibid. vol. iii. p. 374. ; et vol. iv.p. 49. li,8. 203.

— Valentin, Journ. de Med. Contin. t. xiv. — Pearson,
Philosoph. Trans. 1809. — Cheyne, in Edin. Med. and
Surg. Journ. vol. iv. p. 441. — liayle, Sur la Phthisie Pul-
monaire, p. 26. — Double, Semeiologie Generale, &c. t. iii.
p. 81. etseq. — Laentiec, Auscultation Mediate, by Forbes,
passim. — Andral, Clinique Medicale, t. ii. et iii. passim.

— //<#,' Lond. Med. Repos. vol. xviii. p. 207. — Roslan,
Cours. de Med. Clinique, &c. t. i. p. 416. — C. J. B. Wil-
liams, Cyclop, of Pract. Med. vol.ii. p. 127.

EYE, DISEASES OF THE.— Syn. 'o<|>9aX^oj.

Oculus. Das Aitge, Germ. (Eil, Ft. Ucchio,

Ital.

Ci.ASsiF. Sfecial Pathology — Mordid
Structures.

1. The progress of knowledge, in respect of
diseases of the eye, has been very remarkable
since the end of the last century; owing chiefly
to the researches and writings of Beer, Schmidt,
IIiMLY, Scarpa, Benedict, Demours, Ed.mond-
STON, Vetch, Wardhop, VVei.ler, Travers,
Gumirie, Mackenzie, and Lawrence. In the
account that will be lure given of these diseases,
those only which are inflammatory, and conse-

quent upon inflammation, will be considered.
Functional disorders are treated of in separate
articles. (See Amaurosis, Sight, &c.). The
order in which these maladies will be discussed,
will differ but little from that adopted in the truly
valuable works of Mr. Lawrence and Mr. Mac-
kenzie ; to which I have much pleasure in stating
my obligations. — The latter of these writers, and
J. Frank, treat first of the diseases of the eyelids
and lachrymal apparatus, and next of the eye
itself. Mr. Lawrence enters at once upon the
consideration of the inflammatory diseases of the
tissues of the eye-ball, and concludes his cla.ssical
production with those of the appendages. Either
arrangement is unexceptionable ; but I shall fol-
low the latter, merely as being more congruous
with the medical view of the subject, to which I
shall chiefly confine myself. The surgical treat-
ment of such of those diseases as require it, must
be studied in the works now referred to, or in
Mr. Cooper's Surgical Dictionary.'! shall, there-
fore,^Vsf treat of inflammations affecting the ex-
ternal coats of the eye, and afterwards of those
attacking the internal tissues of the organ.
I. Inflammations of the Eye. — Syn. Opft-
thalmia ; Lippitudo, Celsus ; Augenentzundung,
Germ.; Ophthalmie, Fr.; Otta Imia, lta.\.

Classif. — 1. Class, 2. Order (Cullen),
3. Class, 2. Order (Good). III. Class,
I. Order (^Author).

2. Defin. — Pain in one or both eyes, with vaS'
cular injection of one or more 0/ their constituent
tissues, and constitutional disorders

3. Inflammations of the eye are of various
grades and kinds : they commence in any one of
the different tissues forming the organ ; and they
are thus limited more or less, and for a longer or
shorter period of their course, according to the
temperament, habit of body, and diathesis of the
patient ; to the state of predisposition, and the
nature of the exciting causes ; and to the treat-
ment adopted. Before considering separately the
difi'erent varieties of ophthalmia, I shall Jirsl take
a general view of their causes ; and neit of the
numerous forms they present, owing to the varied
concurrence of predisposing and exciting causes.

4. i. Causes. — ^. The predisposing causes of
inflammation of the eye are nearly the same as
those of inflammatory diseases of other organs. —
(a) Temperament, idiosyncrasy, and consequently
hereditary disposition, evidently favour its occur-
rence. The colour of the eye has apparently but
little influence, for Dr. Smith found the re-
lative proportion of cases in light eyes nearly the
same as in dark eyes. — {b) Morbid diathesis,
especially ihe scrofulous, has the most remarkable
effect, and next the gout if and rheumalie. These
not only dispo.se to, but also modify, the disease,
and its consequences, and re<iuire for it appro-
priate modes of treatment. — (c) It is difficult to
determine how far age and sex have any influ-
ence; but advanced age certainly favours the
supervention of chronic inflammation of this
organ. — (d) Climate has a much more manifest
eflect. The excessive cold, and reflected light,
in hyperborean regions; and the great warmth,
dryness, and reflected heat of some countries,
esj)ecially Egypt, Arabia, ike, heightened by the
(juantity of fine dust floating in the atmosphere;
not only predispose to, but excite, oplilhalinia. —
(e) Great exertion of the eyes occasions disease of

EYE -^ Inflammation of — Varieties and Forms of.

849

them ; but chiefly when aided by too full living,
by the use of stimulating liquors, and by an im-
proper management of light, in respect both of the
object on which tiie sight is exerted, and of the eye
itself. — (^') Various ocrupai/ojis, consequently,
are very liable to ophthalmia ; as engraving,
watchmaking, wool-sorting, and the manufacture
of minute objects.-— (g^) The suppression of accus-
tomed discharges, as of the catamenia and h;cmor-
rhoids, and an impeded return of blood from tiie
head, favour the supervention of inflammation of
this organ, by occasioning cerebral corigestion. —
(h} A plethoric habit, and particularly /uZ/iess of
blood ill the head, are very common predisposing
causes; and often exist in connection with the pre-
ceding.— (i) Impaired constitutional power is most
influential, especially during convalescence from
exanthematous diseases. — (k) An unhealthy or
cachetic state, owing to impaired digestive, assi-
milative, and excreting functions, has also a most
marked effect, and is often further associated v\'ith
local or general plethora ; particularly in those
addicted to spirituous or fermented liquors, or who
lead a sedentary and indolent life, or live in close,
smoky, crowded, and unhealthy situations, or are
subjected to anxiety of mind and other depressing
passions. — (/) Too full, or rich living, errors in
diet, and the inordinate indulgence of the appe-
tites, frequently predispose to ophthalmia by
inducing plethora, and consecutively hepatic and
cerebral congestions, imperfect secretion and
excretion, torpor of the biliary and intestinal
functions, and ultimately a morbid state of the
circulating fluids and disordered vascular action.
— (m) Inordinate indulgence of the sexual pro-
pensities has often a powerful influence, es-
pecially in connection with any of the preceding
causes ; the eyes sympathising remarkably with
the generative organs.

5. B. The exciting causes of ophthalmia are
numerous and diversified. Injuries inflicted on
the eye, its appendages, or parts adjoining ;
wounds of a filament of the ophthalmic branches
of the fifth pair of nerves ; carious teeth ; the pre-
sence of dust, or minute foreign bodies, between
the surface of the globe and the eyelids ; the irri-
tation produced by acrid, stimulating, or chemical
bodies, whether in the form of powder, fumes,
or vapours; stimulating, acrid, or caustic appli-
cations to the organ ; operations on the eye, or on
adjoining parts ; the introduction of contagious
secretions, as the gonorrhoeal discharge, or the
matter of purulent ophthalmia; excessive exer-
tion of the eyes, especially with artificial light, at
late hours, or with the head held low, and on bright
or minute objects ; an impure, smoky, or fuliginous
atmospiiere, particularly in manufactuiing towns,
crowded and close streets, confined dwellings,
poor-houses, hospitals, and the low cabins of the
peasantry ; the fogs of large cities, which pre-
vent the smoke and vapours from rising in the
atmosphere, and from being otherwise dissipated ;
exposure of the eyes to cold, or to currents of
air; riding in an open carriage, or in a close
carriage with the face to the horses and the
carriage windows open ; and too full living, or
the abuse of intoxicating li(|uors; are the most
common causes of ophthalmic inflammations.
'J'he eyes, moreover, participate with other parts,
frequently in a very remarkable degree, in the
inflammatory state characterising the exanthe-

VOL. I.

mata ; and hence certain specific foxms of iophthal-
mia hereafter to be noticed.

G. The modes in which these causes act are
suflicienlly obvious : but there are one or two
that require a more particular notice. Exposure
to light IS injurious — 1st, by its sudden or power-
ful impression; 2dly, by its combination with
heat, as in glass-houses, founderies, forges, &c. ;
and, 3dly, bv being reflected or refracted. Owing
to t!iis last circumstance, certain colours, espe-
cially red and orange, or the simultaneous im-
pression of a variety of colours, or their rapid
succession, irritate the eyes in a very remarkable
manner. The reflected light from snow has also
a very great effect ; and from which the Tartars
protect themselves by wearing spectacles of
closely netted black horsehair ; and the Esqui-
maux by an excavated piece of light wood, with
a narrow slit corresponding with the fissure be-
tween the eyelids, and blackened on the inner
or concave surface. Reflected light attended
by high temperature is equally injurious. The
glare from the white chalky roads in some parts
during summer, and from the white houses and
sandy surfaces of some warm countries, is a very
frequent cause of ophthalmia. Another and a
hitiierto unrecognised cause, particularly of in-
flammation of the internal tunics, is reading,
writing, or otherwise exerting the eyes, by the
light refracted by ground glass shades placed
around the flame of lamps used for illuminating
rooms. About fifteen years ago, I was affected
with slight inflammation of the internal tunics of
the eye ; but having fully ascertained its cause to
have been the use of a table-lamp of this de-
scription, it soon subsided upon adopting suitable
treatment and a different kind of light. I have
since had no return of the disease, although I
have continued for many years to read or write
from eight o'clock in the evening till two or three
in the morning.* The intimate vascular and
nervous connection of the eye with the brain
causes it to participate in several of the inflam-
matory states of tiie latter. Hence those causes
which excite increased vascular action, or con-
gestions, in the brain or its membranes, both
predispose to and excite similar aflTections of the
eye, especially of its internal tunics. In a per-
fectly healthy state of the system, a single exciting
cause seldom occasions the disease, unless its
operation be long continued, or very intense. It
is the co-operation of two or more causes, or the
action of several in quick succession, that is most
injurious. But when the system is rendered
susceptible of their impression, by the prolonged
or continued influence of the predisposing agents,
either of the more immediate causes, although
acting singly, will frequently take effect,

7. ii. The Varieties and Forms which in-
flammation of the eye presents, are very diversi-.
fied. The severity or acuteness of the symptoms,

* I write, and generally read, at a desk placed suffi-
cientlyt high to prevent the head from being held low;
and use two lamps with single wicks, the flames of whicli
are equal to two large wax candles, and which are raised
so high that the eyebrows and eyelids completely shade
the eyeballs from the light. Tliese are fed with the
finest sperm oil ; and, the flame being duly adjusted, they
burn eight hours, without any diminution of their light,
and without requiring to be once touched. The chief
advantages of this light are its softness and clearness, the
permanent height at which it remains, and the entire
absence of the smallest trouble.
31

EYE — Inflammation of the Conjunctiva.

850

and the rapidity of the progress, of ophthalmia,
vary from the slightest increase of vascular
injection and action, and the most prolonged
continuance, up to the most violent and rapid
states in which inflammatory action is ever mani-
fested. Hence the conventional terms of acute,
chronic, and sub-acute or intermediate, are to
be viewed with due latitude as to their import.
But ophthalmia, like other inflammations, may be
modified in kind or form, as well as in grade and
duration, owing to peculiarity of constitution,
morbid diathesis, the manifestations of vital power,
and the state of the circulating fluids. Thus,
ophthalmia in the scrofulous, gouty, or rheumatic
diathesis, is different from that aflfecting sound
constitutions; and that occuring in the course
of, or subsequent to, the exanthemata, or during
typhus fever, or after the passage of purulent
matter into the circulation, is individually differ-
ent from either of the foregoing, althougli the
grade of action and of vascular injection may be
apparently the same in all. I cannot, therefore,
agree with Mr. Lawrence, when he infers that
no such distinctions as sthenic and asthenic actu-
ally exist (Treatise, &;c. p. 66.). This conclusion
is the result of considering inflammation merely
as increased vascular action, and without refer-
ence to the state of local and general vital power.
But the phenomena, the progress, and the results
of inflammation, in the various forms and circum-
stances in which it occurs, as well as the effects of
treatment, show, that excited vascular action
does not imply increased power ; and that the
former often exists, not only without the latter,
but even with a diminution of it, as fully shown
in the articles Disease, Erysipelas, Fever, and
Inflammation.

8. Ophthalmia diflfers in degree, at different
periods of its course. Thus, it may be slight and
prolonged, and suddenly become most violent,
acute, and rapid ; or, Irom the latter, it may
lapse into an indolent, slow, or chronic form ;
owing to various contingent causes, to consti-
tution, and to the treatment adopted. It is also
remarkably modified by the tissue in which it is
seated ; by the nature of the predisposing and ex-
citing causes ; but its supervention upon, or com-
plication with, other morbid states, or specific
forms of disease ; and by the age, habit of body,
and regimen of the patient. Out of these cir-
cumstances arise the numerous varieties distinctly
established by modern writers, and recognised by
every observing practitioner, and the arrangements
of them adopted in recent systematic works. The
importance of divisions of this subject is shown
by the diff'erent consequences or terminations
usually observed to belong to each of the varie-
ties, and by the modified treatment they indivi-
dually require. Without carrying the subdivision
as far as .1. Frank, or too far for practical pur-
poses, I shall Jirst consider inflammation of the
external tissues of the eyeball, next those seated
in the internal tissues, and lastly the much more
rare occurrence of inflammation of the whole eye.
In treating of inflammation of each of the tissues,
ts comrrwn form will be first described, and after-
wards those specific or modified kinds, it occa-
sionally assumes from peculiarity of cause or of
diathesis.

JI. Inflammation of the External Tissues
OF THE Eye.— i. Of thk Con.hinctiva. — Svn.

Covjunctivitis, INIackenzie j Ophthalmia, of
numerous writers.

9. Charact. — Redness, from increased vas-
cularity of the external coat of the eye, with pain,
tumefaction, and febrile disturbance of the system ;
the enlarged vessels shifting their places with the
motions of the eyeball or eyelids.

10. The muco-cutaneous membrane that co-
vers the insides of the eyelids, and anterior third
of the eyeball, may be inflamed in particular
parts, or throughout its extent, in every grade of
severity, and for various periods of duration.
When this membrane is inflamed, the vessels are
comparatively large, tortuous, and of a scarlet
colour. They anastomose very freely, or form a
network over the white of the eye, and are drawn
aside by dragging the eyelids, or moved by roll-
ing the eyeball; whereas, when the sclerotica is
inflamed, the vessels are small, straight, of a
pink hue, and unsusceptible of motion, either by
dragging the eyelids or rolling the globe. When,
however, the inflammation is so severe that che-
mosis exists, or the conjunctiva becomes tumid,
and the discharge copious and muco-purulent,
this distinction canunot be made, nor, indeed, does
it altogether exist, as the inflammatory action
from contiguity extends more or less to the sclero-
tica, and even to the iris and the cornea.

A. Mild Inflammation of the Conjunctiva.
— Syn. Catarrhal Ophthalmia, Lawrence;
Conjunctivitis puro-mucosa atmospherica , Mac-
kenzie; Conjunctivitis catarrhalis.

11. a. I have adopted the appellation em-
ployed by Dr. Jacob as the most appropriate ; for,
although the disease is generally caused by ex-
posure to cold, yet it sometimes also arises other-
wise. It is most common in spring and autumn ;
is sometimes epidemic ; affects young persons
oftener than adults ; and frequently attacks most
of the members of a family, or, when it appears
in a school, a large number of children. Expo-
sure to currents of cold air, or to the night air;
north-east or easterly winds, and other atmosphe-
ric influences; damp feet; intoxication; fogs,
smoky apartments, irritating vapours ; and dis-
orders of the digestive organs; most commonly
occasion it. A person who has once experienced
an attack, is very liable to a return of it ; and I
believe, with Mr. Mackenzie, that, in the most
severe cases, when the discharge is puriform, it
may be propagated by contagion ; the disease then
passing into the purulent and severe form.

12. h. Symptoms. — This form of ophthalmia
seldom extends deeper than the conjunctiva. It
may be confined chiefly to the lids (Blepharo-
conjunctivitis catarrhalis ; and may affect also
the globe (Ophthalmo-conjunctivilis catarrhalis).
It commonly commences in the eyelids, or circum-
ference of the globe, and extends gradually to the
cornea, with a sense of stiflPness, smarting, dryness,
and as if dust had got into the eye. The intolerance
of light and pain are slight; and the secretion at
first is diminished, but it is soon succeeded by
watering and increased redness. When more
fully developed, the redness is superficial, some-
what irregular, of a bright scarlet ; and the en-
larged vessels are superficial, and are readily
pushed aside by ])ulling the eyelids. In the most
severe and acute cases, the membranes become
generally and uniformly red ; sometimes with
spots of ecchymosis, or with minute vesicles or

EYE — Purulent Ophthalmia.

851

pustules near the margin of the cornea. There
IS very little swelling, and rarely any chemosis.
An increased mucous discharge, wiiich is at first
thin and colourless, but al'tervvards yellowish or
whitish, proceeds from tiie inflamed surface ; but
it is seldom ia considerable quantity, unless in
the most severe cases, when it is copious and
muco-puriform. Inflammatory irritation fre-
quently also affects the lining membrane of the
frontal sinuses and antrum, occasioning pain and
sense of weight in these parts. The patient com-
plains of chills, of headach, exacerbations of
fever, especially towards night, of impaired ap-
petite, and of sickness or disorder of the stomach.
The tongue is generally loaded, and the bowels
constipated.

13. c. Terminations and Prognosis. — The symp-
toms continue for three or four days; or, under
unfavourable circumstances, for a longer time ;
but they generally yield to treatment, and gra-
dually subside ; the secretion becoming more
puriform and thick, but less copious, until tlie
aftectton disappears. If the inflammation be very
violent, or improperly treated, or if it occur in the
scrofulous constitution, or in persons imperfectly
nourished, or of dirty habits, considerable che-
mosis may ensue, and the sclerotica and cornea
may also become inflamed ; causing opacity, or
even ulceration, of the latter ; and giving rise to
a copious puriform discliarge, capable of pro-
pagating the disease, if introduced into the eye of
a sound person. When catarrhal ophthalmia
has been severe or of long duration, or has
frequently recurred, the palpebral conjunctiva
experiences change of structure, and becomes
thickened, with elevations or granulations on its
surface. The lower lid generally suffers most ;
the granulations being, according to Dr. Eule,
more numerous in the folds of the membrane
between the globe and lid, than on the lid itself.
Catarrhal ophthalmia, also, particularly in chil-
dren of scrofulous constitutions, is liable to de-
generate into the pustular or phlyctenular form
of strumous ophthalmia.

14. d. Diagnosis. — The very slight pain and
intolerance of light, althougli the vascularity be
great ; the superficial and scarlet redness of the
membrane ; the diurnal remissions, and evening
exacerbations ; the motion of the superficial and
enlarged vessels ; and the natural state of the
sclerotica; distinguish this variety from common
injlammation of the external proper coats, or ca-
tarrhal-rheumatic ophthalmia. But the one
affection may nearly approximate, or even run
into, the other, in the most severe cases. The
catarrhal origin, and usually mild character of
this affection, and the mucous secretion, are the
oidy circumstances which really distinguish it
from purulent ophthalmia; the severer states of
the former and the mildest of the latter being so
nearly alliect that they may be justly viewed as
merely grades of the same disease.

15. e. Treatment. — In the mildest states of
the affection, smart purgatives, diaphoretics, and
low diet are sufficient to produce a cure. If the
tongue be loaded, an emetic is of service. In
more severe cases, local depletion, followed by
an emetic, purgatives, and diaphoretics, is neces-
sary. Venffisection is required only in the most
acute states, occurring in young or plethoric
persons, and when both eyes are attacked.

When the affection is connected with disorder of
the digestive organs, it is readily removed by an
emetic, by calomel and James's powder at night,
by an active cathartic the following niornino,
and by^udorifics, aided by diluents, and warm
poppy fomentations to ihe eye. When the in-
flammation is considerable, and not readily re-
moved by these means, local depletions should
be repeated, a blister applied to the nape of the
neck, and purgatives, diaphoretics, and low diet
persevered in. I agree with the German writers
in considering warm applications to the eye pre-
ferable to cold, where the affection is produced
by exposure to cold : but, when it is otherwise
caused, and when the heat and smarting are con-
siderable, cold washes are agreeable and gene-
rally beneficial. When the eyelids are gummed
together in the night, a little spermaceti, or any
other mild and fresh ointment, should be inserted
between their edges in the evening.

16. Mr. Lawrence considers that this affec-
tion is one of those to which the application of
strong astringents is most appropriate, especially
if the inflammation do not extend beyond the
mucous membrane ; and those who more par-
ticularly recommend this treatment, believe that
it may advantageously supersede general remedies,
especially vascular depletion. Mr. Mackenzie
stqtes, that it was most advantageously employed
by Beer in 1817. Mr. Melin directs a strong
astringent, consisting of a solution of four grains
of lunar caustic in an ounce of distilled water, to
be dropped into the eyes twice a day, in the very
commencement of the affection, with the view of
arresting its progress. Mr. Bacot (Treatise on
Sijphilis, &;c. p. 136.) states that Dr. Ridg-
WAY originated this treatment, and that he pre-
scribed ten grains of the lunar caustic to the
ounce of water ; he using this solution in gonor-
rhceal, as well as in catarrhal ophthalmia. Mr.
jMackenzie, who appears to have had extensive
experience of this practice, employs a solution
of from two to four grains of this caustic in
the ounce, and applies a large drop of it to the
eye once a day ; fomenting the organ thrice
daily with a lukewarm collyrium consisting of
one grain of bichloride of mercury and eightounces
of water. He introduces, at night, between the
edges of the lids, a minute portion of an oint- ,
ment containing a grain and a half of red pre-
cipitate to the drachm. Mr. Guthrie advises an
ointment with ten grains of the nitrate of silver
{§ 49.) ; and Dr. Jacob a few drops of a saturated
solution of acetate of lead or of alum, to be
introduced between the lids every night and
morning.

17. A green shade may be worn before the
eyes ; but it is not necessary to confine the
patient to the house, unless the weather be cold,
windy, or rainy. Exposure to a mild atmosphere
is advantageous (Lawrence).

18. B. Severe Inflaimmation of the Con-
junctiva, or Purulent Ophthalmia. — Under this
appellation I shall comprise those forms of con-
junctivitis, whose symptoms are very violent, and
whose progress is very acute ; the discharge pos-
sessing the purulent character. Hence they
have received the appellation of hlennorhaa, and
suppurative ophthalmia; the latter term, as ftlr.
Lawrence remarks, being objectionable. Puru-
lent ophthalmia generally begins in the lininosof

Sf 2

852

the lids. It soon extends to the conjunctiva of
the globe ; and, if not checked, to the cornea,
which it eitlier injures or altogether destroys.
The conjunctiva is svi-ollen and intensely red;
the blood-vessels injected and enlarged ; and the
surface villous, pulpy, or granular. The discharge
from the inflamed membrane is purulent and
copious. When the disease extends to the cornea,
interstitial deposition, causing opacity, and sub-
sequently bursting, sloughing, and ulceration, if
the malady proceeds, is a frequent result ; pro-
lapsus of the iris, escape of the humours, and col-
lapse of tiie tunics, being ultimately produced. It 1
is properly seated in the conjunctiva, and often
goes through its course without extending deeper,
unless the cornea become affected, or ulceration
or sloughing takes place, as now stated.

19. a. Severe Inflammation of the Con-
junctiva OF Infants. — Syn. Purulent Ophthal-
mia of I nf ants ; Purulent Eye of Children, \\' ark;
Ophthalmia Neonaturnm, Auct. Var. ; Ophthalmia
of new-born C/iiW)T(i, Mackenzie ; Blephar-Oph-
thalmitis glandulosa, Blbu. — The term used by
Ware is inappropriate ; and that employed by
Beer implies that the disease originates in the
Meibomian glands, and is incorrect ; these glands
beincr merely involved in the severe inflammation
attacking the whole of the membrane.

20. a. Caxises. — Purulent ophthalmia of new-
born infants has been very generally imputed
chiefly to leucorrhoeal discharge in the mother.
Schmidt, Mackenzie, and Lawrence maintain
this opinion ; and the last writer refers to cases in
which the infant was affected with the disease,
owing to the mother having had gonorrhoea at
the time of parturition. But these are instances
of gonorrhoeal ophthalmia in new-born infants,
which is a still more severe affection than that
now being" considered. I have strong reasons
for concluding that the disease does not so fre-
([uently arise from leucorrhoea in the mother as
is supposed ; for, in many instances in which I
have inquired into the causes, and in two or three
where the intelligence of the mothers seemed de-
cisive of the matter, no such disorder had ever
been complained of. It should not be overlooked,
as Dr. Jacob has, indeed, mentioned, that a mild
form of conjunctivitis sometimes attacks very
young infants from exposure to cold, — mild ca-
tarrhal ophthalmia in new-born children. Of this
I have seen numerous instances. But the pre
sent violent state of disease depends, perhaps, a:
much upon the predisposition as u])on tiie ex-
citing causes ; and there can be no doubt tiiat
infants are frequently born of mothers affected by
leucorrhoea, or even by gonorrhoea, at tiie time
of parturition, without being infected by purulent
ophthalmia.

21. The predisposing causes are, delicacy and
susceptibility of constitution, premature birth,
and whatever depresses the system. The disease
is most common in twins and weakly infants ; in
those newly born ; in tlione subjected to bad or
foul air, to cold, and to insuilicient or inappro-
priate nourishment ; in tiiose deprived of the
motiier's care, and of the mother's breast ; and in
the children of the poor and the dissolute. It is
particularly prevalent and severe in Continental
foundling hospitals, where the infant is without
m:it( rnal care ; but it is not very frequent in
Jying-in hospitals, Lancenueck (Neue Chirurg.

EYE — Purulent Ophthalmia of Infants.

Biblioth. b.iii.p.208.) states, that in the Lying-in ]
Hospital of ^'ienna, where the mothers are gene-
rally atl'ected with leucorrhoea and gonorrhoea,
but where the infants remam with them, the dis-
ease is not common ; while in the foundling
hospital, where the infants are half dead from
cold and starvation when they are received, and
deprived of their mothers, it is very prevalent.
TUe chief catises, according to my inquiries, are
those now stated, exposure to damp and cold air,
improper nutriment, and especially the neglect of
due ablution immediately after birth. In many
of the cases that I have seen, the secretion cover-
ing the cutaneous surface in utero, which had
not been removed from the eyelids and angles of
the eyes, had evidently been the chief cause ;
and 1 am convinced that the presence of this
matter, owing to the changes it undergoes when
allowed to remain in contact with the external
surfaces, especially near natural epenings, after
birth, is much more frequently a cause of puru-
lent ophthalmia, than infection by leuconhcea,
although I do not deny the infiuence of this latter
circumstance.

22. 0. Symptoms and Progress. — 1'his affec-
tion is of the utmost importance, as the majority
of instances of blindness is caused by it. In a
great proportion of cases it is far advanced before
medical aid is required ; it being fre(|uently con-
sidered, at its commencement, as a common cold
in the eye. It generally begins three or four days
after birth ; but it may occur at any subsequent
period ; the liability to it, owing to the nature of
the exciting causes, being remarkably diminished
when the child is some days, or a few weeks, old.
In its ^'rsf stage — the Blephuro-blennorrluva of
German writers — the inflammation is chiefly con-
fined to the lids ; a circumstance further proving
its origin in the cause now, for the first time,
pointed out. The lids at first stick somewhat to-
gether when the child awakes ; and their edges
are red, particularly at the corners. External
redness of them is sometimes, also, observed.
The eye is usually closed, from pain occasioned
by light. The globe is in a natural state ; but
the linings of the lids are red and villous, espe-
cially the lower, the insides of which are covered
with a little white mucus. In the second stage —
Ophthalmo-blennorrha'a of some writers — the in-
flammation is more severe, and extends to the
conjunctiva of the globe. Redness and tume-
faction are increased ; the lids are swollen and
red even externally ; and the discharge becomes
copious and purulent, agglutinates the edges of
the palpebriB, accumulates beneath them, and
bursts out between them, and pours over the
face. The whole of the conjunctiva is now
minutely injected, of a uniform bright scarlet
colour, and tumefied ; its surface is villous ; and
its loose folds between the lid and the globe be-
come enlarged, form tumid rolls, and are finely
granulated, 'i'hese folds often cveit the tarsi,
causing ectropium, which gencially subsides with
the disappearance of the liisense. When the
swelling of the lids is great, the upper usually
overhangs the lower, and is externally of a
blight red. These iq)])earances are aggravated by
crying, when the globe is pushed forwards. 'J'hc
discharge is yellowish in various lints ; and, in
unhealthy or jaundiced children, it is often yel-
lowish green. It is sometimes whitish ; and it is

EYE — PUUULENT O

then less abundant and thicker. It is more rarely
ichorous or sanious ; 'but it is tlien thin and ex-
coriating. An admixture oF blood in tiie dis-
charge is also rare.

23. Both eyes are usually affected ; but the
complaint commences generally a kw days earlier
in one than in the other. The attendant consti-
tutional disturbance is very considerable ; the
tongue being white and loaded, and the bowels
disordered. The infant is restless, feeble, and
ultimately, especially if an unfavourable issue
has taken place, pale, emaciated, and cachectic.
When the disease extends to the conjunctiva of
the globe, its duration, until either of its bad
effects supervene, is various, but commonly from
seven to fourteen days. It, however, is some-
times confined, for a considerable time, to the
conjunctiva of the lids in a slight or chronic form,
before the globe is affected.

24. y. 'J'cnninnlions. — In the course of the
disease, it is important that the practitioner should
examine the eye so as not to increase the disorder.
If the infant be asleep, the tarsus of the upper lid
should be pushed very gently and lightly, up-
wards and backwards; but no further than to
obtain a clear view of the cornea. If it be awake,
the lids should be separated quickly, whilst it is
quiet, and before the muscles can resist. An
attempt to see the eye when it is crying is either
ineffectual or injurious. — 1st. In the less severe
cases, and in the more violent attacks, if early
and judiciously treated, the tumefaction of the
conjunctiva subsides gradually ; the discharge is
lessened, and becomes whitish ; and the mem-
brane gradually resumes its healthy state. — 2d.
Opacity of the cornea may supervene, partially
or generally ; and, from interstitial infiltration of
lymph, either into the tissue of the corneal con-
junctiva, cause a superficial bluish film, or into
the laminje of the cornea, produce dense and
total opacity. — 3d. Adheiiou of the iris to the
opaque cornea may occur, especially when the
inflammation has extended throughout the latter,
and passed to the iris, — 4th. Infiltration of pus
between the lamellaj of the cornea, or onyv,
causing ulceration of the external lamellae, may
take place. The ulceration may be of various
extent and depth, — may affect nearly the whole
surface of the cornea, or penetrate it, causing
prolapse of the iris. This latter may adhere to
the ulcerated part, and the ulceration either cease,
or extend to the interior of the eye. — 5th. Slough-
ing of the cornea, which has been described
by Saunders and Lawrence, but doubted by
Mackenzie, may supervene, partially or gene-
rally. The part becomes dusky, loses ita polish
and vital cohesion, and assumes a dirty greyish or
brownish appearance. A line of separation after-
v/ards forms at the margin, and the dead partis
thrown off. The whole cornea may perish thus,
and the iris protrude through the aperture, pre-
senting an irregular brownish or dirty promi-
nence ; and being either covered by the mem-
brane of the aqueous humour, or nakedly exposed,
tiie humours having escaped. Partial sloughing
generally leaves a ragged ulcer, which often ex-
tends into the anterior chamber, causing prolapse
of the iris. These terminations often quickly
supervene and rapidly proceed, in young, feeble,
and ill-nourished children, until the humours
escape and the eye is destroyed.

niTiiALMiA OF Infants. 853

25. When the entire cornea has either sloughed
or ulcerated, and the humours have not escaped,
the projecting iris recedes, and becomes covered
by an opaque pellicle, the front of the eye being
flattened. After partial ulceration or sloughing,
the iris either adheres to the internal surface of
the cornea, or prolapses through the opening ; the
projecting part gradually subsiding and disappear-
ing, leaving a cicatrix in the cornea. In this case,
the iris also adheres to the cornea, and there is
change of figure, with contraction of the pupil ;
vision being either impaired or lost, according to
the extent of the change. When ulcers of the
cornea are spreading, they are of a dusky or yel-
lowish white, irregular in their surface, and often
with a ragged edge ; but when they begin to
heal, they have a greyish or bluish asjiect; be-
come smooth, soft, and gelatinous, from deposition
of the matter which is to repair the breach ; and
red vessels pass from the conjunctiva, through the
intervening transparent portion of the cornea.
They thus heal, leaving a permanent opaque
cicatrix (Lawrence).

26. J. Prognosis. — Although remarkably vio-
lent, this affection readily yields, if treated early,
and before the cornea has sustained any in-
jury. The appearance of the discharge often
indicates the state of the disease. The whiter
and smaller in quantity, the lower is the grade
of inflammation. The yellower and more co-
pious the discharge, the more acute the disorder.
An admixture of blood in it, indicates a violent
state of action ; but is not, in itself, danger-
ous. A thin, ichorous, or sanious discharge,
marks the existence of sloughing or destructive
ulceration. If there be superficial ulceration
without onyx, probably only a slight speck may
remain. If the ulceration be deep, permanent
opacity will be the result. If the iris protrude,
the pupil will be disfigured, and vision more
or less impaired. If there be considerable
onyx, the matter may be absorbed, or the puru-
lent infiltration may increase, the cornea burst,
and the eye become partially or totally staphylo-
matous,

27. E. Treatment. — In the most acute cases,
when the conjunctiva oculi is brigiit red and
swollen, especially if the cornea looks hazy, or
the palpebrce bright red and tumefied, depletion
by leeches is requisite. A leech may be placed
upon the temple, or, as Mr. Lawrence advises,
upon the middle of the swollen upper lid ; and it
will generally procure a sufficient evacuation.
If both eyes are aflfected, one may be applied to
each temple or superior palpebra ; but in weak
infants, the two leeches should be small. If the
state of the cornea be doubtful, and vascular
action in the conjunctiva still acute, althouu-h
the lids be not much swollen, nor veiy red, it
will be better to apply the leech. Dr. jMon-
teath (Trans, of Weller, &c. vol. i. p. 61.)
advises scarification of the inner fleshy and gra-
nular surface of the lids, in preference to the
application of leeches, the lids being kept everted
until a sufficient quantity of blood has flowed,
the replacement of them being always followed
by arrest of the bleeding. Mr. Mackenzie di-
rects the immediate application of astrinoents ;
but in the more violent cases, before the cornea
has been materially injured, the depletion is be-
neficial. In the less severe attacks, and in feeble

3 13

854

EYE — Purulent Ophthalmia in Adults.

or ill-nourished infants, the astringents about to
be noticed may be at once employed. In every
instance, purgatives ought to be prescribed. One
grain of hydrargyrum cum creta, or of calomel,
may be given, with three or four of magnesia or
of rhubarb, at bedtime, and a dose of castor oil
in the morning. A small blister may be applied
on the posterior and middle part of the scalp, as
advised by Dr. Monteatii ; but it should be
removed in five or six hours, and the part care-
fully attended to. The eye should be bathed
frequently with tepid milk and water, and a little
fresh butler, or a mild form of the red precipitate
ointment, applied between the edges of the lids
at niglit, to prevent their agglutination, and
favour the escape of the discharge.

28. Astringent collyria are more efficacious,
and safer in this affection, than in any other,
especially when resorted to at its commencement.
But in severe cases, when the inflammation has
proceeded so far as to endanger the cornea, it
will be much safer to premise depletion, than to
enter at once upon the use of astringents. Mr.
Ware recommends a preparation formed by
pouring eight ounces of boiling water on eight
grains each of sulphate of copper and Armenian
bole, and tvvo of camphor. Schmidt prescribes a
lotion of two grains of sulphate of zinc, three drops
of liquor plumbi super-acetatis, twelve drops of
spiritus vini camphoratus, and an ounce of dis-
tilled water. INIr. Guthrie directs the nitrate of
silver ointment (^ 49.) to be applied with a brush
over the inside of the lids. JNIr. JNIackenzie em-
ploys a collyrium of one grain of bichloride of
mercury and eight ounces of water, three or four
times in the day ; and, having washed off the
discharge by this lotion, he applies, once, or at
most twice, a day, to the conjunctiva, a solution of
four grains of lunar caustic, or of six grains of
sulphate of copper, in an ounce of water, by
means of a camel-hair pencil ; preventing the
agglutination of the lids by smearing their edges
at night with the mild red precipitate ointment
(consisting of from twelve to twenty grains of the
precipitate to the ounce). Dr. Monteath uses
a nearly similar collyrium to that prescribed by
this writer. Mr. Lawrence advises a solution of
from two to ten grains of alum in an ounce of
water, to be carefully injected between the lids
three or four times in the twenty-four hours, so
as to wash out the purulent secretion ; and after-
wards a soft rag, moistened in the solution, to be
laid over the eye for a short time ; the bowels
being regulated by a mild aperient. If there be
occasion to change the astringent, he prefers the
lunar caustic solution, gradually increasing its
strength from two grains to the ounce, to four or
six, to be dropped between the lids twice or thrice
a day.

29. When the cornea has ulcerated or sloughed,
the infant is generally pale, weak, irritable, and
restless; and tonics are re(iuired. The sulphate of
quinine in the form of syrup, and the resinous
extract of hark blended in milk, and given every
three, four, or six hours, are the best preparations.
The solution of tlie nitrate of silver, or of alum,
may lie applied to the eye. Opacity of the cornea
is generally permanent ; but instances of recovery
have occurred. M. Bii.i.aiu) mentions a case in
which the recovery was spontaneous.

30. ^. I'unUeiU Ophlhulmhi in Cliiidrcn. — 'J"hc

treatment just recommended is most appropriate
to newly-born infants, or to children of one, two,
or three years old. In these latter, and in those
somewhat older, the local depletion should be
more active, according to their habit of body and
strength ; and blisters behind the ears are of
much service. Blisters, unless employed with
caution, and only so far as to produce slight red-
ness, and followed by the application of warm
poultices to the part, often are productive of much
trouble in young infants ; in older subjects, they
are more beneficial. In the latter class of
patients, vascular depletion, according to the cir-
cumstances of the case and of the patient, purg-
atives, blisters, and astringent applications, con-
stitute the chief means of cure. Purulent oph-
thalmia introduced in large or crowded schools or
foundling hospitals, may spread extensively and
prevail long. Mr. Macgregor has described its
prevalence for some years among the children
of the Military Asylum at Chelsea. It was
most severe in those having red hair, or of the
scrofulous diathesis. It commenced in the eye-
lids with itching, sticking together of the lids
on waking in the morning, followed, in twenty-
four or thirty-six hours, by a viscid mucous secre-
tion, extension of the inflammation of the con-
junctiva oculi, redness of the skin around the eye,
and a purulent discharge. General bleeding,
leeching, purgatives, blisters behind the ears and
on the nape of the neck, cold lotions, low diet,
and, subsequently, astringent collyria, and the
unguentum hydrarg. nitratis, at first mixed with
twice its quantity of lard, but afterwards of its
full strength, applied to the lids by means of a
camel-hair pencil, were the remedies found most
beneficial.

b. Purulent Ophthalmia in Adults. — Syn.
Oph. purulenta or purijormis, Suppurative
Oph., Egyptian Oph., Uphthalmo and Blepharo-
hlennorrhxa, Auct. var. ; Oph. contagiosa ;
Oph, catarrhalis bellica ; Blepharolis glandu-
laris contagiosa, Beer ; Adenitis palpebrarum
contagiosa ; Epidemic contagious Oph. Rosas ;
Conjunctivitis puro-mucosa contagiosa vel Egyp-
tiaca, ]\Iackenzie; Purulent Oph, in the Adult,
Lawhence.

31. This affection is essentially the same as
that just described as to both nature and seat;
it commences and extends in a similar manner,
and produces the same ill effects, especially as
respects the cornea and iris. Its severity, its
serious consequences, its contagious properties,
and its extensive prevalence, at the commence-
ment of this century, impart to it the highest
interest. Assalini states, that two thirds of the
French army in Egypt were affected with the com-
plaint. Dr.VETCjH treated 636 cases, including
relapses, belonging to the second battalion of the
52d regiment, from August, 1805, to August,
1806 ; fifty having lost both eyes, and forty, one
eye : and the ophthalmia depot, under his able
care, contained in the summer of 1808, upwards
of 900 cases. Mr. Macgregor mentions that,
the returns of Chelsea and Kilmainham hos-
pitals furnished 2317 cases; soldiers who had
lost the sight of one eye not being included in
the number: and that, from April to Decem-
ber, 1804, nearly 400 cases of this disease
occurred in the Royal Military Asylum ; and
from that time to the end of 1820, upwards

EYE — Purulent Ophthalmia in Adults.

855

of 900 cases additional, exclusive of relapses, had
taken place in the same establishment. About
this time it appeared in a large boys' school in
Yorkshire ; blindness, or serious injury to sight,
having resulted in nearly twenty instances.
Mueller treated 1604 cases, including 200
relapses, in the Prussian garrison of Mentz,
during three years and a half: 1344 were re-
stored to the service ; fifteen became blind in
both eyes ; eighteen had vision impaired in both ;
and twenty-six were blind of one eye, — furnish-
ing the most successful results upon record ; but
the complaint was more mild than in the British
troops.

32. a. Causes. — The much discussed question
as to the propagation of the disease by contagion*
has been fully and ably considered by Edmond-
STON, Vetch, Macgregoi!, Graefe, Mueller,
Omodei, Rust, Lawrence, and Mackenzie;
and completely set at rest by the evidence they
have adduced. My limits will permit only a
brief view of the matter. It has been contended
— 1st. That the complaint is produced by atmo-
spheric and other causes, and that it is not con-
tagious ; — 2d. That, although it arises from these
causes, it is contagious; — and, 3d. That it is a
specific disease, communicable by contact of the
purulent discharge, and not arising sporadically
from other causes. — One of these opinions must
be true ; and, if true in all respects, the others
must be false. In order to arrive at a correct
conclusion, I shall Jirst briefly review the facts
adduced in support of the non-contagious nature
of the complaint ; next, notice those proving its
contagious properties ; and, lastbj, show in what
manner, and under what circumstances, it mani-
fests these properties.

33. 1st. Those who contend that this disease
is not contagious, argue that, in Egypt, the

* It may be supposed from the lines in Ovid,
" Dum spectant laesos oculi, Iseduntur et ipsi,
Multaque corporibus transitione nocent ; "
and the remark in Plutarch (L. v. Symp. 7.) as to " the
readiness and certainty with which tlie contagion of
ophthalmia spreads amongst persons living together;" that
the contagious nature of the disease was well known to
the ancients. Galex (De Differ. Febr. i. c. 2.) enumerates
it amongst infectious maladies ; and Kabbi MoYSES
(Aphor. 'J.i.) avers, that whoever attentively regards in-
flamed eyes, will contract the complaint. Benedictus
Faventinus (Prax. v. i. sect. ii. c. 2.) gives it as his opi-
nion, that a morbid effluvium proceeds from the eyes in
ophthalmia, which, through the medium of the atmo-
sphere, will affect those that are near. The same opinion
is stated by Mercurialis (Prax. lib. i. cap. 38.). Diemer.
BROECK (Observat. 55.) mentions the case of a lady who
was attacked by the complaint, and two or three days
afterwards, three of her servants were also seized. He
arrested the disorder by tlie following coUyrium : —

R Zinci Sulphatis 3j. ; Sacchari Candi jj-; Aquee
Plantaginis 3'j- ; Aq. Rosarum 3 j- M.
Similar facts and opinions are to be found in the writings
of Riedlin {Curat. Med. Mitten. Observ. 187.), Wedel
(Df OpA^Aa/. Jenje. I6h4.), and Boerhaave (De Morbis
Nervorum, ii. p. 512.). Dr. Ed.mondston has adduced a
very striking fact, about to be referred to, from the thesis
of a Dr. Ahmstrono. From this it will appear, that
although the contagious nature of the disease was not
fully shown, nor generally believed in, until it was de-
monstrated by Dr. Edmondston, yet it did not altogether
escape the notice of writers; some of whom, as Diemeu-
BROECK, were at a loss to account for the facts they ob.
served ; or to explain how a virus could be conveyed,
through the medium of the air, from the eyes of the dis-
eased to those of mere spectators. The vulgar belief,
however, in its contagious nature has long subsisted in
various countries ; but the vulgar judge by results and
assemblages of facts, without caring for the explanation,
or disbelieving them because they are unable to account

for them ; and they often judge aright.

country in which it is endemic, and whence it
was brought by the European armies invading
it at the termination of the last and the com-
mencement of the present century, it was not
considered contagious ; that this property was
not noticed by any of the ancient visiters of that
country, or by any who travelled thither before
the period now mentioned ; and that the army
physicians and surgeons, who treated the ma-
lady there, did not suppose it to be contagious.
AssAHNi, a physician who accompanied the
French army into Egypt, denies this property
and refers it to the causes of ophthalmic diseases
existing in that country, especially the powerful
light and glare from the sandy surface, the dust
floating in the air, the night chills and dews follow-
ing the burning heat of day, and other atmo-
spheric vicissitudes, to which the troops in very
active service were necessarily subjected. Hence
he, and other army physicians, viewed it as a
very acute catarrhal inflammation, affecting those
chiefly who were most exposed to these causes.
Those who espouse this opinion, further appeal
to the alleged fact, that there was no dissemi-
nation of it in the families, or districts, to which
soldiers or other persons aflfected by it returned.
But this argument is, in my opinion, more spe-
cious than correct ; for instances were not nu-
merous of soldiers having been dispersed in civil
communities with the disease in its early and
active stages; and where such occurrences did
actually take place, many of the circumstances
favouring contagion thereby ceased to exist. But,
besides, the results were not altogether such as
the non-contagionists have asserted, as exceptions
now and then occurred to this broad and in-
cautious statement. The fact noticed by Wal-
THER, that the complaint seemed to lose its con-
tagious properties when single patients lived in
their families, under the ordinary domestic rela-
tions, is admitted by him to be weakened by one
exception ; and is open to the objection just
offered. The experiments of Mueller, who
attempted to transmit the disease, by applying the
matter to the eyes of dogs, cats, and birds, with-
out infecting them, is contradicted by others
which succeeded. The experiment of Mr.MAc-
kesey (^Edin. Med. and Surg. Joui~n. vol. xii.
p. 411.), who applied the discharge to his own
eyes without communicating the malady, only
shows that what is known and allowed of other
contagious affections also obtains in this, viz. that
the state of health, and of the organ of the ex-
posed person, as well as the state of weather,
frequently both dispose to, and prevent, the com-
munication of a contagious disease ; and that even
inoculation will sometimes fail to convey it, owing
to these and other circumstances.

34. 2d. Numerous facts have been adduced
in proof of the contagious nature of the disease,
to which only the most cavilling scepticism can
object. JMr. Macgregor met with three in-
stances of nurses, in the Military Asylum, having
been infected by the accidental introduction of
the- matter into their eyes, whilst injecting the
eyes of patients ; the affection manifesting itself
within twelve hours afterwards in all the cases.
Dr. Vetch applied the morbid secretion to the
eye of a dog, in which it soon produced great
irritation ; but the animal was lost before the
result could be ascertained fully. Kihia Va-
3 I 4

856 EYE — PURULEKT Ophthalmia in Adults.

sANi, GnAEFFE, and others, produced the disease
repeatedly in dogs and cats by the application of
matter to their eyes ; and M. Guillie introduced
under the eyelids of four blind children the puru-
lent discharge, and the disease was communicated
in each instance.

35. But independently of these incontrovert-
ible facts, others equally satisfactory may be ad-
duced. It is not denied that the disease extended
from the detachments of the French and English
armies which returned from Egypt, to the troops
in Italy, Sicily, Malta, Gibraltar, France, and
England, which had direct communication with
them; the progress of the complaint having been
clearly traced from the infected detachments to
the fresh troops. The excellent accounts fur-
nished by Dr. Edmondston, Vetch, Macoregor,
Rust, Walther, Mueller, Graeffe, and
others, completely demonstrate its spread by con-
tagion, and show that it extends rapidly among
soldiers crowded in barracks, using the same
utensils and linen, whilst the officers, who live
separately, are seldom attacked. Rust states
that, in Mentz, which was garrisoned by Prus-
sians and Austrians, it spread extensively among
the former; while the latter, who inhabited sepa-
rate barracks, in a different quarter of the town,
entirely escaped. Dr. Edmondston adduces a
most conclusive fact. In 1782, the Albemarle
ship of war took on board, in the West Indies,
three sailors, with inflamed eyes, from a slave-
ship, in which the disease prevailed. On the
fourtii day after their reception, the disorder ap-
peared in the Albemarle ; and, by the seventh
morning, twenty-two men were unfit for duty.
Those affected were now separated from the
healthy, and the progress of the malady was
arrested, and, in the course of a few weeks, en-
tirely ceased. Similar facts to the above may be
adduced ; and most of those about to be noticed
in illustration of points connected with this sub-
ject, fully prove contagion. Numerous instances
have occurred in civil life, of the disease extend-
ing from one, to all the members of a family ;
and, in the public service, where the circum-
stances favouring its spread are more numerous
and influential than elsewhere, it has been ar-
rested by separating the diseased from the healthy,
and confining each person to his own utensils,
clothes, and sponges. IMr. Macgregor stales
that, when the complaint was spreading rapidly
in the spring of 1810, among the children of the
Military Asylum, those affected were removed
into a detached building, so as to cut off the
communication between the healthy and diseased;
and that it afterwards declined. I'hat it did not
arise fiom the state of the air, or any other general
cause, is shown by the circumstance of its preva-
lence among the boys for nearly a month, before
the girls were attacked ; and by the fact, that
all the adults who did not mix with the sick
escaped, while those who were connected with
them all suffered, the assistant surgeon excepted.
Similar proofs are adduced by Rust, Walther,
and Omodki, in the works referred to in the Bib-
liography. Mr. Macoregor has given a most
convincing account of its extension, by contagion,
from two boys, brothers, in the Military Asylum,
in his Memoir referred to hereafter.

36. 3d. The origin of the contagious properti/
end the manner of, and the circumstances favour •

ing, its propagation, are matters of great practical
importance, as respects both prophylactic and
curative measures. — (a) As to the origin of the
contagion. Dr. Vetch has made an important
observation, and one which appears to approach
very nearly to the truth. He remarks that, from
whatever cause inflammation of the conjunctiva
may originate, when the action is of such a nature
or degree as to produce a purulent discharge
(Ophthalmo-blennoi'rhcca), the discharge so pro-
duced operates as an animal virus when applied
to the conjunctiva of a healthy eye. To this I
would merely add, of a predisposed or susceptible
person. — The opinion of Mr. Mackenzie agrees
with that now stated. He observes, that it
scarcely admits of a doubt, that the discharge in
catarrhal ophthalmia, especiaUy when distinctly
puriform, if conveyed by a towel, or by the
fingers, to the eyes of other persons, will excite
a conjunctivitis still more severe, more distinctly
puriform, and more dangerous in its effects, than
was the original affection. He has arrived at
this conclusion, from having observed many in-
stances, in which the disease had arisen in one of
a family from atmospheric exposure, and several
others had become affected, it having been, in the
first attacked, comparatively moderate, but, in
the rest, much more violent and puriform. Simi-
lar facts have been remarked by myself. That
the disease may arise spontaneously, and after-
wards extend by contagion, is evinced by the
following occurrence adduced by M. Guillie.
A French slave-ship left the coast of Africa in
1819, with 160 slaves crowded in the hold. No
case of ophthalmia existed among them, nor
among the crew, when they put to sea. But
fifteen days afterwards it broke out in the
negroes, and spread rapidly among them, and
subsequently among the crew, twenty-two in
number, one only of whom escaped. On their
passage across the Atlantic to the West Indies,
they met another slave-ship, the crew of which
was similarly circumstanced to themselves. Near-
ly one half of the crew and slaves lost their sight
in one or both eyes.

37. (h) As to tiie manner of the propagation
of the disease, some difference of opinion is en-
tertained. Dr. Vetch believes that it is not
communicable by a contagious miasm conveyed
through tiie medium of the atmosphere ; and
thinks that direct application of matter is neces-
sary to infection. JMr. 1\Iacgrec;or expresses a
similar opinion, although many of his facts favour
the conclusion at which I shall arrive in the
sequel. Mueller, on the other hand, considers
that the contagion is generally conveyed by the
air, although it necessarily also admits of being
propagated by direct contact, and, in proof of
this position, adduces the fact of the medical at-
tendants and nurses, notwithstanding their care
to avoid the contact of the discharge, having
been fretiucntly affected. Walther entertains
the same ojiinion, and appeals to similar facts in
support of it. Dr. Edmondston, the first writer
vvlio demonstrated the contagious nature of the
conipliiint, and attempted to assign the range and
laws of this property in respect of it, considers
that it is contagious, not only by the contact of
the discharge, but also by fomites, and through
the medium of the atmosphere within a limited
range, when a number of cases are brought

EYE — PunuLKNT OpH'riiAi.MiA IN Adults.

857

together, in close apartments or crowded hospitals.
Such appears to be the opinion of this able physi-
cian, promulgated as early as 1802 ; and, although
not always candidly objected to at the time, and
for some years afterwards, it is now confirmed in
every respect by the more recent experience of
the best writers on the disease in this country and
on the Continent.

38. (c) The circiimstatices favouring the diffu-
sion of this contagion are in no respects different
from those which promote the spread of other
contagions : — Ist. Novelty of morbid impression,
or the unblunted sensibility and unimpaired sus-
ceptibility of those who are exposed to the infecti-
ous miasm for the first time ; as a person coming
out of a pure air into a foul atmosphere or close
apartment, or breathing an efHuvium to which he
has heretofore been a stranger, is much more
sensible of its operation, and much more affected
by it, than one who has gradually become accus-
tomed to it by frequent or continued exposure. —
2d. Whatever increases the discharge, or accu-
mulates or concentrates the emanations from it,
and from the diseased organ ; as want of ventila-
tion, crowding together of the sick, want of clean-
liness, &c. ; will greatly increase the contamina-
tion of the air more immediately surrounding
the patient, and favour the infection of the healthy
who are most susceptible, when they approach
within a certain limited range. — 3d. Whatever
multiplies the chances of conveying the morbid
secretion directly to the eyes of the sound ; as
sleeping in the same bed or apartment, using the
same towels, sponges, and utensils, and the want
of domestic cleanliness; will augment the number
of cases. — 4th. Whatever depresses the vital
powers ; as unwholesome diet, insufficient cloth-
ing, intoxication, exposure to cold, &c., fatigue,
malaria, a confined or foul air, the depressing
passions, and venereal excesses ; will render per-
sons more susceptible of infection. — And, 5th.
Exposure to the more common causes of ophthal-
mia about the same time as to contagion, or
shortly before or after it, will likewise assist or
determine its influence. — It is hardly requisite to
appeal to facts in support of these positions.
The numerous works referred to furnish them in
abundance, especially those of Edmondston,
Macgregor, and Vetch. Mr. Macgregor found
that the complaint was much more severe and of
longer duration in hot and moist, than in cold,
whether; and Dr. Vetch ascertained that a hu-
mid atmosphere and marshy soil increased both
its violence and spread.

39. From the above, it may be inferred — 1st,
that the disease may be produced by common
causes, and without the operation of contagion ; —
2dly, that, when so excited, and existing to such
a degree as to give rise to a puriform discharge, it
is capable of propagating itself, under favourable
or particular circumstances ; — 3dly, that it
spreads, not only by contact, but also through
the medium of the atmosphere, within narrow
limits ; more especially when numbers affected
by it are crowded together, and the air is humid
or impure, and those exposed to the contagion
are predisposed by the operation of the causes
mentioned above {§ 4.). Hence its remarkable
virulency in ships, particularly transports, slave-
ships, barracks, prisons, woikiiouses, and schools ;
and it therefore should be referred to the second

category, stated at the commencement of the
inquiry ( 32.).

40. B. Symptoms and Progress. — The symp-
toms succeed each other with different degrees of
rapidity and severity, even in persons suffering
from the same infection, and in the same place,
owing to the previous health, the habits, and con-
stitution of the patients. The disease is more mild
in females than in males ; and it is more violent
about the period of puberty than at an earlier or
later age. It has also been more severe in one
place, or regiment, than in another ; and it was
evidently more violent among the British troops,
than among the French, Germans, or Italians,
owing most probably to the more phlogistic dia-
thesis and robust constitutions of the former than
of the latter, and to their fuller living and greater
intemperance.

41. (a) The more acute and violent states. —
In its^rst stage, the complaint is confined to the
palpebral conjunctiva; and is attended by stiff-
ness of the lids, itching or watering of the eye, a
sense of sand or some foreign body below the lids,
succeeded by sticking of them together, on waken-
ing from sleep, and greater fulness of them exter-
nally than usual. — It is seldom seen by the phy-
sician at this period ; or until it has advanced to
the conjunctiva oculi, or its second stage. This
membrane then rapidly becomes bright red, re-
markably vascular, and greatly swollen ; the
chemosis being sometimes such as to conceal the
cornea. Patches of ecchymosis are also seen, and
the whole palpebras are much tumefied, and occa-
sionally also red externally. The discharge is
profuse and purulent, often in a few hours from
the commencement, but always soon after the
inflammation has extended to the globe ; and
sometimes it is so copious as to pour over the
face and clothes; but there is no secretion of pus
in the chambers. In this stage, the pain becomes
severe, seated deep in the eye, and attended by a
sense of a foreign body in the eye, of fulness or
great distension, with throbbing in the temples,
and headach. These symptoins, especially the
pain, often remit, or occur in paroxysms, or return
after having been removed for a time. The con-
stitutional disturbance is not severe; the pulse,
tongue, and appetite, not being materially af-
fected. The cornea is liable to the same effects
as have been described above (§ 24, 25.) ; but
the swelling of the lids, and the tumefaction and
overlapjMng of the conjunctiva, and the accumu-
lation of pus over the cornea, or in the depression
of which it forms the bottom, frequently prevent
its state from being ascertained. — In the third
stage, the symptoms gradually subside ; the swell-
ing, pain, and discharge are diminished; the ex-
ternal tumefaction is lessened ; and the lids,
which before were somewhat inverted, from the
cartilages not yielding, are now slightly everted,
especially the lower. As the discharge diminishes,
it gradually loses its purulent characters, and be-
comes thinner, more mucous, or gleety. The
internal surface of the eyelids, the semilunar
meitibrane, and caruncula lachrymalis, which
were the first parts affected, are the last from
which the disease disappears. The right eye is
more frequently, and generally more severely, at-
tacked than the left ; and its sight oftener lost.
In some cases, only one eye is affected; but
commonly both are seized, although an interval

858

of several days occur before the second becomes
inflamed. Such are the features of this disease as
it prevailed in the British army, and as it some-
times occurs in civil life under certain circum-
stances.

42. (b) The milder or chronic states. — These
were most common on the Continent, both in the
army and in civil society. Mr. Macgregor, Dr.
Vetch, Professor W.alther, and Dr. Mueller,
particularly the last, have pointed out, not only
the orio^in of the complaint, in the conjunctiva of
the lids, but also its long persistence in this part,
in some cases, and its entire limitation to it, in
others. In all the grades, the inflammation both
begins and terminates in it. — In the slightest
grades, the patient complains of pressure or un-
easiness, with a sense of dust or sand, in the eye ;
but without redness of the globe, or of the exter-
nal surface of the palpebrs. The conjunctiva
tarsi is villous and dark red ; but towards the
globe it is smooth, and its vessels distended. The
eyeball has an irritated appearance : there is an
increased flow of tears, and a mucous secretion,
but little or no pain. The disease may continue
long in this mild form, or may yield to treatment
in two or three weeks ; or it may pass into a
higher or severer grade. — The second or interme-
diate degree may be an aggravation of the first or
slightest grade, or may commence with all its
characteristic features. The conjunctiva of the
lids has a granular appearance, which becomes
more conspicuous when the inflammatory tension
is abated, and is swollen, dark red, and covered
by a puriform secretion. The lids are tumefied;
the pain is considerable, and as if caused by a
foreign body. This form may continue for weeks
or even months, and pass into the severe or acute
state already described (§ 41.), owing to atmo-
spheric changes or other causes ; unfavourable
consequences to the organ supervening sometimes
in twenty-four or thirty-six hours.

43. (c) The alterations which the conjunctiva
undergoes are of much importance. In the
mildest grade, the membrane appears as if co-
vered with dust, or velvety ; in the severest de-
grees, it seems strewed with rough bodies, or
with granulations, resembling those of a healing
wound. These bodies exist in great number,
arise by a broad basis, and have a round promi-
nence at first, which becomes flattened or angular
by pressure against the globe. The largest of
them are in the middle of the lid, the smallest at
the edge and near the angles. They are some-
times crowded very close, and are most remarka-
ble in the upper lid. Their colour varies from the
darkest blood red to the palest brick hue. Muel-
ler Considers this change of structure not as a
mere eflfect of inflammation, but as proper to the
disease, and as connected with the production of the
contagious secretion disseminating the comj)laint.

44. y. Consequences. — 1. Suppuration of the
Cornea, and destruction by ulceration, sometimes
supervene ; the progress of the disease usually
leading to the escape of tiie humours, and col-
lap-e of the globe. — 2. Ulceration frequently
takes place, to the extent, and in tiie manner, de-
scribed above (§ 24,25.). — 3. Sloughing of the
cornea rarely or never occurs in this variety. Mr.
Lawrence has not met with it, and other writers
do not mention it. — 4. Bursting of the cornea is
less rare, particularly during suppuration or

EYE — Purulent Ophthalmia in Adults,

ulceration. Dr. Vetch met with cases, in which

the rupture occurred without previous change ;
the aqueous humour having escaped by a clear
division or rent in the cornea, which afterwards
became opaque, and projected around the open-
ing ; but this occurrence is very seldom observed.
— 5. Interstitial deposition in the conjunctival
covering, or the corneal lamina;, occasioning
opacity of every degree ; the slighter grades often
disappearing after recovery. — 6. Loosening or
thickening of' the mucous membrane covering the
cornea, with enlargement of its vessels, and dimi-
nution of its transparency. — 7. Opacity from
cicatrisation of ulcers. — 8. Prolapse of the iris,
partial or total {Staphyloma racemosum). — 9.
Adhesion of the iris to the cm-nea (Synechia ante-
rior), either with or without prolapse. — 10.
Staphyloma, general or partial, or other changes,
from extension of the inflammation to internal
parts of the organ. — 11. Weakness or irritability
of the eyes, which usually disappears sooner or
later. — 12. Impaired vision (Amblyopia), arising
from numerous causes ; as turgidity of vessels in
the orbit, and surrounding the optic nerves ; slight
alterations of the choroid, retina, or lens ; and
lesions within the cranium. — 13. Thickening,
induration, and granulation of the conjunctiva of
the lids. — 14. Temporary and permanent ectropium
and entropium. — And, 15. A great tendency to
relapse, upon exposure to very slight causes,
This last especially occurs, when the palpebral
conjunctiva has not been restored to its natural
state, — a result not readily attained after severe
or prolonged attacks, and which Walther
doubts ever to be entirely accomplished. Hence
a person may be considered as cured, but expe-
rience a return of the complaint, from exposure
to cold or intoxication, and may spread the disease
in the family in which he resides.
1 45. 5. Diagnosis. — Purulent ophthalmia in
the adult may be mistaken for the catarrhal and
gonorrhccal varieties. The peculiar change in the
palpebral conjunctiva, the great chemosis and
swelling of the lids, the extreme redness and vas-
cular congestion, the profuse purulent discharge,
the long continuance of the complaint, its tend-
ency to aflfect the cornea, and the disposition to
relapses, sufl'iciently distinguish it from catarrhal
or mild ophthalmia. Nevertheless, the mildest
cases of the former, and the severest of the letter,
hardly differ in any respect. The specific cause
and nature of gonorrhceal ophthalmia, and its
uniformly acute and violent form, distinguish it
from the purulent variety. There are, besides,
other differences, which will be noticed hereafter
{§ 59.).

46. £. Treatment. — (a) Of the most acute, or
highest grade of the disease. — The intention
should be to arrest the violence of the inflamma-
tion, and prevent the extension of it to the cornea.
If the patient be seen sufliciently early, or be-
fore the conjunctiva oculi be much inflamed, or
chemosis have appeared, the treatnient advised in
catarrhal ophthalmia will generally succeed. But,
if the disease be thus far advanced, and has as-
sumed a severe form, the most active antiphlo-
gistic means ought to be resorted to. Vetch,
Mueller, Rust, Walther, Lawrence, and
other expeiienced writers, recommend venisection
carried at once sufficiently far to produce a de-
cided effect upon the circulation, without regard

EYE — Purulent Oi-iitiialmia in Adults.

859

to the quantity abstracted. Drs. Edmondston,
Mackenzie, and Jacob place much less reliance
upon large general bloodlettings, which have
but little effect upon the local inflammation.
This opinion coincides with the result of my own
limited experience. Dr. Jacob has seen the ab-
straction of blood carried to the utmost extent ;
" he has seen repeated bleedings of forty, fifty,
and even sixty ounces, and streams flowing from
the arm and temporal artery at the same time,
without generally beneficial results." After one
full bloodletting, these writers coincide in trusting
chiefly to local depletions, by cupping in the
temples, by the application of from twenty to
thirty leeches over the cheek-bone and temple,
and by scarifications of the inflamed conjunctiva.
This last is advised chiefly by Dr. Edmondston
and Mr. Mackenzie ; but it is objected to by
]\Ir. Lawrence, on the grounds that the wounds
thus inflicted increase the local irritation ; in the
most severe cases, however, the advantage accru-
ing from the practice far outweighs any incon-
venience contingent on it. JVlr. Mackenzie
places scarification of the conjunctiva among the
most effectual means of combating the conta-
gious ophthalmia ; but makes no mention of Dr.
Edmondston, who, many years before, strongly
insisted on this practice. When the chemosis is
great, Scarpa and Walther recommend a por-
tion of the conjunctiva to be cut out, either from
the eyelid or the globe ; several drachms of
blood usually flowing from the incision, with
great relief to the symptoms. When the tume-
faction is such as to protect the membrane be-
tween the lids, or to overlap the cornea. Dr.
Jacob directs an extracting knife to be run from
one end of the tumour to the other, the effused
serum and much blood generally escaping by this
means.

47. Having practised bloodletting so as to
make an impression on the circulation, conform-
ably with the principles espoused in other places
(see Blood, § 64, 65.), and immediately after-
wards applied leeches, or scarified the conjunc-
tiva, according to circumstances, full doses of
clilomel, antimony, or James's powder, and opium,
conjoined, should be immediately taken, and fol-
lowed, in a few hours, by a brisk purgative, and
this latter, by a cathartic enema. If the calomel,
antimony, and opium have been exhibited for the
first time in the morning, they may be given again
at bedtime, if the case be very acute ; the ca-
thartic being repeated at an early hour in the
morning. If the tongue be loaded, or the sto-
mach disordered, an antimonial emetic should
follow the bloodletting, and precede the medi-
cines now directed, wliich should be given soon
after the full operation of the emetic, and repeated
according to their effects. Having thus acted
upon the circulation and the prima via, without
materially diminishing the local action and
pain, diaphoretics and nauseants may be resorted
to. Full doses of Dover's powder, or antimony
conjoined with opium, promoting their operation

system. The most efficient and certain derivative
cathartics, in this disease, are equat quantities of
castor oil and spirits of turpentine, lue same being
exhibited in enemata (F. 151.) ; but they should
not supersede the other means. J'he antiphlo-
gistic treatment ought to be strictly enforced in an
early stage of tiie disease, particularly in robust,
phlogistic, and well-fed persons. In the dark-
skinned races, as well as in persons of relaxed
or cachectic habits, bloodletting is injurious ; and
even local depletions should be cautiously pre-
scribed.

48. The local Treatment is even more import-
ant than the constitutional. After local bleed-
ings, the frequent application of cloths moistened
with cold water, or vinegar and water, and, when
the headach is urgent, or the chemosis great,
the cold affusion on the head, repeated twice or
thrice daily, are favourably mentioned by Wal-
ther, Vetch, Gericke, and Lawrence. If the
cold applications cannot be borne, or if there be
spasm of the lids, icarm fomentations maybe used
for a short time ; but they should not be long per-
sisted in, or too frequently repeated, unless they
be alternated with astringents. Tepid ablution is,
however, both serviceable and requisite. Cold
or warm applications should, therefore, be em-
ployed according to circumstances. Mr. Tra-
VERs prefers those that are tepid, in the painfully
acute stage. Whichever be adopted ought to be
carefully attended to by the practitioner himself.
As soon as the conjunctiva becomes somewhat
paler, or appears flabby, astringent applications
ought no longer to be withheld. In relaxed
habits they should be very early applied, or im-
mediately follow the local depletion. Mr. Me-
lin and Dr. O'Halloran, from having been
dissatisfied with the antiphlogistic treatment,
were led to the use of powerful astringents, not
only in the first stage, but also when tlie purulent
discharge and chemosis were fully established.
Dr. O'Halloran used, once a day, either the
sulphate of copper in substance, rubbing it on the
inner surface of the eyelids after everting them ;
or the nitrate of silver, dropping a ten grain
solution of it on the eye. He also applied foment-
ations, and gave purgatives. If the symptoms
indicated the extension of the inflammation to
internal parts of the eye, then only he directed
leeches.

49. Mr. Guthrie, considering the nitrate of
silver in solution to be ineffective, in the most se-
vere cases, recommends an ointment, made with
ten grains of this salt reduced to an inpalpable
powder, and thoroughly incorporated with a
drachn, of laid, to be inserted between the lids.
The eyes ought previously to be well cleansed
with a tepid solution of alum ; and when the
ointment is inserted, the lids are to be nioved
freely, so that the whole conjunctiva receives it.
If the membrane become white, it is satisfactorily
applied; if not, the ointment should be rubbed
on the inside of the lids. He also directs the
patient to be bled fully, and until an impres-

by diluents and pediluvia, will generally be of j sidn is made upon the pulse ; he employs warm
much service. Nausea kept up by these medi- ] narcotic fomentations to the eye ; exhibits an
cines is sometimes of use, in the more severe or , opiate internally ; inject*, from time to time, a
obstinate cases, before the cornea is afl^ected ; j vveak solution of alum under the lids, to wash
but under other circumstances, it is seldom be- away the discharge ; and applies a mild ointment
neficial. The same remark is applicable to mer- to them at night, to prevent their adhering toge-
cury exhibited with the intentioii of aflPecting the | ther. The next morning the discharge is again

860

EYE — Purulent Opiitji.vlmia in Ai

to be removed, and the strong ointment re-applied,
so that the new action that should be set up may
not cease ; the other remedies are likewise to he
continued. In addition to these, he gives calomel
and opium, so as to affect the mouth j and the
other more common remedies.

50. As different writers prescribe different
astringents, and of various grades of strength; it
were desirable that some more precise knowledge
were attained as to which is the safest and most
efficient. Dr. Jacob, after passing acetate of
lead, alum, sulphate of copper, sulphate of zinc,
bichloride of mercury, and lunar caustic in review,
decides in favour of the undiluted liquor plumbi
diacetatis, and strong solutions of alum, or of the
nitrate of silver; which, however, he recommends
after the painfully acute stage has passed, and in
the chronic or atonic state of the complaint. Mr.
JMackenzie directs a tepid solution of one grain
of corrosive sublimate in eight ounces of water,
to be injected under the lids, for the purpose
of cleaning the eyes ; and, as an astringent,
four grains of the nitrate of silver, or six of the
sulphate of copper, dissolved in an ounce of dis-
tilled water. The solution of alum, or of the bi-
chloride of mercury (j. — ij. gr. to 5 j.) may like-
wise be ttied. Mueller prescribes one, two, or
three drops of sulphuric acid, or two or three
grains of the diacetate of copper, in an ounce of
water. Mr. Briggs states, that a minute quantity
of the oleum terebinthinae introduced between the
lids every morning, on the point of a camel-
hair pencil, the eye being afterwards bathed with
cold water, is most efficacious in checking the
profuse discharge.

51. It will bo observed, from the foregoing,
that some difference of opinion exists as to when
the use of active astringents should be com-
menced. The majority of authorities, as Ed-
MONDSTON, Vetch, Mackenzie, Lawrence,
Jacob, &c., resorting to local depletions, and
soothing or anodyne applications, in the early,
acutely painful, or active inflammatory stage, and
to strong astringents, when this stage is removed,
and the chronic or atonic condition has com-
menced ; whilst some military authorities, as
IMelin, OTIalloran, and Guthrie, advise the
adoption of powerful astringents from the begin-
ing. I agree, however, with the former ; and
with them consider, that the effects of astringents
should be carefully watched, when early, or even
at first employed ; and, if the redness be increased
by them, that they should be laid aside for a
time, and antiphlogistic remedies adopted. The
citrine orred precipitate ointment should be applied
to the edges of the lids at night.

52. In the dark races, astringents ought to be
early and energetically employed. Among the
negro tribes, vegetable astringents and stimulants,
especially lime-juice, are entirely confided in.
Tiie astringents above noticed are, however,
equally approjiriate in them ; and the addition of
anodynes, particularly opium and camphor, is also
of service, with pure air, and suitable diet.

53. Blisterslo the nape of the neck, or behind
the ears, are sometimes serviceable, especially
when kept open for some time. When tiie pain is
very distressing in the acute stage, relief is afforded
by the steam of luit water, to which laudanum and
camphor have been added; and tlio vinum opii
is often a useful application, wlien tiie conjunctiva

is relaxed and painful upon the disappearance
of the discharge. Evacuation of the aqueous
humour by incision has been recommended by
^J'-Wardroi', in order to remove the bursting
pain in the eyes and forehead, and practised in
twenty-three cases by Mr. Macgregor, from a
dread of rupture of the cornea. In the advanced
stage of the disease, exercise in the open air,
exposure of the eye to as much light as it will
bear, and the use of gentle tonics, with a free
state of all the excretions, are serviceable. If,
after depletions, the eye becomes irritable, or tiie
pain intermittent or periodical, the preparations
of bark, with the mineral acids, as Mueller ad-
vises will be of benefit. If ulceration of the
cornea have commenced, a tonic and stmiulating
treatment is required, especially if it spread and
be attended by debility. When ectropium of the
lower lid remains after the inflammation is gone,
and presents a red flesiiy mass, Mr. Lawrence
directs the application of the nitrate of silver in
substance to it.

54. {b)Treatment of the milder grades. — If the
inflammation have extended to the conjunctiva
oculi, however slight, local depletion, low diet,
and purgatives should be directed. When active
disorder is removed by these, the application of
astringents to the diseased surface of the eyelids
siiould be entered upon, and continued until the
morbid state of this part described above (§ 4'3.)
is entirely removed. The solution of alum, or of
nitrate of silver, or of sulphate of copper, the
strength of which should be gradually increased,
or the undiluted liquor plumbi, ought to be drop-
ped into the eye, once or twice a day, the citrine
ointment being applied to the margins of the lids
at night. Exercise in the open air, free ex-
posure of the eyes, and due regulation of all tlie
natural functions are beneficial. Mueller re-
commends mercurial ointments to be rubbed
over the diseased surface of the lids once or twice
daily.

55. When the palpebral conjunctiva becomes
altered cr granulated, in the chronic state, as
above decribed (§ 43.), very active local means
are necessary, as tiie irritation occasioned by
the morbid surface produces vascularity and opa-
city of tlie cornea, or loosening and thickening of
its conjunctival ](iyev — or pannus. With °the
change in the surface of the eyelids, may be
associated some one of tiie unfavourable results
of the more violent attacks, as leucoma, cynechia,
anterior, staphyloma, &c. — JMr. Lawrence re-
marks that, if the globe be free from irritation,
the astringeiits already specified, particularly a
solution of twenty or thirty grains of nitrate of
silver in an ounce of water, should be applied to
the granulated surface, with a camel-hair pencil ;
the lids being everted. If this be not suflicient,
escharotics, beginning with the weaker, and pro-
ceeding to the strongest, must be used. In order
to prevent their injurious action on the conjunc-
tiva oculi, the lids should be everted, tne diseased
part only touched, and tiiey ought to be kept
everted until the effect is produced. The diace-
tate of copper, tlie sulphate of copper, or the nitrate
of silver - the strongest — should be lightly ap-
plied to the granulated surface, previously freed
from moisture; and, after waiting a minute or
two, the lid should be carefully washed and re-
stored. These applications cause severe pain.

EYE — GoNonniicEAL Ophthalmi.i.
reJness, and swelling, with increased discharge,
and should not be repeated until these effects
have disappeared, which may not take place for
five, seven, or eight days. In the intervals of
the escharotics, some astringent solution may be
applied. Mr. Lawrence and Professor Wal-
TiiER. do not speak very favourably of this plan ;
and are more disposed to depend upon antiphlo-
gistic means in tiie first instance, and the sub-
sequent use of astringents, as above directed,
with regulation of diet and of the digestive or-
gans, residence in a pure air, exercise, and a
moderate use of the organ. Rapid improvement,
Mr. Lawrence states, sometimes has followed the
substitution of soothing applications for strong
astringents.

C. GoNORRHOiAL OpHTHALMlA. — Syn. Go-
norrheal Inflammation of the Conjunctiva ;
Specijic Ophthalmia; Conjunctivitis specijica ;
0])hthalnna Gonorrhoica vera. Beer.
55'. Thii is a violent injiammation of the mu-
cous membrane oj' the eyelids and globe, attended
with a profuse discharge of a fluid closely resem-
bling that ichich issues Jrom the urethra in gonor-
rhcca, and occurring in some kind of connection
«'/(/( that C07nplaint. — It is the most violent and
rapidly destructive inflammation to which the eye
is subject; fortunately it is one of the most rare.
It sometimes destroys the eye within a very short
time; or irreparably injures it before medical aid
is resorted to, especially in the lower classes. JMr.
IMackenzie divides it into — 1st, that from inocu-
lation ; 2d, from metastasis; and, 3d, without
inoculation or metastasis. Mr. Lawrence distin-
guishes three forms : — a. Acute gonorrhoea! in-
flammation of the conjunctiva ; — b. jNlild inflam-
mation of this membrane ; — and, c. Gonorrhoeal
inflammation of the sclerotic coat. I shall here
consider chiefly the former ; the third form being
merely rheumatic ophthalmia, occurring, like
other rheumatic afl^ections, in connection with
gonorrhoea.

57. a. !^i/mptoms and Progress. — Acute gonor-
rha'al ophthalmia presents all the fully developed
characters of purulent ophthalmia. Mr. Law-
rence distinguishes three stages ; which, how-
ever, are not very clearly evinced ; although the
division is judicious. In the Jirst stage, which is
short, the inflammation is confined to the con-
junctiva, and is attended with a sensation of sand
in the eye, and soreness, stiffness, uneasiness
on exposure to light, and a thin whitish mucous
secretion. Extreme vascular congestion, intense
and general redness, excessive tumefaction of the
conjunctiva, great cheuiosis, and swelling of the
lids, supervene; especially as the disease ap-
proaches the second stage, which is characterised
by a profuse discharge of thick yellow matter,
closely resembling in its appearance, and in the
stain it communicates to linen, the gonorrhoeal
secretion. When the discharge is established,
the inflammation causes effusion into the cellular
tissue connecting the conjunctiva to the sur-
rounding parts. Hence the very remarkable
chemosis, which is sometimes so extreme, as to
overlap or hide the cornea; and the palpebral
swelling and enlargement, which is occasionally
very greiU. The affection soon extends to the
cornea, constituting the third stage, with ago-
nising pain in the globe, orbit, and head, aug-
mented on exposure to light, and attended by

861

symptomatic inflammatory fever. The danger to
the organ is now most imminent. The swelling
of the lids and chemosis render it difficult, or even
impossible, to obtain a view of the cornea. When
this is the case, attempts to attain this end should
not be made so as to increase the symptoms.
Although pain is most acute in both the eye and
head, as in other instances when the unyieldino-
cornea is the seat of inflammation ; and althouo-h
patients often complain of burning pain, of ten-
sion as if the eye would burst, with deep seated
suffering extending to the brow, forehead, and
head, there are some instances in which little or
no pain is felt. The symptoms are, however,
not equally violent through the whole course of
the complaint ; and the duration of the stages
varies with the constitution and health of the
patient, and the treatment adopted. The frst
and second, particularly the first, visually passes
away rapilily.

58. b. Consequences. — The immediate effects
of the inflammation on the cornea are slouo^hing,
suppuration, ulceration, and interstitial depo-
sition ; these changes leading to escape of the
humours and collapse of the globe, obliteration
of the anterior chamber, and flattening of the
front of the eye, staphyloma, prolapse of the iris,
obliteration of the pupil, opacity of the cornea,
and anterior adhesion of the iris. Sufficient
notice has already been taken of each of these
lesions ; as they do not differ from those super-
vening upon the other varieties of purulent oph-
thalmia, although they more rapidly appear, and
in severer forms, than in them.

59. c. Diagnosis. — The severest grade of />«?•«-
lent ophthalmia closely resembles the acute gonor-
rhoeal. In the latter, however, the swelling of
the conjunctiva oculi is greater, and that of the
eyelids somewhat less, than in the former. The
discharge, however, is thicker, and perhaps more
abundant, and the constitutional disturbance
greater, in the gonorrhoeal, in which the peculiar
granulated change of the conjunctiva of the lids
does not occur. In purulent ophthalmia, the dis-
ease begins in the lids, and advances gradually;
but in the gonorrheal, it seems to commence in
the conjunctiva cculi : in one case, JMr. Law-
rence saw it distinctly begin there; and it at-
tacks most violently and proceeds most rapidly.
The former generally continues long, aftects both
eyes, remits, or returns, rarely destroys the eye by
sloughing, and is much less destructive ; w hilst
the latter more frequently afl^ects only one eye,
and the cornea is much oftener destroyed by
sloughing. This disease is uncommon, occurs in
single instances, and in persons who have had
or who still have, gonorrhoea; whilst purulent
ophthalmia usually affects numbers, particularly
when many live together.

60. d. Prognosis. — Nine casesout o' fourteen
relat(;d by Mr. Lawrence in his treatise on this
disease, were seated in one eye ; out of the four-
teen, loss of vision took place in nine cases from
sloiighing, suppuration, or opacity of the cornea.
In two cases, one eye was lost, and the other
recovered. Sight was restored in the othtr five,
with partial opacity of the cornea and anterior
adhesion of the iris in three of the number. This
writer adds, that so short a period intervenes
between the commencement and full develop-
ment of the complaint, that irreparable mischief

862

is generally done to the eye before aid is resorted
to. In the first or second stage, its progress
may be arrested ; but success even thus early
must not be reckoned upon. If the cornea still
possess its natural clearness, the eye may be
saved; but if it have become hazy or dull, and
particularly if it be white or nebulous, serious
consequences will ensue. Sight may, however,
he restore.! after partial sloughing of the cornea ;
and ulceration may occur in its circumference
without injury to vision. When both eyes are
successively attacked, the disease is often less
severe in the second, which, therefore, is saved ;
but exceptions to this occasionally occur, the
sight of both being lost.

61. e. Causes. — Dr. Vetch found that the
matter of acute purulent ophthalmia, applied to
the urethra of the same individual, excited no
disease; but that, when it was applied to the
urethra of another person, it produced a virulent
gonorrhoea : he therefore infers that the matter
from the urethra, coming in contact with the
eye of the same individual, would not occasion
gonorrhoeal ophthalmia. But Mr. Mackenzie,
Mr. Lawrence, and Dr. Jacob, adduce cases
from their own practice, which were produced in
this way, and refer to others from Wardrop,
AsTRUc, Allan, and Foot. It has been inci-
dentally mentioned by Scarpa and Beer, that
gonorrhoeal matter applied to the eye excites only
slight inflammation ; but they do not refer to the
source whence it was derived — whether from the
same person or from another — the cases ob-
served by Lawrence and the other writers just
mentioned, show that this statement does not
hold in respect of the same person, and that he
may infect himself, although such infection is
not so frequent, as the inattention of gonorrhoeal
patients, particularly in the lower classes, would
lead us to expect ; and the experience of War-
drop, Delpech, I5acot, Allan, and Mackenzie
fully proves that the disease may be caused by
the application of gonorrhoeal matter from a dif-
ferent person, although, for obvious reasons, this
cannot be a frequent occurrence. It is, there-
fore, placed beyond doubt, by the cases observed
by the above writers, that the complaint may be
caused by the contact of gonorrhoeal matter —
1st, from the same individual, and, 2dly, from
another. But as, in the greater proportion of
cases of gonorrhoeal ophthalmia, no application
of matter, either from the same or another in-
dividual, can be traced, in what other way does
the disease arise? It has been very generally
imputed to metastasis in all such ; and the dis-
charge from the urethra has been said to be sup-
pressed by St. Yves, R. cuter, Scarpa, and
Beer, but erroneously, as contended by Delpech
and Lawrence. In the cases which this hist
writer has recorded, the discharge was not stopped
in any one, although it was generally lessened,
but in some not at all. He therefore concludes
that, since the complaint may occur while the
discharge from the urethra continues, and since
it does not take place when that discharge is
stopped, we cannot admit that it owes its origin
to the cessation of the urethral discharge. 'J'his
supposed metastatic form he refers to the state
of the Constitution, considering it as analogous to
those succesMve attacks of ditferent parts whic^h
are observed in goiit and rheumatism ; and he

EYE' — GoNonRH(EAL Ophthalmia.

remarks that, although direct infection operates
equally on the eyes of both sexes, this particular
form seems confined to the male. Beer says
that he has observed it only in young, robust, and
plethoric men.

62. f. Treatment. — The antiphlogistic plan,
and particularly vascular depletion, has been car-
ried to the utmost extent, sometimes with com-
plete, but as often with only partial, success.
Of six cases which Mr. Lawrence saw at an
early period, and treated by extensive depletion,
general and local, loss of the eye occurred in one
only, — a most satisfactory evidence of the pro-
priety of the practice. But whenever the disease
comes late under treatment, no plan can succeed,
so violent and rapid is the disease. The appli-
cation of strong astringents and escharotics to the
eye, in order to arrest its progress, has been ad-
vised, as its consequences have been so destruc-
tive to the organ ; and the nitrate of silver oint-
ment, already described (§ 49.), has been re-
commended by Rlr. Guthrie. The success of
this practice in the severe purulent ophthalmia,
warrants its adoption in this; and active deple-
tions, found so successful by Mr. Lawrence, in
an early stage, may precede it. One circum-
stance, however, may militate against our infer-
ences in favour of it, namely, the original and
principal seat of disease being in the palpe-
bral conjunctiva, in purulent, and in the con-
junctiva oculi, in gonorrhoeal, ophthalmia, the
pathological states are not therefore the same in
both. Notwithstanding, both modes of practice
may be conjoined with advantage, as Dr. Jacob
suggests. The oleum terebinthinae, dropped into
the eye, is deserving of trial.

63. Large and repeated bloodlettings from the
arm or jugular vein, followed by local depletion
and the remedies above advised (§ 62.), are, in
the present slate of our knowledge, most to be
depended upon. But if sloughing or suppura-
tion of the cornea have occurred, this treatment
will be of no service. Mr. Lawrence has seen
mercury employed without any advantage, and
he places no reliance on the reproduction of the
urethral discharge, as advised by Richter,
Scarpa, and Beer. He also thinks blisters to
be of little use. The eyes should be very fre-
quently cleansed by the usual means. VVhen
the inflammatory symptoms have been com-
pletely and quickly subdued, the efl^ects will pass
ofl^in a little time without astringents and tonics;
but when the conjunctiva becomes pale and
flabby, and the patient pallid and weak, the pu-
rulent discharge being still abundant, astringents
locally, and tonics internally, are usually recom-
mended. When sloughing or ulceration of the
cornea is attended by signs of great depression,
quinine and generous diet are necessary, and
astringent lotions are sometimes of service. Mr.
Lawrence prefers a solution of from two to ten
grains of alum in an ounce of water, the solution
of the nitrate of silver, and undiluted liquor
plumbi di-acetatis.

64. g. Mild gonorrha'al Inflammation of the
Conjunctiva. — Mr. Lawrence has described a
very slight variety of gonorrlioeal ophthalmia,
consisting of external redness ot a bright scarlet
tint, with distension of the superficial vessels of the
globe, and increased mucous secretion. In still
slighter attacks, the redness is not deep nor gene-

EYE — ScROFuious Ophthalmiji.

863

ral, the membrane is not swollen, the secretion
is but little increased, and the pain is trifling.
The severer grades of this form approach to those
of acute purulent ophthalmia, tlie conjunctiva
being red throughout, tumefied, and secreting a
copious yellow mucous matter. These milder
states of the disease usually occur in patients
with gonorrhoea of a rheumatic or gouty dia-
thesis, and most frequently in conjunction with
rheumatic afTections consequent upon gonor-
rhcEal disease of the urethra.

65. h. The Treatment consists of antiphlogistic
remedies, co-ordinate with the severity of the
attack, and the strength of the patient; followed
by astringent applications — the best of which, in
the opinion of Mr. Lawrence, is the solution of
lunar caustic.

? 66. D, Pustular Ophthalmia — Pustular
IiiJiammatioH of the Conjtmctiva. — a. Inflam-
mation of the conjunctiva, with small pustules, or
phlyctenulic, sometimes occurs from cold or other
causes, and resembles, in its appearance, and
occurrence chiefly in persons before puberty, the
strumous form of the disease. But it is met with
in those who are not strumous ; and it does not
exhibit the other symptoms of scrofulous or
catarrhal ophthalmia : it therefore constitutes a
distinct variety. It is characterised by distended
fasciculi of vessels upon the conjunctiva, which
run towards the cornea, either terminating at its
margin, or extending a short way over this
boundary, and there form a small reddish or
whitish elevation. This elevation contains, at
first, a little watery fluid (Phlyctenie), but it af-
terwards assumes a pustular appearance. Some-
times only one is observed, at others there are a
greater number extending around the margm of
the cornea. They are usually small ; but, when
single, they are occasionally as large as a split
pea. They are not attended by much pain or in-
tolerance of light. If the complaint is neglected,
the pustules may ulcerate, and the ulceration
spread.

67. b. The Treatment consists in the application
of leeches and blisters in the more acute cases.
The disorder generally disappears, under ordinai'y
circumstances, without ulcerating, when due at-
tention is paid to the secretions and excretions;
milti -aper^'gnts and a saturnine lotion are usually
all that are required.

68. E. Scrofulous Ophthalmia. — Syn.
Scrofttlous Tnfiammation of the Conjtmctiva ;
Stru7tious Ophth.; Infiam, of the Conjunctiva in
Scrofulous Constitutions. — Scrofulous children
are very liable to this disease. It is sometimes
the first manifestation of the strumous diathesis ;
and, if neglected, it often becomes the source of
impaired, or entirely lost, vision. It seldom at-
tacks infants before weaning ; but, from that
period to nine or ten years of age, it is very pre-
valent ; as many as three fourths of the cases of
ophthalmia at this period being scrofulous. Some-
times oidy one eye is affected, at other times both
are inflamed from the first ; and very often the
disease passes from the one to the other. When
both are simultaneously attacked, one is usually
much worse than the other.

69. a. Causes. — a. The predisposing causes are
those of ScnoFui.A (see that article) which may
be very generally referred toclimate, air, exercise,
food ; and to the habits, health, and constitution

of the parents. — B. The exciting causes z.r& ex-
posure to cold and moisture, injuries to the eye,
irritating matters in the air, excessive use of the
organ ; the common causes of catarrhal ophthal-
mia, or an attack of this complaint ; teething,
hooping-cough, and more especially cow-pox,
exanthematous diseases, and porriginous erup-
tions on the scalp and face. Measles and small-
pox very frequently excite it ; and Juengken
represents vaccination as one of its most common
causes. He disapproves of the practice of vacci-
nating children in the first year; as he considers
that a certain degree of constitutional vigour is
required to remove from the system the poison
introduced by inoculation ; and that, when the
child is weak or too young, the morbific matter
is not thrown off, and calls into action the scrofu-
lous diathesis. Beer states that, in Breslau,
where ninety-five cases out of one hundred of
ophthalmia in children are scrofulous, the streets
are narrow and filthy, and the food of the poorer
families unwholesome. Mr. Lawrence and Mr.
Mackenzie think that the complaints described
by Mr. War drop under the denomination of
" Exanthematous Ophthalmia," and by Mr. Chris-
tian under the name of " Porriginous Ophthal-
mia," belong in every essential respect to the dis-
order now being considered.

70. b. Symptoms and Course. — External red-
ness is often inconsiderable, and most apparent at
first in the linings of the lids. It is generally only
partial in the conjunctiva oculi, particular en-
larged vessels, or fasciculi of vessels, running in
this situation towards the cornea, and extending
over its margin, or stopping short of it. Where
the fasciculi terminate, small phlprtence or pustules
form, and contain either a little clear or a yellow-
ish fluid. These pustules may be seated on the
sclerotica or cornea, but more frequently on the
boundary between them ; and may be single, or
several. Their presence has induced Mr. Mac-
kenzie to view strumous ophthalmia as an erup-
tive disease. — The intolerance of light is extreme,
and characteristic of the complaint. The lids are
spasmodically closed, and resist any attempt to
open them ; end, when opened, the cornea is
turned up under the edge of the orbit, and away
from the light. The child puts all the muscles
into action to protect tlie organ ; and hence a
peculiar and characteristic physiognomy is as-
sumed. It seeks the darkest part of the room, or
presses its face against the pillow in bed, to escape
from the light. This excessive sensibility of the
retina (Photophobia scrofulosa) \s not caused by
inflammation, nor is redness even essential to it;
for it is often very remarkable where the eye ap-
pears almost natural; and the child opens its eyes
and sees as well as usual in the dusk. This dis-
ordered sensibility is altogether sympathetic and
functional ; and is dependent, as Rlr. Lawrence
thinks, on the ccmdition of the alimentary canal.
I would impute it rather to the state of the or-
ganic nervous system.

71. There is a copious flow of tears at the
commencement. The external surface of the or-
gan suffers great irritation, extending to the
lachrymal gland, so that when we attempt to ex-
amine the eye, or to expose it to the light, there
is a copious discharge of scalding tears, caus-
ing redness of the lids, and excoriating them and
the face. Owing to the itching and soreness

864

EYE — Scrofulous Ophthalmia.

thereby occasioned, the child rubs or scratches
the parts, which -become sore and pustular, and
produce a discharge which encrusts ; the affec-
tion ultimately extending over the face and
forehead, and in its worst form resembling
crusta lactea and porrigo larvtiUs. The edges of
the lids are often red, swollen, and painful.
There are sometimes an acnd secretion from,
and excoriation of, the nostrils; with redness
and swelling of the alfe nasi and upper lip.
The ears are frequently red and sore, or ex-
coriated behind, and the absorbent glands of
the neck are swollen. The bowels are cos-
tive, the tongue wliite or furred, the abdo-
men distended, the breath foetid, the appetite
is morbid, the head and sometimes the skin are
hot, and the child is restless and grinds its teeth
when asleep. The symptoms are worse during
the day, but remit some wha in the dusk of
evening. The inflammation of the eye may sud-
denly subside, and return as suddenly ; and very
slight exciting causes will bring back the com-
plaint ; which may thus continue with slight in-
termission for months, or even for years. The
affection of the eyes may also alternate with some
other disorder, or symptoms in remote parts. In
the more chronic cases, the health suffers greatly
from seclusion from light, air, and exercise ; and
the patient becomes pale, etiolated, and sickly,
with a dry and harsh skin.

72. c. The Consequences of the diseai;e on the
cornea are often serious, although the external
redness may not be great. The phlyctenular or
pustular elevations in the cornea may subside,
leaving s/ig/ii opaciVi/, or considerable thickening
of the corneal conjunctiva with greater and more
permanent opacity ; but they more commonly
ulcerate, in an irregular form, and with a ragged
edge, the ulcers sometimes extending superficially,
or making their way through the cornea to the
anterior chamber, occasioning prolapse of the
iris. The vessels passing over the cornea may,
without forming pustules, occasion thickening and
opacity, which may proceed so far as to render
the whole corneal covering thick and vascular
(Pannus). Opacity from interstitial deposition
may also occur, either with or without enlarge-
ment of the proper corneal vessels ; and, occord-
ing to Dr. Frouiep, a brownish red discoloura-
tion, from interstitial effusion of blood, may super-
vene. In addition to the opacity, the external
layers of the cornea may yield from the pressure
from behind, and form an external protuberance
(Staphyloma}; or adhesion of the iris to tiie in-
ternal surface of the cornea may take place. In
some instances, the inflammation extends to the
sclerotic coat and iris, and even to the parts seated
boliind them. This occurs most frequently in
prolonged or after repeated attacks; and occa-
sionally is followed by structural change of
these parts, or by dropsical enlargement of the
globe.

73. d. Diagnosis. — The extreme intolerance
of light, and copious flow of tears in connection
with tiie trifling external redness, the pustular
elevations of tlie conjunctiva, suflicienlly dis-
tinguish this affection, wliich fn^fiiicntly, also, co-
exists with enlargement of tiie glands and scro-
fulous irritation of the nostrils, lips, behind the
cars, and in other ])arts of the body. In many
instances, however, of conjunctivitis in children,

it is difKcult to draw a distinction between the
common and scrofulous forms of the disease ;
),he characters of the one gradually merging into
those of the other. This is more especially the
case when the affection of the eyes is associated
with, or consequent upon, either acute or chronic
cutaneous eruptions, particularly such as affect
the scalp and face.

74. e. The Prognosis is favourable, if the cornea
be not affected, or if superficial or slight opacity,
owing to deposition between its laminee, only be
present. Mere vascularity of the cornea will dis-
appear ; but if it be attended by thickening and
opacity, the change will be more or less per-
manent. If ulceration have taken place to con-
siderable depth or extent in the cornea, and
especially if it be accompanied with affection of
the iris, or lesion of the sclerotic coat, vision will
be more or less impaired.

75./. Treatment. — a. Constitutional or inter-
nal means are most important in this complaint.
After the bowels have been freely evacuated, a
course of tonics should be prescribed, with alter-
atives, to promote and improve the various secre-
tions. A full dose of calomel and rhubarb, !and
afterwards equal quantities of the compound in-
fusions of gentian and senna, or the compound
decoction of aloes, repeated according to circum-
stances, will be most serviceable. In some cases,
an emetic will advantageously precede the purga-
tives. Having thereby evacuated morbid matters,
and excited the secreting and excreting viscera,
tonics, especially the sulphate of quinine, will be
productive of the greatest benefit. During the
course of tonics, the hydrargyrum cum creta
should be given on alternate nights, with the
carbonate of potash and rhubarb or jalap.
If the skin be pale, or the child languid and
etiolated, the preparations of iron — especially the
tinctura ferri ammonio chloridi,-the vinum ferri,
the ferrom tartarizatum — may be preferred. An
electuary of sesqui-oxide of iron, confection of
senna, a:^d treacle, may occasionally be substi-
tuted — particularly on the day following that
on which the powder was taken. In some in-
stances, the decoction of bark, with sulphuric acid
may be alternated with these tonics, especially
after mercurials have been laid asiile. Cascarilla
with soda, or any of the tonic infusions, with
small doses of the chlorate of potasli, may likewise
be tried.

76. /3. Pegimen and diet are most important
items in the treatment. The patient should be
warmly clothed, and take regular exercise in the
open air, particularly when it is dry and bracing.
Change of air, occasionally to the sea-side ; and
warm, tepid, or cold bathing, are also beneficial.
In weak or irritable children, warm or tepid
bathing, salt having been added to the water, or
in sea water, should be first adopted ; and cold
bathing tried as the iiealth improves, 'j'hc diet
should be duly regulated ; animal food in mo-
derate quantity, suitable vegetables, and ripe
baked fruits, being allowed ; but all fermented
liquors, indigestible substances, and rich crusts
or pastry ought to be withheld. The usual fari-
naceous food should always constitute a chief part
of the diet. Tin; child ought to wear through the
day a dark shade before the ryes ; and sleep in a
dark but well- aired room, with the head consider-
ably raised.

^7. y. Local Treatment, — When the external
inflammation is considerable, or approaches the
characters of common ophthalmia, and is at-
tended by symptomatic disturbance of tlie system,
local bleedings, and the rest of the antiphlogistic
regimen, should be prescribed, particularly at an
early stage of the complaint. The intolerance of
light is no indication of the propriety of local de-
pletion ; for it is generally aggravated by the
practice, and relieved by tonics and a light and
nutritious diet. JMr. IMACKtNziE advises, parti-
cularly in chronic cases, and in the seat of the
vascular fasciculi, scarijications of the eyes and
lids. Fomentations with warm water, or a warm
decoction of poppies and chamomile flowers, are
of service. Applications as warm as they can be
borne are more beneficial than those that are
cold, which are not suited to scrofulous persons.
The steam of warm water, to which camphor and
opium have been added, is also useful ; or a few
drops of an opiate may be allowed to run be-
tween the lids. After the painfully acute symp-
toms have been removed, and the bowels freely
evacuated, a solution of from two to six grains of
lunar caustic in an ounce of water, dropped be-
tween the lids, is very serviceable in diminishing
the irritability of the organ, and in healing slight
ulcers. A stronger solution may be applied by a
pencil to the ulcerated part, and the red precipi-
tate ointment to the lids at night. In older
children, bliiters behind the ears or on the nucha
are serviceable ; but they ought to be removed
after five or six hours. If thickening and opacity
of the cornea be going on, the free administra-
tion of calomel or hydrarg. cum creta, either alone
or with James's or Dover's potcder, is advised by
Mr. Lawrence, until the mouth is affected.
"When incrustations form in the vicinity of the
organ, tepid ablution, and the mild ointments,
at first alone, and afterwards with the oxide of
zinc, when the state of the complaint and of the
system, or the previous treatment, will admit of
drying them up, should be employed. — In cases
attended by ulceration of the cornea, it will often
be necessary to touch the part, every second or
third day, with lunar caustic, as directed by
Scarpa. Tlie application of belladonna to the
eye or its vicinity, to cause dilatation of the pupil,
will occasionally be serviceable in preventing
either adhesion or prolapse of the iris. — Relapses
should be guarded against by a careful examina-
tion of the eye from time to time, by attention to
the digestive organs, and by an invigorating
regimen.

78. F. EXANTHEMATOUS OpHTHALJIIA. SyN.

Kxanthematoiis Conjunctivitis — Injiammation of
the Conjunctiva occurring during Exunthematous
Fevers. — Inflammation of the conjunctiva is fre-
quently observed in the course oj, or consequent
■upon — (a) Small- pox ; (b) Measles ; (^c) Scarla-
tina ; and (d) Erysipelas. — As to each of these
associations, and the treatment most appropriate
to it, I proceed to offer a few observations.

79. a. Variolous Oplithatmia — Conjunctivitis
Variolosa.— a. Small-pox causes inflammation of

the lids, of the lachrymal sac, and of the eye, dur-
ing the active stages of the eruption ; and it gives
rise to inflammation of the eye, and of the con-
junctiva of the lids, and of the nasal duct, after
the eruption has subsided. When variolous pus-
tules form only on the external surface of the eiye-
Voi,. I.

EYE — ExANTHEMATOus Ophtiialiuia. 86.5

lids, or the ciliary margins, the afl'ection is com-
paratively mild. In confluent or severe cases of
small-pox, the lids are much swollen and closed,
and the oozing of matter usually agglutinates
them, and confines the secretions poured out in
the conjunctiva. As the disease subsides, the lids
are opened, and the eye appears to have been
but little aft'ected. They are, however, often
somewhat injured. The pustules on the ciliary
margins partially destroy the cilia, and render
the margins uneven and liable to inflammation
from slight causes.

80. B. When the inflammation extends to the
globe during the eruptive stage of small-pox, con-
stituting true or primary variolous ophilialmia, and
occasioning pustules on the conjunctiva or cornea,
the affection is very severe, and is often rapidly
followed by suppuration or sloughing of the latter,
and by the more serious consequences of these
changes. As the eyes are closed, and cannot
easily be examined, it is important to ascertain
by symptoms the existence of inflammation of the
globe. I'his is indicated by a sense of dryness,
stiffness, or of sand in the eye, with pain in the
ball, increased on moving it, aggravated by light
although the lids are closed, and attended by
augmented lachrymal discharge as the affection
proceeds.

81. y. A form of the disease may occur two,
three, or four weeks after the desiccation of the
small-pox pustules (secondary variolous oph-
thalmia). It is generally more mild in this case ;
but one or more pustular elevations may form on
the cornea, with redness of the sclerotic, lachry-
mation, pain, and intolerance of light. It does
not terminate by sloughing ; but suppuration and
ulceration often supervene, leaving more or less
opacity, or a permanent white cicatrix, limited to
a small extent, as the surrounding haziness of the
cornea is removed, vision being partially or com-
pletely restored. In scrofulous constitutions, it
assumes the characters described above, and de-
generates into the chronic form.

82. J. The Treatment of these j'orms of affection
must be conducted conformably with the prin-
ciples already explained. When the pustules
are confined to the lids, they may be touched, in
an early stage, with the lunar caustic, in order
to arrest their progress, as advised by JM. Vel-
PEAu ; or they may be opened, and the matter
evacuated ; the incrustations afterwards formed
being removed by emollient applications and fre-
quent tepid ablution. In the two other states,
the danger to the organ is much greater, particu-
larly in ihej'orm attending the eruption. But, as
the affection of the eyes is most common in the
confluent and adynamic states of small-pox, it
cannot be advantageously combated by such free
depletions as some surgical writers have advised.

i In many cases, local bloodletting and free purg-
ing may be of great service ; but, when the con-
■ stitutional powers are much depressed, no plan of
j ascertaining the state of the globe should be neg-
lected^ and a somewhat similar treatment of the
pustules to that just advised should be practised
as early as possible, to prevent their develope-
I ment, and be followed by such astringent applica-
j tions, alternated with soothing means, as the cir-
cumstances of the case may suggest. In the se-
condary variolous ophthalmia, local depletions, active
purgatives, or even an emetic, resorted to at any
3 K

8G6

EYE — Inflammation of the Sclerotic Coat, etc.

early stage, are more appropriate and beneficial.
But the subsequent use of astringents will gene-
rally be required. In all the forms, tonics will
afterwards be necessary ; and the patient should
be kept in a perfectly dark, but well-aired, apart-
ment during the course of the disease.

83. b. Morbiilous Ophthalmia — Conjunctivitis
morbillosa. — Inflammation of the conjunctiva is
a common attendant on measles. It is generally
of a catarrhal kind, and may be either primary —
preceding or accompanying the eruption ; or se-
condary— remaining after, or following the dis-
ease at a short interval. Sometimes pustules form
on the cornea, and pass into ulceration. There
are generally much pain and intolerance of light
in this variety ; but it seldom assumes a severe,
although often a chronic, character. The Treat-
ment consists of local depletion, in the more acute
cases; followed by active purgatives, diaphoretics,
blisters behind the ears or on the nucha, tepid
u-aslies, and the protection of the organ from ligiit.

84. c. Scarlatinous Ophthahnia — Conjunctiritis
Scarlatinosa. — Inflammation of the conjunctiva
may occur in the course of scarlet fever, in simi-
lar modes to those noticed in respect of the other
exanthems ; and although not so common in
scarlet fever as in measles, it is sometimes more
severe in the former than in the latter ; ulcera-
tion occasionally supervening to a greater or less
extent. This is, however, often the consequence
of neglect. The Treatment is, in every respect,
the same as that directed for the morbillous
form.

85. d. Erysipelatous Ophthalmia — Conjuncti-
vitis Erysipelatosa. — Tlie inflammation of tiie
conjunctiva attending cysipelas is preceded by
redness and great swelling of the lids. In rarer
instances, it follows upon an erysipelatous affec-
tion of the throat and posterior nares ; and it is,
in cases of severe affection of the face or scalp,
often attended by much inflammation of, and
effusion into, the cellular tissue surroundmg the
globe. It is most common in persons past middle
age, or of a cachectic habit of body. The con-
junctiva of the lids and ball is more or less in-
jected ; that of the latter often rises in soft yel-
lowish red vesicles around the cornea, and occa-
sionally it is affected in nearly a similar manner
to the pustular varietii already described. In
some cases the redness partakes of a yellow tint,
and in others of a livid or brownish hue. The
eye has a watery appearance, and the cornea is
often hazy from the fluid collected on its surface,
but it is seldom otherwise aflPected. As the dis-
ease sub-ides, the copious lachrymation generally
present U diminished, but the organ regains its
natural state very slowly. The constitutional
disturbance is very severe in this variety. (See
EiiYSiPELAS. ) The Treatment consists of local
diipletions, which, however, should be cautiously
practised ; of emetics, purgatives, blisters, diapho-
retics; and of opening the vesicles that form, with
the point of a lancet. In an advanced stage,
tonics, and other remedies suited to particular
cases, are requisite.

ii. Inflammation of the I'iioplr Exikunai,
Tissues of the Eve. — A, Common Inflam-
mation OF the Exieunai, Tunics. Svn.
— Ophthalmitis externa Idiopathica, Bfkii ;
Ophthalmi't Sclerotica, Vetch ; External In-
JiammalioH of the Globe, Lawhencf; Co-

tarrho-rheumatic Ophthalmia, INIackenzie, —
Fhlegmonoid Sclerotitis. — a. Acute, — b. Sub-
acute, — and c. Chronic.

86. Ciiaract. — Redness of the external proper
coats of the eye, with pain, intolerance of light,
increased lachrymal discharge, and febrile dis-
turbance.

87. (J, Symptoms and Course. — Simple or com-
mon inflammation of the eyes of persons other-
wise healthy may originate in the conjunctiva or
sclerotica ; but, when severe in either, it gene-
rally extends to the other, and also to the cornea.
It frequently also appears almost coetaneously in
both coats; and it presents every grade of seve-

.rity. The external redness usually begins on
the anterior part of the globe, forming a zone
around the cornea, and arises from small vessels
advancing from the posterior part of the sclerotica
to the part adjoining the cornea. As the inflam-
mation proceeds, the redness becomes uniformly
diffused in the sclerotica, and is of a pink, rose
red, or almost violet hue. In the more severe
cases, the distended vessels are seen under the
conjunctiva, occupying the whole surfnce of the
sclerotica, and generally running in nearly straight
lines from behind forwards. When the inflam-
mation is seated in both this coat and the con-
junctiva, the difference as to tint and situation
between the vessels of each is very remarkable.
The patient complains of stifl^ness and dryness of
the eye, is intolerant of light, and feels a burning
or aching pain, with a sense of tension, or pres-
sure, or of dust in the eye (^Xerophthalmia, or
Opht. Sicca). The pain usually increases, and
extends to the orbit and corresponiling side of the
head ; the intolerance of light becomes greater ;
and the pupil is contracted. As the disease ad-
vances, the conjunctiva participates, its vessels
are distended, and the cornea becomes dull, but
not, at first, nebulous or opaque. In more
violent cases, this membrane acquiies a bright
red colour, or even passes into a state of chemo-
sis. At the same time pain and fever increase,
the inflammation extends to the lids, and the
cornea assumes a greyish hue. The dryness
characterising the commencement of the com-
plaint gives place to lachrymation, which is
increased on opening the eye to the light, or
moving it.

88. b. The Effects that present themselves, as
the disease proceeds in an ac^ite form, are observed
chiefly in the cornea, and occasionally also in the
iris. — The former becomes either vascular, and
red or reddish l)rown, or greyish, and subsequently
whits, cloudy, and yellow, as if pus were infil-
trated into its substance. It often afterwards «/-
cerates ; the ulcerations sometimes extending into
the anterior chamber, and causing the usual con-
sequences of this change. Adhesion, also, of the
iris to the cornea may occur either with or with-
out ulceration of the latter, but always with more
or less opacity. When the cornea presents only
the first stage of change, is greyish, cloudy, or
white, ulceration may he prevented, or arrested if
it have begun, by suitable treatment, and if
it have not occurred, the cornea may regain its
natural aj)pearance.

89. c. The sub-acute and chronic states of the
complaint are characterised by h ss severity, but
longer duration, of tiie symptoms described
above, particularly those depending upon the

EYE — Inflammation of the Scleuotic Coat, etc.

867

affection of the sclerotica. They often follow
the neglected or inactively treated acute disease.
In thc<e cases, the conjunctiva of the eyelids is
somewhat irritated or inflamed. The eyes are
painful on exertion, or exposure to much light;
and the lachrymal discharge is thereby increased.
In the more severe and protracted attacks, the
transparency of the cornea and vision are more
or less impaired. Allliough tiie clironic often
thus supervenes upon the acute complaint, owing
to neglect, to errors in diet, to indulgences in
spirituous liquors, or to exertion of tiie organ,
when the inflammation has been only partially
subdued; yet, in persons of a cachectic habit of
body, it may be the primary affection. In deli-
cate or unsound constitutions, also, the complaint
very frequently assumes a sub-acute or chronic
form from the commencement, and continues long,
until an increase of certain of the syniptoms alarm
tiie patient.

90. d. Diugnosis. — Inflammation of the exter-
na] proper tunics of the eye is distinguished from
that of the conjunctiva, by the redness com-
mencing in the sclerotica, in the vicinity of the
cornea, asid extending backwards in the direction
of the orbit, and only consecutively to the con-
junctiva ; inflammation of this membrane usually
following an opposite course, and extending to
the sclerotica only when it advances to the
cornea. Tiie discharge being lachrymal, and
not mucous or purulent ; the seventy of the pain,
and the intolerance of light ; the situation and
direction of the injected and enlarged vessels ;
the peculiar tint presented by the inflamed scle-
rotica ; and the more frequent affection of the
cornea ; are circumstances sufficiently diagnostic
of the complaint. The natural state of the pupil
and iris, and the unimpaired vision, distinguish
it from internal ophthalmia.

advantageous if practised in the manner advised
in the article Ulood (§ 64.), and followed by
the means there recommended ( ^ 65.). In
milder cases, or in more delicate persons, or after
venaisection, local bleeding, either by cupping on
the nape of the neck, or behind the ears, or on
the temples, may be directed ; or leeches applied
on the two latter situations. Mr. Lawrence
advises them to be placed upon the lids, to the
number of from twelve to twenty-four in the
case of an adult. Scarification cf the conjunctiva,
is disapproved of by him, although recommended
by some writers. VVeller advises it when
chemosis is present. In this form of ophthalmia,
tiie modes of depletion now mentioned are the
most appropriate. Cupping in many cases may
supersede venffiseclion ; as a sufficient quantity
of blood may be taken in this way from either of
the situations just named, for the exigencies of
almost any car-e.

93. Purgatives, low diet, refrigerants, when
the febrile excitement is considerable, and dia-
phoretics, are the next most important measures.
Calomel and James's powder, either with or with-
out opium, at bed time ; cathartics in the morn-
ing, and mild diaphoretics and diluents during
the day; are generally appropriate. If vascular
excitement continue notwithstanding, an antimo-
nial emetic should be prescribed ; or it may
follow the depletion, and precede the exhibition
of a full dose of calomel and purgatives. In
the more violent or protracted cases, tartar emetic
may be given so as to keep up a continued nau-
sea. When costiveness is present, or purgatives
act insufficiently, drastic or terebinthinate enemata
are requisite. If the free use of calomel, after
the depletions, aflfect the mouth, the occurrence
should be viewed as favourable ; complete reco-
very being thereby accelerated, and the ill eflfects

91. e. 77ie Proo^nosis entirely depends upon the of the disease on the cornea prevented. Coichicum

has be^n noticed in this complaint by several
writers ; and is serviceable either in the form of
powder with calomel, or in aperient mixtures.
It is most eflScacious after the bowels have been
fully evacuated. When the inflammation has been
nearly removed by the preceding remedies, blis-
ters on the nucha or behind the ears, and warm
pediluvia at bed time, are useful in preventing a
relapse or the passage of the complaint into a
chronic state.

94. The Iccal means, in addition to bleeding,
consist chiefly of coW, warm, emollient, and astrin-
gent applications. The choice of these is a matter
of some difficulty ; but when the disease is only
commencing, or when the patient complains of
great heat or burning in the eye, and experiences
relief from cold epithems, then any of the various
modes of applying cold may be adopted. If;
however, the complaint be advanced, or if cold
occasions an aching or chilling sensation, warm
applications or fomentations should be preferred.
It has been doubted by Mr. Lawrence and
some other writers, whether such as are emollient
andviarcoiic be at all superior to those which are
more simple. The former have been recom-
mended principally by Continental, the latter
by British, physicians. 'J'he doubt has arisen
chiefly from a physiological notion long enter-
tained, although the grounds on which it is
founded admit of a ready refutation. An intimate

degree in which the cornea is afl^ected. — As lon_
as this part is unchanged, or if the lesion of it be
but sliglit, a favourable opinion may 1 e given.
The case becomes serious, when the complaint
occasions chemosis, and a greyish or whitish
alteration of the cornea ; and still more so, if
matter be formed in it. In this case, ulceration
will be inevitable ; and the effect of ulceration or
opacity upon the sight will depend upon their
extent ami situation in reference to the pupil.

92. f. Treatment. — a. In the acute form. — The
predisposing and exciting causes (§ 4, 5, 6.) to which
the complaint may be referred, should be com-
pletely removed. The organ should next be pro-
tected from exertion, and from light and air. If
one only be affected, the other should not be used,
nor exposed to injurious influences. These
measuies, in slight cases, may be sufficient to
cure the complaint ; and have succeeded when
further treatment could not be resorted to. But
others should be employed, particulaily in severe
cases ; and still more so in such as are violent,
or are attended by aflfection of the cornea. Even
in mild attacks, active treatment should not be
withheld, as, even in these, neglect may be fol-
lowttd by serious results as respects the sight.
Bloodletting, general or local, can rarely be dis-
pensed with. The former ought always to be pre-
ferred when the complaint is attended by febrile
disturbance, and should be carried sufficiently

far to impress the circulation. It will be most observation of phenomena — the only legitimate

% K 2

EYE — Rheumatic and Arthritic Ophthalmia.

experience — should alone decide the question.
Although my experience in this matter has neces-
sarily been limited of late years, yet have I seen
enough even of this complaint, to convince me
that fomentations with emollient and anodyne
substances are superior to those which are sim-
ple— -which consist only of warmth conjoined
with humidity. Therefore, when the pain and
intolerance of light are great, the disease some-
what advanced, or even established, warm emol-
lient and anodyne applications ought to be
preferred. Scarpa directs mallows boiled in
fresh milk as a fomentation ; or emollient and
anodyne vapours, to be conveyed '.to the eye
through an inverted funnel. Mr. Mackenzie
directs opiate frictions of the forehead and tem-
ples, and the eye to be kept under the influence
of belladonna. Fomentations with a decoction
of poppy-heads and camomile flowers, or marsh-
mallows ; and the vapour of warm water, to which
camphor and the watery extract of opium have
been added ; are generally beneficial in the cir-
cumstances just stated. Dr. Smith remarks, that
when the pain was not alleviated by bloodletting
or by fomentations, much and lasting relief was
procured by exposing the eye, twice or thrice
daily, to the steam arising from the following
mixture brought to a boiling heat. It is now
eighteen years since a nearly similar combination,
but with much more opium and camphor than is

mucilage of quince-seeds and half a drachm or
a drachm of Sydenham's laudanum, is often of
service. Several other applications, some of them
much more astringent than the above, have been
recommended ; but they are undeserving of par-
ticular notice. The astringent ointments, and
solutions found so beneficial in the treatment of
conjunctivitis (§ 16. 50.), may also be employed
in tlie chronic states of this complaint, particularly
under the circumstances just specified.

96. B. Rheumatic, Catarrho-Rheumatic,
and Authritic Ophthalmia. Syn. — Opht,
Rheumatica et Arthritica. — Sclerotitis Rheumatica
et Arthritica. — Injiammation of the External pro-
per Tunics in Rheumatic and Guuti/ Constitutions.

97. a. The Rheumatic modification of ophthal-
mia. — Sclerotitis Rheumatica or Atmospherica of
iMackenzie — is sealed in the external proper
tunics of the eye, as in the common, or phleg-
monoid, variety just described. The conjunctiva
is only slightly affected ; but the inflammation
sometimes extends to the iris, or cornea, or to both,
but generally in a slight degree. It is commonly
caused by cold, or currents of air striking the
eyes of persons of a rheumatic diathesis. It is
not a common afl'ection, and seldom arises from
metastatis.

98. b. Symptoms and Course. — A stinging or
tearing pain is complained of in the eye, increased
by heat and by a warm bed, and extending to the

here ordered, was prescribed by me with great • orbit and adjoining parts of the head and face
" ■" . . -• The sclerotica is of a rose red, and shines through

the conjunctiva, which is more injected than
usual. There is an increased flovv of tears, aggra-
vated by changes of temperature. The pain sub-
sequently becomes more dull and aching, extends
with greater severity to the neighbouring parts,
and lachrymation is augmented. The intolerance
of light, which was only slight, is afterwards felt
only in a strong light. Dullness or haziness of
the cornea is frequently observed, but is seldom
followed by any serious change. Sometimes
phlyctenula; appear in the conjunctiva oculi and
cornea, but they do not often pass into ulceration.
The biliary and intestinal functions are more or
less disordered ; and febrile disturbance is com-
monly present. The severi'y and duration of an
attack vary very much. Slight cases soon subside ;

relief in a case of the disease

No. 219. — R Mist. Camphors 5 ij. ; Tinct. Opii 3 ss. ;
Liq. Ammon. Acet. 3 0- ; Aq. Rosar. 3 iv. M.

95. (3. The sub-acute and chronic states, espe-
cially the former, sometimes require either vence-
section, or full cupping, particularly in young or
robust persons. In most instances, leeches should
be applied to the vicinity of the eye ; and some-
times either they or cupping ought to be repeated
oftener than once. Purgatives should be freely
employed; and, if the tongue be loaded, and the
evacuations offensive, an emetic should precede
them. Great attention ought to be paid to the
diet ; and animal food must be taken only in small
quantity or nearly relinquished. Counter-irri-
tation is generally beneficial ; and either open
blisters, pustulation by means of tartar emetic

setons, or issues, should be directed to the nape of but severer attacks may give rise to iritis, which
the neck, behind the ears, or to the temples. ' is, however, rarely acute, unless the disease be
During treatment, the bowels should be freely [ neglected, when it may go on to effusion of coa-

opened by stomachic purgatives, particularly if ~ '

the tongue be loaded, and the discharges morbid;
and the regimen as well as the diet rigorously
restricted. If the above treatment have been
actively employed, the complaint will be re-
moved, without the necessity of resorting to as-
stringent or stimulating applications. But, in
neglected cases, they are sometimes very bene-
ficial, especially if the affection of the conjunc-
tiva be considerable, after the above measures
have been appropriately prescribed, and when
the complaint is far advanced, or in a chronic
state. The vinum opii, dropped into the eye,
was recommended by Mr. VVakk ; and is suited
chiefly to chronic cases. The liquid laudanum of
Sydenham (F. 729.), or preparations similar to it,
may also be applied. 'J'he collyriuin praised by
CoNRADi, and which consists of one grain of
bichloride of mercury dissolved in six ounces of
rose water, with the ad<lition of a drachm of

gulable lymph. Rheumatic sclerotitis is not
attended by affection of the lids, nor by che-
mosis : it does not give rise to suppuration, and
rarely to ulceration, the ulcers being small or
peculiar, and healing readily ; and it sometimes
lapses into a very chronic, slight, or recurring
form.

99. c. The Catarrho-rheumatic ophthalmia of
some writers does not differ materially from the
common or phlegmonoid inflammation of the pro-
per external tunics {§ 8fi.), being seated in the
sclerotica and conjunctiva. It is usually caused
by cold, and atmospheric changes; and in the
rheumatic diathesis, very nearly approaches, or
merges into, the rheumatic forin ; the only dif-
ference being in the greater afi'ection of the con-
junctiva, and in the consc(|ucnt manifestations of
certain catarrhal symptoms.

100. d. Arthritic Ophthalmia — Sclerotitis Ar-
thritica. — Arthritic external Opht. — or inflam-

EYE — Inflammation of the Cornea.

869

mation of the external proper coats occurring in the
gouty habit, is oftener attended by irilis, than tlie
rheumatic variety ; but iritis is frequently
observed in gouty persons without sclerotitis.
Sometimes gouty inflammation of the sclerotica is
accompanied with an erysipelatvusfonn ofconjuuc-
tivitis, which Beeu has seen to follow the sup-
pression of gout in the feet by cold. The pro-
gress of this modification of external ophthalmia,
in its early course, is simihir to the rheumatic,
when it is confined chiefly to the sclerotica ;
but when the conjunctiva is also affected, it
hardly differs from the erysiiwlatous variety
already described (§ 85.); When the external
proper tunics are the parts attacked by the gouty
affection, pain of the eyeball is very acute, and
darts in the course of the facial nerves, and is
usually preceded by a pricking sensation. A
flow of acrid tears takes place. The sclerotica
around the cornea becomes of a rose red colour,
which is less vivid towards the circumference of
the globe; and does not extend to the cornea,
but leaves, immediately around it, as a patho-
gnomic symptom, a narrow bluish white ring. The
conjunctiva oculi soon partakes in the redness
and increased vascularity, and is subsequently
congested and varicose ; the bright redness being
changed to a dirty grey or violet colour. Arthritic
ophthalmia runs a shorter or longer course; is
milder in dry weather and in summer, than in
wet weather and in winter ; and is aggravated by,
or accompanied with, derangements of the diges-
tive organs. It is generally associated with
iritis, but arthritic iritis may exist without the ex-
ternal proper tunics being materially affected.
(See Arthritic Iritis, § 134.)

101. e. The Progtiosis in rheumatic ophthalmia
is favourable, unless phlyctenae have formed and
occasioned small ulcers ; or iritis have supervened.
But, in young or healthy persons these ulcers
seldom leave permanent specks or cicatrices be-
hind them. Arthritic ophthalmia is generally a
more serious complaint than the rheumatic ;
and if it be attended with iritis, the association is
much more dangerous to vision. It is also fre-
quently accompanied with affection of the internal
parts.

102. f. Treatment. — a. In rheumatic ophthal-
mia, general bloodletting is rarely necessary, but
local bleedings are often serviceable. Calomel con-
joined with camphor, James's powder and opium,
at bedtime ; and stomachic purgatives in the morn-
ing, assisted by terebinthinate enemata ; are very
beneficial in this variety. Colchicum is often of
use, in conjunction with aperients and alkaline or
niagnesian carbonates : but it should not be given
in the very large doses mentioned by some sur-
gical writers. Its effects ought always to be
carefully watched. After the bowels have been
freely evacuated, the tinctura culchici composita,
or a combination of the powder and camphor,
should be preferred, particularly in delicate or
aged persons. Warm applications and foment-
ations are most appropriate in this varietj' ; and
the steam of boiling water, containing camphor
and tincture of opium, generally affords relief.
Diaphoretics and warm petlituvia are also useful.
If iritis has come on, calomel, in the combinations
just stated, is especially indicated. If the mouth
be affected by it, the good effects will be greater
and more permanent.

103. Besides the above remedies, others may
be employed in chronic or obstinate cases : as the
compound decoction of guaiacum, or the decoc-
tion of bark, with the compound tincture of col-
chicum ; quinine with or without the powder of
colchicum ; Fowler's arsenical solution ; Plum-
mer's pill and aperients; antimony, or ipecacuan-
ha with camphor and opium ; vinous or spirituous
preparations of opium dropped into the eye ;
frictions in the vicinity of the eye with opium or
belladonna, or with both, to alleviate pain and
dilate the pupil ; and counter-irritation by blis-
ters or the tartar emetic ointment behind the
ears or on the temples. If phlyctenulae form,
and run into small ulcers, astringent and stimu-
lating applications will be necessary. In cases
presenting much biliary or gastric disorder, an
emetic will be useful ; and, under any circum-
stances, change of air, regulated diet, attention to
the biliary and intestinal functions, and the repose
or moderate exercise of the organ will be of es-
sential service.

104. /3. The treatment of arthritic ophthalmia
does not materially differ from that recommended
in the rheumatic form. Warm stomachic pur-
gatives, with full doses of the alkaline carbonates,
and the compound tincture of colchicum ; mus-
tard pediluvia ; blisters behind the ears ; and dry
warmth applied to the eye ; and anodynes rubbed
upon the temples and eyebrows ; ^are more parti-
cularly indicated in this variety. If iritis super-
vene, the means directed hereafter in Arthritic
Iritis must be resorted to.

105. C. Inflammation of the Cornea. Syn.
— Corneitis Ceratitis, JvE^cv.TLV ; Keratitis, Ro-
sas.— Corneitis may be either (iCHfe or chronic,
primary or consecutive. Inflammation may com-
mence in the cornea, and be confined to it, or
extend to the sclerotica and conjunctiva, and
sometimes to the iris, or it may begin in either
of these tunics, and advance to the cornea. Cor-
neitis often comes on, in this latter form, in most
of the varieties of ophthalmia which have been
considered ; and presents either the acute, sub-
acute, or chronic states, especially the latter.
The primarii form of corneitis, therefore, remains
to be noticed. It is much less common than the
consecutive, and is most frequently caused, espe-
cially its acute, or severe states, by external injuries,
and by foreign bodies, or acrid substance brought
in contact with the cornea.

106. a. Acute Corneitis may be of various de-
grees of severity in different persons. In some,
there is but little local uneasiness beyond irrita-
tion on ir otion ; whilst, in others of a full habit, or
who are laboriously occupied, exposed to heat, or '
addicted to intoxicating liquors, the inflammation
is most intense, and rapidly extends to the scle-
rotica and whole anterior chamber, with hypopyon.
The more severe states usually commence with a
pink zone in the sclerotica, around the cornea,
which loses its transparency, and becomes mi-
nutely injected with delicate-coloured vessels,
panticularly at its circumference, and dull, tur-
bid, or cloudy. If the inflammation be excited
by a foreign body, ulceration takes place around
it. If the disease be not soon arrested, the pink
zone assumes a deeper tint, and extends further
in the sclerotica ; the cornea is rendered more
opaque, and suppurates ; and the chambers of
the aqueous humour are involved. When the

- 3 K 3

870 EYE — Inflammation o

cornea is penetrated either by ulceration or sup-
puration, tiie aqueous humour escapes, the iris
and cornea coming in contact. When tlie wound
in the cornea is small, it unites by adhesion, and
the aqueous humour is soon reproduced ; but
when it is large, prolapsus of the iris often results.
107. b. Suh-acute and chronic Corneitis are
common in young persons of a fair complexion and
delicate constitution. The cornea loses its trans-
parency, presents a dull grey colour, or becomes
hazy, nebulous, or nearly opaque ; the opacity
commencing at the circumference, and gradually
but unequally extending. The nebulous and
opaque spois are sometimes yellowish, as if mat-
ter were formed : and the surface loses its polish,
and seems rough. The circumference of tlie
cornea is minutely injected with a multitude of
very fine vessels, which impart to it a reddish
brown tint, and occasionally elevate it somewhat.
The conjunctiva often retains its natural pale-
ness, but the sclerotica is minutely injected, par-
ticularly around the cornea. As the brownish
red tint of the circumference of the part increases,
the opacity in its centre becomes greater, and
vision more affected. There is generally much
intolerance of light,notwithstanding the diminished
transparency of the cornea, owing to affection of
the sclerotica. A pintialfcrm of corneitis, which
is generally of very long duration, is sometimes
met with. Inflammation commences in one or
two spots at the circumference of the cornea,
with pain of the eye, and nebulosity; others
being afl^ected in succession. Redness is first
observed in the sclerotica, in one or two points ;
and minute vessels extend from these into the
cloudy spots in the cornea j more or less of which
may become thus affected, or entirely opaque.

108. Although the severe and acute grades of
corneitis often run into suppuration or ulceration,
the slighter or more chronic states do not termi-
nate in this manner, excepting in sub-acute cases,
where partial or circumscribed points of suppur-
ation may occur. The more severe grades are
attended by much pain in the eye, temples, and
forehead ; with tension of the organ, white tongue,
and febrile disturbance, particularly at an early
stage ; and they often pass into the slighter and
ciironic states; but the latter also occur primarily.
Chronic corneitis presents much less febrile dis-
order than the acute, and often continues for seve-
ral months, or remits. The inflammation some-
times extends to the iris, occasioning adhesion of
its margin to the capsule of the lens.

109. c. Scrofulous Corneitis — Corneitis scro-
J'ulosa. — Inflammation of the cornea in scrofulous

habits has been minutely described by Dr. Eno-
niip and Mr. M^f kknzie ; but its local charac-
ters do not diflfer from those of the sub-acute and
chronic forms noticed above (§ 107, 108.). except-
ing that it is more obstinate, and more liable to
return. It is sometimes unattended by redness
of the sclerotica ; and the pain is not considerable.
It is most common about the period of puberty,
and is occasionally connected with amenorrhcca in
the female, and with swollen lymphatic glands.
In the more obstinate cases, increased secretion of
the aqueous humour, and consi (|ucnt eidargement
of the anteiior chamber, occasionally supervene.

110. (/. Treatrueiit. — a. Acute corneitis requires
active depletory and other antiphlogistic mea-
sures. Cupping Leiiind the cars or on the tem-

F THE Anterior Chambeh.
pies is always necessary. Purgatives, and after-
terwards calomel with James's powder, and oc-
casionally with (i/j/ijm, until the mouth is affected,
are beneficial, especially if the iris be inflamed.
In the more obstinate and chronic cases, cupping,
or the application of a number of leeches to the
vicinity of the eye, should be repeated oftener
than once, and be followed by open blisters,
setons, or issues. Mr. Lawrence advises issues
to be inserted in the temples. Astringent and sti-
mulating applications to remove the opacity are
generally injurious. Warm fomentations are
more serviceable, particularly with emollient and
anodyne substances. Emetics, if the digestive
organs be loaded ; and diaphoretics, assisted by
warm pediluvia, if the skin be dry, and fever pre-
sent ; are also useful. — 0. The scrofulous varieti/ ,
especially its more chronic states, is benefited
most by sarsaparilla, sulphate of quinine, decoc-
tion of bark with liquor potassae, the compound
myrrh mixture, the iodide of potassium, and by
small doses of the bichloride of meicury in tincture
of bark. — As this variety often continues many
months, perseverance in the use of these means,
and changes from the one to the other, a dry warm
air, and change of air, with attention to the state
of the digestive organs, and a carefully regu-
lated diet, are inost requisite.
III. Inflammation of the Internal Parts

OF THE Eye. Syn. — Internal Ophthalmia,

Ophthalmitis Interna, Auct. var.

111. Defin. — Inflammation of one or more of
the internal tissues of the eye, occurring either
primarily, or consecutively of external disease, and
attended by impaired vision, and frequently by
constit}itional disorder.

112. In diseases of the internal eye, artificial
dilatation of the pupil is necessary both to the
investigation of their nature and extent, and to
their treatment. Mr. Lawrence has given a
learned account of the agents by which dilatation
may be accoiuplished. Various narcotic vegeta-
bles possess this power, but belladonna in the
highest degree. The tincture, extract, decoc-
tion, infusion, or powder of this plant may be
eiuployed for this purpose, either internally, or
dropped into the eye, or rubbed on the brow or
temple. Hyoscyamus is the next powerful sub-
stance. An aqueous solution of the extracts of
either may be rubbed or placed upon the eyelids
or parts in the vicinity, and washed oflT after re-
maining for about an hour; or it may be dropped
into the eye, when a speedy and certain effect is
desired.

i. Infla.mmation of the Anterior Chamber.
Syn. — Inflammation of the Capsule of the
Aqueous Humour, Wardrop; Aquo-Capsu-
/j((,s-, Mackenzie ; Kerato-iritis, ^osas; Inflam-
mation of the Anterior Chamber, Lawrence.

113. CiiARAcr. — Dijfused muddiness, or
mottled appearance of the cornea, dimness of vision,

J'ullness and tension (f the eye, dullness of the iris,
slightly contracted pupil, headach, white tongue,
and fever.

114. Inflamniallon of the membrane of the
aciucous humour is often consequoit upon the va-
ri(!ties of ophthalmia already described ; buti is
also a primary disease, and is most common in
this form among children. It cannot be consi-
dered, even wiien priiuary, to be confined to the
anterior chamber, or to tiiis membrane. The

EYE — Inflammation of the Inis.

871

posterior chamber, the cornea, and iris, evidently,
are also affected more or less. External inflam-
mation involving the cornea may extend to the
anterior chamber and to the iris ; or inflammation
may commence in ti)e latter, and spread over this
cavity to the cornea, and either adhesion of the
iris to the cornea, or hypopyon, be produced.
Primary inflammation of this membrane presents
the usual phenomena of inflamed serous surfaces;
viz. effusion of albuminous or coagulating lymph,
or of a serous fluid, and very rarely of pus ; the
first of these sometimes becoming organised into
morbid adhesions.

115. A. Symptums. — The anterior chamber is
cloudj' ; the ins becomes dull and dark, its sur-
face assumes a reddish brown tinge, the reddish
tint being most evident in light eyes; and the
pupil is somewhat contracted. The cornea loses
its transparency, becomes nebulous or mottled,
sometimes with an ulcer in its surface. There is
but little exteri>al redness, excepting a pink zone
around tiie cornea. An effusion of whitish or
yellowish matter takes place in the anterior
chamber ; and the patient complains of pain
and aching in the eye and forehead, of fulness
or tightness in the organ, and of intolerance of
light, especially early in the complaint ; these
symptoms subsiding at more advanced periods.
Its progress in children is not rapid. Mr. \Vard-
liop considers the opacity to be seated in the in-
ternal surface of the cornea; and that it arises
from a number of round specks, which give a
mottled appearance to this part, particularly in
adults. lie also believes the effusion into tiie
chamber, which has been generally considered
pus, to be albuminous, and similar to that which
causes adhesions, but not coagulable.

116. -B. HypiipiioH — or the presence of a yel-
lowish matter in the anterior chamber, resembling,
and usually called, pus, and attending or con-
sequent upon inflammation — accompanies the
affection now under consideration. But it more
frequently supervenes, in the advanced course of
inflammation of the external coats, from the burst-
ing of an abscess in the cornea. It may also occur
from iritis, particularly if an abscess of this part
burst into the anterior chamber. Inflammation,
however, of the membrane of this chamber, is
common to all these affections, in a consecutive
or associated form. When matter is effused be-
hind as well as before the iris, it constitutes em-
pi/esis ocidi, or suppuration of the eye. Various
forms and divisions of hypopyon have been de-
vised by Beer, IIichtei!, Benedict, and Jueng-
KEN ; but they do not deserve notice, as they lead I
not to any practical result, and as this is not a ■
peculiar disease, but the result of inflammatory
action consecutively or primarily affecting the
membrane of the chamber, and tissues surround- I
ing it. Whether the matter in hypopyon be pus
or an albuminous fluid, it seems to sink lo the
bottom of the aqueous humour; but, in some j
instances, it appears as if heaped up or in lumps ; !
and, in this case, a minute admixture of blood I
sometimes is seen in it. I

117. C. Treatment. — a. hijlammntinn of the an- I
terinr chamber is readily controlled by local bleed- [
ino-s, purgatices, and calomel with Jameses powder,
given twice or thrice a day. Mr. Wardrop has
strongly advised puncture of the cornea, to eua- |
cuate the aqueous humour, in this and some other I

afl^ections attended by inflammation of the mem-
brane secreting this humour, after suitable treat-
ment has been employed; and jMacgregor,
iMuELLER, Langenbeck, and Benedict speak
favourably of it, as a measure calculated lo pre-
vent rupture of the cornea in purulent oph-
thalmia. Mr. Lawrence, who takes a candid
view of the matter, thus remarks; — "I have
tried it in some instances, but with so little benefit
that I have not been induced to persist in the
practice ; and I have been the less inclined to do so-
in severe inflammations, because the ordinary anti-
phlogistic treatment enables us to control them."

118. b. UypopiioH, being an attendant, rather
than a termination, of inflammation beginning in
or extending to the anterior chamber, requires
the antiphlogistic treatment recommended in the
acute forms of ophthalmia. The only question
is, whether or not the cornea should be punctured
to evacuate the matter collected behind it.
Puncture or incision has been advised for this
purpose by Ware, Richteu, Benedict, Langen-
beck, and Wakdrop. Beer at one time directed
it, but afterwards reprobated it. Dr. Monteath
and- Mr. Mackenzie recommend its perform-
ance in every case in which the chambers are
completely filled; as they consider absorption in
such not to be depended upon, and dread the
bursting and destruction of the eye. Scarpa
and Lawrence, on the contrary, prefer active
antiphlogistic treatment; as they consider that
the operation aggravates the inflammation, and
that when the inflammation is removed by judi-
cious and energetic means, the eff'usion will be ra-
pidly absorbed. In this opinion I entirely concur,
ii. Inflammation of the Iris. Syn. — Iritis,

Schmidt.

1 19. Char ACT. — Fine vessels running in radii
to the edge of the cornea ; dark discolouration of the
iris ; contraction, irregularity, and immobilitii of
the pupil; effusion of coagulable lymph into the
pupil and posterior chamber, occasionally also into
the anterior, causing adhesions of the iris to the
capsule of the lens, loith dimness of sight, sometimes
almost amounting to blindness, pain in the eye, and
nocturnal pain about the orbit.

120. This affection was not known until it was
ably described by Schmidt of Vienna. It may
be consecutive of the diseases already noticed •
but it often occurs in a primary fm-m, and then
generally assumes more or less of the characters
of adhesive inflammation, the danger occasioned
by it to the organ arising chiefly from this cir-
cumstance ; for, if neglected or injudiciously
treated, the pupil may become completely and
irremediably obliterated by efl^usion of coagulable
lymph. Some degree of inflammation of the
sclerotica, and of the anterior hemisphere of the
crystalline capsule, often extending to the cho-
roid and retina, generally accompanies this dis-
ease ; but the iris is the focus of morbid action,
and the situation of the chief lesions. The pri-
mary states of the complaint commence in the
puijillary edge of the iris, spread to the rest of
the iris, to the capsule of the lens, and, perhaps,
to the choroid and retina. The attendant in-
flammation of the sclerotica may be sympathetic,
or otherwise related to it. — Iritis has been di-
vided into the idiopathic, or that occurring pri-
marily in persons of a healthy constitution"; and
the sympathetic, or that afl'ecling those of an

3 K 4

872

EYE — Idiopathic Iritis — Symptoms and Course,

arthritic diathesis, or supervening in the course of
syphilitic cachexia.

121. Causes. — Primary Iritis occurs most
frequently in persons of an unsound constitution
— the gouty, rheumatic, and cachectic ; and
hence it presents certain modifications hereafter
to be noticed. It rarely occurs in young and
healthy persons ; although it may supervene in
them, upon the other varieties of ophthalmia. It
is excited by the common causes of inflammation
of this organ (§ 5.) ; especially by over exer-
tion, and employment of sight on minute or
bright objects ; by external injuries or operations
on the eye ; and by exposure to cold, wet, and
atmospheric vicissitudes. These last are the
common exciting causes in persons imbued with
the syphilitic cachexia, and in those of a rheu-
matic and gouty diathesis. I do not believe that
the use of mercury will cause the complaint, if it
be given so as to affect the moutii.

122. A. Idiopathic Iritis. — a. Symptoms
and Course. — Iritis presents various grades of
severity, and periods of duration. It may hence
be mild or severe ; acute, sub-acute, or chronic.
I shall adopt Mr. Mackenzie's division of iritis
into three grades. — a. In the frst degree, the
vascularity of the sclerotica is barely perceptible,
and exists only in one or more points, and chiefly
behind the upper lid. The ring of the iris next
the pupil is slightly discoloured; the pupil is
not materially contracted, but is somewhat irre-
gular, without its usual clean and sharp edge,
and is hazy ; and the motions of the iris are
limited and slow. Vision is confused and slightly
obscured. There is little or no pain, or aver.-ion
from light. This state of iritis may exist for
many weeks, and yet be completely removed by
suitable treatment.

123. S. The second degree, or that with evident
external inflammation of the eye, is much more
frequent than the foregoing. A zone of vascu-
larity is observed in the sclerotica around the
cornea, the vessels sinking through the sclerotica,
and not advancing into the cornea. The iris,
particularly its inner or smaller rings, is dis-
coloured, either from injection of its vessels
or the effusion of lymph ; and its anterior sur-
face, instead of being smooth and shining, ap-
pears dull, puckered, and swollen, especially
near the pupillary opening, where it is retracted
towards the lens. The pupil is contracted, irre-
gular, motionless, and filled with coagulable
lymph, which generally appears like half-boiled
white of egg. Epiphora and intolerance of light
are considerable, and vision becomes greatly
impaired. The pain in the eye is constant, and
attended by pain in the orbit and forehead, par-
ticularly at night ; and by the usual symptoms of
inflammatory fever.

124. y. The third degree of iritis presents the
following characters: — The eye externally is
much more inflamed than in the foregoing
grades; the redness of the conjunctiva being
sometimes so great as to ma'-k for a time the red
zone of the sclerotica. Both the smaller and
larger rings of the iris are discoloured; the an-
terior surface being swollen, [)uckere(l, and
bolstered forwards so as to ai>pn)ac'h the cornea,
excepting its pupillary edge, which is retracted
towards the lens. Reil vessels and spots of bldod
are sonittimes seen on the iris, but more fre-

quently in the lymph occupying the very con-
tracted pupil. (Jne or more minute elevations,
of a yellowish colour, which are in some cases
specks of effused lymph, in others small ab-
scesses, appear on the surface of the iris ; and
pus discharged from these abscesses, with lymph,
blood, and serum, sometimes occupy the anterior
chamber. The cornea becomes hazy and turbid,
and occasionally dotted with minute brownish
spots. There are at first great intolerance of
light and lachrymation ; and subsequently vision
is completely, and generally permanently, lost.
Flashes of light in the eye are frequently per-
ceived by the patient, indicating the extension of
inflammation to the choroid and retina. The
pain in the organ is constant, great, and some-
times excruciating ; with pain in the orbit and
eyebrow, increased at night. When attended
with extreme pain, especially in syphilitic cases,
very serious changes, even abscess of the ante-
rior chamber, disorganisation of the vitreous
humour, &c. frequently supervene. In these,
the inflammation is extended more or less to the
internal and external tissues of the eye, and ge-
neral ophthalmitis (§ 153.) is the result.

125. 5. The discolouration of the iris arises from
vascular injection and effusion, and is of a yel-
lowish or greenish tint, in light eyes ; or of a
reddish hue, in dark eyes : but it is very fre-
quently dull, muddy, and dark ; and the natural
brilliancy and fibrous arrangement of this part
are lost. The effused lymph is seen first at the
pupillary edge, and afterwards on the lesser
circle of the iris ; causing a villous, rough, ele-
vated, or irregular surface or outline of the part.
The lymph may be in distinct masses of very
various sizes on the anterior of the iris, or at its
pupillary margin ; and, in the most acute cases,
it may fill the pupil or anterior chamber, or even
the posterior chamber. The colour of the effused
lymph is sometimes a light yellowish brown or
ochrey ; but a rusty hue is most common. It is
occasionally of a light dirty yellowish tint, par-
ticularly when it is abundant, and fills the ante-
rior chamber. In this case, or when a small
abscess in the iris is discharged in this situation,
a form of hypopyon is the result. The pupil is
contracted, and becomes more and more so in
the progress of the complaint. The effusion of
lymph and adhesion render it also angular, irre-
gular, and fixed at one or more points, and free
in others. It loses its thin, sharp, and well-
defined edge ; and becomes dull and cloudy, or
otherwise discoloured.

126. £. The acute states of iritis are observed
in persons of a full habit or robust constitution,
after the action of powerful causes, especially if
they continue to act, and the case have been
neglected at the beginning ; and in cachectic
conditions of the frame. They are attended by
the usual characters of severe vascular action ;
especially injection of the vessels, extreme con-
traction of the pupil, effusion of lymph, dulness
of the cornea, external redness, loss of sight,
violent pain in the eye, and severe headach, with
watchfulness, restlessness, and febrile disturb-
ance, terminating, in a few days, in disorganis-
ation of the interior tissues, and in irreparable
loss of vision. — In cliroiiic cases, the origin of
disease is almost imperceptible, and its progress
slow. Little or no paiu is fell, and the external

£YE — Idiopathic Iritis — Consequences — Treatment.

873

redness is very slight or unobserved. At last,
lymph is effused, vision is impaired, and the
complaint is brought under treatment. — The sub-
acute cases are intermediate between these two
extremes. The chronic form may also follow
upon an inactive or partially successful treatment
of the acute and sub-acute forms ; but it usually
presents itself in the Jirst grade ; the acute most
commonly assuming the third, and the sub-acute
the second grades.

127. h. Consequences and Prognosis. — a. Change
of texture and colour of the iris follow inflamma-
tion which has been violent or of long duration.
General adhesion of the iris to the cornea may
occur, and lead to staphyloma ; or the iris may
become adherent both to the cornea and to the
capsule of the lens, occasioning anterior flattening
of the eye. This is, however, very rare. Drop-
sical enlargement of the anterior chamber, with
closed pupil and staphyloma scleroticae, may like-
wise supervene (Lawrence). — B. After acute
or sub-acute attacks, the pupillary margin often
becomes adherent to the capsule of tiie lens, either
throughout, or in one or more points. When the
inflammation has disappeared, the adhesion still
continues, or is reduced to slender threads admit-
ting of partial motion. In some cases, adhesions
of the iris are detached, leaving black marks on
the capsule, which are permanent. — y. An ad-
ventitious membrane may form in the pupil, from
organisation of the lymph effused on the surface
of the capsule. Its opacity is greatest in the
centre ; and it may be connected with partial
adhesion of the iris. In rarer instances, the ad-
ventitious substance is seen in one side of the
pupil, and attached to the edge of the iris (Atresia
Iridis incompleta).- — J. Closure of the pupil fol-
lows effusion into the posterior chamber, and the
formation of an opaque adventitious substance
to which the circumference of the pupil is fixed
(Atresia Iridis perfecta). Tliis adventitious mem-
brane may extend over the anterior capsule,
causing adhesion of the uvea to the lens, and en-
largement of the anterior chamber. — b. Atrophy
of the globe may supervene upon copious effusion
into both chambers, and deposition of lymph be-
hind the iris in such quantity as to cause bulging
of the sclerotica, or to escape through this mem-
brane and raise the conjunctiva. In this case,
the fluid is absorbed after the subsidence of the
inflammation ; but the internal parts of the ball
are so altered that they waste and become flaccid,
particularly after complete closure of the pupil.
The vitreous humour may also be rendered fluid,
and the eye soft, without shrinking in size ; but
this occurs only after acute syphilitic iritis. — ^.
Impaired vision may be the result of the extension
of inflammation to the posterior tunics, although
the disease has been arrested by appropriate treat-
ment ; and may follow the acute, sub-acute, or
chronic states of the disease. The impaired vi-
sion may be caused solely by the lesions produced
in these tunics, or by these and the changes in
the pupil conjoined.

128. c. The Prognosis. — When the disease is
recent, and appropriate treatment is adopted, effu-
sion into the texture, or on the surface, of the
iri-:, will be removed by absorption upon the sub-
sidence of the inflammation. Hence we need not
dread the result, if the changes be confined to llie
iris, although the effusion be copious. But when

the complaint has continued some time, and is
attended by increasing contraction of the pupil
and eft'usion off lymph, with organisation of the
latter into adhesions and adventitious membranes ;
or when the consequences described above
(§ 127.) are present, or inflammation extends to
the posterior parts of the globe and retina, or
to tiie cornea with more or less opacity ; the
greatest danger to vision is to be apprehended.
In most cases, a guarded prognosis should be
given ; for it is often difficult to determine how
far the posterior tunics may be affected. Change
of colour in the whole iris, with great contraction
of the pupd, and an opaque substance in it ; in-
tense external redness, severe and deep-seated
pain, extinction of sight, and flashes of light in
the eye ; large effusion behind the iris, and bulg-
ing of the sclerotica ; and a protruded state of the
iris, and adhesion of the pupil ; are all hopeless
states of the organ. If unfavourable changes
have not appeared, recovery may take place,
although the complaint has been of three
or four weeks' duration, and sight is much im-
paired.

129. d. The Diagnosis of iritis cannot be diffi-
cult, if the history of the case be considered, and
the state of the iris carefully examined. The af-
fection most resembling iritis is inflammation of
the capsule of the lens. Nebulous, contracted,
and fixed pupil, discoloured iris, adhesions be-
tween the iris and capsule, are present in the
latter, which, however, often supervenes in the
course of iritis, and generally attends its most acute
attacks; whilst, on the other hand, inflammation
of the crystalline capsule is attended by some de-
gree of iritis. The one is thus reciprocally conse-
quent upon the other. — Retinitis resembles iritis
chiefly in the great contraction of the pupil ; but
the former is more sudden, its progress more ra-
pid,its attendant headach more violent, and vision
more rapidly impaired, than in the latter.

130. e. Treatment. — The indications of cure
are — 1st, to subdue the inflammation; 2d, to
prevent or anest the effusion of lymph ; 3d, to
promote the absorption of what has been effused ;
and 4th, to preserve the pupil entire. They are
to be accomplished by bloodletting, mercurials,
belladonna, &c. — Bloodletting, in acute and sub-
acute cases ; in young, robust, or plethoric per-
sons; when the pain is -levere, and febrile distur-
bance considerable; and the inflammation extend-
ing to the internal tunics ; must be most promptly
and actively practised. It will often be necessary
to repeat it ; and even to follow it by cuppirig
on the nape of the neck, or behind the ears, or
on the temples. In the circumstances now
stated, local bleeding cannot be confided in
alone. But, in chronic, sub-acute, or mild states,
cupping will be preferable. Leeches may be em-
ployed ; but they are, unless a great number be
applied, much less efficient than cupping. Im-
mediately after the first bleeding, a full dose of
calomel and James's ponder, with opium, should
be^given, and repeated at bedtime ; and an active
cathartic draught (F. 216.) in the morning, aided
by a terebinthinate enema (F. 150, 151.). The
specific effects of inerciirit, which are most effec-
tual in fulfilling the second and third indications,
will be hastened by its combination with an anti-
inonial ; and, if the bowels he acted upon daily
by a draught containing equal parts of the spirits

874

EYE — Sympathetic

of turpentine and castor oil, or a larger portion of
the former, the specific operation of the calomel
will not be prevented, or even delayed, but the
beneficial eflects on the disease will be insured.

131. Belladonna is of great benefit in every
stage of the complaint, and should be applied as
directed above (§ 112.), contemporaneously with
the exhibition of mercury. Altiiough the pupil
be contracted, and effusion or even adhesion has
taken place, the specific operation of the latter,
and the effects of the former on the iris, will
elono-ate or even entirely detach the adhesions, if
they are soft or unorganised. In addition to
these, diaphoretics, diuretics, and warm pediluvia
are beneficial. The bowels ought to be kept
freely open by the substances already noticed.
Turpentine may be used for this purpose, or with
the view of aiding the effects of calomel, or even
as a substitute for it, as advised by JMr. Carmi-
CHAEL, who prescribes it in drachm doses, three
times a day, suspended in almond emulc-ion.
Blisters are of doubtful efficacy ; Mr. Lawrence
decides against them.

132. B. SyjiPATHETic Iritis. — a. Sypliilitic
Iritis, or inflammation of the iris occurring in
persons tainted by the syphilitic poison, is, per-
haps, the most common variety of this disease.
It is a symptom of syphilis in its constitutional
sta^e ; and, although sometimes appearing alone,
it is more frequently one of several secondary
symptoms, especially ulcerations of the throat,
eruptions, swellings of the periosteum, pains of
the limbs, affection of the nose, &c. It occurs
most frequently along with the earlier secondary
affections, and sometimes appears before the
primary disorder is cured (Lawrence). It
rarely occurs as a symptom of syphilis in infants,
although secondary sypliilis is not infrecjuent in
them. It may be either acute or chronic ; it is
often associated with inflammation of other internal
tissues of the organ ; and it is most commonly
determined or excited by exposure to cold, exer-
tion of the eye, or external injury.

133. Diagnosis. — The characters and progress
of syphilitic iritis are nearly the same as those of
the idiopathic form ; yet there are certain points
of difference, which are frequently observed in
the local symptoms, deserving of notice. These
are the tubercular disposition, and the reddisli
brown discolouration of the lymph effused on the
iris; the angular form of the pupil, and its dis-
placement towards the root of the nose ; and the
violent exacerbations of pain felt chiefly in the
brow during the night, and in a sligliter degree or
not at all in the day. 'i'he first and second of
these are, however, not constant; the last is al-
ways present. But the most certain diagnosis are,
the concomitance of other syphilitic affections,
and the iiistory of the case. — Lymph is effused
from tiie margin of the pupil in arthritic iritis,
but not deposited in a distinct form, and the
adhesions are generally white ; and both in it,
and in the idiopathic variety, the pupil com-
monly retains ils circular figure and central po-
sition.

134. h. Arthritic Jrilis. — Inflammation of the
ills is frequent in the goutii diathesis, but less so
in the rheumatic, unless as a consequence of
rheumiitic indanmiation of tlie sclerotica {§ 97.).
In the gouty, it occurs m()St comiiKuily in the iris
from the commencement, although often some

Iritis — Treatment.

other tissues of the organ are affected at the same
time ; but, in the rheumatic, it rarely begins
in the iris. The gouty modification is generally
(/c(((c',and very severe ; the rheumatic, sub-acute,
or chronic, and more mWd. — The former gene-
rally commences with pain of the eye, intolerance
of light, lachrymation, and zonular redness of the
sclerotica. Pains are felt in the orbit, brow, and
forehead. The iris soon becomes dull and dis-
coloured; the pupil contracted, and fixed at one
or more points to the capsule of the lens. The
reddish zone in the sclerotica is of a dull or
nearly livid tint, and does not advance to the
edge of the cornea, but leaves a narrow white
ring between. After a violent attack, with im-
paired vision, the symptoms subside, and sight is
restored, the iris being attached to the capsule by
whitish adhesions. This form of iritis often re-
turns again and again, the eyes recovering almost
completely after repeated attacks. Mr. Law-
rence met with a case in which the disease
returned fourteen times ; yet vision was not ma-
terially impaired, though adhesions in each eye
connected the pupillary edge of the iris to tlie
capsule. But frequently a fresh effusion attends
on each attack, until the pupil is more and more
contracted, and at last filled with opaque ad-
ventitious membrane ; the texture of the iris,
notwiihstanding, generally remaining but little
altered.

135. f. Scrofulous Iritis. — This variety is con-
secutive of strumous ophthalmia (§ 68.), the in-
flammation extending from the external tunics.
It is commonly preceded and accompanied by
changes in the cornea, preventing the lesions of
the iris from being observed. Hence it often es-
capes detection until it has completed its course.
It very rarely occurs as a primary affection. Mr.
Mackenzie adduces a case in which the attack
seemed primary; but its history is not conclusive
on this point.

136. Treatment. — a. The syphilitic variety re-
quires local bleedings and mercurials, as advise I
for the idiopathic disease, and in similar com-
binations, until the symptoms and the constitu-
tional malady, on which the local one is engrafted,
are entirely removed. Turpentine may also bo
emjiloyed as an auxiliary, and to open the bowels,
either as directed by iVlr. Carmichaei,, or as pre-
scribed by myself (§ 130. 131.). Opiate frictions
around the eye, and belladonna, are also of great
service. (General bloodletting is seldom well
borne in this variety, unless in robust or plethoric
persons ; but full or repeated cupping is often ne-
cessary.

137. h. Arthritic Iritis. — The rheumatic
modification requires the treatment recommended
in rheumatic inflammation of the external tunics

— especially Ci/;)pni^-, leeching, blistering, alter-
atives, with colchicum ; and, subsecjuently, cin-
chona or quinine, with full doses of colchicum,
aided by counter-irritation. Turpentine is also
beneficial in this variety ; but it should be given
so as to act moderately on the bowels, Mr.
Waleace advises hark to be given from the com-
mencement, when this disease follows low fevers.

— The gouty modification will be removed by a
very similar treatment to that now stated. Mer-
curials given with any other intention than ihiit
of removing morbid secretions and (excretions,
arc more injurious than btatficial. Colchicum,

EYE- — iNrtAMMATioN OF THE Interxal Tumcs.

875

in full closes, with the alkaline subcarbonates
and warm purgatives, is especially indicated.
Blisters, and derivatives to the lower extre-
mities ; tepid foinentalio}is to the organ ; fric-
tions with opium and belladonna to the forehead ;
a free state of the bowels, and attention to diet;
are particularly requisite. As the attacks are
often repealed, measures of prereittiun should be
adopted. The chief of these are, low living, a
free state of the bowels and of all the excre-
tions, tiie removal of pletiiora, and preserving
the organ from cold or over-exertion, — Notliing
can be added to what has been slated, both here
and in preceding sections {§ 130, 131.), as to
the treatment of the scrofulous mrietif of iritis,
iii. Inflammation of hie Internal Tunics.
Syn. — Internal Ophthalmia ; Ophthalmitis
interna idioputhica, Beer ; Ophthalmitis pos-
terior totalis, Rosas.

138. Defin. — Severe, deep-seated pain of the
eife, with impaired vision, contracted pupil, a
sense of aching, tension, and heat, without much
external redness, but with sy7nptomatic injiamma-
tory fever.

139. A. Inflammation may commence in the
retina, OT in the choroid; but it cannot remain
long confined to either. It frequently extends
from the iris to the latter, and to other internal
parts. The disease probably begins most fre-
quently in the retina, and may, therefore, be
designated retinitis in its early stage. We are
necessarily less acquainted with the phenomena
attending it, than with those accompanying iritis.
Rosas considers that tlie whole retina is not
equally affected, but chiefly the vicinity of the
yellow spot. — The Causes cf retinitis are sudden
exposure to light ; the action of a strong light,
as looking at the sun or bright objects ; the light
and heat of a bright fire ; exertion of the eyes,
particularly when the rays of light are refracted;
and the predisposing and exciting causes described
above (§ 4 — 6.).

140. a. Si/mptoms and Course of retinitis, —
T!ie patient complains of j^ain and aching deep in
the eye ; of a sense of tension or of heat, aggra-
vated by using the organ, by exposure to light, or
by whatever determines the circulation to the head.
The pain is often pulsating, and usually extends
to the brow and head, Tiie pupil is much con-
tracted ; vision is impaired, and hourly becomes
more so. In severe cases, the pupil is nearly
closed, and sight almost or altogether lost ; and
flashes or sparks of light are perceived in the eye.
At this period there is little external redness, ex-
cepting in the sclerotica around the cornea ; but
there are thirst, white tongue, and fever. With
the continuance of the disease, the sclerotic red-
ness increases, and a bright zone is formed
around the cornea ; and the inflammation spreads
inwards to the vitreous humour and to the cap-
sule of the lens, and outwards to the choroid and
iris. This last now loses its natural colour, be-
coming greenish and reddish ; and it is pushed
towards the cornea. Sight is lost, even before
total closure of the pupil takes place. The dis-
ease now may be designated Injiammation of the
internal tunics generally, or the second stage of
retinitis. The redness of the sclerotic extends;
the conjunctiva becomes injecfeil ; the pupil
often obliterated from effusion of lymph ; the
cornea somewhat dull j and general ophthalmia

supervenes. The pain of the eye is unequal, or
pulsative ; is attended by a sense of weight, some-
times of cold ; and chills or rigors are felt. Sup-
puration now occurs, and matter is eft'used in
front of the iris, particularly if the pupil is not
entirely closed, constituting hypopyon ; and blood
is sometimes mixed with it. — Such is the course
of the most acute and severe cases of internal
ophthalmia commencing in the retina, when un-
controlled by treatment; and the results are —
1st, Insensibility of the retina, from change of
structure — Amaurosis ; — 2d, Contraction and
partial obstruction of the pupil, with impaiied
function of the retina, and opaque capsule and
lens ; — 3d, Closed pupil, with the formation of
an adventitious membrane; — 4th, Suppuration
making its way externally, and leading to de-
struction of the eye, and collapse of the coats.

141.6. Chronic Retinitis. — Avery much milder
and more prolonged form of retinitis than the
foregoing, is often observed in persons who greatly
exert their eyes. It is characteri;ed by sensibility
to light ; more or less weakness or obscurity of
vision, especially beyond the distance at which
the eye has usually been occupied ; with gradual
contraction of the pupil, immobility of the iris,
and aching in the eyes and forehead. This slight
grade of the disease is manifestly confined to the
retina. There is but little increase of vascularity
externally ; excepting, in some cases, a narrow or
partial zone in the sclerotica around the cornea.
The complaint is aggravated by stimulants and a
heating regimen ; and benefited by opposite
means. It often continues months, or even years,
with occasional exacerbations ; and either in great
measure disappears ; or becomes greatly aggra-
vated, or assumes the above severe form.

142. c. The Prognosis in retinitis is favourable
in the comnaencement, before the pupil is very
much contracted, or vision greatly impaired ; but
it becomes less and less so in proportion to the
duration of the complaint. If misunderstood at
the commencement, neglected, or ill-treated, the
organ is frequently endangered. If the pupil be
much contracted, and sight lost ; or if sight be
quite gone before the closure of the pupil ; blind-
ness will be the result. — If the disease have gone
on to general ophthalmitis, all that can be hoped
is to preserve the form of the eye.

143. d. Treatment. — Copious general and
local bleeding, the active exhibition of viercuriuls
until the mouth is affected, the employment of
belladonna, cathartics, low diet, and the rest of
the antiphlogistic regimen, as directed for iritis,
with complete rest of the eyes and of the body,
and exclusion of light, are the most efHcacicus
means of cure. Bloodletting, although early
practised, will often fail, if mercury be not freely
administered. Turpentine may be also given to
aid its operation, and act upon the bowels. These
measures will succeed only in the first stage,
before the pupil is closed and sight is lost. Yet, if
suppuration have not occurred, it is still requisite,
in<order to preserve the form of the eye. In the
slight and chrojiic form, local depletion, active
purging, low diet, attention to the digestive func-
tions, and repose of the organ, are the chief
remedies. Open blisters behind the ears, or the
ointment of the potasiio-lartrute of antimony, are
also beneficial.

144. B. Choroiditis — a. Inflammation of thecho'

876

EYE — Arthritic Inflammation of the Internal Tunics.

roid, of the hyaloid membrane, of the capsule, &c., 1
under the terms Chirroiditis, Hi^aloiditis, Capsu-
litis, and Lentitis — have been described by Jueng-
KEN, Rosas, and Mackenzie. But admitting,
from analogy, tiiat inflammation may commence
in, and be more or less confined to, either of these
tissues, for a longer or shorter time, I question
the possibility of their being often distinguished
from retinitis, with which they must necessarily
be in some degree associated. 1 must refer the
reader to the observations of Mr. Mackenzie on
Choroiditis. He believes that the choroid, al-
though generally affected consecutively upon
iritis, is sometimes primarily and separately in-
flamed. The inference is most probably correct;
yet experience shows that such a state of disease
can but rarely be recognised. He states that
choroiditis, in its earliest stages, exists witliout any
signs of disease of the iris, and without any effects
upon the sclerotica and retina beyond those which
must necessarily arise from the pressure of an in-
flamed and swollen membrane. The dark colour of
the choroid shows through the sclerotica, which
thus appears bluish or purplish, and distended. The
part most discoloured protrudes, generally, on one
side of the ball, and near the cornea ; and is of a
deep blue tint, with varicose vessels running over
it (^Sclerotic Staphyloma). Several such tumours
may surround the cornea, or may protrude on the
posterior hemisphere of the organ. A watery fluid
is sometimes effused between the choroid and the
retina during its progress ; and redness is observed
in parU of the sclerotica. Although the iris is not
inflamed, it is always narrowed or drawn towards
the portion of the choroid chiefly affected, causing
displacement of the pupil. There are generally
attendant intolerance of li^ht, pain, hemicrania,
frequently partial opacity of the cornea, dimness of
fcii;ht, proceeding to total blindness, and febrile
disturbance, disorder of the digestive organs. 'J"he
disease is most common in the scrofulous diathe-
sis ; in those who over-use their eyes, without tak-
ing sufficient exercise, and who expose them to too
much heat and light.

145. b. The Treatment consists of copious blood-
letting, active cathartics, mercury aided by tur-
pentine, and counter-irritation, in the earlier
stages ; and, subsequently, the internal use of
the preparations of iodine, or the precipitated car-
bonate of iron ; or the iodide of iron, and the
sulphate of quinine.

146. C. Arthritic Inflammation of the Internal
Tunics — Ophthalmitis Arlhrilica, Benedict and
Rosas. — a. Arthritic iritis frequently is confined
to the iris ; but in gouty persons of very impaired
constitution, inflammation is either extended to,
or almost simultaneously appears in, the retina,
the choroid, the lens and its capsule, and the
vitreous humour ; the sclerotica and cornea be-
ing secondarily affected. It usually attacks
elderly persons, of a full habit, with bloated,
red, purple, and veined faces ; and it generally
terminates in loss of sight, with dilated pupd
and opaque lens or glaucoma. At first the ])a-
tient complains of increased sensibility to light;
of hichrymation ; and of a severe burning or tear-
ing pain deep in the globe, with a sensation as if
the eye were too large for the orbit. A dull and
livirl redness is observed in the sclerotica ; it in-
creases towards the cornea, but if separated from
this part by a narrow white ring. The conjunc-

tiva afterwards becomes injected, and the cornea
dull. The pain is now distracting, and extends
to the orbit, face, and side of the head : the iris
is dark, assumes a dirty appearance, Is irregu-
larly contracted and fixed, the pupil often having
an oblong or oval figure, in the transverse direc-
tion. A greenish discolouration is observed deep
In the eye, from lost transparency of the vitreous
humour. The posterior tissues swell and push
the lens forwards, wedging it Into the dilated
pupil, and squeezing it even against the cornea.
I'he lens also turns green, yellowish green (^Glau-
comatous Cataract), or dull white. The conges-
tion and swelling of the internal coats distend
the sclerotica, or bulge It out In parts ; the
cornea becomes hazy ; and the changes in the
iris, pupil, and external tissues, impart to the
organ a dead appearance. Luminous flashes are
frequently perceived in the eye ; but sight Is
either much impaired or altogether lost — some-
times suddenly — from the commencement. At
this stage the symptoms frequently subside, the
iris preserving Its dull hue, the pupil being fixed
and dilated, and sight totally lost. A varicose
stale of the vessels in the sclerotica sometimes
remains; or a dull leaden appearance, with small
projections or larger bulgings around the cornea,
as in choroiditis (j 144.).

147. This disease generally affects both eyes,
either in succession or at once. Its duration is
various as well as its severity; and it often as-
sumes a less violent form than that now de-
scribed, especially when Its early symptoms have
been mitigated by treatment. In this case,
sight Is more gradually and slowly extinguished ;
the pain is less ; and the external changes, par-
ticularly the bulgings of the sclerotica, are either
less, or but slight. It is difficult to determine
what tissue is primarily affected ; but most pro-
bably the choroid, retina, and iris, are almost
coetaneously attacked. The early loss of sight
indicates an early affection of the retina ; and
the equally early tension and pain show that
congestion and swelling of the choroid is present
from the first.

148. h. The Prognosis is extremely unfavour-
able. If the characteristic symptoms of this affec-
tion be present, and more especially if vision be
lost, permanent extinction of sight will be the
consequence.

149. c. Treatment has hitherto been found to
have little influence on this disease. Neverthe-
less, bloodletting ; warm purgatives, with full doses
of colchicum and alkaline carbonates; revulsants
to the lower extremities, or behind the ears, or to
the nape of the neck ; active doses of turpentine
both by the mouth and in enemata, so as to act
efliciently upon the bowels and vascular system ;
subsequently I'lummer's pill and the decoction of
guaiacum.with the compound tincture of colchicum
and liquor potassaj ; and full doses of sulphate of
quinine, or of cinchona wither without colchicum,
>xc. ; should be fully tried.

150. D. Injlammation of the internal tissues
after fever sometimes occurs. It has been de-
scribed by Dr. Wallace and Dr. jACOn. Of
flirty cases which the former observed, there were
only four who had the disease In the left eye, and
only two who had It in both. It may occur very
soon, or not for some months, after fever ; and it
presents (aos(«ges ; in the _/!'rs( of which, amau-

EYE — Phleomonoid Inflammation of the Ball.

rotic symptoms are alone present : in the second
those of inflammation are superadded. The pe-
riod at which ihe former commences after fever,
and its duration before redness comes on, are
very uncertain. In some cases, dimness of sight
and musccE volitantes have been present from the
earhest period of convalescence, yet the inflam-
matory stage has not supervened for weeks or
months ; and in other instances, the amaurotic
symptoms have not appeared till months after the
lever, and have been soon followed liy the second
stage. The inflammatory changes disappear be-
fore the amaurotic symptoms ( Wallace).

151. Dr. Jacob met with seventy or eighty
cases of the disease in one year. It is most fre-
quent among the poor, in young persons and in
females ; and attacks always only one eye. The
affection of the retina having been present from
a few days to several weeks, the transparent parts
of the eye become more or less clouded or
opaque; the circumference of the cornea pre-
sents an opaque whitish appearance or circle,
resembling the arcus sendis. The anterior cham-
ber seems clouded. The iris is always dull, and
altered in colour; but tubercles of lymph or ab-
scesses are not seen in it ; and it often moves
actively. The pupil is slightly irregular ; yet it
does not contract adhesions, or become closed.
Hypopyon sometimes ensues. In the worst cases,
the lens becomes partially opaque, and presents
an opaline amber colour. When vision is per-
manently lost, it is generally owing to this
change. Impairment or loss of vision is the
earliest symptom ; and there generally are into-
lerance of light, lachrymation, and a stinging or
dartmg pain through the eye to the temple or
nose. Sometimes the sufiering is slight ; but
it is usually increased on exposure to strong
light (Jacob).

152. The Treatment recommended by these
two experienced writers is diametrically opposite.
Dr. Wallace found depletion and mercury
insufficient for a cu]e ; he therefore gave half
a drachm, or a drachm, of bark in powder,
three or four times a day ; or the sulphate of
quinine in two grain doses. Dr. Reid also
employed bark with success in this sequela of
fever. Dr. Jacob, however, states, that bleed-
ing locally or generally, purgatives and anti-
monials, blisters and opiate stupes, and mer-
curials with opium and belladonna, are the most
efficacious means of cure. He adds, that the re-
lief from mercury is so certain, that he has trusted
to it almost exclusively, with the assistance of
belladonna. He has generally found two grains
of calomel, with a quarter of a grain of opium, or
five grains of blue pill alone, three times a day,
answer every purpose ; tenderness of the gums
coming on in eight or ten days. If the pain be
severe, he combines hyoscyamus or belladonna
with the dose taken at bedtime. He tried the
sulphate of quinine in four cases for eight days ;
but finding no relief, he gave mercury, which
effected a cure. The cases occurring after typhus
fever, recorded by Mr. Hewson, and which were
similar to those described by Drs. Wallace,
Heid, and Jacob, readily yielded to mercurial
treatment.

1\ . Inflammation of the whole Eye. Syn.
— Ophthalmitis Idiopathica, Beer ; Ophthal-
mitis Universalis, Weller ; Injiammation of

the Globe, Lawrence; Phlegmonnid Inflam

mation of the whole Ball.

163. Charact. — Severe deep-seated pain; in-
creased inte'^Hal redness and tumefaction ; a sense
of tension, and a feeling of the argmi being too
large for the orbit, and about to burst from it ;
early loss of sight, with discolared iris, and con-
tracted, immoveable pupil ; swelling and immobility
of the globe, with partial protrusion of it and the
eijelids; and severe injiammatorii fever.

154. A. This severe disease has been well
described by JMr. Lawrence. It consists of
inflammation of the internal and external tissues,
and is not of common occurrence. It is met
with chiefly in very robust constitutions, and
persons of a phlogistic diathesis and full habit of
body. It is most frequent in the right eye, as is
the case with ophthalmic inflammation generally.
Mr. Lawrence states, that of 134 cases of oph-
thalmia commencing in one eye, 95 began in
the right. General ophthalmitis is most com-
monly caused by severe injuries of the organ;
by the explosion of gunpowder before the eye ;
by great heat and light striking upon it ;
and fragments of stone, iron, &c. propelled
against it.

155. (/. Symptoms and Course. — At the com-
mencement, the characteristic injection of both
the sclerotica and conjunctiva is evident; with a
severe burning or throbbing pain, and a sense
of bursting distension. The surface of the organ
is stiff and dry ; but copious lachrymation soon
comes on, and is increased by exposure to light.
The external redness increases ; and the con-
junctiva swells into a broad firm ring of chemosis
around the cornea, which it partially overlaps.
There are intolerance of light, dimne-s of vision,
contracted pupil, impaired brilliancy of the iris,
and acute sympathetic fever. This constitutes
the _^rst stage of the disease. — The motions of
the globe and lids now become difficult and
painful; and the pain more and more violent,
extending to the brow, cheek, temple, and head.
The previously blue or grey iris assumes a dull
greenish hue; and the brown or black, a reddish
tint. The eyeball swells and loses its power of
motion; the cornea grows muddy, and, by de-'
grees, opaque ; but vision is generaHy lost before
these changes supervene. The patient perceives
luminous flashes or sparks in his eye, owing to
disordered action in the retina ; and the vascular
distension of the internal tissues generally occa-
sions a sense of bursting. The deep-seated
swelling and external chemosis partially evert
the inffamed eyelids, which thus resemble, espe-
cially the inferior, a red fleshy mass ; and both
the ball and lids are protruded, and immoveable.
The second stage is now fully developed. — Sym-
pathetic inflammatory fever always accompanies
this severe disease. The local symptoms are
preceded, or attended at their commencement
by chills or rigors, followed by headach, white
tongue, thirst, hot and dry skin ; and accelerated,
hafd, and full pulse. These are increased at
night, and accompanied with watchfulness, and
throbbing in the temple and eye.

156. b. The Consequences, or the second sta<fe,
according to Weller, are suppuration and opa-
city of the cornea, &c. If the disease be not
arrested, the pain becomes throbbing ; delirium
sometinies occurs at night; and chills or rigors

EYE PilLEGMONOID INFLAMMATION OF THE BaLL TREATMENT.

are felt, indicating impending suppuration. The
cornea is first a dull white, and then yellow, and
matter is formed. The throbbing and bursting
pain continues, notwithstanding, for some days,
until the cornea bursts externally, and gives exit
to the matter ; the coats of the eye collapsing, and
the form of the organ being lost. When the pro-
gress of the disease has been checked by treat-
ment, the cornea remains opaque, and the pupil is
either closed or very much contracted, and the
aperture filled by adventitious membrane; vision
being either much impaired or entirely lost. Even
v/hen recovery takes place, with an open pupil
and clear cornea, the retina has generally suffered
so much as to cause some imperfection of vision
(Lawrence).

157. c. Diagnosis. — This complaint is charac-
terised by the simultaneous affection of both the
internal and external tunics ; and is distinguished
from the sympathetic or s/)ec//zc inflammation above
considered, by the followmg circumstances: —
(a) Redness, pain, swelling, intolerance of light,
lachryn.al discharge, and impaiied vision, are all
equally and co-ordinately developed ; but in the
specific inflammations, one or other of these is
always predominant over the rest, and accom-
panied by some peculiar local and constitutional
affection. — (ft) These symptoms commence at
the same time in an equal degree, and continue
very nearly so throughout; but in tiie otiier
ophthalmise, this correspondence is remarked nei-
ther at their commencement, nor during their pro-
gress. • — (c) The course of the malady is regular
and continued, and it always terminates in sup-
puration of the globe, if not arrested by treat-
ment ; whilst the others remit more or less, and
only occasionally terminate in this manner. —
((/) Phlegmonoid ophthalmitis is ahvays attended
by severe sympathetic fever; but the specific
forms are generally without fever, even when
most severe.

158. d. Treatment. — Ilis only iu ihejirst singe
that we can expect to preserve the sight. In
the second stage, tiiis will rarely be accomplished.
When vision is altogether lost in this period, the
preservation of the form of the organ can only be
hoped for. If .symptoms of suppuration have ap-
peared, the eye will be destroyed. In the first
and second stages the most active antiphlogistic
measures, as directed in internal ophthalmia
(§ 143.), must be practised : general bloodletting,
cupping, leeches applied around the eye, and sca-
rification of the protruded lids ; with active cathar-
tics ; caion.el and James's powder in full and re-
peated do?cs ; turpentine given by the moutii, and
in encmata with castor oil ; and belladonna ; con-
stitute the chief remedies. If suppuration have
occurred, the anterior chamber being full of mat-
ter, the evacuation of it by a free opening into the
cornea, will give relief, and not increase tiiu in-
evitable mischief.

159. B. General OpJilhnlinilis consequent -upon
til e absorption nj' pnrulent or ryiorhid matters into
the circulation , XDixy occur. It lias been noticed
chiefly after phlebitis, by Mr. Aiinoit and Mr.
lIujcii.NiiinTAM ; and is most frequent in the jiuer-
peral state, as a consequence of uterine phlebitis.
The local symptoms in the early stages arc the
stiiiie as in the idiopathic, but less violent, and
Kiore insidious and rapid, and always terminating
in sup^uration and sloughing of the cornea.

The constitutional symptoms are very differenlj
and are of a typhoid and adynamic type. All the
cases that have hitherto been recorded, have ter-
minated fatally.

160. C. An Intermittent form of Ophthalmia
has been described by some writers, particularly
Hoffmann, Cvrry (Trans, of Med. and Chirurg,
Soc. vol.iii. p. 348.), and Heuter (Lancet,
No. 331. p. 473.); but I agree with Mr. Law-
liENCE, in considering a truly intermitting form of
inflammation of any of the tissues of this organ
as not to have been made out. Exacerbations,
relapses, or returns, of the disease, from persist-
ence or recurrence of the cau.ses, may have been
niistaken for an intermittent form. Frequently
recurring attacks of inflammation in some one or
more of the tissues of the eye, especially of the
conjunctiva, and in slight and chronic forms,
are sometimes caused by the sympathetic irrita-
tion of inflamed or carious teeth. — Of this form
of disease, which is not noticed by writers, I have
seen two or three instances ; the removal of the
adjoining irritation curing that depending upon it.

161. I should now have proceeded to consider
the consecutive and malignant alterations of the
tissues of the eye; but these, in a practical point
of view, fall mostly within the province of the
surgeon, a strictly medical treatment having but
little influence^ in removing them. The malig-
nant diseases of this organ are the same as those
observed in other viscera, and are considered under
distinct and appropriate heads. The functional
disorders are treated of in the articles Amaurosis,
Palsy, and Sight,

BiBLioG. and Refer.' — i. Diseases of the Eye in
GENERAL. — Celsus, lib. vi. cap. 6. — Alexander Trail, lib. i.
cap, 2.3. — Boerhnave, Prelect. <ie Morbis Oculorum.
Paris, 1748. — Triller, De Scarificatione Ocul. Historia,
Autiquitate, et Origine. Viteb. 17.04. — Schuster, Observ.
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— J. Hill, The Fabrick of the Eye, .inil the several
Disorders, &e. 8vo. Lond. 175S. — J. Far7ner,The¥a..
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De IMorbis Oculorum Internis. Vien. 1771. — J. Janin,
Mem. et Observ. sur I'ffiil et sur Ics Maladies, &c. 8vo.
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vol. iii. p. 120. — Dcmours, Sur une Mai. de I'CEil sur-

venue apres la Petite Verole, &c. 8vo. Paris, 1767 II'.

Roiiilci/, An Essay on the Ophth. &c. 8vo. Lond. 1771.

— J. Hare, Remarks on the Ophthahny, Psorophthaliny,
and Purulent Eye, &c. 8vo. Lond. 1780. — O. Chandler,
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— IV. RiitDtey, Treatise on One Hundred and Eighteen
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18C0 O. J. Beer, Ribliotheca Ophtlialmica, in qua

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Guillie, Biblioth. Ophthalm., ou Recueil d'Observat. sur
les M.iladies des Yeux, &c. Svo. Paris, IS'.'O. — J. Velcli,
A Practical Treatise on the Diseases of the Eye. Lond.

1820 B. Trovers, Synopsis of the Diseases of the Eye,

and their Treatment. Lond. 1820. — J. Frank, Praxeos
Medica; Universie Prapcepta, Partis Secunda?, vol. i.
p. 677. Lips. 1821. _ T. G. IV. Benedict, Handbuch d.
Prakt. Augenheilkunde, 5 bande, Svo. Leii)s. 1822 — 182.5.

— G. Frick, A Treatise on tlie Diseases of the Eye, &c.

Svo. Baltimore, 1823 O'Ha/loran, Practical Remarks

on Acute and Chronic Ophthalmia, &c. Svo. Lond.
1S24. — J. IVardrop, Trans, of the Med. and Chirurg.
Soo. of Edin. vol. ii. p. 1. 182G. — A. Watson, in Ibid,
vol. ii. p. 76 — G. J. Guthrie, Lectures on the Operative
Surgery of the Eye, &c. Plates, Svo. 2d ed. 1827.

— C/iristian, in Gla.-gow Med. Journ. vol. i. — Stratford,
Manual of the Phys. and Diseases of the Eye, Svo. Lond.
1828. — Jacob, Trans, of Fellows and Licentiates of Queen's
(oil. of Dub. &c. vol. V. Dub. 1828. ; and Cyclop, of
I'nict. Med. vol.iii. p. 199.— J. CJueng^ken, Die Lchre
V. d. Augenoperationen, &c. Svo. Berl. 1828. ; ant!
Ueber d. Augenkrankheit welchein d. Belgischen Armee
herrscht, &c. 4to. Ber. 1824.— j5. Eble, Ueb. d. Bau und
die Krankh. der Bindehaut des Auges, Svo. Wien.
1828 — W. Mackenzie, A Practical Treatise on the Dis-
eases of the Eye, Svo. Lond. 1S30.—R. Froriep, De Cor-

neitide Scrofulosa, 4to. Jen;p, 1830 A. Rosas, Handb.

d. Theoret. u. Prak. Augenheilkunde, Svo. Viien. 1829.

— jr. Lawre7tce, A Treatise on the Diseases of the Eye.
Loml. 1S.:54, Svo — /•'. A. v. Amman, Zeitschrift, f. d. Oph-
tlialmologie, &c. Svo. Heidelb. b. v. &c — B. Middlemore,
A Treatise on the Disease of the Eye and its Appendages,
2 vols. Svo. London, 1S3.5.

ii. OrnrH.\LMi A OF New-born Children S. T. Quel-

jttulx, De C<ecitate Infantum Fluoris Albi Matris, &c.
4to. Lips. 1750. — ScAfi^c';-, Ueber die Augenentzundung
der Neugebornen, in Medic. Chirurg. Zeitung. No. .39.
1791. — J. C. Stark's Archiv. f. (ieburlslmlfe, &c.
h. iii. St. 4. p. 7;>3. Jenje. 1791. —J. G. Gotx, De Ophth.

Infantum recens Nat 4to. Jena?, 1791 Gibson, in

Edin. Med. and .Surg. Journ. 18U7, p. 159 Hegewiscli,

in Horn's. Archiv. b. id. p. '.08 W. F. Brei/ssig, De

Ophth. Neonatorum, 4eo. Erf. 1793.-^.^1. Schmidt,
Ophth. Bihliothek, b. iii. st. 2. p. IQi. — J. H. Juengken,
Nunquam Lux clara Ophth. Neonat. Causa est occdsion-
alis, svo. terol. 1817. —J. C. Reck. De Conjunctlone
Oculi cum ProHuviis LUeri Materni, &c. 4to. Jen^,
1820 — J. C. .Vf/.'sr/i', De Blephari)phthalmia recens Na-
torum. Berol. 1822. — G. Tiieveneij, De Infantum Ble-

pharo-blennorrhoea. Ber. 1^22 Sm.'tlt, in Edin. Med.

and Surg. Journ. No. GS. p. 351.— Melin, in Lond. Med.
and Phys. Journ vol. liii. p. 184. — W. Mac/ienzi'e, in
Ibid. vol. Ivi. p. 327. ; and Glasgow Med. J(Arn. vol. ii.
p ■H9.—Rj/al/, Trans, of Irish Coll. of Phys. vol. iv.
p. 342. ; et Ibid. vol. v. p. 1 — Amnion, Revue Med. t. iii.
1825, p. 124 — T. A. Amtnon, Monog. f. d. Augenleider

•entziindung Neugeborner Kinder. Svo. Leips. 1S25

Mecktinghaus, De Blephanorrhcea Neonatorum, Svo.
Ber. 1826. . — Storch, De Neonatorum Blennorrhoca, Svo.
Ber. 1826. —J. Henschel, De Ophth. Neonatorum, Svo.
Ber. 1827. — Sc/iorn, De Ophth. recens Natorum, Svo.
Ber. 1828. — V. Ammon, in Encyclopad. W.jrterbuch

der Mediciinschen Wissenschalten, b. iv. p. S9. A. A.

Secmunn, De Contagio Ophth. Neonatorum, Svo. Ber.

■1827.

iii. Purulent Ophthalmia of Adults A. Edmond

stun. Account of the Ophth. which appeared in the Ar-
gyleshire Fencibles, with Observations on the Egyptian
Ophth. &c. Edin. 1803. — 1'. Macgregor, Trans, of Soe.
for improving Med. and Chirurg. Knowledge, vol. iii.
p. 2(1. et acq. — Savaresi, in Journ. Gen. de Med. t. xvi.
p. 2l'S. — Henncn, in Med. and Phys. Journ. Sept. 1,S04

P. .iss.diiii, Observat. sur la Paste, le Flux Dys., et I'Oph-

thalmie d'Egypte, &c. Paris, 1805, 2a ed. Svo. — G.

Power, On Egyptian Ophth. Kc. Lond. 1803. Ues-

genettes, Hitt. Medicale de I'Arm^e de I'Orient, Svo.
I'aiis, \W2.—Reid, On tlieOphthal. that appeared in the
S9th Reg. &c. Svo. Portsea, 1806. — ■/. Vetch, On the
Ophthal. as it has appeared in England since the Return
of the Army from Egypt, Svo. Lond. 1807. — U\ Thomas,
Observ. on the Egyptian Ophth., and Ophth. Purulenta.
Lond. 1809 — Peach, in Edin. Med. and Surg. Journ.
vol. iii. p. 52. 39.5. — C. F. Forbes, in Ibid. vol. iii. p. 430.

— Farre/, Observ. on the Ophth. and its Consequences.
Lond. 1811. — I.arrey, Mem. de Chirurg. Milit. vol. iii,
Svo. Paris, 1812 — I'asani, S>tox\a di-U' Ottalmia Con-
tagiosa d'Egitto e sulla sua Propagazione in Italia, Svo.
Verona, 1816. — H. Omodei, Cenni suU' Ottalmia Con-
tagiosa d" Egitto e sulla sua Propagazione in Italia, Svo.

Mil. 1816 Kraiiz, in Rust's Magazin, b. ii. 1S17.

J. letch. Observations on the Tre.itment, by Sir W.
Adams, of the Ophthalmic Cases of the Armv, 8vo.
Lond. 1818. — J. Panada, Mem. Path. Prat, sulle' Ottal-
mie non sole Epidemiche, ma ancora Contagiose. Pad.
1819. — Ktayskens, Sur I'Ophth. Coiitag. qui regno dans
qutlques Bat. de I'Armee de Pays-Bas. trand, 1819.—
J. A'. Rust, Die ^Egyptische Augcncntziindung unter d.

K. Preu^s. Besatzung in Mainz. Svo. Berl. 1820

J. B. Mueller, Erfahrung. iib. d. Contagio'se jEgyptische
Augenentziindung, &c. Svo. Mainz, 1821.— C. /•'. Grafe,
in Gr. u. Walther,Jouxy\. ti. iii. st. 1. p. W5 —Walt her, in
Ibid. b. ii. St. i. p. 99 — Rust, in his Mag.zin b.xiv. h.3.

p. 548 i^osa.?, Breve Saggio suU' Otialmia, che neoli

Anni 1822, 18i3, &c. Svo. Venez. 1824. — C. F. Graefe,
Die Epidemische Contagiose Augenblennorrhb'e iEgypI
tens, in den Europaischen Befreiungsheeren, &c. fol
Ber. 1823.

iv. GONORnHCE.\L AND SYPHILITIC OPHTHALMIA

Astruc, De Morbis Venereis, t. i. p. 2^5. — Muraf, in

Jlem. de la Soc. Med. d. Emulation, Ann. v. p. 449.

Hufiland, Journ. d. Pract. Heilk. b. xiv. p. 191. — Flajani,
Collezione d'Osservazioni, t. iv. ob. 7. — Spangcnberg
Von Indicat. b. d. Ophth. Gonorrhoica, in Hmn, Archiv',
b. xii. St. 2. 270. — Flemming, in Hufetand u. Bimly,

Journ. d. Pr. Heilkunde, May, 1812, p.47 Foot, Treatise

on Lues Venerea. Lond. 1820, p. 98. — F,. M. Boehmer,
De Ophth. Syphilitica. Ber. \%'i\ —Wetzler , Syphilitisch-
gonorrhoische Augenentziindung, &c., in Ha'rless, Neue
Jahrb. h. xii. st. 1. p. 107. 1826. — Delpcch, Cliirurgie
Clinique, t. i. p. 318. -.Bnco?, Treatise on Syphilis, &c.
p. 132 — W. Lawrence, On the Venereal Diseases of the
Eye, Svo. tond. '[iiSG^ — Lusardi, in Archives Gener.
de Med. t. xvii. p.59'J. — J. M. A. Schon, Nosol. Therap.
Darstell. d. Gonorrhdischen Augencntziindun!;, Svo.
Hamb. 1834. — See also most of the latest Systematic
Works, in Uie first sect, of BiBLiocnAPiiY.

V. Iriiis, &C.—J. A. Schmidt, Ueber Nachstaar u.
Iritis. VVien. 1801.; and Quarterly Journ. of Foreign
Med. vol. i.— Rose, in Trans, of Med. and Chirurg. Soe.

vol. viii. p. 361 Wallace, in Ibid. vol. xiv. p. 286

F. E. Niesar, De Rheumatismi in Ocul. Hum. Afl'ectu
Svo. Bresl. 181.5. — H. B. Scliindler, Comment. Ophth
de Iritide Chronica, &c. Vrat. 1819. — J. Ihomr.on, in
Edin. Med. and Surg. Journ. vol. xiv. p. 91. — Farre, in

Sounder's Treatise, &.C. 2d ed. p. 66 J. N. Kenski/, De

Iritide in Genere et ejusque Speciebus, Svo. Pest.' 1820.

— Herzberg, De Iritide. Ber. \-<2\.— T. Heirson, His-
tory and treatment of the Ophth. accompanviiig the Se-
condary Forms of Lues Venerea, Svo. Dub.'l824 J. A.

Robertson, in E.iin.Med. and Surg. Jnurn. Jan. 1825.

Travers, in'hisand Cooper's Surgical Essays, parti, p. 93.
— H. Carmichael, On the Efficacy of Turpentine inDeci)-
scated Inflam. of the Eye, &c. Svo. Dub. 1829. — G. J.
Guthrie, in Med. Gazette, vol. iv. \>. 5m. —Jacob, in
Trans, of Irish Coll. of Phys. vol. v. p. 468. ~ See also
must of the latest Systematic Works in ihe first section of
the Bibliography.

FAINTING. Syn. — AefTro^-yp^ia, Hippocrates.
A'!To-\,vx^ia, Galen. Syncope (from a-vyx.o7rr(a,
concido); Deliqu'mm Animi ; DeJ'ectiu Aiii-
mcE, Celsus. DefailUince, Fr. Die Ohinncicltl,
Germ. Swonning.

Classif.— 2. Class, 2. Order (Cullen).
4. Class, 4. Order (M. Good). I. Cla.s,
III. Order (Autlior).

1. Defix. — Teininrarii depresfion of the ani-
mal ind vital actions, icilhpallor, cold perspiration,
remarkably weak pulse, or absence nf' pulse at the
iirist ; respiration and sensation also being nearly
abolished for a short time.

2. The terms usetl by Hippoctiates and Ga-
TEN are .synonynious with Syncope, a word of
nioilcrn u^e. I.eipolhymia lias been considereJ by
later wi iters, paiticuliirly Morgagni, Dr. Good,

880

and Dr. Ash, either as the same as syncope, or as
signifying a lesser grade of this affection. Tlie
definition wliich Sauvages has given, of leipo-
thymia, assigns it a specific difference from syn-
cope, or the usual form of swooning or fainting.
He states it to be — " Subitanea et brevis virium
dejectio, superstite pulsus vigore, et cognoscendi
facultate." I have had several opportunities of
observing attentively the whole progress of this
affection ; and I admit the accuracy of this defi-
nition, witii the exception of the continuance of
consciousness, which is generally somewhat im-
paired, although not altogether lost. The pulse is
unaltered from the state in which it was before or
after the seizure, or not materially influenced ; and
in some cases 1 have found it so strong as to pre-
scribe depletion ; but the respiratory actions are
nearly abolished. Leipothymia is, therefore, an
affection of the animal and respiratory functions,
that of the heart not being impaired. The slight
or imperfect seizures often observed to precede
fully developed epilepsy, or to occur between, or
usher in, the severe attacks, and described in that
article (§ 41. 52.), are examples of the leipo-
thymia of Sauvages.

3. Fainting and Swooning are grades of the
same affection, the latterbeing a more complete and
prolonged state of the former. Fainting may occur
after very short or irregular periods — the Syn-
cope recurrens of Good. It is then often followed
by palpitations of the heart. — Swooning is much
less prone to recur, but is sometimes followed by
severe reaction. Sauvages has divided syncope
into as many varieties as there are principal causes
inducing it. — Dr. Good has adopted a somewhat
similar division. As, however, it varies chiefly in
degree, from whatever cause it proceeds, no fur-
ther distinction, than that which I have just made,
need be assigned to it.

4. I. Description, &c. — Fainting is com-
monly preceded by languor, a sense of sinking at
the epigHstrium, anxiety, confusion of intellects,
obscuration of vision, cold partial sweats, giddiness
and ringing in the ears, pallid countenance and
quivering of the lips, and coldness of the ex-
tremities. These may continue for some time,
constituting what is usually called faintness,
and disappear; or they pass into full fainting
or swooning more or less rapidly. It is seldom
that fainting occurs without these precursors ;
but when it is fully developed, respiration almost
ceases, and consciousness is nearly or altogether
lost. The action of the heart, however, still
continues, but feebly ; and, although the pulse
disappears from the wrist, as in full swooning,
it may still be felt in the carotids ; or the heart
will be heard to beat on auscultation. In some
instances, relaxation of the sphincters, and dis-
charge of the excretions, are said to have oc-
curred. I3ut this is rare in swooning, although
it sometimes supervenes in leipothymia, in which
the brain is rather oppressed with blood, tiutn de-
prived of it; and in which the pulse retains its
vigour. Sickness, or even vomiting, sometimes
follows faintness, or accompanies recovery from
fainting.

5. The sensations ushering in syncope arc ge-
nerally more or less distressing to the patient, and
are sonietiiries described as accompanied by
■I feeling of death. Montaigne (Kssais, liv. ii.
cap. vi.) found them rather pleasurable than

FAINTING — Deschiption — Causes.

otherwise ; and therefore infers, that those attend*
ing upon dissolution must be similar. Cham-
BEBET experienced the like feelings. The duration
of the seizure varies from a few seconds to one
or two hours; but commonly from half a minute
to ten or fifteen. It has extended in some instances
to several hours. Much longer periods have been
mentioned by writers ; but their actual occurrence
is questionable.

6. The Consequences or Terminations of syncope
are — 1st, A return of the functions, respiration
becoming more sensible and often suspirious, and
eructations or vomiting occasionally supervening;
— 2d, Palpitations of the heait, or general vas-
cular reaction ; — 3d, Hysterical symptoms, or
a fully formed hysterical paroxysm ; — '^th. Con-
vulsions, general or partial, with or without con-
sciousness ; but they are much more frequently
consequent upon leipothymia than upon true syn-
cope ; — 5th, Partial, or slight paralysis, or pro-
longed vertigo ; — 6th, In cases connected with
passive enlargement of the cavities, of the heart,
and attended by a very slow as well as a very
weak pulse, coagulation of the fibrinous portion
of the blood has taken place in these cavities, and
after some time occasioned death ; — 7th, Disso-
lution has occurred in extreme cases, owing either
to the complete depression of cerebral and nerv-
ous power, and the consequent inaction of the
heart ; or to the asthenia and wasting of the
parietes of this organ, in conjunction with nervous
depression. The fifth and sixth of these are rare ;
instances, however, of the latter, are adduced
in the article Heart. The termination in dis-
solution is not so rare ; and is chiefly observed in
cases of great debility or exhaustion from ex-
treme or protracted pain, or from parturition;
and particularly when a sitting or erect posture
has been suddenly assumed or too long retained
in adynamic fevers, and after exhausting dis-
charges or depletions. Some years since I saw
swooning caused by strangulated femoral hernia,
that passed into complete tetanus of many hours'
duration.

7. II. Causes. — The causes of syncope are
strictly occasional. I shall consider them with
reference to their operation. — a. The causes which
act more immediately 07i the nervous system,
are chiefly various impressions made upon the
organs of sense, and depressing moral emotions.
The odour of various flowers, according to the
idiosyncrasy, sometimes occasions it. FABDinus
HiLDANus has seen it produced by the smell of
vinegar; and M.arcellus Donatus, by soft
music. The airs of their native land have induced
it in persons subject to nostalgia. A'arious un-
pleasant sights, or objects of aversion, have caused
it — as the sight of blood, of surgical operations,
or of a corpse; also sudden terror, fear, anxiety,
disappointment. The impression made by me-
phitic or infectious emanations upon the nerves of
smell, frequently induce more or less of faintness.
Concussions and injuries of the brain ; blows upon
the epigastrium ; shocks of the whole frame ;
gyration; rotatory motions, and swinging; exces-
sive or prolonged pain ; pleasurable sensations
carried to excess, particularly the sexual orgasm ;
the exhaustion consequent upon inordinate ex-
citement, long fasting, and the ai)Strartion of
accustomed stimuli; likewise operate principally
in this way.

FAINTING — Causes.

n

8. b. The causes which affect chiefli/ the vascu-
lar si/siem, are the advanced stages of diseases of
the heart and pericardium, particularly passive
dilatation of the cavities, or softening of their
parietes. In cases of this kind, a fatal termin-
ation often supervenes in the form of syncope, as
remarked by Bomet, Lancisi, Senac, JNIohgagni,
Meckel, and others. The most common of
tiiis class of causes is the loss of blood, particu-
larly from arteries whilst in a standing or sitting
posture. HoFFMAXN met with an instance of
syncope from bloodletting proving fatal, and nu-
merous similar cases are on record. During the
period preceding the stage of excitement in fevers,
syncope may follow the loss of an ounce or two
of blood ; and yet the same patient may bear, a
few hours afterwards, when reaction has become
developed, the loss of two or three pounds
without this efTect being produced. Excessive
discharges and evacuations occasion it, by dimi-
nishing the circulating current, by deriving from
the brain, and by exhausting nervous and vital
power. Various circumstances retarding or pre-
venting the return of blood to the right side of
the heart, will sometimes cause fainting. The
sudden removal of prolonged pressure, as of
dropsical effusions and of the contents of the
uterus in parturition, often occasions it ; but whe-
ther the removal of pressure acts in this latter
manner or not, or in favouring a sudden and over-

propagated to the brain and heart, or may coeta-
neously affect them ; as when syncope follows
gangrene, or the passage of noxious matters
into the circulation, or the ingestion of sedative
or noxious matters, or supervenes upon affections
of the stomach, or occurs after the invasion of
fever, and before reaction comes on. In these
cases, however, congestion of the large vessels
and right side of the heart, owing to, and asso-
ciated with, depressed power of the organic nerv-
ous system, is chiefly concerned in overpowering
or weakening the heart's action, and lessening the
supply of blood to the brain. — The increased
function of remote organs, and the derivation of
vital action from the brain or heart, or from both,
as in impregnation and quickening in the female,
and in various diseases of the abdominal organs,
will sometimes induce fainting. The sudden
transition from a recumbent to a sitting or an
erect posture, in delicate or debilitated persons,
is often followed by vertigo, quickly passing into
swooning ; and is obviously caused by the rapid
return of blood from the head, and the diminished
supply to this part, in conjunction with its sudden
and overpowering reflux to the left side of the
heart.

10. It is unnecessary to adduce every circum-
stance that occasionally causes fainting, as they
may be referred to the above heads ; and as there
is scarcely an occurrence or external agent which

powering reflux of blood to the heart, is difficult will not, on some occasion or other, however rare.

to determine. Something may also be owing to
the consequent diminution of resistance to the
heart's action, and change in the accustomed
states of several viscera, and to the effects upon
the abdominal ganglia. It is very doubtful, that
the syncope, which sometimes occurs upon the
removal of the ligature from the arm after bleed-
ing, and upon stopping the evacuation, arises
altogether from the loss of blood, as fainting often
takes place in such circumstances, although no
indications of its approach existed at the time when
the flow was stopped. In this case at least, if not
in others where pressure is removed from internal
venous trunks, the suddenly increased return of
blood overloads the right side of the heart, and
overpowers its action for a time, until the load is
removed either slowly or more rapidly by re-
storing nervous energy. In this manner general
or relative plethora may cause syncope, the
moving power being insufficient for the body to
be moved.

9. c. There are certain causes of sivooiting lihich
seem to act both upon the nervous sijstem and upon
the heart, or upon the latter through the medium
of the organic system of nerves. — These are — ,
1st. Agents from without that make their impres-
sion on the respiratory passages. Some of the
first class of causes act also in tliis way ; espe-
cially mepliitic or infectious effluvia. Instances
have occurred of persons having swooned upon
exposure to the effluvium of pestilential diseases, '
and of death having soon afterwards taken place.
Such an occurrence could not have arisen from

induce it, when acting energetically on suscep-
tible constitutions. On many, however, of the
occasions in which it has been said to occur
by writers, leipothymia has been mistaken for,
and confounded with, it. Thus Heberden, in
stating that epileptics are liable to faint upon
wakening in the morning, has mistaken this state
for leipothymia, which is common in the hori-
zontal posture, sensation and respiration being
nearly abolished, but the pulse retaining its ful-
ness and strength ; whereas syncope rarely comes
on, and generally disappears in this posture. In
epileptic patients, leipothymia often occurs both
when falling asleep and on wakening; but syn-
cope principally on suddenly assuming the erect
posture.

1 1 . There are some occasional causes, the
operation of which is not easily explained, such
as warm baths, heated rooms, and overcrowded
assemblies ; silting with the back to the fire, par-
ticularly at a meal ; and great rarefaction of the
atmosphere. These, probably, act chiefly on
persons whose circulating fluid is deficient in
quantity, by deriving it from the heart and brain.
They more frequently, however, occasion leipo-
thymia and apoplexy or convulsions, especially in
the plethoric.

12. The occasional exciting causes seldom act
excepting on susceptible or predisposed consti-
tutions. These are — the debilitated by scanty
nourishment, by acute diseases and profuse dis-
charges ; persons whose circulating fluid is defi-
cient in quantity ; the delicately constituted.

the effect produced upon the brain solely, or even ' especially females; and peculiar idiosyncrasies,
chiefly. Indeed, I believe that all agents which Those who possess much sensibility and little
impress nerves of sensation, especially those of moral courage or force of character — who have

smell and taste, act more immediately and ener-
getically upon the heart than is usually admitted.
— 2d. Sudden and intense changes induced in
various parts of the body may be sympathetically
Vol. I.

been effeminately brought up, indulged in child-
hood and youth, and unaccustomed to the con-
trarieties of life — are verj' subject to syncope.
Some females, especially the hysterical, weak
3L

FAINTING — Diagnosis,

and excessively indulged, are remarkably liable
to faint from the sliglitest mental or corporeal
cause; and there is reason to believe that tlie
liability is increased by repetition or the habit of
fainting.

13. Pathological Inferences. — 1. In syncope,
the heart's action never, perhaps, entirely ceases
until it terminates in death. — 2. In fainting
from hiemorrhage, cerebral influence, especially
the voluntary powers and volition, is abolished
before the heart's action is reduced to its lowest
state ; but, unless the swoon be complete, sensi-
bility and consciousness are not entirely sus-
pended. — 3. The like obtains in fainting from
moral emotions and impressions made upon the
senses; cerebral influence is first diminished, and
instantly afterwards the action of the heart is
weakened, the weakened vascular action still
further impairing cerebral power, until fainting is
the result. — 4. Several causes, both external and
internal, or pathological, particularly those already
specified ( ^ 9.), seem to act coetaneously and
co-ordinately upon the brain and heart, through
the medium of the organic system of nerves ; whilst
others of the same class of causes (§ 9.) seem
to influence more immediately and especially
the heart through the same channel. — 5. Cer-
tain causes may suddenly derive the circulating
fluid to the external surface or other parts; and
the sudden diminution of the quantity returned
to the heart and propelled to the brain, may in-
duce faintness or full syncope. — 6. The sudden
reflux of blood to the right side of the heart, es-
pecially when it supervenes rapidly upon the
states just specified, may occasion fainting, by
overpowering the heart's action, and thereby
diminishing the supply of blood to the brain. —
7. Fainting may arise from inflammation of the
heart, or efl^usion into the pericaidiuin. — 8. It
may also occur from the imperfect action of the
heart caused by deficient organic nervous power,
particularly of the cardiac nerves, with or without
dilatation of the cavities, and weakness or softness
of the parietes of the organ. — 9. It may be occa-
sioned by circumstances preventing the return of
blood to the heart. — To either of these two last
are to be imputed the fatal cases of syncope related
by Mr. Chlvalier and Mr. Wokt.hington, in
which the cavities of the heart were found empty
and relaxed, and thelarge veins adjoining devoid of
blood.

14. Indeed, death may supervene in any of the
modes in which syncope is produced, especially
when carried to the extreme. Thus I have seen,
in two instances, a moderate doseof the acetate of
morphine occasion loss of voluntary motion, and
scarcely perceptible pulse and respiration — the
characteristic piienomena of swooning. A larger
quantity might have caused death; its operation
— extended from tiie stomach to the heart and
brain — being tiie same, but so great as to put
an end to the functions of these parts. Other
causes, inducing any one of the pathological
states now assigned, may act, in favourable cir-
cumstances, and in highly predisposed persons,
so energetically, as to terminate allogctiier the
vital actions ; predisposition or pre-existcnt states
of the frame, such as have been mentioned, being
often as influential in producing the result, as the
rnorc direct cause.

15. Ill, Diagnosis. — Syncope may be con-

founded with apoplexy , -nith the seizures to which
the term leiputhiimia is strictly applicable, with
asphyxy, with certain states of hysteria, and with
death. — (a) The strong, laboured, or stertorous
breathing, and the full strong pulse; sufficiently
distinguish apoplexy (see that article, § 66.) from
fainting. — b. In leipothymia, volition and volun-
tary motion are abolished, and consciousness
nearly or altogether : Ijut the pulse either is not
affected, or is even fuller than usual ; and it is
more frequently the first stage of, or followed
by, epileptic and apoplectic seizures, than true
syncope. Frequently, also, leipothymia is inti-
mately associated with epilepsy, the former being
either the earlier manifestations or the lesser
grade of the latter. — c. In asphyxy, the actions
and functions of respiration are the first to cease ;
the circulation of venous blood continuing for
some time, until, owing to the privation of pure
atmospheric air, the passage of blood through the
lungs becomes obstructed, as first shown by Dr.
Williams {Ediii. Med. and Surg. 'Journ, Oct.
1823.), when total arrest of the pulmonary cir-
culation, abolition of the cerebral and nervous
functions, and lastly, cessation of the heart's
action (see Asphyxy, § 14 et seq.), are the con-
sequences. Respiration and circulation are
here quite at an end ; and the countenance and
general surface are reddish, livid, tumid, orbloated;
whereas in syncope the face and surface are pale
and collapsed, and the respiratory functions and
circulation still continue, although in a low and
occasionally almost imperceptible state. In the
former, there is remarkable congestion of the
lungs and head : in the latter, the brain is 'gene-
rally insufficiently supplied with blood ; and the
circulation of the lungs, although languid, is
seldom obstructed, and never altogether arrested,
unless a termination in death supervenes. — d.
Various manifestions of hysteria either very
closely resemble fainting, or are in some way or
other associated with it. The more remarkable
phenomena of hysteria may follow, or precede,
fainting, most frequently the former ; but the loss
of motion and sensation often partakes more of the
characters of leipothymia, than of swooning, the
pulse at the wrist being but little affected. Pain
under the left breast, borborgymi, and a sense of
suffocation, which commonly precede the hysteri-
cal form of syncope, sufficiently mark its nature ;
and even when these are not present, other signs
soon manifest themselves, especially convulsions,
weeping, laughing, &c. (See IIystkuia.) — e.
Syncope is rarely so profound as to be mistaken
for death ; but Pohtal and CiiAniiiiiRET, with
some wiiters on medical jurisprudence, concur
in thinking that it may be both so complete and
prolonged as to endanger premature interment in
countries where the last rite is early performed.
Whether or not the action of the heart, which
cannot be altogether abolished even in such
cases, may be detected by the stethoscope, I
am unable to state ; but it surely cannot continue
many minutes without detection upon a strict
scrutiny, unless death have taken ])lace. The
state of the cornea, which is soon covered with a
film, or deprived of its delicate transparency,
and afterwards collapsed ; the appearances
of the thorax upon examination ; the signs
yielded by auscultation ; the condition of tho
body in respect of flexibility, &c. ; and the

FAINTING —Treatment.

temperature under the armpits, &c.; will ge-
nerally decide the question even in the most
doubtful cases. Placing a mirror before the face,
or down beneath the nostrils, and observing whe-
ther the former be moistened, or the latter moved,
have been long popular means of ascertaining
the certainty of death, as happily shown by
Shakspfare (^Lear, act v. sc. 3., and Henry the
Fourth, activ. sc. 3.)

16. IV. Treatment. — Syncope is frequently
not only its own cure, but often the means of
removing the cause which induced it. — When
occasioned by hemorrhage, the languid state of
the circulation permits the formation of coagula,
which plug the vessels and arrest further dis-
charge ; and the loss of the voluntary powers
causes the patient to fall in the very position
which, of itself, generally restores the use of his
faculties, by facilitating the transmission of blood
to the brain. The i7idications are — a. To remove
the cause of the affection; and, b. To recover the
patient in the seizure.

17. ^. For obvious reasons, the second inten-
tion often may be the first required, particularly
when called to him in the attack. The patient
should be placed in the horizontal position, and
removed to an open and moderately cool air ; and
fragrant and cold water — lavender water, Cologne
water, or simple water — may be sprinkled on the
face, or rubbed on the palms of the hands, &c. In
more profound cases, frictions of the limbs, epigas-
trium, &c. may be assiduously practised in a well-
ventilated chamber; and the usual stimuli —
aether, camphor, ammonia, &c. — given inter-
nally, in moderate or appropriate quantity, as
soon as the patient can swallow. The recumbent
posture should always be continued until recovery
is complete.

18. When syncope supervenes upon blood-
letting, the recumbent posture should constitute
the whole means of restoration ; for unless the
operation has been very injudiciously resorted to,
this will be sufficient for recovery. The use of
stimuli in this case, will only increase the conse-
quent reaction, and often aggravate the disease
for which the depletion was employed. For syn-
cope from diseases cf the heart, a moderate and
discriminating use of stimulants is often neces-
sary; but they may be injurious if it aiise from
inflammation of the heart or pericardium. When
it is caused by hismorrhage, stimulants are very
frequently hurtful, as they inteifere with the con-
sequent changes in the vessels, preventing a re-
turn of the hajmorrhage ; but extreme cases and
circumstances occasionally arise, rendering the use
of stimuli indispensable.

19. If syncope occur after parturition , ehher
from exhaustion of nervous power, or from hae-
morrhage, internal and external stimuli ought not
to be delayed. Swooning from haemorrhage in
the puerperal state always demands immefliate
and appropriate treatment, as it arises not only
from the loss of blood, but also from exhaustion
and the sudden removal of an accustomed pres-
sure affecting more or less all the abdominal and
thoracic viscera — from the combination ot the
three most powerful occasional causes of the af-
fection. Eesides, syncope supervening after the
recumbent posture is assumed, is never devoid of
danger ; and the imperfect contraction of the
uterus so generally conuected with the production

of haemorrhage, will not be remedied by the con-
tinuance of tliis state.

20. Bloodletting has been considered by some
writers necessary to the cure of certain forms of
syncope, especially by those who have con-
founded leipothymia with it, which is often be-
nefited by depletions. Zacutus Lusitanus
relates a case in which he practised it largely ;
but the fainting was there evidently connected
with disease of the heart, — bloodletting being
often necessary in such circumstances, although
requiring much discrimination, both as to its
adoption, and to the mode and extent of em-
ploying it. In the actual state of syncope it
can hardly be resorted to without risk. The
practice in such cases must depend upon the in-
ferred nature of the heart's disease. I was some
years ago called by a neighbouring practitioner to
a patient suffering from recurring syncope, vo-
miting of all ingesta, and severe pain in the epi-
gastrium, with anxiety, &c. The disease was
viewed as acute gastritis, and appropriate treat-
ment adopted ; it terminated, nevertheless, fatallv
in a few hours. On dissection, evidence of in-
tense inflammation of the pericardium, particu-
larly the part reflected over the heart, was
found.

21. When vomiting supervenes during syncope,
a speedy removal of the affection is the conse-
quence, unless the syncope be, as in the preced-
ing case, a sign of a most acute and dangerous
disease, wherein bloodletting should be resorted
to. When fainting arises from the quantity or
quality of the ingesta, the exhibition of an emetic
is generally beneficial.

22. The question has been proposed by
Brauseu, whether bloodletting should be per-
severed in or not, when it almost immediately
causes syncope, without any evident cause ?
Such cases are not infrequent in practice ;
and I have met with the occurrence even
where venaisection appeared most requisite, and
the patient by no means fearful of its perform-
ance. In a case of this kind, which lately oc-
curred to me, copious local depletion was
substituted with great benefit ; but in a still more
recent case, the patient recovered by means of
internal treatment, without bleeding in any way.
The question, theiefore, cannot be answered in
a positive manner one way or the other, but
where syncope takes place, bleeding is not re-
quired in the great majority of cases, and it may
be injurious. At a time when bloodletting was
viewed as the chief remedy in fever, and directed
to be performed as early as possible in the disease, I
had opportunities of seeing it practised in the cold
stage, or previous to the developement of reaction,
of both the remittent and continued types; but
it almost instantly, or before two or three ounces
of blood had been withdrawn, produced syncope
of a piofound and serious kind, and proved ma-
nifestly hurtful. The results would liave been
very different had the operation been deferred to
the s{age of reaction ; and hence, although in-
stant syncope, or even faintness, upon blood-
letting, is an indication of its injurious tendency,
if persevered in at the time, yet a consequent
stale of action, general or local, may arise in a
very short time, in which it will be borne to a
very great extent without this affection resulting,
and will prove most beneficial.

3 L2

884

FEIGNING DISEASE.

23. B. The removal of the causes of the affection,
Avhen these are of a constitutional or structural
kind, must be attempted after recovery from the
seizure. If it depend upon Debility, the means
advised in that article will be requisite ; and m
other circumstances, the treatment suitable to in-
ferred pathological conditions should be practised,
as pointed out in the places where sucii condi-
tions are more especially and appropriately con-
sidered.— The prevention of a return of the
affection will be most effectually secured by this
procedure.

BiuLioG. AND Refur. — Aretceus, Acut. 1. ii. c. 3. —
^e//(«, Tetrab. ii. s. i. c. 9G.—P<iulus Mgineta, 1. ii. c.36.
— Avicc)ina,CAnon. 1. iii. fen. ii. tract, ii. c. 6. — Bauduyn,
Non ergo omnis Syncopes eadem Curatio. Paris, l-')73. —

Albt-rtinu Ue Aftect. Cordis, 1. iii. 4to. Venet. 1018

IVihlholx, Syncopes Natura et Cura. Argent. 1051. —
Marcel/us Donatus, 1. ii. c. i. p. 90. — Primerosius, De
Morbis Mulierum, 1. iii. c. 10.— Df Berger, De Deliquiis

Aniini. Witeb. 1689 Sclienck, Observ. 1. ii. No. 21"J. 226.

— Forcstus, 1. xvii. obs. 8, 9, \0.— Amatus Lusilanus,
cent. ii. cur. 36.— Fabricius Hildanus, 0pp. p. 990— Za-
culus Lusitanus, Prax. Admir. 1. i. obs. Vi5.—Bonet, Se-
pulchret, 1. ii. sect. x. obs. 1. 3. 9. — Lancisi, De Subit.
Mort.p. 130.— TJifrf/m, Lin. Med. 1700. p. 226. — Wedel,
De Syncope et Leipothymia, &c. Jenas, 1715. — I'atcr, De
AffectuMagno.Mortique proximo, Sj-ncopcej usque Causis
et Cura. Witeb. 1723. — Hoffynann, De Animi Deliquiis,
Opp. vol. viii. p. 273. —Mnrgagnijye Sed. et Caus. Morb.

epist. XXV. art. 2. 17 Bratiscr, An Syncope Vensesec-

tioni semper sine aliqua probabili Causa superveniens ab
ea abstinere jubeat. Goet. 1756. (Concludes in the af-
firmative.^— Sauvages, Nosol. Methodica, vol.ii. p. 301 —
Senac, Traitedu Coeur, X.^i.c.W.— Whylt, Works, p. 36.
—Lieutand, Hist. Anat. Med. 1. ii. obs. 794.798.— Vallis-
neri. Opera, vol. iii. p. 521. — Sail/ant, Hist, de la Soc.
Roy. de Med. ad 1770. p. 318. — A' Bergen, An in Pa-
roxysmo Syncoptico Venam Secare liceat ? Fr. 1774 —
Martin. Nouv. Theorie de Syncope. Paris, 1802. —
Portal, Mem. sur la Nat. et le Traitement de Plusieurs
Maladies, t. iv. p. 223. Paris, \S19.—Cliar}ihcret, in Diet,
des .Sciences Med. t. liv. p. 8.5. — IVortliington, Lond.

Med. Rep. vol. xvii. p. 361 Piorry, in Archives Gener.

de Med. t. xii. p. 527 M. Good, Study of Medicine,

Cooper's, edit. vol. iv. p. .546. — E. Ash, Cyclop, of Pract.
Med. vol. ii. p. 138. (Errs in considering the action of
the heart to be altogether suspended.)

FAUCES. See Throat — Diseases of the.

FAVUS AND ACHOR. See Porrigo and Pus-
tules.

FEIGNING DISEASE. — Classif.— Diag-
nosis.— Symptomatology.

1. Disease may be — Isl, Preietided or simu-
lated, the person being in a state of health ; — 2dly,
Artifciallii excited, disorder being actually pro-
duced ; — 3dly, Exaggerated in the description and
appearance given of it, the patient bemg indis-
posed ; — and, 4thly, Artif daily and intentionally
increased, or aggravated during its course. In
these /ou?- modes, disease may be said to ht feigned
or simulated.

2. The objects desired to be accomplished by
those who undergo the inconvenience, suffering,
and moral degradation of feigning disease, are —
u. To escape from being levied into the public
services; — b. To procure a discharge from the
public service ; — c. To obtain both a pension
and a discharge ; — d. To enjoy the ease and
comfort bestowed on the sick, and to escape
from hard work, or unpleasant employment,
mental or corporeal ; — e. To obtain objects of
desire, or to procure compliance with wishes or
caprices ; — f. To avoid punishment ; — g. To
excite compassion or interest ; — h. To deceive.

3. The persons who feign disease with one or
more of these intention* are — a. Soldiers and
sailors ; the foinier being usually called mnini-
/,'erei-s, the latter s/iu/Aers; — H. Slaves and serfs;
— y. The lowest class of labourers, and mendi-

cants ; — J. Members of benefit societies ; — t.
Persons who have received accidental or in-
tended injury, and desire to obtain increased
compensation for it ; — t,. Prisoners for debt, or
for civil or criminal offences ; — n. Young per-
sons of both sexes wishing to escape from the
confinement of school and the labour of study,
or longing for a return to their homes ; — &, The
spoilt or indulged, who desire to excite interest,
or to obtain a compliance with their desires ; — i.
and lastly, Tiiose who wish to accomplish objects
of private or political ambition, or to gain particular
ends. — Feigning disease has been resorted to with
the last-mentioned view, very probably from the
earliest times. Amxon the son of David, Ulysses,
Solon, the elder Brutus, the Roman CyELius
(" Desit fingere CceHus podagram." — Martial,),
" Hotspur's father, old Northumberland," the
Constable Boureon, Pope Julius III., the Earl
of Essex, and Raleigh, grace this class of
malingerers.

4. Disease may be so artfully feigned in one
or other of the modes just stated (§ 1.), as to re-
quire the utmost discrimination and ingenuity to
detect the imposture. It is obvious, as Dr.
Cheyne remarks, that the discovery of it will
be most readily made by those who are the best
physiologists and pathologists, and most accu-
rately informed respecting the operation of medi-
cinal agents. In doubtful cases, the practitioner
should take into consideration the constitution,
education, information, habits, and probable mo-
tives of the person ; and examine more especially
those symptoms which are counterfeited with the
greatest difficulty, in respect not merely of their
individual, but of their correlative, characters.
The frequency and rhythm of the pulse, in con-
nection with the temperature, colour, and hu-
midity of the skin ; the expression of the eye
and face; and the foetor, colour, and consistence
of the excretions ; should especially arrest atten-
tion. A morbid appearance may be communi-
cated to the excretions,' and to the tongue and
mouth ; but a morbid foetor of the former, and
various states of the latter, are counterfeited with
great difficulty. The intelligent observer will
infer much also from the manner of the simula-
tor ; from the consistency of the account given
by him ; and from the relation one symptom
bears to another, in its seat, nature, or severity ;
and will be careful not to lead him to suspect
that the reality of his ailments is for a moment
doubted, until jproofs of detection are complete.
The circumstance of impostors always overacting
their part, overloading their accounts with unne-
cessary details, complaining of their sufferings,
and readily falling into the snare of enumerating
incompatible symptoms, when a leading question
respecting them is put, should not be overlooked.
They are seldom desirous of obtaining medical
aid, or of submitting to the treatment directed ;
and, in every case, strict attention should be paid
to the exhibition of the medicines ordered, vvliich
ought never to be left in the possession of a sus-
pected person. In doubtful, and even in real,
cases of feigning, painful or even severe mea-
sures should not be inflicted, as in most instances,
and especially in the jniblic services, the mind
of the impostor is made up to endure even torture
rather than ;:;/('e /;;.

5. The importance of this subject in private

practice is greater than is commonly imagined ;
as one or other mode of feigning is often resorted
to in civil life, especially among indulged females,
in order to obtain compliance with their wislies,
or to excite interest, or for the pleasure of deceiv-
ing ; and, in sucli cases, the practitioner may
lower himself in the estimation of the person at-
tempting to impose upon him, by not detecting
the cheat. At the same time he should be care-
ful not to treat a person as an impostor unless the
evidence is complete; for he will thereby injure
himself in practice, and, in the public services,
endanger the lives of those whom he wrongfully
accuses. During the late war, wlien many went
into the public services but scantily stored with
medical knowledge, instances were not uncommon
of persons feigning disease with success ; and of
others being treated and punished as impostors,
who were actually suffering the complaints they
made. In proportion, however, to the general
advancement in medical science, such occurrences
will be more and more rare; and, in recent times,
numerous aids have been furnished, in very able
papers on the subject, to those who may stand in
need of them. In the following account of feign-
ing disease, an alphabetical arrangement is
adopted ; indeed, it is the only one which the
subject admits of : —

6. ABDOiMiNAL Tumours have been feigned by
paddings worn in the dress ; and by pushing the
abdomen upwards in bed, or forvvardswhen erect.
Detection is easy in such cases, on examination
of the naked person. When this is resisted, the
inference is obvious.

7. Abortion is simulated by staining the linen
and body with blood, procured either by punc-
ture of a vein in one of the extremities, or from
the lower animals. Detection is diflBcult. The
state of the pulse, the appearance of the mammjE,
and of the countenance, and an examination per
vuginam, may lead to more or less suspicion, but
furnish no proofs of iis occurrence.

8. Abstinence, either total or partial, has been
feigned in numerous instances. jMany of the
persons who have done so, have possessed the
power of abstaining from food for a very long
time ; but deceit has been always practised, when
total abstinence has been said to have been car-
ried beyond a few days. — A woman was con-
demned for the murder of her husband in the 31st
of Edward III. (Med. &; Pliys. Joiirn. vol. xxxi.
p. 50.) She had the wisdom to fast in prison

FEIGNING DISEASE. 885

ledge. During the last wars, numerous French
conscripts were exempted from service by simu-
lating blindness, and using belladonna to dilate
the pupil and render the iris inactive. When the
simulator has had recourse to this means, even the
reflected light of a mirror will not cause the con-
traction of the pupil.

10. Cachexia Aericaxa was formerly pro-
duced by the West Indian slaves, in numerous
instances, by voluntarily adopting a practice
usually caused by disease. It is often connected
with disorder of the stomach at its commence-
ment ; and in this case, the practice of dirt-eating
pnly aggravates the primary affection, or changes
it into the true African cachexy. Whether the
practice be the result of a morbid appetite, or
adopted with the intention of aflecting the health,
or causing death, it may be detected by the ex-
hibition of emetics, and on the examination of the
stools, the egesta being washed. The only means
which succeeded in preventing it, when resoited
to with suicidal intention, was to cause the slaves
to believe that decapitation would be performed
on them after death, as they imagine that this
operation prevents their return to their native
country, and their migration to other states of ex-
istence.— (Williamson, in the West Indies;
and rtyself in Africa.)

11. Cancer is said by JNIahon, Fodere, and
Beck, to have been feigned by mendicants and
others. — A part of the spleen of an animal is
glued on the part, with the smooth side to the
skin, leaving on the outside the appearance of an
ulcerated or diseased surface. Pierre Pigray
adduces an instance in which this mode of decep-
tion was attempted. His account leads to the
inference that it was formerly practised on some
occasions for the purpose of performing miracu-
lous cures. Attentive examination of the part,
and observing whether general signs of cachexia
be present, are sufficient for detection.

12. Catalepsy is not infrequently simulated
by soldiers or sailors, and by hysterical and
capricious females. It may generally be de-
tected, partly by considering the circumstances
in which it is observed, and the kind of persons
who are affected, and partly by artifice. The
use of powerful stimulants; letting fall a drop or
two of a very hot or very cold fluid on the skin of
the patient's neck ; proposing the actual cautery
whilst the pulse is being felt, and marking the
effect ; and suspending to the hand which has

forty days, and was pardoned on account of her been stretched out a small weight attached to a

miraculous abstinence. Ann Moore, w ho gulled
the British public for some years in this way, and
who really possessed the power of fasting for an
unusually long time — eight or nine days, or
nearly the whole period that a person can live
without food ■ — is said to have made a fortune by
the imposture. Very attentive watching and much
trouble are required in the detection of it ; and
wherefore should they be undertaken?

9. Blindness — partial or total — is feigned
chiefly by men in the public services, by mendi-
cants, and by persons endeavouring to avoid con-
scription into the army or navy. Amaicmsls is the
common form a'^sumed, but paralysis of the eye-
lids is also sometimes alleged. Amaurotic blind-
ness, being characterised by a dilated and fixed
pupil, may be detected by the absence of this sign,
and by watching the patient without his knovv-

strmg, which should be imperceptibly snipped,
and observing whether or no the arm be suddenly
thrown up, are the usual means of detection.
The last method was resorted to by John Hunter,
in St. George's Hospital.

13. Concretions of various kinds have been
pretended to be passed from the bowels, urinary
organs, vagina, and stomach, by soldiers and
females. Cases of this kind are adduced by
Dr. Livingston (Edin. Med. Comment. vo\.iv.
p. 452.), Dr. Thomson {Annals of Pliilos. vol. iv.
p. 79.), and Mr. Dunlop (Beck's Medical Juris-
prudence, p. 7.). The most superficial examina-
tion, and the rudest chemical experiments, will
show the difference between the substances thus
used for deception, and the ascertained nature of
the morbid concretions occasionally passed from
the bowels and urinary organs. One of the writers
3L3

886

FEIGNING DISEASE.

in the Cyclopedia of Practical Medicine mentions
a remarkable instance of deception practised by a
young woman at Edinburgh, and continued from
1817 to 1830. She feigned during that time,
hepatitis, epilepsy, amaurosis, aphonia, deafness,
paralysis, gravel, anasarca, ha;matemesis, con-
vulsions, gastralgia, dyspnoea, retention of urine,
vomiting of substances resembUng liver, bone,
&c., and at last concluded by excreting bone
from the vagina. Bone was first detected in the
vagina in 1824, whilst introducing the catheter,
and large quantities were passed, or extracted, —
some even from the bladder. She was received
into the hospital in 1825, and the bones which she
passed were believed for a time to be those of an
extra-uterine foetus. She was there detected by
cutting off the supply, and discharged. She after-
wards had recourse to the same practice, but
at last varied it, and had an illegitimate child in
1828.

14. Deafness and Deaf-Dumbness are simu-
lated by those who wish to escape from the army
or navy, or from criminal trials, and by mendi-
cants. They generally lose their hearing sud-
denly ; whereas real deafness is gradual, or the
consequence of severe illness. The expression
of the countenance and a change in the pulse
often betray the impostor when something of
great importance is said in his hearing. But
some are prepared for this, and are even unmoved
by very sudden noises. Mr. Duneop states, that
a soldmr feigned deafness so well, that firing a
pistol at his ear produced no effect ; but on the
experiment being tried after he had been put to
sleep by opium, he started out of bed. Tiiose
who feign dumhness, are generally unaware that
if a person has acquired the use of speech, he never
can become dumb, however deaf he may be.
The really dumb acquire an expression of coun-
tenance and gestures which are assumed with
great difficulty, and few have sufficient art and
perseverance to counterfeit deafness and dumb-
ness, so as to avoid detection for any length of
time. Some have attempted even to cause deaf-
ness, by introducing solid bodies into the ear, or
by exciting inflammation of it by irritating matters.
Honey and various other substances have been
employed so as to simulate otnrrhoea. The organ
and the discharge from it should therefore be care-
fully examined.

15. Delivery has been pretended, with an
obvious intention, after artificial abdominal en-
largement and sudden subsidence of the tumefac-
tion. In this case the external parts of generation
are moistened by procured blood, and the child of
another substituted as the female's own. Tliis
cheat can be detected only by examining per
vaginam. Soon after real delivery, the vagina
will be relaxed as well as the os uteri ; the latter
tumificd and tender, and the lochial discharge
, flowing. But these signs will become less evi-
dent, the longer the tim'e that has elapsed ; and,
after nine or ten days from parturition, they can-
not be depended upon ; but the well-known state
of the integuments of the abdomen, and the ap-
pearance of the mamma;, will aid detection.

16. Dropsy has been simulated by French
conscripts, who have been said to have actually
inieclcd water into the cavity of the peritoneum,
aiiil thereby produced factitious ascites. — Ana-
sarca of tlie extremities lias been caused by

ligatures artfully concealed; but the imposture
will be detected upon strict examination of the
naked body, and by the absence of a leucophleg-
matlc or cachectic appearance. Cushions fitted
to the abdomen, and padded clothes, are the
modes resorted to by mendicants ; but these re-
quire no remark. Instances are mentioned by
RIangetus, Sauvages, and others, of chronic
dropsi) of the head being simulated by mendicants,
who have daily blown air under the scalp of chil-
dren through a small perforation at the vertex,
until the scalp became enormously distended.

17. Dysentery and Chronic Diahrikea are
often feigned by soldiers and sailors, particularly
in warm climates ; and are sometimes actually
produced by their using irritating substances
for the purpose. Mr. Copland Hutchison has
seen even a fatal result follow such practices. He
ascertained that vinegar and burnt cork were
often used to cause the disease. Suppositories of
soap, and irritating substances introduced into
the rectum, have also been employed to cause
mucous discharges (Cheyne); but drastic purg-
atives are more frequently taken in sufficient
quantity for this purpose. The dysenteric evacu-
ation is simulated by breaking down the faecal eva-
cuation in the urine, and mixing with it tlie blood
procured by pricking the gums. The imposture is
detected by the cleanness of the linen ; by obliging
the patient to use a night-chair, and by watching
his proceedings.

18. Emaciation — partial or general. Gene-
ral emaciation and debility are sometimes occa-
sioned with the view of avoiding some disagreeable
service, or to be sent home from foreign service,
or to procure change of climate. Abstinence
from food and sleep, the frequent use of purg-
atives or diaphoretics, especially antimony, and
excess in spirituous liquors, are the means com-
monly resorted to. Wasting of a limb is caused
chiefly by mendicants, by means of continued
compression ; and the diagnosis between artificial
and real wasting is often very difficult. Detection
must depend upon a strict examination, and a va-
riety of considerationsthereby furnished to the duly
qualified examiner.

19. Epilepsy is very frequently feigned by
mendicants, by sailors and soldiers, and occasion-
ally by females to serve particular ends. In such
cases it is proper to notice whether the person
falls to the ground without regard to the situation
or place ; whether the face be livid, the pupil
fixed, the spasm and convulsions general, the
pulse altered, the insensibility complete, the
mouth distorted and frothy ; and whether sopor
follow the fit, passing into heaviness, vertigo, and
exhaustion, as all or most of these symptoms arc
absent, or Imperfectly evinced in the simulated dis-
ease. The opportune appearance of, and selected
situation for, the feigned paroxysm, the partial or
successive production of the muscular actions,
the sensibility of the iris, the abrupt termination
of the seizure, and the absence of injury to the
tongue, should also be taken into account.
Foaming at the mouth is sometimes imitated by
means of soap kept in it; but it is generally
overdone in this case. The real epileptic is de-
sirous of concealing his infirmity ; whilst the
siniulal((r talks of his disease, and never endea-
vours to avoid publicity. It is chielly, however,
by artifice that feigned epilepsy can be fully

FEIGNING DISEASE.

887

detected. De Haen, observing the sensibility of
the pupil in a girl who feigned epilepsy to avoid
work, suspected the imposture, and desired the
attendants to place her in an erect posture, and
to chastise her severely if she fell. She confessed
the cheat. A beggar in Paris, who often fell into
fits in the streets, was placed on a truss of straw,
ostensibly to prevent him from sustaining injury.
When in the midst of the paroxysm, fire was set
to Qach corner of his bed, and he sprang up and
fled. Sauvages was called to a female who imi-
tated the fit remarkably. He inquired whether,
on the access of the paroxysm, she felt pain ex-
tending from her arm to her shoulder, and thence
to the opposite thigh. She said that she did,
and was detected. ]\Ir. Copland Hutchison
introduced some Scotch snuff up the nostrils of a
man whom he suspected of feigning a fit. It in-
duced a fit of sneezing, and epilepsy was not
afterwards heard of. Dropping alcohol into the
eye (Cheyne), the introduction of nauseating
substances into the mouth, proposing very pain-
ful or dangerous means of restoration in the
patient's hearing, the dread of the actual cau-
tery, directing boiling water to be poured over
the legs, and actually pouring very cold water,
have severally been recommended. Dr. Ciieyne
states, that in the case of a soldier, a table was
placed upon another, and the simulator laid, in
the midst of his fit, on the former. Dread of the
fall terminated the convulsions. In doubtful
cases, particularly in the public services, the
medical man should be cautious in giving an
opinion, and should never sanction punishment.
Dr. Cheyne and other experienced writers state,
that they are "in possession of sufficient evidence
to prove that real epilepsy has often been con-
sidered feigned;" and they might have added —
punished accordingly. But these occurrences,
however frequent in past times, are not likely to
take place often in future.

20. F^tcEs. — Incontinence of faeces is some-
times feigned. It is detected by examining the
sphincter ani, according to the recommendation
of Dr. Cheyne ; who directs that, if it should
contract upon the finger, opium and solid food
should be prescribed, and a watch set over the
person. If he pass solid fasces in bed, he will be
a fit subject for punishment.

21. Fainting and Swooning are simulated by
mendicants, by hysterical or indulged females,
and by sailors and soldiers in order to escape
punishment; but the nearly or entirely absent
pulse, the scarcely perceptible respiration, the
collapse, coldness, and paleness of the counte-
nance, and cold sweats, with coldness of the extre-
mities, are not easily produced at will. Ligatures
or pressure have been used to suppress the pulse,
and washes applied to the face to produce pale-
ness ; the means of detection should therefore
have reference to such artifices.

22. Fever is more frequently produced arti-
ficially, than feigned. Ague is the type selected
when feigning is attempted. The exertions,
however, necessary to sim\ilate the rigors of the
cold stage, will generally be found to be produc-
tive of the sweating stage instead of the former.
Cantharides, and various stimulants, are usually
taken to induce febrile symptoms ; and a tem-
porary acceleration of pulse is often occasioned
by both sailors and soldiers, just before the phy-

sician's visit, by striking the elbow against any
hard substance. Some persons acquire a power
of accelerating the heart's action at will. Emetics
are sometimes also resorted to, to make the decep-
tion more complete ; and the tongue is artificially
coloured by chalk, pipe-clay, brick-dust, tobacco,
brown soap, &c. \Vhen suspicion is excited, the
pulse should be examined a second time on leav-
ing the patient, and preferably in the carotids or
temples ; the state of the excretions being par-
ticularly attended to. Cases of feigned fever are
gennrally ephemeral, and a day or two of close
examination generally leads to detection.

23. Gastric Affections, especially gastralgia
and attacks of vomiting, are sometimes simulated.
The former is detected with great difficulty, and
chiefly from collateral circumstances. Vomiting
is generally produced by having recourse to the
common emetics, or to tobacco, particularly the
latter, on account of its depressing influence on
the nervous system and circulation ; and by pres-
sure on the stomach (C. Hutchison). . I met
with an instance, some years ago, where it way
induced at will, by the action of the abdominal
muscles, without even the aid of irritating the
fauces. In such cases, the state of the appetite
and the appearance of the evacuations should
be examined ; for, unless where tobacco has
been taken to disorder the stomach, the former
is but little impaired. In the case of vomiting
at will just mentioned, the person had no sooner
emptied his stomach, than he proceeded to reple-
nish it again with an appetite. Not only is vomit-
ing produced, but further deception sometimes
is attempted by introducing various foreign sub-
stances into the matters ejected. A singular case
in which a girl was said to have brought up the
larvBB of insects and reptiles from her stomach, is
recorded in the Transactions of the Dublin College
of' Physicians. It afterwards, however, was as-
certained to have been a well-managed decep-
tion.

24. HEMORRHOIDS are sometimes simulated ; the
appearance of the haBmorrhoidal tumours being
imitated by means of small bladders filled or
tinged with blood, and partially introduced into
the rectum (Percy and Laurent). Simple
discharge of blood from the anus is more easily
feigned ; and the deception is detected with
greater difficulty.

25. H«MonRHAGES from the Stomach, or from
the Lungs, are often feigned. In order to imitate
H(c>noptitsis, cough is pretended, and the saliva
coloured by pricking, scratching, or sucking the
gums ; or by holding Armenian bole, brick-dust,
vermilion, &c. in the mouth. An attentive
examination of the sputum, and of the physical
and rational symptoms, will generally lead to
detection. Hiematemesis is often feigned by swal-
lowing bullock's blood, and soon afterwards by
inducing vomiting. If the quantity taken be
considerable, vomiting will often follow without
any aid. Instances of deception practised in this
way are mentioned by Sauvages, Metzger, and
Beck.. A close investigation of the symptoms,
and, if suspicion be occasioned, a strict surveil-
lance, will generally prevent a continuance of the
imposture.

26. IlEAitT-ArrECTiONS have been simulated,
in order to escape from the public services. AIM.
Peiicy and La'jrent state, that a ligature has

3 L4

JEIGNING DISEASE.

been found so firmly bound around the neck,
as to cause a livid and swollen countenance, and
disorder the heart's action. Dr. Quareier and
Mr. Copland Hutchison ascertained, that white
hellebore was often used by sailors to produce
this effect ; vomiting, purgmg, syncope, tremors,
and nervousness, followed by palpitations, being
the usual consequences of a large dose of this
substance. Mr. Dunlop states, that death was
occasioned in one instance by the use of hellebore
with this intention.

27. Hepatic Disorders are often feigned by
soldiers in warm countries, particularly in India;
and by officers and othersdesirous of returning to
Europe. If any doubt of the reality of the com-
plaint exist, the person should be undressed, and
carefully examined by percussion and the stetho-
scope. The absence of enlargement in the region
of the liver, the complexion, and appearance of
the surface and limbs, and the state of the pulse
and respiration, are the circumstances which
should chiefly be considered. It ought not,
however, to be overlooked, that most serious
disease of the liver may exist without enlarge-
ment ; and this viscus may be considerably en-
larged, and even rise up into the right thorax,
■without being felt below the ribs. Hence the
propriety of having recourse to percussion and
auscultation in the investigation, especially when
otiier proofs of disease are wanting.

28. Hernia and Hydrocele have been simu-
lated by blowing air into the cellular membrane
of the scrotum. Mr. C- Hutchison met with an
instance of hernia being feigned, by elevating the
•testes to the external abdominal rings. Detection
in cases of this kind is quite easy.

29. Hysteria is not infrequently feigned. Dr.
DuNGLisoN directs sternutatories to be employed ;
but the affection may be real, although they pro-
duce their usual effect. Detection is by no means
easy, especially when an intelligent female simu-
lates this complaint. In a case to which I was
lately called, the moral circumstances and the
symptoms induced me to infer deception ; and I
accordingly took my leave, by simply stating, in
the patient's hearing, that, if recovery was not
complete in a few minutes, the affusion of cold
spring water over the head and neck would cer-
tainly have the desired effect. It should, how-
ever, be recollected, that females who are really
hysterical are the most prone to feign disease ;
this affection and the desire to simulate others fre-
quently arising from the same cause, viz. uterine
irritation.

30. Jaundice, notwithstanding the difficulty
of the attempt, has been succefsfully simulated,
particularly in France, during the lale war. Con-
scripts employed an infusion of turmeric to tinge
the skin, muriatic acid to give the evacuations a
clay-colour, and rhubarb to heighten the colour
of the urine. But the white of the eye cannot be
changed by art, although smoke has been tried
for this purpose. Washing the surface and pre-
venting access to the materials of deception are the
chief means of detection.

31. Insanity in some one of its various forms
— but most frequently mania, melancholy, and
idiocy — is fre(|uently feigned ; and detection is
by no means easy, 'riicrc can be no doubt that,
in the public services, pretenders often gaine<l their
■ends; and that the really afflicted were soiue-

times treated as impostors. Nor can this be a
matter of surprise, when the great difficulty of
discrimination is considered. In the present day,
madness is most commonly feigned with the view
of escaping from the punishment due to crime ;
and the responsibility of the medical examiner is
consequently great. He should, therefore, have
every facility afforded him, and take sufficient
time to the investigation, that he may arrive at a
correct conclusion. He should endeavour to
obtain from the individual a full account of him-
self; mark its consistency, and place an intelli-
gent watch over him. The expression of the
countenance, and of the eye ; the gestures and
manner ; the state of the tongue, the appetite,
and the evacuations; and especially the duration,
continuance, or frequency of sleep; oi:ght to be
carefully observed. Certain expressions of coun-
tenance and gestures are so peculiar to the insane,
that the experienced observer will infer much from
them. Pretenders generally overact their parts;
assume the more violent or disgusting forms of
mania ; do not maintain the deception when they
believe themselves unobserved ; recommence it
in the society of others ; and possess not the power
of prolonged abstinence froin sleep and food so
generally observed in the truly insane. Sound
sleep soon overpowers the pretender, whereas the
insane are remarkably watchful ; sleeplessness to
a distressing degree often preceding the disease,
and always attending it throughout, for much
longer periods than can ever be endured by a per-
son in health.

32. The insane, during remissions, are desirous
of being considered free from the malady, and
often assiduously endeavour to conceal whatever
may betray them ; but simulators seldom carry
their deception thus far. The real malady usually
commences with slight disorder of the common
modes of thinking and acting ; and advances
slowly through some hallucination, until at last
it is either fully developed, or is suddenly exas-
perated. The feigned disease, on the contrary,
presents not this course ; is not preceded by
sleepless or restless nights, and by a continued
consideration of one topic ; but appears at first in
its full violence. The existence or non-existence
of the causes of insanity, of previous attacks, of
pre-existing eccentricity of manner or thought,
of hereditary tendency, of antecedent affections of
the brain, of injuries of the head, &,c., the cha-
racter of the individual, and the motives for
feigning, will also be considered by the physician.
Care should be taken not to infer deception,
because the motives for it are apparently strong ;
for the circumstances constituting the motives
may be the causes of the real malady. The cos-
tive state of the bowels ; the large doses of
medicine necessary to move them ; the compa-
rative insensibility of the stomach to tartarized
antimony; the generally more frequent pulse,
and the sudden and extreme irritation on any
contradiction, observable in the maniacally in-
sane; should not be overlooked, as they hardly
admit of being feigned. Their disregard of the
decencies, comforts, and affections of life, ought
also to be taken into account ; for, although these
signs are often also simulated, deception in re-
S])ect of them is seldom carried so far as in the
real malady. A person even of pure character,
when truly insane, will often use the grosse.st

FEIGNING DISEASE.

889

language, practise tlie greatest indecencies and
brutalities, and evince the bitterest dislike of, and
malice to, his friends; but simulators exhibit
those symptoms only when they believe them-
selves vifatched, or before others. Dr. Haslam
remarks, that the meliDicholic states of insanity are
feigned with greater difficulty than the maniacal ;
the one presiding principle, the ruling delusion,
the unfounded aversions, and causeless attach-
ments, the peculiar look, the solemn dignity, and
the associations characteristic of the former, can
never be simulated so as to deceive the experienced
observer. Idiocy is most easily feigned ; yet there
are always a hesitation and reflection observable
in the discourse of the pretender ; his disordered
ideas not succeeding each other with the same
rapidity as those of a person whose understanding
has been really destroyed. The simulator will
also, according to Dr. MAnc, repeat (he same ideas,
and often the same words, in order to prove his
madness, that he is requested to repeat, whereas the
truly insane will wander incoherently from what
he is desired to utter. In this form of insanity, the
patient is always pusillanimous and submissive,
unless during impetuous excesses, which only
sometimes occur; and memory and conception
are both defective.

33. It may sometimes be proper, if suspicion
exists, to mention some severe remedy, or to
threaten punishment. The really insane never
heed these ; but those who feign, will often dis-
cover by the change in the pulse, or by looks or
actions, the emotions thereby induced. Zacciiias
states, that a physician ordered, in the hearing of
a person whom he suspected of deception, that he
should be severely whipped; inferring that the
external irritation might be useful if the disease
was real, or too severe a test if feigned. The
threat was sufficient. Fodere, on leaving a
female who had long succeeded in simulating
insanity, said to the keeper, within hearing of the
patient, " To-morrow I shall again visit her; but
if she continue to howl, if she be not dressed, and
her chamber not put in order, you must apply a
red hot iron to her neck." This was sufficient.
The very treatment most conducive to the recovery
of the really insane, is the most intolerable, if per-
sisted in, to the simulator ; who is often all at
once cured upon hearing of his being about to be
sent to an asylum, or of a continued and rigorous
recourse to solitary confinement, low diet, and
repeated counter-irritation. "

34. Lameness is often feigned by sailors, sol-
diers, mendicants, and convicts, by pretending
contractions of the muscles, deformity, the effects
of fractures, and by introducing sharp bodies
under the skin. For pretended cantrnctions of
muscles or joints, a tourniquet may be placed
above the joint, and so closely drawn as to render
the muscles incapable of acting, when the joint
will become moveable. The emaciation of the
limb in these cases is no proof of their reality, as
it necessarily proceeds from disuse of the limb.
— Previous _/'ractin-es of bones is often alleged ;
but the cheat is readily detected on minute ex-
amination. — Malformation, particularly curva-
tures of the spine, elevation of one shoulder,
inversion of the feet, and shortness or distortion
of a limb, are sometimes simulated. There can
be little difficulty in detection, on a careful ex-
amination of the naked body. Pretended distor-

tion of a limb may be ascertained by the use of
the tourniquet, or by straightening it, whilst the
simulator's attention is withdrawn from it, as was
done by Mr. C. Hutchison in a case which oc-
curred to him. Instances have been met with of fe-
males who caused serious swellings and abscesses
by introducing a number of needles into the parts.

35. NEURAi.Gtc, Rheumatic, and other Pains
are very frequently simulated ; and detection is
very difficult, as it is next to impossible to prove
the absence of pain. Inconsistencies in the
patient's account of his case, and contradictions
into which he may be readily led by an artful
examination, are the chief means of detection.
Pain is seldom very severe or prolonged, without
being attended by certain symptoms, according
to its situation. If it affect the joints, swelling,
redness, stiffness, &c. are usually the result ; if
it occur in any part of the abdominal cavity, the
functions of digestion, assimilation, or excretion
will be disordered ; if it affect the thoracic or-
gans, circulation or respiration will be deranged ;
if it occur in the head, loss of sleep will, at
least, be the consequence. The inference should
depend much upon the kind of pain complained
of, upon its continuance or recurrence, and the
nature of the phenomena attending it. If vio-
lent pain is stated to be present, and the patient,
notwithstanding, has a good appetite, sleeps
well, and does not lose flesh, we may doubt its
reality. The effects of remedies should also be
taken into the account, as well as the patient's
desire of, or objection to, those which are of a
severe kind. But the most severe pains may
long exist, even in external parts, without affect-
ing their appearance ; and be referred to internal
organs, without materially deranging the func-
tions. Several instances of this kind have come
within my own observation. These have been
usually called neuralgic ; and have often disap-
peared for a time, either during treatment, or
without the use of any means. Many of the
reputed cures of these would have taken place
without any remedy whatever ; but, to whatever
cause the recovery is attributable, the return of
the pain in some form or degree, is generally ob-
served, although of this as little as possible is
said by narrators of extraordinary cures ; and
sometimes a return of the complaint is the least
unfavourable occurrence, — a more dangerous or
even fatal malady taking its place, especially in
the rheumatic and gouty diathesis.

36. Cases have occurred, which have caused
suspicions of feigning, and yet the results have
shown most serious internal disease. A female,
some years since, consulted a number of physi-
cians respecting a most violent pain in the left
side and loins, extending upwards to the left
mamma. One considered it neuralgic, another
hysterical, a third uterine irritation ; a fourth de-
ception, probably connected with hysteriaj and,
lastly, it was attributed to spinal irritation. The
appetite continued good, the urine appeared
healthy, and there was no emaciation. After
many years of suffering, the lady died ; and
there were found (what, indeed, might have been
expected) a great number of calculi in the urini-
ferous ducts and pelvis of the left kidney. — A
celebrated preacher and theological writer lono-
complained in a similar manner. 'J'he urine was
abundant, and of a good colour, and hence dis-

B90

FEIGNING DISEASE.

ease of the kidney was not suspected by the nu-
merous eminent men whom he consulted ; but
this organ was, nevertheless, found after death,
filled with calculi. I have met with two or
three instances of the most severe pain, recurring
at irregular intervals, in a particular joint — in
the left shoulder joint in one case, and in the
right knee in another — without any apparent
local or constitutional disturbance ; the tongue
being clean, the bowels regular, the appetite
eood, and the flesh and strength undiminished.
An ointment, with a large proportion of veratria,
was employed for some time in one of these
pases, without benefit. The most successful
means, in both, were such as improved the diges-
tive and excreting functions. These cases, in
circumstances admitting of the least suspicion,
might have been considered as feigned.

37. I have no doubt that formerly, when the
pathology of the spinal chord and its membranes
was less attended to than now, many very
severe affections, occasioned by changes in this
quarter, were viewed as fictitious. — 1 lately at-
tended an intelligent tradesman, advanced in life,
who long complained of severe pains in the
thorax, darting through both sides, and often
backwards to between the shoulders. They were
occasionally most violent, and fixed themselves
for a time in one place, and then in another, of
this cavity. The functions of circulation and
excretion were unaffected, but the respiratory
actions were sometimes disturbed. One day he
was unable to get out of bed ; and another he
came down to his parlour. His complaints were
considered chronic pleurisy, adhesions of the
pleura, rheumatism of the thoracic muscles, &c.
When first called to him, I examined the thorax
by auscultation and percussion. The sounds
furnished by both were perfectly healthy. The
liver was thought to rise rather high; and the
stools were deficient in bile. Chronic disease of
the liver was, therefore, suspected. Upon ex-
tending the examination to the spine, two of the
spinous processes of the upper dorsal vertebras were
found very prominent, and pressure in this situa-
tion caused great pain. The treatment was directed
accordingly, and amendment took place. These
cases evince the importance of a very minute
and extended examination, in ascertaining the
cause of pain, and, consetiuently, of proving its
reality. When severe pain is complained of by
females in any external or internal part, an opi-
nion as to its reality or nature should not be given
until the spine is carefully examined, and the
state of the uterine functions inquired into. The
existence or non-existence of tenderness, pain, or
fulness in the hypogastric, iliac, and sacral re-
gions, indicating disease of the uterus or ovaria,
ought also to be ascertained ; for if the least sign
of disorder in any of tliese situations be detected,
we ought not to infer deception, although it must
be admitted that exaggeration, and even decep-
tion, may be practised nevertheless.

38. di'iniiAi.MiA was not infrequently pro-
duced hy soldiers and conscripts during the last
war, by means of corrosive sul)limate, powdered
alum, quicklime, acids, salt, tobacco, and various
acrid powders and mcclianical irritants. The
extreme rapidity of the iiillammation, csjicciiilly
as respects its invasion of the conjum^tiva oculi
and cornea, and the circumstance of the right

eye only being affected, should excite suspicions.
The chronic forms of ophthalmia were also ex-
cited and kept up by extracting the eyelashes and
applying irritants to the edges of the eyelids.
VVhen entire seclusion of the suspected patient
cannot be obtained, as in the navy, the recom-
mendation of iVIr. C. Hutchison to use the strait
waistcoat should be adopted.

39. Palsy and Shaking Palsy are not often
feigned. If, with the loss of motion, or tiie con-
tinued agitation of a limb, or one half the body,
the general health appears to be good, and the
excretions natural, a watch should be set upon
the patient, and his actions observed when he
thinks himself unnoticed. The cold affusion,
electric shocks, moxas, and the actual cautery,
will often have a wonderful effect in suspicious
cases. Even the threat of having recourse to
these means has been sufficient. — In cases of
simulated paralysis, detection may be easily ac-
complished by causing sleep by opium, and then
tickling, irritating, or pinching the motionless ex-
tremity. If the disease be feigned, the limb will
be retracted or withdrawn : and, upon first waken-
ing, it will often be used before the patient recol-
lects himself.

40. Polypus of the Nose has been often imi-
tated, according to MM. Percy and Laurent,
by French conscripts, who have succeeded by
introducing the testes of cocks, or the kidneys of
hares or rabbits, into the nostrils, and retaining
them there by means of sponge to which they had
been fastened.

41. Pregnancy is often pretended, to gratify
the wishes of a husband or relations, to increase
interest, to extort money from a paramour, to de-
prive a legal heir, to delay the execution of punish-
ment, and to avoid labour. A careful examination
of the areolae, of tlie mammae, of the umbilicus,
and of the os uteri, will generally lead to detection,
at least in the more advanced months. (See Preg-
nancy.) Jj

42. Pulmonary Diseases are notoften feigned ; ■
but I have met with instances — two in females —
in which slight symptoms have been exaggerated
into the appearance of dangerous disease, par-
ticularly in the description of them, in order to
accomplish particular ends. In such cases, the
patient has a frequent and short respiration,
and a hacking cougii, with little or no expecto-
ration ; complains of the pain on coughing or
taking a full inspiration, and of night sweats;
evidently desires to be considered very ill ,but is
averse from medicine : as he considers it of no
use ; and even resorts to various means to pro-
duce emaciation, particularly vinegar, tiie oxides
of copper, cream of tartar, tartaric acid, &e.
The state of the pulse, the sounds produced by
auscultation and percussion ; the apparent de-
spondency, instead of the continued and un-
wearied hopes of the patient, characterising the
real disease ; the marked reluctance to have
recourse to issues, setons, or counter-irritants;
and an enquiry into tiie wishes of the patient as
to regimen, ivc. are the chief means of detection.
In private practice, tlie physician should endea-
vour to ascertain wiiether or no the treatment
directed is strictly followed, particularly the in-
sertion of i'.sucs, setons, Ixc. ; for if these be
not adopted after a confident recommendation
of them, strong suspicions of deception should

FEIGNING DISEASE.

391

be entertained, and he should immediately with-
draw.

43. Rectum. — Prolapsus and Fistula of the
Rectum have both been simulated by conscripts
and persons desirous of escaping from the public
services. Ambrose Pare, Percy, and Laurent
met with instances in wiiich a portion of sheep's
gut, or tlie urinary bladder filled with blood, had
been partially introduced up the rectum in order
to imitate 7»-ii/«7)si(s. Fistula has been actually
produced by making an incision near the verge
of the anus, and introducing into it an acrid tent,
particularly the root of white hellebore (Dun-

GLISON.)

44. Rheumatism and Lumbago are often
feigned by soldiers and sailors. Where they are
complained of, without swelling of joints, or ac-
celeration of pulse in the evening, or increased
heat of the affected part, wasting of the limb, dis-
order of the digestive and biliary organs, or loss
of the appetite and looks, suspicion should be ex-
cited. Dr. Cheyne remarks, that those who feign
this disease, " give a glowing account of their
sufferings, alleging that they have entirely lost
the use of the part afliected, which seldom hap-
pens in genuine rheumatism. There is, for the
most part, no adequate cause assigned for the com-
plaint ; no relief from remedial treatment acknow-
ledged ; and, while real rheumatic affections are
aggravated by damp, the impostor complains
equally at all times." (See § 35.)

45. Sight. — Defects of this sense are fre-
quently feigned. Short-sight may not only be pre-
tended, but it may actually be occasioned by the
use of concave glasses, in order to avoid military
service. Those who are truly near-sighted, frown
or knit their brows habitually, when looking at ob-
jects beyond the range of distinct vision, and the
crow-feet wrinkles at the outer corners of their
eyes become early marked. MM. Fodere,
Percy, and Laurent advise that persons claim-
ing exemption on this account should be caused
to read with concave glasses, the book being held
at a proper distance ; and without them, the book
being put close to the eyes; if they cannot read
distinctly in both cases, the imperfection is
feigned. — Xight-blindness, or intermittent blind-
ness (hemeralopia, nyctalopia), is often simulated
by sailors and soldiers serving in warm climates,
where the affection is common ; and it is detected
with difficulty. The deception is practised in
order to avoid night duty ; and has been put a
slop to by associating a blind man with one who
can see, in the various works carried on dur-
ing night, and when the sentries are doubled.
(Cheyne.)

46. Somnolency', or Sopor, has been feigned
with the utmost pertinacity, in order to obtain a
discharge from the public services, or to answer
purposes of revenge, as in the instances recorded
by Dr. Hennen and Mr. Dease. As cases of
sopor sometimes occur, care should be taken to
distinguish between the real and simulated. The
former is seldom, or perhaps never, unconnected
with some cause of exhaustion operating chiefly
on the nervous system, or without antecedent
signs of mental and physical debility, particularly
defect of memory, hesitation of speech, remark-
able languor, ike. I lately attended, with ]\Ir.
BusHEi.r,, a gentleman about sixty years of age,
who continued for many weeks in a state of sopor,

interrupted only by being talked to loudly, or by
taking food. When thus roused, he yawned,
answered slowly, and instantly fell into a quiet
sleep, unattended by any unnatural respiratory
sound. He recovered slowly by the use of tonics
and stimulants, and the occasional exhibition of
stomachic purgatives. No cause but exhaustion
of nervous and cerebral power could be assignetl
for the disease. Such cases, however, most fre-
quently follow injuries of the head, attended by
pressure on the brain, or the slow developement
of tumours within the cranium. Dr. G. Smith
mentions the case of a soldier who feigned a state
of insensibility, and resisted every kind of treat-
ment ; but on proposing, in his hearing, to apply
red-hot iron, his pulse rose, and amendment
rapidly followed. A singular case of feigned
sopor is detailed in the Edinburgh An7iual Re-
gister (vol. iv. part ii. p. 159.). A soldier 18
years of age, confined for desertion, lay, appa-
rently insensible, from the end of April to the 8th
of July, 1811. Electric shocks, the application
of snuff to the nostrils, pins thrust under his
finger-nails, and other stimulants, failed to rouse
him. The sopor being thought the consequence
of injury, the scalp was divided in order to ascer-
tain the existence of depression, and the bone
even scraped ! -yet no complaint was made. The
case was viewed as hopeless, and the man dis-
missed. Two days after his discharge, he was
seen cutting wood some miles from home. But
wherefore should a depression of the cranium be
hunted out by dividing and drawing back the
scalp and scraping the bone ? One would ex-
pect that some tolerable signs of its existence
should have presented themselves before such
serious measures were resorted to. Can we be
surprised at detection failing in such hands ?

47. Tympanitic and Emphysematous Affec-
tions have been simulated, by introducing air
into the digestive canal, and by inflating the cel-
lular tissue, in the manner already stated (§ 28),
IVIM. Percy and Laurent mention the case
of a conscript who simulated an immense tym-
pany by swallowing air; and Dr. Cheyne states,
that this affection was apparently caused by a
number of men in the 84th regiment. The pulse,
tongue, and excretions were natural, but pain in
the region of the liver, and over the abdomen,
which was distended and tympanitic, with insati-
able thirst, were complained of. Deception
being suspected, they were required to take a
cupful of a solution of the sulphate of soda in
weak tobacco water, every four hours, until it
operated. Recovery was speedily effected by
means of this detestable medicine ; but sixteen
men had succeeded in procuring their discharge
before this treatment was adopted. Dr. G.
Smith states, that wonderful cures were often
effected in military hospitals by a medicine com-
posed,of salts, aloes, and assafoetida, given fre-
quently in small quantities, so as to keep the taste
in the mouth. The substances used to produce this
tympany seem not to have been fully ascertained.
It \v41s ascribed to the use of large quantities of
chalk and vinegar.

48. Tumefied Leg is excited by means of an
artfully concealed ligature, and keeping the ex-
tremity in a hanging posture. The writers on
this subject in the Cyclopadia of Practical Medi-
cine state, that a case of enormous enlargement

892

FEIGNING DISEASE.

of the tliigli and leg', resembling elephantiasis,
was sent home from India to be discharged.
A ligature was discovered, and, upon its re-
moval, the swelling gradually subsided. — The
detection and prevention of such cases cannot
be difficult.

49. Ulcers artificially caused were remark-
ably frequent in both navy and army, during the
last war. They were generally produced upon
the legs by various caustics or irritants, by fric-
tion with sand, by quicklime mixed with soap, by
compression with metallic or other bodies, and by
mineral acids. Arsenic, corrosive sublimate, to-
bacco, &c. have also been used for this purpose.
]\Ir. C. Hutchison found a halfpenny between
the muscles of a leg which he removed in con-
sequence of extentive caries of the tibia following
artificially formed ulcers. Intentional ulcerations
are distinguished from the real, by their borders
being less callous, their surfaces more superficial
and less painful, and their disposition to heal.when
secured against tampering, much greater, owing to
their not originating in, or accompanying, con-
stitutional disorder, as in the case of real ulcers.
— In order to prevent this species of deception,
INIr. C. Hutchison had recourse to a wooden box,
in which he locked up the whole limb ; all other
means, as marked or sealed bandages, (Sec, having
been found insufficient against the ingenuity of
malingerers.

50. The Urine presents various disorders in
respect of its characters and of its excretion,
which have been artificially produced or feigned
by persons desirous of escaping from the public
services, and by hysterical females. — Incontinence
of Urine was often simulated by sailors and sol-
diers. The circumstance of this disorder occur-
ring frequently in this class of persons, who are
mostly young, or in the vigour of life, should
excite suspicions of its reality. The simulator
generally chooses the circumstances and place
suitable to his purposes in allowing the urine to
escape. Laurent and Percy state that thegluns
■penis is always pale and shrivelled in real incon-
tinence, and that the urine never comes away
in a stream. M. Fodere finding that this com-
plaint was becoming epidemic in a regiment, and
that blistering the perinaeum and other means
did not cure it, directed the penis of every patient
to be tied, and the knot sealed, none but the person
guarding them being allowed to remove the liga-
ture. The penis was observed from time to time,
to ascertain whether or no distension above the
ligature existed, and whether, when it was re-
moved in order to urinate, the discharge took
place guttatim, as in real incontinence, or in a
stream. The expedient succeeded, and the epi-
demic vanished. (Vol.ii. p. 481.) Percv and
Laurent prescribed twenty lashes to the loins,
with tiie avowed object of exciting the weakened
organs. It was unnecessary to direct it to a
second case. An army surgeon directed a c"old
plunge-bath twice a day with equal success;
and i\Ir. Hutchison, Mr. Cojivns, and Dr. Hen-
NF.N caused a strong opiate to be given at night,
and the length of time the urine was retained
during sleep to be watched ; for, in real incon-
tinence, the urine passes away after a short time
under all circumstances. The patient may also
be caused to undress and stand before the me-
dical man at the time when he states that his urine

usually passes off. In cases of feigning, the ab-
dominal muscles will be seen contracting in order
to expel it.

51. Bloody Urine has been simulated by the
ingestion of beet-root, madder, the extract of log-
wood, the fruit of the prickly pear, the Indian
fig, &c. But blood is more frequently mixed
with the urine. Percy and Laurent state, that
conscripts have injected blood into the bladder,
in order to imitate haematuria. This disease has
even been occasioned by having recourse to
cantharides. A boy in Stafl^ordshire, in 1617,
having accused a woman of bewitching him,
feigned various maladies; and, amongst others,
the excretion of black urine. The wisdom of our
ancestors condemned the woman to be burnt, as
was usual in such cases ; but the Bishop of the
diocese, suspecting imposture, caused the boy to
be watched, when he was detected dipping cotton
in ink, and afterwards introducing it within the
prepuce, in order to give the urine which he pub-
licly voided its dark colour. (Mem. of Literature,
vol.iv. p. 357.)

52. The excretion of Gravel, and of other sub-
stances, has likewise been feigned. In all such
cases, as well as the foregoing, the person should
be made to urinate in the presence of the phy-
sician. The real existence of gravel is ascer-
tained beyond doubt, by close inspection and che-
mical analysis. • — ■ Strictures have also been
feigned ; but the passage of a bougie will always
ascertain their reality in the hands of an expert
surgeon — Suppression and Betention of Urine
have been pretended ; but most frequently by
convicts, and hysterical females. The introduc-
tion of the catheter, and a strict watch will gene-
rally show the state of the case.

53. LIterine Diseases have been feigned and
exaggerated, and I believe more frequently than
is commonly supposed. It was attempted in one
case in which I was some years ago consulted;
but the object becoming apparent I withdrew.
Tills kind of simulation is sometimes adopted with
an evident motive, as dislike of a husband, &c. ; but
in other cases the object is not so apparent. Dr.
Thomson, of Edinburgh, mentions an instance of
of a female in a respectable station, who pretended
to pass vesicular bodies resembling hydatids from
the vagina. They were ascertained to be prepared
from the intestines of a pig, and were made to re-
semble a string of beads.

54. Varicose Veins have been caused by liga-
tures or pressure made in the course of the larger
trunks. They may also be aggravated, when al-
ready present, in a similar way. Attentive examin-
ation, and the means advised for ulcers (§ 49.)
will generally detect the deception, and prevent it.

55. Wounds have been both pretended, and
inflicted intentionally. The feigning of wounds
has been sometimes practised to avoid the danger
of battle, or to be mentioned in despatches.
Means which may occasion the appearance of
a contusion, as abraiding or discolouring the
surface, are chiefly resorted to. Detection will
depend upon attendant circumstances and the
acuteness of the surgeon. INIutilations, or inten-
tional wounds, are more commonly resorted to,
in order to avoid conscription into the public ser-
vices, or to obtain pensions or a discharge.
They are sometimes also practised liy slaves,
mendicants, and revengeful persons. And wounds

FEVER — Pathology
and injuries involuntarily received, have been
aggravated, and their healing interfered with, to
answer particular purposes. Detection in many
instances is difficult, but it will be necessary to
consider the possibility of the patient having in-
flicted tiie wound himself, its nature and extent,
its relation to the alleged cause, to tlie probable
object desired to be accomplished, and all the
circumstances connected with it, before a conclu-
sion should be arrived at. Persons in the public
services, it should be remembered, occasionally
assist each other in causing mutilations, and in
aggravating injuries; so that the moral as well
as the physical relations of the subject should be
carefully weighed in all cases.

56. 1 have given the sum of our knowledge as
to the means of distinguishing real from feigned
disease, and of preventing the consequences of
successful deception. I have endeavoured to
avoid extraneous matters ; and have not intro-
duced amusing instances of simulation, as my
limits must be more usefully occupied. 1'he impor-
tance of the subject is especially great to the naval
and military medical officer ; but it is not less so
to the civil practitioner; and the success of both
in detecting imposture, will mainly depend upon
their science, practical knowledge, and ingenuity.
With a tolerable store of each, they will seldom
be placed in great difficulty , or be obliged to resort
to more painful means of detection, than the dis-
ease would warrant, were it real.

893

BiBLioG. AND Refer J. B. Sylvaticus, Institutio Me-

dica de iis, qui morbum simulant, deprehendis. Madr.
1395j 4to. — Montaipie, Essays, 1. ii. c. 26. — Giii/on, Le-
mons Diverses, t. i. p. 118. — Pigrcetts, Epit. Med. et

Chirurg. p. .508 P. Zacchia;, Questiones Medico-Le-

gales, <S;c. 3 vols. fol. Francf. 1688. — L. Z. Luther, De

Morbis .Simulatis et Dissimidatis, 4to. Erf. 1728 Vogcl,

De Simulatis Morbis, et quomodo eos dignoscere liceat,
4to. Goet. 176P. —De Haen, Ratio Medendi, vol. ii.p. 56.
— Fieliz, in Taschenchbuch fiir Deutsche Wundarzte

ad 17nG Livingston, Edin. Med. Comment, vol. iv. p. 76.

— Keutnntm, De Morborum Simulationc, 4to. IVHtcnib.

1788 7'orff,l'nterhalteiider Arzt.b.iii. p. 7. — Schneider,

De Morborum Fictione, 4to. Franc. 1794 Lentin, Bey-

trage ziir Ausiibenden Arzencywissenschaft. Leips. 1797.
— Suuinllc, Examen des Infirmites ou Maladies qui peu-

vent exempter du Service Militaire, &c. Paris, 1810

P. A. 0. Mahon, Mcdecine Legale, et Police Medicate,
t. i. p. 357. et seq. — Foe/ere, Traite de Medecine Legale,
etd" Hygiene Publique, &e. 2d edit. vol. ii. p. 455. et seq.
■ — J. Hetine?!, Principles of Military Surgery, &c. 2d edit.
8vo. Edin. 1820, p. 455. — GoocA, in Trans, of College
of Phys. Lond. vol. vi. p. 272. — Percy and Laurent, in
Diet, des Sciences Mtdicale, t. Ii. p. 319. — J. G. S?«iW.
Principles of Forensic Medicine, &c. 3d edit. 8vo. p. 408.
— Paris and Fonblanqne, Medical Jurisprudence, vol. i.
p. 'ib^. — F. R. Beck, Elements of Medical Jurisprudence,

3d edit, by Dunlop and Vartva/l, p. 1 A. Copland

Hutchison, Practical Observations in Surgery, 8vo. 2d
edit. p. 141. ; and Med. and Phys. Journ. vol. Ii. p. 87.,

and vol. liv. p. 87 Ckei/tie, in Dublin Hospital Reports,

vol. iv. p. 123. — H. Marsha//, Hints to Young Medical
Officers on the Examination of Recruits and the Feigned
Disabilities of Soldiers, 8vo. 1828; and in Edin. Med.
and Surg. Journ. vol. xxvi. p. 225. — M. Ryan, Manual ol
Med. Jurisprudence, 8vo. Lond. 1831, p. 292.— ii. Dun.
g/ison, A New Dictionary of Medical Science and Liter-
ature, vol. i. p. 389. 8vo. Boston, U.S. 1833.— Sco/^
Forbes, and Marsha//, Cyclop, of Pract. Med. vol. ii.
p. 133.

FEVER. SvN. — riLipsTOf (from Ttuf, Jire) ;
TlvfB^ia, Uvpe^i;. Pyrexia, Pyrexis ; Febris
(from ferbeo, or februo, I cleanse). Fievre,
Fr. Fieber, Ger. Febhre, Ital.

Classif. — 1. Class, Febrile Diseases; 1.

Order (^Culten). — 3. Class, Diseases of

Sanguineous Function ; 1. Order (Good).

III. Class, II. Ordlk (Author, in

I'rej'ace).
1. Defin. — FaiiiJ'ul lassitude, with debility of

the corporeal and mental faculties, alteration oj
the animal heat and of the secreting functions,
accelerated circulation, increased thirst, and aboli-
tion of the appetites.

2. The human frame is liable to sudden and
])ovverful impressions from external causes, to the
nature or intensity of which it is unaccustomed,
and to changes throughout its functions, pro-
ceeding from imperfect or impeded actions of some
excreting viscus. The derangements thus occa-
sioned, are remarkably varied both in degree and
in kind ; and they constantly induce further
changes, terminating either in restoration to health
or in the destruction of the individual. They
have been usually named and classed, according
to certain distinctions assumed from their chief
causes, or from their most prominent features, or
from the modes in which their principal charac-
ters are grouped. As, however, the various
species of change or disorder, thus supervening,
insensibly glide into each other ; and as some
symptoms disappear, and others spring up, from
different intensities and combinations of remote
causes, from the states of the internal organs
at the time when the morbid impression was
made, and from the ever-varying influences to
which the body is afterwards subjected ; so it
must follow that distinctions, which are thus
based, will become unsafe guides in practice.
The manifestations of disease possess no unal-
terable features ; and therefore descriptions of
them are to be received with due latitude, and
the modes and means of removing them accom-
modated to individual and ever-varying conditions.
From these considerations, it cannot be a matter
of surprise, that such diverse opinions have exist-
ed as to the nature of those derangements which
have generally received the name oi fever ; and
that so much discussion has taken place respecting
the differences which exist between them and
other disorders, with which, although arising
locally, the whole frame more or less sympathises.
Nor can we wonder that, owing to the frequent
difficulty of distinguishing between fevers and the
disorders which thus originate, all differences
between tliem have been denied, and that the
former have been actually considered as strictly
local diseases. I shall have frequent occatiou
in the sequel, to notice the grounds on which this
opinion is founded.

3. The intimate connection existing between
all diseases, which, either at their commencement,
or in their course, exhibit febrile symptoms, might
have been less a source of error, if the phenomena
characterising them had been traced more accu-
rately to their origin, and with a stricter reference
to their causes, than they generally have been ;
and if succeeding and consecutive alterations had
been recognised chiefly as effects of the previous
changes. If such a course of investigation had
bee«i followed, deranged actions, arising almost
simultaneously throughout the system, would not
so frequently have been mistaken for those which
are j-eferrible to a single organ or part ; nor
would derangements of the former kind have
been imputed to such a source. There is no
doubt that a certain class of causes will produce
both local and general ailment, in difTerent indi-
viduals, according to circumstances peculiar to
each ; or even in the same persons, at different
periods, owing to his state, or predisposition, at

894

the time of their operation. But, still the more
remarkable phenomena of these separate diseases
proceed in a very diflerent order, and very gene-
rally in so marked a manner, as to be easily dis-
tinguished by the close observer. The most
frequently exciting causes of disorder, viz. mental
distress, atmospherical vicissitudes, exposure to
cold, moisture, &c., shall, according to the state
of the individual at the time, produce an attack of
general disease, unaccompanied by predominant
affection of any particular organ ; and the disorder
shall commence and terminate without any com-
plication. In a second individual, a more or less
evident determination of the malady, or even in-
flammation, shall appear in the advanced course of
the general disease, or even during convalescence.
In a third, the local disorder shall be coetaneous,
and more or less co-ordinate with the general
affection, or e\en outstrip it in violence during its
course. And in a fourth person, local disease alone
shall be primarily caused ; on which, as it in-
creases, and as inflammation becomes more fully
developed, symptomatic fever, or the general de-
rangement, shall supervene. These different states
of diseased action follow the same cause, ac-
cording to the disposition, susceptibility, or states
of the system at the time. One person, according
to this proposition, may have the constitutional
derangement complicated with rheumatic, ca-
tarrhal, bilious, nervnus, gastric, or dyseiiteric
affection ; the general disorder being attended
from some early stage of its course, or from the
commencement, by a heightened disease of a par-
ticular organ, or structure, and thereby consti-
tutincr varieties of fever, which have been thus
denominated and described by Stoll, De Haen,
.Reil, Frank, Hildenbrand, and others, and
have occurred in epidemic forms on various occa-
sions. Another person may have the nervous,
the gastric, or the dysenteric characters super-
induced in the progress of the disease, owing to
external causes continuing in, or coming into
operation ; or to improper treatment : and a third
may experience, in consequence of the pre-existing
state of a particular organ or texture, an attack of
inflammation, from a similar set of causes to those
which produce idiopathic fever. If, therefore,
the species of disease which arise from one class
of causes are thus varied, owing to the predis-
position of certain organs, or to the susceptibility
of the whole system, their number must neces-
sarily be further increased, and their characters
very materially changed, when the additional
influences of marshy exhalations, epidemic con-
stitutions, or specific infections and contagions,
come into operation. Diseased actions become
not only more varied and extended by such
additional causes, acting either singly or in con-
junction, but also much more complicated and
violent.

4. These inferences may be legitimately <le-
duced, from an extensive survey of some of the
circumstances connected with acute diseases.
Their relation with such derangements as have
obtained the appellation febrile, is still more inti-
mate than with those which, strictly local at
their commencement, induce consecutively gene-
ral disorder. It is necessary, however, to the
proper consideration of the pathology of fever,
that due regard be paid to the nature and extent
of Its causes, and of niodifyin<j or determining in-

FEVER — Characteus of.

fluences, as far as they can be ascertained ; and'
that a strict reference be had to the effects ob-
served to follow the application of both classes of
agents, under opposite or varying circumstances.
It will also be requisite, while such an inquiry is
being prosecuted, that none of the early and in-
termediate changes be omitted. Such omissions
have but too often vitiated our speculations on the
nature of disease, and more especially of fever ;
for, instead of recognising the early changes and
states, particularly those which more directly arise
from external agents, consecutive and gross effects
only have more generally been seized upon, and
assigned as the cause of disease. Let it not be
supposed that inquiries, such as have just been
recommended, are productive of no advantage in
practice. The scientific practitioner will con-
sider the most effectual means of preventing, con-
trolling, or removing disordered actions, to be
indicated by a most careful scrutiny into their
nature and extent, and by a judicious inquiry
into early aberrations from the healthy condition.
He will view the primary derangements, in the
relation they hold with their remote or occasional
causes, on the one hand, and with consecutive
or ultimate lesions on the other ; and will thus
trace each individual link of the chain of causation
throughout.

5. If it be asked, What has the treatment of
fever gained by our speculations as to its nature 1
I would answer, almost every thing. I will show
this in a more demonstrative manner in the
sequel, by adducing the opinions which have for-
merly been held upon the subject, with the prac-
tice to which they have led. But, independently
of the practical results of the inquiry, there are
other solid and not less alluring inducements
which will operate on the inquisitive and well-
tutored mind. An individual possessing a mind
so constituted, feels a laudable zeal in examining
into the nature of a class of disorders, which con-
cerns not only the existence of a single individual,
but influences also the prosperity of nations ; and,
who, entertaining even a moderate idea of the
responsibility which the exercise of his profession
involves, can enter upon its practical discharges,
in respect of this class of diseases especially,
without feeling some desire of extending his
knowledge of their nature, in order that the
course he pursues may be both rational and suc-
cessful ]

6. 1. General View of Fever. — Fevers are
the most prevalent of all diseases, especially in
some countries and localities ; and their causes
frequently cannot be avoided nor counteracted
by human foresight or science. Tliey are more
especially prevalent among, and injurious to, the
human species, as the history of epidemic, pesti-
lential, and other fevers fully prove ; and as
evinced by those infectious fevers which often
occur in camps, and follow the rears of armies
during warfare, and which are sometimes much
more destructive than the most hard- fought bat-
tles.— Epidemic fevers are not, however, confined
to the human species ; the causes in which
they originate, and the influence which promotes
theirextension, frequently affecting also tlic lower
animals, — a circumstance of im|)orlance in our
sj)eculations respecting the origin and nature of
this very important class of maladies.

7. i. CiJAUACTtns or FtvLH. — It is impossible

FEVER — CiiARACTEns of.

895

to give a definition of fever altogether applicable
to the various forms and states it occasionally ex-
hibits. To convey, therefore, a proper idea of
what constitutes idiopathic fever, especially, a
description instead of a definition of it is neces-
sary; and, for this purpose, tiiose phenomena
which are the most constantly present, should be
selected : their presence individually, although
invarious degrees, constituting its essential charac-
teis; and enabling the physician, from the man-
ner in which each presents itself, and is associated
with subordinate or contingent phenomena, not
merely to recognise the different varieties and con-
ditions of fever, but also to dislinguisii it from dis-
eases intimately related to it. If one, and espe-
cially if more, of these constant and essential
characters be absent, idiopathic or essential fever
is not present. An intimate view of its various
phenomena can detect comparatively few which
exist always in every form of the disease, and in
some part of its course. These are — ist, Spon-
taneous and painful lassitude ; — 2d, Weakness of
the corporeal and mental faculties; — 3d, Alter-
ations of the secretions ; — 4th, Altered animal
heat; — 5th, Quickened circulation; — 6th, In-
creased thirst ; — and abolition of the appetites.

8. a. Lass((»rfe, although obviously the result
of a morbid impression made upon the nervous
system, is generally viewed as spontaneous, the
patient often not being able to refer it to a par-
ticular cause ; and it is usually attended by a
painful or irksome sensation in the back and limbs.
It is present in every form, especially in some of
the stagesof fever, and is always one of the earliest
and most constant symptoms. It is wanting in
many of the diseases which resemble fever ; and
is manifestly referrible to the depressed state of
nervous energy, more particularly as respects the
organic nervous system.

9. b. U'eahtess of the corporeal and vxental
Faculties is, in many respects, a mode of the fore-
going ; or rather, both are associated effects of the
more immediate impression made upon the system
by the exciting causes of fever. This debility,
as well as the lassitude, often precedes the evolu-
tions of the disease ; and always attends it, but in
various grades throughout. It is especially
evinced in the muscular organs ; and less so in
the mental faculties, particularly at the com-
mencement. But, although these latter are not
much affected as respects some manifestations,
others are more evidently weakened. The powers
of attention, comparison, &:c. are most debilitated,
and imagination least so. There are commonly
a painful or confused feeling referred to the head,
and a peculiar sensation with pain in the loins
and limbs ; these sensations being the more in-
tense, the severer and more dangerous the disease,
and sometimes amounting to an almost entire an-
nihilation of the muscular and cerebral manifest-
ations. These changes never reach above a
slight degree in symptomatic fever, or in other
diseases, unless when the brain is overwhelmed by
effusion of fluid; and then the attendant symptoms
and procession of morbid phenomena, are very
different.

10. c. Lesions of the secreting and exhaling
Functions are amongst the earliest, the most con-
stant, and most important phenomena of fever.
Tiie exhalations from the lungs and skin are evi-
dently the earliest and the most affected j although

the extent of the lesion cannot be readily ascer-
tained and duly appreciated ; and it is not im-
])robable that the more energetic causes of fever
make tiieir impression on the frame through the
medium of the respiratory functions ; terrestrial
exhalations and infectious emanations floating in
the air, and inspired along with it, aflecting the
nervous influence of the lungs, and associated vis-
cera, and impeding the changes which the blood
undergoes during respiration. — Besides these,
the salivary, the gastric, the hepatic, the intestinal,
and the urinary secretions are more or less altered,
as respects either quantity or quality ; the alter-
ations being somewhat different in different types,
and states of fever. — The early and remarkable
lesions of the secreting functions, and the gene-
rally imperfect actions of the excreting organs,
especially in the early stages, are important, not
merely as they fojm a part of the circle of morbid
actions characterising the disease, but, as they
especially lead to most of the ulterior changes and
complications observed in its advanced course.
They evidently depend, at their commencement,
upon deficient organic nervous power, occasion-
ing at first imperfect or scanty secretion and
excretion ; and, at later periods, upon the
morbid or vitiated state of the blood, the secre-
tions and excretions then frequently becoming
free and copious, but altered from their healthy
characters. In symptomatic fevers, the secret-
ing and excreting functions are but slightly dis-
ordered, and seldom to the extent of vitiating the
circulation.

11. d. Alterations of Animal Heat. — The tem-
perature of the body is variously altered in differ-
ent stages of fever. On the invasion and period
of exhaustion, particularly the former, it is often
below the natural standard ; whilst it is generally
above natural, during the period of excitement;
this symptom ciiieffy depending upon the state
of vital and nervous energy, upon the changes
effected by respiration on the blood, and the re-
sulting condition of vascular action. It is not,
however, a mere increase or diminution of heat
which is observed, but a peculiar or morbid alter-
ation of it that hardly admits of description. This
morbid sensation attending that produced by the
change of temperature, and which the physician
duly appreciates, varies somewhat in different
fevers, is partly also dependent upon suppiession
of the cutaneous exhalation and the state of the
circulating fluids, and is most remarkable in the
more dangerous and malignant forms.

12. e. Quickened Circulation has been con-
sidered by writers as one of the most essential
symptoms of fever ; and by some as the chief phe-
nomenon; their definition of fever being, increased
frequency of the circulation with lesion of the
functions. But this definition would embrace
equally all the diseases in which quickened circu-
lation occurs. It should be recollected that in
some stages, particularly in malignant fevers, ac-
celeration of the circulation is not constantly pre-
sent : yet it is seldom altogether absent from the
commencement. The rapidity of the circulation
is, however, often of less importance, than other
states of the vascular system, and the condition of
the blood itself.

13. /'. Thirst is seldom wanting in fevers, dur-
ing all their course, although occasionally absent,
particularly in their advanced stages, and in casts

896

FEVER — General Description.

attended by congestion of the vessels of the head.
It is observed in other diseases ; but it most con-
stantly accompanies fever. — g. The appetites also
are more or less affected. The appetite for food
is diminished or entirely abolished. In rare cases,
a craving for food has been observed in an ad-
vanced stage of fever, but not throughout its whole
course. The appetite for the sex is also abolished
until convalescence has commenced, when it re-
appears, and is sometimes one of the earliest signs
of amendment. These symptoms probably depend
upon the same cause — upon depressed organic
nervous influence, and consequent deficiency of
the secretions.

14. ii. General Description. — The word
Fever is used in a double sense : it is applied —
1st, to that state of constitutional disturbance, in
which the above symptoms are primary, essential,
oridiopathic; and, 2dly, to the general disordercon-
sequeat upon, or symptomatic of, some local dis-
ease. In the latter, the febrile symptoms con-
sist chiefly of increased heat and accelerated cir-
culation ; and without these the patient is said to
be without fever. But when fever occurs pri-
marily — is a disease stii generis — these two
symptoms areseldom the most prominent, and are
always associated with others, especially those
already noticed, which may be much more mani-
fest than they, and which are either altogether
wanting in symptomatic fever, or not similarly as-
sociated, or only occasionally present. This
distinction is necessary, particularly as respects the
treatment, and should never be overlooked. Its
importance will be more apparent in the sequel.
I shall first describe fever as a disease sui generis ;
and next, as a symptom of inflammation, or some
other disease of a particular organ or tissue.

15. Idiopathic Fever presents, during its
whole progress, characteristic symptoms, not con-
sisting merely of increased frequency of circu-
lation and augmented heat, which are sometimes
wanting in certain stages of the disease, but of
other morbid phenomena that are equally im-
portant, that vary in degree and in modes of
association with one another, and that super-
induce other phenomena thereby giving rise to
the different forms and slates in which the disease
occurs ; — it commences with debility and lassitude,
wliich are follmced by chills or rigws ; it is gene-
ralitj composed of several invasions or exacerbations ;
it implicates the whole of the vital endowments
and faculties, the fluids, and the entire organi-
sation ; it is acute and dangerous in its course,
with lesion of the circulation, with alteration of
the animal heat and of the secretions, and with
diminution of vital power ; and it is versatile as to
its symptoms and type, icith el]'orts at sudden
changes or crises.

It). 1st, Fever begins ivith lassitude and debility,
generally followed by chills or rigors. — It origin-
ates in causes wliich affect the vital energies of tlie
system, and occasion debility and lassitude as the
earliest and most rcmakable changes. These are
generally attendetl by an insuperable feeling of
latigue upon the least corporeal or mental exertion
by stupidity, loss of nervous and mental energy, by
iriitability, moroseness, or impatience, and by hea-
viness of the eyes. Upon these supervene various
uneasy sensations ; as, anxiety at the prwcordia,
occasi(ming fretjuent full or laboured inspirations;
a peculiar aud general uneasiness and restlessness;

a feeling of cold, particularly along the spine,
and differing from the real or usual sensation ;
horripilations, involuntary shudderings, and tre-
mors or rigors. The debility giving rise to the
unconquerable sense of lassitude and fatigue
generally precedes the chills for some indefinite
time, and accompanies them or continues after
them. Ciiills or rigors often return and alternate
with flushes, and other incipient disturbances, for
a variable period.

17. 2d. Fever is very frequently composed of
several invasions or exacerbations, one paroxysm,
disposing to otiiers; as in agues and remittents.
But even in continued fevers a similar circum-
stance very often obtains, as evinced by the even-
ing exacerbations, and the aggravation of the
symptoms on alternate days. Some writers, and
more particularly Hildenbrand, consider that, as
in remittents, wherein a new invasion supervenes
before the previous paroxysm had subsided, so in
continued fevers, one fit runs into another. —
" Continuae ergo febres, si non omnes, salterrf
plerajque, prajsertim criticae, e plurimis paroxysmis
febrilibus, quorum unus alterum subintrat, com-
positae sunt."

18. 3d. Fever is a disease of all the vital en-
dowments, functions and faculties, of the fluids,
aud of the ivhole organisation. — If we trace the
progress of fever, from the operation of its causes
through successive changes, we shall find that
the vital power, which is supreme over the phy-
sical properties and functions of our different
structures is deeply afl'ected throughout all its
subordinate manifestations — as the sensibilities of
the nervous systems, the irritability of involun-
tary and voluntary muscular fibres, the organic
contractility of membranous parts. Hence pro-
ceed lesions : ^ — (a) Of the organic functions —
of the respiratory actions and functions, of circu-
lation and of the circulating fluids ; of secretion
and excretion, of digestion, assimilation, sangui-
faction, and nutrition ; of the appetites, both na-
tural and acquired, &c. — (/;) Of the cerebro-
spinal aud animal J acuities — of tlie functions of
sense and voluntary motion, and of the powers of
mind : the expression of the countenance and
the attitudes are changed; the senses either per-
form their parts imperfectly, or the mind takes an
insuflicient cognisance of their reporls ; the atten-
tion is wavering and quickly fatigued ; the intel-
lectual powers and states are languid, feeble, or
otherwise disturbed ; the judgment is perverted by
internal and involuntary impressions and concep-
tions ; and ultimately all the mental endowments
become exhausted and disordered, by prolonged
wakefulness, or overwhelmed by a continued
sopor. — (c) Ofthejiuidsandivholeorganiuition:
— The fluids and soft solids undergo changes
in their .appearances, form, and properties. The
blood is evidently altered in various ways at
different periods of the disease. Its serum is often
at first in considerable (]uantity, and its crassa-
mentum loose ; but afterwards the latter generally
becoines more firm or cupped ; and ultimately
again loose, or imperfectly separated from the
.serum. In many cases it is still more remark-
ably altered, as shown in the article Blood
(^78 et seq.) both in colour and consistence.
The sef)'p((()».s, which arc at first chiefly diminished
in quantity, ultimately are changed in quality.
They become more offensive, of a darker colour.

FEVER — Genehal DEScnipTTOv.

897

and more irritating and septic to the tissues with
which they come in contact. — The soft solids
are to a certain extent affected, owing to the
changes previously induced in the powers of
life and in the circulating fluids, as respects
the form, appearance, and properties of all their
parts. The cutaneous surface loses its lively
tint, is changed in colour, or assumes a dirty,
dusky, or earthy Iiue. The integuments become
loose or turgid, harsh or burning; the muscles
and cellular parts suffer a diminution of their
consistence, and subsequently of their bulk ; and
the physical, as well as the vital, properties of all
the tissues, especially their cohesion and elas-
ticity, are very much impaired. Ultimately, the
soft solids present a more flabby, dusky, brownish,
or livid hue, and are softer and more lacerable
than natural. Thus the eyes, lips, mouth, the
countenance and whole physiognomy, the skin, the
flesh, the habit of body, and the postures of the
patient, exhibit the universality of disease. From
these facts, fever maij be defned pathologically, or
with reference to the vital and organic changes,
to be an acute affection oj all tlie functions, and of
all the fluids and soft solids of the frame.

19. 4th. Fever proceeds with lesions of the cir-
culation, of the secretions, and of the aniynal
temperature ; and with depression of vital power. —
The pulse is generally accelerated in some one
stage or other. When it rises not above, or sinks
below, the natural frequency, the cause may
either be congestion oftiie vessels of the head, or
the morbid state of the blood, or the influence of
the supine posture on certain constitutions. In
these cases the pulse often becomes much more fre-
quent when the ti unk of the body is raised to nearly
an erect position, or even wlien tiie head is elevated
{§ 12.). The secretions I have already stated
(§ 18.) to be early and remarkably clianyed.
The extent and consequences of the alteration
will be especially considered hereal'ter. The
temperature is altered during some period in all
fevers. Instances, however, occur, in which in-
creased temperature does not supervene on the
cold stage : there are also cases in which coldness
soon follows upon more or less of heat ; and
others in which the alteration either way is very
slight. Still some change may be felt, generally
in degree, but also in respect of other sensations
connected with it, excited in the patient and in tiie
observer. In some cases, especially early in the
disease, the patient's feelings n;ay be those of cold,
wiiilst the surface is actually warmer than natural.
The depression of vital pmver is evinced from the
commencement," in all the functions ; and does J ative influence of life, so as to lead to the salu

served to remain longer, it may generally be con-
sidered symptomatic of superinduced inflammation,
or of altered structure, or a relapse. Intermiltents,
however, are often of much longer duration, but
each paroxysm may be considered as a distinct
attack. Remittents, also, sometimes continue
longer; but seldom or never, unless associated
with visceral disease, which prolongs the febrile
action, or converts it into a symptomatic fever,
retaining more or less of the remittent, or passing
into the continued type. The danger of fever
results from its nature, and varies with its type,
form, and violence; for it is liable to sudden
vicissitudes in its progress, and is prone to produce
changes of structure having a fatal tendency.
Even the most mild form of fever may suddenly
change its character from internal or external
causes, or from abortive or irregular efforts at a
crisis, or from an injudicious regimen or treat-
ment, and put on a most dangerous form ; or,
owing to predisposition or pre-existing disease of a
part, give rise to fatal disorganisation in some
important or vital organ.

21. Gth. Fever is mutable in its characters.—'
It is but one disease, or genus, comprising several
species, and subordinate varieties — numerous
and ever-varying forms and states resulting from
tlie nature, the combination, and the intensity of
the causes, acting upon peculiarities of consti-
tution and predisposition. Hence we cannot be
surprised to find fever mutable in many of its
characteristic phenomena — to observe one species
or variety closely approximate others — and even
to meet with instances of one type, or form, sud-
denly or unexpectedly changing into another, in
some period of its progress. Thus it is not unusual
to see a simple tertian change to a quotidian or
double tertian ; or an intermittent pass into a
remittent, or this latter into a continued form.
Occasionally the disease alters from mild to severe,
or from nervous to malignant. It sometimes is
simple through a great part of its course, without
any one organ suffering a predominating dis-
turbance, and yet it suddenly becomes very dan-
gerously complicated, and thereby assumes very
different features.

22. 7th. Fever evinces a tendency to sudden
changes or crises, owing to the conservative in-
fluence of vital resistance and reaction. These
are generally of a salutary nature, when not
rendered abortive by some external or internal
cause, by the injudicious interference of art, or
by pre-existent lesions of an important viscus.
When they are fully evolved under the conserv-

not the less exist, because vascular excitement or
reaction becomes great or excessive during a part
of the disease. Althougii vascular action is in-
creased for a time in most fevers, yet vital power
or resistance is lov/ered nevertheless, especially in
other systems and organs, and is afterwards further
exhausted in propoition as vascular action has
run high, and it ultimately becomes remarkably
lowered with the contamination of the fluids and
of the soft solids ; impaired power augmenting the
changes of these, which, in their turn, increase the
depression, and often even accelerate the extinction
of life.

20. 5th. Fever is acute and da7is:crous in its

tary termination of the disease, they have usually
received the name of Crises. They are observed
not only in continued fevers, but still more
remarkably in the paroxysms of an ague, each of
which, when once commenced, will proceed until
the powers of life terminate it by a critical change.
Idiopathic fevers have frequently been denomi-
nated critical, as distinguishing- them from symp-
tomatic fevers, which less frequently experience
this mode of termination, and generally in a less
decisive manner. When salutary processes super-
vene, and are developed so as to terminate the
disease, a more rapid and perfect return to health
is experienced, than under other circumstances.

course. — A single attack of fever scarcely ever 1 It would seem that the evacuations by which
continues beyond thirty days. ^Vhen it is ob- 1 favourable changes are brought about, are in

Vol. I.

3M

898 FEVER —

some respects a depuratory effort of nature, more
especially as those evacuations generally occur
through the medium of organs which eliminate
hurtful materials from the circulating fluid.
Hence, one of the safest modes of practice is that
which keeps these salutary processes in view,
avoiding whatever may prevent them, and pro-
moting their evolution ; attending at the same time
to the preservation of the powers of life, and ward-
ing oft' danger from weakened, over-excited, or
oppressed organs.

23. When we take into consideration the con-
servative influence of the vital energy, the salutary
changes brought about by it, and the circum-
stance that every method of cure, or every agent,
cannot act in a similar manner in all cases — and
that, even during the most injudicious treatment,
certain of the agents are calculated to meet the
exigencies of some cases, either in supporting the
powers of life, or in favouring or determining
some critical evacuation — the reason will readily
appear, why recovery often takes place in fever
from the most opposite means, or v/hen left
entirely to nature ; and we shall easily under-
stand wherefore all do not die who are improperly
treated, and how na,ture often not only overcomes
the disease, but also the effects of injurious agents
prescribed for it. Of the means which are em-
ployed in the treatment of fevers, there are not
any which become more dangerous from in-
appropriate use, than the extreme measures fre-
quently resorted to — namely, large depletions
and active stimulants. The former may destroy,
in a few hours, cases which nature or opposite
measures might have preserved, and the latter
may over-excite, and inflame to disorganisation,
viscera which require to be unloaded, or to have
their actions moderated.

24. It not infrequently, however, happens
that the critical eflforts are imperfect owing to
exhausted vital power, or insufficient from the
nature and severity of the disease, or misdirected
or irregularly exerted in consequence of some
controlling or determining influence; and hence
they become sources of increased disorder, or
superinduce structural change. Such results are
sometimes favoured by over-active, inefficient, or
inappropriate means of cure ; and very often by
organic lesions having taken place in so great a
degree, and so early in the disease, that the salu-
tary efftirts attempted cannot subdue them, but
merely tend in some instances to their aggravation
and danger.

25. The evejit in fevers is directty produced by
critical changes, and indirectly by the assistance
of art : it isfavoiu-dhle, if the powers of life remain
unsubdued and act without obstruction ; it is un-
favounihle, if tiiey languish or are overwhelmed.
So much are we indebted to the conservative
efforts of life exerted throughout the frame in the
cure of fevers, that more is often to be ascribed
to this source than to the interference of art; and
I may add in the words of Professor IIilijkn-
JiHANi), " Inde enim pendet, quod miseri ac inepti
medici famam, (|uam buccis inffatis non accipere,
sed verccundi natura; magistr;i; reddere deberent,
in febribus sanandis sibi conficiunt. Inde pendet
quod oninis secta; medici, ac oppositarum me-
•Icndi rationum adsecta;,<le felici eventu in febrium
tractatione gloricntur. Inde demum pendet, (|uod
quasvis theoriurum ad fcbres curandas applicata,

Symptomatic.

sanatorum aagrorum practica exempla offerre va-
leat." (Vol.1, p. 53.)

26. Symptomatic Feveii. — Fever may be
a concomitant or an eff'ect of another disease,
which would still remain were it possible to
remove the attendant fever; but which being
removed, the concomitant fever would cease.
In as far as it consists of accelerated circulation,
fever may be associated with the majority of
diseases ; but it is still merely a single symptom,
wherefore other phenomena should be present
before even symptomatic fever ought to be said
to exist. Whatever irritates or stimulates the
circulating system ,to a stronger or more frequent
action, or inflames a particular part, is productive
of symptomatic fever. Its cause exists within
the frame, and more rarely it acts from without ;
as irritation or inflammation of particular tissues ;
the presence of foreign bodies, or of calculi, worms,
or hurtful ingesta; the absorption of hurtful or
acrid matters, or of contaminating secretions ;
surgical operations, external injuries, and violent
exertion. Fever proceeding from these sources
has been termed injiammatory , irritative, fever,

from irritation, fever of the vascular system,
symptomatic infammatory fever , symptomatic fever ,
chronic fever, hectic fever, according to the pecu-
liar irritation, or local disease, on which it at-
tends.

27. Fever is associated with other diseases in a
twofold manner : — 1st. Essentially, forming what
are called febrile diseases or symptomatic fevers
strictly speaking ; as in tabes pnrulenta , in which
it is merely a symptom, but one which is uni-
formly present. 2d. Accidentally or contingently,
not naturally and constantly, but merely from
the association of some occasional disturbance or
complication, as in amenorrhoea, chlorosis, dropsy,
rheumatalgia, &c. ; or as a consequence of treat-
ment. In symptomatic fevers, the constitutional
afl^ection is neither so severe, nor so generally and
equally extended to all the functions, nor so en-
tirely implicates the fluids and soft solids, as in
idiopathic fever. Hence they are more readily
traced to their origin — to the irritation in whicli
they arise. The functions which chiefly mani-
fest disturbance in their progress are those of
circulation and secretion — the latter often very
slightly. Others are also occasionally disturbed,
as those of the skin and of the nervous system, but
generally in an indirect and slight manner. Con-
sequently the chief characters of symptomatic
fevers are quickened pulse, heat of skin, disorder
of its transpiration, and thirst. The excretions,
muscular power, and the faculties of mind, are
but little altered. The pulse retains greater tone
and sharpness, and the general surface more
animation than in idiopathic fever. The external
physiognomy, the posture, the extreme prostra-
tion of muscular power, the profound alterations
of the vital endowments of the fluids and of the
organisation itself, characterising the latter, are
either altogether absent, or present in a very
slight degree merely, unless when morbid matters
are conveyed into the circulation during the
course of certain symptomatic fevers, and thereby
vitiate both it and the soft solids, disordering also
the different secretions and excretions. Such
occurrences sometimes take place, and have fallen
repeatedly under my observation, particularly
when inflammation attacks the internal surface of

FEVER — Diagnosis — Geneiial Course.

899

vessels, or when purulent or sanious matters are
taken up and conveyed into the blood, as in cer-
tain puerperal and other diseases. The vitiation of
the circulation thus produced, and the effects upon
the nervous system and other structures, are such
as to give rise to a state of disease altogether simi-
lar to some of the worst forms of idiopathic fever.

28. The (ii»'nfio;i of symptomatic fevers depends
entirely upon the nature of their causes, and the
permanence of the original affection from which
they proceed. Sometimes tliey are short, or even
ephemeral, the irritation which occasioned them
being removed by the actions which it induced :
in other cases, their continuance is often very long.
But the character of the phenomena experiences
but little alteration, and tiiey seldom undergo
much change in their type. They are not, how-
ever, devoid of efforts at a critical evacuation ;
but these are more frequently inefficient and
abortive, than in idiopathic fevers, owing more
to their being insufficient to remove the primary
malady than to defective vital energy. They are,
however, occasionally relieved or even removed
by spontaneous hajmorihages, vomitings, diar-
rhoea, copious perspirations, and critical secre-
tions of urine. Unfavourable terminations fre-
quently also take place owing to congestions,
obstructions, or disorganisations in some vital
organ, arresting its functions. The treatment of
symptomatic fevers is necessarily directed less to
the particular phenomena they present, and more
to their origin, than that of idiopathic fever. It is
generally founded upon the intention to remove
the cause ; and, when this cannot be accom-
plished, to render it less injurious.

29. II. The Diagnosis of Fever. — From the
description which has been given of the patho-
gnomonic symptoms of idiopathic fever, and of the
general characters of symptomatic fevers, the dif-
ferences between both, and between the former
and other diseases, will be evident. The distinctions
just stated between idiopathic and symptomatic
fever equally exist between the former and in-

Jiiimmatioii ; this latter being one of the chief
causes of symptomatic fever. Inflammation, in
its primary and phlegmonoid form, attacks not only
a single tissue or part, but also in a manner indi-
cating its locality ; the resulting constitutional
affection differing in its mode of supervention and
in its characters (§ 7. et seq.), from fever, as above
described. It should, however, be recollected
that inflammation frequently supervenes in parts
or organs at some period of the course of idiopathic
fever, or even at its commencement ; and indeed
the fevers of some seasons, or epidemic*, are very
generally thus complicated. In these cases, how-
ever, the inflammation does not present the cha-
racters it assumes in the previously healthy frame,
but those it puts on when occurring in a very
unhealthy or cachectic habit of body ; it being
engrafted, when supervening in the course of
idiopathic fever, upon a morbid condition of the
constitution as respects the vital endowments, the
fluids, and the soft solids. Hence, when once
excited, particularly in membranous or cellular
parts, inflammation rapidly extends or passes into
disorganisation, owing to the remaining tone of
the vessels, and to the already reduced vital re-
sistance being rapidly exhausted by the generally
as well as locally increased vascular action. It
presents, in such circumstances, many of the cha-

racters possessed by erysipelatous inflammation,
and very nearly approximates to it ; but is fre-
quently still more dangerous, insidious, and rapid
in its progress to fatal disorganisation.

30. Fever dift'ers fiom diseases usually deno-
minated cachectic, inasmuch as in them the ex-
ternal habit and appearance of the soft solids are
principally affected, and the powers of life much
less tiiau in fever. They supervene gradually
and imperceptibly, and proceed slowly, without
much, or even any, acceleration of pulse, or in-
crease of temperature. They present not the
complete prostration of muscular power, the
versatility of character, the mutability or dis-
position to change, and the efforts at vital reaction,
wJiich distinguish fever; and nature does little
towards removing them, whilst art effects much.

31. Fever difl'ers from disorders termed nerV'
oiis, in the latter being altogether referrible to
the cerebro-spinal nervous system, or parts inti-
mately connected with it, whilst other systems
and organs are either unaffected or not propor-
tionately affected. They present but little change
of the circulation, or of animal heat, or of the
secretions, or of the intrinsic condition of mus-
cular power, or of the soft solids in general. They
are, moreover, generally chronic ; they follow no
determinate course, are cured with difficulty, and
yet are seldom removed by the unaided efforts of
nature. Other diseases, as those which are local
or attended with increased discharges, are at once
distinguishable from fevers by their essential or
pathognomonic symptoms.

32. III. Of the General Course of Fever.
— Fever commonly runs a determinate course,
unless death occur so early as to prevent it. In
order to give precision to our knowledge of the
usual progress of the disease, and to enable us to
employ the means of cure with a stricter reference
to existing pathological conditions, several stages
or periods have usually been pointed out, accord-
ing to the changes observed in its course. Writers
have differed materially as to the number of
stages into which fever should be divided, and as to
the terms by which they should be designated. As
respects eruptive fevers, no difficulty need exist as
to either. I shall pursue, therefore, that arrange-
ment which my observation of the progress of
fever has convinced me to be correct, and which
is applicable to continued and periodic fevers
equally with those which are eruptive. — Fever
consists — 1st. Of the formative or precursory
stage ; — 2d. Of the period of invasion ; — 3d. Of
excitement or reaction, comprising (a) incremental
excitement, and (6) stationary excitement; — 4th.
Of the stage of crises; — 5th. Of decrement, or
decline ; — and, 6th. Of the period of convalescence,,

33. A. The Formative or Precursory Stage;
Stadium Opportnnitatis, Hildenbrand ; Sta-
ditim Prodromorum, Reiche, Heli.ing, and
RiCHTER ; The latent Period, of Dr. Marsh ;
The Stage of Incubation, of French writers ;
77)6 dormant Period, of English authors.- — -Al-
tiiough the precursory symptoms of fever have
been fully enumerated by Celsus (De IMed. lib. ii.
cap. 2.), they were overlooked by writers until
the middle of the last century, when Tissot,
Reiche, and Helling, directed attention to them.
FoRDvcF, and other more recent authors on fever
in this country, have left them entirely unnoticed.
In my papers on fever published between 1819

3 M 2

900

and 1828, and in my lectures delivered from
1823 to 1827, particular notice was directed to
the subject, and these symptoms were described
as constituting a most important stage of the dis-
ease, inasmuch as in it the nature of fever would
be most advantageously studied, and either its
subsequent course remarkably meliorated, or its
further progress prevented, by appropriate and
energetic treatment. (Loiid.Med.Bepos. vol.xxviii.
p.23B. ; and other Refer, in Bibliog.)

34. The phenomena described above, as cha-
racteristic of idiopathic fever, never proceed
immediately from the remote causes. 'J'lie im-
pression made by them occasions a succession
of changes before those which really constitute
fever supervene. These early changes, being
productive of those which constitute the deve-
loped disease, may aptly be called formative ;
and the symptoms by which they are indicated,
precursorij. The exciting causes of fever seem to
act primarily upon the nervous system of organic
life, thereby producing changes in the vital mani-
festations of the frame, which gradually increase
until they arrive at a certain pitch, and terminate
in one of the modes hereafter to be noticed. The
more intense the exciting causes, the predispos-
ition being equal, the shorter will be the duration
of this period, and the sooner will the lesions con-
stituting fever be brought about (§ 15.). — (a)
The earliest effect which is made manifest after
exposure to the more energetic causes of fever,
as infectious effluvia or noxious exhalations, is a
feeling of constriction or oppression in the chest
or at the preecordia, attended by frequent sigh-
ing, gaping, forced and lengthened inspirations,
and by a seiise of uneasy depression, or nausea,
evincing the morbid impression made upon the
nervous system through the respiratory organs.
The pulse is weak, slow, irregular, sometimes
remittent or reduplicating, and readily accele-
rated by slight exertion. — (b) The natural and
acquired appetites and desires are diminished ;
nausea is readily excited by food ; and the bowels
are either costive or easily acted upon by purg-
atives; Venus sile^, and all the organic Junc-
tions are impaired. — (c) The patient feels
debilitated and fatigued ; complains of lieadach,
vertigo, or confusion of ideas ; is morose, low-
spirited, sluggish, indolent, or incapable of exer-
tion and of directing his attention long to any
object; he readily perspires, and his breathing
becomes shoit and quick, on the least exertion ;
his sleep is unsound and unrefreshing, and he
awakens with a sense of lassitude or with pains
in his back and limbs, — in short, all the cerehro-
spinal functions are weakened or disordered. —
(d) The external expression and appearance are
somewhat altered. The countenance and skin
are unusually pale, sallow, or unhealthy ; more
rarely red. The eyes are languid, and deficient
in brilliancy. The breath is fcttid or cool ; and
the tongue often loaded. The urine is sometimes
pale and copious ; and the cutaneous surface
dry, cool, and harsh. 'J'hese symptoms vary in
severity, and often are so slight as to escape i)ar-
ticular attention. They frequently are insuf-

fEVER — General Course.

to fourteen days. The severer and the shorter this
period is, the more acute and the more rapid will
be the subsequent progress of the disease, and
vice versa : there are, however, exceptions to
this. Fever may be cut short in this stage by
active and judicious means ; but not afterwards,
unless occasionally in slight cases. — (/) The
pathological conditions characterising this stage,
are, depression of vital power throughout the
frame, with slight internal congestion, particu-
larly of the lungs, liver, &c. ; with imperfect
change of the blood in the lungs, and with di-
minished secretion and excretion,

35. B. Stage of Invasion ; Principium vel
Initium Febris, Auct. var. — (a) The cold stage, of
writers — is attended by debility, lassitude, pain-
ful uneasiness, or sinking at the epigastrium, a
sensation reseinbling cold' running down the
back, with formication or chills extending over
the limbs and general surface. The pulse is
constricted, small, weak, or accelerated ; the re-
spiration is slow, irregular, or suspirious, and
attended by anxiety at the prascordia, and occa-
sionally by a slight dry cough. On these super-
vene gaping, sighing, pandiculation ; a sense of
weight, pain, or constriction in the head ; gid-
diness, moroseness, depression of spirits, and
disorder of the senses ; lividity of the lips and
nails ; pallor of the skin ; the cutis anserina, and
shudderings, rigors, or shiverings, followed by
or alternating with irregular flushes. After the
rigors cease, a sense of chilliness often continues
for some time, although the skin has become hot.
These symptoms present various grades and modi-
fications in the different types of fever : in some
the feeling of cold is actually attended by re-
duction of the temperature ; and in others the
heat is not materially, if at all, diminished, or it is
even increased. 'J'he former is most commonly
seen in the cold stage of periodic fevers, the lat-
ter in the invasion of continued fevers. In all,
however, the cutaneous transpiration is altogether
arrested, and the skin is harsh and dry. The
pulmonary exhalation is also diminished, and the
breath is cold. Copious discharges of pale urine
often take place, evidently arising out of the
arrest of the exhalation from the skin and lungs.
Loss of the appetites, costivene?s, thirst, and
occasionally sickness and vomiting, are likewise
present. — (^) The duration of this period
may be very short ; or it may be for many hours,
alternating with slight flushes. The shorter and
more intense it is, and the severer the rigors, the
shorter and severer will be the consequent vas-
cular reaction, and the more nearly ajiproaching
the inflammatory type ; and the longer its dur-
ation, the more prolonged will be the fever. The
imperfect evolution of this stage, or its slight oc-
currence, particularly when it is not attended by
rigors, very generally indicates a severe malig-
nant or typhoid state of disease. In some of
the most dangerous cases of fever, I have seen this
stage so slight, as to be confounded with the pre-
ceding one. 'J'liis period having supervened, the
disease cannot rea(iily be cut short by bloodletting,
emetics, &c. ; although in the slighter cases, and

licient to induce the patient to confine himself, i more inflammatory type, these means have suc-
— (e) 'J"he duration of this stage is various iu | ceeded in some instances. — (c) The pathologi-
diff'ercnt fevers — from twenty-four hours, as in ical stales of the first period are increased in
plague and some cases of typhus, to several | this, particularly the general depression of vital
weeks, as in ague ; but it is geiieiully from three J endowment; the impeded functions of tlie lungs,

FEVER — General CounsE.

901

liver, &c. ; the interrupted exhalation and secretion,
excepting the urinary secretion ; and the imper-
fect depuration and arlerialisation of the blood.
Hut the lowered vital powers become more cen-
tralised ; and the congestion of the large vessels,
especially those of tlie thoracic and abdominal
viscera, greater, — conditions wtiich terminate
themselves, by inducing rigors, shivering, vomit-
ing, and reaction of the vascular system, with
the subordinate phenomena of the next stage.

•36. C. Period of Excitement. — a. Incremental
excitement or reaction — incrementum vel aug-
mentum morbi. — («) This stage commences with
the disappearance of certain of the foregoing
signs, with the increase of those that remain, and
with the supervention of others. Fever in its more
literal sense now begins, and manifests its specific
form. Tlie gaping, pandiculation, formication, and
rigors disappear ; and the stricture and collapse
of the countenance and general surface are fol-
lowed by increased warmth and turgescence.
The chilliness, however, continues for a short
time. Pulmonary transpiration returns in some
degree ; respiration becomes full, frequent, and
sometimes laboured, and the breath hot. The
urine is now diminished, high-coloured, limpid
and clear, and its discharge is often attended by
scalding. The muscular debility, feeling of
fatigue or lassitude, the pains in the head, loins,
and limbs, the thirst, and the anxiety at the
prajcordia, are all increased. The countenance
becomes turgid ; the eyes shining, but with an
expression of languor; the cheeks flushed, and
the cutaneous surface hot, burning, and tur-
gescent. The appetites are now entirely abo-
lished ; the tongue is loaded or furred, or
both ; the pulse is free, full, and accelerated ;
often strong, and vibrating in the neck ; but
varies remarkably in tone with the particular
variety of the disease. There are also a sense of
weight, fulness, and aching of the head, with gid-
diness, confusion of ideas, and sometimes with
mental indifference, which short and disturbed
slumbers seem to aggravate; a morbid suscepti-
bility or disorder of tlie senses ; and occasionally
moroseness, restlessness, or jactitation. These
symptoms generally increase, often presenting in
the continued type slight remissions in the morn-
ing, with exacerbations in the afternoon and
evening, and which are most severe on alternate
days; and, during the progress of this stage,
delirium often supervenes, especially when it
reaches its height. — (fc) The duration of incre-
mental reaction or excitement varies with the
type and form of the disease — from an hour or
two, as in ague, to two or three days, as in con-
tinued fevers. It is generally shortest in the
most severe and violent attacks ; but it never
extends beyond seven days. — (c). It consists,
jmthologicallii, of reaction of the vital powers,
expressed chiefly in the vascular system, fre-
quently with a preponderance or determination
towards particular organs — of the efforts of life
to overcome the more immediate effects of the
exciting causes, especially the internal congestions,
and the superinduced changes in the blood.

37. During this stage, determinatio.i to par-
ticular organs or textures frequently occurs, and
thus the fever becomes complicated, or resembles
idiopathic inflammation the more closely, the less
severely the vital power and the circulating fluids

are impaired or vitiated. Such determinations or
consecutive inflammations are observed prin-
cipally in the encephalon, spinal chord, linigs,
liver, stomach, and boxcels ; they are caused
chiefly by the predisposition, previous diseases,
and existing slates, of these viscera ; and by cli«
mate, season, habits, and occupations, and the
circumstances of the individual ; whatever dis-
orders, irritates, weakens, or causes habitual
determination, or increased momentum of the
circulation to either of these organs, thus com-
plicating the fever. Hence the cerebral compli-
cation is most common in the studious ; the gastric
and hepatic, in those addicted to the pleasures of
the table or to intemperance, and in hot climates,
or during warm seasons; the pulmonary, in cold
countries and seasons, and in persons much ex-
posed to the open air ; and the intestinal or
dysenteric, in the ill-fed, in persons using un-
wholesome water or living upon innutritions and
watery food, and in low and moist situations.
The prevailing epidemic constitution has also a
most powerful influence ; the complications, as
well as the particular form and type, of fever, de-
pending upon it, and the nature of the exciting,
concurring, and determining causes.

38. &. Stationary reaction — stadium eoctionis
of the humoralists — consists of the persistance
of the above symptoms, with slight modifications
and frequently with increased affection of parti-
cular organs. — (a) During its progress, restless-
ness continues, with watchfulness ; delirium is
often constant, or appears for the hrst time ; nerv-
ous power is gradually and almost imperceptibly
exhausted ; the pulse generally loses tone, and
becomes more accelerated ; the tongue is deeply
furred and loaded, and often also parched, and
mucous sordes collect about the teeth. Respir-
ation is quick, or moaning, and the breath is
foul, heavy, offensive, sickly, and loaded with
vapour ; the urine is still scanty, high-coloured,
and clear ; the bowels are either costive or irre-
gular, and the stools morbid and offensive ; the
countenance becomes pale, heavy, collapsed, and
of a sallow or unhealthy hue — sometimes muddy
or lurid ; the eyes are suffused, watery, heavy,
and occasionally injected ; the skin continues
hot, pungent, or burning, and it afterwards either
evinces a disposition to transpiration, or becomes
damp and clammy ; or it is the seat of petechiae,
or of eruptions, which, in the exanthematous
fevers, appear at an early part of this stage ; the
prostration of muscular power is increased, and is
often so great that the patient cannot retain his
position on one side, but falls into the supine pos-
ture; adipose matter is subsequently absorbed,
and the body lives upon itself; and, if the patient
be not delirious, he complains of severe pains, or
of a bruised sensation, or of soreness in his limbs,
back, and loins, with confusion, vertigo, or pain
in his head.

39. (I>) The symptoms vary remarkably in this
stage with the type and form the fever assumes —
with ihe complications above alluded to — with
those which may supervene during the advanced
progress of this period — with the more latent
changes in the mucous surfaces, or in parenchy-
matous structures — and with various influences
and circumstances occurring during the disease.
In some varieties of the continued type of fever,
the whole of this period proceeds with little or no

3M 3

902

FEVER— Types and Forms.

evening exacerbation, wliilst, in others, exacer-
bations are very manifest ; but this depends much
upon the prevailing epidemic constitution. In
general, fever caused by infection, and compli-
cated with serious visceral disease, or charac-
terised by severe affection of the fluids and soft
solids, is strictly continued ; whilst that produced
by terrestrial emanations assumes somewhat of the
remittent form, although presenting much of the
continued type. — (c) The duration of this state of
vascular reaction is sliortest in agues, in which it
does not exceed a very few hours ; and, in con-
tinued fevers, it is brief in proportion to the seve-
rity of the disease. It rarely, even in the more
protracted cases, exceeds fourteen days. — (d) The
j>athological states of the early part of this stage
continue in great measure in this part of it ; but
vascular action exceeds vital power, which is
gradually lowered ; and the circulating and se-
creted fluids and the solids themselves become
vitiated as already stated, and as will be more
particularly shown in the sequel.

40. D, The period of Crisis — Stadium Criseos
— Judicium Febris. — Crisis in fevers is a sudden
change taking place at a particular period of the
disease, and terminating it. A crisis is brought
about chiefly by the efforts of nature, or, in other
words, by the febrile action itself inducing changes
in the functions and organs, productive of a salu-
tary effect. Although it often takes place by the
unaided efforts of life, it is frequently assisted by
art, and should not therefore be preferred before
art judiciously employed. The critical days are
the 2d, 3d, 4th, and 5th (quotidian period);
the 7lh, 9th, and 11th (the tertian period) ; tlie
14th, 17th, and 20th (the qiiartan period). After
the 20th, crises are obscure, and seldom occur
till the 27th or 28th. Salutary changes are ob-
served chiefly on the above, unfavourable changes
on the intervening days ; but death may happen
on any day. A very cold climate or season,
or either extreme of temperature, the impure air
of an hospital, the continued operation of the
causes, the complications, great vitiation of the
fluids and solids, an active treatment, interfere
with, retard, or prevent crimes. If the exacerbations
be well marked, and vital energy not very much
reduced, a favourable crisis may be more con-
fidently expected. Crises are sometimes inde-
cisive, or consist of several abortive attempts
before the end is attained, especially when the
powers of life are much lowered. When several
critical efforts are required, each succeeding one
renders the task more easy for the next, until the
disease is gradually subdued. (See Crisis, and
Critical Evacuations.^

41. E. Period of Decline — Decrementum —
Declinatio. — Sometimes the decline is prompt
and rapid, especially after a marked crisis (see
art. Crisis) ; at other times it is giadual and
slow, particularly when only slight and imperfect
crises have occurred, or when the disease termi-
nates in resolution without any very manifest
critical evacuation. In the former case, the de-
cline passes quickly into convalescence ; in the
latter, this stage is often characterised by slight
exacerbations, called by some writers posthumous
crises, wiiich are a[)t to be misunderstood. In
the fevers of tiiis country, which frequently de-
cline gradually, or in the second of these modes,
the syinptoms indicative of vital disturbance ge-

nerally subside in the order in which they ap-
peared. Organic nervous influence and the
dependent functions are the first to be restored ;
the respiratory, secreting, and excreting actions
become natural ; the perspiration more general,
free, and, if it have previously been offensive,
clammy, or partial, more natural and genial ;
the tongue begins to clean on the sides and point,
and is more moistened by the commencing return
of the secretions poured into the mouth ; coma and
delirium subside ; and the patient regains his
power over the alvine excretions, if it has been
lost ; the sensorial faculties and sleep reappear,
and the latter becomes more refreshing ; the loco-
motive powers are freer and more energetic, the
patient being enabled to turn upon his side, the
sense of soreness and lassitude being diminished ;
the appetites and desires return, and the excre-
tions are gradually re-established. The action of
the heart is the last to subside to its natural fre-
quency, and generally continues long afterwards
to be readily excited by slight stimuli. The
urine is abundant, and deposits a copious sedi-
ment ; the bowels become free, the motions con-
sistent and feculent, and the skin gradually as-
sumes a clear and healthy appearance ; but
emaciation increases rapidly, or now is more
apparent ; absorption, more especially of the less
animalised and less highly organised parts or
molecules, proceeding rapidly as soon as vascular
reaction subsides.

42. F. Convalescence — Stadium Refectionis —
Convalescentia, — I agree with Richter and
HiLDENBRAND iu Considering this as a stage of
fever. The propriety of this view is obvious, espe-
cially as regards the future health of the patient.
It is, however, altogether distinct from the ma-
lady, inasmuch as it does not present any of the
constituent phenomena, which still continued to
exist in the stage of decline, but merely those of
debility consequent upon acute disease. During
its early progress, the bulk of the body still con-
tinues to diminish, or does not increase until it
is far advanced ; all the symptoms entirely dis-
appear ; the appetites, desires, digestive functions,
the secretions and excretions, are re-established,
but are apt to be disordered, and therefore require
supervision; the cuticle and sometimes the -nails
are exfoliated, and the hair falls out. Irritability
and sensibility often are increased ; and tinnitus
aurium is sometimes troublesome ; but these sub-
side as health is restored. — Belapses are apt to occur
in this period, especially from premature exposuic
or indulgences, or from disorder of the digestive
organs ; but they more rarely follow when fever
arises from infection or from a specific contagion,
though other diseases may be thereby occasioned.

43. IV. Of Tin-. Tvpes and Forms or Feveu.
— i. These ftte determined by the following ciV-
cumstances : — n. ]?y the previous health, the tem-
perament, and habit of body, and vital energy of
the patient; — h. Hy tlie state of the vascular
system, particularly as to the existence of ful-
ness or deficiency of blood; — c. By the specijic
kind of miasm or cause exciting fever; — (/. By
the prevailing epidemical constitution; — e. By
other causes, predisposing, exciting, concurring,
and determining ; and by the intensity of their
action ; — f. J5y tlie external and internal — the
physical and 7noral — injiuences, to which the
patient is subjected, from the period at wiiich

FEVER-— Types and Foums— Terminations.

903

the morbid impression was made upon the frame ;
— S- ^y ^^^ internal civigestinns, determinations,
or injianunations superinduced in its early course ;

— h. By tlie intensity of the morbid impression
made upon the vital endowments, especially of
the organic and cerebro-spinal nervous systems ; —
i. By the degree to which vital power is sup-
pressed or lowered throughout the frame ; — k. By
vitiation of the fi)Ti(/(i//(in- _/ii(i(i»- and soft solids ;

— and, /. By the treatment and regimen during
the commencement and early progress of the
fever. These circumstances both determine the
particular type, the form, and tlie complications of
fever, and change one type or form into another.

44. ii. The Tijpes and Forms, which usually
present themselves as the result of the remote and
efficient causes, and as influenced by the above
circumstances, are —

A. The Intermittent, — a. of a quotidian, —

b. o( 3. tertian, — c. of a quartan, type; either of
which may be — a. simple, — $. double or redu-
plicating,or iii-egnlar, — and, y. complicated — 1st,
with abdominal visceral disease, — 2dly, with ce-
rebro-spinal aflection, — 3dly, with alterations of
the fluids and soft solids, — and, 4thly, with.vis-
ceral lesion and with change of the fluids and
solids — the pernicious or malignant agues of some
parts, particularly in warm climates.

B. The Remittent: — a. Simple, — b. bilious,

c. inflammatory, — d. bilio-inflammatory , — e. ady-
namic or malignant, — /". gastro-adynamic , — g.
typho-adynamic, or associated with severe cerebral
aflection, — h. complicated — a. with pulmonary
disease — (3. with disease of the spleen, — y. with
disease of the large bowels, — i. slight and chronic.

C. The Continued: — a. Ardent fever, — a,
diary fever, — B. bilious, inflammatory fever. —
/(. Synochoid, — a. simple, — |5. complicated, with
predominant affection — 1st, of the stomach and
liver — mild gastric fever, of authors, — 2dly, of
the intestinal mucous surface — mucous fever, —
3dly, of the cerebro-spinal system — nervous fever.

— c. Typhoid or Adynamic fever, — a. simple, — ■
B. complicated with predominant affection — 1st,
of the gastro-intestinal mucous surface — ady-
namic, of French writers, — 2dly, of the lungs
and bronchi, — 3dly, of the cerebro-spinal nervous
system — ataxic, of Pinei., — 4thly, of the mucous
surfaces and brain — /i/p/nis, of writers, — 5thly,
of these surfaces, brain and skin, with efflores-
cence or eruption — exanthematic typhus (Hil-
DENBRAND),orwith petechias — petechial typhus, —
6thly, of the vascular system and circulating fluids

— malignant or putrid fever.

D. Pestilential Fevers : — a. Evincing pre-
dominant affection of the fluids and solids, and of
the gastro-intestinal mucous surface, with yellow
skin — epidemic yellow fever ; — b. of the fluids
and solids, and of the lymphatic glands — plague;

— c. of the vascular system and blood, and of the
lungs and gastro-intestinal mucous surface, with
spasms — pestilential cholera.

E. Ex anthematous Fevers: — a. Scarletfever,

— a. mild or benign, — 0. synochoid scarlatina,

— («) simple, — (b) complicated; — y. adynamic
scarlatina — (a) simple — (6) complicated, — the
complications in both varieties being with inflam-
mation of the throat, or of the gastro-intestinal
Tnucous surface, or of the membranes of the brain,
or of tlie respiratory surfaces, or with any two or
three of them ; — b. Meades, — a, mild, — B> sy-

nochoid measles, — (a) simple — (b) complicated

— y. adynamic measles — (a) simple — (h) com-
plicated — the complications being nearly as above ;

— c. Small-pox, — a. mild, — /?. synochal — (a)
simple — (6) complicated, — $. adynamic or con-
fluent — (a) simple — (6) complicated — the
complications being nearly as above ; — d. Erysi-
pelas may be similarly divided.

F. PiiERPERAL Fevers : — a. Inflammatory, — .
a. inflammation of the uterus — 0. of the ovaria
and tubes — y. of the peritoneum — 5". of any two
or all of them ; — b. Synochoid puerperal fever, —
a. complicated with inflammation of the peri-
toneum — /3. with inflammation of tlie uterine
veins, &c. — ><. with inflammation of the uterus
and appendages; — c. Malignant or adynamic
puerperal fever, — a. simple — (3. complicated with
predominant aflection — (u) of the blood — (6)
of the fluids and peritoneum — (c) of the fluids,
serous surfaces, and soft solids generally — (d) of
the blood, the uterus, or of the uterus and appen-
dages— (e) of the internal surface of the uterine
vessels, substance of the uterus, &c.

45. iii. Of the Conversion of Type, Form, S;c.—
The above types, forms, and states, not only may
result from some one or more of the above circum-
stances (§ 43.), but they also may be variously
clianged and modified by them, during the course
of the disease — a simple state of fever becoming
more intense or complicated, according to deter-
mining influences — the intermittent type becom-
ing irregular or complicated, or passing into a
simple, severe, or complicated remittent, and this
latter into the continued type, frequently with
predominant affection, either of the nervous or
vascular system, or of some important viscus, or
of both. This change of a slighter into a severer
disease, and of simpler states into those which are
more complicated, commonly arises from the cir-
cumstances just stated (§ 43.), and more especially
from those concurring and determining causes
about to be enumerated (§ 64, 65.); and is much
more frequent than an alteration from a severe to
a slighter form of fever, as that of a continued to
a rer^ittent, or of the latter to an intermittent type,
which, however, sometimes occurs.

46. V. Terminations. — Fevers terminate —
1st, in a return to health ; — 2dly, in some other
disease ; — and, 3dly, in death, A. A termination
in health is favoured — a. by a previously sound
constitution, and a spare habit of body ; — b. by
the absence of great intensity of the remote causes,
and by their nature ; those which are slight,
or which proceed from endemic sources, or act
singly, being less noxious than those arising from
living animal bodies crowded together, or from
the sick, or from various associations of animal
effluvia, and of other causes ; — c by the absence
of unfavourable influences and accidents, phy-
sical or moral, during the progress of the disease,

— d. by a complete removal from the continued
operation of the exciting, and even of the pre-
disposing, causes during the treatment, and by
the advantages of wholesome air and judicious
management ; — e. by the easy circumstances
and equable mind of the patient; — and, ^". by
the occurrence of a crisis. The modes by which
fevers terminate in health, are — 1st, by crisis, to
the production of which art can only indirectly
tend, but still tends very powerfully in some
cases ; — 2dly, by a resolution of the disease*

3M 4

904 FEVER— Terminations —

without any crllical discharge. This is the most j
frequent mode observed in the fevers of tliis cli- I
mate; and results, in a great measure, from the
treatment adopted for them, particularly in their
early stages, which generally interferes with, or
prevents the occurrence of, the natural evacu-
ations constituting crises (see this article). It is
chiefly when artihcial evacuations have not been
pusiied far, that crises manifest themselves.

47. B. Tenniitiitiuiis in other diseases aro owing

— a. to previous disease, or the condition of par-
ticular viscera at the time of attack ; — b. to the
severity and concurrence of the causes, and the
intensity of the disease ; — c. to local determi-
nations supervening during the progress of fever,
giving rise to complications ; — (/. to improper
treatment, as a too heating regimen, the con-
tinued use of cathartics, or the adoption of such
as are too irritating; — e. to incomplete or im-
perfect crises ; — f. to the too early or too li-
beral use of stimulants or tonics during the
disease, or during convalescence ; — g. to the
continued operation of the causes during treat-
ment; — h. to the occurrence of new, determin-
ing, or superadded causes, as crowding of the
sick, bad ventilation, mental perturbations, in the
progress of the malady ; — and, i. to neglect, and
to a blind confidence in the efforts of life. The
diseases which may be thus superinduced, are —
a, inflammations of particular organs ; — /3. en-
gorgements, obstructions, and enlargements of
glandular viscera, particularly the spleen or
liver; — y. effusion of serous fluids into shut ca-
vities, as into the peritoneal and pleural sacs ; —
^. partial or general anasarca ; — s. ulceration or
abrasion of mucous surfaces — chronic diarrhoea
and dysentery ; — ^. haBiiiorrhage from mucous
membranes; — ». inflammation of some part of
the vascular system; — &. apoplectic, paralytic,
or epileptic seizures; — i, mania and insanity in
some one of its forms.

48. C. A terrnination in death is favoured —
a, by constitutional vice, excessive vascular ful-
ness, and a bad habit of body ; — b. by the in-
tensity of the cause and of the disease; — e. by
the continued operation of the chief causes ; — d.
by the nature of the complication; — e. by neg-
lect or improper treatment ; — /. by unfavourable
crises ; — • and, /;. by the other circumstances just
mentioned (§ 47.) as productive of consecutive
diseases. — This result cannot be imputed to any
single change. Two or even more of the fol-
lowing are evidently concerned in its production :

— a. Extreme suppression of organic, nervous,
or vital power ; — B. Lesions of organs arresting
their functions, and impeding those actions ne-
cessary to continuance of life ; — y. Mtiation of
the fluids, changing the condition of, or destroy-
ing, nervous influence and the rest of the vital
manifestations; — J. J^xhaustion of vital power,
and alterations of the intimate organisation of the
viscera, as in malignant fevers ; — e. Organic
injury sustained by the nervous system, espe-
cially its larger masses; — ■^. Diminished or ex-
hausted irritability of the heart, the patient ex-
piring as in fatal syncope; — ». Suftbcation from
effusion into the bronchi ; — b. Congestion of the
lungs, heart, and large vessels, to an extent beyond
Uie vital power of these parts to overcome ; — and,
». Deficiency of idood so considerable as to destroy
tho relative conditions of the contained fluid and

Appearances after Death.

containing vessels ; for when the tonicity, the or-
ganic contractility, of the latter is much impaired,
as in the advanced stages of adynamic fevers, and
the amount of circulating fluid is also greatly les-
sened, the vessels will be unable to accommodate
themselves to their contents, and the consequences
must necessarily be most dangerous, if not speedily
fatal.

49. VI. Of thk ArrF.AUAxcES after Deatif.
— A. — a. Cases have been met with, wherein the
most careful examination has failed to detect any
lesion, or strictly morbid appearance, in any of
the general systems, or individual textures, or in
the fluids contained in the large vessels. It must
be admitted, therefore, that changes may take
place in the nervous system, or in the blood,
suflicient to cause the most acute disease, or even
to subvert life, without being so gross as to be
demonstrable to our senses; but allowing this,
the fact now staled is important, inasmuch as it
most materially affects the question as to the
nature of fever. — b. Other cases have been ob-
served— and much more frequently than the fore-
going— in which the morbid appearances were
not commensurate with the intensity of the symp-
toms referrible to their seats, and were quite in-
sufficient to account for a fatal issue. — c. Fre-
quently also, lesions of parts have been discovered,
which were not indicated by symptoms, or by
the usual symptoms, or very slightly and imper-
fectly ; those changes having been more or less,
or even entirely, latent during life, although
their nature evinced their existence and progress
during the advanced stages of the disease. This
circumstance may have arisen from an oppressed
or exhausted state of the brain ; or from the
changes in the circulating fluid impairing sensi-
bility; or, as Dr. Alison suggests, in his very
able and lucid exposition of the Pathology of
Fever, from an enfeebled state of the circulation at
the time when these local affections take place.

50. -B. As to the nature of the changes observed,
opinions are somewhat difierent. — Many writers
have viewed them as purely inflammatory ; others
as consequences of irritation, or of inflammatory
irritation ; this condition being viewed by them
as a lesser grade or modification of inflammation.
It is important to entertain precise ideas as to
their nature ; and to mark the circumstances in
which they differ from those changes indisputably
resulting from pure inflammation, particularly as
occurring in a previously healthy constitution. —
1st. The lesions observed in fevers rarely present
effusions of lymph or pus, especially in the ady-
namic and typhoid fevers, — consequences com-
monly following true inflammation; and the
cases in which these effusions have been detected,
have been instances of local inflammation super-
vening in the course of the more sthenic or in-
flammatory forms of fever. — 2dly. The lesions or
inflammatory appearances have been more super-
ficial, diff'used, and attended with a darker disco-
louration, and greater softening of the artected
and adjoining parts, than in idiopathic inflamma-
tion.— 3dly. The appearances thus characterised,
difl'er the more from inflammation, the lower the
type of fever and the more vitiated the circulating
fluids. — 4lhly. They more nearly resemble ery-
sipelatous inflammation, than any other. — 5thly.
They are met with in certain tissues more fre.
quently than in others; and, excepting deficient

FEVER— Appeaban'ces aiteh Death.

cohesion and discoloration, are commonly limited
to these tissues.

51. C, The organs most frequenily altered in
structure, are, the digestive mucous surface, the
liver, the spleen, the bronchial surface, the lungs,
and the brain and its membranes. But tlie fre-
quency of the alterations of each differs widely in
different fevers ; the first and last of these tex-
tures being upon the whole most frequently and
seriously changed. — a. The digestive mucous
surface is very generally affected in some fevers,
particularly in certain that are endemic, as in
the fevers of Paris, and in warm or marshy
countries. Tiie alterations of it are often insi-
dious, latent, or much greater than the symptoms
indicated ; and they differ from tlie appearances
commonly resulting from common inflammation,
in the dark discolouration attending them, in their
being confined to spots or patches, and in the less
frequent effusion of lymph. — They consist — 1st,
of livid or brownish red patches, covered by a
dark reddish mucus; — 2dly, of softening, tu-
mefaction, or thickening of the discoloured spots :

— 3dly, of infiltration of the submucous tissue
with darker sanious fluids resembling small ecchy-
moses or internal petechia; ; — 4thly, more rarely
of effusions of small portions of lymph in spots
scattered over the membrane; — Sthly, of abra-
sions, slougliings, and ulcerations of this tissue,
either sparingly scattered, or aggregated, — the
latter most frequently in the lower ihum, or near
the termination of the ilium. These changes are
most common in the parts of the membrane oc-
cupied with Peyer's and BuuNNEn's glands, but
they also occur in the mucous membrane itself.
Their frequency in different parts of the canal in
fevers is the same as stated in the article Diges-
tive Canal (§36.). — These lesions are seldom
seen alone. They are most frequently accom-
panied with changes in the mesenteric glands and
in tiie encephalon, and are obviously advanced
consequences of the general disease ; as thev are
observed chiefly in the more protracted cases.
They are the com.mon causes of the intestinal
ha;morrhages, of the severe pains, and the sinking
sometimes occurring in the latter stages.

52. C. Alteratiiins of the liver and spleen are
much less frequent in this country, than in warm
climates, and the countries of the south of Europe.

— a. The change in the liver consists chiefly of
congestion, injection of its vessels, softening, and
enlargement. — b. The bile seldom presents a
healthy appearance, either in the gall-bladder or
in the hepatic ducts. — r. The affection of the
spleen is most common after the periodic fevers
of miasmatous localities ; and consists chiefly of
great enlargement, softening, and even gangrene.
— d. The pancreas and kidnei/s are not often altered
in structure, and the peritoneum still more rarely,
excepting in puerperal fevers, and after perforation
of the digestive canal.

53. D. The lesions of the respiratory and cir-
culating organs are frequently very important. —
a. The fauces and larynx sometimes are covered
by an aphthous exudation, or are cedematous, in-
filtrated, tumefied, and softened; but tlie larynx is
seldom affected to the extent of impeding respir-
ation, unless in eruptive fevers. — /;. The bronchial
mucous membrane is often injected in patches, of
a dark red or livid hue, somewhat thickened and
softened, and covered by a discoloured, viscid,

905

and frothy mucus. — <?. The pulmonary parerf
chyma is occasionally cedematous, or condensed
by infiltration of a dark fluid, and at the same
time somewhat softened. The changes in the
bronchial surface and in the substance of the
lungs often co-exist ; and are also attended by
gravitation of the fluids to the more depending
parts of these organs ; and by exudation of the
more seious portions, — alterations which are not
alone consequent upon death, but which often
precede it, and constitute the " Feripneumonie
des Agonisuns " of Laennec. The changes, more-
over, in the respiratory organs, particularly in
the typhoid states of fevers, are often attended
with lesions within the cranium and in tlie diges-
tive mucous surface. — d. Gangrene of the lungs
occurs only when inflammation of them supervenes
in the course of fever ; and the same remark is
applicable to alterations of the pleura or pericar-
dium. Inflammation of these latter textures
sometimes takes place during convalescence, ow-
ing to premature exposure, and during the decline
of fevers, particularly eruptive fevers. — e. The
heart is sometimes softened, and its substance dis-
coloured, particularly in adynamic or malignant
fevers ; and occasionally a sanguineous serum is
found in the pericardium. — f. The blood in the
cavities of the heart and large vessels is often also
more or less changed. (See art. Blood, § 128.)

54. £. The lesions within the head most fre-
quently consist of a morbid increase of the serous
exhalation from the encephalic membranes, espe-
cially in the ventricles, and beneatii the arachnoid;
but the amount of the effusion is seldom very con-
siderable. The blood-vessels within the cranium,
especially of the pia mater and substance of tiie
brain, are frequently turgid with a dark or fluid
blood. Slight extravasations of blood are also
rarely observed. These appearances have fre-
quently little or no relation to the coma existing
in the latter stages ; and the same may be
stated as to the changes in consistence which
are sometimes seen in the substance of the
brain, — these changes, however, being neither
uniform nor frequent. — The dura mater is rarely
affected.

55. F. Lesions are not so common in the spinal
chord as within the head ; but such as occur there
are similar to these just stated. No uniform con-
nection has been established between the morbid
appearances in this situation and the pain in the
back and loins, or other affections of the voluntary
muscles, although some pathologists believe that
these symptoms depend upon congestion or effu-
sion within the spine.

56. Upon the whole, the changes observed in
particular parts are chiefly advanced consequences
of the disease, the most violent or malignant states
of fever often being evinced rather in the altered
colour, elasticity, and cohesion of the tissues,
than in grosser lesions ; these latter being most
commonly superinduced on the former. It is
important, however, to distinguish them from
lesions which have existed before the occurrence
of fever. The blood and all the secreted fluids
are evidently more or less diseased ; although it
is difficult to show in what the change of these
consists. (See Blood, § 1 15. and 128.)

57. YII. The Piiognosis of Fevers is of the
utmost importance as respects a knowledge of the
changes taking place in their course, and of the

906

FEVER— Prognosis.

signs and tendency of these changes, as well as
the reputation of the physician. — It is often dif-
ficult, owing to the mutability of the disease, and
to the liabiHty to err in appreciating those signs
by whicii changes of the functions and of the or-
ganisation are indicated, particularly when the
chief manifestations of life, and sensibility and or-
ganic contractility, are more or less impaired or
perverted during the course of fever. The pro-
gnosis depends, generally, upon the following cir-
cumstances : — a. The nature and intensity of the
predisposing, exciting, and concurring causes; — b.
The character of the prevailing epidemic, or epi-
demic constitution ; — c. The type, form, and state
of the disease ; — d. The states of. the various
functions, and of nervous and vital energy; — e.
The congruity of the symptoms, and various con-
tingent phenomena ; — /'. The influences, treat-
ment, and regimen to which the patient is sub-
jected;— and, g. The enticul or other changes
which may take place.

58. A. — a. The predisposition caused by debi-
lity, acute sensibility, or a plethoric and cachectic
habit of body ; a previously morbid, or congested
state of the internal viscera, particularly of the
liver, bowels, and spleen ; and advanced age ; in-
crease the danger from fever. Some epidemics,
however, most frequently attack the young and
robust, and prove even more fatal to them. But,
although sporadic fever may be also common in
this class of patients, it is less dangerous in them
than in the foregoing. — 6. The exciting agents,
particularly specific animal miasms ; their con-
centrated form ; the concurrence of several
causes, either contemporaneously or in quick
succession ; their prolonged action, or continu-
ance during the disease ; and certain of the cir-
cumstances, inducing unfavourable terminations
(j 48.) ; render the prognosis much more serious.
Some importance should also be attached to the
character of the prevailing epidemic, as respects
its open or insidious form, and the effects follow-
ing a treatment appropriate to the usual states of
the disease.

59. B. — a. The intermittent type is less se-
rious than the remittent, and this latter than the
continued ; but the more the fever is inclined to
change, to become irregular, or to pass into one
of a graver character, the more serious it is.
The more complete the intermission, or the re-
mission, so much less is the danger; and the
more disposed continued fevers are to evince a
remitting form, the more favourable is the cir-
cumstance. The longer fever has continued, the
more difficult will be the cure ; and relapses are
more unfavourable tiian first attacks. — h. The
inflammatory and sthenic species are much more
generally favourable than the adynamic forms.
— c. The simpler the fever, the more certainly
will recovery take place; and the more complicated,
the greater is the danger. The adynamic /iic?/!,
with predomiiuiiit affection, of an important in-
ternal organ, especially the intestinal mucous
surface, or the brain, or the lungs, is accordingly
amongst the most dangerous ; more especially if
the vascular system and circulating fluids, or the
soft solids, also become vitiated.

fiO. C. 'I'he more that the organic nervous in-
Jluence is suppressed, diminished, or disordered
tlirougliout the different viscera, the more unfa-
vourable sliould be the prognosis; the functions of

the viscera, the state of the fluids and secretions,
and the appearance of the soft solids, evincing the
extent of the disorder and of the danger. — A
weak, small, and quick pulse; a dark, dry, and
contracted tongue ; profuse, ofl^ensive, viscid,
and unnatural perspirations ; watery, foetid,
flaky, membraniform, and unhealthy stools ; dis-
coloured, scanty, and brown urine ; livid or
discoloured nails, fingers, eyelids, lips, and nose, in-
dependently of the cold stage ; a discoloured, dark,
and dry mouth and throat ; and an offensive
and penetrating odour proceeding from the patient;

— are dangerous symptoms. A pulse of 120 or
upwards, unless in the puerperal state, is unfavour-
able, and so much the more so as it is above this
number. A brown or black coating, and deep,
reddish fissures, or a dark or livid colour of the
tongue ; stridor of the teeth ; a movement of the
lips and lower jaw as if eating; firm closure of
the jaws and lips ; extreme anxiety at the praj-
cordia ; tumefaction, tenderness, or pain of the
epigastrium, hypochondria, or abdomen gene-
rally ; tympanitic or flatulent distension of the
abdomen ; copious or repeated discharges of blood
by stool ; a sudden irruption of the catamenia,
and an equally sudden disappearance of them ; a
moaning, weak, quick, abdominal, or gasping re-
spiration ; coldness or rawness of the expired air ;
hiccup ; excessive increase, or diminution, or
irregular distribution, and otherwise morbid state,
of the animal heat ; sunk features ; rapid ema-
ciation ; great difficulty or impossibility of acting
upon the skin by sinapisms or blisters; an earthy,
or deadened, unnatural, lurid appearance of the
external surface ; yellowishness of, or petechiae
and livid or purple blotches on, the skin ; and
dark mucous soides on the lips or gums, or sani-
ous discharges from the latter or from the nose ;

— are very unfavourable circumstances.

61. D. The unfavourable symptoms, more
directly depending upon the cerebrospinal nerv-
ous system, are, — a. extreme pain of the head;
excessive sensibility or depression of spirits ; tumid
or red countenance, injected watery eyes, con-
tracted brows, &c., quickly passing into delirium,
sopor, or coma ; prolonged watchfulness, or early
somnolency or torpor ; convulsive movements,
trismus or spasms of parts, great restlessness, and
continued tossings ; despair of recovery ; and a
presentiment or feeling that death will ensue : —
b. And still more unfavourable are, early mental
indifference, particularly to the issue of the disease;
insensibility or sopor ; profound coma, and diffi-
culty of being roused ; relaxation of the sphincters,
and unconscious evacuations ; excessive loss of
muscular power ; inability to retain any other
than the supine posture, especially early in the
disease, and in connection with extreme pain in the
back and loins ; falling down towards the foot of the
bed ; a position of the limbs and body, depending
upon their gravity, and dififerent from that usu-
ally preferred by the patient ; inability to assume
a posture diflerent from that in which he is
placed ; picking with the fingers at the bed-
clothes ; subsultus of the tendons ; catching after
objects in the air; alternate dilatations and con-
tractions of the nostrils during respiration ; loss
of voice or speech ; trembling of the tongue, or
inability to protrude it ; an open mouth or relax-
ation of the lower jaw; difficulty of deglutition ;
and dilatation and insensibility of the pupil.

FEVER-

62. E. Unusual or incongruous symptoms
also denote danger, especially if the patient is
more depressed by, or sinks faster under, the dis-
ease, than its apparent severity should warrant.
The presence of severe symptoms, of which he
makes little or no complaint, is much more dan-
gerous than restlessness and anxiety when the
symptoms are not so severe. Unquenchable
thirst, the tongue being moist, and febrile heat
moderate, the absence of thirst, the tongue and
mouth being dry, and tlie temperature high ; and
remarkable craving for food before remission of the
symptoms, the tongue remaining dry, &c. ; — are
unfavourable symptoms ; the first indicating dan-
gerous lesions of the stomach and liver, the
second oppression of the brain, and the third in-
flammatory action of its substance, with extreme
debility. — An early collapse of the countenance,
or a pale lurid hue of it, with rapid emaciation,
indicates a very dangerous form of fever, with
vitiation of the circulating fluids. The more
complete the change in the expressions, appear-
ance, and habits of the patient, during the early
stages of the disease, the greater the danger. A
remarkable acuteness of the senses of hearing
and sight is more unfavourable than an opposite
condition. Changeablenessof the urine, especially
if it becomes limpid and scanty, from being
copious and turbid, or ceases to deposit a sedi-
ment ; an unnatural sound on deglutition ; a
marked or unusual sinking, or protrusion of the
eye ; a diminution or an enlargement of the ob-
jects seen, or double vision; openness of the
eyes during sleep, or sopor ; the patient suppos-
ing himself in a different bed or house to his
own ; and his urging a removal to his friends, or
to a church, or to the altar ; — all denote danger.

63. F. The more mild, open, and uncompli-
cated the disease, or devoid of any of the above
unfavourable signs, the more certain will be re-
covery. The occurrence of crises at due periods,
and their spontaneous and full evolution, are also
very auspicious. But if the critical evacuations
are imperfect, or if the exacerbations, or aggra-
vation of particular symptoms, usually preced-
ing them, only are observed — the efforts being
thus abortive — or if the disease afterwards be-
come more severe, danger should be appre-
hended ; especially if the tongue be drier, the
secretions more disordered or suppressed, and
organic nervous power further diminished after
such attempts. (See art. Crisis.)

64. VIII. Causes. — i. Remote. — A, The
predisposing causes are not the same in all
fevers ; for there is a certain susceptibility of
frame, which favours the action of the exciting
causes of epidemic and of certain specifically in-
fectious fevers, independent of the states tliat
predispose to the sporadic occurrence of fever.
There seems also to be a certain innate suscepti-
bility to the infection of eruptive and yellow
fevers, that is destroyed by an attack of the dis-
ease, the same infection not producing its specific
eflPects a second time; and this susceptibility, par-
ticularly when yellow fever is epidemic, is gene-
rally connected with high irritability of the
muscular system, vascular plethora, and a robust
state of the frame. — The most influential of the
predisposing causes are — dread of the disease;
change from a cold to a warm cHmate ; peculiar
idiosyncrasy ; acute sensibility and irritability ;

Causes.

907

the excessive use of food, especially animal food,
and of spirits, wines, and malt liquors ; moist
states of the air and diminished electricity ; pre-
vailing winds from the south and east ; fatigue
and exhaustion of mind or body, from whatever
cause ; accumulations of bile on the biliary ap-
paratus, and morbid colluvies in the prima via ;
insufficient and unwholesome food ; a close and
moist atmosphere ; whatever lowers the moral and
vital energies ; and the general predisposing causes
adduced in the article Disease (§30 — 38.).

65. B. The exciting causes are the preceding,
particularly when several act contemporaneously,
or with much intensity ; as a moist, warm, and
stagnant air, rapidly carrying oflT by induction
the positive electricity of the frame ; a saburral
state of the prima via ; accumulations of vitiated
bile ; and mental or bodily exhaustion ; mias-
mata, terrestrial exhalations, and foreign gases
floating in the air ; emanations from decaying
vegetable matter ; the exhalations from crowds
of persons or animals in a confined space and
stagnant air, as in transports, camps, crowded
barracks, prisons, &c. ; the effluvia arising from
putrid or decaying animal matter, particularly
when concentrated, or mixed with the emana-
tions from decomposed vegetable matters ; the
miasms generated by copious secretions and dis-
charges from the sick, as in crowded wards of
hospitals, particularly lying-in hospitals, close,
crowded, and low apartments, &c. ; eflFluvia spe-
cifically infectious, as those of typhus and scarla-
tina ; the force of imagination, or the impression
produced on the mind by the sight of a person in
the disease ; fear, dread, or terror, and any of
the depressing passions acting long and energeti-
cally ; remarkable exertion of mind and body,
and consequent fatigue of either or both ; defect
of the natural or accustomed stimuli, as of food,
drink, tobacco, opium, &c. Certain of the
causes, as infectious effluvia, miasms, &c., are
especially active, and may therefore be said to
be the specific, efficient, or essential agents of
the disease ; whilst others, as fatigue, cold, defect
of stimuli, and certain of the predisposing causes,
may act merely concurrently, or consecutively,
as respects the principal exciting agent, or in
such a manner as to determine or aid its efTecls.
I would refer the reader to what is advanced re-
specting the specific and determining agents and
influences in the articles on the Causation of Dis-
ease (§ 55 — 63.), on Endemic INFLUE^■CES,
and on Infection.

66. ii. Of the Proximate Cause, or those
Changes more immediately consequent on the ex-
citing oi- efficient Agents of Fever. — A. Opinions
of the ancients, and of former miters. — Fevers
have been considered as essential or distinct
diseases from the earliest records of medicine ;
and the extent of the ravages then produced
by them may be inferred from the circumstance
of a separate divinity having been assigned to
th^m in the Grecian and Eoman mythology.
The Greeks invoked their divinity by the appro-
priate name nvpsro; ; the Romans by the appel-
lation Febris (Pliny, 1. ii. cap. 7. ; et ^-Eeian,
Var. Hist, l.xii. cap. 11. p. 566.). The latter
even erected temples for her worship on the Pala-
tine jMount, in the Via Longa ( Vico Longo), and in
the place of the Monument of INIarius (Valerius
Maximus, 1. ii. cap. 5. p. 55.). — The popular

908

FEVER — Views op the Ancients hespecting.

dread which gave rise to such a medium or mode
of deprecation* not only marks the destructive
prevalence of fevers in these countries, but also
indicates the noxious eftects of the Pontine Marshes
in the time of the lloman republic.

67. The earliest opinion of the ancient Greeks
respecting the immediate cause of fever appears
to have been that of Anaxagoras (Plutarch, in
Vita Peuiclis, p. 155.); etiam Aristotle, (De
Gener. Aiiim. l.iii. cap. 6.) — the contemporary
of Hippocrates. He attributed all acute dis-
eases to an abundance of bile. Aristotle (De
Part. Animal, l.iv. c. 2.) combated this doc-
trine ; but it became prevalent nevertheless.
Hippocrates, instead of entering into specula-
tions which the want of data and first principles
rendered futile, set a better example, by directing
attention to the varying phenomena of the dis-
ease, and to their relation with the vicissitudes of
season, &c. Plato (Tim.eus, p. 497.; et Galen,
De Dogmat. Hipp, et Plat. 1. viii. p. 324.) con-
sidered that fevers, and, indeed, all diseases, arose
from a disproportion of the different physical ele-
ments which enter into the composition of the body.
Continued fevers, he supposed to arise from super-
fluity of fire ; a quotidian from abundance of air ;
a tertian from predominance of water; and a
cjuartan from that of earth. This is, perhaps,
the first attempt at explaining the types of fever.
It appears to have had but little influence, not-
withstanding its universal adoption, in changing
the modes of practice already recommended by
Hippocrates.

68. The dogmatists (Galex, de Nat. Hum.
p. 279.) of the following age, in conformity with
their doctrine, conceived fever to proceed from
the abundance of bile, its quantity determining
the type of the disease. The maximum, in their
opinion, produced continued fever of an ardent
character ; a less quantity, quotidians ; and the
minimum, quartans. Praxacoras (Ruffus,
lib. i. chap. 33. p. 109.) of Cos, one of the most
faithful followers of Hippocrates, adopted a simi-
lar theory, and endeavoured also to account for
the cold stage of the disease, by supposing its
source to exist in the vena cava. This opinion
possesses some features of the more modern doc-
trine of congestion, which no doubt exists, botii
in the vena cava and other large veins, during
the cold stage, as a part of the series constituting
the diseased actions which obtain the name of
fever. Erasistratus was the first who con-
tended for a connection between fever and inflam-
mation (Galen, Comment. II. in L. de Nut. Hu-
man, 'p. 27.)- He conceived these morbid states
to consist in a transfusion of the blood into the arte-
ries, disturbing the spirit they contain, and giv-
ing it an irregular direction. The former he
believed to arise from the presence of blood in
tlie large arteries ; the latter, from a congestion
(*ttpE;(/.7rTa)3-i?) of this fluid in the capillaries
{Ihid. de Ven(csect. adc. Erusist. ■p.2.). He was
equally averse from bleeding and purging, which
had been long and generally in use in the treat-

* The following is from a votive tablet to the god-
dess : —

Fehii . fti'va: . Fcbri .

sancice . Fcbri . mngna: .'
Camilla . .imnta . pro .
JUio . male . riffcrto . p .

ToMMAsiNr, in fin^vius, Thcsaur.
Komati. Antiq. t. xii. p. 867.

ment of these maladies ; and in conformity, as he
supposed, with his theory, recommended spare
diet, emetics, lavements, warm baths, frictions,
&;c. (Ibid. p. 15, 16.)

69. Asclepiades, the founder of the Methodic
School, adopted a great part of the doctrine of
Erasistratus respecting the fundamental corpus-
cles, and the pneuma or spirit of the dogmatists.
He explained the heat which t^ikes place in fever,
by the motion of these corpuscles ; and accounted
for sensation, pain, &c. by a simdar hypothesis
(Ca:;Lius Aurelianus, 1. i. c. 15. pp. 46. 48.57.).
According to him, fever consists in an increase of
heat, and of the pulse {Ibid. 1. ii, c. 33. p. 151.).
The other phenomena of fever and of inflam-
mation, he considered to proceed from a dispro-
])ortion between the particles and their pores.
'J'he elementary corpuscles, he supposed to pass
from the lungs into the heart and arteries, and to
produce occasionally, during their volatilization
from the body, an obstruction in the channels
through wliich they circulate ; the larger causing
the most obstinate obstruction, and, consecutively,
the most violent fevers : and the lesser, slighter
attacks. I'he type of the disease was ex-
plained after the same manner. The longer
the intervals between the febrile accession, the
more subtile the atoms were supposed to be
which had become impacted in the vascular
pores (Idem. Acut. l.i. c.l3. p. 42.). Ascle-
piades conceived that nature could do nothing
of herself in removing this state, and that all
must be attempted by the physician. Celsus
(lib. iii. c. 8. p. 469.) informs us, that " As-
clepiades officium medici esse dicit, ut tuto,
ut celeriter, ut jucunde curet." Agreeably to
this maxim, he prescribed gentle medicines, and
dietetic means, instead of the violent remedies of
the empirics (Ccel. Aurel. Acut. 1. i. c. 14.
p.'44.). Enemata, bloodletting, dry cupping,
frictions, gestation, exercise, bathing, and, more
rarely, emetics, were the agents which he recom-
mended. (Pliny, lib.xxvi. c. 3. p.392. ; Ccel.
Aurel. 1. c. et lib. iii. c.8. p. 215.)

70. Soranus (CciL. Aurel. ^c(/(. l.ii. c. 33.
p. 153.) conceived fevers to consist in an absolute
relaxation of the vessels and their pores. Cassius,
the Eclectic (Cassii latrosophistic, Naturales et
Medicinales Quecstiones, Ed.CoNR. Gessner. Ti-
GUR. 1562.), was of opinion, conformably with
the chief doctrine of the Rlethodics, that they arise
in consequence of a different arrangement taking
place in the primary and invisible corpuscles ;
while he adopted the hypothesis of the more an-
cient dogmatist, by considering the increase in
the temperature to be the result of friction be-
tween these particles, disengaging their integral
heat. The views of fever adopted by the Eclec-
tics, led to few modes of practice which had not
been previously employed. IIehodotus (Ori-
bash's, Collect. 1. vi. cap. 28. p.228. c( passim),
the disciple of Aoatuinus, who embraced more
of the pneumatic system than of any other, placed
great confidence in warm bathing and in sudor-
ifics. These he considered to be serviceable, by
fortifying the pneuma or spirit, and assisting it to
expel heterogeneous particles. He attempted,
also, to determine, with more precision, the time
and circumstances in which bleeding, as recom-
mended by Hipi'ocRAiEs, ought to be prescribed.

71. Galen (De differ. Feb. lib. i. passim) altri-

FEVER— Views op the Akcievts respecting. 909

buted the varieties of fever to a degeneration of pu-
trefaction of the humours, and to a certain change
in the pneuma, developing an unnatural degree
of heat. He supposed the lieart and arteries to par-
ticipate consecutively in this derangement, and to
produce the subsequent phenomena. Continued
fevers, according to him, had their cliief source in
an alteration of the pneuma, and of tlie humours;
quotidians in a degeneration of the mucus ; tertians
in a similar change of the yellow bile ; and quar-
tans in a putrefaction of the black bile, whicii he
considered the most slowly moved, and to require
the longest period for the production of the pa-
roxysm. The doctrine of Galen continued to be
almost implicitly and universally adopted for many
ages; and even down to modern times, it has had
its partisans. The writers in medicine who flourish-
ed during the decay of the Roman empire, and the
Arabian physicians, introduced but few modifica-
tions of his theory.

72. Aiinus (Tefrrt/n'/)/. IJ. serm. ii. cap. 54. et
passim) and Palladius explained the phenomena
of fever in a nearly similar manner to Galen.
The former paid particular attention to the good
effects arising from cool apartments, and ventila-
tion, during treatment; and employed the thera-
peutical means recommended by Hippocrates
and Galen. While Palladius (De Fehribus,
cap. 9. p. 30.) admitted the opinion respecting the
degeneration of the humours, he considered the
disease to arise, also, from other causes — such as
external or internal irritations, engorgement or
suppression of the secretions and transpirations,
and putrefaction of the blood itself.

73. During the seventh and eighth centuries,
the Arabians attributed fevers to superabundance
of impure or thick blood, which they conceived
to be connected with a similar state of the bile,
and other humours. They pretended, although
not very appropriately, to dilute the former by
purging, and to evacuate the latter by bleeding.
Aaron of Alexandria, and Rhases (Contin, Vih.
xvii. cap. 6. sect. 360. et passi/n), introduced no
change into the humoral pathology. They, how-
ever, determined with more accuracy the types of
continued fever; and paid greater attention to
their production, especially in an epidemic form,
by the influence of seasons and of certain states
of the atmosphere, than had been bestowed upon
the subject since the time of Hippocrates. Ali
(Abulfayg. Hist. Dynast, p. 32(j.), surnamed
the Wise, a physician of the tenth century, de-
serves notice, more from his recommendation of
emetics, as prophylactics against that state of the
humours which he supposed to be productive of
fever, and on account of hi? employment of
bleeding in intermittents, than from any innova-
tion which he made in the received theory. Avi-
CENXA (Sprengel, Ilist. Mcd. vol. ii. p. 358.)
appears to have introduced the greatest change
in the doctrine of Galen of any of the Arabian
writers. He attributed the phenomena of fever,
and other acute diseases, more to a superabund-
ance of the difl!erent humours, than to a degener-
ation of their constitution. Gilbert*, an English

* Gli.BERTi Anglici Co?»pendiii»! Mcd/ciiiiP, tain Mor-
boruni Vniversalium, quam I'ariiciiliiriuin., non solum
MediciSySedet C/ii/rurgidstit/lisaimiim, edit. ^Mich.Venet.
HE Capella, 1.510, 4to. This production of our country-
man is curious, on account not only of-its medical but
also of its metaphj'sical and dialectic character. The fol-
lowing proposition, which he Btates, and immediately

physician, in the middle of the thirteenth century,
entertained the opinion, that as the changes which
supervene in the humours are infinite, so the
phenomena of fevers may be equally various. He
defined fever to be a greater heat than natural,
developed by the heart, and propagated by means
of the arteries throughout the body, which de-
ranges the other functions in its course, and pro-
motes the further degeneration of the humours
which first gave it oiigin. He admitted, that the
heat of the body was not materially increased in
many cases, and not at all in others; and that his
definition was consequently incomplete. He, how-
ever, endeavoured to get rid of the difficulty by in-
volving it in a cloud of scholastic subtleties.

74. Arnald of A'illanova (^Breviar. lib. i.
cap. 26. p. 1121. et passim) introduced astrology
into the doctrine of fever, by attributing derange-
ments of the humoui's to the influence of the
heavenly bodies. INIenoho Biancheli (De
Omiii Gen. Febr. et jEgritud. Venet. 1536,
fol. — a rare icork), an Italian physician of the
fifteenth century, gave a similar definition and
theory of fevers to that already given by Gil-
bert. IMiciiEL Savonarola (Fraciica Canonica
de Fehribus, cap. ix. f. 36.), a professor at Fer-
rara, about the same period, deserves mention on
account of the view which he took of the influ-
ence of climate in modifying the patiiology and
phenomena of fever. There are few other au-
thors who wrote during the middle ages, deserving
of notice. All of them either more or less im-
plicitly adopted the doctrine of Galen, or mixed
it up with a farrago of scholastic subtleties and
astronomical suppositions.

75. The removal of the trammels of the schools,
and the revival of medical science in Europe,
may be dated from the writings of J. Fernelius
(^Opera Pathologica, ^c. sec. iv.). This eminent
author and H. Augenius (De Febribus, sec. ii. c.4.
p. 50.) were the first to impute the proximate
cause of fever to changes in the living solids.
They denied that the fluids constituted any part
of the organisation, and consequently inferred
that their influence in the production of the dis-
ease could not be primary. They very justly,
however, adniitted their consecutive derange-
ment. Felix Plater (Praxis Medica, vol. ii.
c. 2. p. 39."), one of the first writers who, since
the revival of learning, turned attention to the
true source of medical science — accurate and in-
timate observation — stated that, when the sensi-
bility of a part is disordered by an excessive
increase of its animal heat, the result is fever, the
type of which he conceived to depend upon the
particular fluid which is afi'ected. He believed
that, when the fluids contained in the vessels of the
mesentery are disordered, fever assumes an inter-
mittent tyjie ; and that the further the part whose
sensibility is affected, is removed from the heart,
the longer is the fever in being produced. Enough,

endeavours to solve, considered in relation to the time at
which it was written, deserves transcription, and evinces
also the metaphysical partiahtics of the author. " Where,
fore is the vegetating or vital principle destroyed at death,
and not tlie intellectual ? Because the vegetating or vital
principle is derived from matter, and may be regarded as
its simple product. Consequently it must necessarily cease
to e.\ist with the derangement and destruction of the
materials w'licli produce it. The intellectual principle,
on the conti'ary, is not a simple form ; it possesses different
attributes, not derived from the materials of the bodv, and
therefore must endure after death." (Fol. 2*5, 240.")

910

however, has been stated to show that his facts

are more valuable than his doctrine.

76. Thomas Cajipaneli.a *, the celebrated
Italian metaphysician and pathologist of the six-
teenth century, discarding the opinions of Aris-
totle, conceived that the vital spirit, which is
produced from the most subtile of the animal
humours, and is nourished by the blood, is con-
cerned in the production of all diseases, although
itself undergoes no change, being only irritated
or excited by the aeriform matters and flatuosi-
ties contained in, or proceeding from, the fluids.
He considered that, as respects its nature, fever
can scarcely be called a disease, since it results
from the reaction or the efforts of the vital spirit
to resist vitiation and putrefaction of the fluids,
and thus to preserve life. He attributed the
crisis and critical days to lunar influence, and
explained the action of remedies on the principle
of their exciting or reducing the temperature of
the body. Van Helmont {De Febribus, c. 16.
p. 783.) ascribed fever to the influence of the
archeus or vital principle. — Although the found-
ation of the doctrine, which afterwards became so
generally adopted, owing to the form it assumed
in the hands of Hoffmann, Cullen, and others,
was laid by these writers, another theory was
soon afterwards promulgated. Owing to the in-
creasing enthusiasm with which chemistry then
began to be cultivated, the chemical pathologii
firft proposed by Paracelsus (Op. Omnia Med.
Chemico-Chirurg. 4to. Basil. 15B9.), and sup-
ported by Sylvius (Op. Med. 4to. Amst. 1679.),
AViLLis (Oper. Omnia, 4to. Geneva, 1680.), Ker-
OER, BoRELLi (De Motu Animal, pars i. et ii.),
Wedel (P/ii/sio/. Med. et Pathol. 4to.- Jenae,
1679.), and others, obtained a very general sup-
port ; and although all the phenomena of fevers
were not explained by some according to the
principles of this school, yet its doctrines were
conveniently adduced to account for various states
of disorder.

77. It is unnecessary to notice the drearaings
of Fludd, Digby, INIaxwell, Greatrake, and
others, of the sect of the Rosicrucians, which
appeared early in the seventeenth century, as to
the nature of fever. It is impossible to cast even
a glance at the ravings of this sect, without en-
tertaining ideas the most humiliating of human
nature and intellect. Yet they found followers
in Europe, particularly in Germany, as late as
the middle of the eighteenth century; and, even
now, emanations of their doctrine may be traced
in some of the reveries which have recently been
promulgated in that enquiring country. Leav-
ing opinions calculated only to excite the most
humiliating suggestions respecting the extent of
human knowledge, and e(]ually abasing reflections
on tiie state of medical science in this country at
that epoch, we arrive at a period presenting opi-
nions more in accordance witii calm and unbiassed
reason than those immediately preceding.

78. 'J'lie writings of Sydenham (Opovt Omnia.
Lcyd. 1742, 8vo. best edition) tended to dissi-
pate the " thick-coming fancies" of the humoral

* Horn in ISfiS, and imprisoned for his metaplijsiral
opinions from l.Wg to Ifi'if, when ho was set at hhcrty by
I'opo UniiAN VII. He afterwards went to Paris, where
lie (lied in Ui39. ('riiiADoHCiri, Sloria, &c. t. vii. p 140 ■
(.AMi-ANRLLA, Metaplius. 1. ii. p. 39. ; ct Medecin. 1. i. c. i.
art. 1—4. 8vo. Lcyd. 1G35.)

FEVER — Views of the Moderns.

and chemical pathologists; and, although tinc-
tured by the chemical hypothesis, he nevertheless
directed attention to the operations of nature.
Baglivi {Op. Omnia, Ven. 1716, 4to.), at a later
period, trod nearly in the same path as Syden-
ham ; and, like him, attended to the prevailing
character of epidemics, and viewed their pheno-
mena in connection with the seasons and atmo-
spherical vicissitudes. Stahl {Theoria Med.
Vera, 4to. Matfc, 1737.), the disciple of Wedel,
forsaking the doctrines of his master, adopted a
theory in many respects similar to that proposed
by Van Helmont (Op. OmJiia. Amst. 4to. 1664.)
and Cami'anella. The psychico-chemical, or
bio-chemical, hypothesis of Staiil subsequently
received the support of Sauvages (Noscl. Method,
2 vols. 4to. Amst. 1768.), who, in addition to the
efforts of the anima, the increased motion of the
fluids, and augmented secretion and excretion of
the salino-sulphureous particles, added tiie doctrine
of Boerhaave, of accelerated circulation to re-
move a mechanical obstacle.

79. Although recent opinions as to the proxi-
mate cause of fever may be traced partly to Fer-
NELius and others, yet it is to Hoffmann (De
Generat. Febr. Halas, 1715.), the cotemporary of
Stahl, that we are indebted for some excellent
ideas. He placed the chief source of motion in
the nervous system, and considered that certain
affections of nervous influence induce a general
spasm of the extreme vessels, driving the blood
from the capillaries into the large vessels, the
heart and large arteries thus becoming irri-
tated. A nearly similar hypothesis was soon
afterwards framed by Boerhaave (Pralect,
Acad. 2 vols. Goet. 1744.) from opinions en-
tertained at difTerent periods, more particularly
from some of those promulgated by Hoff-
mann. Boerhaave, adopting no single nor
general principle, to which alone he referred the
different manifestations of fever, kept his atten-
tion more especially fixed upon the relation sub-
sisting between the exciting causes, and the actions
they induce in the system, explaining at the same
time the latter conformably with the pathologi-
cal doctrines of the time. He considered that
a quicker and a stronger action of the heart
was induced, during fever, by an accession of
the influence of the brain and the cerebellum, in
order to overcome the resistance oft'ered by the
smaller vessels ; and that fever was therefore an
exertion of life to avert death. Cullen (First
Lines of Fract. of Pliys. vol. i. p. 42.) illustrated,
in a much, more satisfactory manner, the doc-
trine of the living solid, as first proposed by
Fernelius, and so ably extended, and, indeed,
established, by Hoffmann. The application of
it to the theory of fever, which had been made
by these and other writers, was more ]ireciscly
explained by Cullen, and more conformably
with many of the phenomena. The opinions
of this very acute and philosophical physician
held a stricter reference to the early changes
tiian had been generally entertained. The causes
of fever he supposed to net by debilitating the
nervous energy, inducing diminished influence of
tlie brain, and conse(!utive atony of tiie superficial
capillaries, accompanied with spasm ; reaction
of the heart and larger arteries supervening in
conse(|ucnce of this state. Tliis doctrine was
fartlier illustrated and modified by Cvurie (Medi-

FEVER — Views of the Moderns.

911

cal Reports, S^c. Lond. 1805, passim'), Gre-
gory (Lectures, S)C.), and W. Philip {On the
Nature of Fever. Ediu. 1807, p, 89.), the last of
whom ascribed febrile reaction to a contest be-
tween the capillary and larger vessels ; and it was
most conducive to the employment of emetics at the
commencement, and of diaphoretics through the
course of the disease. Amongst the other neuro-
pathologists, Selle {Ihtd. Fyretologiie Metliodicte.
Berol. 1768, 8vo.) and Tode (De Febrium Indole.
Hafn. 1769.) deserve notice. The former imputed
fever to a peculiar condition induced in the nervous
system in general ; the latter referred it to a cer-
tain irritation in the common sensorium. Schaf-
FER (^Versuche, ii. p. 44. et seq.) and Tiiorer
(De Actione Systematis Nervosi in Feb, Gott,
1774, p. 257.) ascribed it to a similar state of the
nerves.

80. The experiments and arguments of Haller
having tended to establish irritability as a principle
inherent in the muscular fibre, and independent of
the cerebro-nervous system, furnished materials for
doctrines founded upon such views. Several modi-
fications of these successively appeared. Stole
(^Aphor. de Febribus, p. 208. ; et Rat. Med. vol. i.
et ii. Vindob. 1768, 8vo.) considered fever to be
morbidly increased irritability of the heart; J. C.
Juncker {Be Spusmo Febrili Dissert, Hal. 1769.)
viewed it as augmented irritability of the heart
and arteries, the nervous influence being, at the
same time, diminished; Elsner {Varius Febris
Status. Regium. 1789, Doering. I. p. 1 10.) ima-
gined it to be an irregular distribution of the
irritability in consequence of certain internal
stimuli; and Doser {De Fehve. Wirceb. 1795,
p. 17.) ascribed it to a similar condition of this
principle, the irritability of involuntary organs
being heightened, and tliat of the voluntary les-
sened. Other pathologists called in the vital in-
fluence, in a more particular manner than had
heretofore been done, in order to explain the
phenomenon under consideration. Kramp {Fie-
berlehre nach Mechanischen Grnnds'dtzen, Heidelb.
1794. ; et De Vi vitali Arteriarum Diatribo. Ar-
gent. 1786, p. 411,) referred fevers to an increase
of the vital force of the vessels, beyond that which
is requisite to the natural circulation of their fluids.
Fordyce {Dissert, on Fever, jmssim) imputed
them to eflTorts made to overcome obstacles op-
posing a free and healthy circulation ; and Reil
(^Mevwrab. Clinic, S)C. fasc. iv. p. 107.) con-
ceived them to result from an exalted state of
the vital influence aflfecting chiefly the heart and
blood-vessels. Along with this statg of the vital
energy, he supposed its disposition and qualities
to be changed in the different kinds of contagious
fevers ; and hence the alterations which super-
vene in the constitution of the secietions, &c.
Sprengel (Galen's Fieberlelire. Bresl. ]788,
8vo.) and C. F. Hufeland {System der Pract.
Heilk, Jen. 1802.) acknowledged, as the proxi-
mate cause of fever, a morbid reaction of tiie
vital influence, which they imagined to take place
throughout the system,

81. The doctrine of Brown {Elementa Medi-
ciniE. Edin. 1780, 8vo.) was remarkable chiefly
for the manner in which tlie vital phenomena
were explained by it. In this respect, also, the
opinions of his contemporary Darwin (Zoonumia,
vol. iv. p. 333.) were no less distinguished, al-
though greatly inferior to those of Brown in point

of originality, simplicity, and philosophical saga-
city. Brown considered life to be preserved by tlie
operation of the exciting fluids on the excitable
solids, and iiealth to be the result of their equa-
ble and reciprocal action. This action he con-
sidered to be deranged by the causes productive
of disease. Fever he supposed to be an asthenic
state of the system, arising either from the ab-
straction of the natural stimuli, or from the
causes of the disease having directly or indirectly
exhausted the excitability. The notions of Dar-
win were merely more involved modifications and
illustrations in different terms of the same tlieory.
From these have arisen the new Italian doctrine,
which attributes an opposite state of the system
to fever from that imputed to it by Brown,
The opinions concerning the nature of disease,
and the action of remedies, introduced by Rasori
{Delia Febre Fetecchiule di Ge)iova ; Del Me-
todo di Curare, 6;c, del Prof. G. Tomhiasini.
Bologna, 1821, &c. &c.), have produced so
great a revolution in the piinciples of his master,
as to entitle him to the honour of being consi-
dered as the founder of a new school.

82. The ideas of the humoral pathologists
have been lately revived in Germany by Cii. L.
Hoffmann (Hildenbrand, Institutiones Medicce,
vol. i. p. 93.), Wedekind {Kachricliteii liber das
Franzusische,&;c. Leips. 1797, 8vo.), and IIerzig
{De Febribus in Genere, Colon. 1790, 8vo.). They
suppose some change analogous to putrefaction
to supervene in the blood, which, irritating the
vessels, produces fever. At a still later period,
the opinions of the bio-chemists have been at-
tempted to be restored. J. C. Stark and G. F,
Parrot (Hildenbrand, 1. c. ; and Hufeland's
Journal, passim) attributed the proximate cause
of the disease to an excitation and disturbance of
the calorific process, and to the abundance of
carbon in the blood. G. C. Reich {Von Fieber
und dessen Behandlung. Berl. 1800, 8vo.) as-
signed a defect of oxygen in the organisation
as the cause; J. C. Barrens {Uber Fieber und
Sauksciure. Leip. 1802.) imputed too great an
abundance of this substance to the system during
fever; and J. C. Harles {Nene Untersuch. Uber
das Fieber. Leip. 1803.) referred the whole phe-
nomena to the agency of electricity.

83. Although fever and local inflammation
may arise simultaneously from concurrent pre-
disposing and exciting causes, or from epidemic
influence, yet the identity of both diseases did
not become an article of pathological belief, un-
til towards the close of the last century. Rive-
Rius {Pra.v. J\led. sec. xvii. c. 2.), indeed, had
very justly stated, that acute and malignant fevers
very rarely run their course without inflammation
of some viscus : but he remarks, in a manner
worthy his high reputation, that the superinduced
inflammation is difl^ereut from that which is pri-
mary or idiopathic. Other writers had conceived,
from the predominance and character of certain
symptoms occurring in the progress of fever, that
inflamnjatory action is no infrequent attendant
upon it. CoiTER, of Groningen, was surprised
when he found no inflammatory appearances
within the head, in cases where the cerebral
symptoms were very remarkable; — and \\'illis
long afterwards supposed fever to be an inflam-
mation of the spirits {spiriUium phlogosis). Dr.
Gkandvilliers is, however, the first writer, who

912

I'EVER — Views o» the Modehns.

has distinctly ascribed fever to inflammation of
the brain, he having remarked, in 1757, this organ
especially afl^ected in an epidemic characterised
by malignant symptoms ; and Dr. Wendel-
STADT, in his description of an epidemic that pre-
vailed in 1794 and 1795 in Wetzlar, attended by
delirium in some cases, by catarrh or pneumonia
in others, or by both delirium and pneumonia,
considered inflammation of the brain to have oc-
curred from the commencement. Still the exist-
ence of essential fever cannot be said to have
been called in question, until the appearance of
the works of Ploucquet (Erposit. Kosolug.
Tx^phi. Tubing. 1800.) and Clutterbuck (7n-
quirii into the Seat and Nuture of Fever. Lond.
1802.), in which this disease is ascribed to inflam-
mation of the substance of the brain. This
doctrine was soon afterwards controverted by
Dr. Beddoes (^Researches concern. Fever as con-
vected %vith Injiam. S)C. Bvo.) ; but INIarcus, of
Bohemia, forsaking the pathology of Brown,
became a convert to it, and its most zealous sup-
porter (^Ephemer. der Heilk. b. i. St. 2. &c.
1809.) ; and other writers of inferior note es-
poused the doctrine both in Marcus's Epheme-
o-ides and in Horn's Archives.

84. Shortly afterwards, another theory of fever
made its appearance ; and in France, at least, at-
tracted considerable attention, owing to the copious
writings of BitousSAis and of his pupils. This
pathologist maintained that the mucous membrane
of the digestive canal is the primary seat of fever,
and presents the most general and unequivocal
lesions after deatii ; affections of other organs
being merely consequent upon, or sympathetic
of, disease of this part. Althougli several
writers, especially Rahn (^Briefwechsel,S;c. p. 250.
Zurich, 1787.), and Beddoes (Op. cit. p. 63.),
considered the gastric system most frequently
afi'ected in fevers, it was reserved for Buoussais
to conclude that " all the essential fevers of au-
thors are to be ascribed to gastro-enteritis, simple
or complicated." (Exam, des Doct, Med. 6jc.
t. i. p. 34.)

85. These two theories are the most important
of those which have had reference to the local
origin and seat of fever. 'I'hey are manifestly
founded on narrow views of the deranged actions
consequent upon prolonged mental depression
and anxiety — upon change of climate, season,
and weather — upon the operations of endemic
agents and epidemic influences — upon the action
of various infectious miasms — according as each
or several of them may affect persons differently
predisposed, by temperament or diathesis — by
lialiit of body and constitutional energy — by the
state of tiie secreting and excreting viscera —
and by the circumstances in which they are
placed. They appear also to be deduced from
mistaken conceptions of the actual sequence of
the disordered actions characterising the various
species of fever — sporadic, endemic, epidemic,
infectious, &c. — however they may be associated
or complicated with more or less local disease,
cither at their commencement, or in tlieir progress.

86. 'i"he opinions which have recently been
most ado])ted on the Continent, esj)ecial!y in
(Jermnny, are those wliicli were tauglit hy .T. V.
KiiANK ( IJ<- Cnrandis Horn. ]\lorhis, ^;r. t. i. p. 34.)
and \'. N. ah JIu.denhkanu (Inxtiliit. I'ract.
MeJ. t. i. p. 96.). The former of tlieso writers

confesses that he despairs of conveying any exact
idea, or even of coming to any satisfactory con-
clusion, respecting the proximate cause of fever.
He thinks, however, that fever may be viewed as
resulting from iriiiation induced by an unaccus-
tomed stimulus, the powers of life reacting, or
making efforts at reaction, in order to remove it.
Hildenbrand states nearly the same proposition
in different words, in concluding that the cause of
fever is to be found in a morbidly increased re-
action of the vital forces, owing to the irritation
of a morbific stimulus. He further remarks —
1st, That all fevers are caused by an absolute or
relative irritation, and consequently that they
are all at their commencement irritative; — 2dly,
That the reaction of fever never follows mere
debility, although it is attended by debility ; and
that the debility of the vital powers is always
secondary and the effect of the morbid irritation,
or, adventitious as in the progress of the disease.
— Admitting that it is difficult to explain — al-
though I think it quite possible — how reaction
of the vital forces can take place in tiie system in
consequence of a cause primarily producing
debility, more especially in the part where the
impression is primarily made ; still it is evident
that all the causes of fever are not positive sti-
muli or irritants in their primary action, and con-
sequently that their immediate effects on the
surface to which they are applied are not exciting.
Indeed, we have no evidence that the effects
which are proximately consequent upon their
application, are similar to those which uniformly
result from those stimuli, with the action of which
we are acquainted. Stimulating effects undoubt-
edly follow, remotely, in a maj-ority of instances,
but they supervene in consequence of interme-
diate operations taking place in tiie system itself.

87. The opinions of Dr. Jackson are not mate-
rially different from those of Hildenbrand. lie
considers the material cause of fever to be of an
irritative kind; — that it enters the body by the
absorbents of the first passages, proceeding into
the circulation ; and that it produces the febrile
act by irritating the extreme series of organic
capillaries, thereby occasioning subversion of the
existing mode of action, and giving rise to changed
or unnatural forms of action, through which the
different secretions and functions are diminished,
increased, or modified, in various ways and degrees.

88. I am not aware that any opinion has been
promulgated different from those now briefly
stated, up to the period when my own views as
to the pathology of fever were published. Dr.
Armstrong was the most copious and recent
writer on fever at that period ; but, afver an at-
tentive perusal of his work on typhus, and of his
published lectures, I am unable to ascertain
what his vievvs are, or wherein they differ from
those generally entertained at the; time, especially
from those previously publisiied by Dr. Jackson,
excepting that he particularly insists upon con-
gestion, as an important pathological state of
some forms of the disease ; — but in this he
merely followed SrAni,, Juncker, R. Simiencjei,,
Jackson, and some other older as well as con-
temjiorary Continental writers. Upon the whole,
his views, botii pathological and ])ractical, are so
contradictory and vacillating, that a reference can-
not be made to them witii any degree of confidence.

8y. IX. riiiuotoGjcAL iJxAi liS— i. The i^AULV

FEVER — Pa
Changes in Fever.* In approacliing the pa-
thology of fever, there are certain circumstances
to be kept in view: — a. That the chief causes,
particularly malaria and animal effluvia, exert a
noxious or poisonous influence upon the economy :
— b. That tliuse agents, usually tainting the
surrounding atmosphere, when acting injuriously
on the frame, pass along with it into the lungs
during respiration, — the extensive surface there
exposed to the tainted air ; the organic properties,
relations, and functions of this surface ; the con-
stant renewal of the air brought in contact with
it, &c., favouring the action of these agents
in this quarter in preference to any other with
which they can have any communication : ■ —
c. The uncertain period that elapses between the
time at which the morbid impression is made,
and that at which it developes the fully formed
malady ; this period being usually of several
days' duration, often much longer, and occasion-
ally very much shortei-, or almost instantaneous,
especially when the cause is intense and the pre-
disposition strong: — d. The general character of
symptoms constituting the formative and invadmg
stages (§ 33. 35.): — e. The state of function or
vital manifestation throushoul the frame, and the
evident changes in the fluids and solids, in the
various periods of the malady : — f. The compli-
cations and local determinations which supervene
in the course of fever, and the periods at which
they present themselves: — g. The external ap-
pearances and nature of the lesions observed after
death, the seat of these lesions, their number and
extent, and the relation they bear to the symptoms
during life : — h. The obvious difl!erences between
the structural changes and those usually conse-
quent upon common inflammation: — audi. The
frequent absence of any lesion sufficient to ac-
count either for the symptoms or for death.

90. Existing opinions as to the nature of fever,
particularly as respects the changes immediately
following the exciting causes, may be reduced to
the following : — 1st. That fever arises from inflam-
mation, seated, according to some, in the brain,
and, to others, in the digestive mucous surface,
but sometimes aUo reflected upon the brain: —
'2d. That it depends upon congestion of the large
vessels and internal viscera: — 3d. That it pro-
I ceeds from the direct contamination of the cir-
I culating fluids by its material cause, — the nervous
' symptoms, local afifections, inflammations, Sec.

* The views embodied in this chapter, and indeed
throughout the whole ofthis article, which arenot assigned
'i to some otlier writer, especially those on the Nature and
\ Complications of Fever, were promulgated by me on various
1 occasions, and in different works, since 1819. In 1820, 18'Jl,
and 1822, they were published in the Foreis;7t Medical Re-
■ view, the Medical and Physical uournal, the London Me-
dical Repository, and other works (see the Refereyices.). In
i the winter of 1820 and 1821 they were fully stated, in an-
i swer to the views of Dr. CLUTTKRBt'CK, during a discussion
, at the London Medical Society, in wliich tliat able phy-
sician and myself were chiefly en^'aged, for three successive
evenings. They were also fully developed in my lectures
from 1824 to 1827, and in the Westminster Medical Society,
as reported in the medical journals of the day. My expe-
rience of fever had been considerable previously even to the
earliest of these dates. I had treated the most malignant
types and complications of fever in the most pestilential
climates within the tropics ; I had closely observed the
tvphoid forms of it which prevailed in Germany and
France soon after the late war ; and had seen and treated
it as it presented, itself in various parts of Great Britain
since the year 1810. I state this, in order to show that
whatever opinions are here offered, similar to those con.
tained in works which have appeared subsequently to 1821
and 1822, are certainly at least not derived from them.

VO L. I.

THOLOGY OP. 913

appearing in its course, arising from the action of
vitiated blood upon the organs: — 4th. I'hat the
causes iir^t afl'ecl the cerebro-spinal nervous
system, the phenomena of fever arising from
the changes produced by them upon this system :
— and, 5th. That the morbid impression is first
made upon the organic or ganglial nervous sys-
tem, and, owing to the circumstance of tiiis
system actuating the circulating, secreting, and
excreting viscera, is manifested, in an especial
manner, by the changes observed in the state of
vascular action, in the animal temperature, iu
the functions of secretion and excretion, in the
circulating fluids, and in the other functions
which are more or less intimately dependent upon
the ganglial system. (See my views respecting this
system, in the Appendix to M. Richerand's Ele-
7nents of Pliysiologi), p. 556. : and as to its patho-
logical relations, is;c., parlicularly in connection
with the causation of fever, in the Lond, Med.
liepos. vol. xvii. p. 376.)

91. A. The doctrines imputing fever to inflam-
mation of the brain, or of the digestive mucous sur-
face, are subverted by nearly tlie same facts and
considerations: — a. Inflammatory appearances
are not uniformly observed in fatal cases, and
a fortiori cannot generally exist in those which
recover. — b. The lesions which actually exist,
although possessing certain of the characters usu-
ally ascribed to inflammation, are wanting in
others, especially those indicating sthenic, or
purely inflammatory action ; therefore these le-
sions, as stated above (§50), are either not the
consequence of inflammation, or the result of an
inflammation remarkably modified from the com-
mon or idiopathic kind, by some superadded
cause, or by pre-existing changes in the state of
viial power, and of the circulating fluids, as will
appear hereafter. — <?. As the lesions, whatever
their nature may be, are often inadequate to ac-
count for the symptoms, or for death, they are to
be looked upon as contingent phenomena, or
inerely as the grosser portion of those changes,
supervening throughout the frame ; the whole
group of symptoms, their succession, and the
ultimate issue, depending more upon the functional
disorder in the first instance, and the consequent
changes in the fluids and general organisation,
than upon the more palpable lesions of structure,
which occur in different parts from various in-
fluences determining or exciting a predominant
state or grade of the morbid or general action,
during its course, to some particular viscus or
structure. — d. The inflammatory appearances
observed after fevers are not co-ordinate with
those produced by inflammation, nor are they
identical with, or even similar to, them (§ 50.). —
e. These lesions are not restricted to the same
situation or viscus, the inflamm.atory complica-
tions or local determinations whence they proceed,
being chiefly seated in different organs, in differ-
ent cases and different epidemics ; — the stomach
and bowels being principally or predominantly
affected in one case or in one epidemic; the head
in another; the lungs in a third ; the liver in a
fourth ; according to various predisposing, con-
current, and determining influences, as previous
disorder, mental distress, the temperature, season
and weather, the state of the air and of the local-
ity, fatigue, exposure to cold, &c. — /', The ex-
istence of vascular congestion, although more
3 N

914

common than the other inflammatory appearances,
in no way supports this doctrine of fever, inas-
much as it may be present to the extent observed
in most instances of fever, without causing much
disturbance, or it may supervene shortly before
death, or even immediately after dissolution. But
readily granting its existence even early in the
disease, it is merely one of several changes con-
sequent upon others much move important, as
will appear in the sequel (§ 9-2.). — g. Those who
believe in the inflammatory origin of fever do not
aoree respecting the particular viscus which is its
especial seat ; some assigning one organ, others
another : the diversified complications, or pre-
dominance of morbid action in one viscus, or
even in several, over others, in diflferent cases and
epidemics (e), furnishing ihem with the only ar-
guments they can assign in favour of their opi-
jjions. — h. The changes supervening in the
blood, in the secretions, and in the general organ-
isation, during the progress of fever, cannot be
explained by, or reconciled wUh, its origin in local
inflammation. — i. The appearances considered
inflammatory, and to which this class of patho-
loi^ists refer in support of their doctrine, most
frequently take place in the progress of fever,
and seldom at its commencement, as shown by a
careful observation of the symptoms. — k. The
tendency to a favourable termination, and to
natural crises, is much more remarkable in
fevers, than in iiijiammations. — I. The general
characters of fevers vary remarkably in diflerent
epidemics and epidemic constitutions, — a cir-
cumstance not remarked in respect of inflamma-
tions, or in a much slighter degree, — and lastly,
the juvantia and l/edeiUia, in both respectively,
indicate a great difference between them. The
extent to which depletions can be carried in both,
and the frequent benefit derived from very oppo-
site measures in the former, and which are inju-
rious in the latter, are also no mean proof; for
although vascular depletions are often requisite
to control the local determinations or even in-
flammations which supervene in the course of, or
early in, fevers, yet they cannot, owing to the
state of vital power, be carried so far as in pure
inflammations ; and, although evacuations >i-e
most necessary in some epidemics, and tonics or
stimulants injurious, still the former cannot be
practised to the same extent, at least in this cli-
mate, as in the phlegmasia- ; whilst in epidemics
of an opposite character, bleeding is often inju-
rious, and opposite means are required, — a cir-
cumstance not observed respecting inflammation.

92. B. Certain of the arguments now urged
are equally applicable to the doctrine of conges-
tion, or irregular distriliution oj the blood. — a.
The espousers of this opinion do not agree among
themselves as to the chief scat of congestion ; but
granting that congestion very frequently, or even
generally, exists at some period of the disease,
especially in the large vessels adjoining the heart, it
is only one link of the chain of morbid causation
and action, itself being caused and attended by, as
well as inducing, other changes equally import-
ant. Besides, iliose instances which occasionally
occur of remarkably great congestion of the
large vessels of internal viscera, as from asphyxy,
&c., are not followed by the phenomena of idio-
pathic fever ; and although, as I shall have to
show hereafter, many of the worst forms of fever

FEVER — Pathology of,

are attended by congestion as one only of the
various changes that characterise them, yet others
of a slight kind, as ague, are accompanied with
still more remarkable congestion during the cold
stage of each paroxysm, without further mischief
than the subsequent reaction which it aids in
developing. — t. When congestion becomes con-
siderable, it is referrible to the noxious influence
of the exciting causes exerted primarily upon the
organic or ganglial nervous system, and conse-
cutively upon the vascular system ; the action of
the heart being tliereby weakened, and the tone
and resiliency of the vessels impaired ; and hence,
when the morbid impression on the former is very
intense, the effects produced upon the latter are
also severe, congestion being only one of these
efl^ects. — When, in consequence of the persist-
ence of the morbid impression, or change prima-
rily produced in the ganglial nervous system, the
effects upon the heart and vessels continue, the
resulting congestions, with the other concomitant
lesions, either cannot be removed, or are re-
moved with difliculty ; the heart being rendered
unable to exert a due reaction in order to over-
come them ; the vessels being incapable of that
degree of tonic resistance necessary to a healthy
circulation and a regular distribution of blood ;
and the capillaries being impaired in all their
functions, owing to the state of nervous power
influencing them, and of the circulation in them.
Thus congestion is established as one of the more
evident lesions tiiat follow the primary changes in
fever, — but only as one of subordinate importance.
93. C. To the doctrine that imputes fever to
the direct contamination of the circulating fiuid
bii the material cause, the following objections
may be urged : — a. The febrile cause, acting as
a poison, should instantly affect the appearance
of the blood if it made its first and principal at-
tack in this way ; but, when the cause is ener-
getic, the effecls, instead of progressively and
gradually appearing, as they necessarily would
do in this case, instantly manifest themselves in
the functions of the nervous systems, more espe-
cially of the organic nervous system, and in the
functions of the organs actuated by it. I shall,
however, have hereafter to show, that the blood
is the next animal constituent that becomes af-
fected, although frequently in no very manifest
manner, at first, especially when disease slowly
developes itself upon the exciting causes. — It
should not be overlooked, in our researches on
this sul)ject, that agents which especially aflfect
or depress the organic nervous influence, pro-
duce also co-ordinate effects upon the vascular
system and on the blood itself, owing to the inti-
mate connection subsisting between these two
systems.— /). In cases where the morbid impres-
sion lias been already made, either by malaria,
or by infectious effluvia, the full developement of
the disease may be prevented during the first or
second stage, by substances which produce a
powerful restorative or tonic action on the nerv-
ous systems, particularly that of organic life, —
an efiect that could not result if the blood were
the primary or principal seat of the disease. A
powerful stimulant or tonic will instantly cut
short an ague, even when given at the commence-
ment of the cold stage, — an effect that would
vainly be looked for, if its chief seat were in
the blood. — c. The phenomena and progress of

FEVER — Pathology op.

9i;

those diseases, as scurvy and purpura haEsmor-
rhagica, ia which tiie blood is especially altered,
furnish analogous indications that it is not the
primary nor sole seat of fever, but that it is
merely secondarily affected, to an extent vary-
ing remarkably in different fevers and epidemics ;
and that the change in this constituent is only a
part of the general slate of disease — is only
one of tiie many lesions forming idiopathic fever.
— d. The abatement of fever after crises has
been considered as evidence of the primary affec-
tion of the blood. Granting that morbid matters
carried into the circulation, or generated in it
from a morbid seminium, are eliminated from it
in the form of crises, or by less manifest evacu-
ations, still this is no proof that the blood is
primarily or chiefly changed ; but merely that it
is one of the animal constituents affected, more

chiefly, concerned in the production of the dis-
ease j but may be readily solved by means of
the nervous system of organic life, if we take
into consideration its functions and structural re-
lations, especially with the vascular system, the
circulating fluids, and the excreting viscera. (See
Disease, §65.) — rf. I'he early lesions, whether
of function or of organisation, characterising the
first as well as the advanced periods of fever,
cannot be accounted for by assigning the cere-
bro-spinal nervous system as the primary seat of
the disease ; for, — 1st. As this system cannot
influence the action of the heart and the state of
the vessels, excepting through the medium of the
organic nervous system, and thus only to a very
limited extent, changes in it do not explain the
alterations of vascular action, and still less the
vitiation of the blood , — 2dly. As it does not con-

particularly in certain forms of fever, as the erup- i trol animal heat, so it cannot induce those remark
live and infectious ; for we often observe critical I able extremes and morbid states of temperature
discharges occurring without any permanent distinguishing the malady ; — 3dly. As it does not
benefit, as in remittents ; and recovery taking j supply, nor materially influence, secreting sur-
place in others without any crises. Whilst, tiiere- ! faces and glands, so it cannot give rise to those
fore, a numerous class of fevers, especially the | early changes of function which they present,
periodic and simple continued, present little or nor to those lesions of structure which they often

no evidence of contamination of the blood
their course, unless they change their cliaracters
and become complicated, a different class, as the
adynamic and malignant, presents as little evi-
dence of this change at their commencement ;
the vitiation of the circulating current appearing
either consecutively upon the morbid impression
made upon the nervous system of organic life,
or nearly contemporaneously with this impression,
and in a less manifest degree, although progres-
sively advancing, owing to the affection of this
particular system, and its infliience upon the cir-
culation. But the arguments which are about to
be offered in support of my views as to the primary
lesions in fever, will more clearly show in how far
the blood is concerned in causing many of the
phenomena of fever in its more severe forms.

94. D. The doctrine that Ihe causes of fever
first ajf'ect the cerebrospinal nervous sijstem is in-
validated by the following considerations: — a.
This system either does not send nerves, or it
supplies but few nerves, and those often indii'ectly,
to the organs especially or essentially affected in
idiopathic fevers, as the heart, blood-vessels, se-
creting viscera, lungs, &c. — b. 1'hat the chief
avenues to this system open to the invasion of the
exciting causes, are the organs of sense and the
cutaneous surface. Of these, the sense of smell is
the principal. Although this sense is evidently
impressed by several of these causes, when acting
intensely, and admitting that the brain is somev/hat
affected in consequence, still the effect produced in
this quarter seems inadequate to explain the chief,
and far less the whole, of the early phenomena. —
c. In some instances, the intense operation of the
effluvia generating fever, has produced its effects
almost instantly, and even caused death itself
with equal rapidity, — a result, which the total
annihilation of the cerebral functions could not
produce ; but which would necessarily follow the
interruption or suppression of the influence trans-
mitted to the heart and lungs by the nervou

subsequently experience ; — •4thly. As it does not
j materially affect the actions of assimilation and
nutrition, so it cannot occasion the remarkable
I changes they present in fevers ; ■ — and, 5thly. As
i it does not present aberrations of function, in the
[ slighter and simpler states of fever, equal in de-
j gree to those manifested by the viscera chiefly
j supplied by the nerves of organic life ; and as,
I when such aberrations supervene in a remarkable
j manner, they are generally consequent upon
those of the organic nervous and vascular sys-
tems and of the blood itself, so the primary im-
pression made upon it must be much less ener-
getic than is supposed by those who support the
present doctrine ; although I may grant that it
partakes, in some measure, or in some forms of
fever, of the morbid impression especially and
principally made upon the nervous system of or-
ganic life, and extended to the organs which it
actuates.

95. E. That the efficient agents of fever act pri-
marily and chiejiy upon the organic or ganglionic
nervous system, is evident from what has been now
adduced ; and is further proved by the following
facts and inferences : — a. The intimate connection
of this system with the organs of circulation, re-
spiration, assimilation, and secretion, on the one
hand, and with the cerebro-spinal nervous system
on the other, and the influence exerted by it over
theirfunctions in health, are sutHcient to show, that
morbid impressions made upon it must necessarily
affect all the organs and parts, with which it is re-
lated.— b. The functions primarily disordered in
I fever, and chiefly affected in its course, are pre-
cisely those which are especially subjected to the
influence of this system. As we cannot, consist-
ently with our knowledge of the animal actions
in health and in disease, infer that a grave and
permanent disorder of any one function can exist,
unless either the influence that actuates it is im-
paired, excited, or otherwise altered ; or the struc-
j ture of the organ, which is the instrument of the

system of organic life.^rf. The generation of | function, is more or less affected ; we are neces-
fever within the body itself cannot be explained sarily led to inquire as to which of these sources
upon the supposition that the cerebro-spinal nerv- the disorder is to be imputed. Having inferred
ous system is primarily and solely, or even ' from the nature and extent of the disorder, from

3 N 2

916 FEVER— Pa

the causes in which it arose, and the suddenness
and manner of its occurrence, as well as from
various other circumstances, that it does not con-
sist of lesion of structure, we are therefore com-
pelled to adopt the former alternative, and, from
the kind of disorder, to infer the manner in which
the influence actuating the organ is affected.
Thus, observing that respiration, circulation, se-
cretion, and animal heat are primarily and espe-
cially disordered at the commencement of fever,
and that various other morbid phenomena are
consequently produced, and finding no structural
or local change to account for the affection, ue
refer it to the state of the influence which actuates
these functions. Anatomical and physiological
evidence concur in showing that the nervous
system of organic life is chiefly concerned in the
production of those functions ; and therefore it
may be inferred that this system is first impressed
by the causes of the disease.

96. But it is not merely requisite to show the
particular system first affected, but also to ascer-
tain, as nearly as possible, the nature of the
affection. This, however, can be only a matter
of inference from the kind of disorder manifested
in the functions especially subjected to the in-
fluence of this system. What, therefore, is the
general character of the disorder which these
functions first evince 1 — 1st. The respiratory-
actions are inadequately performed, volition being
often exerted in order fully to dilate the lungs,
and the changes in the blood ai'e imperfectly pro-
duced ; — 2dly. The action ofthe heart is weakened,
and the tone of the pulmonary vessels- lowered,
so that the circulation is languid, irregular, &cc.,
and congestion supervenes; — 3dly. Secretion and
excretion are impeded or interrupted, animal
temperature diminished, and ail the functions
indicate at first depression or suppression of the
organic nervous influence. 'J here is, however,
reason to suppose that this influence may not only
be depressed, but that it may be otherwise alteied,
according to the cause which afl'ects it, par-
ticularly by specific infectious miasms. It is
chiefly to this circumstance, that the opinions of
Jackson, Frank, Hildenbrand, and others, re-
specting the irritation excited by the material
cause of fever, is to be imputed. Whether the
alteration in question be called an irritation, or
any tiling else, is immaterial, if the term adopted
convey any idea of what the change is, in most of
the circumstances in which it occurs. But if by
this irritation be meant a form of excitement, the
term is applicable only to the state of vascular
action often consequent upon, and attended by,
the alteration of nervous influence, and not to the
slate of the influence itself. The whole that we
know of the matter, from observation of the ear-
liest phenomena, is, that the change evinces
diminished power or influence of the system of
nerves actuating the organic functions, and very
frequently an otherwise altered or morbid state
of this influence which cannot well be described,
but which is vaiiously modified in different fevers,
and is generally attended by depression ; these con-
ditions still continuing in diverse grades, although
vascular reaction supervenes, which, when it be-
comes excessive, increases them, atrd, in con-
sequence, hastens on disorganisation. From this
it will appear, that the exciting causes of fever
first depress or ollierwise alter, or both depress

TirOLOGY OF.

and alter, the healthy influence exerted by tiie
nervous system of organic life. That they pri-
marily irritate or excite this system does not
appear from the phenomena, unless either of these
states associates itself with some other morbid
condition which deflects it from its usual forms;
but of this we have little proof, unless it be found
in the stage of reaction. 'Jhis much, however,
is apparent, — that certain causes seem to depress
the organic nervous influence more than others ;
and tliat some alter it more from the merely dy-
namic states, and impress it with a specifically
mor'bid character.

97. But, whilst disorder of this influence is
thus considered the chief and primary constituent
of the morbid impression made by the causes of
fever upon the economy, it may be a»ked. Is tiie
impression entirely limited to this quarter? or are
the cerebro-spinal influence, and the cir'culating
fluid itself, also partially and primarily affected? —
1st. As to the former of these, it may be inferred,
from a consideration of the circumstance of the
nerves of one of our senses being extended over
the upper part of tlie respiratory passage — the en-
trance to a most important and vital organ — in
order to convey, by their reports, intimations of
the presence of such gases or vapours, as, if re-
ceived into the lungs, would prove injurious,
that the more intense causes will act in some
measure upon the brain, although in a com-
par-atively slight and evanescent manner. The
lungs evidently digest the air received into them,
as much as the stomach digests the food ; and the
entrances into both organs are guarded by two
sentinels — the senses of smell and taste — taking
cognizance of whatever passes into them. But
in cases where injurious effects follow the in-
gestion of hurtful matters, is it in the stomach or in
the nerves of taste that the morbid impression is to
be looked for? and if it be in the former, and not in
the latter, that they are to be found, no moie should
we infer, as heretofore, that the morbid change is
first produced on the brain, and not on the nerves
of the lungs, when noxious effects follow the re-
spir-ation of a tainltd or infectious air — recollecting
always, that respiration does not mean simply the
passage of air into and out of the lungs, but the
actual digestion of this air by them, the important
changes excited by its constituents upon the blood
and upon the organic nervous influence, and those
effected by this influence upon the blood, and upon
the air received into the organ.

98. From various considerations and researches
into the subject, in diflFerenl climates, I infer, that,
although the more intense causes may affect the
brain, and thereby heighten and accelerate the
effects upon the heart and stomach arising from
the impression made upon the organic nervous
system, jet their action in this quarter is evan-
escent; and, as I have shown (^94.), insirffi-
cient to explain the phenomena. .Judging from
my own sensations on having inspired an air so
loaded with infectious effluvia as to be remar-kably
offensive to the smell, the mor-bid impression was
fir-st sensibly felt in the lungs themselves ; numb-
ness, weight, or oppression in the chest, was in-
stantly felt ; fre<|uent forcible inspir-ations were
made, and continued for long afterwards to be made,
in order fully to dilate the lungs, which felt as if
they were partially deprived of their resiliency ;
the pulse became weak, and the animal tem-

FEVER — Pathology or

perature was lowered ; but tlie functions of
the brain were not impaired. In this case, the
lungs were certainly the first organ affected, and
abiiost instantly afterwards the action of the heart
and the functions of the stomach. Instances,
moreover, are not infrequent, in which the febrile
cause has made its impression, and the patient
has been removed from every chance of having
that impression renewed ; and it has not, until the
end of weeks, and even months, given rise to its
specific effects. In this case, is the cerebro-spinal
system, or the nerves of organic life, or the blood,
affected, and the seat of the latent, or almost la-
tent impression ? I have observed the phenomena
occurring during this period, in cases of rabies,
of small-pox, of measles, of scarlatina, of typhus,
and of marsh or periodic fevers ; and in every in-
stance they have not indicated any affection of the
cerebro-spinal system, but disorder more especially
of the functions depending upon the nervous sys-
tem of organic life. This period, moreover, is
frequently shortened or prolonged ; the symptoms
attending it, diminished or aggravated ; and the
impending malady even prevented, by means
which act more especially upon the latter system.
Hence the importance of this inquiry ; for by
arriving at just conclusions as to the constituent
pait of the economy first affected, and the mode
in which it is affected, we are the more enabled to
guard against lever, or even to remove the morbid
impression after it has been made, and before it
has developed itself into open disease.

99. The opinion that the morbific causes even
partially operate by first 'inducing changes in the
blood, cannot be reconciled with the arguments
already stated, and with others which may be
offered, although there are circumstances which
seem to favour it, the most forcible of which is
the piopagation of certain diseases by means of
a virus, and the long period a virus or morbific
miasm often takes to incubate or produce its
full effects. But if we look closely into these
very circumstances, we shall find that they are
not so conclusive of the opinion they are ad-
duced to support as is supposed ; for in the
case of an inoculated virus — the most favour-
able to the doctiine of primary contamination of
the blood, — the consequent infection will be
hastened by whatever depresses, and retarded by
whatever exalts without exhausting, organic
nervous power ; it will be accelerated by the
usual concurring and determining causes, as a
close, foul, moist air, by cold, by excesses of any
kind, and by despondency ; and it will be re-
tarded or even prevented by a dry and pure air,
by the use of tonics, or what communicates
power and increases vital resistance to the in-
vasion of a noxious cause. The phenomena,
also, observed between the application of the
cause — whether a contagious virus, an infec-
tious miasm, or an emanation from the soil —
and the explosion of the malady, however pro-
longed the intervening period may be, cannot be
referred to any alteration of the circulating fluids,
that may not be shown to be entirely dependent
simply upon the existing state of organic nervous
or vital power. In rabies, in which the longest
formative or incubating stages is observed, symp-
toms referrible to the organic nervous system are
the first to appear, and the functions depending
upon this system are those which especially lau-

917

guish during this period. The same is observed
in agues, and in the specific infectious maladies.
I5ut even granting that a portion of the animal
miasms passes into the blood, and vitiates it, the
morbid impression is not the less made by them
on the nerves of the organ, and not the less un-
productive of the principal part of the phenom.ena
more immediately supervening. But this topic
is more fully illustrated in the article Infection.

loo. In order to show what appears to be the
common procession of phenomena consequent
upon the impression of the exciting causes, I
shall presume that a person in health, with no
particular organ especially predisposed to disease,
is exposed either to infection by the effluvium
from a patient in typhus, or to the operation of
marsh exhalations. In these cases the exciting
causes, floating in the air, are received into the
lungs, and, if they be concentrated or enercetic,
they slightly, although they may sensibly, affect
the organ of smell in their passage. But their
chief action is exerted ujion the nerves of the
lungs themselves. It may even be admitted
that they also partially affect the blood during
the digestion of the air which is their vehicle
by the lungs : of this, however, we have no satis-
factory proof; and as their direct operation on
the nervous influence of this organ is sufficient
to produce all the phenomena, it is unnecessary
to assign an additional agency to explain
them. The morbid impression having been thus
principally made in this quarter, it is necessarily
extended to those organs which are chiefly sup-
plied with the same system of ner\es; and thus the
lungs, the heart, and blood-vessels, the digestive
organs, and the secreting and assimilating func-
tions, almost immediately experience the eflfects.
As respects the lungs, their vital resiliency is
somewhat impaired ; hence the frequent and
forced inspirations ; and the changes efl^ected by
the air upon the blood, which, although chemi-
cal, are partly also vital or influenced by the
organic nervous power of the organ, are more or
less impeded. This latter fact I endeavoured to
put to the test of experiment. In a paper written
at the commencement of 1815, 1 had endeavoured
to prove that many of the phenomena of fever
were referrible to diminution of the changes pro-
duced in the blood by respiration ; and in 1817,
when engaged in ascertaining the alterations
efl^ected in the respired air, under various circum-
stances, I found, in two cases of ague and in
one case of remittent, just before the cold stage
of the former, and near the first accession of the
latter, that the changes in the resnired air were
diminished from one fourth to one third their
usual amount. These expeiiments were too few,
and not sufliciently varied, but they serve to
illustrate the subject.

101. The efl^'ect, then, of the morbid impression
on the organic nervous influence of the lungs be-
ing to diminish the changes caused by respiration
on jthe blood, and to render the pulmonary circu-
lation more languid, one source of the alterations
observed in this fluid in the early stages of fever
is made manifest. These alterations, at this
period, seldom extend beyond a darker or more
venous appearance of the blood than usual, the
crassamentum being often soft and imperfectly
separated from the serum. Almost contempo-
raneously with the effect upon the lungs, the
3 N 3

918 FEVER —

action of the heart and the tone 'of the vascular
system generally, become diminished. Hence
the increasing languor of the circulation, the in-
ternal congestions, and the deficient secretion
and excretion ; the=e last, however, depending
as much upon the state of organic nervous in-
fluence as upon the circulation in the secreting
organs. The congestions of the large vessels, and
the changes in thequantityand quality of the blood,
consequent upon deficient secretion and excretion
of its watery and noxious constituents, having
reached a certain pitch, bring about vascular re-
action, if the organic nervous or vital iufluence
be not too far reduced, or otherwise altered, by
the exciting causes ; but when the morbid im-
pression has been very intense, and the more
immediate changes very great, reaction either
takes place imperfectly, or does not supervene at
all in extreme cases, vital power being insuffi-
cient to develop increased vascular action. Such
appears to be so far the progress of the pheno-
mena, as respects the organic functions. 'Jlie
cerebro-spinal manifestations are also early af-
fected— in a slight and passing manner by the
impression made by the noxious effluvia on the
nerves of smell ; but much more seriously by
the influence exerted by the organic nervous
system upon the brain and spinal cord, or ex-
tended from the former to the latter, and conse-
cutively by the changes in the states of vascular
action and of the blood.

102. F. Consecutive Pathological States. — AVhen
reaction thus supervenes upon either of the spe-
cific causes mentioned above (§ 100.), it may be
variously modified according to the association of
various grades of increased vascular action and
of diminished or otherwise altered nervous or
vital power, and to the local determinations or
complications attending it. When, in conse-
quence of the nature and intensity of the causes,
relatively to organic nervous energy, the former
do not depress the latter beyond the power of
reaction, whereby the morbid impression is ef-
faced, and the effects upon the different organs
and on the blood are removed, the more sthenic
forms of fever take place, vascular action is high,
and nervous or vital power not greatly impaired.
But when the nature and intensity of tlie causes
are such, in relation to vital power, as greatly to
depress or otherwise change it, the more adynamic
forms are produced, and vascular reaction is much
less energetic, the depressed state of vital power
being a prominent and increasing feature through-
out the disease. In some of the latter forms,
vascular action becomes either excessive or tu-
multuous relatively to the state of nervous or
vital power, owing to the effects produced by
the secondary changes in the blood, upon the
heart and blood-vessels, and on the organic nerv-
ous system, and rapidly exhausts itself, or passes
into disorganisation ; and in others reaction does
not supervene, the tone of the vessels being pro-
gressively diminished, and the blood with the
soft solids more and more changed. Hence re-
sult, in the last stages, discolouration, softness,
flaccidity, lessened vital cohesion, and infiltration
of membranous and parenchymatous tissues,
with effusions of fluids from mucous and serous
surfaces.

103. G. Local determinations and complicatio72S
may attend fever from an early period, or appear

Pathology or.

at any time during its course, or even at its de-
cline ; owing to the circumstances influencing
its terminations (§ 47.), but especially to the
following: — 1st, To pre-existing functional or
structural lesion of an organ or tissue; — 2d. To
the predisposing and concurring causes; — 3d.
To the nature and intensity of exciting and spe-
cific causes ; — 4lh. To the character of the
epidemic ; — 5th. To various determining or con-
secutive influences; • — • 6th. To the efl^ects of re-
action upon certain viscera; — 7th. To interrupted
excretion; — 8th. To the morbid states of the
circulating fluids exciting disease, quickly passing
into disorganisation; — and, 9th. To injudicious
treatment.

104. a. Pre-eiisting disease of a part, especially
when seated in the alimentary canal, brain, or
lungs, aggravates fever and gives it a modified
form, A loaded or congested state of the liver,
also, in respect either of its vascular system or
of its biliary ducts, often disposes to fevers, and
imparts to them a bilious or gastric character.
Various lesions observed after fever, and some-
liiTies imputed to it, have existed previously, or
have been merely aggravated by it, particularly
those seen in the pleura and in the liver, and
some of those found within the cranium.

105. b. The predisposition arising from the use
of unwholesome water and food especially favour
the low types of the disease, with lesions of the
mucous follicles and membrane, which can
hardly be said to be inflammatory, and con-
tamination of the blood ; that from excessive men-
tal exertion or anxiety, increased afl^ection of the
brain ; and that from gross living and intem-
perance, complications with disease of the liver,
stomach, and bowels. The cancurring deter-
mining, and consecutive agencies, not merely de-
velop the action of specific causes, as shown in
the article Disease (§ 61.), but they also com-
plicate the fever produced. Thus cold both
aids the operation of other causes, and occasions
increased pulmonary disorder ; and the influences
of season, weather, climate, confined air, &c.
cause aggravated aflTections of the intestines, or
of the liver, of the brain, of the respiratory pas-
sages, or of the circulating fluids.

106. c. The nature and intensity of the chief or
specif c causes often determine the complication. —
Malaria most frequently causes congestion of the
liver and spleen ; the emanations from persons
afl^ected by low fevers, aggravated affections of
the digestive canal, of the brain, atid often also
of the lungs; and the exanthematous eflluvia,
their specific eruptions, and disease of the digestive
mucous surface and pulmonary organs; these
local aggravations of the malady appearing chiefly
where the causes have acted most intensely rela-
tively to the state of vital power and predisposi-
tion, or have been aided by concurring influ-
ences. The complications in fevers produced by
the former of these causes are the least severe, and
those arising from infection the most dangerous,
owing to tiie slates of vascular action, of vital
power, and of the circulating fluids generally ac-
companying them ; the first of these states being
often excessive, or of an unfavourable kind ; tlie
second depressed or otherwise altered ; and the
third more or less changed from its natural con-
dition, or even contaminated.

107. d. The complications are diflcrcnt in re-

FEVER — Pathology of.

919

spect of their seat, nature, ami severity, and the
states of local action, of vital power, and of the
circulating and secreted fluids, in different epi-
demics, often independently of season, climate,
weather, and locaHty, although these have much
influence in many that are limited in their dif-
fusion. Consequently, the complications are
much more prone to pass into disorganisation in
one epidemic than in another; but those occur-
ring in the epidemics of warm countries are more
uniform in their character and seat than those
observed in the epidemics of temperate countries.
It is chiefly upon a close observation of all the
circumstances connected with their complica-
tions, that a successful treatment of epidemic
fevers depends.

108. e. Reaction or vascular excitement occa-
sions local determinations and complications,
■which generally present more or less of an in-
flammatory character; the brain, alimentary
canal, the liver, or lungs, most frequently being
the seat of the predominant affection, and evinc-
ing the effects of it after death. If, however,
vascular action far exceed vital power, the super-
induced local affection seldom presents many
of the truly inflammatory characters, as shown
above (§ 50.), and it often rapidly passes into dis-
organisation, or gives rise to sanguineous, serous
or sanious effusions, but very rarely to the eflTu-
sion of lymph or of albuminous fluids, unless in
the most sthenic state of the disease.

109. f. Interrupted excretion induces compli-
cations frequently at far advanced periods of
fever, especially implicating the bowels, the liver,
and brain. They are generally of a most severe,
although often insidious form, owing to their
association with depressed or exhausted states
of the constitutional powers ; these states having
been more or less concerned in causing the im-
perfect excretions, and with alterations in the
blood, which the latter has contributed to pro-
duce ; and they often quickly pass into struc-
tural lesions, not so much from tlie inflammatory
or increased vascular action which attends them,
as from the septic and contaminating effects of the
retained excrementitial matters upon the tissues,
and from their depressing influence on the nerves
of the part.

110. g. Morbid states of the hlood induce the
most dangerous complications, and, like the pre-
ceding, most frequently at advanced periods of
the disease, the mucous membranes, Peyer's and
Brunner's glands, the brain, and the lungs, be-
ing the parts chiefly affected. As the changes
in the blood are chiefly caused and attended by a
depressed or altered state of organic nervous
power, the local affections caused by them, whe-
ther they be characterised by increased vascular
action or by simple congestion, generally pass
quickly into structural lesions, especially of the
mucous membranes, or give rise to effusions of a
sanguineous, foul, dark, or sanious fluid, either
from these membranes or from serous surfaces.

111. h. Injudicious rpgimen and treatment dixe,
much more frequent causes of aggravated local
lesions in fever than is supposed. External heat
or cold inappropriately emj.loyed ; the improper
use of stimulants and tonics ; the neglect of suit-
able evacuations early in the disease ; and the
use of acrid or irritating purgatives; frequently
occasion or heighten predominant affections of

the intestinal mucous surface, of the liver, and of
the brain. Excessive doses, or the prolonged
and inappropriate exhibition, of antimonials, espe-
cially tartar emetic, in the manner often resorted
to in Italy, have evidently caused serious irri-
tation and ulceration of the mucous membrane
of the stomach and bowels, without producing
either sickness or vomiting after its first operation
in this way. The too early and free use of bark,
or of quinine, in periodic fevers, or before morbid
secretions have been evacuated, and congestions
of the liver removed, has often induced serious
inflammation and structural change in the liver.

112. ). It must be evident from the foregoing
that the predominant affections or complications
of fever must vary, not merely in their seat, but
also in their intimate nature, in its different types
and forms; the low and adynamic states being at-
tended by those which are the least inflamma-
tory, the most imperfectly indicated by the
symptoms, and the most prone to pass quickly
into disorganisation ; this event, indeed, often be-
ing the first indication of their existence. It re-
quires, tlierefore, a close scrutiny of the various
functions to detect them, especially when they
are seated in the intestinal canal and lungs. Al-
though the complications in the former of these
situations may be indicated by tenderness on
deep pressure, by distension or fulness of the
abdomen, and by the appearance of the evacu-
ations, yet they may be present, nevertheless,
without any such signs, even the stools evincing
no very material disorder. When the stools are
copious without any amendment, and particu-
larly if they continue so, the pulse being
weak, soft, and very frequent, and the skin
harsh, lurid, or discoloured, we should dread
the presence of disease of the digestive mucous
surface and follicular glands ; and if these
symptoms be attended by flatulent distension of
the abdomen, and by blood in the evacuations,
this complication most probably exists. The com-
plication with disease of the substance if the liver
is often equally obscure in the adynamic varieties,
more especially when the brain is much affected ;
for, although fulness and tenderness in the region
of the organ, or a rising of this viscus high into
the right thorax, as detected upon percussion, may
sometimes be present, yet serious lesions may su-
pervene without any of these indications being
observed.

113. k. ]Most serious disease and even disor-
ganisation may affect the lungs, particularly in the
low forms of fever, without cough or pain being
complained of. This organ, therefore, should
receive due attention, and its state be inquired
into by percussion and auscultation, which will
very often detect bronchial affection, and be-
patisation or infiltration of it, although these
lesions may be either imperfectly or not at all
indicated by the usual symptoms. When the
pulse is very soft and weak ; the lips, tongue, and
skin qre dark, lurid, or livid; the delirium is low
or muttering; and the respiration is hurried and
laboured ; the changes effected on the blood in
the lungs are evidently impeded, and the cause
exists either in depressed nervous influence, or
in more palpable disease of the respiratory ap-
paratus, or even in both ; for the latter is often
the indirect consequence of the former. In the
low forms of kver, the changes that supervene

3 N 4

920

in the bronchial surface, or in the substance of
the lungs, as well as those that take place in the
alimentary canal, possess but little of the truly
infiammatory character, excepting capiirary in- ^
jeetion, sometimes with infiltration of a sangui-
neous serum into the adjoining tissues, or with
efTusion of a similar fluid from the injected sur-
faces.

■ 114. I. Tredominant cerebral affection l6ss fre-
quently amounts to actual disease, or passes into
disorganisation, in fevers, than has been very ge-
nerally supposed; the disorder most commonly,
existing in this quarter, in low Tevers especially,
being more functional than structural — depending
more upon the state of organic nervojjs influence
in the organ, than uppn inflammatory or other
lesions. The effusions and cqngestions observed
in fatal cases, are probably in great measure yost
mortem changes ; and, even granting their exist-
ence during life, they are often insufficient to ac-
count for the symptoms referrible to this part.
Whatever the alterations existing within the cra-
nium may be, there can be no doubt that, when the
affection of the brain is very predominant, lesions
in other situations are very seldom complained of,
and with difficulty detected. The above complica-
tions, as well as others casually alluded to, will be
more fully elucidated, vv-hen the particular species
of fever come under consideration.

115. m. It is evident, from what has been
stated respecting the pathology of fever, that a
most scrupulous and minute inquiry into the
slates of organic nervous or vital power, evinced
in all the functions, and of vascular action and
tone — into the evidence of local congestions, or
predominant visceral affection — into the existing
functions and lesions of individual organs — and
into the conditions and appearances of the secreted
and excreted fluids, of the blood, and of the solids
— should furnish the basis of our curative inten-
tions, and direct the choice of individual means.
Norought it to be overlooked, that the mutability of
fever is so remarkable, that the pathological states
actually existing at the time of investigation, may
change their characters and even their nature, in
an hour or two afterwards ; that each successive
stage is very different in the grouping of the phe-
nomena, and in the conditions of vascular action
and vital power, from that which preceded it ;
that serious complications or predominant affec-
tions may suddenly arise and become almost
irremediable in a very short time ; and, conse-
quently, that the treatment devised should be
promptly administered ; and prescribed either with
reference to the usual successions of morbid states,
or merely for a period, in which no very important
change is likely to take place.

116. X. Gi'.Ni.iiAL Tkf.atmext. — The treat-
ment of fevers is prophiilaclic and curative. The
former has been little attended to by writers, and
but imperfectly understood ; and the latter has too
frequently been directed, v^illiout due attention to
pathological states, and often with an imperfect
knowledge of their seat and nature, liefore a
general view of the curative treatment of fevers is
exhibited, a few remarks on their prevention will
be necessary.

117. i. I'noiMivi.ACTic INIkans. — The pre-
vention of fever should have reference — 1st, to
the avoidance of its causes, and the seclusion of
those fiulfering infectious forms of it; — 2dly, to

FEVER— General Treatment,

means which may

destroy or dilute its more
specific agents, and counteract their operation ; —
3dly, to measures calculated to fortify the frame
against the impression made by them; — 4thly,
to means which may prevent the development ol
disease after the impression has been made ; — and,
Sthly, to a treatment calculated to arrest its furtiier
progress at a period when arrest is still within the
reach of art. The^Vst, second, and third of these
are so fully insisted upon in the articles Endemic
Influence (§20.) and Infection, that little
further -need here be advanced respecting them ;
the remarks offered under these heads having
especial reference to periodic and infectious fevers
respectively.

118. A. Measures calculated to fortify the
frame against the impression of the exciting catises

often succeed in preventing Jficr, especially when
these causes are of casual occurrence and of
short continuance, or when their presence is
known or suspected, and their nature tolerably
understood. 15ut in epidemics, particularly those
which are pestilential, where these conditions do
not obtain, means of this description generally
fail, their causes being more generally diffused,
and in almost continual operation. The measures
resorted to, in order to resist the causes of fevers,
should have reference to the habits and circum-
stances of the individual, to his constitutional
powers, and his habit of body. All the predis-
posing causes should be carefully avoided. Vas-
cular plethora ought therefore to be reduced, and
vital power and resistance promoted where it is
lowered. High irritability, vascular fulness, and
rigidity of fibre, seem to predispose to several
pestilential epidemics, especially to yellow fever ;
and, although these states will often resist for a
long time the operation of marsh exhalations,
particularly in temperate countries, yet such is
not generally the case as respects persons mi-
grating from cold to hot climates ; for they com-
monly experience, in consequence of these states,
niuch more violent attacks of fever than those
who have been seasoned to the country; the fever
in them often evincing inordinate excitement and
re-action, and consequently assuming characters
which have caused it to be confounded with the
true or epidemic yellow fever. The most effi-
cient resistance to the action of the causes of fever,
is afforded by a due performance of all the or-
ganic and mental functions. Hence, whatever
over-excites or depresses them will be injurious.
Confidence, continued mental occupation, and
moderate excitement, are especially efficacious
in resisting the causes of most fevers. There is
a moral courage sometimes possessed by persons,
the weakest perhaps in respect of physical power,
that enables them to resist infectious and epidemic
influences, more successfully than the most robust,
who are not thus mentally endowed.

119. 'J"he (piarter in which the most active
causes of fever invade the system should not be
overlooked, for the casual or temporary operation
of infectious eflluvia, when their presence is anti-
cipated, may be easily and certainly guarded
against by the use of the aromatic spirit of vinegar,
or by keeping a small piece of camphor in tlie
mouth. When terrestrial emanations are pre-
sent, care should be taken not to be exposed to
the morning or night air, especially witii an empty
stomach, as they arc then most concentrated ; nor

to sleep in apartments upon or near to the ground
floor, for the body is most susceptible of their in-
fluence on these occasions. When such precau-
tions cannot be used, a cup of coftee should be
taken before going abroad, and a pill with two or
three grains of qumine and one or two of camphor
at bedtime ; but tliese means are of most benefit
in cases of short residence in unhealthy localities,
for which occasions I have directed the following
pills with success : —

No. 220. B Camphora? rasjE 3j. ; QuininiE Sulphatis
3 ss. ; Pilul. Galbaiii Comp. 3j-; Pulv. Capsici gr. xvj,;
Balsami Canaiieiisis, q. s. M. Fiant PiUiIae xxxvi., qua-
rum capiat duas vel tres hora somni. _^^

120. The system should not be stimulated by
wines or spirits, unless better means are not
within reach, and even then these should be used
in very moderate quantity, otherwise exhaustion
and its attendant predisposition will result from
them. The same objection is applicable to cigar
smoking ; care ought also to be taken not to in-
hale the breath, or the effluvium proceeding from
under the bed-clothes, or from the evacuations of
persons in continued fevers, whatever means of
resistance may be employed ; but more especially
with an empty stomach, or in states of debility or
exhaustion, should this precaution be observed.
During the prevalence of epidemics, of which in-
fection is one of the chief elements, or causes of
diflfusion, strict seclusion can alone be depended
upon. Still, other means should not be neglected.
It has been supposed, that external irritation, or
the discharge from an issue or seton, will prevent
an attack of epidemic or pestilential fever ; and
cases have occurred to countenance the opinion,
but they are not suflficiently conclusive. Upon
the whole, a due regulation of the digestive, the
secreting, and the excreting functions; avoidance
of all causes of physical and moral depression ;
and a proper recourse to the additional means re-
commended to prevent InfectiOiV, in that article,
are most to be depended upon,

121. B. After the 7norhid impression has been
made, the development of fever may often be pre-
vented, if the patient no longer remain subjected
to the operation of the exciting causes. We have
seen that disease is frequently many days in form-
ing, the system manifesting slight disorder only
during the time (j34.). The object on such
occasions should be to enable the frame to main-
tain a successful struggle against the impression
that has been made, and its more immediate
effects. With this view, all the causes enumerated
in the article Dise.ase, under the name of deter-
mining or consecutive (§ 61.), should be carefully
avoided, especially exposure to cold, to wet, and
moisture ; the use of cold fluids, and of cold,
indigestible substances; excesses of every kind,
and the common causes of physical and menial
depression ; and the patient ought to remove to a
pure, dry, and open air. Tonics ought at the
same time to be employed, especially such as de-
termine the circulation to the external surface,
improve the tone of the digestive organs, and pro-
mote the secretions and excretions, particularly
those of the bowels and liver. When the actions
of the bowels require aid, cold and debilitating
aperients should not be prescribed. Warm and
stomacliic purgatives or laxatives, or these com-
bined with tonics, are the most appropriate. When
the impres.-ion has been energetic, and made by

FEVER — GENEn.\L Treatment. 921

infectious effluvia, an immediate recourse to stimuli,
aromatic spirits, spi

especially camphor, ainmoni

rits of nitric ffither in tea, See; or, if these be not
at hand, to warm wine whey, or brandy and water,
will generally prevent any ill effiects. The diet
should be regular, moderate, nutritious, and easy
of digestion ; the stomach having nothing to do
that it cannot perfectly accomplish. If these be
tound insufficient, a warm /)«(/(, followed by active
friction of the surface; and if reaction have not
supervened, icarm diaphoretics may be directed.
If the patient still continue to complain of the
■symptoms of the formative stage, an emetic, with
aromatic adjuncts (see F.-198. 402.), should be
exhibited, and repeatetl until it fully operates;
after which the diaphoretics may be repeated, or a
moderate dose of- calomel, with five or six grains
of camphor, and one or two of opium, may be given,
which- should be followed J in a few hours, by an
active stomadiic cathartic (F. 181. 216. 266.).
These means have been "^eiiiployed by me in se-
veral instances during tRe formative stage of fevers,
with- perfect success." But in cases where we sus-
pect inflammatory irritation to have commenced
in the alimentary canal, and during the pre-
valence of epidemics characterised by this com-
plication, emetics, particularly those containing
tartarised antimony and acrid purgatives, should be
withheld, and the other means be resorted to, espe-
cially the ivarm bath, to which stimulating sub-
stances may be added, and frictions of the surface.
Internal irritants of the digestive mucous mem-
brane should be also abstained from in the form-
ative stage of the exanthemata, for in them this
membrane is generally irritable and injected ;
and it readily becomes inflamed upon the injection
of stimulating and acrid matters ; the healthy
development of the eruption being thereby pre-
vented. It is chiefly in robust constitutions, and
after the operation of other causes than infection,
that severe shocks, by active emetics or cathartics,
are best borne ; whilst the other remedies, especi-
ally camphor, calomel, and opium, warm diapho-
retics and diluents, tonics with camphor and
ammonia, external derivatives, and warm, mild,
but efficacious purgatives, are most suitable when
the morbid impression has been made by infectious
emanations. This treatment may not succeed in
arresting the fever, but it will seldom fail of short-
ening the premonitory stage, and rendering the
subsequent disease more mild or of shorter du-
ration ; for it frequently is observed that, when the
formative period is allowed to continue, and to
develop the series of changes to which it leads
when left to itself, the consequent disease assumes
a very severe or dangerous form.

122. C. The arrest of fever may be also suc-
cessfullij attempted, during the stage of invasion
(§ 35.), or up to the commencement of vascular
reaction, or excitement; but when once this period
has supervened, the fever will run a regular course,
although it will often be much shortened by treat-
merit. Fevers, I believe, caused by infection are
very rarely arrested after reaction is established.
The means just advised for the formative stage
may likewise be tried in that of invasion ; but
much discrimination is requisite in the choice of
means. Camphor, ammonia, and warm diapho-
retics and diluents, sometimes with opium, when
the head is not affected ; the warm bath, the
vapour or heated air bath, and frictions subse-

922

FEVER — Curative Treatmekt.

quently ; are the most generally appropriate. In
robust persons, and where terrestrial emanations
have been tiie chief cause, a warm emetic (F. 198.
402.) and active stomacliic purgatives (F. 181.
216. 266.) may also be exhibited, but they should
more rarely be ventured upon in other circum-
stances, for the reasons just assigned : the recipes
now referred to, however, will not be attended
■with the lea>t risk. ^V hen there is tenderness at
the epigastrium, with other signs of gastric irri-
tation and depression of nervous power, instead of
an emetic or cathartic, a large sinapism, or a
warm turpentine epithem, should be placed upon
this region, and over a great part of the abdomen ;
or, in other cases, upon the insides of the thighs;
but neither of these ought to be resorted to if re-
action have supervened, nor continued after it has
come on.

123. ii. Curative Treatment. — The indi-
cations of cure in fevers are — 1st, to remove the
exciting, and all other causes likely to exert an
unfavourable influence on the patient, and to
place him in a pure, dry, and temperate air ; —
2dly, to moderate vascular action when it be-
comes excessive ; and to impart tone and energy
to the vascular system, in states of depression or
exhaustion ; — 3dly, to support vital power,
especially when associated with imperfect re-
action, or when resulting from depressed or
exhausted organic nervous influence and vascular
action ; — and, 4thly, to remove local obstructions,
congestions, determinations of blood, or predo-
minant states of action, or other disease, in par-
ticular viscera. This last may be termed the
symptomic treatment of fever, the others the vital ;
inasmuch as they have especial reference to the
states of organic nervous power, and of vascular
action.

124. In endeavouring to fulfil these indications,
there are various circumstances to be kept in view,
viz. — a. The previous health, age, and condition
of the patient, in relation to the existing states of
vascular action and power, and of individual
functions. — b. The nature, intensity, and com-
binations of the causes of the disease, and the
imfavourable influences which still continue to
operate, and cannot be removed. — c. The man-
ner in which diflferent pathological states modify
the operation of many of the most active medi-
cines.— (/. As precise a recognition as the symp-
toms will afTord, of the ever-changing conditions
of vascular action, of nervous power, and of
exhalation, secretion, and excretion during the
course of tiie malady ; and strict appropriation of
the means of cure, not merely as respects tiieir
operation in health — their physiological action ;
but as regards their influence on disease, espe-
cially existing states of it — their therapeutical
cflects. Tlie importance, and, indeed, tiie necessity,
of attending to these circumstances in the treat-
ment of fevers, is well illustrated by the action of
antimonials, in their various forms and states. -The
potassio-lartrate of antimony is one of the medicines
most generally employed on theContinent, particu-
larly in Italy, as aciinir((-s(i;Hi(/fl /If, in what is called,
by the modern Italian school, the stimnlant-dia-
tliesis of fever ; and it is an excellent remedy in
several forms of the disease, during the stages of
excitement, in which it may be given in very large
doses. 15ut the tolerance of such doses depends
mainly upon the states of vascular excitement and

of vital power, and on the repetitions of the medi-
cine ; for they may be remarkably injurious in states
of low action, in the very young or in the aged, in
persons previously ill fed, in fevers attended with
predominant aflPection of the digestive mucous
surface, especially when of a low type and caused
by infection ; it often occasioning in these, espe-
cially when taken in very large quantities, serious
lesion of the mucous membrane of the stomach
and bowels. Keeping, theiefore, these indications
and circumstances in view, the treatment of fever
must be directed according to its type, its par-
ticular form, its varying conditions and compli-
cations, and its existing stage or period, and with
due reference to the measures which have already
been adopted.

125. A. The patient should he removed from
the exciting, concurring, and consecutive causes,
and be placed in as pure and dry an atmosphere
as possible, in a large well-ventilated apartment ;
but out of the way of currents of air, and in an
equable and moderate temperature. When an
elevated situation or chamber can be selected,
the advantage should not be neglected, particu-
larly in large towns. The earlier in the disease
that this intention can be fulfilled the better ; as
the more completely the functions of respiration
are performed, especially as to the changes ef-
fected by it on the blood, the less risk there will
be of future vital exhaustion, and of contamination
of the circulating and secreted fluids. Nor should
it be overlooked that, although the pulmonary
functions are imperfectly performed during the
formative and invading stages, they are more or
less completely restored as reaction is developed,
and tiiey often assume their accustomed activity,
unless the bronchial surface, or substance of the
lungs, have been inordinately afl^ected by conges-
tion or determination of blood during the early
stages ; the subsequent activity of this organ con-
tributing to restore the impaired purity of the cir-
culating fluids, and to prevent or counteract much
of the vitiation they afterwards would experience
from an impeded elimination of hurtful matters,
particularly in circumstances unfavourable to the
due performance of the several depurating func-
tions, of which the lungs are themselves one of the
most important, and a dry, pure and temperate air,
one of the most effective agents.

126. B. The moderation of excessive vascular
action is obviously necessary ; but the particular
means by which it should be effected, and the
grades of action that should be interfered with,
are not so evident. These are points which must
not be determined by tiieory, but inferred from
extensive experience and observation. If the
patient was previously in good health ; if the
causes were not remarkably intense, or are im-
perfectly known ; if the symptoms do not indi-
cate great excess of action, or serious irritation of
any paiticular system, or determination to any vis-
cus, or congestion ; then little need be attempted,
and certainly no active means should be resorted
to, especially among the poor, and persons of a
spare habit of body. In the licli and well fed,
or those wiio arc more plethoric, simple saline
refrigerants and diajihoretics, mild aperients, and
cooling diluents and diuretics, may be employed,
rather with reference to consequent changes, than
as respects the existing state of disorder — to the
prevention of future lesion, the removal of ob-

FEVER — Curative TnEATMEvr

structicns, and the preparation of the organs for
salutary or critical changes. These means exert
a solvent or relaxing operation upon the capillary
vessels; they promote secretion, soothe vascular
irritation, equalise the circulation, and facilitate
the excreting actions.

127. When vascular action rises ahovo the
state just mentioned, it should be considered
excessive, and more energetic remedies employed.
Inordinate action varies remarkably in grade,
and somewhat in kind, with the causes which
induce it, with the consequent state of organic
nervous power, and with the constitution, habit
of body, and age of the patient, from that just
noticed, to the vehement forms, which are rapidly
followed by exhaustion, by a dissolved or other-
wise altered condition of the blood, by lesion of
capillary action and tone, and by structural
change, especially in mucous surfaces and paren-
chymatous viscera. The most intense forms of
reaction, and consequently the most rapid in their
course, often have nearly passed off before the
patient is brought for treatment, the effects of
morbid action being then only observed, and the
exact nature of the disease frequently mistaken.
But in proportion as the action of the heart and
the pulse are strong, frequent, full, and hard; the
countenance and surface injected, turgescent, and
animated ; the eyes bright and prominent ; re-
spiration full, deep, and laboured ; animal heat
increased, or acrid and burning ; the excretions
diminished or suppressed; the animal functions
unbroken, consistent, and free ; the course of the
disease, whether epidemic or sporadic, acute and
rapid, and the type perfectly continued ; so
much the more active and immediate should be
the means employed to lower the excited action
on which these depend, and to prevent its dan-
gerous tendency. — These means have been
usually named from the morbid states they are
employed in removing, as antiphloghtic, anti-
sthenic, contra-stimulant, refrigerant, lowering,
eiacuant, S)C., and are very numerous; although
the remedies which are appropriate to particular
forms of excessive action are much more limited.

128. a. Vascular depletions were resorted to
by the ancients, generally with the view of di-
minishing inordinate action, or of diverting an im-
petuous motion of the fluids from vital organs;
and observation taught them, that, when pushed
far, with an intention of curing or arresting the
progress of fever, they were frequently injurious.
A nearly similar practice was adopted by the best
Avriters, from Hippocrates to Sydenham, who
both illustrated it. Sydenham explicitly states,
that bleeding is required to repress the tumultu-
ous or irregular motions of nature, and remove
the flux of blood from an important organ or part,
to which the febrile impulse has determined it ;
and the ideas held respecting the practice, among ,

923

which broke out amongst his followers to South
America was given by Dr. Franklin to Dr.
Rush, and was a principal cause of the change
which took place in the practice of the latter
during the epidemic fever of North America in
1797. Dover was a Buccaneer leader, and no
mean physician, and practised both professions
much in the same spirit. He ordered bleeding to
a very great extent at the commencement of the
disease, — a treatment successfully adopted in our
own times, under similar circumstances ; and which
I have resorted to in the ardent fever occurring
within the tropics. In a case, wherein I directed
bloodletting before reaction had supervened, the
loss of three or four ounces caused profound and
prolonged syncope ; yet, within four hours, when
reaction had come on, fifty ounces were taken
before any effect was produced upon the pulse ; —
and before the sun of the same day had gone
down, forty more were abstracted at one time, —
in all, ninety-four ounces within twelve hours.
But the patients for whom this practice has been
prescribed with success have been young, robust,
or plethoric, and removed from the continued in-
fluence of the causes which produced the disease.

129. a. The extent to which bloodletting
should be employed, and the good effects from
it, will depend on the particular form and com-
plication the disease assumes, on circumstances
peculiar to the patient, on the character of the
epidemic, and on the period at which it is re-
sorted to. It may be injurious, from being car-
ried too far, or not far enough, — and from being
resorted to before reaction has supervened, or
when the reaction is about to pass into exhaustion,
or in cases in which it is not indicated. Its
effects will depend upon the manner in which
these and other circumstances are weighed by
the practitioner; but it should not be overlooked,
that it depresses the vital energies much more
remarkably in fever than in idiopathic inflamma-
tions ; and, when inappropriately or too freely
practised, it prevents or retards salutary evacua-
tions and crises ; and either disposes to unfa-
vourable changes, or renders convalescence diffi-
cult and prolonged. Hildenbrand very justly
remarks that, even in cases where the propriety of
the practice is undoubted, a moderate quantity
only should be taken away at one time, and the
eflects upon the disease, as well as the appearance
of the blood, should be carefully observed, before
its repetition be directed. This precaution is
especially requisite at the commencement of epi-
demics, if depletion be employed late in the dis-
ease, and if vascular action be tumultuous, or
much exceed nervous or vital power.

130. Large bloodlettings have been directed
with the view of arresting or shortening the fever;
and, when the person has been robust, the con-
stitution sound, the cause not very intense, and

judicious writers of recent times, nearly agree ! its effects not very violent, the practice has occa-
with the above, although they differ as to the | sionally so far succeeded as to subdue the morbid
employment of it in certain types and forms of ! excitement down to that grade which is necessary
fever. When the symptoms just stated (§ 127.) | to the restoration of the secreting and excreting
are present, bloodletting should be promptly and j functions, and the production of a salutary crisis,
decidedly employed ; and when tiie patient is re- ; We sometimes observe a large or full depletion
moved into a pure air, beyond the influence of 1 in a few hours afterwards followed by a general
the causes, and is robust, plethoric, and young, • perspiration, and copious alvine evacuations. But
it may often be carried to a great extent. This this result should not be confidently calculated
appears to have been the case with Dover's pa- upon, even in the class of patients just mentioned,
tients. His account of the treatment of the fever and least of all in fevers arising from infection

924

and mental anxiety, or during epidemics, how-
ever early in the stage of reaction it may be re-
sorted to. JNIuch discrimination is necessary, even
in cases where the practice appears to be indicated,
not to run a risk of mischief by having recourse
to it.

131. When, in the progress of fevers, but more
especially at their commencem^ent, signs of local
determination or of predominant vascular action
appear in the head, lungs, or abdominal viscera,
depletions, both local and general, are most
requisite. If, however, these affections come on
in advanced periods of the fever, although deple-
tion to some extent is required, the existing states
of vital power and action, and even of the blood
itself, often forbid it to be practised nearly to the
amount generally required in idiopathic inflam-
mations,— unfavourable terminations or even gan-
grene rapidly supervening, owing to these states,
upon a too free recourse to it ; for it is not so much
from excessive action, as from diminished power,
and alterations of the circulating fluids, that these
unfavourable results occur in the progress of
fevers. Ttie earlier, however, the predominant
local disease or complications appear, the more
energetically may bloodletting be employed.

132. (3. The chruinstances more especially
requiring recourse to vascular depletions may be
summed up as follows : — (n) Inordinate excite-
ment, or irritation with rigidity of fibre, and gene-
ral increase of the animal heat; — (6) When
the patient is robust, plethoric, or young; the
sanguiferous system being so surchaiged as to
prevent the free exercise of the functions ; — (c)
When the general reaction of the vascular sys-
tem is such as to endanger vital parts, or too strong
to allow a salutary or critical change, or so vehe-
ment or tumultuous as quickly to exhaust vital
power ; — and, (rf) When the blood is determined
to, or vascular action is inordinately increased in,
an important organ. — In these conditions blood-
letting is employed, with the following intentions :
— a. To remove the excitement and irritation,
and relax the exhaling and secreting surfaces and
organs; — B. To diminish the load which oppresses
the vascular system, congests it, or overpowers
the organic nervous influence that actuates it ; —
■y. To reduce the excessive reaction, and thereby
to guard important viscera, to prevent consequent
exhaustion, and to favour the supervention of
salutary evacuations ; — J. To remove or divert
the increased impulse or action from important
organs.

133. y. Ihcre are certain considerations and
symptoms contra-indicating bloodletting, that
should not be overlooked. Some of these I have

•seen but too often neglected, even by old practi-
tioners ; and others so remarkably misinterpreted by
them, as to iiave been their only reasons for having
recourse to depletion, although actually the strong-
est indications against it. — A very fre(|uent, soft,
and open pulse seldom or never admits of deple-
tion, for in such cases the tone of tiie vessels is
insufficient to accommodate tiiem to a diminution
of their contents ; consequently, remarkable sink-
ing and depression, with increased rapidity of the
circulation, &c., supervene. Tiie pulse may be
also open, soft, expansive, and tumultuous, indi-
cating excessive action beyond vital power, as in
certain forms of adynamic and malignant fevers
attended by contamination of the circulating

FEVER — Curative Treatment.

fluid. In this state, the loss of even a very few
ounces of blood will produce bad effects. Vas-
cular depletion is seldom well borne in fever,
when the pulse ranges so high as 110, and still
more rarely if it reach 115 or 120, in adults.
Irritable females, however, and those in the puer-
peral state, offer exceptions to this.

134. Great prostration of strength and of vital
power ; the supine posture ; languor of the eyes ;
paleness or collapse of countenance ; a lurid com-
plexion ; a dark or flabby state of the tongue,
with indentations of the teeth on its edges, or dark
mucous sordes on the tongue, gums, and teeth ;
great sadness and depression of spirits ; low deli-
rium ; tremblings of the hands, and especially
of the lower jaw ; a feeble, small, and weak, or
an open, compressible, and undulating pulse; a
frequent and hurried respiration ; incontinence of
fseces or urine ; coldness of the extremities, or
of the ears or nose ; coldness or rawness of the
expired air ; softness and flabbiness of the soft
solids; and a dirty, muddy, lurid, or discoloured
appearance of the integuments; are the strongest
indications against any kind of depletion, and in
all circumstances of fever.

135. In addition to these, the noxious nature
of the exciting causes ; their concentration, and
their intense operation, as in the case of infectious
effluvia ; imperfect ventilation, &c. ; the cha-
racter of certain epidemics ; the continued in-
fluence of the contaminated air, or of the infec-
tious emanations that caused the fever ; previous
depression and insuflicient nourishment ; the pre-
sentiment of an unfavourable issue, or mental
distress and anxiety ; the circumstance of the
patient being treated in the midst of the malaria,
or marshy exhalations, that caused the disease, or
in an hospital, camp, house, or low street, in
which infectious (ever is prevalent ; all militate
against bloodletting, or indicate a necessity of
caution in respect of it, according to the form
which the disease assumes. — Vascular depletion
also is not so well borne by persons living on a
poor watery diet; nor by the studious and ex-
hausted ; nor by the fat, bloated, cachectic, and
intemperate ; nor by residenters in low marshy dis-
tricts ; nor by liiose confined in close factories, or
living in close or low apartments and streets ; nor
by persons passed fifty ; as by those differently
circumstanced. But the various species of fever
furnish peculiar indications in favour of or against
bloodletting that will be considered in their proper
places.

1 36. S'. Of the repetition of bloodletting. — Pi'e-
viously to determining upon a second depletion,
the effects both immediately and more remotely
consefjuent upon the first, and the character of
the disease, should be most carefully studied. It
may happen that the first bleeding, although small,
has produced fainting, followed by so strong re-
action as to render a second or even a third full or
moderate bleeding indispensable. This is chiefly
observed when the first has been practised too
early, or before the stage of reaction has been
fully developed. If the fever is complicated,
and tiie local affection presents much of the in-
flammatory character; if the patient has been
relieved by the former bleeding ; if the pulse
remains good ; if reaction, or determination to
an importiint organ be diminished, the symptoms
which indicated the fiist depiction still persisting

fEVER— Curative TnEATMENT.

925

to a certain degree ; we may proceed to a second,
but always with circumspection. If, on the con-
trary, the pulse becomes weak, and the strength
sinks, we never ought to repeat the bleeding. In
all cases, the piiysician should attentively observe
the pulse during the flow of blood, in order in-
stantly to assure himself of the propriety of deple-
tion : for if it become feeble and irregular, and
the patient at tiie same time more distressed, the
evacuation should be immediately stopped. The
blood drawn in the first instance sometimes fur-
nishes indications for or against the repetition of
bloodletting; but such indications siiould seldom
be acted upon alone. The inflammatory coat,
and cupping of the coagulum, are favoured by
cold, dry weather, by the puerperal states, by
the rheumatic diathesis, and by the blood being
taken in a full stream, and in a deep and narrow
vessel. — But this condition, as well as a very
loose or dissolved coagulum, or imperfect separ-
ation of it from the serum, and the other states of
the fluid described in the article Blood (§78. et
seg.), should be duly considered, in connection witii
the other phenomena, before they can be made
the basis of curative indications. Van Rotter-
dam justly states, that when the crust consists of
a delicate bluish membrane, covering a greenish

139. b. Refrigera)its, internal and' external,
are of great service in moderating vascular ex-
citement; and some of them produce this efTect
more than others, without lowering vital power.
— a. The choice of internal refrigerants siiould
depend upon the form fever assumes, and upon
their especial action. In the early part, and more
sthenic forms of excitement, sedative refrigerants
should be selected, as the nitrates of potash or
soda — the various neutral salts, the mineral, and
vegetable acids. Several of these may be advan-
tageously conjoined, as a solution of the sulphate
of magnesia, with that of the acetate of ammo-
nia ; and other substances, also tending to pro-
mote the exhalations and secretions, may be added.
In the far advanced stage of excitement, and in
its more adynamic or low states, refrigerants which
are more restorative and antiseptic — a.?, camphor
in small doses, ihe hifdrochlorate and acetate of am-
monia, the spirit of nitric either, and the various
atherial preparations, particularly citioric aether —
are upon the wiiole to be preferred ; and may be
conjoined w^ith nuinerous other substances, ac-
cording to existing morbid conditions. The refri-
gerant effect of several of these is only relative
to the state of action at the time, but it is not
the less beneficial. Thus, in the low excitement

gelatinous matter, the crassamentum being livid, characterising adynamic fevers, or when vas-

soft, and floating in a thick and greenish serum, a
second bleeding will prove most mischievous ; —
and I may add, that least of all should depletion be
repeated, in any mode, if the colouring matter be
precipitated to tlie bottom of the weak crassamen-
tum, and of a blackish or purplish colour.

137. £. Local bloodletting is required chiefly in
very young patients, or after general depletion,
or in local determinations and complications, or
in circumstances that render the propriety of
bloodletting doubtful. It is most serviceable
when the head is affected, and then either cup-
ping or leeches may be employed, but preferably
the former, when a quantity exceeding six ounces
is to be taken away ; and either mode may also
be adopted when tlie viscera in the large cavities
are affected. If leeches be employed late in
fever, particularly in its low and complicated
forms, care should be paid to the bleeding after
their removal, as it is apt to continue, and is
arrested with difficulty. Dry cupping is some-
times useful in states of internal congestion,
when the detraction of blood can hardly be
risked.

138. ^. The question has been often agitated.
How late in fever sliould bloodletting be prac-
tised? but it evidently cannot be answered by any
absolute rule, or without reference to the ensemble
of existing phenomena. In the cerebral and
pulmonary complications, as well as in others in
some cases, bloodletting, in one mode or other,
may be employed until an advanced or critical
period. But reaction having come on, and the
indications for it being evident, the earlier in
the disease it is resorted to the better. In the
stage of crises, both vascular depletion and all
perturbating means should be avoided. The in-
dications already noticed respecting this remedy
will assist the practitioner as to both the latest
time of resorting to it, and the repetition of it ; but
in these matters, as in many besides, he must be
guided chiefly by his pathological knowledge, and
powers of practical observation and discrimination.

cular action exceeds vital power, and the heat of
surface is of a morbid kind, both the vascular
action and the unnatural heat are best reduced
by the more restorative refrigerants, as by cam-
phor, the hydro-chlorate of ammonia, chloric
aither, &c., all which may be given in conjunc-
tion (F. 431.). Much benefit will also result from
a j udicious choice of refrigerant beverages or drinks
during the stage of excitement. A selection suit-
able to particular cases may be made from those
prescribed in the Appendix. (See F. 592, 593,
594,595.915 and 916.)

140. 0. External refrigerants are of great ser-
vice, but they often require much discrimination.
The patient, especially in warm weather, should
be laid upon a hair mattress, covered only by a
single sheet, and his surface sponged, in the more
active states of febrile excitement, with cold
spring water. If this be done frequently, as
much benefit and much less fatigue will be ex-
perienced, than from the cold afl'usion, which,
although more rapidly lowering the animal heat
than it, hastens the return of the cutaneous reac-
tion. If much determination to the head exist,
the hair should be cut off, and cold, in various
forms, as the afj'usion of a stream of cold water,
evaporating lotions, &c., should be resorted to, the
head being placed on a cool pillow. Formerly,
there was much difficulty in regulating the tem-
perature of the head ; for, although one half of
it was readily cooled by lotions, the other half
was kept remarkably hot by the feather pillows
in constant use. I frequently, therefore, placed
under the pillow-case a Iblded piece of cotnmon
floorcloth, which, by intervening pieces of linen,
might'be so managed as to carry off the excessive
heat of the head, as rapidly or as slowly as could
be desired. Pillows may now be filled with
either air or cold water, and their temperafure
regulated according to circumstances.

141. In cases of determination to internal
viscera, excepting to the liead, the use of external
refrigeratits is mere or less hazardous j and, if

926

the local complication be serious, and the general
excitement of a low or adynamic form, it siiould
be laid aside. But when this form of reaction is
general, and not attended by excessive determin-
ation to, or congestion in, any of the thoracic or
abdominal viscera, tepid, or ivann sponging and
ablution, will prove both useful and grateful.
Whether cold, tepid, or warm sponging be adopt-
ed, the addition of bicarbonate of soda or of
potash, or the bi-borate of soda, to the water
thus used, will tend to relax the skin, and will
cleanse it from tiie impurities which impede its
functions. In cases accompanied by an acrid
heat of surface, tepid sponging, or the tepid l)ath,
medicated as just directed, will be advantageously
followed by frictions with sweet oil, which, by
relaxino- the exhalants, will cool the surface.

142. c. Antimnnials are amongst the most
energetic contra-stimulantsm fever; but they are
not suited to all fevers, nor to all their stages.
They are most serviceable in the more sthenic or
inflammatory forms, in those arising from other
causes than infection, in some epidemics more
than others, and in the earlier periods. The best
preparations are the true James's powder and the
-potassin-tarlrate, the former of which may be con-
joined with calomel and small doses of camphor, or
with mild aperients ; and the latter may be given
in various salme solutions, or in the patient's coin-
nion drink. Tartar emetic has been employed most
largely in Italy to lower febrile excitement, but I
believe that it will be found equally beneficial and
less injurious to the digestive mucous surface when
used in moderate doses. I have frequently given
as much as three or four grains in the course of
the day in solution ; but from one to two grains has
been equally serviceable. It is especially indi-
cated when pulmonary affections supervene in tlie
course of fever ; but it should not be prescribed
in low or adynamic fevers, even vilien thus com-
plicated, unless with great caution, and in com-
binations hereafter to be noticed. A judicious use
of either of these medicines early in the stage of
active excitement, will often either entirely super-
sede depletions, or prevent the necessity of having
recourse to those which are large.

143. B. Inordinate depression of vascular ac-
tion, during the period of the disease which usually
follows that of invasion, is very much less frequent
than the states of excitement. It sometimes
requires the most active means to remove it, but
these means should have reference to the cause,
and the vaiious pathological states attending it.
This condition generally arises from the intense
impression of the exciting cause on the organic
nervous influence, preventing thereby the evolu-
tion of vascular reaction ; the stage of excitement
either not following the earlier changes, or ap-
pearing in an irregular and imperfect manner.
In such cases, whicli are most common in certain
epidemics, and in some localities productive of
the more concentrated states of malaria, there is
generally more or less congestion of the large
vessels, and parenchymatous viscera; and llie
vascular depression is dependent — 1st, upon low-
ered nervous influence; — 2dly, upon an over-
loaded or oppressed state of the circulating and
vital organs — the state of co»^'es((iiM so stiongly
insisted upon by Staiii. and liis disciples, but
whicii 1 have shown (§ 92.) not to be a primary
change, us believed by more recent writers. In

FEVER — Curative Treatment.

this case, the means advised for the stage of in-

vasion (§ 122.) should be resorted to, especially
the heated air or the vapour hath, and warm baths,
followed by frictions of the surface. In some
cases, especially when irregular or unavailing
efforts at reaction are made, the abstraction of a
few ounces of blood from a vein, whilst the pa-
tient is immersed in a warm bath, and frictions of
the surface are being employed, will often assist
in restoring circulation to the surface, and in
removing the internal congestion. If the pulse
rise during the flow of blood, a larger quantity
than otherwise might be safe may be taken, or
the operation may be repeated, according to the
eft'ects observed after tiie first evacuation. If a
satisfactory result is not soon observed from these,
a hot turpentine epithem should be placed over
the epigastrium and abdomen, and covered over
with oiled silk, or leather, so as to prevent eva-
poration ; and be either kept there or renewed
until erubescence of the surface is produced. In
the inore dangerous cases, a similar epithem may
also be applied to the insiJes of the thighs. At
the same time, moderate doses of camphor or
ammonia may be given internally, in warm dilu-
ents, or small quantities of tiie chlorate of potash.
Depressed vascular action, whether occurring in
the early progress of the disease, or consequent
upon some grade or other of excitement, being
cliiefly .an effect of the change in the state of
organic nervous power, although often associated
with congestion at the commencement, and with
vitiation of the circulating and secreted fluids in
the latter stages, should be further combated by
the measures which are re(juired for tiie fulfilment
of the next intention ; an especial attention to these
conditions being paid in the remarks about to be
ofl^ered.

144. C To support organic nervnus and vital
power, especially when associated with imperfect
vascular reaction, or witli a moibid state of the
blood, or when proceeding from exhaustion, is of
the greatest importance; but the circumstances in
which the accomplishment of this intention be-
comes requisite, and the treatment most appro-
priate for it, in the various states of fever, are
amongst the most diflicult topics of practical
medicine. In certain varieties, especially those
tliat commence with low excitement or imperfect
reaction, the debility is owing in great measure to
s)f/;pessi(m of power — to the overloaded state of
the vascular system, consequent upon interrupted
exhalation and secretion, preventing its free re-
action upon its contents. In such, power is best
restored by moderate vascular depletion, tiie pulse
becoming more free and developed as the con-
gestion and load are removed. It is in this class
of cases that early evacuations are most requisite,
as the best means of preserving vital power, and
arc the oftenest neglected ; whilst in others, par-
ticularly those which are characterised by ex-
cessive action, although attended by loss of
vascular tone and nervous power, or by a vitiated
state of the blood, or botii, depletions are inap-
propriate, and the most likely to be injuriously
resorted to. In certain adynamic fevers, in which
reaction assumes tliis latter form, and apparently
indicates bloodletting rather llian opposite means,
if employed sufliciently early and witii much
circums[)ection,some advantage, or little mischief,
may result from it, especially if the patient was

FEVER — Curative Treatwent

in health, well-fed, or at all plethoric, before the
attack. But when the pulse is very quick, broad,
or open, the vessel yielding on a gentle pressure
of the finger, as well as before the impulse of the
heart upon the column of blood in it, depletions
should either not be attempted, or be accompanied
with remedies which will restore nervous power.
In general, however, they are in any mode
hazardous in such cases ; tlie febrile poison or
cause having infected the organic nervous influ-
ence, and the vascular system, as well as its
contents, and prostrated vital power in such a
manner as to be roused only by tonics and re-
storatives. But even in these circumstances,
stimulants should at first be cautiously used and
judiciously selected ; for a too early recourse to
them, especially to such as are at all heating, may
be very injurious. When this state of the cir-
culation occurs late in the disease, or is consequent
upon a more vigorous reaction, and an obviously
vitiated state of the blood, the most energetic
means of restoration are necessary.

145. Debility from suppressed power is frequent
in the early periods of fever, when the brain and
lungs are predominantly affected, and is best
relieved by moderate depletions and derivatives.
Care should be taken to distinguish this form
of debility, as, whether occurring early or late,
the use of stmiulants would be more injurious
than beneficial, unless in peculiar circumstances,
and when these medicines are conjoined with
other more appropriate means. The association
of this state with vascular conjestion, in these
as well as in other cases, requires rather the
treatment directed for depressed vascular action
(§ 143.) than that for exhaustion.

146. It must be evident from the foregoing,
therefore, that numerous circumstances must be
duly considered before restoratives — either of a
tonic or stimulant kind — should be resorted to
in fevers. These circumstances furnish the true
indications for the employment of them, and are
chiefly the following : — a. The intense operation
of the causes of infectious and epidemic fevers,
these generally requiring, caieris paribus, an ear-
lier and more liberal use of restoratives than those
which are sporadic; — 6. The summer and au-
tumnal seasons; — c. An age past the meridian ;
— d. Imperfect nourishment and clothing; the
patient iiaving lived chiefly on vegetables, or on
fish, or salt provisions, or having been addicted to
ardent spirits, or to sexual indulgences ; — e. An
intermittent, remittent, or low tijpe of fever, or any
of its adynamic _/())7ns, especially if uncomplicated
with any inflammatory state ; — _/'. The continued
operation of the poisonous efliuvia which caused
the disease, as in low marshy situations, the close
air of crowded hospitals, &c. ; — g. Signs of real
debility or of exhaustion, especially when at-
tended by a moist or flabby tongue, by a very
soft and quick pulse, the secretions not being
suppressed ; — h. An indifferent or apathetic state
of mind, despair of recovery, mental depression,
&c. ; — and, ('. The symptoms enumerated above as
contra-indicating bloodletting (§ 133.). Besides
these, there are numerous others, which appertain
more especially to certain species and forms of
fever, and which will be noticed hereafter. Va-
rious circumstances may, however, arise, which
will render vascular depletions, and a recourse to
tonics, and even to stimulants, nearly at the same

927

time, extremely proper. Remittents and inter-
mittents, particularly in warm countries, and
several complicated states of continued lever, often
exemplify this.

147. The selection of means in order to support
nervous and vital power must have reference to
the cause and form of fever, and to existing patho-
logical states and complications. In endemic fevers,
the various preparations of cinchona and sulphate
of quinine are upon the whole most appropriate.
In those caused by infection, lhesa.me preparations
with camphor, the chlorates, especially the chlo-
rates of potash and soda, serpentaria, arnica,
camphor with opium, wine given in Seltzer water,
yeast, carbonic acid, various tonic infusions taken
with the citrate of ammonia in a state of effer-
vescence, spirits of turpentine, pyroligneous acid,
kreosote, the mineral acids and lethers, especially
the hydrochloric or chloric, and chloric (Ether ; and
in the complicated states of fever, especially ex-
ternal derivatives, vesicatories, sinapisms, epithems
with warm turpentine, or liniments wuh this latter,
and camphor, capsicum, &c., are the most eflicient
remedies. When the blood appears contaminated,
or the excretions acrid, offensive, and excoriating,
combinations of tonics with antiseptics, as the de-
coction of cinchona with the chlorate of potash —
a combination which I have used for many years
with much success — or with chloric acid and
chloric ffither ; the pyroligneous acid with kre-
osote ; spirits of turpentine, &lc. ; and these, or
similar substances, administered in enemata ; are
the most to be depended upon. But the appro-
priation of these and of other remedies to the par-
ticular forms and states of fever, is more fully
shown in the sequel.

148. D. The promotion of the exhalations, se-
cretions, and excretions, by emetics, purgatives,
diaphoretics, and diuretics, is a most requisite in-
tention in the cure of every type and form of I'ewer.
By a judicious selection of means belonging to
these classes of remedies, adapted to existing
pathological conditions, vascular action may be
developed when it is low or suppressed, or mo-
derated when it is excessive ; nervous power may
be relieved when it is oppressed, or supported
when it is exhausted; and the circulating fluid
may be preserved in a state of comparative purity,
or relieved from the contamination it mav have
experienced in the course of the disease.

149. a. Emetics were formerly more employed
in fever than at present. — Svdekham, Stoll, and
many others, prescribed them very generally ;
but the recent views as to the seat of fever in the
brain, and digestive mucous surface, have tended
to bring them into disuse. In the early statues
of the simple and sporadic forms of fever, they are
often of great benefit, especially in arresting them,
as advised above (^ 121, 122.), or in developino-
imperfect action. They are seldom productive of
much service after the excitement has become
fully established or stationary, and should not be
employed in the cerebral complication, or when
tendeiness or pain are felt in the abdomen, espe-
cially at the epigastric region. AVhen prescribed
thus early, they are calculated to prevent con-
gestions of the lungs and liver, and even to remove
them at their commencement. Sydenham, from
a fear of their efl^ects upon the brain, seldom
prescribed them until bloodletting was premised,
and thereby lost much of the benefit they are

928 FEVER — CuRA

calculated to afford, inasmuch as the period at
which bloodletting could be advantageous, was
raore advanced than that in which emetics are
most serviceable. Ipecacuanha is, upon the whole,
the best substance that can be used. Tartar
emetic is not so safe, if there be tendency to the
gastric complication, or in low infectious forms of
the disease. Some authors have recommended
emetics at a late period ; but I have had but
litile experience of them later in fever than I have
advised them. In the early stages I have both
frequently prescribed them, and seen them pre-
scribed, with benefit. They may, however, prove
beneficial in more advanced periods, especially in
tlie bronchial complication, and to answer par-
ticular purposes; but they sliould be conjoined
with such other substances as will assist them in
answering tiie especial intention with which they
are directed.

150. 6. Purgatives are the most generally
prescribed medicines in fever, in this countr}';
and are at least amongst the most useful when
judiciously selected. Calomel early in the disease,
in conjunction with Jameses powder, and in the
adynamic states with camphor, &c, — jalap with
cream of' tartar, in sporadic cases — the mild neu-
tral salts, OT the more cathartic salts in mild doses,
in similar circumstances, — rliiLbarb in nearly all
fevers, variously combined, — spirits of turpentine
with casior or olive oil, &:c. when the head is
much affected, and in certain states of the ab-
dominal viscera ; and various other mild aperients,
as manna, tamarinds, prunes, &c., with the ci-
trates, tartrates, &c. ; are the most serviceable.
The phosphate of soda, or any of the strong neutral
salts, either alone and in small doses, or with
diaphoretics and diuretics, will frequently pro-
duce both refrigerant and evacuant effects. They
are indicated ciiiefly during the stages of excite-
ment, more especially in sporadic and endemic
fevers.

151. In general, the purgatives used in fevers
should be mild, and such as are not calculated to
irritate or inflame the digestive mucous surface.
They should be employed with the intention —
1st, of simply removing mucous sordes and accu-
mulations from the prima via; — 2dly, of pro-
moting the secreting and excreting functions of
the collatitious viscera, and of the intestinal sur-
face ; — and, 3dly, of thereby unloading the vas-
cular system of a part of the efl'ete materials
conveyed into it, and liable to accumulate in, and
contaminate, tiie blood. They should rarely or
never be prescribed with a view of deriving the
circulation from other parts to tiie digestive canal ;
for, in fevers, irritants of any kind acting upon
this part will often react upon the brain and liver ;
with the exception of the purgatives just en\ime-
rated. If oils be employed, especial care should
be taken that they are quite fresh, otherwise tliey
may occasion great danger. In pulmonary com-
plications, the addition of the potassio-tartratc of an-
timony in small dojes.or of ipecacuanha, to the pur-
gatives, will be useful, and uill promote their ope-
ration. In advanced stages, the utmost discrimina-
tion is necessary in the selection of purgatives, and
more especially if we dread the presence of disease
of the mucous follicles. In these, doses of rhubarb
sudicic-nt to evacuate freely the bowels, with the
liydrargyrum cum creta, cain])hor, and ipeca-
cuanha, are most beneficial. This lesion is com-

TivE Treatment.

monly connected with, if it be not caused by, the
injurious remora of sordes or morbid secretions in
the canal, and by a vitiated state of the blood;
the aperients or purgatives selected should, there-
fore, not merely be mild, but possess tonic and
antiseptic properties, or be conjoined with such
substances, especially camphor, cinchona, sul-
phate of potash, the chlorates, or kreosote,

152. c. Diaphoretics should be prescribed with
strict reference to the existing degree of excite-
ment ; for if the vascular action mount above a
certain pitch, the cutaneous exhalation cannot be
procured until it is reduced ; and if it sink too
low, the perspiration will either be interrupted, or
become partial or clammy. In the stage of ex-
citement, therefore, depletions and refrigerants
are the most efficacious diaphoretics ; or such
substances as relax the skin by acting on the
digestive mucous surface, as calomel with anti-
mony, and in some forms of fever especially, with
opium ; or ipecacuanha with nitre and opium, &c.
During this period, the more cooling diaphoretics
should be selected, especially those mentioned
under the head of refrigerants, (^ 139.), and
emollients and relaxants, will often very materially
aid their operation, especially if gastric and in-
testinal irritation be present. Whenever vascular
action, or vital power, particularly the latter,
sinks materially, the warm or stimulating dia-
phoretics, as camphor, serpentaria, ammonia,
arnica, &c., should be preferred, and be combined
with tonic infusions, &c., according to the cir-
cumstances of particular cases and existing patho-
logical states.

153. d. Diuretics are upon the whole less re-
quisite in fevers, tlian the preceeding ; but they
are often useful adjuncts to tonics, diaphoretics, or
even to the milder purgatives. The Eetherial pre-
parations, especially the spirits of ?(ifr(c (Ether,
citric acid, and the citrates, the tartrates, and
most of the neutral salts, and nearly all the refri-
gerants (139.), may be thus employed. They are
indicated more especially in the pulmonary, cere-
bral, and hepatic complications of fever ; those of
an antiphlogistic kind being the most appropriate.

154. e. Mercurials are often necessary in fevers,
especially calomel, blue pill, and the hydrargyrum
cum creta. Calomel is of great service as a de-
obstruent purgative, in fevers arising from ende-
mic causes, especially when the liver becomes
obstructed ; in conjunction with opium, after
bleeding, in the gastric and other complications ;
and with camphor and opium, in certain malignant
states, which will be particularly noticed. //(/-
drargi/rum cum creta is most useful with ipecacu-
anha and rhubarb, or with camphor and opium,
in the intestinal afl'ections occurring in the pro-
gress of the disease. Of the use of mercurial

frictions in continued fevers I have not had much
experience ; but in periodic fevers, when the
liver has become enlarged, 1 have directed them
with advantage ; using either the ointment with
camphor, or the mercurial liniment with the coin-
pound camphor liniment, or one of those in the
Appendix (F. 306.31].). Mercury pushed so far
as to affect the mouth or to produce su//i'«(i())i, has
been considered both a prophylactic and a cure
for fever. I have tiied to affect the system in the
most malignant forms of fever in warm climates,
without succeeding ; and where 1 have succeeded,
there was every reason to believe that recovery

FEVER— CunA

would have taken place nevertheless. In some
complicated states of fever in this country I have
given very large doses of calomel and camphor
with opium every four or six hours, with success ;
and although recovery has taken place, as fre-
quentl}' without the mouth having been affected,
as otherwise, I have generally considered tiie
latter a favoui'able occurrence. 'I'liis treatment
was introduced by me about fifteen years ago, and
was then resoned to in many cases in a publie
institution : it was taught in my lectures, and pub-
lished in several periodicals ten or twelve years
since. 1 he circumstances in which it is calcu-
lated to succeed will be pointed out hereafter.
That mercury possesses no projjhylactic influence
against fevers, has been satisfactorily shown by
several able writers, and proved by my own ex-
perience. A person, who>e mouth was affected
for the cure of sj'philis, was seized with malignant
remittent fever, in Africa, in 1817, and came
under my care soon after the attack. lie died a
few days afterwards; the most active treatment
having failed in developing vascular reaction, and
in supporting the vital powers. A nearly similar
case is mentioned by Dr. Graves, in his excellent
lectures. I believe, however, that instances in
which salivation has followed a mercurial treat-
ment of fever, without recovery having taken
place, are very rare.

155. E. It is often necessary to remove local con-
gestions, determinations of bUiiid, or predominant
states of vascular action, or other disease of -parti-
cular viscera, during the progress of fever, and
thus to protect important viscera from injury
during the febrile action.- — a. One of the most
dangerous and most frequent complications —
one which does not limit itself to any particular
type or form of fever, although more frequent in
some localities than in others, and in some epi-
demics— is predominant affection of' the digestive
mucous surface, particularly of tlie lower part of
the ilium and cfficum. This condition is more par-
ticularly noticed hereafter, with reference to its
early occurrence ; when it forms the mucous gas-
tric and intestinal fevers of authors. It is chiefly
to its occurrence in the advanced stages that I shall
here advert. Notwithstanding the erroneous views
of Broussais and his followers as to this point of
pathology, we are indebted to them for the great
attention which ha^ been paid to it in recent tmies.
Unfortunately, lesions in the small intestines may
proceed to a fatal issue in fevers, without any evi-
dent sign of their existence. Those symptoms,
nevertheless, which are most frequently observed,
as well as those which are occasionally connected
with them, should receive due attention. When,
therefore, pain or tenderness are felt in the abdo-
men or epigastrium on pressure, with tension and
burning heat, a loaded tongue with red point and
edges, a soft and very quick pulse, from twelve to
twenty leeches should be applied ; and after the
bites iiave bled sufficiently, a warm turpentine
epithem or fomentation in the same situation will
prove of great benefit. This epithem has been
very frequently employed by me, since 1820, in
the complicated states of fever, in both public and
private practice, and has been publicly recom-
mended by me for them on several occasions soon
after that time.

156. a. If this complicationappear early in fever,
a repetition of these means will often be neces-

VOL. I.

ivK Treatment.

929

sary : and, if the bowels be not sufliciently free,
or if the evacuations be acrid and offensive, lax-
atives, especially rhubarb with the hydrargyrum
cum creta, ipecacuanha, &c., and emollients or
demulcents, will be necessary. If it occur
very late in fever, and be attended with much de-
pression, or with diarrhaa, small but fretiuent
doses of the hydrargyrum cum creta, with cam-
])hor, ipecacuanha, and opium, ought to be given,
the above epithem being also resorted to ; and, if
these fail, the chlorates, particularly the chlorates
of potash or of lime, should be prescribed, with
the preparations of cinchona, or of tormentilla ; or
the treatment advised for the Asthenic Forms of
Dysentery (§ 88. et seq.) may be employed. In
these latter cases the affection of the mucous
follicles is either consequent upon, or coclaneous
with, contamination of the circulating and se-
creted fluids; therefore the chlorates, cinchona
wiih hydrochloric acid, chloric aither and opium,
camphor in large doses, kreosote, and other tonic
and stimulating antiseptics, are especially indi-
cated. If dark grunious or bloody stools, and
more particularly if large discharges of blood take
place, turpentine should be administered by the
mouth, and in demulcent enemata, it being the
most efficacious means we possess in such circum-
stances, as well as when flatulent distension of
the abdomen supervenes. Ulceration of the fol-
licular glands, and softening and even sloughing
of the mucous surface of the. bowels, may take
place in the latter stages ; and, although these
lesions are often preceded by the symptoms just
noticed (§ 155.), and attended by evacuations
indicating their occurrence, no very conclusive
evidence of their existence may be observed, unless
they terminate in perforation and peritonitis. This
is more especially the case, when the abdominal
symptoms are marked by severe cerebral afl^ec-
tion. But ulceration may especially take place
in this insidious manner also when the sensibilities
are not thus obscured, and even during the pe-
riods of decline and convalescence. — These more
extreme changes in the internal surface of the
bowels, can be met only in the manner just ad-
vised, tlie medicines being exhibited both by the
mouth and in enemata ; and by the means re-
commended in similar states occurring during
Dysentery (§ 89.). — I( peritonitis consequent
upon ulceration and perforation supervene, tere-
binthinate epithems, or sinapisms, and large doses
of opium, as advised by Dr. Graves and Dr.
Stokes, or of camjjhor and opium, are the most
rational means. The administration of other
medicines by the mouth or by injections, or, in-
deed, the ingestion of any substance whatever,
may increase the mischief, by its passing through
the perforation, which may possibly be repaired,
if the actions of the bowels be restrained by the
reinedies ju'^t advised; the natural processes
which sometimes take place in such cases, being
thereby favoured. I'he application even of
leeches may be injurious, particularly if this oc-
currertce take place late in, or during adynamic
states of, fever, by depressing the powers of life
too low for the exertion of the usual processes of
reparation.

157. B. The occurrence of diarrh<^a, of a. m'\]d
character, the stools being feculent and not re-
markably unhealthy, should not beinteifered with,
pjore especially at a critical period of tlie dis-
3 O

930

ease. But when the symptoms of inordinate
vascular determination are present, the evacua-
tions being watery, offensive, or otherwise mor-
bid, small doses of hydrargyrum cum creta and
Dover's powder should be given every four on
five hours ; and, if these fail, and more especially
if the type of fever be low, the stage far advanced,
and vital power depressed by the evacuation, the
more active means just mentioned (§ 157.) should
be administered. This complication is more
common, and more apt to assume a dangerous
form, in some localities than in others. Tims
it is more frequent and severe in Paris than in
London, and in London than in Edinburgh, pro-
bably owing to the water in common use in these
cities.

158. y. When flatulent distension of the abdo-
men comes on in any of the forms of fever, but more
particularly in adynamic states, Piorry advises
that an elastic tube should be introduced into the
rectum in order to carry off the flatus. I am,
however, not sure that the discharge of it in this
manner is so beneficial as may be supposed ; and
I am confident, that at the period of the disease
when this is a troublesome symptom, the internal
surface of the bowel will be readily Injured, owing
to its tender and almost softened state, even by
the incautious introduction of a clyster-pipe. 1
have, since 1820, recommended and employed
the spirits of turpentine, in cases of this kind,
— by the mouth, in several forms (F. 216.), in
enemata(F. 150, 151.), and in warm epilhems
and fomentations placed upon the abdomen. This
substance is especially indicated where, witli the
abdominal distension, and intestinal affection,
there is also delirium or coma ; and is equally
beneficial in a relaxed, as in a constipated state of
the bowels ; for, by modifying the dose and the
combination, it will increase or restrain their ac-
tions, according as either effect is desired. In a
remarkably dangerous, and indeed hopeless, case of
this description, which I attended in 1822, with
Mr. BvsHELi. of Crawford Street, this medicine
was resorted to with Instant benefit and ultimate
success ; and, although 1 have met, both pre-
viously and subsequently to this date, witii nume-
rous instances, in public and private practice,
where it has proved equally beneficial, I refer to
this in preference, because It is amongstthe earliest
cases of the kind, of which I can find the notes,
where I employed this medicine in consultation
with another practitioner, — the fact thus not
resting merely upon the testimony of an observer,
who may be supposed to be over-partial to a
medicine which he was the chief means of bring-
ing into general use (see my Menwirson the Action
(ind Use (if Terehinthiniile liemedies in various Dis-
eases, in the Lond. Med.and I'hijS. Journ. for July
and August, 1821.), but also upon that of an
equally competent observer. A nearly similar in-
stance to that now referred to is adduced by Dr.
Graves (^Lond. Med. and Surg. Jour)i. vol. ii.
p. 781.).

159. The nature and treatment of the com-
plications of fever with intestinal disease have not
always been well understood ; for, as they liave
too frequently been considered as merely inflam-
matory, and not lis consequences of the |)alhologi-
cal states explained above, so have they been
viewed as contra-indicating the exhibition even of
mild purgatives. — This, however, is not the case;

FEVfiR — Curative TnEATiiENT. ■

inasmuch as they may not only be occasioned by
the insufficient use or neglect of these medicines
early in the disease ; but also aggravated by the
same cause, at a later period. The septic and ir-
ritating effects of the morbid secretions and e.tcre-
tlons poured into the alimentary canal, and even
from its own surface, during the course of adynamic
fevers, when its mucous membrane possesses its
minimum of tone and vital resistance, require both
that the intestinal contents should not be allowed
to accumulate and remain long in contact with it,
and tliat they should be rendered less injurious by
dilution and the exhibition of antiseptic substances,
— indications of which both reason and experience
have shown the propriety and success.

160. ft. 'The compliciitions of fever icith severe
lesions of the respirator}/ functions and structures
aie more frequent, and often occur earlier, than
generally supposed. — The influence of early im-
pairment of these functions in tlie production of
the consecutive phenomena of fever should of it-
self attract a particular attention to them during
the progress of the disease. We shall generally
find that, in proportion as the causes of fever act
intensely upon the lungs, and impede the changes
of the blood in them, the more severe and corn-
plicated will be the form of the disease, and the
more disposed will this organ be to experience
either manifest or concealed disorder, generally
consisting of a peculiar congestive form of bron-
chitis, or of congestion of the lungs and bronchial
lining, or of determination to these parts, or of
asthenic or nervous pneumonia, passing into con-
densation of portions of the organ, in the lower
types of fever ; or of perlpneumony or more purely
inflammatory states of both the lungs and pleura,
in the more inflatnmatory varieties. There are
also other circumstances which should influence
the treatment of these complications, viz. — a.
I'heir greater frequency in the low adynamic
fevers, than in the sthenic ; in the continued,
than in the periodic types ; and in some epide-
mics, seasons, and localities, than in others; — b.
The particular stage of the feverin which they ap-
pear ; — c. The part they seem to act in superin-
ducing fui ther complications, especially cerebral
and hepatic affections ; — and d. Their particular
form and character in relation to general vascular
action and nervous power. It must be evident
that, inasmuch as this com])licatlon may super-
vene, and proceed to a fatal length, without de-
tection, especially when the brain is much affected,
an attentive inquiry after it should be made by
means of auscultation, through the progress of the
disease, and even during convalescence.

161. a. In cases where the local aflTectir.n, as
well as the general dise.ise, evince most of the in-
flammatory characters, general or local depletions,
according to the circumstances of the case, are
especially indicated. Of the latter, cupping is the
most useful, es[)ecially between the shoulders,
— and if leeches be applied, the glasses may be
placed over the bites. In the adynamic states,
local depletions only are adinissiblc ; and if
leeches be used, attention should be paid to the
bleeding afterwards. If further depletion cannot
be ventured upon, drii cupping on the back or chest
will sometimes be serviceable. Great advantage
will also accrue from resorting to external deriva-
tion or revulsion, after sufficient depletions iiave
been practised. The repeated application of blisters.

so as to produce merely a rubefacient effect ; or
of sinapisms ; frictions with irritating liniments
(F. 299, 300.), especially with capsicum, croton
oil,&e. ; and stinging with nettles ; are frequently
beneficial. But I have found, in numerous cases,
since 1821, of both common and eruptive fevers,
where these means have failed, that warm tere-
bintliinate epithems, placed over the chest or
epigastrium, or even upon the insides of the thighs,
and retained or repealed until erubescence and
burning heat were caused, have produced decided
benefit. Such instances have occurred where
I have met with other practitioners, amongst
whom I may mention JMr. FAX0>f, Mr. Barn-
well, Mr. Painter, Mr. Bryant, Mr. Byam,
Dr. T. Williams, and INIr. Leese, who have
witnessed with myself the efficacy of this appli-
cation.

162. B. Antimonials, especially the tartar emetic
solution, have been much employed in this com-
plication ; but the caution already offered re-
specting their use(§ 142.), particularly in the low
forms of fever, should not be overlooked. The
doses of the potassio-tartrate of antimony ought
not to exceed the quantity advised above. When
judiciously employed, and following moderate de-
pletions, it is productive of great benefit, and very
frequently prevents the necessity of recurring to
bloodletting. In some of the states of predomi-
nant pulmonary affection, where, although occur-
ring early in the disease, vascular depletion can
hardly be ventured upon, this substance, eitlier
alone, or with camphor and small doses of squills
and opium, will often prove efficacious. In such
low forms of the complication, especially when
supervening late in fever, even tartar emetic may
not be cither beneficial or indicated. In these,
the external derivatives j\ist mentioned ; ipecacu-
anha with camphor and opium, or also with squills;
the decoction of senega, and other medicines ad-
vised in the Asthenic Furm o/' BRONcniTis ( 79.
84.) ; will prove most serviceable. It will some-
times become a question, whether or not wine and
the more active tonics and stimulants, sometimes
required at an advanced stage of adynamic fevers,
should ever be administered when complicated
with nervous or asthenic bronchitis or pneumonia.
To this I would answer, that, having resorted to
the means already advised, or merely to dry cup-
ping, the external applications and the internal
medicines just insisted upon, without benefit, vas-
cular depletion not being further admissible, the
administration of appropriate stimulants and tonics
should not be longer delayed, and more especially
in an advanced stage of fever, the external means
being repeated and assiduously persisted in. Be-
fore, however, wine and the more heating stimu-
lants and tonics be resorted to, the effects of cam-
phor in full doses, or of ammonia, with opium,
&c., should be fully tried. If the bronclii be
loaded with accumulated mucus, and the respira-
tory functions thereby obviously impaired, the ex-
hibition of an emetic (F. 198. 402.), or repetitions
of it, will be serviceable, however late in the disease.

163. y. The treatment just advised is also ap-
plicable to the more rare complication with pleu'
ritis. Vascular depletions are more generally re-
quired, and maj' be carried to a somewhat greater
extent in it, than in associated bronchial and pneu-
monic afl^ections. Full doses of calomel, James's
powder, and opium, are particularly indicated ;

FEVER — Curative Treatment. 931

and if the mouth become afl^ected, the occurrence
may be considered favourable. The external re-
medies sliould be strenuously enforced, particu-
larly the turpentine epithem, on the outside of
which a piece of soft leather or oiled silk may be
laid, in order to prevent evaporation. The tartar
emetic solution should also be prescribed ; and
the more largely, the more manifestly sthenic or
inflammatory the fever and local affection ; in
order to economise the loss of blood.

164. c. l be affections nf' the cerebral functions
owing to their nature, often present more promi-
nent characters in fevers, and hence attach to
themselves greater importance than they are
actually entitled to. Even in cases where they
have been most remarkable, the post mortem exa-
mination has not disclosed any lesion sufficient
to account for them. The circumstance of their
being more frequently caused by the state of or-
ganic nervous influence in the encephalon, and by
morbid changes in the blood, and of their being
often consequent upon affections of the respiratory
functions and of the digestive mucous surface, has
been too generally overlooked ; and a treatment
has consequently been adopted, more calculated to
interfere with the salutary eflx)rts of nature, than
to remove morbid conditions which have actually
existed. If we analyse those cases which present,
in the common estimation, very prominent lesions
of the cerebro-spinal functions, and compare
these lesions — whether of mental manifestation
or of voluntary power — with those evinced by
the other organs or systems, — with the functions
of digestion, assimilation, circulation (comprising
the changes afltcted by respiration on the blood),
secretion, and excretion — in what will the pre-
dominance of cerebral disorder be found to con-
sist ! and, still more, to what organ or system will
the balance of morbid action incline? Keeping,
therefore, this inference in view, that prominent
symptoms, especially those connected with the
sensative functions, do not always prove, or truly
indicate, the amount of lesion, or even its seat in
the part disturbed, the cerebral complications of
fever should receive a due but not an exclusive
attention, even when most predominant. In proof
of this position, 1 can appeal to no very limited
experience, and to those who, like myself, have
witnessed the worst forms of typhus fever, as they
occurred in various parts of France and Germany
soon after the peace, whether or not death was
caused more by the cerebral than by the other
changes, judging from an intimate analysis of the
symptoms in the latter stages, and of the morbid
appearances. Indeed, in many instances, the le-
sions of other organs were individually greater
than those found within the cranium.

165. In cases of fever attended by very marked
determination of blood to the head, or by vascular
action increased to an inflammatory state, or by
severe cerebral symptoms at advanced stages of
the 'disease, vascular depletions ; full doses of calo-
mel, with purgatives, or followed by them, espe-
cially by Formula 216., and enemata (F. 140.
150.) ; and cold applied to the head, particularly
the cold aft'usion on it, the rest of the body being
kept moderately warm, or revulsants being applied
to the lower extremities; should be promptly re-
sorted to. Bloodlettings ought not, however, to be
too implicitly confided in, for they will never of
themselves remove this complication. No advaa-

30 2

932

tage will accrue from opening the temporal artery
or jugular vein, above that derived from bleeding
from the arm ; and even this will not be frequently
requisite ; the more especially as an equal or even
greater benefit, at a less waste of blood, will re-
sult from cupping largely on the nape or over the
mastoid processes, or from leeches in the latter
situation and occiput. Both bleeding and the
cold affusion on the head may be carried to an
injurious length, especially if it be attempted to
remove, or materially to benefit, within an inade-
quately short time, this complication; many of
the phenomena of which are dependent upon, and
inseparable from, tiie fever, and to be removed
only with it. Let not, therefore, this or any
other treatment be mischievously persisted in,
with the mistaken view that it can accomplish
what the nature of the disease renders impossible ;
but at the same time, let it not be insufficiently
employed. Purgatives, especially those with ca-
lomel, with James's powder, or other antiiiionials,
should follow early depletions, particularly if this
complication occurs early in the fever; and at
later periods the calomel may be given with
opium, every four or six hours, the bowels freely
opened, and derivatives applied to the insides of
the thighs or calves of the legs. As to the treat-
ment of Coma and Detjrium in fever, it is unne-
cessary to add any thing to what I have advanced
in those articles, and at other places in this. It
should, however, be recollected, that other com-
plications may coexist with predominant cerebral
aflection, particularly in adynamic fevers ; and if
this affection be very severe, or consist of deli-
rium or coma, and more especially if it depend
upon a morbid state of the blood, these complica-
tions may be thereby masked, and proceed to a
fatal height before they are delected. This we
have seen to be the case as respects the lungs and
intestines, and it is not less so as regards the
liver and spleen. Nor should the readiness with
which sphacelation occurs, either from the pres-
sure of the body, or from excoriating discharges,
and inattention to cleanliness, and to the pre-
servation of a dry state of tiie linen, or from blis-
ters or injuries, "be overlooked ; for an early in-
quiry after the first indications of this occurrence
will ofien prevent much trouble, suffering, and
danger,

166. F. The regimen and ranagement nf pa-
tients in fever are much more essential to re-
covery than is sometimes si:ppo?e(l. Not ordy
are the purity, dryness, and rapid renewal of the
air deserving of attention, but also its tempera-
ture, which ought to be regulated, as well as
the quantity oT the bed- clothes, accordmg to
the states of vascular action and vital power.
The patient should be skieencd from too free a
current, p;n-ticularly of cool air, and especially
in fevers of low excitement, as the pulmonary
and, indeed, other complications may be induced
by this circumstance. When excitement is fully
developed, the air should be cool, and the clothes
light; but in other conditions, especially when
the temperature of the body does not rise above
natural or is depressed below it, proportionately
increased warmth is necessary, in respect of bntli
the air and the quantity of bed-clothes. The
room aNo should be darkened, all noise excluded,
and mental excitement or irritation carefully
avoided. The mouth and gums ought to be

FEVER — CunATivE Theatmekt.

washed from time to time, and the linen changed
very frequently ; the surface of the body being
sponged with simple or medicated water, of a
temperature in relation to the forms of fever, as
stated above (§ 140.). All the evacuations ought
to be passed in the bed-pan without leaving the
supine posture ; and if they take place involunta-
rily or unconsciously, oiled silk should be placed
next the bed, and folded sheets underneath the
patient. Care must be taken that retention of
urine or over-distension of the bladder does not
occur, without being detected at oii'-e and reme-
died. 'J'he accounts of tiie nurse must not be
trusted to in this, more than in other matters, but
the state of the abdomen above the pubes care-
fully examined. If pressure cause excoriations,
or threaten sloughing, measures should be imme-
diately taken to prevent further mischief. The
part may be washed, as Dr. Graves advises, with
u solution of ten to fifteen grwins of nitrate of
silver in an ounce of water, or with a weak solu-
tion of the super-acetate of lead in spirits of tur-
pentine ; or with this latter and dilute pyroligne-
ous acid ; or it may be covered by defensive
plasters. If sloughing occur, carrot poultices
copiously sprinkled with the chlorates, particu-
larly of lime, or with spirits of turpentine, or with
kreosote, must be employed ; or poultices with
bark, to which either of these may be added ; and
pressure removed from the part and its immediate
vicinity bj' air-pillows, or by the use of Dr. An-
nott's hydrostatic bed. But these unpleasant
occurrences should be prevented, where the ap-
pearance of the soft solids and the prostration of
the patient indicate a disposition to them, by hav-
ing early recourse to these latter means, and by
supporting vital power by the means appropriate
to existing pathological states.

167. G. The food and diink in fevers should be
varied with the existing states of vascular action
and power. In periodic fevers, light food maybe
allowed in proportion as the apyrexial period is
complete. But in continued fevers, particularly
during the early stages, and whilst excitement
continues, no food beyond thin water gruel, fresh
whey, and orangeade or lemonade, should be
given. The best drinks during excitement are
those prescribed in the Appendix (F. 592. etseg.),
or any of the miineral acids in sugared water, and
(lavoured by lemon peel, or weak black tea, accord-
ing as they may be congruous with the medicines
prescribed internally. Thus, care should be taken
not to allow the patient any of the mineral acids,
wiien calomel, or any of the other preparations of
mercury, is being taken. But when vascular re-
action is low or imperfect, and vital power consi-
derably depressed, or when the pulse is very
ra|)id, tumultuous, and soft. Seltzer or soda water
with old wine, hock, or weak punch, or wine
whey, spruce beer, brisk bottled stoiit or brisk
bottled beer, &:c., according to the peculiarities of
the case and the previous habits of the patient,
may be allowed. If coma be present, green tea is
one of the best beverages that can be allowed ;
and if the powers of life be very depressed, it may
bu made into a weak punch ; the patient also be-
ing often roused by talking to him on lively inter-
esting topics. He may be allowed oranges, grapes,
or lemons sweetened with sugar, particularly when
the mouth is foul and dry ; but care should be
taken that neither the i)ulp nor the stones are

FEVER— Curative Treatment. 933

should not be overlooked. Hence the great suc-
cess ascrihed by the older writers to an emetic ia
such circumstances. Therefore, after the action
of an emetic, tiie bowels also ought to be freely
opened by a mild purgative, the operation of
which may be promoted by enemata ; and the treat-
ment, in other respects, should proceed according
to the type and form the disease assumes, and the
stage at which our assistance is required. If a
relapse is merely threatened, or if the symptoms
characterising its invasion be present, the remedies
ju~t mentioned are especially indicated, with the
other means above advised (§ 121,122.) in this
period. (See the art. Debility, § 36. 43. 45, 46.
for still more paiticular directions as to the ma-
nagement of Convalescence and as to the mea-
sures that ought to be adopted.)

Swallowed. These will often both refresh and
^eed the patient as much as is necessary until the
decline of the disease. If the fever be prolonged,
or of a slow nervous character, very light nou-
rishment may be allowed as the excitement sub-
sides, such as roasted apples, jellies, in some cases
asses' milk, sago, arrow root, tapioca, wine whey,
chicken or mutton broth, weak beef tea, &;c.

168. fl. Convalescence from fevers requires the
utmost discrimination of the physician, and yet
both the patient and his friends are but too eager
to supersede Iris functions. The ill consequences
of mismanagement in this period are chiefly —
1st, Relapse ; — 2dly, Inflammatory atfections of
the lungs, bowels, or brain; — -Sdly, Dropsical
effusions ; — and, 4thly, INIental alienation. These
are usually caused — a. by the patient getting up
too early from bed ; — b. by errors in diet ; — c.
by too early exposure to the weather, to the
sun's rays, to cold, malaria, &:c. ; — </. by men-
tal excitement or irritation ; — and, e. by pre-
mature exertion of the physical powers. Con-
valescence is prolonged and difficult, and the
consequent risk of some one of the ill effects of
mismanagement supervening proportionately great

— a. when the fever has been unusually severe ,

— B. when it has been very promptly and actively
treated at its commencement, and either quickly
subdued, or thereby rendered of short duration ;
— ;;'. when it has slowly subsided without any
regular crisis; — J'. When it has been complicated
in the severer forms stated above.

169. /. Relapses, as well as inflammatory or
other affections of the principal viscera, are most
frequently caused by getting about too soon, and
by indulgence of the appetites, particularly that
for food, which very generally requires restraint at
this period. When the disease has been short-
ened by large bloodlettings, these, or other ill
effects, as mental alienation in persons predisposed
to it, are very apt to occur. 'I'he greater is the
necessity, therefore, to place the patient upon the
strictest diet and regimen during convalescence.
At the same time he should not be kept too low,
either in respect of food or medicine ; otherwise
anaemia, dropsy, mental disorder, chronic debility,
and rheumatism, &c. may be thereby producetl.
Change of air, sea-voyaging, and travelling, with
due precaution against cold or wet, will parti-
cularly assist recovery. If either of these cannot
be adopted, the use of gentle tonics, especially
when the situation is not remarkably healthy ;
and strict attention to the bowels, and indeed to
all the secretions and excretions ; are particularly
necessary. The patient should not be in too great
haste to remove llie hair after fever, or to have it
cut too close ; and he should be particularly careful
not to expose his head to the sun's rays. The
return to his occupations — whether mental or
physical — as well as to his usual food, ought to
be gradual. As the cuticle and hair generally
fall off after severe fevers, warm or tepid baths,
when convalescence is far advanced, will promote
the patient's comfort.

170. If, notwithstanding these precautions, a
relapse takes place, the treatment should proceed
according to the principles developed in this
article with reference to its cause, the progress it
has made, the state of action, and of power,

&c. The fact of the greatest proportion of cases jg^,.^ Konigs. 17»2.- Togf/, Analecta de Febribi
of this kiud being occasioned by errors in diet I Halis, 1782 Burserius, Institut. Med. Pract. vol. ii

BiBLioG. AND Refer. — Medici Antiqui, Graci, La-
tini, atque Arabcs, qui de Febr. scripserunt, fol. Venet.
1.51)4. — Aviccnna, Canon. 1. iv. fen. i. tract.!, cap. i. —
Concoyct^iu, 'De Febr. Liber. Papi.-p, 14.S5 J. M. Sa-
vonarola:, Pract. Canonica ile P'ebr. Lugd. l.^GO B.

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Fezold, De Prognosi in Feb. Acutis. Lips. 1778

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Analecta de Febribus.

3 O 3

FEVER, INTERMITTENT — Pathoiogy.

934

F. G. GoMhagen, De Diagnosi Feb. in Primo Stadio.
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Fever, 8vo. Ed. 1785 M. Stall, Aphor. de Cognos. et

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M. Bt-rzig, Dc Febribus in Genere. Colon. 1791 —

J. C. Reil, Ueber die Erkenntnis. u. Cur. d. Fieber.
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cap. xxxvii Haygarth, On the Prevention of Fevers,

8vo. Bath, 1801 G. Fordyce, Five Dissertations on

Simple, Intermittent, and Continued Fevers, &c. 8vo.

1794_1803 E. Ham, Versuch einer Pract. Nosol. der

Fieber. Brauns. 1800. — G. C. Reich, Von Fieber. u.
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Chemischer Hinsicht.Svo. Berl. 180!.— G.3i.ftaM,Ueber
die Reichische Fieber-Theorie. Erlang. 1801. — Thos.
Clark, Observat. on the Nat. and Cure of Fevers, &c.
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Nat. and Seat of Fever. Lond. 1802.— r. Beddoes, Re-
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et de la {meilleure Methode de les trailer, &c, Paris,
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1799. ; Treatise on Fevers, &c. 8vo. 4th edit. 1826. ; et
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Stanger, on the Suppression of Fever, 12mo. Lond,

1812 Stoker, Treatise on Fever, 8vo. Lond. 1815. —

T. Mills, On Bloodletting in Fever, 8vo. 1818. — J. &
Ackermann, De Construend. Cognoscend. et Curand.
Febr. Heidel. 1809. — Brera, Annotazioni, &c. cap. i. —
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Pinel, Nosographie Philosophique, t. f. passim. —

— Pujol, Oiuvres de Med. Prat, par Buisseau, t.i'i. passim.
— Faurnier et f'aidy, in Diet, des Sciences Medicales,
t. XV. p. 240. — J. van Rotterdam, On Bloodletting in
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Institut. Pract. Med. t. i. Vien. 1816. —Le«5o?«, Me-
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Reports of Practice in Clin. Wards of Infirmary in Edin.
8vo. ed. 1818, p. 14. et seq. — A. G. Richter, Die Specielle

Therapie, &c. b. i Bateman, On Contagious Fevers,

8vo. Lond. 1818. ; and Reports on the Dis. of Lond. 8vo.

1819 Black, Clinical and Pathol. Reports, &c. Newry,

1819. J. Johnson, Influence of Tropical Climates on

European Constitutions, 4to. edit, passim. — Dickson, On
the Prevalence of Fever, and on Houses of Recovery,
Brist. 1819. — R. Jackson, History and Cure of Febrile
Diseases, 8vo. 2 vols. Lond. 182(i. — C. E. Lucas, The
Princip. of Inflam. and Fever, 8vo. Lond. 1822. — C. F.
Tacheron, Recherches Anatomico-Pathol. sur la Med.
Pratique, vol. ii. 8vo. Paris, 1823. — F. Barker, and
J. Cheyne, Report of the Fever lately epidemic in Ire.
land, &c. 2 vols. 8vo. Dub. IS'Zl.— Author, in Quarterly
Journ. of Foreign Medicine, vol. ii. p. 433. 1819 and 20,
and vol. iii p. 7.99. ; Lond. Medical Repository, Jan. 1822,
p. 19.; in Ibid. May 1822, p. 376.; in Ibid. June 1822, p. 483.,
ibid. Sept. 1827, p. 236. ; Lond. Med. and Phys. Journ.
Dec. 1820, p..530. ; Medico-Chirurg. Review, vol. viii.

p. 36S. J. Annesley, Researches into the Diseases

of India and Warm Countries, imp. 4to. vol. ii. p. 409.

Cheyne, Report of the Ilardwicke Fever Hosp. &c, ;

Dublin Hospital Reports, vol. i. p, 1., et vol, ii. p. 1. et
vol. iii. p. 1. — Goodison, in Ibid. vol. i. p. 191. — Proud-
foot, Ibid. vol. ii. p. 2."i4. —Speer, in Ibid, vol. iii. p. Itil.

Jl. Marsh, in Ibid. vol. iv. p. 4 )4. — R. J. Graves and

W. Stokes, in Ibid. vol. v. p. I.— S. l'ercival,in Transact,
of Association of King's and Queen's Coll. of Phys.
Dublin, v<jl.i.y>.'24X — O'Brien, in Ibid. vol. i. p. 404.,
et vol. il. p. 472. — R. Gratlan, in Ibid. vol. i. n,433., et
vol. lil. p. 3l6.--,S'<ote)-, la Ibid, vol.li. p.397.— /'. Barken,

in Ibid. vol. ii. p. 515. — R. Reid, in Ibid, vol iii. p.l.,rol.r.
p. 266.— W. Pickets, Ibid. vol. iii. p. 194. —J. O'Brien,
Ibid. vol. iii. p. 448., vol. v. p..'jl2., et Ibid, new series,
vol.i. p. 258. — R. J. Graves, in Ibid, vol.iv. p. 408. — Ho-
sack, in Med.-Chirurg. Review, by J. Johnson, vol. ii.
p. .54. — Bally, in Ibid. vol. vii. p. 498. — Chambers, in
Ibid, vol.vi. p. 161 — Hewett, in Ibid, vol.vi. p. 198. —

Broiissais, in Ibid, vol.vi. p. 336 O'Reardoh, Ibid.

vol. X. p. 259., et vol. xi. p. 181. — Stoker, Ibid. vol. xi.
p. 337. — J. Johnson, Ibid, vol.xii. p. 342. — Smith and

Tireedie, Ibid. vol. xii. p. 385 O'Brien, Ibid. vol. xiii.

p. 408. — Stevens, Ibid. vol. xvii. p.323. — Hackett, Ibid,
vol. xviii. p. 149. — Roots, Ibid, vol.xix. p. .538. — Latham,
Ibid. vol. xix. p.544. — J. R. Park, The Pathology of
Fever, &c. 8vo. Lond. 1822. — D. Pring, Exposit. of the
Principles of Pathology, and of the Treaf. of Dis.&c. 8vo.
18'23. — /'. A. Brera, De' Contagi e della Cura de' loro
Affetti, &c. &c. 2 tom. Padov. 1829. ; et Prolegomeni Cli-
nici per servire d'Introduzione teoreticaallo Studio Prac-
tice della Med. 8vo. Pad. 1823. —A. N. Gendrin, Re-
cherches sur la Nat. et Causes prochaines des Fitvres,
2 tom.8vo. Paris, IS'iS.— Coutaticeau et Rayer, Diet, de
Medecine, t. ix. p. I., et t. xii. p. 340. — Froclick, Reuss,
and Pitchaft, in Revue M^dicale, 1824. t. i. p. 163. 323. —
Van Dekeere, Nouv. Biblioth. Medicale, t. ix. p. 358. 530.
— J. C. A. R^camier, Recherches Physiologiques sur
I'Etat Febrile ; en Recherches .sur le Traitm. du Cancer,
t. ii. p. 285. Paris, 1829 ; et Rev. Medicale, 1824, t. i.
p. 193. — J. Bauillaud, Traite Clinique et Exp^rim. des
Fievres dites Essentielles, 8vo. Paris, 1826. — W. Stoker,
Patholog. Observat. on Contin. Fever, Ague, Tic Dolo-
reux. Measles, &c. 8vo. Dublin, 1829. — J?. G. Boisseav,
Pyretologie Physiologique, ou "I'raite des Fievres, &c.
ie edit. Paris, 1831. ; et Nosographie Organique, &c.
t. i. passim. Paris, 18'i8. — Tommasini, Dell' Inflam.
e della Febbre Continua, &c. 2 t. 8vo. Pisa, 1826. ; et
Sullo Stato attuale della Nuova Patologia Italiana, &c.
Milano, 1827. — i/aj!n«(/, Glasgow Med. Journ. vol. ii.
p. 294. — Bright, Reports of Med. Cases, &c. vol. i. p. 176.
et seq. Lond. 1827, imp. 4to. — ElUotson, Lectures on, in

Med. Gazette, vol. x., and Lancet, vol. xvii. passim

Clanny, in Ibid. vol. xvii. p. 107. — F. J. V. Broussais,
Exam, des Doct. Med. et des Systemes de Nosol. t. i.
Paris, 1826.; et Commentairesdes Proposit.de Pathologie,
&c. 2 tomes, 8vo. Paris, \ii29.—Andral, Clinique Medi-
cale, t. iii. iv. et v. passiin. Paris, 1830. — Roche et San-
son, Nouv. Elemens de Pathol. Medico-Chirurg. t. v.
Paris, 1831. — Alison,in Ed. Med. and Surg. Journ. vol.
xxviii. p. 294. ; and Principles of Pathology. Edin. 1833,
p. 161. — Law, Edin. Med. and Surg. Journ. vol. xxxiii.

p. 80 — S. Smith, Treatise on Fever, 8vo. Lond. 1830

i/?//c/arad, (Jonspectus Morborum. Ber. 1831 W.Stokes,

Lectures on Practice of Med., in Med. and Surg. Journ.
vol. V. passim. See also the Bibliogkaphy subjoined to
the chapters on the Special Forms of Fever : the above
having rel'ereuce chiefly to Fever generally.

Those who wish a further reference to the subject may
consult also the collections of Bonet, Manget, and
Ploucquet, where comparatively few of the above works
will be found, in this case, as in every other throughout
the work,

XI. Intermittent Fever. Svn. — AittXEiVovTEf
TTupEToi, Hippocrates and Galen ; Anelus,
Young and Good ; Kalte Fieher, uecheljieber.
Germ. ; Paludal Fever, Periodic Fever, Ague,

171. Defin. — The febrile phenomena running
their course rupidJy, observing a certain succession,
usually terminating in crises, and returning after
regular apyrexial intervals.

172. Interraittents have been divided by mo-
dern writers — into the quotidian, tertian, quar-
tan, &c. ; into vernal and autumnal, — into
regular, erratic, and anomalous, — into simple,
complicated, and masked (Fourrier, Vaidy, &c.).
But in addition to these types, which have refer-
ence merely to the intervals between the acces-
sions of the paroxysms, agues assume certain
forms or cliaracters, whicli are still more im-
portant than they are, in a practical point of view.
These have been variously distinguished by
writers. .T. V. Frank has arranged them into the
nervous, the gastric, and injhimmatory, the second
and third of these, in being complicated, often as-
suming a rem'ttent type. .T. Frank has divided
them into 1st, iheevident, and '2nd, the masked ; the
former being — a. benign; b. malignant ; c. regular ;
Had, d. irregular, M. Pinel has classed them

FEVER, INTERMITTENT — Simple Ague,

935

into iiijlammatorii, gastric, mucous, adynamic, and
ataxic; — M. Boisseau, into be)iigit, pernicious,
or complicated, and erratic, anomalous, or masked ;
— and the Author, into — a. the simple, or un-
complicated ; S. the injlammatury ; y. the ady-
namic; J. the complicated ; and, e. the anoma-
lous, or masked. — I shall follow the same arrange-
ment here.

173. — i. Simple Ague — Mild, uncomplicated,
or benign Intermittent — appears after a longer or
shorter interval from the time when the morbid
impression was made by its cause upon the sys-
tem. During tlmformatire or premonitory stage,
symptoms of disorder may be more or less mani-
fest ; but they are often very slight, or hardly dis-
cernible, until shortly before the paroxysm, which
may occur suddenly or unexpectedly, with the
MsxiaX invading symptoms ($ 35.). The premoni-
tory phenomena are essentially the same in ague
as have been described (§ 33.) ; but frequently,
during the few days immediately preceding the
full developement of the fit, slight fever appears,
and returns about mid-day or a little before ; con-
sisting of accelerated pulse, white tongue, thirst,
lassitude, and pains in the back and loins, loss of
appetite, high-coloured urine, &c.

174. a. The fiillti developed paroxtism com-
mences with a cieeping chilliness along the spine,
■with languor or a sense of fatigue, paleness and
slight collapse of countenance, lividity of the
nails, and a feeling of universal coldness. The
temperature of the surface is reduced ; the skin
is dry and rough, sometimes with livid patches,
or spots, especially on the extremities ; shiver-
ings, tremblings, or rigors occur ; and the teeth
chatter. Sighing, oppression, or anxiety at the
praecordia, yawning, stretchings, difficult or forced
respiration, occasionally cough, and nausea, are
also present. The patient complains of a con-
strictive pain in the head and temples ; of aching
of the back and loins ; and of clamminess and a
disagreeable taste in the mouth. The tongue is
white or loaded ; the appetite lost ; the urine
limpid, sometimes pale, and voided often ; and
the bowels are generally constipated. Sickness
and bilious vomiting soinetim.es supervene and
hasten the next period ; the pulse is constricted,
small, weak, and often accelerated ; and the
mental powers are weakened, or overpowered. —
Such is the cold stage, which answers to the
period of invasion described above {§ 35.).

175. b. These symptoms, having continued
from half an hour to three, very rarely to four,
hours, are followed by transient flushes of heat, at
first alternating with rigors ; by restlessness ;
great heat of surface ; flushings and turgescence
of the countenance and skin ; rending headach
and throbbing of the temples ; by a full, strong,
and free pulse ; high-coloured and scanty urine,
intense thirst, and most of the symptoms charac-
terising the period of excitement (§ 36.), with the
first part of which especially, this, the hot stage,
corresponds.

176. c. After a time varying from two to eight
hours, but most frequently three or four, perspir-
ation breaks out over the forehead and breast, in-
creases rapidly, extends over the whole body, and
soon becomes profuse. All the symptoms now
subside quickly ; the urine being more abundant
and depositing a laterititious sediment ; the bowels
being more readily acted upon, and the n in!

more composed. A sense of exhaustion only now
remains, and the patient often falls asleep ; and the
paroxysm is at an end. This, the siceating stage,
corresponds with the periods of crises and decline
(§ 40, 41.). The whole duration of the fit varies
from four to sixteen hours, the common length
of it being about six or seven.

177. A. The Types and Intermissions. — The pa-
roxysm, having terminated more or less completely
in health, some degree of lassitude and debility
usually remaining, is renewed after an interval,
the duration of which constitutes the type of ague,
— alter twenty-four hours, in the quotidian; after
forty-eight hours, in the tertian ; and afterseventy-
two hours, in the quartan types. The most com-
mon of these is the teitian, which is considered the
primary type of fever. These form the primary
and regular types of intermittents ; but there are
others which are irregular, as the double, triple,
and reduplicating tertian ; the double, the triple,
and reduplicating quartan, &c. Of these, the
double tertian is the most common, and differs
from the quotidian only in having, on alternate
days, fits corresponding in severity, character,
and duration. The triple tertian has two fits on
one day, and one the next. A duplicated tertian
has two paroxysms in alternate days, with one
whole day of intermission. A double quartan has
a fit on one day, a slighter fit the next, and a
complete intermission on the third day ; the par-
oxysms returning in a similar manner on the
fourth and fifth. A triple quartan has a par-
oxysm on each day — on the two usual days of
intermission ; but, as in the case of the double
tertian, the fit of each differs in character, and
period of accession, so that the one returning
every fourth day is alike. The duplicated quar-
tan has two paroxysms on one day, with two
whole days of intermission. Besides these, in-
tervals of four, five, six, seven, or eight days may
occur, or even longer periods, constituting erratic
or atypic Ibrms of ague; and maybe caused by
treatment, by atmospheric vicissitudes, or states
of the digestive organs ; but they are compara-
tively rare.

178. a. The quotidian usually begins in the
morning, and continues the longest ; having the
shortest intermission, or period between the ter-
mination of one fit, and the commencement of
the next. — b. The tertian usually appears about
noon: the duration of the fit being about seven
or eight hours, but that of its hot stage being
often the longest.— r. The quartan commences
in the afternoon (from two to five), and has the
longest cold stage, and the shortest paroxysm.
— d. The tertian is the most common, the regu-
lar quotidian the least so. — e. Agues are most
prevalent in spring and autumn ; tertians and quo-
tidians in spring, and in adults of a sanguineous
or bilious temperament; and quartans in autumn,
in very young persons, in females, and in the lymph-
atic temperament. Tertians are the mildest and the
shortest in duration ; and sometimes disappear of
ih^iselves. Quartans are removed with greatest
difficulty, particularly in autumn ; and they occa-
sionally continue till the following spring.

179. B. The longer the apyrexial interval, the
more complete is the restoration to health; but
during this period, or inJermissio)!, the patient often
complains of weakness, of heaviness or pain of
the head, of a sense of cold, want of appetite, &cc. ;
304

FEVER, INTERMITTENT — Complicated Ague,

936

many of the symptoms stated above, as indicating
the formative period of fever (§ 33.), being pre-
sent. Indeed, the interval in every respect cor-
responds wilh this period. When the ague
continues some time, although it may not cliange
its type or form, as it is then prone to do, es-
pecially in warm climates, the patient becomes
weaker, loses flesh, has a sallow hue, and expe-
riences obstruclions or enlargements of the spleen,
liver, mesenteric glands, ix.c., with a deranged
state of the secretions and excretions ; the disease
passing into the complicated states (^ 183.), or
terminating as will appear hereafter (§ 189.).

180. C. The conversion of one type of ague
into another often occurs: tertians and (juartans
changing to quotidians, or to double or triple ter-
tians and quartans, especially when they become
aggravated ; and quotidians into tertians when they
are somewhat ameliorated. Agues, particularly
quotidians, may also be converted into remittents,
or even into the continued type, by the constant
operation of the exciting causes, or by other
powerful determining influences ; but they often
assume a complicated or an irregular form in the
course of transition. When the fits of a quotidian,
or of a double tertian, or of a triple tertian, ap-
proach each other so closely that the one is
hardly finished before the next commences, the
fever has been called sub-intrans, or sub-intrant ;
and differs but little from a remittent type, ex-
cepting that the cold and sweating stages may be
somewhat more marked in the former.

181. ii. Inflammatory Ague. — Intermittents
with more or less of inflammatory excitement have
been described by Sydenham, Pringle, Hux-
HAM, Selle, Fizfau, Boisseau, &c. Mr. An-
NESLLY and the Author have shown their fie-
quency in warm climates, especially during the
cold seasons, in elevated situations ; and in persons
of a previously healthy constitution. They are
characterised by very severe rigors in the cold
stage, followed by vomitings and intense vascular
reaction ; unquenchable thirst ; by severe and rend-
ing headach, sometimes with delirium ; by great
heat and by (urgescenceof the countenance and of
the whole surface. The reaction during the hot
stage is generally attended, particularly in ple-
thoric persons, by marked determination to, and
vascular turgescence of, particular viscera, ac-
cording to accessory or determining causes. 'J'he
organs which thus evince a predominance of vas-
cular action, are, the encephalon ; tlie liver and
stomach, especially in warm climates, and in au-
tumn in cold countries ; the lungs and bronchi, in
some instances ; and the uterine organs, in rare
cases. — Tliis form generally assumes a tertian
or quotidian type ; is easily removed if actively
treated, owing to its common occurrence in sound
constitutions; but it rapidly passes into oroanic
change, or into the remittent or continued type, in
hot climates, when neglected or improperly
treated.

182. iii. Ague With oppresr-ed Power , OT TpaT\.;\\i-
ing more or less of an adiinamic character, is
often met wilh in Europeans who have resided
long in hot miasmatous countries ; in debilitated
persons living in low, marshy, and moist coun-
tries; and in the intemperate ; but it rarely occurs
in these in an uncomplicated state. Whilst vascu-
lar reaction and vital power rise above the standard
presented by simple agtie, in the inflammatory

form ; they sink more or less below it, in the
adynamic. — The cold stage is often attended, in
this latter, by general tremblings, rather than by
strong rigors; and is followed by nausea and
vomiting ; developing a burning or pungent heat
of the skin, which is dry, and occasionally some-
what sallow. The pulse is very quick ; the
tongue loaded, and red at the edges ; and the
epigastrium tender and oppressed. This state
nearly approaches the gastric varieti/ of Conti-
nental writers. ?»Iore frequently, however, this
form commences with horripilations, seldom
amounting to trembling or rigors ; often with nau-
sea and vomiting ; fulness at the epigastrium, and
headach. To these succeed increased heat, al-
ternating at first with chills ; a quick, oppressed,
but not hard or full pulse ; somnolency, and im-
perfectly developed and hot and sweating stages.
— Thirst is not much increased ; the heat is mo-
derate ; the skin is sallow, yellowish, or lurid ; the
urine citron coloured; and the subsequent per-
spiration is scanty, or offensive. — This form
usually assumes a quotidian, double tertian, or
triple quartan type ; more rarely tertian ; and
sometimes erratic. It commences also irregularly,
either early in the morning, or in the evening, or
at night. The intervals are attended by more or
less disorder ; by an unhealthy appearance of the
surface, a loaded tongue, and morbid excretions.
The lower grades of ague are more frequently
complicated (§183.) than simple ; or, if the lat-
ter, they soon superinduce congestions, obstruc-
tions, and organic lesions of important viscera,
most frequently of the stomach and bowels, of the
spleen, liver, mesenteric glands and pancreas.

183. iv. Complicated Ague — Intermittent per-
nicieuse, of the French — Intermittentes comitate,
of ToRii, — the Malignant, of some writers —
is very frequent in warm climates, and in marshy
districts in the south of Europe ; and is sometimes
met with in parts of this country. It usually
presents the preceding form as respects the states
of vascular action and power, but it may assume
more or less of the inflammatory character, par-
ticularly in the early paroxysms. It often has
less perfect intermissions than the foregoing forms,
especially after two or three paroxysms ; is gene-
rally quotidian, double tertian, or triple quartan ;
and frequently passes into a remittent or nearly
continued type, especially in Europeans who have
resided long in hot countries, and in the intem-
perate. It appears in two ways; — a. primarily
in a faulty constitution, or in persons with previous
disorder of some important viscus, — and, h. as
an advanced grade of either of the preceding
forms. The most Irequent complications are with
diseases of — a. the digestive and biliary organs
and spleen ; B. of the thoracic viscera ; y. of
the cerebro-spinal functions ; and, 5'. of other
parts.

184. A. ]['ith disease of the abdomijial organs,
ague presents diversified symptoms, according to the
viscus especially affected. — a. If the stomach be
particularly diseased, severe, burning pain at the
epigastrium, with tenderness, distension, nausea,
and vomitings, which are increased by whatever is
taken into the stomach ; distressing flatulency ;
dry or red tongue ; high-coloured and scanty
urine ; sallow or depressed countenance ; yellow
streaks around the mouth ; imperfectly developed
hot stage, with a sharfi quick, and contracted

pulse; pungent heat on the trunk, with little al-
teration or even depression of it in the extremities ;
intense thirst, hiccup, and headach or delirium,
are commonly present. — b. If the livei- is prin-
cipally aflfected, fulness, pain, oppression, or ten-
sion at the epigastrium, right dypochondrium,
and right shoulder : oppressed breathing ; bilious
vomiting ; diarrlioea, or a dysenteric and morbid
state of the stools, which are sometimes black
or bloody ; a jaundiced, sallow, lurid, and iiarsli
appearance of the surface ; and the other symp-
toms just enumerated: are complained of. — c. If
the bowels are chiefly disoidered, the fever assumes
a dysenteric character, the evacuations being
very morbid ; sickness and vomiting are less ur-
gent, or are altogether absent ; and the hot and
sweating stages are imperfectly formed. — d. If
the spleen be diseased, more or less enlargement
is very eviilenl in tlie region of it ; extending into
the epigastrium, and over a great part of the ab-
domen ; most of the other phenomena being also
present. — These complications may co-exist, or
one or two of them may predominate; but they
seldom continue long without assuming still
more dangerous features ; and the patient some-
times dies in the cold stage. The heat of surface
often passes from an acrid or pungent state, to a
clammy or raw condition, as tiie paroxysm sub-
sides ; and the coldness or lividity of the extre-
mities frequently continues through its imperfectly
developed stages — syncope, great debility, quick,
small, and weak pulse ; a dry, brown, red, or raw
state of the tongue ; constant thirst ; anxiety and
oppression at the proecordia; and lastly, delirium,
coma, or death taking place.

185. B. The pulmonnry complication is much
less common than the abdominal ; but I believe
that congestion of tiie bronchi and lungs obtains
to a greater or less extent in most forms of ague,
especially in the cold stage ; and that, in the more
severe states, a sub-inflammatory condition, or
active congestion, often exists, although in a form
that can be recognised only by the aid of the
stethoscope. Dr. Stokes has adverted to this in
his able paper on the treatment of ague. But in
ordinary circumstances, the respiratory organs
merely participate with other viscera of the large
cavities in the congestion characterising the cold
stage. If, however, symptoms of inflammatory,
sub-inflammatory, or congestive disorder of these
organs-continue throughout the hot stage, the ague
may be justly considered as complicated with such
disorder. The symptoms, even when the pulmon-
ary affection is most severe, are not always very
decided, unless the pleura be implicated, which is
seldom the case. Those of catarrh, or of bron-
chitis, are the most common ; but the substance
of the lungs may be seriously affected without
much cough being present ; the respiration b^^ing
only short, quick, or laboured. Particular atten-
tion is therefore necessary when this symptom is
complained of. The paroxysm of ague in this
complication is usuMy quotidian, or double ter-
tian ; and, in character, it may be more or less
inflammatory, and but rarely adynamic, unless it
has continued for some time.

186. C. The cerebral complication is seldom
observed in the early course of ague ; but it often
supervenes on the adynamic and the inflammatory
forms, and upon that attended by the complica-
tions already noticed, especially the abdominal.

FEVER, INTERMITTENT— Masked Ague. 937

According to the particular character which the
cerebral complication during the paroxysm pre-
sents, it has been denominated the delirious, apo-
plectic, lethargic, comatose, soporose, epileptic, con-
vulsive, or paralytic, these affections occasionally
occurring — the delirious and comatose being the
most frequent, the epileptic and paralytic much
more rare. Torti, Starck, VVerliiof, and
Bailly, have adduced cases of the apoplectic
complication ; but it is rather a termination of the
disease — recovery from it being rare. The con-
vulsive state occurs chiefly in children, as ob-
served by Stoll, especially in warm countries.
These states seldom occur in this country, unless
towards the close of a neglected or improperly
treated ague, when the functions and state of the
more important excreting organs have been over-
looked. They are, however, more common in the
south of Europe, as shown by the numerous cases
adduced in the works of Grottanelli, Baillv,
and others.

187. D. Besides the above, several other com-
plications have Ijeen noticed by writers : of these
the most remarkable are, the rheumatic and ar-
thritic, the neuralgic, the asthmatic, the nephritic,
and uterine. But although instances rarely occur
in which these affections accompany a fully deve-
loped paroxysm of ague, they present themselves
rather as masked intermittents, or without a
clearly defined fit.

188. V. Masked Ague — Simulating Intermit-
tent— Febres Intermiltenies larmte, of foreign
writers — may assume most diversified forms ; or
rather, during seasons in which intermittents are
very prevalent or epidemic, numerous affections,
especially those of the nervous system — as neur-
algia, rheumatalgia, arthritic rheumatism, and
sciatica; gout; headach and hemicrania ; amau-
rosis; toothach ; otalgia; catarrh and asthma;
palpitations; painful affection of the spleen, ne-
phralgia, hysteria ; singultus ; gastralgia, or e;;-
teralgia, or colic ; epistaxis ; various disorders of
the stomach; and paralysis — may put on an in-
termittent type. Of the^e, the rheumatic and
neuralgic are the most common ; and as they fre-
quently are occasioned by the same causes as
produce ague, acting in a less intense mode, the
circumstance of their intermittent form cannot be
a matter of surprise. A case of intermitieiit_/f((t»-
lency lately occurred to me, the quantity of flatus
eructated daily from noon to three or four o'clock
being enormous, the patient continuing to belch
without intermission. The type of masked ague
is generally quotidian, double tertian, or tertian,
and sometimes quartan or double quartan. As in
other forms, it is most common in spring and
autumn, especially the former, and when easterly
winds prevail ; and is usually attended by more
or less disorder of the digestive, biliary, and
excreting organs — a successful treatment mainly
depending upon attention to this circum-
stance.

189. vi. Consequences and Terminations op
AcuEk — A. The Effects of ague depend upon —
a. the previous health and strength of the patient;
— h. the intensity of the causes, and the duratinu
of their action ; — c. the continuance of the dis-
ease ; — d. the treatment adopted ; — and, e. 'he
other circumstances noticed above {§ 47.). Inf"..---
miltents seldom continue long, even in the sicile
form, or return frequently, without materidUy

938 FEVER, INTERMITTENT

impairing the vital energy and vascular tone of
the viscera of the large cavities, especially those
of the abdomen. Hence arise — 1st, the compli-
cations described above; — 2dly, remittent or
continued fevers, vi'ith more or less affection of
particular organs, or of the circulating and se-
creted fluids ; — 3dLy, inflammations or structural
change of internal viscera, superseding the pe-
riodic seizures; — 4thly, dropsical effusions; —
5thly, chronic dysentery and diarrhoea; — and,
6th ly, a fatal issue, chiefly in the cold stage,
owing to insurmountable congestion of the lungs,
heart, liver, and spleen, or to rupture of this lat-
ter organ.

190. The congestions of tliese viscera, in con-
nection with impaired organic nervous power,
more especially of the liver and spleen, give rise,
by frequent repetition, t(^ enlargements, to a torpid
state of the former, and consequently to engorge-
ments of the portal vessels and of the hepatic

— Appearances — Prognosis.

mous size. On the Gold Coast of Africa it has
been found double this weight in Europeans. I
saw a case in which it was nearly eleven pounds.
Its envelope sometimes presents appearances of
chronic inflammation — is injected, thickened, and
almost cartilaginous. Its consistence internally is
rarely increased ; but is most frequently dimin-
ished ; its structure being friable, oftener almost
diffluent, or consisting of a greyish black semifluid
substance, traversed by greyish fibrous shreds or
fibres, and containing a sanguineous fluid of a
purphsh hue, or resembling wine lees. Instances
have also occurred where adhesions have formed
between the spleen and stomach, and between the .
spleen and colon in others ; and the thick black
blood of this viscus has been thus discharged
into the digestive canal by ulceration, the matters
passed from the bowels or thrown oflT the stomach
presenting a blackish appearance (Morelli,
Gaste, Bailly). — c. The digestive mucous sur-

ducts; to imperfect secretion and assimilation of i /ace is, in various parts — in the ilium, the caecum.

the chyle absorbed and passed into the mesenteric
veins; to obstructions of the mesenteric glands ;
to obstructed circulation and its consequences,
through the veins contributing to form the portal
circulation ; and ultimately to an unnatural state
of the blood, and structural lesions of the digestive
mucous surface, and of the large secreting and
excreting glands. Hence old and complicated
agues are accompanied with a sallow, sunk or
bloated, and oedematous countenance ; pale lips ;
foul, loaded tongue ; yellowish, foul, or lurid skin ;
fulness, distension, or tenderness at the epigas-
trlutS, both hypochondria, and over the abdomen ;
pain and aching between or under the shoulders,
and in the loins ; clay-coloured, or dark, watery,
offensive, and otherwise morbid stools, the bowels
being more or less disordered ; dark-coloured and
scanty urine ; great debility and dyspnoea ; and a
weak, irregular, and frequent pulse. If rupture
of the spleen occur, acute pa\n is suddenly felt
in the splenic region ; with diffused fulness, pain,
and tenderness of the abdomen ; small frequent
pulse, cold extremities, syncope, &c.

191. B. Appearances in Fatal Cases. — Death
may take place either from overpowering con-
gestions in the cold stage, or from rupture of the
spleen ; but it most frequently results from the
superinduced disease of internal viscera, in con-
nection with exhausted organic nervous power,
and sometimes with a morbid state of the circulat-
ing fluids, particularly in tlie adynamic and com-
plicated forms. The chief lesions are seated in
the liver, sj)I(en, digestive mucous surface, and
lungs. — a. The liver \s often enlarged; its con-
sistence being either increased or diminished ; tu-
bercular or purulent formations being, moreover,
dispersed through its substance. Increased con-
sistence or density, softening, purulent or tubercu-
lar formations, &c. may also exist separately, or
in various combinations. Engorgement of the
vessels with dark blood ; distension of the hepatic
ducts and gall-bladder, witii a dark or greenish
black, thick, and viscid bile ; thickening and in-
jection of the duels and gall-bladder, &c. ; are
often observeil in connection with other lesions,
but more especially with enlargement and soften-
ing of tiie substance of the viscus. — b. The spleen
is often remarkably enlarged. JMorgagni and
GiiOTTANEi.i.i found it to weigh eight pounds. In
Eomc localities, it occasioually reaches an enor-

colon, stomach, duodenum, and ORsophagus-
more or less altered ; often softened ; injected
with dark blood in patches or spots ; and occa-
sionally ecchymosed. The mucous follicles are
frequently enlarged or inflamed in various parts.
Ulceration is seldom observed, unless the disease
has been complicated with diarrhoea or dysentery ;
and then this lesion, with thickening and softening
of the coats of the bowels, especially of the caecum
and large bowels, and peritoneal injection, is ge-
nerally observed. — d. The mesenteric glands are
sometimes enlarged, and present signs of obstruc-
tion or of chronic inflammation ; more especially
when lesions of the digestive canal are very re-
markable.— e. The jmncreas is occasionally en-
larged, in some instances so as to obstruct by its
pressure the common bile-duct. — f. The lungs
are sometimes congested ; but seldom otherwise
changed, unless pulmonary complications have
existed, when similar lesions to those described
above (§ 53.) are observed. — g. The brain and
its membranes are not often much altered, unless
in the comparatively rare cases in which coma
has attended the fit ; or apoplexy, or convulsions,
or paralysis, has occurred in it ; when congestion,
injection of the pia mater, eftusions of serum
between the membranes, or in the ventricles, are
the usual appearances. — /(. Dropsical effusions,
especially in the peritoneal cavity, and cellular
tissue ; a pale, flaccid, or softened state of the
structure of the tienrt ; and more or less discolour-
ation of a yellowish, or lurid, or dirty hue; are
sometimes also observed, particularly in the more
adynamic or pi-otracted cases.

192. vii. Prognosis. — It is evident that an
opinion as to the result of ague should depend es-
pecially upon the form and pathological condition
in which it presents itself. As to these, enough
has been advanced to enable the reader to form
his own opinion. But in the adynamic and com-
plicated forms especially, and in protracted cases,
the diagnosis should be more or less unfavourable,
or at least very guarded. The circumstance, also,
that even in more favourable states of the disease,
a very dangerous complication, or structural
change, may occur, ought not to be overlooked, —
apoplexy, coma, paralysis, fatal congestions of
abdominal or thoracic viscera, or rupture of the
spleen, may supervene. The epidemic prevalence
of the disease, and more particularly the influence

FEVER, INTERMITTENT — Diagnosis — Causes.

939

of the locality, should be taken into consideration.
In some situations, as in this country, ague is a
comparatively mild disease ; whilst in others, as
in some parts of Italy, Austria, Hungary, Hol-
land, low warm countries near the sea coast, &c.
they are very serious maladies.

193. viii. Diagnosis. — Ague may almost in-
sensibly pass into remittents, especially when it
assumes the quotidian, double tertian, or triple
quartan types, or tlie adynamic and complicated
forms. i3ut in the latter there is no complete
apyrexia, and the cold and sweating stages exist
very imperfectly. Hectic fever may be mistaken
for either of these types. But in hectic the pulse
is always accelerated in the intervals, whilst in
ague it falls to a natural frequency. The febrile
paroxysm of hectic commences in the afternoon,
and the sweating stage is of long duration ; in
quotidians, it begins earlier, its first stage is more
severe, and its last is shorter, than in hectic. In
ague the countenance is sallow, and the skin
muddy or discoloured ; in hectic the former is
flushed, and the latter clear.

194. ix. Causes. — A. Remote Causes. — a.
The predisposing causes of ague are, whatever de-
presses the physical and mental powers, more es-
pecially the causes fully described in the article
on the Causatiim of Disease (§ 23. 27. 30. 33. and
35.). — b. The exciting causes are chiefly, if not
solely, exhalations from stagnant water, or from
marshy or clayey soils — from the various sources
pointed out in the article on Endemic Influences
(§5. et. seq.). Some authors, as M. Boisseau and
Dr. Good, state that agues may arise from other
causes than from malaria. JM. Broussais believes
cold and moisture sufficient to occasion them;
and IM.Vaidy supposes that they may be pro-
duced by the influence of the mind and by irri-
tation. Dr. Good and Mr.CoopER refer to the rare
occurrence of ague in London from the com-
mencement of the present century to 1822 or 1823,
and to the frequency of the disease since this time,
as a proof of other causes than malaria being in
operation. But as respects London and its vici-
nity, changes have taken place sufficient to ex-
plain the circumstance. The streets have been
Macadamised, constantly watered, and covered
by a wet clayey mud ; the soil surrounding the
metropolis has been turned up for the purposes of
building, &c. to a much greater extent since that
period than formerly ; and the muddy and marshy
banks of the river have been unusually disturbed
and inundated by the swell from the paddles of
numerous steam-vessels. It should also be recol-
lected, that the morbid impression may have been
made upon the system many days or weeks before
some determining or accessory cause — as ex-
posure to cold, errors in diet, &c. — has occurred
to bring it into action ; and that without such oc-
currence, no eflPect might have followed the impres-
sion produced by the specific cause of the dis-
ease.] Besides, after an attack of ague, very slight
causes — as cold and moisture, painful injuries ;
improper diet, indigestions; north-east or easterly
winds, &c. — will bring it back after months or
even years have elapsed ; the fully developed dis-
ease leaving the frame remarkably liable to be
affected by the diffusion in the air of the smallest
proportion of marshy effluvia. That agues may
be caused by infection, has been believed by
Werlhof, Cleghorn, Marx, Fordyce, Kon-

TUM, Amelung, Audouard, and Bailly ; and
instances have been adduced by them in support
of the opinion. Dr. Brown states, that he has
met with cases which have led him to suspect
that such was the fact. The epidemic prevalence
of agues is, however, a better established fact, and
has been admitted by most writers ; the circum-
stances concurring to cause it being noticed in the
article on Epidemics.

195. -B. T)ie proximate Cause or Nattire of
Agues. — a. Willis attributed agues to a periodic
fermentation in the blood ; F. Deleboe to the ab-
sorption of an acid fluid from the pancreas ; and
BouRELi.i to irritation of the nerves, by an acri-
mony of their fluids. Torti had recourse to some-
thing out of each of these three doctrines. Boer-
HAAVEand Stoll came nearer the truth, in view-
ing them as an affection of the nerves that admitted
of no further explanation. SELLEand J. P.Frank
considered them to result from a peculiar irritation
of tlie nervous system, und more especially of the
nerves of the digestive organs. Dr. Reil, and
M. Roche have entered into long and intricate
explanationsof the periodicity of the morbid ac-
tion : the former imputing it to the intermittent
character of all the organic and nutritive func-
tions ; the latter to the periodicity of the exciting
cause, and to a disposition of the organisation to
repeat the phenomena, it has several times expe-
rienced, M. Broussais attributed intermittents,
as well as other fevers, to inflammatory action in
the digestive mucous surface ; and modifications
of the doctrine have been offered by some who
profess to belong to the same school — inflam-
matory irritation in some part of the digestive,
or even of any of the abdominal organs, havin^
been assigned by Boisseau, Mongellaz, &c. M.
Bailly', taking into consideration the circum-
stance of the localities of agues being those in
which epizootics most frequently occur ; and ob-
serving that, whilst the latter is always continued,
the former is periodic, although the causes are
manifestly the same ; has come to the conclusion
that the intermittent action is owing to the peri-
odical change from the vertical to the horizontal
position, which man only experiences. All these
hypothesis, however, fail of fully explaining not
merely the periodicity of the several states of ague,
but also their difference of type. Those who es-
pouse the doctrine as to the origin of intermittents
in inflammation of some part of the digestive
organs, are met by the fact urged by Tommasini
and others, that true inflammation is not periodic,
but continued. Whilst some endeavour to get rid
of the difficulty by giving to the morbid action
the name of inflammatory irritation. If, by this
latter term, be meant a lower or slighter grade of
increased vascular action of a part causing irrita-
tion of its nerves, a sort of amalgamation of the
inflammatory and of the nervous doctrines is mani-
festly attempted — more or less of either being
assumed, as the circumstances of particular forms
of the disease may seem to require. The facts of
]M. ]\loNGFLLAZ as to the intermittent character of
some forms of inflammation ; and that recorded
by Dr. Elliotson, in which the bites of leeches
became irritable and inflamed during a fit of a^ue ;
certainly do not prove the cause of ague to be
inflammation, but merely what d priori reasoning,
and a full recognition ot the phenomena connected
with the disease, might suggest; namely, that

940 FEVER, INTERMITTENT— Treatment.

either pre-existing or superinduced inflammation,
if it be not sufficiently intense to supersede tiie
intermittent type, will be aggravated during the
paroxysm, especially the hot stage of it.

196. b. From attentive observation of the dis-
ease in localities the most fertile in its cause, I
conclude —(<i) That paludal exhalations act in the
manner already stated {§ 95.), and especially affect
the nervous system oforganic life ; — (6) That con-
sequently the organs, which are especially actuated
by this system, expeiience the chief effects of
the morbid action ; the functions of circulation,
calorification, digestion, secretion, assimilation,
and excretion, evincing the principal disorder, and
the organs perfoririing these functions the chief
lesions in protracted, or fatal cases, as shown by
the appearances described above (§ 191.); — (c)
That where, owing to the specialty of the ex-
citing cause, and the intensity or continuance of its
operation, its peculiarimpres-ionis fully made upon
the organic nervous system, either pre-existing, or
superinduced di-ease, inflammatory or even struc
tural, if existing in a slight degree, or in a chronic
form, will not supersede the periodic or intermit-
tent type ; but if such disease be acute or active,
or associated with high irritability of fibre and
vascular plethora, the type will be either con-
tinued or remittent, or change from the intermit-
tent to either of these types ; — (d) That a similar
conversion of type will result from contamination
of the circulating and secreted fluids when it
reaches a considerable height; — (e) That in lo-
calities productive of malaria, the slighter diseases,
especially those consisting chiefly of disordered
function, or of altered sensibility, assume more or
less of the intermittent type; only the most acute
maladies, or those of altered structure, or attended
by contamination of the blood, assuming a puiely
continued course ; — (_/ ) After \ ievving the eflects
of malaria arising from the various sources pointed
out in theaiticle on Endemi? Influences (5 5.),
on the human frame, in the various epochs of ex-
istence ; after considei'ing the nature of the agents
by which such effects may be coupleracted, or
removed ; and after the experience of the primary
and consecutive action of this particular cause
upon my own system ; I believe that it has a
primary, specific, and uniform tendency to impair
the energy of all the vital manifestations; — (g)
That the morbid impression having been made by
it, and the formative changes having reached that
pitch necessary to the production of the cold
stage, the consecutive alterations proceed in the
manner sta'od above (^ 101.), but much more
rapidly and imperfectly, and in a way insufficientto
efface the primary morbid impression made by
the cause upon the organic nervous system; con-
sequently the morbid state of this system is little
affected by the successive changes characterising
the paroxysm ; and continuing the same after,
as it was before the fit, is equally efficient in
operating a return, after an interval of varying but
of short duration, of the same succession of phe-
nomena.

197. From this last inference, and fiom previous
observations, it will appear, that each paroxysm
is a complete febrile seizure, the successive and
critical changes of which are insufhcicnt in most
instances for the restoration of health ; that the
disorder remaining after the suLisdencc of the fit
i3 in every respect similar to that characterit^ing

the formative or premonitory stage of fevers gener-
ally; and that it is necessary to the cure of the
disease, tliat it should be treated in a nearly simi-
lar manner. This view is supported by the fact
of relapses of continued fevers being common,
when their duration is shortened by an active or
very depletory treatment at their commencement.
As to the periodicity of the return, or the relapse,
of the febrile paroxysm in ague, it seems to be the
consequence of the specific nature of the exciting
cause, of the morbid impression made by it upon
the organic nervous system ; and of the continu-
ance of this impression, or rather of the morbid
state it occasions ; for, as long as the morbid
condition of this system is uneffaced by treatment,
change of air, or by the full evolution of critical
changes, it operates a return of the febrile parox-
ysm after an interval which may be prolonged or
shortened by the state of vital power, and peculi-
arity of temperament or diathesis. As to any
further explanation of the matter, I can add no-
thing to what is given in the article Disease
(^ 155—157.).

198. c. The consecutive changes, and the loiu or
complicated forms of ague, are manifest conse-
quences of repeated seizures, or returns of the
disease, in connection with predisposition, and with
the intensity and continued operation of the
cause. Owing to the impaired tonicity of the ves-
sels, consequent upon depressed vital power, and
to the frequent returns or severity of the cold
stage, congestions, and subsequently torpor, ob-
struction, and organic change, of internal viscera,
often take place, the large vessels becoming en-
gorged, and the cavities of the heart itself some-
times softened, or distended and enlarged. — The
changes ob-^erved in the digestive mucous surfac'e
are chiefly attributable to the same causes, and to
the morbid condition of the biliary and pancreatic
secretions. The low or adynamic forms are evi-
dently results of the intensity of the cause in re-
lation to predisposition and the state of system —
of the continued opei'aiion of the cause, as when the
patient cannot be removed from the locality produc-
tive of the malaria — of complications supervening
in the course of the disease — and of changes in the
circulating and secreted fluids.

199. X. Treatment. — Ague is treated with
compai'ativeease and success, when the patient is
removed into a pure air, and when it is neither
complicated nor of a lov/ grade. If removal is
impr-acticable, it is often very difficult to manage,
and dangerous as respects its consequences or
sequelaj, although an unfavourable result may be
long deferred. — The ti'eatment, however, in either
case, naturally divides itself into that applicable
— a. to the paroxysm, — b. to the interval, — and,
c. to the ejfecis often consequent upon repeated
attacks.

200.^4. During the paroTiism, — The principal
intentions that should be kept in view in the treat-
ment of the fit, are — 1st, to guard important vis-
cera from injurious congcstrons during the cold
stage ; 2dly, to protect internal organs from the
cfltcts of excessive or- inflanrmatory reaction in
the hot stage ; arrd, 3dly, to promote an abundant
perspiration in the sweating stage, whereby the
vascular system and the internal viscera may be
relieved.

201. a. Treatment of simple ague. — The means
advised by Stoll are here generally sufficient.

FEVER, INTERMIT

He employed warm diaphoretics, and external
warmth, in the cold stage ; refrigerants during the
hot stage, and bloodletting if the patient was ple-
thoric ; and diluents and diaphoretics in the sweat-
ing stage. In some cases, a warm emetic (F. 198.
402.), administered at the commencement of the
cold stage, is of essential service, especially when
the biliary secietion requires to be promoted. —
Emetics at tlie beginning of the fit have been
strongly recommended by De Bcurges, Cleg-
horn, HUXHAM, IMURRAY, CuLLEN, TrNKA,

Otto, and Thomson ; but, although they may be
serviceable in any of the forms of the disease, it is
chiefly in the simple ague that they are unattended
by any risk. They are contra-indicated by ten-
derness in tlie epigastrium or hypochondria ; but
in other circumstances they usually siiorten the
cold stage, and render the paroxysm milder. In
slight attacks, when no particular viscus is predo-
minantly affected, and the patient is neither very
plethoric, nor rnucii debilitated, and the disease
has not been of long continuance, little further
than diluents and diapiioretics, to promote the
sweating stage, is necessary, until the intermission ;
when the usual means to arrest the disease are to
be employed.

202. b. In the more inflammatory furm, and in
plethoric or a'hletic persons, especially in spring,
bloodtetting, general or local, or both, is necessary ;
if determinations to the lungs, head, or liver be
remarkable, it should not be dispensed with ; and
still more especially if the paroxysms be pro-
longed and the apyrexia incomplete, — as these
circumstances indicate the supervention of visceral
inflammation. In tiiese cases, the depletion may
be practised in the hot stage, especially at its com-
mencement, and when important parts are
threatened by the severity of reaction ; altliough
in some instances it i? better deferred until the in-
terval, when tlie state of disorder and the effects
of the evacuation may be more justly estimated,
than during the tumult of reaction. Dr. IMack-
iNTOSH, however, advises it to be resorted to in
the cold stage ; and in cases of the kind now
being considered, or when congestion is great, in
plethoric persons, it may be safely and beneficially
practised. But in ordinary circumstances, or in
the lower fornss of the disease, 1 believe it to be a
hazardous remedy in this particular stage. This
opinion is substantially the same as that which
Dr. W. Stokis has stated, after the full trial
which he and JMr. Gill gave the practice. Cool-
ing diaphoretics and diluents with diuretics, espe-
cially the potassio-tartrate of antimony, nitrate of
potash, liquur' ammonias acetatis, &c. arc all the
additional means usually required.

203. c. In the low or adi/unmic form of iigue, a
warm emetic (F. 198. 402.) should be given only
at the commencement of the cold stage, and when
mdications of inflammatory action in the stomach
or liver are absent. — Warm diaphoretics and anti-
spasmodics in this stage, the warm bath followed
be frictions of the surface and of the extremities,
and the vapour bath, often shorten the hot stage,
and give rise to a profuse and salutary perspir-
ation. In several countries, the vapour bath at
the beginning of the fit constitutes the chief, and
almost the oidy, remedy against the disease ; the
copious perspiration follov\ing it, removmg inter-
nal congestions and proving a perfect crisis. — If
the paroxysm be attended by great fulness, and

TENT — Treatment.

941

tenderness at the epigastrium and hypochondria,
local depletions should be resorted to in a decided
manner, and hot fomentations altervvards ai)plied.
Where this practice has been already employed ;
or where the states of vascular action and vital
power contra-indicate it, — which, however, will
seldom be the case as long as the disease retains
its periodic type; or even immediately after local
depletions; a mustard poultice, or the warm tur-
pentine epithem, shouU be placed over the stomach
and abdomen, and retained or renewed until
it cannot be longer endured, or until a copious
perspiration is thereby produced ; the latter appli-
cation especially causing an abundant and salu-
tary sweat. During the course of the paroxysm,
diaphoretics should be freely administered with
small or moderate doses of opium ; camphor, am-
monia, a?tlier, warm wine whey, &c. may be also
used with this intention. If great irritability of the
stomach be present,the external means just advised
will relieve it ; or a large dose of calomel with
opium, or with camphor, also, will have the effect.

204. (/. 'J'he paroiysm of complicated ague is
often irregular, tlie hot and sweatmg stages mi per-
fect, and the intermissions incomplete, the disease
assuming the characters commonly called sub-in-
trant (§ 180.). The cold stage is also frequently
severe or protracted. In these, particularly at the
commencement, the u'((7'm ovvapour bath is a valu-
able remedy ; especially in the lower and more
congestive forms. If tlie complication be of an
inflammatory nature ; and if the lungs, liver,
stomach, or head, be predominantly affected,
general or local depletions, or both, should not be
dispensed with. "l"he circumstance of the hot
stage being imperfectly developed, is no proof
that internal inflammation or structural change
may not be present ; but is the strongest evidence
of the existence either of these, or of congestion,
and the most conclusive argument for vascular
depletions and the external applications mentioned
above (§ 203.). If inflammatory excitement be
developed within the head, during the fit; or if
delirium, or coma, with increased heat of the
scalp, be present; the aflTusion of cold water on
it, or cold applications, should not be neglected.
If the disease be nat only complicated, but also
adynamic, a combination of the means advised in
th:s and the preceding paragraph, according to
the predominance of vascular determination, and
of impaired vital power, will be necessary. — If
diarrhxa or dysenteric symptoms exist, the internal
and external means, already advised (§ 203.), es-
pecially the vapour bath, the warm epithems, the
combination of diaphoretics with opium, &c. will
be most appropriate.

205. B. Treatment in the Intermissions. —
Having, b^ the above means, prescribed appro-
priately to the diiferent forms and states of the
disease, conducted the paroxysm to a sale conclu-
sion, tiie next object is to prevent its return. —
Our endeavouis to fulfil tliis intention should be
equallv strenuous in all the forms of ague ; for,
although the fit has been slight, a much severer
one may follow. Even a comparatively and ap-
parently slight paroxysm may produce almost ir-
remediable mischief in an important viscus ; and
however mild, its frequent return often occasions
serious st! uctural change.

206. a. After the paroxysm, and especially if
the disease be recent, an emetic should be admi-

942 FEVER, INTERMITTENT —Treatment

nistered, and its operation promoted by diluents.

If it have been given at the beginning of the fit,
and acted freely, it may be dispensed with now.
But it sliould not be administered if symptoms of j or bark should be prescribed, at first either with

the upper regions of the abdomen, are complained
of. Morbid secretions and local disorder being
removed by these means, the sulphate of quinine

determination to the brain, or of inflammatory ac-
tion of the stomach, liver, or spleen, be present.
After its full operation, a large dose of calumet —
from ten to twenty grains — ought to be given ;
and, about four or five hours afterwards, a pur-
gative draught. If these act not sufficiently in a

purgatives, or alternately witii those whicii will
act decidedly. It is chiefly to a neglect of this
practice that complications and unfavourable con-
sequences so often follow the use of bark, quinine,
or of arsenic ; for these often interrupt excretion,
and over-excite and inflame loaded, obstructed.

few hours, a cathartic enema should be exhibited, i or congested organs.

Having removed local congestions or general | 209. d. When the patient cannot be removed

plethora by depletions, and evacuated morbid se- i from the continued influence of malaria during

cretions and fcecal accumulations, cinchona or the
sulphate of quinine may be exhibited, to prevent
the return of the fit. These are almost indispens-
able preliminaries to the quinine or bark, especi-
ally in the complicated and congestive forms :
for, without them, it will either not be retained on
the stomach ; or, if retained, will convert conges-
tions, or slight forms of inflammatory irritation, to
active inflammation, or to structural change.

207. b. If the stomach remain irritable after
the fit ; or if pain or tenderness at the epigastrium,
with other symptoms of inflammatory irritation or
congestion, be present ; the full dose of calomel,
either alone or with opium, ought not to be with-
held ; for, as Mr. Annesley has shown by his
instructive experiments (^Sketches of the Diseases of
India, S^c. 2d ed. p. 374.), this remedy has the ef-
fect, in large doses, of diminishing vascular action
in the stomach and in the upper portions of the in-
testinal canal. When prescribed after depletions,
general or local, and the external measures de-
scribed above (§ 203.), the internal disorder will
be removed, and the quinine, which is almost in-
dispensable to the arrest of the disease, will be re-
tained without uneasiness. If guf/Niie, especially
its sulphate, cannot be procured, the hark in sub-
stance, in large doses, must be substituted ; and
conjoined with ammonia, or camphor, capsicum,
or opium, &;c. shortly before the expected acces-
sion of the paroxysm. The decoction with serpen-
taria, the extract, or the compound tincture, may
likewise be employed, but chiefly as an adjuvant.
In every state of the disease, during the exhibition
of quinine or bark, the excretions demand atten-
tion : a full dose of calomel, especially in warm
countries, ought to be given from time to time,
and followed by active purgatives and enemata.
If the alvine excretions, and the biliary and otiier
secretion';, be not freely promoted during the ex-
hibition of bark or quinine, great risk of superin-
ducing inflammation, congestion, obstruction, and
enlargement of the abdominal viscera, or violent
determination to the head, will be incurred.

208. c. If tiie disease have been of long stand-
in^, congestion, obstruction, or enlargement, or
chronic inflammatory action in some abdominal
organ, has probably taken place. In these, the
immediate use of hark or of quinine will be of
doubtful efficacy. The treatment should, there-
fore, be commenced with sufficient local deple-
tions, followed by the external means already no-
ticed ($203.), and by the repeated exhibition of
purgatives, a full dose of calomel having been
premised and given again at bed-time, as circum-
stances may require. This treatment is especially
indicated in those more severe cases in which the
intermissions are imperfect, the tongue much
loaded, and fulness, distension, or uneasiness in

the treatment, we must nevertheless trust to the
energetic employment of the above means ;
thereby removing morbid secretions, improving
the secreting and excreting functions, subduing
local disease, and making a powerful tonic impres-
sion upon the organic nervous system and diges-
tive organs. With this last view, the doses of
quinine or bark should be as large as the stomach
will bear, and exhibited shortly before the expected
return of the paroxysm, or immediately after the
sweating stage, when the intermissions are short
or incomplete. Its effects will often be promoted,
and it will not so readily offend the stomach, if it
be given with camphor, opium, capsicum, pepper,
cinnamon, &c. according to the peculiarities of
the case. In these circumstances, as well as when
the disease presents an adynamic form, or is inore
or less complicated, especially when the tongue is
much loaded, or flabby and pale, the paroxysms
prolonged, and the intermissions imperfect, calo-
mel in full doses, at bed-time, either alone, or with
James's powder or opium ; a warm stomachic
purgative the following morning (F. 216. 266.),
thereby procuring three or four evacuations daily ;
and the quinine alone, or combined in the manner
just stated, during the intermissions, or until the
accession of the cold stage ; are most to be de-
pended upon. If the spleen be much enlarged,
and the patient subjected to the enervating influ-
ence of malaria, calomel must be given with
greater caution, and its efl^ects watched. In such
circumstances, the purgatives selected should be
prescribed with a tonic ; as the sulphate of qui-
nine with the sulphate of magnesia ; the decoction
of bark with the sulphate of magnesia and the
tincture of senna, or with the compound decoc-
tion of aloes ; or the compound infusion of gentian,
or the infusion or decoction of cinchona with the
infusion of senna, and warm tinctures.

210. e. In cases of protracted, irregular, com-
plicated and reduplicating ague, as well as in those
of a low form, and in those occasionally following
remittents or continued fever in warm climates,
the liver, spleen, and digestive mucous surface, are
generally more or less diseased. The intermissions,
even when distinct or perfect, are accompanied
with great languor, general uneasiness, want of
appetite, a foul or loaded tongue, a sense of op-
pression in the epigastrium and hypochondria,
and unhealthy countenance and skin; the upper
abdominal regions being often full, tumefied, or
tense. Here, local depletions, if they be not
contra-indicated, and calomel, followed by purga-
tives, as already advised, should precede the ex-
hibition of quinine. We must not, however, wait
for til!! removal of these signs of congestion and
obstruction, before ref-orting to (]uinine or the
bark ; for the patient may sink too low, and vital

power become insufficient to resist the progress of
disorganisation. It should, therefore, be given as
soon as free evacuations have been procured, and
the tongue begins to clean. As long as the tongue
is moist, the circumstance of its being loaded must
not prevent the administration of quinine, if it be
otherwise indicated ; but it should be conjoined
with a purgative, or the latter ought to be given
in the intervals between its exhibition. In ordi-
nary circumstances, I have prescribed calomel, or
blue pill, with or without opium, at bed-time;
an active and stomachic cathartic early in the
morning ; and quinine or the bark in a large dose,
with campiior, &c. shortly before the return of
the fit, or soon after the subsidence of it, when the
intermissions are short.

211. f. When the livei- becomes enlarged, and
more especially if it be also tender or painful on
examination, local depletions followed hyfoiiient-
utions and poultices; in some instances by the
turpentine epilhem ; in others hy blisters, and a
judicious employment of purgatiies, and of the
hark or qninine ; as circumstances may warrant,
are indispensable. In most instances of enlarge-
ment of the liver consequent upon ague, purga-
tives, if appropriately combined, and firmly per-
sisted in, have a most remarkable and beneficial
effect. If enlargement be connected with torpid
function, or if the latter only be present, the mer-
curial ointment with camphor may be rubbed over
the hj'pochondrium ; or a large plaster formed of
the emplastrum ammoniaci cum hydrargijro, or of
it and the emplastrum picis, or the waim nitro-
hydrochloric lotion, mny he applied over the hypo-
chondrium and epigastrium. An issue or seton in
the right side may also be resorted to if the above
fail. In cases of enlargement of the spleen, in ad-
dition to the use of tonics and purgatives conjoined,
the turpentine epithem, or the plaster, or the lotion
just mentioned, may also be tried. In all cases
of ague, and especially in the protracted, the ady-
namic, and the complicated, the excretions, par-
ticularly those from the bowels, should be care-
fully and daily examined ; and from these, from
the appearance of the tongue, the hue of the skin
and countenance, and from the state of the abdo-
minal regions, should our therapeutical inferences
chiefly be drawn. The presence, however, of en-
largement of the liver and spleen, especially of the
latter, although requiring other and appropriate
remedies, must not prevent us from having re-
course to quinine ; for the ague must be lemoved
as soon as possible, in order that its repeated re-
turn may not increase the local affection ; and as
soon as this object is attained, the local disorder
will the more readily yield to proper means.

212. C. Uemedies emplotjed to prevent the return
of the Jit. — The most certain of these, quinine
and bark, have been already noticed. But nu-
merous other substances have a similar operation,
although in a much slighter degree. Indeed, any
substance which stimulates, in a more or less per-
manent manner, the nervous system of organic
life, tends to efface or to supersede the morbid
state or impression made upon th.is system by the
exciting cause of the disease. Hence stimulants
and antispasmodics have a febrifuge action, al-
though in a much less degree than bark ; and
even affections of the mind of an exciting kind
exert a similar influence ; whilst the depressing
passions increase the malady, tend to complicate

FEVER, INTERMITTENT — Treatment. 943

it, and cause an earlier as well as a severe return
of the paroxysm.

213 . a . Cinchona ,'oT Peruvian hark,wzLS brought
to Spain in 1632, and came into use in England
in or about 1655. It soon afterwards fell into
discredit, so that Cromwell died of ague without
the exhibition of it. According to Sir G. Uaker,
Drs. PinjKAN, Brady, and Willis, counte-
nanced its employment; but Sturmius (Fehri-

Jngi Peruviani Vindiciarum, Pars prior. Antw.
1659.) first established its reputation. Svuenham,
JMoRTON, and Lister extended it in this country,
and ascertained the circumstances in which it was
most beneficial. The prepai'ation of gifna'xe and
cinchoniiie from the bark, and the combination of
the former with sulphuric acid — the sulphate of
quinine — has been one of the greatest triumphs
of pharmaceutical chemistry. This latter substance
has, since 1820, in most instances of ague, super-
seded the bark, as the small dose in which it is
exhibited — from two to ten grains — renders it
less offensive to the palate and stomach. After
morbid matters have been evacuated from the
bowels, it maybe given in a full dose — six or
eight grains- — immediately after the fit, or shortly
before its return ; or a large dose followed by
smaller doses every three or four hours ; or the
latter by the former, may be exhibited. Inflam-
matory or congestive complications do notcontra-
indicate its use, as shown above, if the requisite
evacuations have been practised ; for, in ague
especially, the almost simultaneous employment
of depletions, purgatives, and quinine, is often
both appropriate and beneficial. The quinine or
bark should be continued, and the digestive func-
tions carefully attended to, for a considerable time
after the disappearance of the fits. In cases where
even the sulphate of quinine cannot be taken in
sufficient quantity without oftending the stomach,
jM. De JMautin {Etv. Medicate, Sept. 1827.) has
shown that it may be applied efficaciously to the
skin denuded of the cuticle, having reduced it to
very fine powder and mixed it in cerate. It thus
is absorbed into the circulation, and acts upon the
organic nervous system through the medium of
the vascular system, with which the former is so
intimately associated.

214. b. Dr. Fowler's solution of arse;n'c holds
the next place to quinine or bark in the cure of
ague. Dr. Brown advises it in preference to
quinine, when ague is attended by inflammatory
determinations. This may be the case, but I
have found quinine, employed as above directed,
or given in solution with a neutral sulphate, -as
that of soda or magnesia, equally beneficial in
such cases with the arsenical solution. The dose
of this solution should not exceed twelve drops,
given every four hours during the intermission,
either alone, or with a few drops of laudanum, or
with the tincture of hyoscyamus. The sulphate
of zinc, in doses of two or three grains every
four hours, or as much as the stomach will
bear, is also efficacious ; but chiefly in mild
casesj or when inflammatory action is present.
It was much praised by Sir G. Blane, and is the
best emetic that can be prescribed in the disease.
The hydrochloraSe of ammonia is also capable
of arresting the fits, and is best given in an in-
fusion of cinchona, or of orange peel, or of cloves,
in as large doses as the stomach will retain. It
was much employed by Muys, Werlhof, Senac,

944 FEVER, INTERMITTENT —Treatment

Pringle, and Brocklesby ; and i3 most appro-
priate to the inflammatory states of ague, ftlon-
Tox gave a scrapie of cham'unUeJiowi'rs, ten grains
of salt of wormwood, and as much of the calx of
antimony, every sixth hour; Dr. Heberdejj,
myrrh in large doses ; and Dr. Cullen, formeHtj'/
and gentian witii oalls.

215. c. I'he pieparations of iron have b^en
employed, especially ihcjerri ammonio-chloridum
by Staiil, TiiiLiER, Huxham, and Hartmann.
The cyanide of iron has lately been strongly re-
commended by Zollickoffer, who prescribed it
in doses of four grains twice or thrice daily. — The
trisnitrate of bismuth has, likewise been given by.

Henkesen ; phosphorus 'Wilh bark, by Hufelaxd ;
the flower of sulplilir, in full or large doses, by
RivERius and Ue Haen' .pqwdered carbony in
doses of two drachms, shortly before the fit, by
Pierquin; ammonialed copper, by M'Causlanet,
BiANCHi, and Bhej^a; Dippel's animal oil, by
Werliiof and IIaleer; and cobweb, by Pavi^ivi,
Grant, and .Tackso^j. -:— I have given the chlorate
of potash witii benefit in the decoction of bark, and
in the infusion of valerian, with a little tincture of
capsicum. Charcoal was employed in ague by
Jackson, Calvert, and Tully {Edin. Med. and
Surg. Journ. vol. x. p. 15. 403.), and was found of
service when the gastro-intestinal mucous surface
was much aftected.

216. d. The barhs of various astringent, tonic,
and aromatic trees and plants have been tried,
both before the introduction of the ci/ic/io/m into
practice, anrl subsequently as a substitute for it.
The most esteemed of the^e are the iciliow bark.
This substance was prescribed by Closius, GiJNZ,
Stone, Resenblad, Thilenius, Hilscher,
James, Styx, and White; the angustiira barh,
by Wilkinson and Brande ; the bark of the Swie-
teiiia fehrifiiga, by Roxburgh ; cascarilla hark,
by Hecker and others; the pomegranate bark,
by Rehmann ; the bark of the Ilex aqnlfoUum, by
RorssEAU ; the barks of \\\e chestniU free, of the
elm, and of the oak, by various writers; and the
carapa bark of South America, which has been
said to iiave succeeded wiicre cinchona had failed.
Various other stimulating, aromatic, and tonic
vegetables have been employed, and some of them
are still in use, either as adjuvants of the bark, or
of quinine; or in the form of infusion, as veiiicles
for other substances. 'I'he most useful of these are
quassia ; scrpentaria (Lysons, &c.) ; Calamus aro-
maticus (Gui.BRAND, MosELEY, and Horn) ; ar-
nica (Aaskow, &c.) ; and Capsicum annuum
(Hergius and myself). — Ammonia, camphor, the
allters, castor, J/i((.i/f, mifrrh, ginger, black pepper,
garlic, mustard seed, &:c. have likewise been em-
ployed, chiefly as adjuncts to more permanent
stimulants and tonics or ia large doses with opium,
slioilly before the accession of the fit. Of these,
the most serviceable are camphor and ammonia.
Piperin, the active princij>le of black pepper, has
been lately employed by Bertini, Gordini, and
others, in doses of one or two graiiH, to arrest the
paroxysms ; and salacina, and alkaloid found in
willow bark, has been very recently recommended
as a substitute for quinine. Igmiiius's bean, and
the preparations of nux vomica were formerly used
against ague, by Paui-i.ini, Bocriiu), Aaskow,
Clm.i.en, Horn, and Fouoi'ier ; and their ac-
tive principle, sfriyc/oiw, niiiy also be found useful j
in the lower grades of the disease, especially when I
c-jmplicated with diarrhcea ; \a whi-di, as well

as in the rfj/senfen'c complication, the tormentil,
ipecacuanha, Dover's powder, the hydrargyrum
.cum creta, and opium, are useful adjuncts to
other medicines.

217. e. 'J'he mineral acids, especially the hy^
dro ■ and nitrochloric, have been given in the
deco;;tion of bark, especially when the liver or
spleen have been enlarged. I have employed
the latter in such cases ; and, in a state of very
weak solution, as a common beverage for the
patient during the intermissions. The sulphuric
acid, similarly exhibited, has been recommended
by Storck and Joeruens. It is an useful ad-
junct to the sulphate of quinine. The citric and
acetic acids have been directed, but chieliy as an
addition to the drink taken in the hot stage, in
which, however, acid drinks should not be taken,
as they tend to diminish the perspiration, which is
more or less salutary. — j^ihers, especially the
sulphuric and hydr.i-ciiloric have also been pre-
scribed in large doses, either alone, or with cam-
phor and opium, shortly before the paroxysm, with
the view of shortening the cold stage (Hoffmann,
Glutton, and Davidson). — The volatile alkali
has been likewise employed similarly combined,
and with the same intention ; and the various pre-
parations of antimony have been given before and
during the paroxysm, and throughout the inter-
missions, in conjunction with bark or other febri-
fuge tonics. Alum was at one time much used in
ague, it having been recommended by Ettmuller,
Lindt, RliJEi.LER, and others. Lange and De
Meza prescribed it with aromatics, and sulphuric
acid, or aether; and Adair, with cinchona. —
The sulphate of iron has been tried by several
writers; but is of inferior efficacy to the sulphate
of 7inc, or to the tincture of the sesqui-cldoride of
iron. The Prinos verticillatus, and the bark of the
Frunus Virginiana, and F. silvcstris, have been
mentioned in favourable terms by Barton and
other writers ; the bark c f the pine, by Berzelius ;
and valerian and gentian, by Vaidy and
others.

218./. Anodi/nes have been used in conjunction
with, and as adjuvants of, antispasmodics, stimu-
lants, and diaphoretics. Opium lias been exhi-
bited witii these, and with antimonials, shortly
before tiie fit, by IM'Causeand, Breda, and Tiio-
MANN'; witii Ci(»i/;/ioj', by Senac and Amelung ;
with ipecacuanha and nitre, by Dover; and with
aloes and camphor, by Audouard. The extract
of belladonna has been prescribed with bark and
other tonics, by Hufeeand and Erdmann ; the
Lauro-cerasus, by Browx Langrisii ; hitter al-
monds, by Bi.RCH's; and the powdered leaves of
the Laurus nobilis, by Sir G. Baker, given in
doses of two scruples, in bitter decoctions, shortly
before tlie ])aroxysni.

219. "■. In olil and protracted cases, attended
by inl'arciijn of the abdominal vi&cera., mercurials,
especially calonu 1, have been employed in fre-
quent doses, until slight salivation was produced,
by Wilms, Staiil, Baker, and Lysons ; and the
propriety of the practice, in some circumstances,
is confirmed by more modern experience. — In
similar cases, repeatedyViftfojis of the surface have
jiroved serviceable, especially with some one of
the liniments prescribed in the Appendix ( F. 299.
311.). Frictions alongthe spine, with stimulating
substances, have been advised by Hautesierk,
Van Swieten, De Haen, Tknka, and others . •
ruhefacienis and 6/(»(frs over the epigastric"" and

FEVER, INTERMITTENT— Treatment.

945

upper regions of the abdomen have been directed
by KonTUBi, Sciilegel, and the writers just
quoted ; and are of essential benefit in conges-
tions, inflammatory irritations, or obstructions of
the abdominal viscera, and in the low forms of
the disease. Frictions with the antimonial oint-
ment have been preferred by INI. Peysson. Com-
pression of the lower extremities by ligatiires,
shortly before the paroxysm, has been advised by
TnoTTEu and Kei.lie ; and the cold hath during
the intermissions has received, since the appear-
ance of the work of Dr. Cuhkie, numerous and
often indiscrin.inating trials. In the simple form
of ague, or during convalescence, when the prac-
titioner is convinced, by a careful examination of
the patient and the state of the excretions, that no
complication exists, either a common plunge bath,
particularly in sea-water, or the shower bath, will
often prove serviceable, especially when it is fol-
lowed by a genial glow on the surface.

220. /(. Mashed or anomalous ague requires a
nearly similar treatment to that already recom-
mended. The decided and repeated use of cho-
lagogue purgatives, both before, and alternately
with, a liberal use of quinine, or other tonics, or
of the scsqriioxide of iron, especially when the
complaint assumes a neuralgic character ; change
of air, and attention to the digestive and excreting
functions, are the chief and most successful re-
medies. In the more painful or spasmodic forms
of these affections much advantage will accrue
from conjoining quinine with camphor and col-
chicum ; neither these nor other stimulants or
antispasmodics impairing the sedative action of
colchicum, in as far as regards pain. In some
cases of this kind I have given the chlorate of
potash in the decoction of bark, and the infusion
of valerian with camphor and the compound
tincture of colchicum, with benefit. The alkaline
carbonates in large doses, with energetic tonics, and
the kreosote, are also sometimes efficacious.

221. D. Treatment of the Sequela:. — The treat-
ment of agues should not terminate with the dis-
continuance of the paroxysms. The functions of
the digestive and excreting organs must be re-
stored, and the more severe consequences of the
disease in the abdominal viscera removed ; other-
wise, a return of the fits will follow the slightest
causes ; or the obstructions in these viscera will
induce very serious structural lesions. Certain of
the complications are also among the most serious
sequelas of ague, especially diseases of the liver,
mesenteric glands, large bowels, &c. ; for these
may both accompany and remain after the fever ;
or they may not be very manifest, although
doubtless previously existing, until the fever has
disappeared. This is not infrequently the case
with dysentery and chronic diarrhoea, particularly
in warm climates : and with dropsies in this
country, which, however, are only contingent
consequences of the disease. The treatment
must mainly depend upon the nature of the con-
secutive aflection, which, as respects the liver,
commonly consists of enlargement, chronic in-
flammation, or both, with or without more or less
obstruction of the portal circulation, or of the
biliary secretion. In either case the means
which have been recommended by JMr. Annesi.ey
and myself, viz. local depletions, followed by re-
peated blisters or setons ; a full dose of calomel,
taken occasionally at bedtime; the hydrargyrum

Vol. I.

cum creta or blue-pill the intervening nights ; and
mild purgatives early in the morning; will be
found most beneficial. After these have been
persisted in, according to the nature of the case,
and the more active symptoms have been entirely
removed, this organ continuing torpid, the ?((7ro-
htjdrochloric acids used both internally and exter-
nally, and exercise on horseback, will be of service ;
bufmercurials must have been relinquished some
time before the use of the acids. Lastly, a course
of Cheltenham or Harrogate waters, or judicious
substitutes for them, used daily and perseveringly,
will confirm the recovery.

2"22. If the spleen or the 7nesenteric glands be
enlarged, frictions of the abdomen with warm sti-
mulating liniments (F. 31 1.) * stomachic purga-
tives, as aloes, rhubarb with sulphate of potash, and
small doses of the sulphate of iron ; the iodide of
potassium in moderate doses; and blisters, setons,
moxas, &c. .will be found most successful. In
neither of these states of disease will depletions be
required, unless pain and tenderness on pressure
be complained of, when local depletions, followed
by blisters or the turjoentine epithem, will be suffi-
cient.— The most appropriate treatment, in cases
of consecutive dysentery and dropsy, is fully de-
scribed in these articles.

223. E. The diet during the intermissions
should be light, nourishing, in very moderate quan-
tity, and taken at a time not too close upon the
accession of the paroxysm. If the disease be of an
inflammatory form, or associated with active de-
termination to an important viscus, abstinence, as
directed by Celsvs, Senac, Tessieu, &c. should
be observed. Whilst purgatives are being em-
ployed, broths and weak soups are most suitable.
In the paroxysm, diluents only are admissible.

224. F. During convalescence, strict attention
should be paid to the diet and regimen, and to
the states of the digestive and excreting organs.
The latter should be assisted occasionally, and
always when they are sluggish, by the usual
means ; and quinine, the other preparations of
bark, or difl^erent tonics, should be continued .*"or
some time after the disappearance of the pa-
roxysms. Regular and moderate exercise, espe-
cially on horseback, also, will materially promote
recovery. Exposure to cold easterly or northerly
winds, or to the night air and moisture, ought to
be carefully avoided ; and if change of air cannot
be enjoyed, or if the patient be still liable to be
exposed to malaria, the Prophylactic Measures ad-
vised in the article Endemic Influences (§ 20.)
should be adopted as far as circumstances wjU
permit.

BiBLioG. AND Refer Celsiis, De Med. 1. iii. c. 15.—

Aviccnna, Canon. 1. iv. fen. i. tract. 2. c. 68. — Sennert,
Diss. viii. De Febr. Intermit, in Genere. Vit. 1618. —
Ettmuller, Opera, vol. ii. p. 277. — De Bourgcs, Ergo
Febr. Intermit. Vomitus. Paris, 1624 — Willis, De Fe.
bribus, cap. o. — Closius, Observ. 28 — Morton, De Fe-
bribus, cap. 3. — E. Stahl, De Febr. Intermit. Corruptis
et Turbatis. Hal. 1713. — il/i(^i, De Usu praiclaro Salis
Ammoniaci ad Febr. Intermit. Franc. 1716. — J. Drake,

Orationes tres de Febr. Intermit. Lond. 17+2, 4to

Hartmkinn, Prax. Chymiatr. 1. ii. c 125 Triller, Thes.

I'harmaceut. t. ii. p. 604. — Haller, De Pra;i)ar. Olci Ani-

mali.s ejusquein Febr. Interm. Usu. Goet. 1747 Slone,

in Philosoph. Trans, vol. liii. p. 195. — Cartheuser, De
Febr. Intermit. Epideniicis. 1749. — "Gcscnius, Betra-
chung der Wechselfieber, &c. Helrast. 1752. — Huxham,
0|<era, vol. ii. p. 29. -^ A. Thomson, Edin. Med. Essays,
&'C. vol. iv. p. 326., vol. v. p, 75 — Hautesierck, Recucil,
&c. vol. ii. — '>'. Coley, Account of the late Epidemic
Ague. Lend. 1755. — F, Torti, Therap. Specialis ad Febr,
3P

946

FEVER, REMITTENT. — Causes.

Interm. Perniciosas, &c. 4to. 1756. —P. Senac, De Tle-
cond. Febr. Intermit, turn Remitt. Katura. Amst. 8vo.
1759. — Bat/nal, Siir la Methode de guerir les Kiev. Ma-
ligiies Intermit. 4to. Paris, 116X—Guiiz, De Cortice
Salicis Albifi Cortici Substitueiido. Lips. 177'-'. — Tasier,
Febr. Intermit. Cito Compescend. Abstinentia. Pans,
l-nS.—Borrieu, in Hist, de la Soc. Roy. de Medecine ad

17711. p. 343 fan Swieten, Comment, ad 759.— G. Baker,

ill Trans, of Coll. of Phys. vol. iii. p. 141. —D. Monro,
Ibid vol ii. p. 3'25. — liosenb/ad, De Usu Corticis Sa-
licis'in Febr. Intermit. Lund. 17S2. et Doering, vol. i.
p 140 — Thilenius, Medicin und Ctiirurg. Bemerkung.
p lag— S/oeTcA, Ann. Med. vol. ii. p. 163. — G. Cleg-
horn on the Epid. Dis. of Minorca from 1744 to 1794,
8vo ' Lond. 1779, 4th ed. — Linnmus, in Amcenitat. Acad,
vol ix Ups. 1773. — Bang, in Act. Soc. Med. Havn.
vol ii. p. 214. — Stall, Aphor. de Feb. p. 133. — Trnka
de Krxowitz, Hist. Febr. Intermit. 8vo. Vindob. 1775.

i. Chalmers, on the Weather and Diseases of South

Carolina, 8vo. Lond. 1776. — M'Causland, in Edin. Med.
Comment, vol. viii. p. 250. — Murray, De Temp. Exhib.
Emetica in Febr. Interm. Max. Opportune. Opusc. vol. iv.
n 1.— Stall, Ratio Med. &c. vol. iv. p. 476. — J. C. Fidler,
De Febr. Intermit. Vien. and Prag. 1784. —Z)<? Meza,
in Acta Soc. Med. Havn. vol. i. p. 138 , vol. iii. p. 394. —
De Haen, Rat. Med. Par. vol. xi. c. \.— T. Fowler, Med.
Reports on Arsenic in the Cure of IntermiU. &c. 8vo.
Lond. 1786. — Burserius, Institut. Med. Pract. vol. i.
p 200. —G. Kellie, Ed. Med. Comment, vol. xix. p. 271. ;
and Ann. of Med. vol. i. p. 409., vol. ii. p. 127. —Brandr,
Experim. and Observat. on the Angustura Bark. Lond.
1791.-_ S. Ja»^es, Observ. on the Bark of a Species of
Willow. Lond. 179^. — C. Strack, Observat. Med. de
Febr. Intermitt. &c. Offenb. 8vo. 1787. — Thompson,
Treatise on the Febris Intermittens, 8vo. Lond. 1787. —
Ditrand, Sur les Fievres Intermit. Malignes. Par. 1788.

Bang, Act. Soc. Reg. Med. Havn. vol. iv. p. 123.—

Aaskuw, in Ibid. vol. ii. n. 19. — Gulbrand, in Ibid. vol. ii.
p. 206. — Aashf'pn, in Ibid. vol. iii. p. 370. — Bcddoes, in
Med. Facts and Observ. vol. vii. n. 2. — Davidson, in Ibid,
vol. V. n.7.— Winterbuttotn, in Ibid. vol. vi. n. 1 — Box.
burgh, in Ibid. vol. vi. n. 9 — Wright, in Ibid. vol. vii., et
Ann. of Med. for 1797. — Froinent, Mem. sur les Maladies
en Italie, &c. 8vo. Par. 1798. — Darwin, Zoonomia,

vol. iii. Monis, Med. Observat. and Inquiries, vol. iii.

Rush, in Ibid vol. v. — Fordyce, Second Diss, on Fevers,

8vo. Lond. 1796. — White, Observ. on the Willow-bark,
8vo. Bath, 1798. — ]>/' /.rare. On the Fevers of St. Do.

mingo. Spangenbcrg, Hist. Fedr. Intermitt. quiE Anno

18U0. Philippot. Ssviit. &c. Wurceb. 1801. — Thomayin,
Annalen liir 1800, p. 133. — J. Breda, De Variis Opium
Scopo Febrifugo adhib. Methodis. L. B. 1800. — Bianchi,
in Brera, Coiiimentari Medici, t. ii. n. 2. — Styx, in Nor.
disch. Archiv. b. i. st. i. n. 4. — Hilscher, in Tode, Med.
Chirurg. Journ. b. v. st. 4. — Erdmann, Horn, N. Archiv.
b. i. p. 249. — Horn, Ibid. b. ii. p. 132. ; et b. iii. p. 339. —
Amelung, Hufeland, Journ. d. Pract. Heilk. b. xviii. st. 2.
p. 97. — Kort'um, in Ibid, b. xv. st. 3. p 10 — Hufeland,
Ibid. b. ix. St. 3. p. 101. — Werlhof, De Febr. &c. sect, iv.
^ 2. — J. Richard, De Insidiosa Quorund. Febr. Intermitt.
tum Remitt. Natura el Curatione, 8vo. Lyon. 1801. —
Marcus, Magazin fiir Therapie Klinik. b. i. h. i. p. 28. —
Fizeau, Journ. Gun. de Med, t. xvii. p. 459. — io»v«2:,
in Ibid. t. xxxiii. p. 361, — 0«o, De Vomit, usu in Febr.
Interra. Franc. 1803. — Michaelis, in Hufeland u. Himly,
Journ. b. i. p. 107. — P. A. Colombat, Mem. sur une Epid.
des Fievres Intermitt. AdynamiccTaxiques, 8vo. Paris,

1809. Coutanceau, Sur les Fievres Interm. Periiicieuses

qui ont regne Epidem. a Bourdeaux, in 1805. Paris,

1809. Rehman, Notice sur une Remfede propre a rem.

placer la Quinquina. Moscow, 8vo. 1809 — B S. Barton,
Collect, towards a Mat. Med. of the Unit. States, 8vo.
Phil. 1818, passim. — Alihcrt, Des Fidvres Pernicieuses
Intermitt. 8vo. Paris, XBWi. — Hecker, Ann. dor Ge-
sammten Medicin. Jan. 1810, p. 595. — Daivson, On the
Walcheren Disease, 8vo. Ipsw. 1810. — Davis, On the
Fever of Walcheren, 8vo. Lond. 1810. — G. Blane,

Trans, of Med. Chir. Soc. vol. iii Ferguson, in Ibid.

vol. ii. p. 180. — Trumjtf, Ucber d. Wechselfieber und
ihri? Heilart. Wien. 8vo. 1810. — HUdcbrandl,\n Horn's
Archiv. IHll, Sept. p. 311.— Vaidy, in Journ. Gi'n. de
Med. Cont. t. xviii. p. 335. ; et Diet, des Sciences Med.
t. XV p. 300. — Desruelles, Journ. Univers. des Scien.
Med. t. xxxii. p. \n. — Bail/y, in Rev. Med. t. ii. 1825,
p. 384.; and Traitt^ Anatomico.Pathologique des Fit}vres
Intermitt. Simples et Peiniciou.ses, Kc. 8vo. Pari.s, 1825
(Contains a great 7nass of iiifortnalion.) — Uildenlirand,
Instit. Med. Pract. \o\.'n.—JISuiiill(iiid, Des Fifevres ditcs
Essentielles, 8vo. Paris, 1826, \>. .^>U>. —• Bo/sscaii, Traite
des Fidvres, p. 532. — P. B<ii/ir, in Diet, de Medecine,
t. xii. p. 3.34. — Puccinotti', Hrvue Med, t. iii. 1825,
p, .'JOl. (An Account of Agves at Home from 1819 to 1822.)

Bcrtini, in Ibid. t. ii. 1824, p. 294.— Gordini, Ibid. t. iii.

182.5, p. :}13. — Blaud, Nouv. Biblioth. Mtd. t. iv. p. 2.57.
— Bracket, Archives Gener. de Med. t. ix. p. 34<). —

I'eysson, in Ibid. t. iii. p. 4,55 Brichetcau, Il)id. t. xvi.

p. 2.32. — Lassalvy, Journ, des ProgrCs des SJcicnccs Med.

t.\\\\. — Pierquin, in Ibid. t. xiv. p. 250. —• Delourmel,
Archives, &c. t. xix. p. 523 — Guerinde Matners, Journ.
des Prog, des Sc. Med. 2d ser. t. ii, p. 55., et t. iii. p. 93 —
Jtard. Journ. Univers. des Scien. Med. t. xxxii. p 352. —
Henkesen, Nouv. Journ. de Med. t. xii. p. 37. — Zollickoffer,
Philadelph. Journ. of Med. Sciences, vol. v. p. 207. {Prus-
siate of iron, gr. iv — vi.) — IV. F. Chatnbers, Lectures in
Lond. Med. Gazette, vol. ii. p. i. — J. Elliotson, in Ibid,
vol X. p. i. — Lobstein, Repert. Gen. d'Anat. el Physiol,
t. ii. p. 3,39. — Pousseaw, Journ. Hebdom. t. iv. p. 433. —
W. Stokes, in Edin. Med. and Surg. Journ. t. xxxi. p. i.

J. Brown, in Cyclop, of Pract. Med. vol. ii. p. 220.

See also the Bibliographv to Fever in general ; and
Ploucqet's Repertorium, which contains a numerous
list of foreign works, down to the commencement of this
century, very few of which are here referred to.

XII. Remittent Fever. Syn, — Exacerbating,
Puroxifsinal, Sub-continual, Endemic, Endemial,
and Endemical, Fever, of various writers.

225. Defin. — The febrile phenomena evincing
striking exacerbations and remissions, one jiaroxysm
occurring in the twenty-four hvurs.

226. This fever, although holding a middle
rank between agues and continued fevers, ap-
proaches the former most nearly in its causes,
phenomena, and consequences. It is most com-
mon in warm climates, and in the warmer coun-
tries without the tropics, in which it is most
prevalent in summer and autumn. It is strictly
a disease of locality and climate, and hence very
generally denominated endemic ; but as climates
and localities vary remarkably, so is it modified in
character from the mildest form, in which it is
similar to simple ague in every respect but the
complete remissions, to the more malignant states,
in which it so nearly approaches yellow fever in
warm countries and seasons, and continued fever
in temperate climates, as to have been frequently
confounded with them. To intertropical prac-
titioners, especially, as well as to those in tem-
perate countries which abound with the endemic
causes of disease, this fever presents great interest.
It is not infrequent in the vicinity of London ;
and in marshy localities in the southern counties of
England, and Ireland, during the summer and
autumnal months.

227. i. Causes. — The predisposing and exciting
causes have been noticed above (§ 194.), and
more especially in the articles Disease (§31. 55.)
and Endemic Influences. Dr. Chambers has
supposed that remittents arise from two principal
sources: — 1st, from marsh-miasmata; 2dly, from
sudden vicissitudes of atmospherical temperature
precipitating some other deleterious principle
evolved from hidden sources. — Of this latter,
however, we can have little or no knowledge ;
and, even granting the evolution of such a prin-
ciple, we have no evidence of any sources from
which it can arise different from those pointed
out in the articles now referred to. As, there-
fore, the exciting causes of endemic fevers in
adults are chiefly emanations from the soil —
from decaying organic bodies on its surface or
commingled with it — and from stagnant putrid
water; and, as these causes are necessarily varied
in concentration, activity, and in their nature,
according to the states of the air, and to the
varying proportions of vegetable and animal
matters undergoing decay, so it must be inferred
that the effects produced by them, even when the
constitution of the recipients is the same, will be
also varied : but, when we consider the great
variety of habit, organisation, temperament, and
susceptibility, it must necessarily be concluded
that the forms and states of fevers resulting from

FEVER, REMITTENT — Description.

947

these causes must be still more remarkably diver-
sified, and will vary, not merely in type, from a
simple tertian, through the remittent forms, to a
purely continued state ; but also as to vascular
action, vital manifestation, and visceral compli-
cation. Remittents, therefore, and as observation
has repeatedly proved, are merely severer grades
of the same pathological states as constitute in-
termittents ; a more concentrated form, or in-
tense action of the exciting causes which produce
the latter, either absolutely or relatively to the
predisposition or susceptibility of the individual,
also occasioning the former. That concentration
of the exciting causes, or intensity of action, is,
in some measure, concerned in creating the dif-
ference, is shown in the constant residents of an
unhealthy locality having ague at one season,
when the exhalations are rationally inferred to be
neither abundant nor intense ; and remittents at
another, when these causes are either the one or
the other. That the state of the recipient has a
marked influence, is proved by persons recently
arrived in districts productive of endemic fevers
having some one of the forms of remittent at the
same time and place as those who have been long
resident have ague. Remittents are most pre-
valent in autumn, next so in summer, and the
least so in spring. They rarely occur in winter,
in temperate countries, unless in those which
nearly approach the tropics.

223. ii. DEscniPTioN, &c. — From the varying
forms remittents assume, owing to the circumstances
just mentioned, it is evident that all divisions of
them must be purely conventional, and founded
on degrees of severity, and on alterations of their
most prominent features. 1\I. Beaumes has dis-
tinguished them into three grades — the severe,
the less severe, and the benign ; and M. Boisseau
into the injiammatory , the bilious, the mucous, the
adynamic, and the ataxic. The last three of
these are merely modifications of the adynamic,
as respects the state of vital power and vascular
action. I shall adopt a nearly similar arrange-
ment to that which I have stated above (§ 44.).

229. A. Mild remittent appears after slight
ailments of several days duration ; the precursory
symptoms being chiefly uneasiness at the epigas-
trium, lassitude, and pains in the back, limbs, and
head, with restlessness at night. These may con-
tinue for some time ; the formative period, or the
time elapsing from the impression of the cause to
the invasion or development of the febrile phe-
nomena varying from five or six to about thirty
days, as determining or accessory circumstances
may arise to accelerate or reinforce the action of
the chief cause. The stage of invasion is similar
to that already described ; it being attended by
coldness of the surface, and frequently by shiver-
ing. The coldness is soon superseded by heat,
by febrile flushes, or by alternations of heat and
cold, by nausea, and t)ccasionally by vomiting,
which soon develope the stage of excitement.
With it, the pains of the head, back, and limbs
become remarkably aggravated ; the mouth is
clammy and dry ; the tongue white or loaded ;
the surface very hot and parched ; the face
flushed ; the features tumid ; and the pain of the
head attended by a feeling of distension and
throbbing, often passing into delirium. The
pulse, which, at the invasion, was small, irre-
gular, and weak, is now full, large, strong, and

frequent ; thirst is urgent ; the bowels consti-
pated ; and the urine scanty and high-coloure<l.
There is alwiiys more or less tenderness at the
epigastrium, with nausea, and often with vomit-
ing. These syiuptoms generally continue from
about ten or twelve to eighteen hours, when
perspiration breaks out ; the pulse falls in fre-
quency and strength ; the irritability of the sto-
mach subsides; delirium disappears; atid the
skin becomes cooler : but there is merely a
remission or abatement, but no intermission, of
the febrile symptoms. The remission usually
continues from three to nine or ten hours, when
an exacerbation occurs, sometimes preceded by
chills or shiverings, at other times not, and the
severer symptoms are renewed. Thus the dis-
ease proceeds with alternate remissions and ex-
acerbations, the former generally taking place in
the morning, until the seventh day, or the ninth,
eleventh, or fourteenth day, or much later, in
temperate countries, when a copious perspiration
generally puis a termination to its progress.
This form of fever has a particular disposition, as
Dr. Jackson has remarked, to a favourable cri-
tical change on the seventh, fourteenth, twenty-
first, and twenty-eighth days ; but in warm
countries it seldom continues longer than fourteen
days.

230. B, The injiammatory form frequently
attacks sanguine plethoric Europeans residing in
warm miasm.atous climates. It differs from the
foregoing chiefly in grade, and the greater degree
of vascular reaction in the period of excitement,
which is sometimes so great as to exhaust the
tone of the vessels and the powers of life, and
even to change the blood, thereby simulating
some forms of epidemic or continued fevers, espe-
cially when the remissions become obscure, as is
often observed in the worst cases. It commences
either as the foregoing, or with rigours, pain and
sickness at stomach, and oppression at the prae-
cordia, followed by vomiting, headach, great
dejection of spirits, and mental delusions of a low
or gloomy kind, sometimes impelling the patient
to suicide, which, in two instances, I have seen
attempted even before much complaint had been
made. In other cases, the patient falls down in
a state of syncope, following several days of in-
disposition, with a cold pale surface, and dejected
countenance. The pain of the stomach and head
increase, is attended with vomiting, sometimes of
bilious matters, at other times of a whitish fluid,
with fulness and tenderness at the epigastrium.
The vomiting is generally followed by vascular
reaction : the pulse, from being small, weak,
irregular, or intermitting, becomes full, strong,
and very quick ; the face injected and tumid ;
the eyes prominent, watery, and red ; the thirst
intense ; the throat arid and sore ; the tongue
furred, its edges red ; and the headach and de-
lirium increased. In about twelve or fourteen
hours a copious perspiration breaks out, the
symptoms subside, and the pulse falls to about
ninety. After a short remission, the thirst, pain
at the stomach, headach, &c. are aggravated,
and the delirium and vomiting return. If the
disease be neglected at the beginning, the remis-
sions disappear, the skin becomes dry and caustic,
or moist and clammy ; the pulse small and irre-
gular; the tongue black and crusted, and the
vomiting, pain at the epigastrium,. &Ci more
3P 2

948

constant. In the most severe and unfavourable
cases, yellowishness of the skin, or vomiting of
matters like cotree-grounds, or both, occasionally
supervene. The bowels, which, before the at-
tack and at its commencement, were torpid, are,
at further advanced stages, irritable ; the evacu-
ations being watery, greenish, and, at last, almost
black ; the urine being very scanty and high
coloured. If the disease be not actively treated
at the commencement, an unfavourable termi-
nation takes place between the third and seventh
days ; but it is often prolonged beyond this
period, and it then generally occasions visceral
disease.

231. Such is the inflammatory remittent of
warm climates. A nearly similar fever attacks
unseasoned Europeans lately arrived in the West
Indies and inter-tropical Africa, and often pre-
sents an obscurely remittent or almost continued
type. It has been very generally mistaken for
true yellow fever, owing to the malignant symp-
toms it assumes at an advanced period, or state
of exhaustion consequent upon the vascular ex-
citement of the early stage. The inflammatory
remittent, the bilious inflammatory, the adynamic
or malignant remittent, and the ardent or season-
ing fevers of Europeans lately arrived in warm
countries, are merely modifications of each other,
and differ essentially from epidemic yellow fever,
with which, however, they have been all most
singularly confounded.

232. C. BiVw-iiiflammatory remittent fever dif-
fers but little from the foregoing in its characters
and course. It is most prevalent in Europeans
who have not resided long in a warm miasmatous
country, and in low marshy localities, or in
thickly wooded districts. In temperate climates, it
is observed chiefly in the autumns consequent upon
very warm summers ; and in the bihous or bilio-
sanguineous constitutions. It is often dependent
upon the vicissitudes of season, especially wet
seasons following great warmth, or a very hot
summer consequent upon a wet spring ; and it is
often very prevalent or almost epidemic during
the hot months, after very heavy rains, within
the tropics. Violent determination to the brain
characterises the commencement of reaction, in
this variety ; and inordinate affection of the liver
and digestive mucous surface, the more advanced
stages. Pain in the head is most severe, espe-
cially in the forehead and sockets of the eyes ; the
conjunctiva is yellow or suffused ; the counte-
nance and skin become dusky or yellow ; the
tongue is loaded by a bilious coating ; and the
evacuations are bilious ; especially the matters
thrown off the stomach. The bowels are at first
costive, but they afterwards often become irritable
or dysenterically affected. After the vomiting
has continued some time, the appearance of the
matters is changed, and ultimati'ly assumes in
fatal cases the characters just described (§229.).

233. D. The adynamic or malignant remittent is
•ne of the severest and most fatal of endemic fevers.
- — a. It is observed only in places where the en-
•lemic causes are concentrated or intense relatively
to the state of predisposition ; and is seldom ush-
ered in by shiverings, but generally by a pro-
longed sense of cold, universal collapse of the
vital powers, and of vascular action. Pain in
the head of a peculiar constrictive kind ; mental
depression and insane delusions; imperfect effoits

FEVER, REMITTENT — DEscRiPTrov.

at reaction ; remarkable lassitude and pain in
the loins and limbs, are present at the commence-
ment, with great anxiety, pain, and oppression of
the preecordia, and nausea, sometimes giving rise
to vomiting, which assists in developing the stage
of excitement, and in partly overcoming the inter-
nal congestions. The pulse is small, constricted,

or irregular ; the skin becomes dry and caustic,
or moist and clammy ; and impresses the hand of
the observer with an acrid or tingling sensation ;
the eyes are watery and injected ; the tongue is
clammy, moist, or flabby and coated, and after-
wards dry, rough or brown ; the face is flushed,
but dusky or purplish : the bowels are costive,
subsequently relaxed or irritable, and the urine is
scanty, high coloured, or suppressed. After twelve
or fouiteen hours, a slight remission is observed,
after which the symptoms are exacerbated; the
stomach is remarkably irritable ; the epigastrium
painful and tumid; the breathing hurried; and
the patient restless and distressed. In the more
dangerous cases, hiccup, constant vomitings,
j'ellowish discolourations of the skin, exudations
of blood from the digestive mucous surfaces,
low delirium, and death, supervene between the
fourth and seventh days.

234. b. This variety is variously modified, in
different circumstances and persons. It some-
times assumes more of a cerebral or typhoid cha-
racter ; at others, it is bilious or gastric, accord-
ing to peculiarity of season or concentration of
the cause. In some inter-tropical countries it
becomes epidemic, or rather this endemic is more
than usually prevalent. Occasionally the remis-
sions are indistinct from the commencement, and
they generally become so after three or four days.

— a. In some cases the vascular excitement is at
first more or less intense, with remarkable deter-
mination to the head, liver, and stomach, and ma-
niacal delirium, the disease very nearly approach-
ing the inflammatory, or bilio-inflammatory forms.

— /3. In others, vascular reaction is very low and
imperfect; the pulse small and quick; the ab-
domen tumid and hot, whilst the extremities are
cold or clammy; the evacuations foul, morbid,
and ofl^ensive ; the tongue fuliginous ; the gums,
spongy, or oozing a bloody sanies ; the vomiting
constant, and ultimately grumous and dark ; the
stools towards the close, black or pitchy; the
urine scanty or nearly suppressed ; the solids
flaccid ; and the skin earthy or discoloured. In
both these states, a yellowness of the surface oc-
casionally presents itself about the third or fourth
day, beginning in the conjunctiva, neck, and
breast. The yellowness often passes to a pale
greenish hue, in patches, shortly before death ;
and the soft solids present a liquescent state,
having lost their vital cohesion.

235. c. In other cases of this form, the symp-
toms are at first mild, and the excitement incon-
siderable ; when, after two, three, or four exa-
cerbations, the powers of life appear suddenly
exhausted; the pulse becomes weak and flutter-
ing; the tongue foul, black, and dry; the eva-
cuations offensive ; the prostration of strength
extreme ; and the factor of the perspiration re-
markable. At last, great anxiety ; tenderness and
tension of the epigastrium : fulness of the hypo-
chondria ; collapsed features; a squalid or yel-
lowish surface; vomiting of dark or grumous
matters, supervene, and indicate the utmost

danger. This insidious Modification of the ady-
namic form generally occurs in persons highly
predisposed, or who have suffered from bowel
complaints, or who are debilitated, and are sub-
jected to the more concentrated effluvia.

236. d. In some instances the remittent com-
mences in so mild a form, that the patient is even
able to walk about his apartment j and, for several
days, complains only of irregular exacerbations of
fever, when,suddenly, violent and malignant febrile
action supervenes, which rapidly exhausts vital
power, and either quickly carries off the patient,
or induces serious structural change in several
of the abdominal organs. In other cases, vascu-
lar excitement is hardly manifest at any period of
the disease ; the exacerbations consisting merely
of increased anxiety, restlessness, general distress,
and niental depression, occasionally with aug-
mented sickness ; and pain in the head, epigas-
trium, and loins; the pulse being but little acce-
lerated until the close, and the temperature, unless
at the epigastrium, rather under than above na-
tural. In these, however, the weak, soft, and open
or irregular pulse; the dark-coated, or soft, flabby,
and lobulated tongue ; and the blackish-greenish-
brovvn, and morbid excretions, in connection with
the other symptoms, denote extreme danger. It
would seem as if the causes had nearly annihi-
lated the irritability of the moving fibres, and de-
prived the system of its ability of reacting upon,
or superseding, the morbid condition induced by
their first impression.

237. E. CompiicatedRemiltents. — Complications
are observed in the inflammatory, bilio-inflamma-
tory, and adynamic forms ; the alterations that
take place in the seats of predominant disease,
being the chief causes of unfavourable termin-
ations. The importance, therefore, of recognising
them at an early period must be evident. — a.
Amongst the earliest complications in remittents
are i/ijiammatory states of the mucous surface oj' the
stomach and duodenum. This condition is indi-
cated by constant irritability of stomach ; by ful-
ness, heat, and tenderness of the epigastrium ; and
by a foul loaded tongue, with red sides and apex.
This pathological state often extends to the ..mall
intestines, and even to the large bowels, as indi-
cated by tumefaction and tenderness of the abdo-
men ; by a sense of inward soreness or heat ; by
irregularity of the bowels, or frequent, scanty, and
morbid evacuations; and by diarrhoea or dysen-
teric symptoms. If the large bowels be chiefly
affected, the dysenteric symptoms are more urgent ;
and on examination soreness or tenderness will
often be complained of in the region of the caicum
and course of the colon, llemittents thus associ-
ated often pass into, or terminate with, dysentery.
The gastric complication is frequently induced by
the irruption of an acrid bile at the commence-
ment of the fever; the morbid state of this secre-
tion irritating and inflaming the parts over which
it passes. I'he intestinal affection probably arises
from the same cause, or from accumulations of
mucous sordes or other morbid matters in the
bowels. But collections of acrid and morbid se-
cretions and of fa;cal matters most frequently oc-
casion the dysenteric disorder ; and a morbid state
of the bile frequently contributes its aid also in
producing this complication.

238. t>. Disease of the liver is a conunon com-
plication of remittents, espc'^'^'ly in the East

FEVER, REMITTENT — DEScniPTioN. 949

Indies and in warm climates; and even in this
country. In most cases of this fever, the func-
tions of the liver are disordered ; but actual struc-
tural change is also common ; and may appear
early in the disease, or at later periods. The
biliary secretion is most frequently increased ; in
a few cases it is diminished ; and in some it is
accumulated in the ducts and gall-bladder for a
time, and is afterwards let loose, increasing the
disorder of the stomach and bowels. But, whe-
ther in excess or diminished, it always is more or
less changed in quality. The structural afl^ections
of the liver attending remittents are nearly the same
that are met with in agues, excepting that in-
flammatory action, acute congestion, or moderate
determination, aflects its internal structure more
frequently in the former than the latter, and the
vascular action partakes more of the asthenic
character. With congestion and inflammation,
more or less enlargement also exists; and occa-
sionally puriform matter is formed ; but the latter
is seldom evinced by diagnostic symptoms; signs
of diseased structure of the viscus being only
apparent. Even when horripilations or rigours do
occur, they are liable to be mistaken for the cold
stage of the paroxysm. — Softening of the internal
structure of the liver, with or without congestion
or enlargement, is a common lesion in the adyna-
mic states of this fever. I have observed it most
frequently after fulness, tenderness, a sense of
burning, or pain in the right hypochondrium and
epigastrium, with great anxiety, intense thirst ;
dark-coloured and loaded tongue, very quick and
weak pulse ; offensive evacuations, and dark gru-
mous vomiting. — Disease of the spleen is a com-
mon complication in old European residenters in
hot climates, and in many localities in the south
of Europe. It is similar in kind to that already
noticed. In the low forms of remittent compli-
cated with disease of the liver or spleen, the greatest
care should be observed to avoid roughness in the
examination of the abdomen and hypochondria.
Too great or sudden pressure has produced irre-
parable injury in such cases.

239. c. Determination to the brain of an aclive
kind, rather than pure inflammation, often occurs
early in the more severe remittents. In the most
prominent of this class of cases, the symptoms of
cerebral excitement, and increased vascular ac-
tion in the brain, are superseded by stupor, coma,
low delirium, and typhoid or adynamic symptoms.
The peculiar delirium, insane delusions, and men-
tal depression or apprehension, which often aflects
the patient from the commencement, seems to be
less the result of iniiammatory action in the
brain, than of impaired nervous and cerebral
power. It often passes ofl^, or it changes into a
state of apathy or indifference to the result of the
disease, and strong disinclination to take the me-
dicines prescribed. This effect upon the spirits
and mental powers evidently arises from the pe-
culiar or specific action of marsh poison, which,
as I know well from experience, occasions a dis-
tressing feeling of depression an" despondency,
even when it does not induce open disease. Ma-
niacal excitement oi delirium often passes into
coma or stupor, and the patient expires as if in a
qiiJct sleep.

240. d. The association of remittents with pul-
monary affeciiiuis is observed in temperate coun-
tries, especially in the spring and summer ; and

3 P 3

95(J

FEVER, REMITTENT — Diagnosis.

more rarely in warm climates. The pulmonary
functions are more or less impaired during the
formative and invading periods ; but acute dis-
order is seldom developed until the period of
excitement, and consists chiefly of bronchitis, ca-
tarrh, and pneumonia, of a nervous or congestive
form. In some cases congestion of the lungs, and
of the bronchial surface, commences during or
shortly before the period of invasion ; and either
partially continues throughout the disease, or
passes into a low form of inflammatory action,
and even into hepatisation. Rheumatism is also
occasionally complicated with remittents ; and
erysipelas sometimes supervenes when a part is
injured, the cuticle abraded, or the skin divided.
Ulcers and sores not unfrequently take place on
the lower extremities in the course of remittents,
as well as of intermittents, particularly in low,
wooded, and swampy districts within the tropics,

241. F. The terminations of remittents are —
1st, In restoration of the healthy functions ; —
2d, In a chronic form of remittent ; — 3d, In
organic change of one or several important vis-
cera, particularly of those which manifest predo-
minant disease during the progress of the fever; —
4th, In fever of adifferent type; — 5th, In dys-
entery;— and, 6th, In death. Although any
of the consequences pointed out above (§ 47. 189.)
may arise, changes of the viscera of the abdo-
minal cavity are by much the most common, in
this class of fevers, as well as in agues. The
Prognosis is apparent from what has been ad-
vanced, and in every respect agrees with what has
been stated on the subject above (§ 57. et seq.).

242. G. The lesions observed after death from
remittents, as respects both their seat and nature,
differ but little from those already described in
connection with agues. They, however, are of
that kind which are generally observed to result
from acute action in connection with deficient
power. The liver is usually injected, remarkably
softened, of a dark colour, friable, and sometimes
enlarged. The spleen is often so soft as hardly
to admit of being handled. The digestive mucous
surface is softened, injected, ecchymosed, of a
dark hue, and sometimes thickened, abraded, or
even ulcerated in the lower parts of the canal.
The mesenteric glands occasionally, and the pan-
creas more rarely, are enlarged or otherwise
changed. The bronchial lining is generally dark,
injected, and soft. The lungs are sometimes con-
gested, infiltrated, condensed, or inflamed. The
pleura and pericardium often contain some dark
sanguineous serum ; and the substance of the
heart is frequently soft, flaccid, and readily torn,
the cavities being occasionally dilated, more es-
pecially after the adynamic states of the disease.
Adhesions between the pleura; are rare. The
changes within the cranium consist chiefly of con-
gestion of the veins of the pia mater and sinuses,
with a fluid dark blood ; and sometimes of effusion
of serum into the ventricles, and between the
membranes. But the lesion of the encephalon
are seldom very great, or in relation to the severity
of the cerebral symptoms during life.

243. iii. Diagnosis.— It mi^Kt be supposed that
the remissions would be a sufficient ciimacteristic
of this fever, and tli(!y certainly are so as respcita
the remitting type. But the occasional occurrence
of yellowness of the skin, and of black vomit, in
the udvanceil stages of its more intense forms, lias

been the means of confounding it with two other
species of fever, in which also yellowness of the
skin and black vomitings occur — the bilio-in-
fiammatory or ardent fever, which attacks only
new comers to an inter-tropical country, especially
America and Africa — and the true infectious
yellow fever, which sometimes spreads in a most
pestilential form. The more intense and ady-
namic forms of remittent, the bilio-inflammatory
or ardent seasoning fever of Europeans recently
arrived in a hot climate, and the true yellow fever
arise from different causes, and present different
phenomena at their commencement and early
course, although the character of the symptoms
often approximates in their last stages.

a. 244. As respects the intense and adynamic
states of marsh remittent, it has been shown above
that the exacerbations seldom continue above four-
teen or eighteen hours, so that one takes place daily,
varying, however, in intensity, so that they thus
usually present a quotidian or double tertian type ;
but in the bilio-inflammatory , or ardent seasoning
fever of Europeans, the type is continued, or a
remission does not occur till after thirty or thirty-
six hours, a difl^erent train of symptoms then
usually appearing. These two fevers arise from
different causes ; — the remittent always proceeds
from malaria in some form ; hence it is common
to all warm countries, and to temperate regions
in warm seasons, and varies remarkably in severity;
the hilio-injlammatory or ardent fever may pro-
bably also arise from the same cause, but it is
more especially the eflfect of temperature upon
European constitutions, or of atmospheric vicissi-
tudes and other causes acting concurrently with
these ; hence the much greater uniformity of its
character, in which it nearly approximates to the
bilio-inflammatory form of the remittent. Whilst
remittents can, in every instance, be traced to ter-
restrial exhalations — to the sources described in
the article Endemic Influences, ardent fever
often appears where the operation of such causes
has been impossible, and where I have endea-
voured in vain to account for its occurrence, ex-
cepting in the way stated hereafter.

245. b. These two diseases are the seasoning fe-
vers of Eiirnpeans arrived in a hot climate — ardent
fever commonly appearing in robust plethoric per-
sons who have emigrated to the West Indies, inter-
tropical Africa, &c. ; the intense forms of remittent,
in those less robust, or who have not been attack-
ed by ardent fever, and who have been exposed to
malaria after their arrival. This statement is illus-
trated by the following facts, which came under
my own observation in 1817 and 1818 : — Some
young men arrived from Europe in a place within
the tropics, during the healthy season, and where
no sources of malaria then existed. They soon '
were attacked by the common ardent fever, with
two or three exceptions, and recovered by means -
of the treatment advised for this disease ; but
during the unhealthy season, several of them had
remittent fever ; and those who had not been at-
tacked by the ardent seasoning, had the morei
severe forms of remittent, which was their sea-
soning. In the East Indies, bilio-gastric fever and
the inflammatory forms of remittent are the most
fre(|uent fevers in recently arrived Europeans ;
but in the West Indies, ardent fever is the most '
common, e^pocially in the young, plethoric, or
robust — in those much exposed to the sun's rays,

FEVER, REMITTENT — Diagnosis.

951

who use great exertion, and live freely or intem-
perately, who neglect their bowels, or cheek the
perspiration. — la the latter, the yellow skin and
vomitings of dark matters are most freiiuent, and
appear earlier than in the intense forms of remit-
tent, and both diseases, although distinct, have been
denominated yellow fever, from the contingent ap-
pearance of a single symptom, towards their close,
and have thereby been confounded not only with
each other, but also with another fever distinct
from both, and merely because one or at most two
symptoms are common to all three, but only in
the last stage of the most unfavourable cases.

246. c. The true or pestilential yellow /isi'er is dif-
ferent from severe remittents and from ardent fever,
neither of which is infectious, whilst true yellow fever
is eminently infectious. — a. Ardent fever occurs
only in Europeans recently arrived in hot climates,
and never in the acclimated, nor in aboriginal or
native inhabitants : it cannot attack the dark-
skinned races, and the assimilated European. —
0. The severe forms of remittent affect both those
who have recently arrived in miasmatous districts,
after they have been exposed to endemic causes,
and those who have resided longer, and become
seasoned or acclimated, especially when the causes
have been concentrated or intense. They may
also attack individuals from adjoining districts,
especially from elevated situations, when they
descend to the low grounds, and swamps near
the sea, or the embouchures of rivers; but they
rarely affect the aboriginal inhabitant, and the
negro races. — y. The true yellow fever, on the
other hand, attacks the unseasoned, the seasoned,
the constant resident, and the dark-skinned races
—the negro as well as the European — all within
the sphere of its infection ivho hare not previously
had the disease. A former attack protects from
true yellow fever; but remittents will occur again
and again in the same person ; and even ardent
fever will occur a second time, if the person who
has once been affected by it has returned to Eu-
rope, resided long in it, and afterwards gone to a
warm country ; although on this second visit, the
fever will much more probably be an inflamma-
tory remittent, than the ardent or bilio-inflamma-
tory disease. The remittent is endemic in warm
climates, and in several temperate countries in
warm seasons, especially those abounding with
the sources of malaria ; the ardent fever oc-
curs only among persons who have recently ar-
rived from cold or temperate climates, into a very
hot country ; and true yellow fever appears only
occasionally, and then the infection may either
extend to a few only, the circumstances favouring
its diffusion not existing, or to great numbers,
the disease thereby becoming epidemic. Thus,
the first and second of these fevers are always
occurring, especially the first; the third, seldom,
or after long intervals.

247. The confusion which has thus arisen from
confounding three diseases so essentially distinct
has been perpetuated by published works and in
official returns. Thus a practitioner observes fever
in the West Indies among sailors or soldiers
lately arrived ; and has to treat, although the
locality is healthy, a number of cases of ardent
fever, with high action at the commencement,
and, in some of the most unfavourable of these,
with yellowness of the skin, black vomit, &c. in
the last stage. He finds large depletions cure

the disease; and notwithstanding his range of
observation is confined, and the symptoms referred
to contingent, he publishes, to inform all whom it
may concern, that he has had numerous cases of
yellow fever to treat, that he cured nearly all of
them by large bloodlettings, and that the disease
was neither contagious nor infectious ; all which
was very true, with the single exception of the
disease being yellow fever, the ardent or bilio-
inflammatory, arising from very different causes,
having been mistaken for it ; and very probably
a case of true yellow fever had never come within
the sphere of his observation during his residence
in the country ; or if it has appeared, it has been
mistaken for the disease now instanced, or for a
severe remittent ; or indeed all three may have
been confounded together, as most commonly is
the case. — A second practitioner arrives in a
part of the country where the intense or concen-
trated states of remittent are endemic, and where
it presents the inflammatory, or bilio-inflamma-
tory form, in persons more recently arrived from
Europe, and where also yellowness of the skin,
&c. occasionally appear in the last stage. He
finds that bleeding kills as many as it cuies when
indiscriminately and incautiously employed, and
has therefore recourse to mercurials, especially
calomel, observing that, when salivation occurs,
the patient is generally safe. He also believes
that he has had yellow fever to treat, that it is
the endemic of the country, and not infectious,
and that mercury given to produce salivation and
not bleeding is the cure for it. He writes to con-
vert those who entertain different opinions from
himself, and thinks that no one else knows
anything of the matter. The same errors are
committed in this case in the former, except-
ing that another disease has been mistaken for
yellow fever, although that malady has either
never been seen by liim, or has been confounded
with the endemic of the country. — A third prac-
titioner has enjoyed a more extensive range of
observation : he has observed not only both these
diseases, but a third also ; he has recognised the
origin of the three in very different causes ; has
noticed marked distinctions between them, in
their early stages especially ; has ascertained the
infectious nature and the only occasional occur-
rence of one of them, to which the name of yellow
fever is most applicable ; he has watched the be-
ginning, progres^s, and devastating spread of this
malignant disease; and he has experienced the
inefficacy of treatment in its most severe cases.
These important facts and many others connected
with the subject are placed before the public, but
are controverted by the first and second practi-
tioners, and those who, having observed, like
them, in one confined circle, and during a period
of no great duration, have, notwithstanding, be-
come instructors of others ; and who, wanting
the experience of those whom they oppose, have
not even inspiration to plead either in behalf of
their doctrines, or as an apology for their intru-
sion. Thus the inexperienced are bewildered by
contrariety of opinions, or misled by partial views
which do not apply to the circumstances and dis-
eases which often will present themselves. It will,
therefore, be better for him, who has to treat for
the first time the fevers thus generally confounded
with each otiier, to apply himself to the task with a
mind well instructed in pathological principles and
3 P 4

962

FEVER, REMITTENT— Treatment.

■with a due knowledge of disease and of therapeu-
tical agents, but perfectly unbiassed by doctrine or
by the reputed efficacy of certain modes of treat-
ment ; otherwise, he may find out, after some un-
toward experience, that neither the doctrine, nor the
practice founded on it, apphes to the cases which
he is called upon to treat. I never shall forget
with what bitterness an amiable physician many
years ago told me, on my meeting him in an un-
healthy climate within the tropics, where he had
arrived some months before myself, of his want of
success in treating the fevers of the country.
Being desirous of the guidance of those who had
written on the disease, he had treated it at first
conformably with the instructions given in books,
and the first nine cases terminated fatally in rapid
succession. The practitioner should observe and
think for himself ; and whilst his mind is open to
the suggestions which works will furnish, he
should ascertain the states of vital power, and
of local and general morbid action, in each case,
and employ medicinal agents appropriately to
these, and with promptitude and decision, guided
but not weakened by caution.

248. iv. Treatment. — A. Of the mild remit-
tent,— The treatment of this form differs not mate-
rially from that advised above for agues, espe-
cially when the remissions are distinct. At the
commencement, before reaction is developed, and
when there are no indications to forbid their ex-
hibition, emetics are generally of great benefit.
After their full operation, a large dose of calo7nel,
or of calomel and opium, may be given, and an
action produced on the bowels by purgatives and
cathartic enemata. These means having been
repeated until morbid secretions and faecal accu-
mulations are evacuated, bark or quinine may be
prescribed, if the remissions are distinct, and the
patient not removed from the unwholesome loca-
lity. But in cases where the previous health and
long residence of the patient in an unhealthy
climate do not forbid it, moderate bleeding in the
stage of excitement will shorten the disease, and
render the remissions more perfect. During re-
action in the early exacerbations, repeated doses
of James's powder with calomel, or the poiassin-iar-
trateof antimonii given in solution every hour or
two, or every half hour, in full doses, commencing
it in the cold stage, so as to produce voiniting, and
continuing it in this manner throughout the sub-
sequent reaction, will frequently accelerate a fa-
vourable termination ; and render large vascular
depletion less necessary. In old residents in
warm climates, or in those constantly living in
an unhealthy situation, this medicine will often
supersede bloodletting, if the bowels are early
and freely evacuated. In the mild autumnal
remittent, also, of this climate, a similar treat-
ment is appropriate; bleeding being required
chiefly in the young, robust, and plethoric. Sub-
sequently, refrigerants, cooling diaphoretics, and
other appropriate means may be employed.

249. B. In the injlammatorij and bilir,-in-
Jlammatoni forms, the practice, early in the dis-
ease, should be energetic. — a. In the cold stage,
or that of invasion, and when, although there may
be most severe headach, the heat of the scalp
and the action of the carotids indicate that it is
not inflammatory nor dependent upon fulness of
blood ; and when exc('s>ive vascular jiction in the
Btomacli and liver has not yet been developed.

an active emetic is of essential service. As soon
as the stage of excitement is developed, and pro-
portionately to its excess, and to the degree in
which vascular action becomes predominant in
the head, liver, or stomach, should bloodletting,
generally or locally, or both, be practised ; the
quantity having relation to the constitution, habit
of body, &c. of the patient. In order, however,
that depletion may be productive of benefit, it
must be practised early in the disease ; for, if
deferred till the excitement has partly exhausted
the powers of the system, its good effects cannot
then be obtained ; the nature of the pathological
states admitting of local depletions only, which,
however, should be einployed in order to remove
such local congestions as may have taken place.

250. b. Full doses of calomel, followed by pur-
gatives (F. 181. 216. 266.) and cathartic enemata
(F. 140, 141. 150.) are also early requisite; the
first of these having been given soon after the opera-
tion of the emetic, and combined with James's pow-
der. During the vascular excitement, particularly
when the skin is very hot and dry, the cerebral
symptoms strongly marked, and the abdominal
viscera free from congestions, cold applicatums
should be kept to the head, and the cold affu-
sion frequently resorted to. When vital power is
much impaired by the impression of the exciting
causes, or exhausted by the previous excitement,
and when the abdominal viscera are congested,
as evinced by the fulness and tenderness of the
hypochondria and epigastrium, the cold affu-
sion is a hazardous measure, the constitutional
powers not being always sufficient to bear the
shock, and the overloaded viscera sometimes suf-
fering further from the external impression. In
such circumstances, especially when the pulse is
quick and irritable and the skin harsh, the tepid
bath, and sponging the surface with cold or tepid
water, will be preferable. A certain degree of
vital power is necessary to a successful applica-
tion of the cold affusion; the surface being hot
and dry, and the internal viscera not seriously
congested.

251. c. When the head is much affected, leeches
to the temples, behind the ears, and to the occi-
put, or cupping, will be serviceable ; evaporating
lotions, or the cold affusion on the scalp being
resorted to : but even these may he injurious if
employed too late, or in states of exhaustion.
The appearance of the face and eyes, the heat
of the scalp, the expression of the countenance,
and the action of the carotids should guide the
practitioner, and not the degree of delirium or of
insane delusion ; for these may be most remarkable
where vascular action in the brain is lowest, as they
depend more upon nervous and cerebral power than
upon vascular action. When much heat, pain,
tenderness, and fulness of the epigastrium or hypo- •
chondriu, with nausea and vomiting, are present ;
the matters thrown up being viscid or ropy and
abundant, and yellow, green, or yellowish green,
or dark green, or colourless, and n)ixed with al-
buminous flakes, energetic vascular depletion
should be early resorted to, otherwise the vital
tone of the mucous coat and capillaries of the
stomach will be soon exhausted, and dark gru-
mous vomiting sui)ervene. In these cases, a
large bloodletting from the arm, and twenty
grains of calomel, with two or three of opium,
should be promptly prescribed. If these be fol-

lowed by marked mitigation of the symptoms
and a copious perspiration, this latter should be
encouraged by cooling diaphoretics ; but if the
symptoms continue or return, either a repetition
of these remedies, or a large depletion near the
seat of the chief disorder, ought to be directed.
A large blister should be afterwards applied, or
the warm turpentine epithem. The latter is pre-
ferable, inasmuch as its effect is almost immediate,
as it excites a copious perspiration, and as it may
be renewed from time to time with additional
benefit. Purgatives may now be given, and they
will generally be letained ; but those which are
least irritating to the stomach should be selected,
and their action promoted by cathartic enemata.
In the intervals, the liquor ammoniaj acetatis,
with camphor mixture and nitrate of potash, may
be prescribed, or other cooling diaphoretics.

252. d. K the bite be secreted in great quantity
and acrid quality, the consequences of the active
determination to the liver occasioning this dis-
order, and the effects of the morbid secretion
upon the digestive mucous surface, ought equally
to be guarded against, by local depletions, by
external derivatives, cooling diluents and demul-
cents, and by aperient injections. If symptoms
of inflammatory action in the liver are manifest,
the same measures should be promptly and ener-
getically employed. If the bowels be inordinately
affected, a similar treatment is necessary ; the
external rubefacients being applied over the
abdomen ; and a large dose of calomel and
opium should immediately follow the depletions.
All these ought to be repeated according to cir-
cumstances ; emollient and laxative medicines
being exhibited by the mouth and in enemata,
and cooling diaphoretics in the intervals. When
soreness, tension, or fulness of the bowels con-
tinues notwithstanding, the external applications
(§251.) shoulil be repeated. If with fulness of
the abdomen, there is much load on the tongue,
and oppression at the epigastrium, purgatives,
especially in enemata, should be persisted in.

253. e. The exhanstion of the advanced stages,
produced by the previous excitement and by
the treatment, demands attention. If the above
means have removed all local disease along with
the morbid excitement, and if the patient is
beyond the influence of the causes, little more
is necessary, as the system soon rallies. But
if he be constantly subjected to them, the con-
sequent exhaustion will be thereby increased, or
its character modified, and the adynamic con-
dition superinduced. In such cases, suitable
means are devised with great difficulty. If the
exhaustion be attended by a distinct remission,
the pulse falling in frequency, and the tongue
remaining moist, the irritability of the stomach
having subsided, the exhibition of bark or quinine
should not be delayed ; for by it chiefly are we
to hope to prevent an accession of the febrile
action, and to preserve the powers of life from
the noxious influence of the surrounding causes.
But the eflPect of this substance should be care-
fully watched : as long, however, as the tongue
is dry or rough, with the papillae erect, the pulse
hard or irritable, and the skin hot and harsh, the
remains or unfavourable consequences of the
previous morbid action are still unsubdued ; and
these the cxliibilion of bark would incrfa-^e. In
this case, local depletions, tepid or warm bathing.

FEVER, REMITTENT — Treatmekt. 953

purgatives, diaphoretics, and external rubefacients
are still required. If the symptoms and circum-
stances of the case warrant the use of bark, the
decoction with the carbonate of soda and nitrate
of potash, or with the liquor ammoniaj acetatis
and hydro-chlorate of ammonia, may be first
employed, and subsequently the more active
preparations of this substance ; but, during its
exhibition, the secretions and excretions must
be promoted by purgatives with mercurials, &c.
The decoction may be given for this purpose with
the neutral purgative salts, or quinine with either
of the sulphates, so as to keep the bowels freely
open. If calomel has been freely given at the
beginning, and the bowels well evacuated in the
progress of the disease, blue pill, with the aloes
and. m-yrrh pill, and ipecacuanha, maybe taken
at night, and the bark or quinine in the day. It
is chiefly in cases where depletions and purgatives
have been too long delayed, or insufficiently
prescribed, and where the latter have been laid
aside too soon, that the bark either fails, or occa-
sions congestion or obstruction or consecutive
inflammation of any of the abdominal viscera.

254. C. The adynamic states of remittent fever,
occurring primarily, or supervening secondarily
upon either of the other forms, are the scourges
of intertropical countries ; and present such a
variety of characters in both hemispheres — the
yellowness of the skin and dark grumous vomiting,
predominating in the western hemisphere (the
Yellow Remittent Fever o( Dr. Chisholm) — that
methods of cure which shall be appropriate to
their varying forms are often devised with as
great difficulty as with want of success. In
every condition, however, the removal of morbid
secretions and accumulations from the prima via
is a necessary preliminary. At the period of
invasion, the sense of cold being prolonged, and
the nausea not attended by free vomiting, and
more especially if the formative stage be charac-
terised by dysenteric symptoms, as sometimes
observed in hot climates, the exhibition of an
emetic will be useful. — a. In the more malignant
states of this form, in which the stage of excite-
ment commences with tumultuous vascular re-
action concentrated cliiefly in the viscera of the
large cavities, and principally in those of the ab-
domen, bloodletting, either general or local, or both,
should be practised early in this stage, especially
in persons of a robust, plethoric, and sanguine
constitution ; for, if this state of reaction be not
speedily moderated, the vital tone of the viscera
which chiefly experience it is soon exhausted, and
collapse of the vital powers, with organic change
and yellowish discolouration of the skin, super-
venes as early as the third, fourth, fifth, or sixth
days, in unfavourable cases, and later in those
which are less so, followed soon after by dark,
grumous vomitings, and all the symptoms to
which the term malignant may be appropriately
given. Emetics are beneficial only in the form-
ative and invading stages of these cases,. and are
hurtful if administered in the irritated and in-
flarried states of the stomach and liver generally
attending reaction. After free depletion, from
ten to twenty grains of calomel should be ex-
hibited, with one or two of opium, and be repeated
according to the eftect and the circumstances of
the case, if the first bleeding lias been insuf-
ficient, a second should be directed within twelve

«54

FEVER, REMITTENT— Treatment.

or eighteen hours, and followed by the calomel
and opium ; and the bowels ought to be freely
opened. In the worst forms of marsh fever,
particularly in hot climates, the secretions of the
liver are often interrupted or suppressed, large
doses of calomel and active purgatives being
especially required in them. If the mouth be-
come affected, the circumstance is favourable,
although we should hardly make this a specific
indication unless other intentions be also fulfilled.
The warm bath, followed by frictions of the
surface, or by the terebinthinated epithem on the
abdomen, and by diaphoretics, will also be of great
service.

255. b. Whilst vascular depletions are thus
necessary in the more concentrated and inflam-
matory states, which rapidly pass into the adyna-
mic or malignant form, they are inapplicable to
those in which the powers of the system are
insufficient to produce vascular reaction ; at least,
they should never be employed until efforts at
reaction are made, when a small or moderate
general or local bleeding may be directed, espe-
cially after the warm or vapour bath and frictions
of the surface, with the view of relieving the
overloaded vessels of the large viscera, and of
removing congestion of the venous trunks and
auricles of the heart. If an adynamic state has
continued from the commencement, the skin of the
trunk being harsh and dry, the extremities damp,
the pulse weak and rapid or irregular, the tongue
dark and coated, the bowels disordered or costive,
and the evacuations morbid, the vital energies of
the frame should be roused by means of the hot
or vapour bath ; by assiduous frictions with sti-
mulating liniments (F. 299, 300. 311.); and in-
ternal congestions removed by warm diaphoretics,
stimulants, purgatives, and mustard poultices,
or the hot turpentine epithem applied over the
epigastrium and hypochondria, and, in extreme
cases, on the insides of the thighs also. In this
latter class of cases, calomel is still indicated,
especially if the stomach be irritable ;, but it
should be conjoined with large doses of either
camphor, ammonia, or capsicum, with opium.
Subsequently, the bowels having been very freely
evacuated, and the states of the tongue, of the
pulse, and of the skin not forbidding, bark in de-
coction, or sulphate of quinine, may be pre-
scribed.

256. c. A similar treatment is indicated when
an adynamic or malignant state supervenes on
that of low excitement — when the skin becomes
yellowish or dusky, and the irritability of the sto-
mach urgent or disposed to pass into the dark
grumous vomitings, indicating great dantrer. This
affection of the stomach is much more violent when
it is consequent upon excitement than when it
occurs in the course of a fever in which excite-
ment has been imperfectly expressed ; for, in the
former case, the vital power of the organ is ex-
hausted, and the organisation affected ; in the
latter, power is simply diminished or suppressed,
restoration being more easy in it than in the
former. In both circumstances, the external de-
rivatives just mentioned, and calomel in the com-
binations specified, are chiefly to be relied upon.
When the vomiting consists of a pumjjing up of
the contents of the stomach, rather than of active
retchings, cordial stimulants should Im; employed
in nddition to these ; and aromatic spiecs, am-

monia, ether, camphor, opium, &c., may be
variously combined. Fluids evolving carbonic
acid, as spruce beer, seltzer-water, soda-water,
bottled stout, &c., may also be prescribed. In a
few urgent cases, I have found from half an ounce
to an ounce of the spirits of turpentine, taken on
the surface of milk or any aromatic water, with
half a drachm of magnesia, allay the irritability
of the stomach, lower the pulse, and render the
tongue moist, after other measures had failed ;
and I have exhibited this dose, or F. 216., as a
purgative, three or four hours after a bolus con-
sisting of ten or fifteen grains of camphor and
calomel, with one, two, or three of opium, had
been taken ; promoting the action of the bowels
by warm cathartic enemata, if necessary.

257. d. In low, miasmatous districts, bark or
quinine, in suitable combinations, is often neces-
sary in an advanced stage of the adynamic states.
The former in substance, however, or the latter in
large doses, generally irritates the stomach, and
it then proves injurious. The infusion of bark,
therefore, with the chlorate of potash , or with hydro-
chloric acid or ether ;. or the decoction with hydro-
chlorate of ammonia, or with nitrate of potash, and
the solution of the acetate of ammonia ; should be
first employed : and subsequently, the quinine
with acids. But while we thus endeavour to sup-
port vital power, morbid secretions and fa:cal col-
lections should be fully evacuated, either by mild
purgative draughts, — and preferably by those of
a stomachic or tonic kind, — or by enemata, or by
both. If the combination of the mild preparations
of bark with the antiseptics and refrigerants just in-
stanced are inefficacious, the more energetic pre-
parations with ether, or the preparation of ammo-
nia, or with aromatics, &c. must be resorted to..

258. D. The complicated states must be treated
with reference chiefly to the condition in which
vascular action and vital power are manifested.
The treatment of the more inflammatory compli-
cations has been already described. The compli-
cations of the more adynamic states are so diversi-
fied, that the measures already recommended, as
well as others about to be noticed, must be adapted
to individual circumstances. If an irritable or dy-
senteric state of the bowels occur, morbid secretions
or faecal accumulations have probably caused ir-
ritation of the mucous coat. A full dose of calo-
mel should therefore be given, if it have been
neglected, and be followed by a common purging
draught, by castor oil, or F. 181. 216. 266. ; and,
in a few hours, laxative enemata, and demulcents
should also be administered. After the full oper-
ation of these, anodynes, with gentle alteratives
and light tonics, or the preparations of bark or
quinine in the forms above mentioned, may be
exhibited. In the adynamic states, this compli-
cation is very unfavourable, especially when the
stools are very dark, black, or otherwise morbid ;
and the abdomen swollen and painful. Calomel,,
with camphor and opium, is necessary in such;
and large blisters, or the other external applica-
tions previously directed (§251.), are especially
indicated. Tonic purgatives, &c. are also re-
quisite ; and bark or quinine in large doses, and
in forms of combination most appropriate to this
particular class of cases. The other complications
either have been already noticed, or demand no
material modification of the treatment. Whether
seated in the head^ thorax, or abdomen, the state

FEVER, HEMITTENT — Chhonic — Pathology.

of vascular action, in connection with vital
power, requires attention; local depletions, ex-
ternal derivatives and revulsants, active purgatives
and diaphoretics, with diuretics, constituting the
chief means of cure.

259. E. A treatment has been strongly recom-
mended by Dr. Stevens for the advanced stages,
and malignant or adynamic forms, of remittent and
other fevers j but I am not aware that it has
been satisfactorily or properly employed by other
practitioners. One of the substances, at least, —
the chlorate, or oxymuriate of potash,- — I have
often prescribed as a tonic and stimulant, and
for a great many years, both at the infirmary
for children, and in private practice ; and I am
quite convinced, from an extensive experience of
its effects in low states of fever, of its very bene-
ficial effects. It has often a remarkable and rapid
effect upon the state of the tongue, rendering it
more moist and clean. Dr. Stevens state that,
when adynamic symptoms appear, after venesec-
tion, mercurials, cold affusion, and purgatives
have been prescribed, no time should be lost in
exhibiting non-purgative saline medicines, espe-
cially the carbonate of soda, the chlorate of
potash , and common salt ; and that these should be
repeated every hour during the disease. These
substances lie believes to act beneficially upon
the constitution of the circulating fluids, and to re-
place that portion of the saline constituents of the
blood, which he supposes to be lost or changed in
the early course of the disease-

260. F. If the remissions become hardly distin-
guishable, the states of morbid action being in
other respects as above treated of, the method of
cure must still be the same as recommended for
the inflammatory, bilious, concentrated, and ady-
namic or malignant forms respectively ; the nature
of the disease being no further changed hy the conti-
nued tijpe thus assumed, than that the constitution
suffers more decidedly, and the vital powers sink
more rapidly under the unremitting state of dis-
ease induced. Hence the means of cure should
be the same in kind, but administered, in warm
climates especially, with greater promptitude and
decision.

261. G. Whercremittentsassume the intermittent
type, as they occasionally do in \inhealthy localities,
the liver, spleen, or mesenteric glands, or all of
them, are more or less disordered, or actually dis-
eased ; and enlargement or obstruction of one or
more of them generally soon afterwards becomes
evident. In cases of this kind, although the
active exhibition of bark or quinine is necessary to
prevent the return of the paroxysms, which, by
their continuance, would increase the mischief,
yet the full operation of purgatives and deobstru-
ent laxatives is equally requisite; for, without
them, neither will l\re obstructions already existing
be removed, nor the intermittent disease be safely
arrested, nor the bark or quinine exhibited with
permanent advantage to the patient. In cases of
this kind, change of air is next in importance to
the employment of suitable medical treatment ;
and, in all cases, the one should accompany the
other. If remittents pass into dysentery, disease
of the liver, and of the mesenteric glands, with
the other changes in the large bowel^:, fully de-
scribed in that article is a common pathological
state ; and the treatment nuHt be directed ac-
cordingly, and as fully detailed under the above

955

head. The regimen and convalescence of the
patient, and the means proper for the prevention of
relapses, differ in no respect from what has been
stated on these topics under the treatment of in-
termittents (i 223, 224.).
XIII. Chronic or Obscure Remittent. Syn.

-^Anomalous or relapsing Remittent; Slight

Nervous Fever, I. Macculloch.

262. Charact. — Slight febrile exacerbations
and remissions, with headach, &;c. ; recurring i«
daily, occasionally in reduplicating, paroxysms;
continuing for an indefinite peiiod, and giving rise
to various disorders of the digestive organs and
7iervous system.

263. This very slight form of remitting fever
often continues a very long time when its nature
is mistaken. It is by no means an infrequent
disease : three or four instances of it have been
treated by me very lately ; and before my at-
tention was directed to it by the writings of
Dr. Macculloch, other cases had disappointed
my anticipations as to their nature and tieatment.
It appears in delicate persons, and commonly
arises from the less energetic action of the same
causes which produce the more decided and acute
forms of marsh fever, and generally in a primary
mode ; but it also may follow the simple remittent
described above. It bears the same relation to
the definite and severe disease, as the slight, ano-
malous, or masked intermittent does to regular
ague. When it is so marked as to be esteemed
a fever, it is often mistaken for hectic ; and in its
slighter modes it is confounded with what is com-
monly called debility, chronic debility, chronic
dyspepsia, delicate health, nervousness, low spi-
rits, hypochondriasis.

264. A, In the cases which have occurred to
me, exposure to malaria was manifest ; and to two
patients the cause was assigned and explained,
and a different residence recommended. Whe-
ther it may arise from other sources, is not deter-
mined ; but I entirely agree with Dr. ]Macculloch
in believing that malaria is far oftener present
than has been imagined, more especially during
late years, and around the metropolis. In those
cases which have been traced to this source, the
whole character of the disorder is that of remittents,
as shown by its tendency to critical periods, and
its diurnal remission, &c. It often, also, terminates
in an intermittent as slight and obscure as the
original disease ; while it is not infrequently
followed by local affection of the nervous system,
especially periodical headach, toothach, inter-
mitting rheumatism, and neuralgic pains. Its
frequent recurrence or relapses, especially during
north-east or easterly winds, and in the outskirts
of the metropolis, thereby resembling anomalous
or masked ague, is also a circumstance deserving
of remark, and an argument for considering it,
with Dr. Macculloch, as a modification of re-
mittent, and as the eflfect of a slighter dose or
different conditions of the marsh poison. By mis-
taking this fever for other diseases, the sufferings
of the patient are often materially aggravated ;
whilst, having recognised its natare and cause,
not only the means of cure, but also those of pre-
vention become obvious. In many cases the cure
and prevention are accidentally hit upon either
by tlie practitioner or patient ; and the state of ill
health complained of removed by change of air,
or a visit to a watering-place.

956 FEVER, REMITTENT

265. -B. The symptoms consist chiefly of great
muscular weakness, which often appears unac-
countable, of sinking sensations, and disinclination
to exertion. A slight chill is often present in the
forenoon, or about midday, or a creeping cold
down the spine. During the afternoon, evening,
and night, a slight degree of febrile excitement is
manifest, and the palms of the hands become hot
or burning. The tongue is generally white, and
the apex and edges are often somewhat red. The
urine is often pale and abundant in the morning,
and hio-her coloured, and more frequently voided,
in the evening and night. The patient is some-
times unable to follow his occupations in the
morning ; he wakens unrefresheJ, either from a
feverish, restless, or disturbed sleep, or from a
lethargic, dreamy, and prolonged sleep ; he is
fatigued all morning, without knowing where-
fore ; is depressed, anxious, and irritable ; or
complains of want of mental energy or abiUty,
and of dull headach ; and, as the chills and
sinkings of this period pass into a gentle febrile
excitement, he feels more restored in the after-
noon or evening. In the case of a delicate, most
talented, and accomplished female, subject to
this disease, and liable to relapses of it during
cold easterly winds, although tiie most distress-
ing, sinking, and exhaustion were often felt in the
morning, so that she was hardly able to dress
herself, or to get up to breakfast ; yet she often
could in the evening exert and enjoy herself.
The pulse is occasionally not materially disturbed :
it is frequently accelerated and a little hard, in
the course of the exacerbations, but is commonly
weak and slow in the remissions. The bowels
are generally sluggish; the evacuations slightly.
disordered; and the appetite, when the heat is
considerable, and the exacerbations very marked,
is much diminished, and generally capricious.
The patient loses flesh during the attacks, and
various anomalous symptoms referrible to the
stomach, bowels, and other abdominal viscera,
often present themselves ; and, when they become
prominent, are liable to be considered and treated
as the original complaint.

266. In many cases, although these ailments are
both real and distressing, the patient is considered
as either feigning, or hypochondriacal. In these
more especially, and when the course of the com-
plaint is less regular, the time of the day when the
exacerbations and remissions occur, varies much.
If they are tolerably regular, they often present a
quotidian, tertian, or double tertian character, the
symptoms being worse on alternate days. In the
more chronic cases, the mind becomes irritable or
despondent, and in some instances this latter feel-
ing is most distressing. Dr. ELi^ioTbON confirms
the remark of Dr. Maccum.ocii, that the exacer-
bations are often unobserved from occurring in the
night ; increased heat, oppression of the head, and
depression of spirits, amo mting to hypochondri-
asis, being tiic chief symptoms. The nights are
frequently the periods of greatest suffering. A
gentleman, who consulted me in the summer of
1834, described them as being most distressing.
In another case, an inability to think, with con-
fusion of ideas, was comi)lained of; an inflam-
matory dyspepsia, a burning sensation at the
stomach, and other symptoms of irritation of tiie
digestive mucous surface ; sp(Uigiiioss of the gums,
and soreness of the ton"uc, which often becomes

— CHnoNic — Treatment.

smooth and divested of its papillae, occasionally
appear in the advanced course of the disease ; and
ultimately seri(5us disorder of the abdominal organs,
prostration of organic nervous power, and a state
of ill health, amounting to general disease, super-
vene.

267. In some instances, this complaint assumes
more of the intermittent character, and at diflfer-
ent times it seems to vacillate between the remit-
tent and intermittent types ; b>it there is rarely
any distinct cold stage or a greater feeling of cold
than that above mentioned (§ 265.), excepting at
the commencement of an attack, or of a relapse.
Signs of functional disorder of the liver, and of
torpid function of the colon, often appear, espe-
cially in this class of cases ; and the disease is
frequently considered a form of liver complaint ;
the heavy or dull headach sometimes attending
it being imputed either to the same source, or to
the accompanying affection of the stomach.

268. In conclusion. Dr. Macculloch de-
scribes this form of remittent as modified chiefly ia
degree and duration, it being often so slight as
to reqtiire some attention in tracing its form, and
even its existence. It is apt to become habitual, or
to recur at frequent but variable intervals, during
even an indefinite course of many years; varying .
in such a course its characters and symptoms,
and being in some cases a marked chronic inter-
mittent, in others remittent, and in some so brief
and imperfect in its remissions as to be almost
continued. Its accessions are of the ordinary
duration of remittents, and they commonly observe
the quotidian or double tertian periods. It is,
moreover, often a primary disease : sometimes it j
is consequent upon ague, or the severe states of |
remittent, or even upon continued fever ; and, '
whilst it is especially caused by malaria, in some
of the slighter modes of this poison, it may pos-
sibly arise from other sources ; or, after a first
attack, a relapse may be caused by cold, moisture,
atmospheric vicissitudes, the use of cold or drastic
purgatives, vicissitudes of temperature, intem-
perance, bloodletting, and excessive evacuations.

269. Treatment. — a. The slighter, primary,
and more recent states of this complaint are re-
moved by the sulphate of quinine, the prepara-
tions of bark combined appropriately to particular
cases, by Fowi er's solution of arsenic and
change of air ; the bowels being duly regulated by
laxatives, or mild purgatives combined with bitter
tonics (F. 266. 562. 572.) But the more chronic
states, especially when the nervous system is
much affected and the patient has become
desponding and hypochondiiacal, are treated with
much less success. If it degenerate into con-
firmed hypochondriasis, the case is one of the
most diflicult that conies before the practitioner.
In some instances an active exhibition of mlphate
of qiiiniue is of great benefit. Dr. Ei.lioison al-
ludes to a case in which five grains were given
three times a day without benefit ; but the dose
having been increased to ten grains, relief was pro-
cure!. When signs of inflammatory irritation of
the digestive canal exist, the decoction of bark
should be first employed with the nitrate of potash,
or with the hydrocidorale of ammonia; and if the
tongue be flabby, and thegumssjiongy.asinthecase
above alluded to, the decoction may be given with
hydrochloric acid, or with the nitio iiydiochloric,
or with the chlorate of iMtash. 'i'he combination of

FEVER, REMITTENT, OF

aloes, or the aloes and myrrh pill, with sulphate of
quinine and inspissated ox-gall, will be found the
most successful purgative : it proved so in one of
the cases I lately treated. I'he krecsote was em-
ployed by me in another case, in conjunction with
quinine, in doses of from one to four drops three
times a day. The patient was much benefited,
-but went on the Continent soon afterwards.

269. b. Early change to a dry and icholesome air,
whenever the patient's residence is at all in fault,
is the chief part of the treatment. Without this,
relapses will be frequent. Healthy watering-
places, travelling, and the rest of the means di-
rected in hiipnchcndriasis, must be resorted to
when the disease has proceeded so far as to be
attended by despondency. Sea-voi/aging, which
generally proves so beneficial to persons recover-
ing from the remittents of warm countries, is also
very serviceable in this complaint. It is a much
more safe mode of enjoying change of air than
that too often adopted by patients of this kind;
for many of them, preferring to travel on the
Continent, are in numerous places and on many
occasions much more exposed to the efficient
cause of the disease than if they had remained in
England. Indeed, the worst instances which I
have seen, or which I have heard, have been
those who had experienced attacks of ague or of
remittent fever in Italy and in warm countries ;
and, on their return to this country, had suffered
from the slighter causes occurring in it, or from
the east winds of spring, and then blamed the
climate of England for a disease which, if not con-
tracted, had at least its seed sown, in the countries
which have been objects not only of their prefer-
ence, but of their eulogies.

XIV. Remittent of Children. Syn. — In-
fantile Remittent Fever, Butter ; Fehris ver-
minosa, of various authors ; Spuriniis ]Vorm
Fever, JMusgrave; Febris 7niicnsa verminosa,
GoiJLis; Hectica InJ'anlilis, Sauvages ; Febris
lenta, Hoffmann.

270. Charact. — Exarcerbations and remissions,
of fever in children, with loaded tongue, loss of
appetite and fesh, unnatural evacuations, pains in
the abdomen and head, and much irritability ;
generallii chronic in its duration.

271. i. Remote Causes. — This disease usually
affects children from nine or ten months to twelve
or thirteen years old. It was very generally
imputed by writers in the three last centuries to
worms, which are rather a complication than a
cause of the complaint ; but a complication of
remarkable frequency on the Continent, particu-
larly in the unhealthy localities where this affec-
tion is most common, and often misunderstood;
both this complaint and worms in the prima via,
being occasionally concomitant effects of one and
the samecause, which hasbeenvery generally over-
looked. The remarks of Hoffmann, Baglivi, De
Haen, Brera, and Goicris, as to the influence of
the latter disorder in causing the piienomena of
infantile remittent, should, therefore, be considered
merely as proofs of the frequency of this con-
comitancy ; whilst our experience of the disease,
in this country in particular, demonstrates its
independent nature. Dr. INIusghave, in his
" Essay on the Worm Fever," was the first who
distinctly stated this; but a nearly similar
opinion had been given by Professor Sinclair,
of Edinburgh, long previously, and had also been

CHILDREN — Description.

957

entertained by Dr. ]\Iusgrave's contemporary,
J)r. ^VILLIAM Hunter. Dr. Clark confirmed
the statement of Musgrave ; and the subject was
soon afterwards set at rest by the publication of
Dr. Butter's work on the " Infantile Remittent
Fever."

272. Dr. Butter assigned debility of the
digestive organs, errors in diet, accunnilations of
morbid matter on the prima via, and the peculiar
irritability of childhood and proneness to fever,
as the principal causes of the complaint. I be-
lieve it to be often caused by improper food, by
collections of mucous sordes in the digestive
canal, owing to a neglect of the bowels ; and by
too cold or thin clothing; in connection with
debility of constitution, and morbid irritability of
the frame. But, iiaving observed it most com-
monly in situations evidently productive of humid
exhalations ; in low, cold, and moist localities ;
and after exposure to a cold air after rain, par-
ticularly at night or in the morning, or during
easterly winds ; I am led to infer that it arises
most fretjuently from the same causes as produce
other periodic fevers ; namely, terrestrial exhala-
tions, or miasmata, and that less intense or con-
centrated states of these exhalations, than are
required to produce either agues or remittents in
adults, will often occasion the latter in children.

273. ii. Description. — This complaint usually
commences gradually ; the bowels being irreuu-
lar, generally costive, but sometimes relaxed or
irritated. Febrile exacerbations, witii drowsiness,
occur in the course of the day and evening, the
child often evincing little disorder during the
remission, excepting a loaded tongue and peevish-
ness. The pulse varies in frequency with the
exacerbations, and ranges from 100 to 140. The
appetite is variable. Tliese are often the chief
symptoms of several days, when the complaint
becomes aggravated, and a distinct chill or rigor
is sometimes observed; followed by vomiting,
and a more violent paroxysm of fever, drowsiness,
flushed cheeks, and shooting pains through the
abdomen and head. The child constantly picks its
lips, nose, and eyes ; and even pushes substances
up the nostrils; and occasionally stiflfness of the
neck, great sensibility of the general surface, and
tenderness, in the course of the spine, are observed.
After some time, the functions of the digestive
canal are almost entirely destroyed, the ingesta
being either thrown oflP unchanged, or passed un-
digested from the bowels. In older children, the
evening or night exacerbations are often at-
tended by deliriuiu. In some instances, par-
ticularly in very young children, convulsions
occur, and render the diagnosis a matter of
difficulty, unless the patient be carefully observed
during the remissions. Such is the most common
form this complaint assumes. Dr. Butter has,
however, distinguished three varieties, which he
has denominated the acute, the slow, and the low.
There are some grounds for this division ; or,
rather, the complaint presents numerous modifi-
catians, which may be arranged under these or
similar heads.

274. A. The acute variety is generally pre-
ceded by symptoms of indisposition, but it may
occur rather suddenly. The bowels are irregular
— commonly costive; the evacuations are mor-
bid and offensive ; the urine turbid, pale, or
milky; and the tongue is loaded, especially at

958 FEVER, REMITTENT, OF

the root. Fever supervenes, and is ushered in by
cold, rigors, or chills ; the child being hot and
restless at night. The febrile exacerbations gene-
rally recur in the afternoon, and during the
night; but there are often three fits, one also
occurring in the forenoon ; and, in the most
severe cases, the remissions are very indistinct.
During the exacerbations, the child is drowsy ;
and, if it sleeps, starting, moaning, and even
screaming, or incoherence, are observed ; some-
times with vomiting, flatulent distension of the
abdomen, accelerated respiration, and cough.
The pulse varies from 120 to 160, according to
the age. The cheeks are usually flushed ; the
abdomen and palms of the hands being hotter
than other parts of the body. Occasionally, the
paroxysm terminates in a slight perspiration,
which is often partial ; the child falls into a quiet
sleep, and the pulse sinks in frequency. During
the remissions he picks his lips or nose ; is irritable,
and without appetite. The bowels are acted upon
with difficulty ; the evacuations are generally
unnatural, but present no constant character ;
and worms are occasionally voided. The urine
is "now transparent, of an orange colour, and its
quantity in relation to the fluids taken ; and all the
other symptoms noticed above are present in an
aggravated form. As the disease declines, the
exacerbations become mild and short, and often
terminate in a gentle perspiration, with a sound
or refreshing sleep ; the urine deposits a sediment,
and is pale ; the appetite returns ; and the stools
assume a healthy aspect. But the pulse remains
frequent, and the flesh and strength are regained
very slowly, unless change to a mild dry air is
adopted. If this form of the disease be either
neglected, or improperly treated, or if the child
remain in a moist or miasmatous situation, organic
change, in some important organ supervenes ;
or the complaint passes into the chronic form,
hereafter to be described ; or degenerates into
marasmus from mesenteric disease. It usually
terminates in from two to four weeks in the more
favourable cases.

275. -B. The more adynamic variety, or state
of the complaint, is the least corhmon ; except-
ing in low, humid, and miasmatous situations. It
is sometimes prevalent at the same season with
the Choleric Fever of Infants (see this ar-
ticle), evidently depends upon the same causes as
it, and is a very closely allied complaint, differ-
ing from it merely in the type of the fever, and
the degree in which the digestive canal is affected.
This variety commonly begins more suddenly
than the others; the earlier exacerbation being
attended by the same symptoms as the preceding,
but by greater affection of the head, and by deli-
rium in the older children ; and (|uickly passing
into more or less exhaustion. When this change
takes place, the child beconies quiet, or indifferent
to external objects, and indisposed to the least
exertion. He dozes, and is incoherent in the
exacerbations ; and, in the remissions, he lies in
one position, contanlly picking his face, parti-
cularly his lips and nose, until they become sore ;
or keeping his hands in continual motion. He
usually, however, takes both food and drink, al-
though sparingly. The countenance is anxious,
pale, and unhealthy ; the eyes reddish, especially
the edges of the eyelids; the lips arc covered
with dark, ragged crusts, or exfoliations of their

CHILDREN —Description.

epithelium ; the tongue and teeth are loaded with
dark sordes ; the bowels are much disordered —
often irritable ; and the stools are very offensive,
watery, greenish, or otherwise morbid, and pre-
ceded by much griping and flatulence ; both the
stools and the urine are frequently passed invo-
luntarily. When a favourable change takes place,
the symptoms gradually subside ; the voice, which
was nearly lost, is regained or becomes stronger ;
the eyes are more lively ; the tongue is cleaner,
and the evacuations improve ; the exacerbations
being shorter, and the remissions more perfect
and prolonged. This variety is generally more
chronic than the preceding, but less so than
the next. It usually continues from one to two
months.

276. C. The chronic form of remittent in chil-
dren either makes its approach gradually and
insidiously, or follows the acute. The ciiild
wastes ; the abdomen enlarges ; the breath is
offensive, and the strength fails. There is com-
monly only one exacerbation in the twenty-four
hours, and it seldom appears before evening,
lasting till morning, and terminating in sweats.
The pulse is usually about 100 in the day, but
rises to 140 in the evening. The tongue is white
or loaded, but moist, and has often a strawberry
appearance ; the bowels are generally costive,
and the stools always morbid. The child com-
monly keeps up, but is disinclined to move, or
complains of aching in the limbs on exertion.
There is little or no appetite or thirst ; and the
other phenomena characterising the complaint,
in its common form, are present in various grades
of severity. If the disease is not removed, tym-
panitic distension of the abdomen, emaciation,
harsh discolouration of the skin, enlarged mesen-
teric glands, aphthous sores on the lips and tongue,
chronic diarrhoea, and lientery supervene. When
the disease declines, all the symptoms gradually
amend ; the nocturnal exacerbations abate ; and
convalescence is established after a period varying
from two to four or five months.

277. This disease is generally sporadic, but is also
sometimes epidemic. It is endemic in unhealthy
localities ; and many of the children born of Euro-
pean parents in hot or unhealthy climates are cut
off by it before they reach their sixth or seventh year.
When it occurs epidemically, it usually assumes
the first or second of the above forms; and proves
both more rapid in its course, and more dangerous,
than in the ordinary states. — Dr. Sims, after de-
scribing the fevers prevalent in London in the
years 1769 and 1770, which seemed chiefly to
result from the endemic sources surrounding the
metropolis and the state of the seasons, gives a
very graphic account of this complaint, as it ap-
peared epidemically during these years, and simul-
taneously with these fevers. As his description
very nearly represents the disease as I have seen
it in very low and miasmatous situations, 1 shall
abridge it at this place. He remarks, that it was
called by some a worm fever, though worms were
seldom the cause ; but as that ap])arently lay in
the stomach and intestines, the error did not ma-
terially affect the practice. It was most common
in children of a sallow complexion and thin habit,
who Ikad been over-fed, with the mistaken view of
supporting and nourishing them. — The leading
symptoms were, heat, thirst, quick, full pulse,
vomiting, coma, and sometimes slight convulsions.

FEVER, REMITTENT, OF CHILDREN — Nature.

959

an universal soreness to the touch ; a troublesome
phlegmy cough, and great peevishness when not
comatose. The fever was constantly of the re-
mittent kind, the cheeks ofien appearing highly
flushed, at other times pale. It lasted for several
days, but seldom beyond a week ; nor was the
fatality attending it very considerable. Many of
those who were seized by it had been subject for
some time to symptoms which are thought to point
out the existence of worms in the -prima via, as
picking of the nose, grinding the teeth, starting
out of sleep, swelling of the belly, white urine,
short dry cough, &c. ; yet worms scarcely ever ap-
peared. These symptoms were evidently, as stated
above, the early stage of the complaint — those
described by Dr. Sims its fully developed state.

278. iii. Diagnosis. — This complaint is most
liable to be mistaken for hydrocephalus, in its acute
or subacute forms. Dr. Pemberton has pointed
out the differences between them with tolerable
accuracy. In the latter, there are occasional
screaraings in the sleep, tossings of the hands
above the head, continual endeavour to thrust the
head backwards, and an intolerance of light, with
more or less strabismus. But in this fever there
is seldom screaming or intolerance of light, and
never strabismus ; the hands being brought to
the head merely to pick the lips and nose. In
hydrocephalus the faculties are totally destroyed,
and the patient cannot be roused to an exertion
of sense, reason, or even of consciousness. But
dn the delirium of this fever, he can be at any
-time recalled to his senses, which he will often
retain for a .few minutes. In the former, food, or
^ny thing given, however nauseous, will be taken ;
but in the latter, often neither food nor medicine is
taken. The stools in this disease are more easily
procured, more curdled, and contain more shreds
of coagulahle lymph than in hydrocephalus.
Convulsions seldom occur, excepting at the com-
mencement of the disease ; or at its in^vasion ; and
■when they disappear, the faculties are perfectly
restored.

279. Dr, Sims considers that there is the ut-
most difficulty in distinguishing between both
these diseases, in children under five or six years
•of age, until hydrocephalus has proceeded to the
■second stage. There is much truth in this, es-
pecially where symptoms of cerebral irritation
.coexist with those of disease of the digestive
mucous surface^ in the infantile remittent, as is
sometimes the case, and as I have several times
observed. Yet, in most instances, this disease
may be distinguished from hydrocephalus with
considerable certainty : more particularly by the
remissions; by the absence of distinct stages.; by
its prolonged course ; by its affecting delicate,
phlegmatic, and over-fed children ; by the pains
in the belly and head being indistinct, dull, or
but little complained of; by the paleness of coun-
tenance and sluggishness of manner; by the
heaviness and soundness of the sleep ; by the
perspirations after the exacerbations, and after
«atlng and drinking ; by the free stale of the ex-
•cretions, especially the urinary ; and the compara-
tive ease with which stools are procured .; by the
perfect condition of the senses, and tolerance
of light; by the unceasing itching of the nose;
by the rare occurrence of vomiting ; by the little
wasting of the body, and the fulness or flatulent
ctate of the abdomen ; by the absence of palsy of

any part : by the constant peevishness ; and by
the absence of any expression of pain or distress of
countenance. — (See also Duopsy of the Head,
§24G.)

280. iv. Terminations AND Prognosis. — The
most common termination of this complaint is a
return of the healthy functions ; but, owing to
original fault of constitution, to great debility, to
the influence of an Impure air, to improper diet,
to Injudicious treatment, and to neglect, obstruc-
tion and enlargement of the mesenteric glands,
lienterlc diarrhoea, chronic hydrocephalus, and
tubercular disease of the lungs may supervene.
The prognosis is, however, favourable when the
child comes early under treatment; and more
especially if the symptoms subside, and the remis-
sions are prolonged and distinct. An unfavour-
able prognosis should be formed only when the
disease is not benefited by the use of suitable
remedies; when the exacerbations become severe,
more frequent, or prolonged ; when the abdomen
is tense and swollen ; and when indications of
any of the organic diseases just mentioned appear.

281. v. The Nature of infantile remittent fever
may be inferred from the causes producing it, the
circumstances in wliich it appears, and the early or
premonitory symptoms. These indicate impaired
organic nervous power, and imperfect perform-
ance of the functions actuated by the organic
nervous system. Most recent writers have im-
puted this complaint either to derangement of the
digestive canal, or to a depraved condition of the
secretions of this part — which amounts to the
same thing. The French pathologists view it as
symptomatic of inflammation of the digestive
mucous surface: but of the truth of this doctrine
there is no conclusive evidence. Post-mortem
appearances certainly lend it no support. The
few instances in which I have observed them,
presented chiefly enlargement of the mesenteric
glands and of the spleen, with a few tubercles in
the lungs. The digestive organs were not in-
flamed ; but the intestines were distended by
flatus, and their coats attenuated. Similar
changes of the bowels and mesenteric glands have
been remarked by Hoifmann and Pemberton.
From an extensive experience of this disease, I
infer — a. That it proceeds from causes which
impair the energy of the organic nervous system,
and of the organs which this system more imme-
diately actuates; — h. That, in consequence of
this morbid condition, whether it arise from im-
pure air, or proceed from unwholesome food, the
excreting functions, particularly those of the
digestive canal, are imperfectly performed ; con-
sequently mucous sordes, &c- accumulate on its
internal surface, and become both a source of
irritation and a nidus for the generation of worms;
and hence the complication of this complaint
with the vermlnatlon occasionally takes place ; — «.
That the disease is frequently long in forming,
preliminary changes being required, as in other
fevers, to develope the more acute symptoms ; —
d. Tliat It does not consist of Inflammation, is
shown by the character of its early symptoms;
by Its course, termination, and consequences;
and by the juvantia and Itedentia ;—~e. That it
does not altogether arise from a depraved state of
secretions of the digestive organs, nor from irri-
tation of these organs, although these changes
are very probably induced in its early course^ is

k

FEVER, REMITTENT, OF CHILDREN — Treatment.

285. D. When the disease assumes the adynamic
state, above described {§ 275.), and when it has
been of long standing, or considerable exhaus-
tion has supervened, a further modification of the
treatment is requisite. If the bowels have not
been sufficiently evacuated, the above means
should be employed for the purpose ; and either
the sulphate of quinine, or the preparations of
bark, or of other tonics, especially cascarilla,
ought to be taken during the remissions. In all
the varieties of the complaint the remissions
should be selected for the exhibition of bark,
quinine, or other tonics, commencing at the sub-
sidence of the exacerbation. In this state of
the complaint, I have prescribed, for many years,
the chlorate of potash in an infusion of valerian,
or of cinchona, with great benefit, keeping the
bowels moderately open, and directing the above
Imiment (F. 311.) to be rubbed along the spine,
or over the abdomen.

286. £. When much pain is felt, and the belly
becomes distended with flatus, the enema advised
above should be administered ; and either an ano-
dyne fomentation applied to the abdomen, or the
liniment rubbed upon it. MusonAVE recommends
poultices, or fomentations with the warm decoc-
tion of rue and aromatic herbs. A decoction of
chamomile flowers, poppy heads, and rue, in the
form of fomentation ; and a little spirit, or oil, of
anise-seed, added to the medicine, will generally
give relief. A warm bath at bed-time, or the
semicupium, some salt, or mustard flower, or
both, having been added to the water, will also
be serviceable, especially in the low or advanced
states of the complaint.

287. Dr. Butter placed much dependence upon
the extract of conium, in doses of one grain in the
day for every year that the patient was old, in
conjunction with saline aperients. It is of little
service of itself; but is often an useful adjunct
to the medicines already advised, especially if the
child be very peevish, the abdomen pained, or the
bowels irritable. Dr. Cheyne relied most upon
colomel with antimony at bed-time, and the com-
mon purgatives, giving the former more frequently
if the complaint seemed liable to pass into hydro-
cephalus. Dr. Clarke and Dr. Pembehton
insisted chiefly on tonic infusions, after the bowels
were freely "evacuated. These are generally
serviceable in the circumstances and combinations
pointed out, and the addition to them of the ex-
tract of conium is also beneficial. In some old
cases, in which there was reason to suppose that,
in connection with debility, there was some de-
gree of obstruction of the mesenteric glands, I
have given the iodide of ])otassiuiii internally, in
small doses, with great advantage ; but care
should be taken not to prescribe it in doses large
enough to irritate the stomach and bowels, other-
wise it will increase the disorder,

288. F. The regimen and diet constitute a prin-
cijjal part of the treatment. Change of air, as early
as possible, especially to a mild and dry air, and
elevated situation, is always most serviceable.
Warm clothing, frictions of the surface after the
warm baths, and light but nourishing diet, are
also very beneficial, purticularly when con-
valescence has commenced. During the com-
plaint, ass's milk, rusks, and weak broth, are
suitable food. But, in the acute form, or at the
commencement of the disease, even these may be

960

proved by the facts that such depravation must
itself proceed from anterior disorder, and that a
treatment based solely upon the above doctrine
is not generally successful; a free and healthy
state of the alvine evacuations being often brought
about without the complaint being removed;-—
f That in order to cure the complaint with the
least delay and the greatest certainty, it is neces-
sary to evacuate morbid secretions Irom the prima
via, to impart energy to the organic nervous sys-
tem, and to change the morbid states of the
various related or dependent organs.

282. vi. Treatment.—^. The practice advised
by"MusGRAVE, Butter, Sims, Pemberton, and
others, although furnishing valuable hints, is
more or less defective; for, whoever trusts to it
alone, or those whose resources extend no fur-
ther,'will occasionally find the disease by no
means so easily managed as they expected, and
will see it prolonged until the treatment is taken
out of their hands, and, by the common sense of
the parent, limited to change of air, and light
nourishment; which, although amongst the most
efficient remedies, have been very generally over-
looked by writers. In all cases the treatment
should be commenced with a moderate dose of
calomel and James's powder at night, and a suffi-
cient quantity of the bitter aperient mixture
(F. 266.) or of rhubarb and sulphate of potash,
or o"f rhubarb and magnesia, to act upon the
bowels. If these are inefficient, an enema should
be thrown up ; and from an experience of many
hundred cases, I would recommend for this pur-
pose equal quantities of castor oil and spirits of
turpentine in water-gruel. At first, the above
powder should be repeated every night, or on
alternate nights, and the purgative in the morn-
ing, the injection being also employed every
thud or fouith day; At a more advanced stage ot
the treatment, and when the evacuations have
improved, they may be prescribed less frequently.
The choice of" other means must depend upon the
peculiar features of the case.

283. B. If the disease be of the form in which
it usually presents itself (§ 273.), and the evacu-
ations have been improved by the above means,
an infusion of cinchona, or of cascarilla, or of
valerian, with liquor ammoniie acetatis, will be
found of great service. If the bowels be still dis-
ordered and torpid, the sulphate of quitiine may
be given in a solution of any of the neutral sul-
phates ; and the abdomen rubbed assiduously with
a warm stimulating liniment (F. 311.), light nou-
rishing diet, or a course of ass's milk, and change
of air, being afterwards ordered.

284. C, If the complaint be of the acute form
(§ 274.), and the child be plethoric and strong,
afew leeches may be placed over the epigastrium
at the commencement of the treatment, and after-
wards a mustard poultice, or any ruhefacienl epi-
them may be applied ; but the puiyatives just
mentioned, or similar medicines, should be pre-
scribed ; and the solution of acetate of ammonia
with sweet almond emulsion, and camphor mix-
ture, should be taken in the course of the day.
After the more acute symptoms have abated, the
infusion or decoction of cinchona, or the infusion
of cascarilla, or of calumba, may be given with
small doses of liquor potassa;, or of the hydro-
chlorate of ammonia, or thenitrate of potash, or with
liquor ammoniae acetatis, sweet spirits of nitre, &c.

FEVER, HECTIC — Description.

too exciting. Tlie effect of whatever is given
should be carefully watched ; and the articles of
diet selected accordingly. When convalescence
is established, the preparations of iron, and due
attention to the states of the bowels, are most
necessary.

BiBLioG. AND Refer T. Bates, An Enchiridion of

Fevers incident to Seamen in the Mediterranean, iSrc.

12mo. Load. 1709 J. Grainger, Hist. Febris Ario-

malae Batav«, &c. 8vo. Edin. 1753. — P. Desperrieres,
Des Fievres de I'Isle de St. Dominique, 12mo. Par.
1G73. — Tissot, De Febribus Biliosis. Lausanne, 8vo. I7G8.

— Cleghorn, On the Epid. Dis. of Minorca, 3d edit.
passim. — D. I.ysons, Pract. Essays on Intermitting Fe-
vers, 8vo. Bath, 1772. — J.Sims. Observat. on Epidemical
Disorders, 8vo. Lond. 1773, p. 163. {On Infantile Remitt.)

— Elsacker, De Febr. Remitt. Contin. Biliosis, Putri-

dis, &c. 8vo. Antw. 1774 S. Musgruve, On the Nature

and Cure of the Worm Fever, 8vo. Lond. 1776 J.

Lind, Treat, on the Putrid Fever of Bengal in 1762, 12mo.
Edin. 1776. — Hollo, Observat. on the Diseases of the

Army of St. Lucia, 8vo. Lond. 1781 B. Rush, Medical

Inquir. and Observations, p. 104. — D. Ryan, On the Re-
mitt. Fevers of the West Indies, in Simmons's Lond.

Med. Journ. vol. iii. p. 63 IF. Butter, Treatise on the

Infantile Remittent Fever, 8vo. Lond. 1782 J. Clark,

Observ. on the Dis. in long Voyages to Hot Countries, 8vo.

Lond. 1792. vol.i. p. 157. 2d edit B. Moseley, Treatise on

Tropical Diseases, &C.8VO. Lond. 1789, p. 171. Uladnever
seen the true pestilential yelloiv fever. The disease de-
scribed by him under the appellation of" Endemial Causus,
or Yellow Fever," is the seasoning or Climate Fever, to be
noticed hereafter.) — R. Jacl,so7i, Treatise on the Fevers
of Jamaica, 8vo. Lond. 1791. — JV. Boag, On the Fevers
and Dysentery of Hot Climates, in Med. Facts and Ob-
servat. vol. iv. p. 1. — C. Strack, Observat. Medicin. de
diversa Febris Continuse remittentis Causa, et qua diversa

eidem Medendum sit, ratione, 8vo. Mogunt. 1789

Beaumes, De I'Usage de Quinquina dans les Fievres Re-
mittentes, 8vo. Paris, 179U. — Pereboom, De Ascaridibus
et Febre Remittente. Francf. 1791. — A. Comparetli,
Riscont. Medici delle Fehbri larvate Period, perniciose,
t. ii. Pad. 8vo. 179.3. — F. Balfour, A Treat, on Putrid
Intestinal Remitting Fever, 8vo. Lond. 1796. — W. Cur-
rie, Observat. on Hemitt. or Bilious Fevers, 8vo. Philad.
1798. — fl. Hamilton, Observat. on the Marsh Remitt.
Fever, &c. 8vo. Lond. 1801. — T. Clark. Observat. on the
Fevers and other Dis. of the E.ast and West Indies, 8vo.

Edin. 1801 /■'. fVendt, De Febribus Remittentibus Se-

mestrii Hiberni, Anni 179-5, 1796. Erling. 1796. — Ihmter,

On the Diseases of Jamaica, 3d edit. p. 118 J'. Amhrogi,

De Cognoscend. et Curand. Febribus Pseudo-perniciosis,

' 4to. Bom. 180.5. — L. L. Rossi, Delle Febbri Perniciose,
8vo. Milano, ISOJ. — Pi)ickard, Notes on the West
Indies, &c. vol. iii. let. 12. p. 134.— T. Sutton, Practical
Account of a Remitting Fever among the Troops, &c. 8vo.
Cant. 1806. — R. Robertson, Observat. on Fevers from

Marsh Miasmata, \c. 4 vols. Lond. 1807 J. B. Davis,

A View of the Fever of Walcheren, &c. 8vo. Lond.
1810. — G. P. Dawson, Observat. on the Walcheren Dis-
eases, &c. Ipswich, 1810. — T. Wright, Hist, of the Wal-
cheren Remitt. 8vo. Lond. 1811— J. 3/. Coley, Treatise

on the Remittent Fever of Infants, 8vo. Stourb. 1813

C. Fowel, Treatise on the Endemic or Yellow Fever of
Tropical Climates, 8vo. Lond. 1814. — C. R. Pnnberton,
On Diseases of the Abdominal Viscera, 8vo. Lond. 4th
edit. p. 163 Gibson. Edin. Med. and Surg. Journ. vol. xi.

— Fournier et Faidy, Diet, des Sciences Med. t. xv.

p. 411 Denmark, Trans, of Med. and Chirurg. Society,

vol. vi. p. 296. — J. B. T. Beaumes, Traite des Fievres Re-
mittentes, torn. iii. 8vo. Montp. 1821. — TV. Burnett,
Practical Account of the Bilious Remittent Fever of the
Mediterranean, iSrc. 8vo. 2d edit. Lond. 1816. — /?o//rf,

De Febre Minorca, 8vo. Ed. 1817 M'Cabe, in Edin.

Med. and Surg. Journ. Oct. 1819. — N. Dickinson, Ob-
servat. on the Inflammatory Endemic incidental to
Strangers in the West Indies from Temp. Climates, iVc.

8vo. Lond. 1829 Good/son, in Dub. Hosp. Reports,

vol.i. p. 191. { On the Remittent of Coif u.) — C. Chisholm,
Manual of the Climate and Diseases of Tropical Coun-
tries, 8vo. Lond. 1822, p. 32 .7. Johiison, On the In-
fluence of Hot Climates, iS:c. passim. — J. B. Monfalcon,
Histoire Medicaledes Marais, ou Traite des Fievres Inter-
mitt, et Bemittentes, 8vo. Paris, 1826. — J. Bouillaud,
Traite Clinique des Fievres Essentielles, &c. p..518.—
J. Anneslei/, Sketches of the Diseases of India, 8vo. 1826,
passim. — J. Annesley and Author, Researches on the
Nature and Treatment of the Diseases of India and of
Warm Climates, &c. 2 vols. imp. 4to. vol.ii. -p.im. et seq.

— M. Good, Study of Medicine, edit, by S. Cooper, vol. ii.
p. 160. (Remittents, the contimted inflammatory of warm
climates, or seasoning fever, and epidemic or true yellow
fever, arc all mixed up together in a co)ifus,d manner. ) —
J. Macculloch, Essay on the Remittent and Intermittent

961

Diseases, or Marsh Fevers and Ncuralgi?., &c. 2 vols.
8vo. Lond. 1828; also, On Malaria, an Essay, 8vo.
Lond. 1827. — P. F. Xapple, Kssai sur les FiC-vres Hemitt.
et Intermitt. &c. 8vo. Paris, 182S. — E. G. Boisseau,
Pyretologie Physiologique, &c. p. 648. 3d edit. — R.
Leti'ins, On Infantile Remittent Fever, in Edin. Med.
and Surg. Journ. vol. xxxviii. p. 11.5. — J. Ilenncn, Me-
dical Topography of the Mediterranean, &c. 8vo.
Lond. 1830, passitn. — W. P. Dewees. Practice of Pliysic,
&c. vol. i. p. 109. 8vo. Philad. 1830 — J. Boyle, An Account
of the Western Coast of Africa, with the Causes, Sympt.,
and Treatment of the Fevers of Western Africa, &c. 8vo.
Lond. 1831, p.71— 201.— M'. S<i-!'<'«s, Observat. on the
Healthy and Diseased Properties of the Blood, 8vo. Lond.
1831, p. 163. etseq. — Brown, Cyclop.of Pract. Med. vol.ii.
— J.Joy, In Ibid, vol.ii. (Infantile Remitt. )--H\Twini7ig,
Clinical Observat. on the Diseases of Bengal, &c. 8vo.
Calcutta, .1832. (Approves of a moderate bloodletting in
Europeans in India, upon the approach of the cold stage
of agues.) — W. E. E. Convell, On the Functional and
Organic Changes of the Liver, and the Agency of He-
patic Derangement in producing other Disorders, &c.
8vo. Lond. 1835.

XV. HecticFever. Svx. — 'Ektix^ (from extikoj,
constitutional, and this from s'^if, habit of
body) ; Febris hectica, Febris marasmodes, Fe-
bris tabida, Febris lenta, Febris umatoria, F
ampherina Hectica, Atropltia, 7'<ifes,Auct. V ar. ;
Epanetits Hectica, Young and Good ; Das
schleichendes Fieber, Hektiscbes Fieber, Germ.;
Fievre Heclique, Fr.; Ftica Febbre, Ital. ; Hec-
tic liemittent, Decline, Sjc.

289. Defin. — Cltronic, remittent, or sub-
continued fever, uith loss of strength and Jtesh,
generally depending itpon organic lesion or some
evident or concealed source of irritation.

290. This disease is characterised by its slow
and insidious approach ; its prolonged duration ;
by emaciation and frequency of pulse ; by febrile
exacerbations at noon and \n the evening', ov after
a meal, with heat in the palms of tiie hands and
soles of the feet ; and, lastly, by colliquative
sweats and diarrhoea. — The question, as to whe-
ther this fever is ever idiopathic, or always pro-
ceeds from some evident or concealed local
irritation, has been much discussed. Tiie greater
number of systematic writers contend that it is
occasionally a primary afTection, or independent
of local lesion. Amongst these are S.\uv.\gis,
Sagar, LiNN.ius, Stoi.l, Parr, Pinel, V\'il-
LAN, Good, &c.; whilst Vogel, Cullen, IIe-
BERDEN, and others, entertain a different opinion.
Believing that it is, in verp rare cases, not assign-
able to any local lesion or irritation, but is owing
rather to debility or exhaustion in irritable con-
stitutions,— that, although not a primary affec-
tion, it cannot always be attributed to any local
lesion, the nature and seat of which can be recog-
nised,— •! have introduced it at this place. ]5ut,
whilst I admit this, I must confess that the ar-
guments adduced by those who consider that
hectic is sometimes independent of local irritation,
aie bv no means conclusive. Dr. Peiicival, in
his remarks, published by Dr. Good, states that
he has seen idiopathic hectic last three months
" without any pulmonary affection, and then to
break out in the lungs." But the lungs may be
diseased for a long time without their functions
being manifestly disordered, otherwise than in
causihg the hectic fever, wliich may be thus
erroneously considered idiopathic. There can-
not be the least doubt that various changes may
take place in parts possessed of a very low
grade of sensibility and imperfect powers of re-
paration, as the parenchyma of several viscera,
particularly the lungs, liver, kidneys, mesenteric
glands, bones, Sec, unattended bv any pheno.

3Q

FEVER, HECTIC — Description — Causes and Varieties.

962

menon wliich will enable us to recognise their

precise seat and nature, and yet give rise to hectic

fever.

291 . Mr. J . Hunter contended for its idiopathic
existence, by supposing that the constitution may
fall into the same mode of action, without any
local cause whatever, as proceeds from such
cause. This is, however, no argument. He fur-
ther observes, that nothing is more common than
for hectic to exist in patients in whom no local
disease whatever can be traced ; and that, in such
cases, either random suspicions are to be thrown
upon' the lungs, liver, kidneys, heart, or me-
senteric glands, as casual symptoms may sug-
gest, or its idiopathic nature must be inferred.
Admitting that there is some truth in this, it
should still be contended, that improved means
of diagnosis, and a more intimate acquaint-
ance with the origin and relations of morbid
actions, have greatly abridged the number of in-
stances in which no local lesion can be detected ;
and that, instead of this circumstance being
common, it is remarkably rare. It is somewhat
singular, that the same author, — M. Broussais,
— who has written so ably against the existence
of fever as an essential or idiopathic disease,
should have produced, in 1803, a work on hectic
fever, in which its idiopathic nature is strenuously
contended for, and its various forms very mi-
nutely described — the least idiopathic of all
fevers having been considered by him chiefly as
such; — M. Broussais had, however, not then
changed his opinions as to the nature of fever.

292. i. Descrittion. — The early symptoms of
hectic are — emaciation with a pale, and oiten lair,
skin ; increased frequency of pulse, especially at
noon and evening, with some degree of hafdness or
sharpness ; rapid or short respiration on any ex-
ertion ; and increased heat of skin. — The exacerb-
ations are at first very slight ; but ihey soon be-
come more evident, particularly in the evening; are
preceded by a slight or marked chill ; are attended
by increased heatrwliicli is most evident in the hands
and face, the skin being at first dry ; and terminate
in a free, profuse perspiration, especially the even-
ing paroxysm, which usually subsides in this man-
ner early in the morning. The bowels are costive,
but afterwards readily acted upon ; ultimately they
are relaxed, and colliquative diarrhoea supervenes.
The urine is various, but most frequently pale and
without deposit ; more rarely high-coloured, and
with a lateritious sediment. As the disease ad-
vances, the delicate circumscribed bloom on the
cheek, which was at first only occasional, is more
constant and general, especially during the exa-
cerbations ; the throat and fauces are red, dry, and
irritable ; the tongue is often clean, red, smooth,
without papillffi, and glazed, and ultimately,
with the lips and fauces, is covered by aphthous
exudations; the eyes are sunk in their orbits,
from the absorption of adipose matter, but are
brilliant and expressive, their whites pearly and
clear; the whole frame is emaciated, and the
temples excavated ; the hair falls out , the ankles
and sometimes the legs arc oedematous; sleep is
unrefreshing, feverisii, and disturbed ; and de-
bility with a sense of lassitude is constant, but
the patient's spirits are unbroken or even san-
guine. At last the diarrhoea and colii(iuative
sweats become daily more abundant ; the respir-
ation short and precipitate; and the debility !-o

great, that the patient often expires when attempt-
ing to speak, or on assuming a sitting posture, &c.
During the course of the disease, the sensorial
functions preserve their integrity ; but sometimes,
towards the close, slight delirium occurs. In those
cases especially which depend upon organic
change in the respiratory organs, there are more
or less dyspnoea, cough and expectoration ; the
nails become incurvated ; the last joints with the
extremities of the fingers fusiform, and the ex-
pectation of recovery gains strength with the
progress of disease. (See Tubercular Consump- •

TlON.)

293. MM. Broussais, Fournier, Vaidv,
Boisseau, C0UTAN9EAU, and some other writers,
have divided hectic into three stages: the Jirst
continuing as long as the appetite and strength
are not materially impaired, and the remissions
are distinct; the second consisting of a small,
quick, and frequent pulse, accelerated during
the exacerbations, with debihtating perspirations,
burning heat of the palms of the hands and sole§
of the feet, and rapid emaciation ; the third su-
pervening with the colliquative diarrhoea, oedema
of the lower extremities, extreme emaciation and
prostration of strength.

294. ii. The Causes of hectic fever are re-
markably diversified. — It most commonly pro-
ceeds from suppuration, ulceration, chronic in-
flammation, excessive action, and irritation of a
secreting organ or surface ; from caries, necrosis,
or structural change of osseous parts ; and from'
slow inflammatory action of any part whatever
of the fiame. It also attends upon various ad-
ventitious and malignant productions. But in
all these, it is merely a symptom of the extent to
which the constitution is influenced by the local
change. M. Broussais has distinguished several
varieties of hectic according to the nature and
seat of its principal causes ; as, the Gastric, the
Pectoral, the Genital, lUmorihagic, Cntaneons,
Moral, &c. Hh.denerand enumerates the foN '
lowing : the hijlammatory, Putrid, Kervovs, Gas-
tric, Atrabilious, Pituitous, Verminous, Entero-
mesenteric, and Suppuratice, to which may be
added the Puerperal. As each of these varieties
attaches to itself more or less importance, and as
the division adopted by INI. BnoissAis has been
very closely followed by numerous recent writers,.
I shall ofl'er a few remarks in illustration.

295. a. Gastric Hectic is distinguished by ano-'
rexia, thirst, dryness of the mouth, prolonged .
and diflScult digestion, and more or less of the
usual concomitants of indigestion, especially
eructations, flatulence, acidity, cardialgia, &c'.
Sometimes the appetite is unimpaired, or is'
even increased, but digestion is faulty. The
tongue is loaded, the mouth clammy, and the
taste disordered. There are often uneasiness at ,
the stomach, tenderness of the epigastrium, aiid'
frontal or sub-orbitar cephalalgia. 'I'he complaint
is exasperated hy healing food, and the abuse of.
stimulants, which occasion a sense of heat in the
stomach, or pain and cardialgia, with acid or
acrid eructations. Ultimately the patient' he-
comes pale ; the breath foetid ; the bowels costive,
irregular, or even irritable ; and the symptoms of
hectic fully developed. In children, picking of
the nose, mucous diarrhea, and occasionally
the cxpidsion of worms, are also ob.served ; and
the disorder is almost identified with, or is merely a

FEVER, HECTIC —

modification of, the lemittcnt of cliilJren (§ 270.).
This form of iicctic is very probably connected,
as BnoussAis, Boisseau, and others believe, with
chronic irritation of the digestive mucous surface ;
but debility, more especially of the organic nerv-
ous system, is the primaiy and most important
constituent of the disorder. The hectic some-
times observed to follow lactation, particularly
when prolonged, is often of this kind. M. Enous-
sAis has distinguished the connection of hectic
with cutaneous eruptions, by the denomination of
Cutaneous Hectic. But the constitutional disturb-
ance is less the effect of the affection of the skin
• than of the disorder of the digestive organs, with
which the latter is very generally associated as a
symptom.

296. b. Pectoral Hectic consists of the consti-
tutional disorder consequent — 1st, upon inflam-
mation or ulceration of the larynx, and irritation
of the epiglottis ; — 2dly, upon the various forms
of bronchitis ; — 3dly, on the several lesions of the
lungs; — and 4thly, upon chronic alterations of
the pleura. It should, however, be recollected,
that any of the various kinds of pectoral hectic may
be associated with gastric disorder ; indeed, the
advanced stages of the former are always attended
by more or less of the latter. Hectic arising
from these lesions is fully treated of under the
respective heads.

297. c. Genital Hectic conshls of debility, as-
sociated with febrile exacerbations, caused by
excessive sexual indulgences, or by masturb-

' ation ; by irritation of, and mucous discharges from,
the sexdal passages ; and, occasionally, by irri-
tation of the urinary organs, — These phenomena
not merely occasion, but also accompany and
perpetuate, the hectic symptoms, until other
Viscera are drawn within the vortex of morbid

■ action ; the digestive organs, especially the mu-
cous surface, or the lungs, or even both, becom-
ing also diseased, and ultimately evincing the
fnost prominent affection. I'he ill-regulated or
excessive indulgences and dissipations of youth
are often productive of irritation of the sexual
and urinary organs, attended by more or less

■ discharge ; by debility, febrile exacerbations, and
indigestion. If the indulgences which induce
this disorder are continued, organic nervous power

. is prostrated further still ; digestion and assimi-
lation are rendered more imperfect; circulation
through the lungs more irregular ; and ultimately
tubercular formations are developed in this organ,
especially if the diathesis or other causes conspire
with this in forming them. — It is an important
fact, and one which is too generally overlooked,
that hectic fever, induced either by irritation of
the sexual organs, or by disease of the lungs, is
attended by a remarkable propensity to masturb-
ation, which counteracts but too generally every
irieans of cure.

•■298. d. Puerperal Hectic is that form of slow
fever which sometimes affects delicate females
during lactation, and which, if the cause be con-
tinued, may superinduce pulmonary disease. It
also' sometimes follows protracted or excessive
lactation, and passes either into pectoral hectic,
or into a chronic state of debility, with especial
disorder of some one of the aidominal viscera.

299. e. Hemorrhagic ■ Hectic, or tiie slovv
fever consequent upon lofs of blood, is to be at-
tiibuted rather to tiie pathological stale giving

Causes and Varieties.

968

rise to the haemorrhage, than to the debility
caused by the loss of blood. Hectic, even in its
slighter forms, seldom follows large bleedings
from wounds ; whilst it is a very common se-
quence of hfemorrhage from the pulmonary and
digestive mucous surtaces; for there is generally
antecedent disease, tither of the mucous surfaces
themselves, or of parts intimately connected with
them, that sooner or later would very generally
be productive of hectic fever, if no haemorrhage
had ever taken place. '\^ hen hectic follows the
suppression or disappearance of haemorrhages,
either occasional, habitual, or periodic, chronic
inflammation or irritation of some important vis-
cus, more especially of the lungs, the liver, the
uterus, &c., should be suspected.

300. y. Some authors have distinguished a form
of hectic from mental or 7noral causes. — 1 here
can be no doubt, when the mind becomes pos-
sessed by a predominating passion or desire, or
constantly ruminates on some depressing senti-
ment, or continually regrets the loss of endearing
objects, that the powers of life will gradually
languish, and that, in delicate constitutions espe-
cially, many of the symptoms of hectic or slow
fever will be produced ; and, although the men-
tal affection may not induce more than the earlier
stage or slighter grade of the disease, in sound
constitutions, it will frequently occasion, especi-
ally in the weak, and in those endowed with a
morbid diathesis, structural change in the lungs
and other susceptible organs, owing to the con-
tinued depression of organic nervous power which
it causes, and to the changes resulting therefrom.
Every observer must have remarked the series of
changes following the loss of loved objects, disap-
pointed or abused aflections, unmerited neglect, &c.;
and have recognised the influence of the mental
impression upon the functions of digestion, assimi-
lation, circulation, and respiration successively,
until a predisposed organ — most frequently the
lungs, the heart, or the liver — indicated a predo-
minance of disorder and fatal tendency. In these
cases, the slighter forms of hectic, the pallor, ema-
ciation, febrile exacerbations, sleeplessness, and
debility, advance slowly, and become impercepti-
bly associated with shortness of breath, dyspnoea,
short cough, hectic flushes, and morning |)eispir-
ations ; the lungs very frequently evincing most
serious disease. In all instances of this kind, it
is important to ascertain the changes more imme-
diately consequent upon the exciting cause. In
every case which I have seen sufficiently early,
the vegetative or organic functions were in a
debilitated or blighted state ; the appetite was
diminished ; digestion impaired ; the pule lan-
guid, slow, and weak; the circulation through
the lungs imperfect and impeded, as indicated by
frequent sighing, and oppression in the thorax ;
and the impulse of the heart very deficient, or at
times either irregular or excessive, as if this organ
were labouring to overcome the congestion con-
seqiien.t upon the impeded circulation through
the lungs. The tubercles which generally form
in the course of these aftections cannot be ascribed
to inflammatory action, as they originate when
the organic nervous power of, and circulation
through, the lungs, are most impaired ; but are
rather a result of these latter pathological states.

301. g. As to the other varieties mentioned by
Hii.DiNBRAND, a fcw remarks may be necessary.
3 Q 2

964

FEVER, HECTIC— Prognosis— Pathology.

— a. Iiijiammalory Hectic is merely that form of
symptomatic fever which usually attends chronic
inflammation of an internal viscus, or of a deep-
seated part. — 13. Putrid hectic is the fever
sometimes attending scorbutic affections, or gan-
grenous and spreading ulceration, &c. ; or arising
from unwholesome and innutritions food. —
7. Nervous Hectic is the constitutional disturbance
observed in persons labourino- under mental
afflictions, &c. (§ 300.), or chronic disorder of
the nervous system, and in chlorotic and hysterical
females. — 5. Atrabilious Hectic presents itself in
persons long subject to disorder of the liver and
other digestive organs — whose portal circulation
has become congested or obstructed, their bi-
liary and intestinal secretions morbid, and their
digestive canal torpid or overloaded. Such per-
sons are morally and physically depressed ; are
melancholic and hypochondriacal, sallow, squalid,
and thin ; are often affected with shortness of
breath, colicky pains, disordered bowels, tenesmus,
and hemorrhoids ; the stools are dark, foetid, and
scybalous, and the abdomen fre([uently hard or
tense. — e. Pituitotis Hectic is merely a modification
of the gastric (§ 295.), attended by pituitous col-
luvies in the prima via, owing to imperfect power
of the organic nervous system. It is common in
children, and is characterised by pallor, leuco-
phlegmatic indolence, and torpor ; swollen lym-
phatic glands, increased secretion of mucus ;
tumid abdomen; fluor albus ; the collection of
viscid mucus on the tongue and teeth ; coryza,
mucous diarrhoea, and obscurely remitting and
slight fever. — C Verminous Hectic is a modi-
fication of the foregoing, or the association with it
of worms in the intestinal canal. It is occasion-
ally observed in delicate and relaxed, or rickety,
or scrofulous, children ; and in those who live in
low, damp, close, and unhealthy localities and
apartments, and who are subject to chronic bron-
chitis or winter catarrhs. — rj. The ILntero-mesen-
teric is a modification of the pituitous and gastric,
particularly when occurring in children ; or is
rather the association of enlargement of the me-
senteric glands with the affection of the digestive
mucous surface, chiefly constituting these varieties.
It is hence closely allied to the affection already
described under the head of Infantile Remittent
(§ 278.). — (See also art. Meseniehic Decline.)

302. h. The varieties of hectic which arise, from
the formation of matter in internal viscera, from
tuberculous ulceration, froin carious bones, &c.,
from the irritation of foreign substances, and
from chronic inflammation affecting parts possess-
ing a deficient power of reparation, present gene-
ral features of resemblance, but vary in the more
minute details, and difler not materially from the
general description given above (§ 292.).

303. iii. PuoGNOSis. — The duration of hectic
varies from a very few weeks to a number of
years; but, however long, the tendency of tiic
disease is fatal, unless circumstances occur or
medical means be used to arrest its course — un-
less the causes on which it depends are removed.
— The f^ini^er is owing entirely to these causes,
and is great according to their nature. — In cases
of caries, or of other local diseases which admit
of removal, the fever disappears soon after the
fiRjjaralion of the morbid from the healthy parts.
Wiien the diiicase (lc[)cnds upon the continued or
repeated inilation of a secreting surface or gland,

as in its sertial and puerperal varieties (§ 297, 298.),
and in the chronic forms of bronchitis and diarrhoea,
it generally disappears with the cause which pro-
duced it, unless serious disease of some important
viscus, as of the lungs, has been superinduced in
its course. But when chronic inflammation con-
tinues to destroy, or to alter the structure of,
some vital organ or deep-seated tissue, or when
the substance of an internal viscus is in a state of
suppuration, or when hectic proceeds from tuber-
culous formations, recovery seldom takes place.
Yet, in some of these cases, the powers of life
continue long to resist the progress of disorganis-
ation ; and occasionally at last are successful, not
only in limiting it, but also in removing the chief
of whatever changes had taken place. This is de-
monstrated in the adhesions of serous surfaces, in
the absorption of purulent collections from the
substance of internal viscera, or in their discharge,
and in the subsequent cicatrisation of the parts
afl^ected. Both the liver and lungs furnish proofs,
although in rare cases, of such occurrences.
Even a lobe of one of the lungs may be entirely
destroyed by suppuration, and the patient recover.
Where the cause is obscure, and we doubt whe-
ther the disorder is idiopathic or the consequence
of some lesion that eludes detection, the patient
being young, and vital power not far reduced,
hopes should be entertained. But when strength
is far reduced, emaciation extreme, and colliqua-
tive diarrhoea or perspiration is present, there is
little or no chance of recovery.

304. iv. Pathology. — A. The Lesions, postmor-
tem, consist — 1st, of those whicii causedlUe fever
(§294.) ; — 2d, of alterations of themucoussurface
of the digestive canal, upon which the diarrhoea
present in the last stage mainly depended ; — 3d, of
disease of the lymphatic and mesenteric glands ; —
and, 4lli, of redness and inflammatory discolour-
ation of the lining membrane of the heart and large
vessels. — The various lesions from which this
fever may proceed, require no further notice than
has been taken of them in other articles ; but
those which are evidently consequent upon its
early stages, which aggravate it in its course,
causing the more severe symptoms characterising
its latter periods, are deserving of attention.—
The changes in the digestive mucous surface
consist chiefly of tubercular depositions, and of ul-
ceration seated more especially in the lower part of
the ileum and in the caecum, with softening, and
frequently with superficial redness, of the mucous
membrane. The ulcers, however, are often un-
attended by redness, thickening, or unequivocally
inflammatory appearances ; and are entirely simi-
lar to those described in the aiticle Digestive
Canal (§ 36, et seq.). The changes in the ab-
sorbent glands are the same as those described in
the article LvMi'iiATtcs.

305. The lesions of the circulating system have
been overlooked, until notice was directed to ihcm
by Boi'iLi.Ai'i), who has given the details of a
number of cases of hectic, in which the internal
mend)rane of the heart, and large vessels, both
arterial and venous, presented more or less of in-
flammatory redness ; the substance of the heart
itself being often soft and flaccid, and atheroma-
tous depositions being sometimes found in the in-
ternal membrarjc of the arteries. — Several years
ago, 1 observed the internal lining of liic pul-
monary vein, and of its principal branches, of a

dark red and reddish brown colour, in a patient
who died with tuberculous excavations in the
lungs; and I have seen similar appeaiances sub-
sequently in two or three cases of this disease. —
But whether these appearances are the result of
inflammatory irritation induced in tiie internal
surface of tiie circulating system, or depend upon
the action of the blood upon this surface after
death, has not been satisfactorily ascertained.

306. B. Nature, 6fc. of Hectic. — Pathologists
have supposed that the disease depends upon the
gradual absorption of purulent, sanious, or other
morbid matters into the circulation ; and others
have believed that it arises entirely from the local
irritation — no such absorption occurring. — It is
necessary to keep in recollection a few facts,
which will serve to elucidate the matter. — (a)
Large excavations, &c. often take place in the
lungs without much cough, and with little or no
expectoration, but with severe and rapid hectic:
absorption, in these at least, must exist to a cer-
tain extent. — {b) In such cases, the diarrhoea
and night sweats are frequently very great. —
(c) In caries, the hectic is also severe in propor-
tion to the evidence of absorption. — (d) The
glands in the vicinity of carious, suppurated,
ulcerated, or tuberculated parts, often become
affected. — (e) Irritation, excessive pain, foreign
substances, &c. may long exist in deep-seated or
internal parts, without inducing hectic, or causing
more than the symptoms of its slighter forms or
early stages, as long as these causes do not give
rise to morbid secretions in the substance of the
affected tissue ; but, as soon as matter is collected,
or a fluid is formed from the destruction of the
surrounding organisation, the usual signs of con-
firmed hectic appear. — (J') Purulent matters
have evidently formed in the liver, and occasioned
hectic: the patient has recovered; and, having
afterwards died of some other disease, has pre-
sented proofs, in the changes observed in this or-
gan, that an abscess had existed in it. — (g)
Lesions of the blood-vessels are not infrequent in
the advanced stages, of the worst forms of hectic,
or those caused by tubercles and suppuration.
— These facts induce me to infer — 1st, that
absorption actually takes place ; — 2d, that it pro-
ceeds slowly — the depurating viscera, especially
the kidneys, bowels, and skin, generally removing
the morbid matters, or preventing their accumu-
lation in the blood to the extent of causing very
manifest or rapid clianges in it ; — and, 3d, that
tiie absorbed matters ultimately afl^ect the blood,
and not improbably the vessels also in which they
circulate. I believe that the diarrhoea character-
ising the last stage of hectic, is caused as much
by the disordered state of the blood affecting the
mucous follicles and membrane, as by inflamma-
tory irritation ; and that, when this latter condi-
tion exists, it arises chiefly from the blood, and
the morbid secretion poured out by these tissues.
The alteration in the blood may readily be sup-
posed to discolour, or otherwise affect, the inter-
nal surface of the vascular system, or even to
inflame or disorganise it, in those vessels which
proceed from the part which is the seat of caries,
su|)piiration, or of tubercular ulceration. — As to the
softening and flaccidity of the heart, upon which
]\I. BouiLLAUD places some stress, I have seen
nothing beyond what is presented by other muscu-
lar parts in these cases, the heart having partici-

FEVER, HECTIC — Treatment. 965

pated in the emaciation or deficient nutrition of
the rest of the body. — From these considerations
I therefore conclude, that hectic fever is most fre-
quently the result — 1st, of local irritation, of a
slow inflammatory kind, either latent or manifest,
and generally consequent upon, and associated with,
debiUty ; — and, 2dly, of the passage of morbid
matters into the circulation, where they occasion
most of the severe phenomena uniformly and con-
tingently present in the last stage.

307. V. Treatment. — The means of cure must
have immediate reference to the cause or patho-
logical state on which the hectic depends. Dur-
ing the first and second stages, they may be often
employed with success. But when the third
stage has supervened, we can expect nothing
from them beyond alleviating the more distressing
symptoms. — a. When the disease proceeds from
the association of disease of the digestive mucous
surface, with debility (§ 295.), the treatment
should consist chiefly of strict attention to diet —
the farinaceous and easily digested articles of
food being selected ; of attention to air, gentle
exercise, and to the state of the excretions ; of
gentle tonics conjoined with small doses of ipe-
cacuanha and anodynes ; of the infusion of cin-
chona with the solution of acetate of ammonia,
or with small quantities of the nitrate of potash
and sweet spirits of nitre, of bitters associated
with laxatives, or of emollients with mild narco-
tics, according to the circumstances of the case.
The bitter infusions may likewise be given with
hydrocyanic acid, or with the extract of hop.
\Vhen we suspect the existence of alterations of
structure, they may be conjoined with the liquor
potassa;, or with Brandish's alkaline solution and
coniurn. If the preparations of iodine be tried,
very small doses only should be exhibited. A
weak solution of the iodide of potassium, or of
the iodide of iron, is most appropriate in such
cases, either alone or with a narcotic, as hyoscy-
amus, conium, or extractum humuli. (See Sto-
mach — Diseases of.)

308. b. The treatment of the pectaral and la-
ryngeal forms of hectic is so fully stated in the
articles on the individual chronic diseases affect-
ing the respiratory organs and passages, that no-
thing need be advanced on the subject at this
place. It is only in the early stages of these
forms of hectic especially, that material advan-
tage can be hoped from medicine. The means
just enumerated will often be found of service-
but they require to be modified according to the
peculiar features of the case. Gentle astringents
and tonics, mineral acids, &c. are sometimes
also useful. Of these, the infusion of roses with
sulphate of zinc, sulphuric acid, and narcotics, is
most appropriate.

309. c. The seiual and puerperal forms of
hectic generally soon disappear upon the removal
of their respective causes, if serious changes in
remote organs have not been superinduced by a
continuance of the irritating and exhausting dis-
charges, in which the hectic originates — by the
practices inducing and perpetuating the disease.
In these forms the recovery depends much upon
the patient himself. Early rising ; mental and
bodily occupations ; low regimen ; the avoidance
of stimulating beverages, heating foods, and of
warm condiments; travelling or voyaging ; change
of air J and a prudent regulation of the imagin-

3 Q 3

966

FEVER, HECTIC— TuEATMENT.

atioii ; are among the most effectual means of cure.
Seltzer water, soda water ; the mineral waters of
Pyrmont, Carlsbad, of Gielenau, of Ems, of Vichy,
of Bath, of Tunbridge, &c., are severally useful, if
appropriately prescribed. — When the disease is
occasioned by suckling, the cure is generally
speedy, if the cause is relinquished before an im-
portant organ becomes affected ; and if a restor-
ative regimen, with change of air, be adopted. In
such cases, the mistura ferri composita, and cha-
lybeate waters, or the mineral waters just men-
tioned, are very serviceable.

310. d. The treatment of the other varieties of
hectic is not materially different from that now
stated. — When the disease follows licemorrliages,
the means of cure should be directed especially
to the pathological state of which the haemorrhage
is the result. (See that article.) — If it be connected
with cutaneous eruptions, the state of the digestive
organs, and of the frame generally, ought to
claim an especial notice ; and if it originate in
mental emotions, such measures as are the best
calculated to divert the mind from contemplating
the sources and relations of its misery should be
prescribed. — 'Vhe atrabilious, pituitous, ixnd ver-
minous varieties require'the combination of tonics
with warm purgatives (F. 557 — 663. 572—576.),
chalybeate mineral waters, and vegetable and
mineral deobstruents.

311. e. When the irritation and absorption of
morbid matter are the causes of hectic, tlieir
sources should be removed ; especially when they
consist of carious bones, diseased joints, puriform
collections, &c. But when this indication cannot be
accomplished, or when the preservation of a limb
requires that every means should be tried, the
treatment ought to be directed with the view —
1st, of diminishing irritation ; and, 2dly, of coun-
teracting or resisting the contaminating influence
of the morbid secretion on the circulation. — The
first of these is to be fulfilled by a judicious use
of opium, morphia, hop, henbane, hemlock, &c. ;
— the second, by medicines which support vital
energy, and tliereby resist the extension of disease,
or promote the powers of reparation ; as digestdjle
nourishment, dry and pure air, gentle tonics, an-
tiseptics, absorbents, and astringents. These may
be variously conjoined, according to the peculi-
arities of the case — anodynes and narcotics with
tonics, and tonics with antiseptics and absorbents.
Thus, the infusion of cinchona may be prescribed
with iiydrochloric acid and the hydrochloride of
morphia; the infusion of cascariUa with the so-
lution of the acetate of ammonia and the acetate
of morphia, the tonic infusions or decoctions with
the alkaline carbonates, or with the solution of
potash, or with the chlorates, and the extract of
hop or of hemlock, &c. Camphor may likewise
be conjoined with narcotics, in cretaceous and
absorbent mixtures. When vascular action be-
comes much excited, the nitrate of potash, or
the hydrochlorate of ammonia, may be given with
such of the foregoing as are chemically com-
patible with them ; and digitalis or the potassio-
tartrate of antimony may be prescribed in the
more inflammatory cases, and when the bowels
are not irritated.

312._/'. Various ?(r^e«< s^^mptoms require to be
palliated during the advanced ])rogress of the
disease. Great lieiit of shin will be relieved, and
consequent perspiiation diminished, by cold or

tepid sponging the surface with equal parts of
spirits, of solution of the acetate of ammonia, and
of rose water. — Restlessness may be diminished by
the anodynes already enumerated, or by hydro-
cyanic acid, combined with gentle tonics and re-
frigerants. Camphor, henbane, and the nitrate of
potash, or hydrochlorate of ammonia, are the most
generally useful in this state, excepting when the
bowels are relaxed, when opium, hop, or the ex-
tract of poppy should be substituted. When
diarrhaa supervenes, the pathological conditions
to which I have attributed it (§ 306.) should be
kept in view, as a treatment founded upon them
is the most successful in practice ; — we should
endeavour, in these cases especially, to counteract
the contaminating influence of morbid secretions
upon the circulation, and to impart tone to the
digestive mucous surface. The means that are
calculated to fulfil these intentions are also re-
storative of vital power, enabling it thereby to
resist the extension of disease. The tonics and
narcotics already mentioned (§ 311.) may be em-
ployed with these views ; or certain of them may
be conjoined with the chlorates of lime, potash, or
soda ; or with creasote ; or with cretaceous mix-
tures ; or these latter may be given with the com-
pound tinctures of camphor or of opium ; or with
tonic and astringent extracts : or the acetate of
lead, or the sulphate of copper or of zinc, may be
prescribed with opium.

313. 0-. The Diet and Regimen are most important
parts of the treatment of hectic ; but they should
be varied, or even different in its different states.
In most cases the food should be digestible and
moderately nourishing. The milk of asses, or
milk warm from the cow, goat's milk or whey,
fresh butter- milk, warm milk with one or two
tea-spoonfuls of very old rum in it; shell-fish,
especially oysters ; farinaceous and mucilaginous
articles of diet; jellies, particularly those made
with Iceland or Carrageen moss ; and grapes in
considerable quantity ; have severally been re-
commended, and are more or less beneficial, ac-
cording as they are appropriately prescribed. In
most cases, the patient should take very gentle
exercise in the open air, when it is mild, and ex-
pose himself to the sun and air as much as possi-
ble without the contingent ri-ks. In some in-
stances, especially those caused by debilitating
discharges, by caries, &c , old wine, especially
sherry, port, hermitage, anil Burgundy, may be
allowed with much benefit ; and either old l\Ia-
deira or sherry may be taken in Seltzer water. It '
is in such cases, especially, that the mineral
waters recommended above {§ 309.) are most
serviceable. (See also the articles AiiscESs(§ 55.),
Adsoiu'tiox (§ 15.), Blood (§ 143, et seq.),
IMesenthuic Decline, Tubercles, Tubercular
Consumption, &c.)

Bihliog. and Uefeu Aelius, Tetral). ii. scrm i. cap.

'iS.—Avicenna, Canon. 1. iv. fen. i. tr. 4. cap. i — 0. Cicsar,
l)c HortirS I'obro, fol. Vcnet. Vi^l. — Montamis, Trao
tatus (Ic t'cbrc Ilcctica, Svo. LiiKil. 15(;0. — J. Ilel{feUI,
l)c Ilcctica' CDgiiitionc rt Curatione. Krf. 1G34 — Za-
culns iMsilnnus, Med. I'rwst. llistor. l.iv. n.iO.— Fores-
lux, l.iv. (>l)s.2— '). — f'csli, l)e Ilectic-a Cardiacs. Erf,
l(i'.l7. _ Morton, Phthisiolog. 1. i. cap. 5. — G. E. Stahl,
Dc I'cbrc llccticA. llala\ !«)!); et De Feb. Ilect. Ab-
sccssum Intern. Comite. Hal. \l\f). — Ilojf'ninmi, Da
l'"cbrc Lont.'i. Opera, vol. ii. p. \f<i. — Fischer, l)c I'hthisi
OastricA. Erf. \7]'J. — /ittrc/iarri, I)c I'Hiriliiis IMcscn-
tcrlcis Acutis. Host. \727. — Ilnnrnc Larif;nsfi, 'i'licnry
andl'ractico of Physic, 'id cd. p. '257 — Arnold, DcIlcdicA ■
Stomachica. Altdorf. 1743. — llrcndcl, l)e I'htliiscos I Icc-
tica-iiuc Discriniinu ct Sctaccoruni utrubiciuo Ubu. (iuct.

V!5i.—Pt'lit, Traitedes Malad. Chirurg.t.i. p. 125. (From
caries.) — Biic/iiwr, De Ilecticorum Deliriis, malo Omine
orimidis. Hala;, I7fi"'. — Grant, On Fevers, &c. Loud.
J771. — iV. GnJJi///, Observat. on Hectic and Slow Fevers,
12nio. Lond. I77(). — F. Curtius, Animad. in Febrem
Hect. Svo. Dresd. 1781. — Fournier, Beobacht. iiber das
Schleichende Fieber, ttc. Leips. 1782. — Hebcrdcn, in Med.
Transactions, vol.ii. part i. — Trnlia, Historia Febris Hec-
tica;omnis JE\i Observatacontinens. Vindob. 1783. — U'il-
lan, On Diseases of London, Med. and Phys. Journ. 1802,
vol. i. p. 29.'i. — F. J. J'. Broussais, Recherches sur la
Fievre Hectique, Svo. Paris, 1803 — Pincl, Nosographie
Philosophique, t. i. p. ,3.57. Cth edit. — Otto, in Stark's
Archiv. b. iii. p. 383. — 3/. A. Petit, Traite de la Fievre
Entero-Mesenterique, 8vo. Paris, 1814. — llildcnlirajul. In-
stitut. Med. Pract. vol.iv.p.774. — Fournier ct IHii/i/, Diet,
des Sciences Med. t. xv. p. 290. — Covtanirau, Diet, de
Medecine, t. x. p. 546. — M. Good, Study of Medicine, edit,
by .S'. Cooper, vol. ii. p. 215. ; et Percival, in Ibid. p. 217. —
J. Boitillaud, Traite des Fievres dites Essentielles, &c.
p. 4155. — Brown, Cyclop, of Pract. Med. vol. ii. p. 245.

XVI. Fever, Continued. Syn. — nuperJis
avvexh^ ; Febris continens ; F. contitnia ; Febris
civiiiiiua continens, Burserius; Enecia, M. Good :
F. Septenaria, Auct. Lat. ; Anhaltendes Fieber,
Germ.; Fievre continue, Yr,; Febbre cuntinua,
Ital.

314. Defin. — The changes constituting fever
proceeding in one series, frequently loith a tendency
to exacerbation and slight remission.

315. i. Of the Division of continued Fevers.
— Fevers of a continued type are so remark-
ably modified by the circumstances stated above
(§ 43.), by varied combinations of causes, states
of constitution, predisposition, and by epidemic
influence, each form insensibly passing into the
one nearest allied to it, that every attempt at
arranging them must necessarily be more or less
conventional, and depend upon characters, which,
although tlie more prominent and universal, as
respects certain species, yet occasionally disap-
pear, or blend with others distinguishing cor-
relative forms and varieties. Owing to .this
circumstance, the divisions of continued fevers
adopted by writers have been arbitrary and varied.
Stoll arranged them as Injiammatory, Putrid,
Bilious, and Pituitous, — a division not materially
different from that previously made by Sydenham,
Hoffmann, and Boerhaave. — Cullen, Parr,
and others distinguished three species — namely,
Synocha, Siiuoclius, and Typhus: J.P.Frank,
also three — the Inflammuti'ry, Gastric, and Nerv-
ous. lliciiTER, four — the Injiammatory , Nervous,
Putrid, a.nd Gastric. Borsieri, live — the Ephe-
mera, Simple Synochus, Putrid Synochus, Slow
Nervous Fever, and Hectic. J. Frank, four — the
Typhoid, Gastric or Bilious, Bheiimutic or Catar-
rhal, and the Inflammatory : and IIildenbrand,
five — the Inflammatory, the Septic, Nervous,
Gastric, and Hectic. Dr. Fordyce, in his dis-
sertations, attempted no arrangement beyond that
into the regular and irregular forms. Pinel,
desirous of giving precision to his descriptions,
divided fevers of the continued type, into Inflam-
matory, Bilious or Gastric, Mucous or Pituitous,
Putrid or Adynamic, and Malignant or Ataxic ;
and has justly considered the plague and puer-
peral fever as distinct from the fevers belonging to
these orders. A nearly similar arrangement has
been followed by Boisseau and Bouillaud.
Dr. Wilson Philip has described only two
species — Synocha and Typhus. Dr. W. Good
three — Inflammatory, Typhus, and Synochal Fever.
IIufelanu, four — Inflanunatory Fever, Nervous
Typhus, Putrid or Infectious Typhus, and Gastric

FEVER, CONTINUED — Pathologv. 967

Fever. Dr. Tweedie has divided continued fever
into Simple, Complicated, and Typhus. Dr. Arih-
STRONG, into the Common Simple, Common Con"-es-
tive, and Typhus: and Dr. Burne, into the
Inflammatory and the Adynamic, either of which
lie believes may be simple, or associated with local
inflammation. Dr. Arjistrong, having recanted
his former opinions respecting fever, and discarded
the influence of infection in causing it, has denied
the existence of a synochal or simpleinflammatory
fever; has considered congestive fever to pass into
simple fever, or inflammation, when excitement
supervenes ; and has argued, that typhus always
arises from malaria, is essentially the same disease,
as intermittents and remittents, and differs from
them only in type. The various fallacies into
which he lias fallen respecting the diseases under
consideration, will appear more fully hereafter.

316. Dr. SouTHwooD Smith has viewed con-
tinued fevers, " as one great malady never differing
in nature, but in every two cases differing in
intensity, and giving rise by these difi^erences to
various forms of disease" — that this difl^erence
alone is the cause of the different forms it assumes.
He accordingly admits only of grades of inten-
sity— the first or lowest grade being Synochus
mitior ; the second, Syn. gravior ; the third.
Typhus mitior ; the fourth, Typh. gravior.

317. This view, as involving fundamental princi-
ples of pathology and practice, which, if implicitly
followed, would lead to very serious results, re-
quires a few remarks. Dr. Sjiith's position is
that continued fever never differs in nature. Now,
by the nature of a disease is understood its seat,
the tissues affected by it, or the exact patholo-
gical condition, whether of vital function or of
structure, constituting the malady. If, therefore, it
can be shown that in the continued fevers, even
of temperate climates, the state of function and
organisation are always the same in kind — that
the vital manifestations and structures are affected
in them all in a similar manner, but in different
grades of severity, — it will be conceded that
fever never varies in its nature. As this position,
however, is merely assumed, without any attempt
at ascertaining its stability, it must still be
doubted, until either it or its opposite be proved.
If we closely observe the mode as well as the
degree in which the vital manifestations in the
nervous system, in the muscular system, in the
blood and vascular system, &c. are affected, in
the various forms of continued fever, and the
consequent changes in the various functions and
structures, we cannot fail of concluding that, how-
ever nearly they all may approximate each other,
they diftei- as essentially in nature as in grade. —
What is the difference as to intensity between the
continued fevers enumerated above (§ 44.), or
even between the epidemics observed at different
epochs and seasons, if intensity be the only source
of distinction 1 In the paragraph just referred to,
other essential differences, arising out of the
prominent affection of particular functions, tissues,
and systems, are slated ; and from these, as well as
from the very distinct and even opposite manner
in which the vital manifestations, more particu-
larly the organic nervous power, are affected,
the varieties of continued fevers result. If fevers
were modified in severity merely, they would be
mutually convertible into each other, and cither
species indifferently would rise from one and the

3Q 4

963 FEVER, CONTINUED

fame cau^e. But no such occurrences are ob-
served ; for the nature, as well as the intensity, of
sever varies with the kind and combination of
causes producing it. Will infectious typhus
communicate simple continued fever, or bilious
inflammatory fever, or gastric fever, or climate
fever, or epidemic yellow fever; or will these
species of continued fever arise from the same
cause, and admit of being resolved into grades
of intensity merely? No one capable of dis-
tinguishing disease ever saw the typiius miasm
occasion any of these fevers, nor the causes
usually giving rise to either of them produce
typhus. Neither of them is convertible into the
other ; and however closely allied or equally
severe certain varieties of each may be, some-
thing more than difference in intensity is to be
recognised. 'J'he causes of each are distinct, the
features of each different, the course and duration
ditferent, the external appearance and internal
lesions diflerent, and yet no difference as to
severity or intensity may often be ascertained by
the ablest pathologist. Is it to this assumed dif-
ference of intensity merely that we are to impute
the admitted fact, that, in the very same period or
stage, the treatment which is beneficial in the one
fever is death in the other, — that large depletions
are required at the commencement of one species,
and most injurious at the same period of another?
The very varied, and even opposite, treatmeflt
required in several epidemics, even when tiie
same organs are prominently affected, cannot be
referred to grades of. severity ; for fevers, even of
this climate, may be equally violent or severe,
and terminate fatally after the same duration, and
j'et be aggravated, or ameliorated, by opposite
measures. The great pathological truth, — which
ought never to be overlooked, and without a full
recognition of which, in estimating the nature and
treatment of fevers, our experience will be worse
than useless — will be deceptive, and our know-
ledge worthless empiricism, — namely, that the
vital manifestations rnay, all or severally, be va-
riously affected by the causes productive of fever
— maybe lowered or heighiened, or otherwise
changed ; and that these chan^'es, whether as to
kind or as to degree, should be irnade the basis of
distinction, in arranging the varieties and forms
of fever, and in devising indications for their cure.
In the following inquiry, something more than
intensity of action will be recognised and made
the grounds of arrangement and treatment, in-
asmuch as each of the several kinds of fever
presents characters having stricter reference to
tiie nature, than to the grade, of disorder — to the
stale of vital manifestation in the several systems
and structures, and to the seat and grouping of
the predominant lesions, much more than to inten-
sity of morbid affection. 'J'he arrangement, there-
fore, about to be followed, will not materially
differ from the sketcli already given (§ 44.).
But all the kinds of fever there enumerated
cannot be treated of under this head; their im-
portance, and, still more, certain peculiarities of
character, as well as of the circumstances in which
they occur, reiiuii-ing, conformably with the form
of this work, that tiiey should be discussed in
separate articles. Jn considering, therefore, the
various kinds of continued fever, those only which
are rnosl ititimatcly related to each other will be
comprised under Uiis head; the more simple states

— PuOONOSTIC SvMPTOMS.

being first described, and the more complicated
and dangerous forms successively reviewed.

318. ii. Of the Prognostic Symptoms in Continued
Fevers. — a. The countenance. — When the expres-
sion is serene, confident, clear, and animated, the
disease is of a mild and uncomplicated kind ; in
the advanced stages this state indicates a favour-
able crisis. If the face is large, injected of a
crimson or dark colour, with prominence of the
eyes, or is agitated and anxious in the early stages
of fever, the morbid excitement and determin-
ation to the head occasioning this appearance will
speedily exhaust the powers of life, and, in a
later period, will soon be followed by malignant
symptoms, or fatal collapse. VVMien the coun-
tenance is tinged of a yellowish or earthy hue,
or is withered-like or sunk, or constricted, and
especially if it exhibit distress, or want of serenity
and confidence, extreme danger may be appre-
hended. A full, bloated, waxy, or livid coun-
tenance, particularly if it assume a tawny or
mahogany tinge, indicates very dangerous con-
gestion and approaching death.

319. b. Eiternal surface. — If the skin be soft
and perfect in its sensibility, its heat not excessive,
although augmented, but without a feeling of
pungency or burning ; and if its temperature
be equally diffused ; a mild attack may be ex-
pected. But when the skin is dry and harsh, as
if thickened, and the heat is ardent, caustic, or
unnatural; if the surface be little sensible, not
readily acted upon by rubefacients or blisters ;
or if vesicated parts assume a dark or black hue ;
if the heat be ardent in the head or trunk, par-
ticularly at the epigastrium, and lowered in the
extremities ; if the skin be thickened, apparently
withered, dusky, dark, or livid in parts, or yel-
lowish, flaccid, tawny, streaked of different shades,
lurid, or otherwise changed from its natural hue ;
if It be damp, greasy, puffy, or bloated, or studded
with very dark petechias, vibices, or blotches, or
unusual eruptions ; or if parts pressed upon show
any tendency to gangrene ; great depression of
the vital powers, with contamination of the cir-
culating fluids, should be inferred, and the danger
considered great. The more florid, however, the
spots are, the less is to be feared ; and when the
black or violet petechias assume a brighter tint,
a more favourable opinion may be formed. Large
black or livid spots are often attended by dan-
gerous haemorrhage from the bowels. Small
dusky brown spots, like freckles, are very un-
favourable signs. Large livid or dark greenish
marks seldom appear till very near the fatal
period. (IIuxham.) — If the skin be covered
by warm, general, fluid and copious perspiration,
attended by an open or free pulse, a favourable
issue may be expected. But, if the perspiration
be cold, clammy, scanty, or partial, with a nau-
seous or disagreeable odour, especially if the pulse
be wciik, small, very fretjuent, oppressed, or
irregular, there is much danger, 'i'lie occurrence
of erysipelatous or erythematic inflammation in
the scat of sores or of abrasions ; the breaking
out of old ulcers, or the operiing of cicatrices ; or
a foul, gangrenous stale of old sores ; denote sink-
ing of the powers of life, and a tendency to a
dissolution of the textures. — Einaciotion, when
moderate, and in due relation to the duration of
the disease, is rather favourable; but, when it is
exf'essivc or rapid, it indicates ulceration in the

FEVER, CONTINUED

bowels. Little or no wasting, or a bloated and a
soft or tumid state of the surface, is very un-
favourable, and, with discolouration, indicates a
malignant malady. — The supine ])osition ; in-
ability to turn or remain upon tlie side ; falling
dovyn i'n the bed ; or the head being buried deep
in the pillow, from frequently throwing it back, or
rolling it about ; are indications of great danger.

320. c. The abdomen should be carefully ex-
amined, in order to form an idea of the probable
state of the stomach, liver, spleen, and bowels. —
Tension, oppression, and pain in the hypochondria
and epigastrium, indicate predominant affection of
the liver, stomach, or spleen ; nnd, if to these be
superadded sickness and vomiting, or a sense of
internal heat or burning, tumefaction or tender-
ness, a bareh or caustic heat of the surface of
these regions, with a parched skin, great thirst,
dark-coated tongue, or great anxiety at the priE-
cordia, a very severe form of fever, which will
probably pass rapidly into exhaustion, with vari-
ous malignant symptoms, should be anticipated.
— A tympanitic ordisteuded abdomen ; soreness,
tension, intolerance of pressure ; or a sense of
heat or burning ; with a hot, dry, harsh, and dusky
skin ; or with watery, foul, and morbid alvine
discharges ; or with a dark-coloured tongue ; are
most unfavourable signs. If any of these be
accompanied with irregular or irritable bowels,
and the state of the discharges just mentioned, or
with mucous or bloody stools, asthenic inflamma-
tion, frequently with ulceration, or some equally
dangerous lesion of the intestines, is present. If,
at an advanced period, or after any of these symp-
toms particularly indicating disorder of the bowels,
very acute pain suddenly occurs in the abdomen,
extending from a circumscribed spot, with vomit-
ing, collapse of the features, increased frequency
and smallness of the pulse, abdominal distension,
tenderness, &c., perforation of the intestines, and
its consequences, have taken place.

321. (/. Anxiety at the epigastrium and prsecor-
dia, with intolerance of pressure, depends upon the
affection of the nerves of organic life, and serious
lesion of the stomach and heart, and accompanies
the worst forms of fever. — When attended by
great restlessness, it is a most unfavourable sign.
It often ushers in, and accompanies, dark, gru-
mous vomiting in malignant and disorganising
feves. — Singultus is also often consequent upon
this sensation, especially when the stomach, or
superior and posterior parts of the liver, or both

' organs, are much affected. V\ hen it appears
late in the disease, and has been preceded by
pain, or by a sensation of heat or burning at the
epigastrium, or by distension, oppression, and
tumefaction in the hypochondria, dissolution is
generally impending, particularly if the singultus
be obscure or suppressed, and attended by anxiety
or tension at the prascordia.

322. e. Sensibil.ity and excitability vary much
in difierent forms and stages of fever. — During
moderate excitement, or reaction, when there is
no disorganising tendency in any viscus, these
manifestations of life are increased and equally
diffused. But when the disease evinces at its com-
mencement, or at an advanced stage, depression
of the vital powers, with signs of contamination
of the fluids, and tendency to a solution of the
vital tone or cohesion of the tissues, the excitability
■or irritability is evidently diminished, either by the

— Prog.vostic Symptoms.

969

exciting causes, or by previously increased action,
or by both ; and, in such cases, it is often un-
equally manifested, or concentrated in those
viscera which are most severely affected. ]\Ior-
bidly increased sensibility and excitability, espe-
cially when so great as to give rise to spasms or
convulsions, or augmented activity of all the
senses, and of cutaneous sensation, are indications
of affection of the membranes and surface of the
brain and spinal chord, with a tendency to exhaus-
tion, great in proportion to the degree of sensi-
bility displayed. — In many of the forms of fever
characterised by severe cerebral affection, followed
by stupor, black tongue, low delirium, or coma, the
vital manifestations under consideration are sup-
pressed by the cerebral congestion, as well as une-
qually diffused or manifested. In all such instances
the prognosis should be very unfavourable. But,
when these vital states seem neither suppressed nor
much lowered, nor very inordinately excited, nor
unequally manifested, the surface of the body, the
senses and nervous system generally, still retaining
their susceptibility of external and internal impres-
sions, a favourable issue may be expected. When
the extremities are cold or clammy ; the skin thick,
dry, loose, or hide-like ; the countenance sallow
or collapsed, with increased or caustic heat at the
epigastrium ; we may infer the.excitability to be un-
equally pianifested ; to be diminished in the periphery
of the body and augmented in the more central parts,
particularly if irritability of the stomach and bow-
els, with morbid discharges, be also present.

323.^'. The cerebral functions are more or less
disturbed in most continued fevers, and require, as
well as the state of the senses, the close observ-
ation of the physician. — If the sleep be sound,
undisturbed by frightful dreams or sudden starl-
ings unattended by stertor, or moaning, and
especially if the patient awakens in a more ra-
tional or refreshed state, a favourable issue is
indicated. But in proportion as the sleep devi-
ates from this, are severity of disease and danger
to be apprehended. An agitated, unrefreshing
sleep indicates increased vascular action in the
brain ; and tiiis is still more to be dreaded, if
there be continued watching. Want of sleep
often precedes delirium in its worst forms. Stupor,
or a desire to sleep, without obtaining it, indicates
great danger. — Violent and furious delirium, or
early delirium, with great excitement of the cir-
culation, irritable or rapid pulse, crimson-coloured
and injected countenance, prominent eyes, and
rending headache, indicate a state of vascular
excitement, which will soon be productive of
dangerous exhaustion, even if the brain escape
immediate or irremediable mischief. — If delirium
be attended by convulsions, startings of the ten-
dons, or tremors, the danger is great, and often
near. It is not less certain, although somewhat
delayed, if followed by profound coma, relax-
ation of the sphincters, unconscious or involun-
tary discharges, &c. A mild delirium is not
unt'ayourable when unattended by signs of ma-
lignaiicy, or extreme exhaustion of the powers of
life ; and if it appear in the advanced course of
the disease, and chiefly in the evening. AVhen it
follows a state of stupor, it is often indicative of
recovery. Very lively or very low delirium, the
latter especially, is unfavourable. If the delirious
patient slates himself to be dying, he is generally
right, although there may nut be many signs of

970 FEVER, CONTINUED

danger present. Indifference to death, with an
apparent desire of it, and a firm persuasion of
being perfectly well, are also unfavourable.

324. g. If the eyes be calm, or slightly animated,
in the early stages, a mild form of fever may be
expected, — at advanced periods, a favourable
change has commenced. Agitated, wild, ter-
rified, confused, muddy, painful, prominent,
turgid, or suffused eyes, indicate a most severe
disease, at an early stage, and great danger in
advanced periods, especially if the whites of the
eyes become of a dusky or dirty yellow. Into-
lerance of light attends cerebral excitement ; and
rolling of the eyes, with a wild, unfixed stare,
ofien precedes severe delirium or convulsions.
A dull, sluggish state of the eyes, want of ani-
mation, sinking in their sockets, a dark hue of
the conjunctiva, with a sad expression, are un-
favourable. A pearly whiteness, with agitation
and prominency, is a symptom of dangerous con-
gestion of the lungs and liver; and, if succeeded
by a dirty yellow hue, or dulness of the cornea,
indicates approaching dissolution. Partial pa-
ralysis of the retina, indicated by black spots, or
other dark objects floating before the eyes; closure
or falling of the upper eyelid, or dosing with the
eyelids half closed ; are dangerous symptoms. —
Slight deafness without pain in the ears, is not an
unfavourable sign.

325. h. The tongue and nwuth furnish important
indications in fevers. — In the course of the milder
forms the tongue is foul, coated with a yellowish
or cream-coloured mucus, and generally furred ;
it is sometimes a little red at the sides and apex,
and rather dry, or moderately moist, in the centre.
In proportion as it departs from these states, the
danger is increased. If it be covered by a milky,
whitish, or mealy coating, and if it be also large,
flabby, or swollen, early in fever, an adynamic or
malignant state of disease may be expected. If
it become rough, dark-coloured, with prominent
papilla;, and not particularly coated, but dark
red, especially towards the sides, serious aft'eclion
of the alimentary canal, or of the liver, should
be feared ; more especially if the symptoms re-
ferrible to the abdomen and these viscera be
also urgent. If to these appearances be super-
added dryness, and contraction of its breadth,
serious or fatal changes within the head, or large
cavities, have supervened. When the tongue is
wiiite, or coated with the papilla;, erect or excited,
and the edges red and fiery, vascular action is
then inordinate in some internal organ, although
no other symptom may inJicale this state ; and
vascular depletions are required. If it be covered
by a deep yellow coaling, congestions of bile in
the biliary ducts and gall bladder are evinced ;
and if this pass quickly into an excited, dry,
and brownish state, the supervention of con-
gestion, or inflammatory action in the substance
of the liver, or the digestive mucous surface, or
in both, with diminidied vital power, may be in-
ferred. A (lark or brick-coloured, or livid redness
of the tongue, with a glossy surface, or a surface
])aitially covered by a partly detached coating,
or black crust, or with a dark, scanty, tenacious
laucus in the mouth, or on the teeth or lips,
show extreme prostration of vital ])ovver, with
contamination of the circ\dating and secreted
fluids. A leaden-coloured, sodden, or parboiled-
likc, flaccid, smooth, enlarged, tremulous, or dimi-

— Prognostic Symptoms.

nished or shrunk, tongue, are all unfavourable
signs. If this organ become, in the progress of
fever, thickly covered by a dark or fuliginous
coating, or exhibit, in addition, deep fissures,
the apex and sides being of a brownish or dark
hue, the adynamic state is extreme, and the
digestive mucous surface will readily pass into
ulceration or sphacelation, if, indeed, the former
lesion have not already commenced. — Vital ex-
haustion, contamination of the fluids, and solu-
tion of the soft solids — the constituents of marked
malignancy — are evidently present, if the gums
readily bleed when touched, if they and the teeth
are covered with a black viscid mucus ; if the
former discharge a dark dissolved blood, or
ichorous bloody sanies ; or if a similar fluid
escape from the nostrils or posterior fauces. An
inky state of the surface of the tongue sometimes
ushers in these symptoms, and also evinces the
malignant condition. On the other hand, if the
tongue becomes cleaner at its edges or apex, or
moister round the margin, particularly if other
favourable signs appear, a salutary change has
commenced.

326. i. Thirst is often very urgent, or even in-
satiable ; but, although indicating the intensity of
disease, it is not of itself a dangerous symptom. —
The absence of thirst, especially when the tongue
and fauces are dry, rough, and parched, is always
an unfavourable sign. A constant desire of drink,
yet the patient drinking little when it is given him,
and a difficulty of deglutition, are very dangerous
symptoms.

327. /c. The evacuations yrom the bowels furnish
important signs to guide the practitioner in the
treatment and prognosis, — In the milder forms
of fever the bowels are readily acted upon, and
the evacuations are generally feculent, but va-
rying in colour and consistence, according to the
state of the biliary and other secretions, and the
purgatives employed. When the stools give re-
lief froin uneasiness in the abdomen, or reduce
fulness of it, a mild disease may be expected.
If the most active cathartics are required to pro-
duce evacuation, the stools being watery, scanty,
or otherwise morbid, and voided with a sense of
confinement or difficulty, the abdomen being
full or tense, or hot and uneasy, a severe, fever
may be anticipated, and general or local deple-
tions, or both, are indicated. If copious fecu-
lent stools follow this state, a favourable crisis
may be looked for. Frequent, scanty, bilious
evacuations, presenting every variety of colour,
from a light green, or greenish yellow, to a
greenish black, sometimes watery, at other times
mucous and streaked with blood, occasionally
feculent and extremely ofl'ensive, often accom-
pany the worse forms of bilious or autumnal
fevers, and indicate danger, particularly if they
assume a pitchy npjiearance. When the stools
are smooth, dark biown, or blackisli, like treacle,
the danger is great. When they are intimately
mixed with blood, or bloody sanies, or purulent
mucus, or are ochrey, very fre(|uent and exhaust-
ing, organic changes in the mucous surface of the
intestines, or in the liver, are evinced. If dis-
charges of blood are found in the stools, espe-
cially if unmixed with other matters, ulceration
in the large bowels may be inferred. If the
blood be grumous, black, and mixed with the
faecal matters, it has generally proceeded from

FEVER, CONTINUED

tlie small intestines. If the stools consist cliiefly
of u liglit yellow or serous iluid, or are passed
involuntarily or unconsciously, great danger may
be apprehended.

328. 1. Tlie urine is always more scanty in fevers
than in health, excepting during the premonitory
and invading periods, when it is often pale and
copious. As reaction is developed, it is dimi-
nished, and higher coloured than natural. In
proportion to the extent of these latter changes,
may the disease be considered as severe. —
In the most dangerous forms of fever, parti-
cularly those characterised by morbidly increased
action, rapidly passing into the malignant or
adynamic states, the urine is extremely scanty,
and its secretion nearly suspended. If it also
present a muddy, or greenish brown, or greenish
black hue, great danger exists. A greenish or
dark urine is often observed in severe inflam-
matory, bilious, and gastric fevers, sometimes
with a muddy appearance, or with darker clouds
in it. When this kind of urine becomes paler,
deposits a sediment, especially if it assume a
brick colour, and is abundant, a favourable
change is taking place. If this secretion become
more copious and more natural, with a due de-
posit, the fever is declining. But if it be more
scanty, or suppressed, or passed involuntarily,
or if retention occur, extreme danger exists.

329. m. The respiration is generally frequent or
irregular in all severe forms of fever. VVhen it
is also attended by a sense of constriction or
oppression, or when it becomes siiort, %urried,
difficult, and laborious, or suspirious, great danger
is evinced. A still, quiet respiration, the motions
of the thorax being scarcely percepiible, is also
unfavourable, especially when stupor or torpor is
present. A slower state of respiration than
natural, occasionally interrupted by deep sighs,
or by convulsive heavings of the chest, is a sign
of danger. A very hot state of the expired air
early in the attack indicates an inflammatory or
malignant fever. A coldness or rawness of the
expired air, particularly if it have a fishy or
otherwise offensive odour, indicates either a ma-
lignant disease or approaching dissolution. In
all cases of disordered respiration, especially if
cough be present, the stethoscope should be used,
unless there be any dread of infection.

330. n. The pulse, to the experienced and ob-
serving physician, furnishes the chief indications
of danger, as well as of treatment. If it be under
100 or 110, at the same time free, energetic, and
regular, the disease will be mild and tractable.
But if it rise above the latter number, if it become
also irregular, tumultuous, or oppressed, then
danger is to be dreaded. If it reach 120, and
especially if it rise above this number, the danger
is very great. If it mount to 130, recovery sel-
dom or never occurs, unless in cases of hysterical
and irritable females, or those in the puerperal
state. Smallness, weakness, irregularity, inter-
missions, or startings of the pulse; or a too open,
broad, and very soft pulse, the pulsation ceasing
upon slight pressure of the finger ; are all indica-
tions of great danger. If it become less frequent,
more free and expanded, a favourable change
may be hoped for. An intermission every fifth or
sixth beat, at the acme of the disease, is sometimes
an indication of crisis.

331.0, The blood taken from a vein furnishes

— PnoGNOSTic Symptoms.

971

very important indications, both as to the means of
cure and as to the result. — If it be not materially
different from natural, or if the crassamentum be
merely slightly cupped, a favourable opinion may
be formed. But if the clot be loose, gelatinous,
or imperfectly separated from the serum ; or if it be
dissolved or broken, and tinge the serum ; or if the
serum be of a brownish or greenish hue ; or if the
more remarkable changes mentioned in the article
Blood (§ 129. et seq.) be present; most danger-
ous disease obviously exists, depending no less
upon the alteration of this fluid than upon depres-
sion of the vital manifestations with which this
alteration is associated, and of which it is usually
the consequence.

332. p. The prognosis, moreover, depends very
much upon the form, of the fever : at least one
third of the more malignant kinds of fever termi-
nating fatally, according to the usual modes of
treating them, and not more than one case in fif-
teen or twenty of the milder forms. — The nature
of the prevailing epidemic must be taken into
account, in connection with the circnvistances that
seem to favour or extend it. Of these the most
remarkable are full living, and a plethoric state
of system. Although the epidemic fevers, lately
prevalent in Ireland, have been produced by the
wretched circumstances of most of the lower
classes, and have readily spread, owing to these
and other allied causes, the mortality has not
been generally great in these classes, in proportion
to the number affected ; whereas, amongst the
higher orders, the extension of fever has been
relatively less, but the proportion of deaths to the
affected much greater, than in the lower. Per-
sons who live chiefly on animal food, or who
partake of it very largely, are in greater danger
from continued fever than those who live abste-
miously, or chiefly on vegetable diet.

333.(7. T^^G age and strength of the patient should
also be taken into the calculation. — Early age and
stiength do not furnish the protection from fever,
nor yet from an unfavourable termination, that is
very generally supposed. Indeed, in some malig-
nant fevers, the young and strong are placed in
the greatest jeopardy ; as in epidemic yellow
fever and plague. The continued fevers of this
climate are most prevalent from the fifteenth to
the thirtieth years. The proportion attacked
during this period may be reckoned, as to all the
other periods of life, as three are to two; whilst
the number of deaths in the former, compared
with the latter, may be considered as ten to nine;
showing that, although the predisposition to fever
is greatest at this particular period, the danger is
less. After forty years, the risk rapidly increases
with the progress of age.

334. r. Sex has some influence as to the progno-
sis of fevers even in this country. But, in warmer
and more unwholesome climates, and in certain
epidemics, it should have considerable weight.—
In fevers proceeding from infection, marsh exhal-
atiops, and suppressed perspiration, and in various
epidemics, a larger proportion of males is gene-
rally attacked, owing chiefly to the circumstance
of their being exposed more than females to those
causes. The latter are, also, upon the whole,
less severely affected, owing — 1st, to their much
less exposure, and the consequently less intense
action of the causes; — 2dly, to the less rigidity of
their fibres; — and 3dly, to the periodic discharges

972

to which they are subject
females attacked are less frequent.

XVII. Fever, Ardent; Fe&cis^rrfens. — Charact.
— The stages or series of febrile phenomena pro-
ceeding with rapidity and regutarity ; the period
of excitement being very acute, and attended by
greatly increased vascular action ; no morbid
seminium or infectious miasm being generated
in their course, as observed in modern times.

336. Under the generic denomination of Ardent
Fever may be comprised those more acute forms
of fever vvliicli are attended by great vascular ex-
citement, and which, owing to their nature and
severity, generally run their course in from one to
fourteeu days, and are but seldom prolonged be-
yond nine or eleven days. They may be divided
into the more ephemeral and the inflammatory.

i. Ephemeral Fever. Syn. — Diary Fever,
Febricula, Ephemera, Febris diaria, Auc. Var. ;
Simple Fever, Fordyce ; Das eintagige Fieber,
Germ.; Fiivre ephemtre, Fr.; Effimero, Ital.;
Efemera, Span.

337. Charact. -^ I/tcreosec/ frequency and
strength of jjulse ; with heat of skin, headache,
thirst, and ivhile excited tongue ; terminating in
perspiration generally ivithin twenty four hours.

338. Simple Ephemeral Fever may occur in a
very mild and slight form, — the Ephemera mills
of Dr. Good; or in a much more acute state, —
the E. acuta of this writer. But intermediate
grades between these may also present themselves.

339. A. Causes. — The mildest variety is usually
caused by excessive or prolonged muscular exer-
tions ; by the more violent passions and emotions
of the mind ; by protracted study and mental oc-
cupations or excitements ; by vicissitudes of tem-
perature, and exposure to a warm sun ; and by
disorder of the digestive organs, proceeding gene-
rally from the quantity and nature of the ingesta. —
The more acute states usually arise from the above
causes, from a surfeit, from temporary obstruction
or congestion of the biliary organs, from the pre-
sence of ffecal collections and morbid excretions
in the prima via, and from violent exercise under
a hot sun.

340. B. Symptoms. — a. The milder form of ephe-
meral fever is rarely preceded by chilliness or
rigors ; but it generally commences with lassi-
tude, yawning, stretchings, and a sense of irrita-
tion or of undue excitement. Tlie pulse becomes
frequent, the skin hot, and the head pained. The
patient tosses in bed — is restless; cannot sleep,
or sleeps in a very disturbed and interrupted man-
ner ; and his tongue and mouth are dry. These
symptoms frequently commence in the afternoon
or evening, and subside in the course of the suc-
ceeding morning, in a gentle perspiration ; thus
terminating in from eight to fourteen hours. But
often, also, when the cause has been more severe,
and the disorder has come on at a later hour, the
patient continues feverish in the morning after a
restless night ; is indisposed to leave his bed ;
feels unrefreshed, and unable to make any exer-
tion ; and passes the day in disquiet. 'J'owards
evening, tiie restlessness and other febrile symp-
toms increase ; but in the night, or at an early
hour in the morning, he falls into a (piiet slcfj) ;
a perspiration lireaks out ; and he awakens re-
freshed and restored.

FEVER, EPHEAIERAL.

hence deaths amongst 341. b. The more acute form often begins — es-
pecially when it is caused by disorder of the diges-
tive organs, or by cold — with chilliness or rigors,
succeeded by great heat of skin and throbbing
pain of the head. The pulse is frequent, strong,
and full ; the face is flushed ; the urine high-
coloured ; the tongue is white, the papillae erect ;
and the secretions and excretions are diminished.
These, and the usually attendant symptoms — as
restlessness, languor, want of sleep, and general
uneasiness — having continued from twelve to
twenty-four hours, a free perspiration supervenes,
generally towards morning ; the urine deposits a
sediment, and the disorder disappears. When
this form of fever proceeds from mental emotions
or excitement, and from exposure to a hot sun,
or from muscular exertions in warm weather, or
from a rapid transition to a hot climate, it is sel-
dom or never preceded by chills or rigors, and,
if not actively treated by antiphlogistic remedies,
is often prolonged beyond the period just men-
tioned, and assumes all the characters of the next
species — Inflammatory Fever.

342. C. Diagnosis. — These states of disorder
may be mistaken for the commencement of some
one of the more serious forms of fever. But they
may readily be distinguished by ascertaining their
causes ; by the absence of the usual premonitory
signs of fever ; by the sthenic and acute vascular
excitement, nervous energy being very little im-
paired ; by the rapid increase of the heart's ac-
tion, by the slight depres^on of the muscular
powers ; and by the circumstance of pain being
either hardly complained of in the loins and limbs,
or altogether absent. •

343. D. Treatment. — The febrile symptoms soon
subside after the digestive canal is freely evacu-
ated, especially when they have arisen from the
irritation produced by retained excretions. When
they are caused by the ingesta, an emetic should
be given immediately, and its operation promoted
by the usual means ; but it is contra-indicated in
all other cases. Afterwards a dose of calomel
ought to be administered, and allowed to act
upon the secretions for five or six hours. Cooling
saline purgatives, conjoined with small doses of
antimony, or of ipecacuanha, as advised by
Vater and Gianella, or of the spirits of ]Min-
DERER, repeated at short intervals, will then
hasten recovery, and remove the morbid secretions
which have disposed the frame to these febrile
attacks, — When the disorder has been occasioned
chiefly by atmospheric vicissitudes, diaphoretics,
especially after the bowels have been freely eva-
cuated, and a tepid or warm bath, are more par-
ticularly indicated.

344. If the febrile attack have been caused
by inordinate mental excitement and exertion, or
by fits of passion, by anxiety or other aft'ections
of mind, cold shoulil be ajjplied to the head, in
the form either of att'usion, of cold water, cold
sponging, evaporating lotions, &c. ; the bowels
freely evacuated, and diaphoretics prescribed. — If
it be produced by exposure to, or by muscular
exertions under, a hot sun, and whenever vas-
cular action is excessive, or the patient ])lethoric,
full bloodletting ought to be practised pre-
viously to the last specified means, which
should be assiduously employed, and accom-
panied by cold sponging of the surface, and
the inlernal use of refrigerants and saline niedi-

FEVKR, INFLAMMATORY — Forms,

973

cines. The febrile attacks which follow exposure
to the sun in warm climates, or even the quick
transition from a cold or temperate to a hot
country, when treated thus actively at their com-
mencement, generally subside within twenty-four
hours. But it is comparatively rare that a sea-
soning or climate fever runs its course in so short
a time, unless in delicate or thin persons, and
when the attack is very slight. In these cases,
particularly when the stomach is irritable, much
benefit will accrue from the frequent exhibition
of small doses of the nitrate of potash, or of it
and the muriate of ammonia, in solution, as pre-
scribed by Hillary, nearly as follows : —

No. 221. PotasstB Nitratis gr. xx. ; Ammonije Hydro-
cliloratis gr. xij.; Mist. Camphora; 3vj.; Aquee 3x. M.
fiat haustus, quartis vel sextis horis sumendus.

BiBLiOG. AND Refer. — Galen, De Differ. Febr. l.i. c. i.

— Patilus JEifineta,\. ii. c. 1.5 Oribasius, Synop. 1. vi. c.6.

— Avicenna, Canon. 1. iv. fen. i. tr. i. cap. .5. — Sennertus, De
Feb. 1. i. c. G.—J. Lotnmius, Medicin. Observ. 1. i. de Febr.
Diaria. — //o)-s<ms,Opera, vol.ii. p.l. — Zacultts Lusitanus,
Med. Pr. Hist, l.iv.; et Pr. Admirab. 1. iii. (Exvinoetve-
nere.) — Forest us. Op. 1. i. obs. 1 — 4. ( J'igiliie, .■Eslus soli's,
SfC.) — J'ater, De Ipecacuanhae Virtute Febrit'uga. Witeb.
1732. — R. Manningham. Sympt. and Nature, &c. of the

Febricula, or little Fever, r2ino. 174G Gianella, De

Admirab. Ipecac. Virtute in Febr., &c. Pat. 1754. — Lud-

wig, Institut. Med. Clinic, pars i. c. i Eisner, Beytriige

zur Fieberlelire. Kiinigsb. 8vo. 1789 J. P. Frank, De

Curand. Iloniin. Morb. t.i. p. 156 — J. B, Burserius, lu-

stitut. MediciniE PracticEe, t. i. p. 272. Edit. Lipsiae

G. Fordyce, Dissert, on Fever, dissert, i. p. 30. — Hvfelnnd,
Conspect.Morbor.Classisi. Ord.i.Gen.i. Sp.l. — P.Pinel,
Nosographie Philosophique, &c. t.i. p. 18. — M.Good,
Study of Med., edit, by S. Cooper, vol.ii. p. 110.

ii. Inflajimatory Fever. Svn. — KajJcros,^]^-
pocrates ; 2woxos,2Lii'€X'/J<^'^e7i"«''"&>5€s,Grffic.;
Sijnnchus Imputris, Galen; Fel)ris Sanguinea,
Avicenna ; Synocha Biliosa, Sennert. ; Febris
septenaria. Plater.; Synocha simplex, F. acuta
Sanguinea , Hoffmann ; Febris continens vel
Sijtiocha, Stahl ; F. continua non Putrida,
Boerhaave ; Synocha simpler, J uncker ; Febris
Iiijiammatoriu, Stoll ; F. Iiijlammatoria sim-
pler, Huxham and Ilildenbrand ; Synocha,
Sauvages, Culleii, &c. ; Febris continua In-
Jiammatoria , J. P. Frank ; F. continens In-

■ Jlammatoria simplex, Selle ; Febris Sthenica,
Brown ; Enecia Cauma, M. Good ; Dijnamic
Fever, Stoker ; Calentura continua. Span. ;
Fievre Angiott'nique, Pinel ; Fierre Inflam-
matoire continue, Fr. ; Synoshische, Entz'iindliche
Fieber, Entzundungsjieher, Germ. ; Febbre
Injiammatoria, Ital.

345. Defin. — Pain in the head, back, and
limbs ; heat generally and greatly increased ;
pulse full, hard, and accelerated ; thirst urgent ;
urine in small quantiti^ and high coloured ; the
bouels constipated, irith restlessness and anxiety.

346. A. Forms. — a. jNIild Inflammatory Fe-
ver. — a. The fever which usually arises from cold
and dry states of the air, in cold climates, in
elevated situations, or in temperate countries, from
atmospheric vicissitudes or other causes, assumes
either simple or complicated forms, and is gene-
rally sporadic. Its epidemic occurrence is compa-
ratively rare, especially in its simple state. It
appears chiefly during winter and spring, or
during north and north-east winds. In its com-
plicated states, which are most frequent, it forms
a connecting link between idiopathic fever, and
visceral inflammation ; the local affection ap-
pearing in the early or advanced course of
the former, the general disorder, or symptomatic
fever, being consequent upon the latter. Thus

inflammatory fever, and local inflammation, arise
most frequently from the same causes acting upon
different constitutions, habits of body, and states
of local or general predisposition; — the simple
form of inflammatory fever appearing in the
young, plethoric, and robust, and in those pos-
sessed of no local predisposition ; the complicated
form taking place in persons whose previous
ailments, habits of life, or avocations, have in-
duced a disposition to predominant action in some
important viscus, or from a concurrence or suc-
cession of external causes tending to the more
especial disorder of one or more organs ; and the
primary local inflammation occurring from a
predisposition of some part so great as to expe-
rience the onus of morbid action from the com-
mencement, or soon after the impression of the
exciting causes, or from the kind and concurrence
of these causes. — In the /csf case, the whole
frame seems to participate equally in the dis-
ordered action from the beginning ; in the second,
the disorder is also general from the first, with
predominance of it evinced in some organ, either
at a very early period, or in some advanced stage:
in the third, the earliest symptoms of disease are
referred to a particular viscus, and with the in-
crease of such disease the whole system sympa-
thises.

347. 13. The symptoms of this variety are
uniform in kind, but vary in severity. The
premonitory signs are usually slight, or of brief
duration. Hence the attack seems sudden, and
is conmionly ushered in with rigors or chills
which are of short continuance ; and, altliout^h
often well marked, are occasionally so slight as
to escape observation or recollection. The rigors
or chills seldom recur, and are rapidly followed
by general vascular reaction : the skin and in-
teguments become full, injected, dry, hot, and
burning ; the countenance full, glowing or red
and animated ; the eyes injected, intolerant of
light, but lively ; the pulse frequent, strong,
bounding, and full, sometimes hard or oppressed •
respiration is frequent, an4 the expired air hot •
the nostrils and mouth are dry ; the tonoue white
its papilla; excited or erect ; and the lips full and
red. The" external appearance of the body evinces
increased vital action ; the whole surface ap-
pears glowing and animated ; the internal sens-
ations indicate generally increased vascular ac-
tivity ; and all the secretions and excretions are
diminished or obstructed. The patient complains
of great thirst and heat ; of a severe of throbbing
headache and vertigo ; of anxiety at the prscordia •
of increased sensibility, especially in respect of
light and noise; of restlessness, 'watchfulness
and of frightful dreams ; and of nausea or sick-
ness. Taste and smell, owing to imperfect
secretion on the surface of the organs, are im-
paired or abolished. The pulse seldom reaches
I 10 beats in a minute ; and the heat of skin,
although greatly increased, is in due relation with
the activity of the circulation ; and does not im-
part the harsh and unpleasant sensation to the
hand of the observer, that characterises the more
unfavourable kinds of fever. Upon issuing from
the vessel, the blood is usually red or florid, viscid
and thick ; and separates perfectly into serum
and coaguhim : the former of which is limpid,
watery, and in small quantity ; the latter firm and
sometimes cupped, but it seldom exhibits the

FEVER, INFLAMMATORY — Complications, etc.

974

buffy coat unless local inflammation have super-
vened. .,

348. The symptoms commonly increase in
severity : the tongue becomes red and dry ; the
urine more scanty, and of a higher colour ; the
bowels more constipated, and the watchfulness
more prolonged. In children, heaviness, drowsi-
ness, or sopor, .is frequently observed ; and in
adults, delirium or reverie sometimes occurs. All
the phenomena usually are exasperated in the
evening ; their mitigation in tlie morning being
attended by partial perspiration, or a relaxed,
moist, and warm state of the surface. On the
third or fifth day they reach their acme. At this
period they often appear somewhat mitigated ;
but generally continue from two to four days
longer, with manifest efforts at a critical change,
which usually takes place about the seventh or
luath day, and rarely later than the fourteenth.
The crises commonly observed are — haemorrhages
from the nostrils or from the haemorrhoidal vessels,
more rarely from the uterus ; a copious and ge-
neral perspiration ; and a free secretion of urine,
depositing a sediment. After the natural evo-
lution of one or more of these evacuations, the
symptoms rapidly subside, and convalescence
speedily advances.

349. Although the epidemic occurrence of this
form of fever is rare, instances have been recorded
by Ingrassias, Hoyer, Heister, Van Swieten,
and Navieres. In these, the symptoms and
progress of disease coincided entirely witli the
description just given. — Bloodletting, and the
rest of the antiphlogistic regimen, were adopted
in these epidemics, and recovery took place in
nearly all the cases.

350. y. This fever may be said to be endemic
in warm countries, during dry seasons, especially
amongst Europeans who have recently removed
to, or who reside in, these countiies. Viut in
them it frequently either assumes a severer form
than that now described ; or, after an imperfect
effort ^t crisis, subsides into a state of dangerous
collapse. Relapses, also, from errors in diet, or
from intemperance and premature exposure, are
much more common in them, than in persons
residing in northern and temperate climates,
generally owing to the concurrence of malaria in
producing the fever, which, however, more usu-
ally assumes the form noticed hereafter (§ 354. ef
seq.) — Mild inflammatory fever is seldom pro-
tracted beyond seven days, unless it assume an
unfavourable and complicated form. The con-
tinued fever, which occurs during the hot and
dry season, in the more southern parts of Europ^e,
in the East and West Indies, and in other places
•within or near the tropics, particularly among
the natives of cold and temperate countries who
have recently removed thither, is generally either
of this kind, or of the complicated or severe forms
about to be described. The modifications it pre-
sents in different climates, result chiefly from
the difference in the constitution and habit of the
affected, from the intensity and concurrence of
the causes, and from the association of malaria
with high grades of temperature, and the other
circumstances already insisted on.

•irA. 5. The complicated statrs of injlammalnri/
Jeter are more common than the more sim[)le
form, wliftiher observed in warm, or in temporate
&nd cold, regions. They depend chiefly — («) on

the season and climate ; — (b) on the habits and
occupation of those affected ; — (c) on the con-
currence and succession of the remote causes ; —
and, (d) on the previous state of particular or-
gans.— They generally appear sporadically ; oc-
casionally they may be said to be epidemic ; and
in some places they are endemic. — Theirepidemic
appearance is chiefly intemperate countries during
dry and hot seasons, and to a limited extent. Their
endemic prevalence is observed under the circum-
stances assigned above (§ 350,). The complications
may be either almost coiitaneous with the develope-
ment of the fever, or consequent upon it, at any
period of its course. They may be either so slight
as to constitute merely an exalted affection of a
certain organ, or a determination to particular
parts ; or so severe as to amount to a state of
sthenic inflammation, rapidly passing into disor-
ganisation.

352. (a) The complication tuith ■predominant
action or injiamynation in the bruin or its mem-
branes, occurs principally in very hot climates,
in soldieis and sailors who have been exposed
to a powerful sun, and been required to make
considerable bodily exertion when thus exposed ;
in persons who have been intemperate, or have
felt the exciting passions of the mind ; and in
those who have over-exerted their intellectual
powers. In these, the fever is often very sudden
in its attack ; and the symptoms referrible to the
head indicate every grade of affection, from active
determination of the circulation to this part, to
fully developed inflainmation. In many of such
cases it is difficult to determine whether the local
or the general affection is the primary one, so
early has been their co-existence. In these, tiie
patient sometimes falls down from the suddenness
and severity of the affection, with a red or tumid,
countenance, injected or suffused eyes, and hot
scalp, but without loss of consciousness. In others,
predominant disorder in the head appears only
in the advanced progress of the fever; the patient'
complaining of severe throbbing and distracting
headache, and of a feeling as if the cranium
would bur>t from internal distension. In either
case, violent delirmm, or maniacal excitement,
often supervenes, and rapidly passes into coma,
or stupor, or is removed by treatment. In all,
the secretions and excretions are impaired, and
the bowels constipated.

353. (b) Predominant affection of the lungs, or
pleura, forming the pulmonic complication, is.
observed chiefly in cold or temperate climates
during dry and cold seasons, and high winds; and.
in elevated situations. In intertropical countries it.
occurs only in the cooler seasons, and in elevated
localities. Sudden vicissitudes of temperature,
damp clothes, and exposure to the night air,
after experiencing heat and fiitlgue, are the most
common exciting causes. — 'J'iie aff'ection of tlie
lungs is frequently either not fullv developed,, or"
is latent at the commencement of the fever, and
is, consequently, often overlooked after it is esta-
blished, unless it extend to the bronchi on the
one hand, or to the pleura on the other; and then
the symptoms characteristic of either will direct
attention to the complication. The stethoscope
should therefore bo employed whenever the
breathing is laboured or oppressed in the inflam-
matory states of fever observed in the circum-
stances just stated. — Tliis fever may present algp

FEVER, INFLAMMATORY— Severe Fonjis

prominent Hepatic, Gastric, and Enteric disease;
but, in such cases, it will very nearly resemble
the forms of fever described under the names
gastro-biliinis and mucous.

354. h. Severe Inflammatory Fever. — The
disease described by the names of Sifnochus
CaiisoHi'rfes, by Gilbert ; o( Synocha Causodes,hy
Manget ; of Synocha Ardens, by Sauvaces ; of
Ende/nial Causus, by Moseley ; of Infiammatory
Endemic, by Dickenson ; of Climate or Seasoning
Fever, by several viriters ; and of Endemic Yellow
Fever, by others ; differs from the foregoing or mild
form of infiammatory fever (§346.) only in grade,
as insisted on by Jackson, and proved by my ovvn
observation. This is the disease which most fre-
quently attacks new comers into the West Indies,
more especially sailors and soldiers; and which has,
as already stated (§ 244 — 247.), been confounded
by recent writers with the aggravated forms of
bilious fever on the one hand, and with epidemic
or pestilential yellow fever on the other. It was
also prevalent during the last war among the
British troops and sailors in the Mediterranean,
and was described by Burnett, Irvine, Boyle,
Brunton, Down, and others; but it generally
assumed a milder form than in tiie West Indies.

355. Whilst the milder form of infiammatory
fever is common among the white and assimilated
European population of warm climates, the severe
or aggravated form occurs among those who have
more recently arrived in tiiem, and more especially
among the young, the intemperate, the robust and
plethoric, and those who are exposed to the sun, to
vt!ry high temperature, and to the night air. In most
warm climates terrestrial exhalations are also fre-
quently more or less concerned in the causation of
the continued as well as of the remittent types of
fever : the type being determined, as shown above
(§43.), by the nature, intensity, and combination
of the causes;. and by circumstances peculiar to
the patient, particularly the novel, or the habitual,
"operation of the endemic influences to which he
is exposed. But, although malaria may be a
concurrent cause of this fever, especially in re-
spect of persons who have recently arrived in the
West Indies, yet I believe that, where its ope-
ration is most unequivocal, the kind of fever pro-
duced by it is different from this, — premonitory and
cold stages preceding reaction, which is much less,
violent than in this, the resulting fever being of

_ the bilious continued form, about to be noticed.
« — J\ly experience fully accords with the ob-
servation of Dr. Stevens, that, when a young
Northern stranger is subjected soon after his
arrival in the West Indies to the higher ranges
of temperature, his clothes are soon drenched ;
and that, if he be exposed to a current of air
in this state, the cold produced will constrict the
vessels of the skin, and prove the exciting cause
of fever, which, in favourable circumstances, will
often, be the mild form of inflammatory fever,
such as has been described above, and as is often
observed in temperate climates. The causes which
produce a severe affection in young and plethoric
strangers, seldom affect the older residents, and
never the natives of the country or the dark races.
Women and children, the aged, and the weakly,
are much less liable to it than the robust and ple-
thoric.

356. o. The history of this form of fever has not
be§n given with the requisite precision by the

975
various writers on it ; most of them having mixed
it up in their descriptions, with the inflamma-
tory varieties of remittent, and with the more con-
tinued states of fever produced by terrestrial or
vegeto-animal exhalations, concomitantly with
the other causes of .intertropical fevers. — The
aggravated form of inflammatory fever- is seldom
preceded by very marked premonitory symptoms..
The attack is usually sudden. Giddiness, faint-
ness, and general uneasiness, sometimes, however
precede it for ten or twelve hours.* There is,
occasionally, a slight and brief chilliness at the
commencement, especially in the less violent cases,
rapidly followed by a sense of universal heat ; by
flushed face, frontal headache, and vertigo ; by
inflamed, heavy eyes, and great sensibility to light
and sound, by pain in the occiput, neck, back, and
limbs ; and by a strong, full, Ifard, and accele-
rated pulse. A sense of heat, oppression, pain, or
anxiety, is felt at the pra;cordia, sometimes with a
dry cough, and pain in the side ; respiration is
quick, laborious, suspirious, or anxious ; the
tongue is white, excited, and its edges red ; the
fauces are arid, thirst urgent, and skin hot and
dry ; the urine is scanty ; the bowels costive; and
there is generally nausea, but seldom vomiting
until some time after the attack. If the disease
be not mitigated by treatment, the patient becomes
extremely restless ; the headache is rending and
intense ; vascular action is excessive; and the heat
very great. A'omiting now supervenes, and fol-
lows the ingestion of whatever is taken to allay
the urgency of thirst. The matters thrown off are
generally tinged with bile ; and a bilious yellow
suffusion of tlie skin is frequently observed. Bil-
ious vomiting and purging occasionally occur
with the yellowness of the surface, and, in the
slig.. er cases, become a favourable crisis. There
is often great drowsiness, but no refreshing sleep.

* Dr. Moseley states that there is a small degree of
chilliness and horror, but never a rigor. Dr. Ja°ckson
remarks that there is more or less of horror and shiver-
ing, but tlie cold is rarely great: Mr. Dickenson, that
tliere is increased excitement from the commencement
and that a slight chilliness at the onset is observed only
in the slighter cases (§346.)- Dr. Steven.s observes in
several places, that there is no cold stage at the beginning •
and Dr. Brunton, that languor, debility, and oppression
are complained of, with chilliness. — This discrepancy in
the account of the commencement of a most dangerous
disease, and on a point so necessary to a knowledge of its
pathology, may be in some measure explained. Dr.
Jackson has described this form of fever in connection
with the more inflammatory states of remittent, from
which it is perfectly distinct. The description of the
other writers is more correct ; for in several cases, in
which I had an opportunity of observing the commence-
ment of the disorder, no rigors, and hardly any chills, were
remarked. Even some of those w ho complained of chills
presented a warmer state of skin than natural. The pure
climate fever I therefore infer does not commence with
shivering or rigors ; and seldom with chilliness, unless
currents of air, cold, &c. have been concerned in causing
it by suddenly checking the perspiration. But the con-
tinued fever attended with high vascular action, arising
from malaria and atmospherical heat and vicissitudes, that
isfrcquently met with in^-arm climates and in hot seasons,
is commonly preceded by manifest premonitory symptoms,
and by a cold stage. These two diseases, w hich frequently
resemble each other very closely, have been generally
confo'unded with one another, more especially as they
are observed in the West Indies. Nor should this be a
matter of smprise, inasmuch as that very many of the
instances of fever which present themselves in men in the
public services, as well as in civil life, arise from a com-
bination of malaria with climatorial intlucnces, and that
the cases which are produced by a concurrence of such
causes are perhaps more numerous than those which
spring from either alone — from marsh exhalations on
the one hand, or from high temperature and its vicissi-
tudes on the other.

FEVER, INFLAMMATORY — Severe FonMs.

976

These symptoms of excessive excitement proceed
with various degrees of violence, and occupy a
period of from twenty-four to sixty hours, but
most commonly from twenty-four to forty-eight
hours. During this period blood taken from a
vein is remarkably florid, warm, and fluid. The
fibrin coagulates firmly, but the crassamentum
is without crust, and is rarely cupped.

357. ;8. The excitement, having reached its
acme, is quickly followed by exhaustion. This
is indicated by a subsidence of the most urgent
symptoms: the pain and heat are lessened; the
sicin becomes damp or clammy ; and the patient
has a sense of cold or slight chilliness. This de-
lusive remission is a state of great danger : in some
cases, it passes into rapid sinking — into a speedily
fatal collapse : but, more generally, irregular de-
terminations of blood, or indications of especial
lesion of particular parts, are evinced before death
ensues. With the diminution of heat and pain,
the pulse falls ; the countenance becomes anxious
and distressed ; the eyes sunk, the pupil dilated ;
vomiting continues without intermission, espe-
cially if the cerebral affection has abated ; some-
times delirium is present, at others there is great
insensibility or tendency to coma, and in these
cases the stomach is more tranquil.

358. 7. D/sco/(ii(rffl(ioHof theskin generally takes
place in this stage : appearing in yellow, yel-
lowish brown, and livid patches. It never occurs
in the period of excitement, for it is quite dissi-
milar from the bilious yellowness occasionally
observed in that period. It is commonly attended
by passive hiemorrhacre from the nose, gums, eyes,
ears, &c. , and by black and grumous vomiting.
The change of colour, and haemorrhage, proceed
from exhaustion of the vital influence in the ex-
treme vessels, and from the changes induced in
the mass of blood. The matters thrown off the
stomach consist at first of ingesta and serous fluid,
often coloured by bile. In a more advanced
stage they are ropy, mixed with numerous small
shreds, flocculi, or films, which soon acquire a dark
brown, purple, or black colour ; but do not, at
first, communicate much of the same tint to the
fluid containing them. Afterwards, tlie matters
vomited are more intimately mixed ; and, from
dark-coloured blood which has been effused into
tlie stomach, vitiated bile, and other morbid se-
cretions, assume a dark or coffee-grounds appear-
ance. At the same time dark-coloured matter,
resembling tar mixed with black b!oo;l, is freely
discharged from tiie bowels.

359. The other symptoms characterising this
stage, and preceding dissolution, are — soft quick,
intermitting, or irregular pulse ; clammy, cold, or
partial sweats ; deep and heavy respiration ; cold-
ness of the extremities; black urine, or suppres-
sion of urine ; singultus, convulsive sighs ; tremors
and subsultus tendinum ; faltering speech : low
muttering or ravingdelirium ;strugglingsto get up
in bed ; dark or raw appearance of the tongue ;
livid lilotches over the body, particularly tlie
priccordia ; faintings or coma, and glazed eyes. —
'i'he hliiod at this perio<l is black, thin, and dissolved,
its fibrin seems diminished, and it does not sepa-
rate info crassamentum or serum ; or if it does, the
former consists of a thin dark jelly, with the black
colouring matter precipitated towards the bottom
of llic vessel.

3G0. Such is the usual progress of severe in-

flammatory fever, as it fell under the author's ob-
servations, and as observed by the most eminent
writers, under circumstances which seemed to pre-
clude the influence of marsh exhalations. It has
been a most prevalent and destructive disease
in the West Indies and Mediterranean, during hot
seasons, amongst sailors and soldiers unseasoned '
to these climates. It is not liable to recur ; and,
unlike the continued form of fever caused chiefly
by malaria or marsh exhalations, it is neither pre-
ceded by, nor passes into, disease of a periodic
type, nor is followed by enlargements of any of
the abdominal viscera, unless the patient has been
exposed to such exhalationsduring convalescence.
A first attack prevents a second, if the individual
continue in the climate which caused it ; but if he
return to a cold country, and reside thereuntil the
energy of his system is restored, he becomes liable,
upon his return to the hot climate, to a second at-
tack, although less so than before, and in a milder
form. Numerous proofs of this position have
come under my observation. This fever will not
prevent those diseases which proceed from marsh
exhalations ; but if the person who has been
seasoned by it, be seized by fever from this cause,
the periodic type will be assumed, and visceral
disease will frequently supervene.

361. Of a number of persons whom I treated in
this fever in 1817, and who soon afterwards were
exposed to marsh exhalations in their concentrated
form, not one escaped agues, remittents, or dysen-
tery.— I do not believe that this — the climate or
seasoning fever — will exempt from pestilential
yellow fever, although it may lessen the sus-
ceptibility to it, when the individual has not
intermediately ciianged the climate. — Instances
are numerous of seasoned persons — of those
wlio have suffered this, the climate, or severe
inflammatory fever — afterwards being seized with
endemic or remittent fever, or with, the pestilential
disease.

362. 5. The complications of the grade of ardent
fever are not so distinct as those presented by tlie
milder form. — Some cases occur in which the
cerebral symplonis are of greater intensity than
usual, and closely resemble those of the most se-
vere plireuitis. Such are most common in persons
who have undergone much exertion whilst ex-
posed to a very iiot sun, shortly before the attack.
But these symptoms, even when most violent, sub-
side upon the supervention of exhaustion, and of
the constant vomitings attending tiiat stage. — In
almost all instances, ihe gastric affection is exces-
sive, particularly at an advanced period ; but this
is so characteristic of the malady, that it can
hardly be called a complication. Often, however,
when the cerebral aftuction is very great, the gas-
tric irritability is not remarkable ; and when the
latter is excessive, the former is but slight. — liiliary
disorder is sometimes very jiromineiit, especially
during the period of excitement ; but it seldom
amounts to morethan functional disturbance — than
an evacuation of bile, often in groat quantity,
and of morbid riualily. 'J'here is evidently excited
vasculnr action in the liver, as well as in other
important viscera, but it is not actual inflamma-
tion— at least, suppuration is never observed in
dissection of fatal cases. (For Diagnosis, see
^2-)3— 247.; and "ki r.r.ow Ki.vin.)

3()3. 7j. 'JlllMINAIlONS AND PliOC.NOSIS. rt.

Ardent or severe inflammatory fever, if not arrested

by an early and energetic antiphlogistic treatment,
rapidly terminutes in exhaustion of vital power with
alteration of the blood, and organic change of the
internal viscera, manifested especially in certain
tissues. — 1st. A resolution or subsidence of the ex-
cited action, without the supervention of the stage
of collapse or exhaustion, seldom occurs, unless
an appropriate treatment has been adopted. When
the period of excitement is early and duly mode-
rated, the severe symptoms of exhaustion either do
not appear, or are very slight, debility of short
duration being only present; and the patient rapidly
recovers without any visceral disease. The stage
of exhaustion is great in proportion to the violence
of excitement, and in it the more unfavourable
terminations occur. — 2d. Organic change of some
important organ may supervene during excite-
ment, but rarely to an extent sufficient to produce
death: it consists chiefly of vascular injection;
discolouration and softening of parts ; effusion of
serum, lymph, or blood ; and takes place most
frequently within the head, and in the digestive
organs. Purulent matter is never formed in tiiis
period, nor subsequently.

364. /). In the stage of collapse, several
changes occur ; but death is owing rather to their
conjoint influence, than to eithersingly. — 1st. Ex-
haustion of vital power is always present, but not
to an extent sufficient of itself to arrest the organic
functions. — 2d. Deterioration or change of the
blood obviously takes place, and is shown by the
state of this fluid both during life and after death ;
but the nature of this change is not fully ascer-
tained; whatever may be its nature, it is merely
consequent upon the altered state of organic nerv-
ous influence. — 3d. It is very probable that ex-
haustion of this influence, and the resulting changes
in the blood, so affect the irritability and tonicity
of fibrous and contractile structures as to impair
these vital manifestations, and thereby to favour or
even to induce the alterations observed towards a
fatal close, particularly those affecting the capillary
system and mucous tissues ; for the vital tone of
the extreme vessels and of the digestive mucous
surface being thus impaired, and the blood being
more fluid and dissolved, as well as otherwise
altered, haemorrhage readily occurs, with dis-
colouration of the skin and of membranous parts ;
the blotches, &;c. observed during the latter stages,
proceeding from these pathological states. That the
head should appear to suffer, especially during the
period of excitement, is a necessary consequence
of the physical relations of this part, in connection
with general vascular excitement ; and that the
stomach and digestive mucous surface should
evince predominant disorder at an advanced stage,
may be ascribed to the irruption of acrid or viti-
ated secretions, particularly the biliary, to the
state of organic nervous power, and to the changes
induced in the blood.

365. c. The Prngnosis entirely depends upon
the period at which the disease is subjected to ap-
propriate treatment, and upon the violence of the
seizure. — When the stage of excitement has but
recently commenced, the treatment about to be
recommended will generally arrest the disease ;
but the nearer this stage approaches its acme, or
that of exhaustion, the greater is the danger, as
those changes in the organic nervous influence, in
the blood, and in the vital tonicity of contractile
parts, may be considered as having begun j and

FEVER, INFLAMMATORY — CAtJSEs. 97?

active depletions are then -not so well endured
nor productive of the same efltcts, as at an earlier
period. When symptoms of collapse appear,
the danger is very great ; and in propoition
to the progress of this stage and the urgency of
its characteristic phenomena, particularly dis-
colouration of the skin, black vomit, and passive
haemorrhages, it becomes extreme ; recovery
seldom taking place when these symptoms are fully
developed. — When the cerebral affection is very
remarkable at an early stage, the danger is even
then great, as the effects of the treatment impe-
ratively required, conjointly with the exhaustion
consequent upon excessive action, will induce a
slate, which, although much less dangerous than
that which would indubitably follow unrestrained
action, is still attended by much risk, and often
requires the prudent exhibition of restoratives, &c.

366. (/. The Duration of this fever varies from
two to six or seven days. A fatal termination
commonly takes place on the fourth or fifth day.
— On examination, post mortem, more or less evi-
dence of increased vascular action, olten amount-
ing to inflammation, oritsconsequences, is observed
in the membranes of the brain, in the internal
surface of the stomach and bowels, and more
rarely in the pleura and serous membranes of
the abdomen. The digestive mucous surface is
studded with numerous dark or ecchymosed spots,
from which a fluid black blood seems to ooze.
The liver is frequently congested, sometimes larger
and softer than natural, and of a dark colour,
owing to the quantity of black blood in its vessels.
The spleen is somewhat enlarged, soft, and friable ;
and the omentum injected. — The serous as well
as the mucous surfaces, especially in the abdo-
minal cavity, often present livid or dark patches.
The blood is everywhere fluid, black, and dis-
solved. The internal surface of the heart and
large vessels, both arteries and veins, was of a
dark red or livid tint in a few cases which I ex-
amined ; but this point requires further investi-
gation, as my opportunities were not sufficient for
the satisfactory examination of it in respect of
the universality of its occurrence, and the exact
changes on which its appearance depends.

367. C. Causes. — a. Disposition to, and pre-
disposing causes of, injlammatory fevers. — If we
view these fevers as affections of the vascular
system chiefly, we may impute the disposition to
become affected by them to the high irritability
of the heart and arteries. As respects symptom-
atic fevers, this explanation may be conceded,
inasmuch as the irritability of the different parts
of the vascular system is derived from the same
source, namely, the ganglial nervous system ;
and as all causes of irritation, which act with
sufficient energy, relatively to the state of irri-
tability, upon a single part of the system, afl^ect
the whole. — I here refer the operation of the
irritating causes to the state of the irritability
because their action is merely relative : therefore,
where the susceptibility to irritation passes beyond
the ijsual standard, slighter causes will induce
inflammatory and symptomatic fevers, than when
it is either below or at the natural state. The
condition of the irritability may vary not only in
difl'erent individuals, but also in the same person
at difl'erent epochs of life, and in the different
organs of the body ; the irritating causes tlius
exciting a relative action on difl'erent indi-

3R

978

FEVER, INFLAMMATORY — Nature of the Disease.

viduals, on the same person at different periods,
and on the different viscera. But although
the disposition to be attacked by inflammatory
and symptomatic fevers depends greatly upon the
state of irritability, yet the disposition to be seized
by other continued fevers does not appear to arise
from the same circumstance. Indeed we perceive
that increased irritability of the vascular system
has little or no influence in favouring the operation
of the exciting causes of several continued fevers ;
and that other manifestations of the living organ-
isation, besides this, dispose more remarkably to
them.

368. The predisposing causes of inflammatory
fevers consist, ^iVst, of high irritability and tonicity
of fibre, more especially when conjoined with
vascular fulness and imperfect performance of
any of the secreting or excreting functions — of
an inflammatory diathesis, or of rude health, or of
a gross habit of body ; — second, of those states of
season, climate, or atmosphere, which tend to pro-
duce this diathesis. — Hence these diseases occur
chiefly in young adult men ; in the plethoric, florid,
and robust; in persons of a sanguine and irritable
temperament ; in those who have experienced the
suppression of an accustomed evacuation, or who
live fully and richly, or intemperately, or who
pursue healthy occupations in the open air, or who
habitually take invigorating exercise : and they are
most prevalent in cold and dry, or very warm and
dry, seasons and climates ; in highly elevated lo-
calities ; and amongst mountaineers, sailors, sol-
diers, and persons living in the country.

369. b. The exciting causes are — (a) What-
ever directly stimulates, in an inordinate manner,
the nervous and vascular systems; as, change of
climate, especially migration from cold or tem-
perate, to very warm or dry countries ; exposure
to the rays of a warmer sun than has usually
been experienced ; exercise in the sun's rays ; the
influence of dry winds ; and very dry and cold
states of the air ; sudden vicissitudes of v/eather
or of season; the accumulation of electricity in
the frame ; a heating or very full diet, warm condi-
ments or sauces, and stimulating liquors; change
from a low to a rich or full diet ; the intemperate
use of wines or spirits, especially in connection
with atmospheric heat or vicissitudes ; great bodily
exertion ; violent mental excitation and emotion ;
— (6) \\ hditever indiiectly induces great excite-
ment or vascular reaction; as, the impression of
cold when the body is overheated and perspiring ;
sleeping on the ground or in the open air, espe-
cially when exposed to the night dews, or to the
moon's rays, particularly in warm and intertro-
pical countries ; the operation of marsh effluvia or
malaria, especially under similar circumstances,
or after intemperate indulgences; an overloaded
slate of the digestive organs, and obstruction of
the excretions.

370. c. I'he chief causes of the varieties of this
fever, which attack Europeans after their mi-
frratinn to luurm climates, are — their early age, ple-
thoric habits, and phlogistic diathesis; inattention
to their bowels during the passage, and their use
of salt provisions and spirituous or vinous liquors ;
increased intemperance, and incautious exposure
to the sun and to the night air ; excessive fatigue,
or alternations of indolence and great exertion ;
and suppressed perspiration. Dr. Jackson remarks

attack of fever during the first year of their resid-
ence in a tropical country ; and that the fevers that
occur from these causes are often of the most aggra-
vated kind, and rapid in their course, more especially
among troops crowded in barracks or transport
ships, where the heat of the climate is augmented
artificially ; the excess of heat influencing the
febrile form, increasing the violence of the sym-
ptoms, and retarding the progress of recovery.

371. A question has arisen, as to whether or
not the inflammatory states of fever in warm
countries are caused by malaria, or by the other
causes now instanced. There can be no doubt
that malaria very frequently produces in the ple-
thoric, young, and robust, who have recently
arrived in a hot climate, fever of an inflammatory
and continued kind. But it must also be con-
ceded that this fever chiefly occurs, even in persons
thus constituted, during the dry season, and at
times and in places where the existence of ma-
laria is doubtful, or, at least, by no means proved.
It is notoriously admitted that the inflammatory
states of continued fever, in both the East and
West Indies, appear among those soldiers, sailors,
and civilians, who have not been long in a warm
country, and who have not sufl'ered from disease
since their arrival ; and that they take place
chiefly during the dry and warm seasons, and in
situations where the usual effects of malaria are
never observed. This is the result of the ex-
perience of Jackson, Annesley, Boyle, Twi-
ning, Con WELL, and of other experienced prac-
titioners in warm countries. It agrees with my
own observations ; and is even admitted by Dr.
Ferguson, who has gone much further than any
one else in assigning malaria as the cause of inter-
tropical fevers. I believe that the other causes as-
signed above (§ 367 — 370.) will, in these coun-
tries especially, produce fever of an inflammatory
or bilio-inflammatory kind, in unacclimated Eu-
ropeans ; but that, when those causes are not
associated with malaria, the fever resulting from
them will generally subside, under judicious
treatment, without evincing those dangerous
symptoms which characterise fevers proceeding
chiefly from terrestrial exhalations. Although
some of the causes, especially those which relate
to atmospheric temperature and climate, are
very different as to their nature and action, yet
they are mainly instrumental in producing fevers
having many common features, but diflfering in
severity and duration.

372. D. Nature OF THE Disease. — Fevers
produced by paludal miasms, or by infectious
emanations from living or dead animal matter,
are universally preceded by well-marked sym-
ptoms, characteristic of the stages o( pre7)i<mitinn
(§33.) and of invasion (§ 35.). But inflam-
matory fever, especially in its more severe form,
is seldom preceded by more than chills, unless
cold, or other causes which suddenly arrest
the cutaneous excretions, have been concerned
in producing it. In these fevers a poisonous
agent has infected the frame and more or less
depressed its vital energies, particularly as tiiey
arc manifested in the organic nervous sys-
tem ; vascular reaction being consequent upon
such depression, as shown above (§ 95, 96.).
But in this fever, the injurious agent, or primary
pathological change, is generated within the

that persons tlius circumstanced rarely escape an | system from tlie action of new and unwonted

FEVER, INFLAMMATORY — Natuhe of the Disease.

979

influences, generally climatorial or atmospheric.
That this agent is not of a depressing kind, as
respects its primary operation, is manifest, from
the general absence, at the commencement of the
disease, of tliose phenomena which indicate this
kind of action. That it is of an irritating or ex-
citing kind, may be inferred, not merely from the
character of the invading symptoms, but also from
the changes primarily induced by the remote
causes. — If we inquire into the nature of these
changes, we shall find them — 1st, As respects
the mild injiammatorii fevers of cold or tem-
perate climates, to consist — (a) of the organic
and nervous excitement consequent upon the
rapid and increased oxygenation of the blood
dunng cold and dry states of the air, probably
aided by the accumulations of the electro-motive
agencies in the system which these states mani-
festly favour; — {b) of the super-abundance of
irritating matters in the circulating fluids resulting
flora casual interruptions to one or more of the
eliminating or depurating processes constantly
going on in the animal economy; — (c)of the
combination of these circumstances or primary
pathological conditions. If we grant that the
former of these obtains, it is very obvious that the
occurrence of tlie latter will further excite and
increase it ; even a susceptibility to the former,
as marked by high irritability of fibre, may be
readily kindled into morbidly increased action,
by causes of irritation which may have accu-
mulated either within the vessels — in the blood
itself; or external to them — in excreting organs
and surfaces. These pathological states are the
obvious results of concurrent causes, which pri-
marily excite the sensible and susceptible parts of
the frame, and which retard or prevent the dis-
charge of irritating materials from the vital cur-
rents which supply and sustain these parts ; the
accumulation of these materials either increasing
the excitement, or giving rise to it. It must ne-
cessarily follow that the excitation thus induced
will exhaust itself to a degree, and with a rapidity,
co-ordinate with its intensity, and thereby induce
the phenomena characterising the advanced periods
of the disease, which are especially remarkable in
the severe or climate fever of warm countries,

373. 2d. As respects the severe in/lammatory or
climate fever, the procession of phenomena must
necessarily be different, as it generally arises from
causes different, or even opposite, to those just
instanced — from a very high temperature, often
conjoined with ricii, nutritious, and heating food,
stimulating drinks, and suppressed perspiration.
Either of these is alone sufficient to induce the
disease ; but, when they co-operate, the effect is
more certain and severe. They all act in a similar
manner : they excite the organic nervous system
inordinately ; increase the actions of the liver,
and irritate its vessels ; alter the constitution of the
blood, causing it to abound with stimulating and
injurious materials ; and render the secretions and
excretions acrid or morbidly exciting. Thus the
most violent states of this fever often proceed
directly from these causes, without any evidence
of primary subaction or a cold stage, unless de-
pressing agents, such as cold, human effluvia, or
malaria, concur with them in producing disease ;
in which case the consequent fever will present
features modified accordingly. If cold act upon
persons who are under the influence of these ex-

citing causes, a slightly cold stage will often be
directly induced thereby. If animal or vegeable
miasms concur with them, the fever will present
adynamic or malignant characters in propoitioa
to the activity of either of these agents. But
when the above direct causes of excitement act
solely or principally, their influence upon the
organic nervous system is very energetically ex-
pressed, and manifested throughout the vascular
system, especially that of the brain, liver, and
digestive mucous surface. Thus, inflammatory
fever differs from the other varieties of idiopathic
fever — 1st, in its proceeding from causes, the
primary action of which is exciting or iirilating ;
2d, in excitement or irritation being more or less
evinced by it from the commencement.

374. Of the changes that take place in the ad-
vanced period of the disease, the most remarkable
are those afliecting the blood and the digestive
organs. As the stage of excitement merges into
that of exhaustion, the blood changes from a florid
to a dark colour ; loses its property of separating
into crassamentam and serum, and of firmly co-
agulating ; becomes more ffuid ; and seems de-
prived of much of its fibrinous and albuminous
constituents. (See art. Blood, § 128.). Ac-
cording to Dr. Stevens, its saline ingredients are
also greatly diminished. The chief cause of these
alterations is evidently exhausted organic, nervous,
or vital power ; and this is further evinced by a
loss of the tone of the extreme vessels, and of the
irritability of the moving fibre, always co-ordi-
nately observed in cases presenting this change
in the blood. Among the most striking con-
sequences of exhaustion of vital power, as thus
manifested in the extreme vessels and blood, are,
discolouration of the skin, and passive haemor-
rhages from mucous surfaces — phenomena cha-
racterising the last stage of the most unfavourable
cases of the intense disease. The gastric dis-
turbance in the early stages generally proceeds
from excited vascular action, and from the pas-
sage of irritating secretions into the stomach, in
connection with an increased susceptibility and
irritability of the organ. In the latter stages, it
more especially results from the morbid secretions
poured into the stomach, and the irritated or in-
flamed state of its villous surface.

375. The source of the black matter passed
from the stomach and bowels in the last stage of
this and of other severe fevers of warm countries,
has been variously stated. Some consider the
black colour to proceed from the exudation of dark
blood, which, in mixing with the secretions of the
stomach, liver, and bowels, imparts to them a still
darker tint. Some ascribe it chiefly to the bile, and
secretions from the digestive mucous follicles, which
are often both very dark and thick in the last stage
of the more malignant kinds of intertropical fevers ;
and others believe it to arise both ways. There
is no doubt that all the secretions poured into the
digestive canal are more or less diseased, par-
ticularly in the latter stages ; but it is as clear,
that tne black colour mainly depends upon the
state of the blood ; and that all the matter ejected
upwards and downwards, presenting this appear-
ance, does not consist of altered secretions merely,
— a great part of it probably being an exudation
of blood from the mucous surface. I believe, also,
that these mutters vary very remarkably in the
ardent climate fever, in the more malignant forms

3R 2

930

FEVER, INFLAMMATORY — Treatment.

of marsh or endemic fevers, and in the pestilential
yellow fever — the diseases thus characterised.
Dr. Jackson remarks that the secretions from the
digestive mucous surface are ropy and clear during
the early periods-, and are brown or black, in the
latter — sometimes black as soot ; and that the
sooty or ink-like colour is chiefly observed where
the head and stomach are simultaneously attacked.
When we consider that the blood becomes darker
than natural, as well as otherwise changed, early
in the period of exhaustion, and that the liver
and mucous follicles of the digestive canal, with
the kidneys, are the principal organs of depuration,
or channels by which the elements producing
these changes are eliminated from the circulation,
we need not be surprised at the secretions which
these elements go to form, and which these
organs excrete, presenting somewhat similar cha-
racters. It must however be admitted, that the
share which the secretions perform in producing
this phenomenon, or tliat which the exudation
of blood has in giving rise to it, will vary much in
different varieties or cases of intertropical fevers.
— The rapidity with which a dissolution of the
tissues takes place after death, in the severe forms
of climate fever, deserves notice, as marking the
rapidity of vital exhaustion, and as resulting from
the changes of theblood ; these changes commenc-
ing with the stage of exhaustion, and advancing
until this fluid is no longer capable of influencing
the nervous system,andof preserving the irritability
of contractile parts — or until it poisons, instead of
exciting, the sensitive and moving tissues.

376. E. Treatment. — The means that should
be employed in the mild and severe forms of in-
flammatory fever are the same — the only differ-
ence being in the promptitude and energy with
which they ought to be administered. In the
mild disease, particularly in cold or temperate
climates, the febrile excitement is much more
prolonged than in the severe, which rapidly ex-
hausts itself by its violence. The necessity, there-
fore, of restraining it at its commencement is
great in proportion to its activity. In the milder
forms, vascular excitement may continue several
days, and depletions may be practised with ad-
vantage as long as tliis state persists ; but, in the
severe, the period in which they can be employed
with benefit passes away sometimes in a few hours ;
and continues seldom beyond the third, and rarelv
beyond the fourth day. As in the state of excite-
ment, so in that of exhaustion, the treatment is the
same in all the varieties of this fever — the only dif-
ference being in the choice of means, in the activity
with which they should be employed, and in the
appropriation of them to the varying circum-
stances of the case.

377. a. — a. Duriiif^ excitement, and especially
at its commencement, vascular depletions should
be practised, and carried as far as the state of the
pulse and other circumstances will jjcrmit ; and
in the manner described in the article Bi.ooo
C§ 64.). The observations already made on
this subject ($ 128 — 138.) will guide the inex-
perienced practitioner; but it should not be over-
looked, that, in the intense climate fever, vascular
depletion should be prompt, from a large orifice,
large, and repeated, to be successful ; and that
the (juantity of blood abstracted should depend
ciiicdy upon tlie eflect produced, JJr. .Iackson
justly remarks that it should be taken in (juautity

sufficient — whatever may be the amount — to
relax the surface and set free the secretions.
Less than three pounds is rarely sufficient to
produce this effect ; and six have not been more
than sufficient on some occasions : but what-
ever the amount may be, it will do compara-
tively little good if we stop short of the quantity
which is requisite to effect a decided change.
If delayed until the excitement is about to ter-
minate in exliaustion, no benefit — or even mis-
chief— may result from it ; for the tonicity of
the vascular system will have then become too
far weakened to admit of the vessels accom-
modating themselves to a considerable loss of
blood. When, therefore, the symptoms indicat-
ing the passage of excitement into collapse, or
the deceptive abatement of the febrile action in-
dicating this state, is observed — and particularly
if yellowish blotches appear about the mouth,
face, or breast — the time for bleeding with advan-
tage has passed. If, however, headach is still
urgent, the pulse still strong, and the features
have not collapsed, blood may yet be abstracted
cautiously and in moderation. When the cere-
bral aflPection is considerable or persistive, and is
unattended by marked symptoms of exhaustion,
depletion, genera! or local, may be repeated.
Where the headach is particularly intense —
rending, throbbing, &c. — with hot inflamed
eyes, one bloodletting, however large or early,
will seldom be sufficient. In such cases, the
body should be immersed in a tepid, or slightly
warm, bath, and well scrubbed with brushes, &cc.,
until the cutaneous circulation is rendered free.
Cold should also be applied to the head, both
during the bath, and subsequently, the hair
having been cut off. After the patient is re-
moved to bed, the vascular action and headach
will often become again excessive ; and, although
a very few hours only may have elapsed, will re-
quire the repetition of very large depletions. Spon-
taneous liEemorrhage during excitement should
not be arrested. In the most severe cases, espe-
cially when determination to the brain is great,
epistaxis often occurs, but is generally slight, or
almost instantly disappears. In these, vascular
depletions, aided by the other means appropriate
to this stale, ought to be most energetically prac-
tised ; for nothing else will save from fatal changes
taking place within the brain, or from as fatal ex-
haustion, and its effects.

378.fi. Pio-^atifes, in one form or other, are a ma-
terial part of the subsequent means. Calomel with
Julap and James's poirder may be given, in the form
of pill, from time to time ; and, after a few doses
have been taken, a cathartic enema should be
administered, and repealed. As to the choice of
the enema, the practitioner should be guided by
the progress the disease has made. At an early
period, sea watev, with or without the addition of
castor oil, orofextract ofcolocynth,is appropriate:
subsequently, olive oil and oil of turpentine may
be substituted for the latter. — Emetics are not
suited to any state of this fever; although they
are often serviceable in fevers wliich have been
confounded with it, more especially at the com-
menccment of the various forms of marsh faver.

379.)/. Refri^^erants, when judiciously exhibited,
arc valuable adjuncts in the period of excitement.
Those already enumerated, both internal and er-
tenial{§ 139 — 141.), should be persevcringly em-

FEVER, INFLAMMATORr — Treatment.

ployed. Of these, the nitrate of potash, the nitrate
of soda, and lu/drochlorate of ammonia, and in-
jections of cold sea water, as recommended by
Mr. Dickenson, are most deserving of notice.
Hillary prescribed a scruple of nitre and twelve
grains of Iiydrochlorate of ammonia, tliree or four
times a day, in water; and Dr. Conwell has re-
cently shown the propriety of this practice, and its
applicability to other states of febrile action. In
the more ardent climate fever, this medicine
should be very frequently exhibited during ex-
citement ; cold applications to the head, and the
cold affusion being also assiduously employed.
The refrigerants just mentioned may likewise be
taken frequently in conjunction with the liquor
airmionia- acctatis and sjiii itus atlicris nitrici. After
depletions, they will often prevent the distressing
irritability of the stomach, which increases with
the unfavourable progress of the disease, and allay ,.|
it when present. Although this is the most violent
form of fever which comes before the physician,
yet it may be arrested at an early period with I
greater certainty than any other, by the decided
employment of the foregoing measures.

380. 5. External derivatices, and more particu-
larly blisters, have been very much employed
against tiie inflammatory forms of fever, with the
view of allaying the irritability of the stomach,
and protecting it and other viscera from impend-
ing injury. I5ut I believe that they have been
as often injurious as beneficial; and that, owing
to a too early use of them, they have increased
the general excitement, and not derived from in-
ternal parts. It is only after vascular action is
subdued as low as may safely be attempted, by
the foregoing treatment, that blisters * should be
employed in this disease; but they ought never

* The following case will show the progress of the
disease, as well as its cerebral coinplication, iii its most
severe form ; and the little effect which a depletory prac-
tice, short of what it requires, produces upon it.

A soldier of a full and gross habit of body, aged 28,
just arrived in the West Indies, during the hot and dry
season, was attacked, at six o'clock in the morning, with
giddiness, severe headach, and pain in the back and limbs.
He came under treatment at six in the evening (twelve
hours after the attack), and then these symptoms were
violent ; the face was flushed, the eyes heavy and in-
jected ; the breathing was laboured ; the pulse frequent,
sharp, and contracted ; the heat great, and skin dry ;
thirst vehement ; tongue white and foul. He was
anxious, restless, and complained of oppression at the
priEcordia. He was bled to thirty-two ounces : a purging
bolus was given immediately, repeated in four hours, and
accelerated by an enema. He seemed a little faint from
the bleeding, and expressed ease, but no decided relief.
He passed the following night in much distress.

Second day of disease, in the morning, he complained of
anxiety and uneasiness at the pra?cordia; sighed frequently,
and breathed witKcatchins and difficulty at times. Pulse
quick, hard, and strong ; the skin very hot and dry ; in-
tense pain in the head and luins. Bowels not freely
opened by the purgatives. Was bled to fourteen ounces :
the skin became moist ; the pains remitted, but did not
cease. Blisters to the head and epigastrium ; calomel
and James's powder every third hour ; inunction with
mercurial ointment ; saline diaphoretics. He sw'eated co-
piously in the afternoon, had some evacuations by stool,
and seemed relieved.

T/iird day. — Anxiety and sense of burning at the prse-
cordia; nausea and vomiting ; ineffective motions down-
wards ; skin dry ; pulse strong, not Irequent : thirst ur-
gent ; eye and countenance lurid ; temper irritable and
impatient ; alarmed at his situation ; complains of the
blisters on his head, which give sensations of burning.
The skin is dry, and the heat rather above natural. The
tongue is somewhat rough and foul.

Fourth day. — Symptoms more unfavourable. He vo-
mits occasionally, and his nose bled in the act of vomit-
ing : anxious, restless, and very uneasy. Pulse regular,
full, and strong ; ideas confused ; countenance irregularly
tinged yellow.

981

to be applied on the head, unless in the stage of
exhaustion, when coma or lethargy is present, and
the pulse becomes weak and intermittent. The
exhibition of mercurials with the view of inducing
salivation should not be attempted in tiiis fever ;
for this effect has never been produced unless in
the milder cases, which would have recovered
nevertheless.

381. h. The period of exhaustion presents
comparatively few chances of recovery, especially
when far advanced, and in severe cases ; but
these few should not be thrown away, either by
a temporising or a trifling practice; or by the use
of means already known to be unavailing. 'J'here
can be no doubt, that the change commencing in
the blood with the accession of this stage is one
of the chief pathological states which should at-
tract the attention of the practitioner ; but the
exact nature of that change has not been satis-
factorily demonstrated. That it partly consists
of diminished crasis, or a weakened vital attrac-
tion between the globules of the blood, and con-

F/Ji/i day. — Somewhat delirious; extremely restless
and anxious ; eyes red and muddy ; gums red and hot ;
no salivation ; pulse regular, full, but not weak ; skin
dry and of a deep yellowish shade ; the blistered surfaces
dry and of a dark red approaching to a livid hue. He was
washed with salt and water. Frequent small dark viscous
evacuations.

Sixth day Delirious, with extreme restlessness ; pulse

soft, full, and slow ; skin damp and clammy ; heat mo-
derate; vomits glutinous matter of a black colour ; dark
blotches in the skin ; and a black sanies exudes from the
nose and mouth. — He died in the afternoon, five days
and twelve hours from the attack.

Dissection. — The vessels on the surface of the brain
were remarkably turgid, giving a livid appearance to
several places. Considerable effusion of lymph, and ad-
hesions between the membranes had taken place, par-
ticularly near the falx. The stomach and intestines
contained a large quantity of black matter. In the latter,
it was thick as tar, and viscous as birdlime. The gall-
bladder was half full of black bile.

Remarks. — The above case was not treated by the
author. Twelve hours were lost before the patient re-
ceived assistance. On the second day the bleeding was
insufficient, and should have been carried further and
repeated. The pulse evinced the necessity of it. In this
disease, as in many others, the pulse may be safely fol-
lowed. If the pulse become an unsafe guide, the fault is
most generally that of the observer, who cannot interpret
it aright. The application of two blisters at this time,
before vascular action was suflficiently reduced, and more
especially the application of one of them to the head,
during predominant action in this quarter, was sealing
the fate of the patient, — the bleeding in the first instance
being just suiiicient to give freedom to the circulation,
but not adequate to reduce it ; the blister adding fuel to
the fire when it was about reaching its height. The in-
unction of mercurial ointment with the view of affecting
the system was as fruitless, and just as rational, as
respects this fever, as to attempt to extinguish a con-
flagration by a surgeon's syringe. On the third day,
the great strength of pulse, and burning sensations
in the head and preecordia, clearly indicated that large
bloodlettings could alone have saved the patient,
although late in the disease. The local complication,
having prevented the sudden accession of this stage, and
prolonged vascular excitement, admitted of a later re-
course to depletions than in other circum.stances. Even
on the fourth day, owing to the cerebral complication,
the pulse retained its strength, and, with all the other
symptoms, evinced that bleeding should even then have
been practised. After the first day nothing appropriate
was done but much to aggravate the disease. As to the
dissection, the usual routine only was gone through, and
whicti, if pursued in a million of cases, would not ad-
vance our knowledge of the disease one step. The sym-
ptoms on the second and third days ought to have sug-
gested a minute examination of the vascular system and
blood ; but these, as well as the digestive mucous sur-
face, weie unexplored. In this case, as in many others,
the name of the disease, contradictory opinions as to its
nature and origin, and empirical reports of successful
methods of cure, mistificd the practitioner, and paralysed
the treatment, w hen he ought to have been guided by a
knowledge of morbid actions, and of rational means of
1 removing them.

3 R 3

982

FEVER, INFLAMMATORY — Treatment.

sequently of a defective power of coagulating,
and of altered colour, has been shown by Towne,
and by every writer since his time, and is gene-
rally admitted : but the observations of Dr.
Stevens, as to the progressive loss of saline in-
gredients, which the blood undergoes with the
progress of exhaustion, although now publislied
several years, have not received that confirmation,
for whicii there have been sufficient time and op-

and that, in order to supply the deficiency, he at
first gave a strong solution of this salt with ni-
trate of potash. He subsequently found that the
chlorate of potash and other active saline agents
answer the purpose equally well, especially those
which do not irritate the stomach ; and he now
seems to prefer a combination of the chloride of
sodium carbonate of soda and chlorate of potash.
The basis of this pathology and treatment is the

portunity. They are not, however, therefore, j relation subsisting between the colour of the blood

altogether to be thrown aside, more especially as
my experience has furnished me with facts calcu-
lated to support them in some measure. The
exhaustion in this disease arises, — 1st, from the
previous excitement; and 2dly, from the changes
induced in the blood in the course of this stage ;
especially at its acme, manifestly depressing
the organic nervous influence, the tonicity of
the vascular system, and the action of the heart
itself, to an extent often incompatible with the
continuance of life. It is in this manner that
death generally takes place in the intense cli-
mate fever ; for, however considerable the lesions
are which the early excitement had occasioned
in the brain or digestive organs, death is seldom
the result of them alone in either of those parts.
It should, moreover, be recollected that the dis-
ease cannot be cured by bloodletting merely,
however necessary it may be to the subduing
of excitement in the early stage ; for although
this state may be lowered by it, still dangerous
exhaustion may nevertheless supervene with the
characteristic changes of the blood, and all the
consequent phenomena described by the earlier
writers on this fever, particularly by Towne,
Warren, Hume, Lining, Hillary, &c.

382. a. From these considerations it is manifest
that the intentions of cure, in this stage of the
disease, should be — 1st, to support or rally the
manifestations of life in the different organs — to
oppose the progressive vital exhaustion ; 2dly, to
counteract those changes which take place in the
blood and vascular system. These indications
should be simultaneously carried into effect ; for
the alterations in the state of vascular action and,
tone, as well as in the constitution of the blood,
are more or less dependent upon the change in
the organic nervous influence. — At the com-
mencement of this period, and when vascular
action still continues high in the encephalon or
digestive mucous surface, a moderate local de-
pletion may precede measures calculated to fulfil
these intentions ; but even this form of depletion
can seldom be carried far ; for the tonicity of the
vascular system generally, and especially of the
capillaries supplying the mucous surfaces, is too
far exhausted to admit of that accommodation of
the vessels to a considerable diminution of theii'
contents, which is so requisite to the restoration of a
healthy state of circulation. The characteristic
phenomena of the last stage — the hasmorrhages
and discoloured blotches — are manifestly owing
as much to the exhaustion of organic nervous in-
fluence and of irritability, as to the attendant
changes in the Ijlood. It is to these latter changes
almost solely that Dr. Stevens directs his means
of cure in this stage ; but it is evident that the vital
conditions on which they depend should receive
equal attention. He states that the quantity of
the chloride of sodium is greatly diminished in the
last stage of this and other malignant diseases ;

and the saline matters contained in it. The
power of certain salts, particularly the chloride of
sodium, the nitrate of potash, the tartrate of potash,
&c., as well as of the alkaline carbonates, to ren-
der the venous blood florid, and to afl^ect its
fluidity and coagulating powers, was long since
fully demonstrated by Verheyen (vol. ii. p. 29.).
ScHWENKE (^Hiematolcgia, p. 190. et passim),
s, Hales (^Hemastat. p. 154.), Ellee {M^m. cle
I'Acad.des Sc. de Berlin, t. vii. p. 13.), Boerhaave
{Elementa ChymiiE, t. ii. p. 378.), Petit (^Lettre
Seconde, p. 34.), Haller ( Elementa Physiol, t. ii.
p. 74.), Sauvages (S(tr CEffet des M6dicamens,
p. 37.), and others. A combination of the nitrate
of potash and of the htidrochlorate of ammonia was
always employed by Hillary in this disease, and
is applicable to every period of it. Sea water has
long been a popular remedy for it and other West
Indian fevers, and is very strongly recommended
by Arejula and Mr. N. Dickenson as an enema.
Dr. CiiisnoLM employed, in 1798, the chlorate of
potash, and remarked its effects upon the blood ;
but, as Dr. Stevens justly states, he exhibited
other substances calculated to counteract its in-
fluence on the disease. But granting that the
colour of the blood is changed to its healthj' state
by these salts, it does not follow either that they
shall be absorbed into the circulation during the
advanced stage of this fever, or that they shall
have the effect of rallying the exhausted powers
of life. As to both these circumstances, the san-
guine expectations of Dr. Stevens require confirm-
ation. There can be no doubt that, to be service-
able, these medicines should be given sufficiently
early in the exhaustion to allow time for their ab-
sorption ; and that substances which irritate the
digestive mucous surface, and prevent or delay
absorption, should not also be exhibited. In the
present state of our knowledge, and judging from
some experience of the effects of these salts in the
advanced stages of other severe fevers, I infer
that they ought not to be confided in alone, but
should be conjoined with such other means as are
calculated to rally or support the vital manifest-
ations, and promote the excreting functions —
always recollecting that, in order to preserve the
blood in a state suitable to the continuance of
life, the depnrative actions of the various emunc-
tories require to be ])romoted.

383. B. In the early stage of exhaustion, Hil-
lary's saline mixture may be prescribed ; or the
same salts — the nilrale cf potash and hiidrochlorale
of ammonia — may be given in camphor julap; the
quantity of camphor being regulated according to
the giade of depression. The chlorate of potass
may likewise be given in the same vehicle ; or the
citrate or tartrate of potash or soda, with an ex-
cess of the alkali. It is very important, to avoid
such means as will increase the irritability of
stomach characterising this stage of the disease ;
and 1 believe that these medicines are much less

FEVER, BILIO-GASTRIC.

983

likely to have tliis effect than almost any other.
A full dose of cuhmei will often have the efiect
of allaying for a wliile the irritable state of this
viscus; but, when exhaustion is very considerable,
its sediitive influence on the organic nervous en-
ergy will be injurious, if it be not combined with
camphor ov ammonia. During the course of this
stage, little benefit will accrue from such purg-
atives as irritate the stomach. An occasional
Seidlitz powder, or the saline medicines just men-
tioned, assisted by frequent injections of sea or
salt water, with the addition of an ounce or two
of sweet oil, will prove much more serviceable
than more active means, which will only increase
the inflammatory irritation of the digestive mucous
surface, and exhaust its vitality. Dr. Jackson
most frequently prescribed a combination of
calomel, James's powder, nitre, sulphur, and soda,
in the form of bolus, which was given every fourth
hour; and afterwards the infusion of senna, with
liquor ammoniffi acetatis, so as sufficiently to pro-
mote the action of the bowels.

384. y. In a further advanced state, and more
especially if the pulse become irregular or inter-
mittent, the more energetic restorative and ner-
vine medicines should be prescribed, variously
combined with one another, or with the saline
substances just mentioned. Warm or rubefacient
epithems, or sinapisms, should be also applied
over the epigastrium, or to the lower extremities ;
and hot wine with spices ; or champagne ; or
large doses of camphor with nitrate or chlorate of
potash ; or brandy and water, as the vehicle of
effervescing salts ; or half drachm doses of tur-
pentine, every two hours, in milk, or in spruce or
ginger beer, may be resorted to, according to cir-
cumstances. But, before the exhaustion has
proceeded thus far, these remedies, in more mo-
derate doses ; the preparations of ammonia, con-
joined with saline or other medicines, the warm
bath, &c. ; may be employed, with a cautious
observation of their effects. — Upon the whole, the
principles developed above, in respect of the
treatment of exhaustion of vital power in fever
(§ 143—148.) should be adhered to.

385. 5. During the progress of the stage of ex-
haustion, much attention ought to be directed to
the beverage of the patient. Spruce beer, soda
water, Seltzer water, bottled porter, bottled small
beer, may be allowed, but only in small quantity
at a time, as a considerable draught is generally
followed by vomiting. These beverages may,
moreover, be made the vehicle for the exhibition
of refrigerant, antacid, or saline medicines, as
the nitrate of potash, the alkaline carbonates,
&c. During convalescence, the diet should be
carefully regulated, and confined at first to fari-
naceous articles, in moderate quantity.

386. c. The modified form of inflammatory
continued feier, arising from the concurrence of
terrestrial exhalations, with climatic influence,
must be treated, in the periods of excite-
ment and of exhaustion, conformably with the
views explained above. This form of fever,
after the inflammatory excitement is subdued by
copious depletions, sometimes assumes a remittent
character. In this case, the exhibition of bark or
the sulphate of quinine during the remissions will
be necessary. Whatever complication, also, which
may either characterise this fever from its com-
mencement, or appear in its course, must be

treated by depletions, local especially, and de-
rivatives, according to the principles already ad-
vocated.— (See Bilio-Gastric Fever.)

BiBLiOG. AND Refer, — Hippocrales,^^ii-^,fj,ian , passim ;

Tli^i vovirm, vol. iii. p. 489. — Aretwns, Aciit. 1. ii. c.4.

A'ilius, Tetrab. ii. serm. i. c. 78 Paulus JEghuta, 1. ii.

c. '28 Oribasius, Synops. 1. vi. c. 18, 19. — Aviccnna,

Canon, l.iv. fen. i. tr. 2. c. 41 Sennertus, De Kebribus,

I. ii. c. 12. — Zacutus Ltisitamis, De Med. Prsst. Hist.

1. iv. hist. 10 — 14 Ii. Morton, Exerc. de Febribus In-

flammatoriis. Lend. 8vo. I(i94 Bartholinus, Ue Usu

Nivis Medico, c. \'.i. 23. — F. Hajfrnaiin, Opera, vol. ii.
p. 118 — Ii. Toivne, On the Diseases of the West Indies,

8vo. 1726 A. Piquer, Tratado de las Calenturas, &c.

Valen. 8vo. 1751. — Lining, Edin. Essays and Observat.
vol.ii. p. 404.— jy. Hillary, On the Dis. of Barbadoes ;

and on Putrid Bilious Eever, kc. 8vo. Lond. 17C-5

Stall, Rat. Med. ii.p.217.; iii. p. 97. U39. ; iv. p. Gl. (Re-
marks the putrid characters it asstmies in the last stage.)

— Hullo, Observ. on Dis. of Army of St. Lucia, 8vo.
Lond. 1781. — /?. Moseley, Treat, on Tropical Diseases,
on the Climate of the West Indies, &c. 8vo. Lond. 1784.

— lieil, Memor. Clin. fasc. iv. p. 179. ; et De Febre In-
llanimatoria Simplici. Hal. 1794. — J. P. Frank, De Cu-
rand. Horn. Morbis, 8vo. vol.i. CI. i. Ord. ii. Gen. iii. — J.

Frank, Prax. Med. Sec. vol. i. p. 278 W. Lempriire,

On Dis. of the Array in Jamaica, 2vols. 8vo. Lond. 1799,
passim — Navieres, Sur une Epidemie de Fievre In-
rtam. 4to. Paris, 1804. — ^. Vilaseca, Noticia de la Ca-
lentura America. Palma, 8vo. 1811. — P. Pincl, 'Noso-
graphie Philosopb. &c. vol. i. p. 20. 6th edit.— Tunnel,
Essai sur la Fievre Inflam. ou Angiotenique, 8vo. Paris,

1823 J. Brunton, De Febri Minorca?, &c. Ed. 8vo.

1815 J. S. Doii'n, De Febre Inflammat. Biliosa, 8vo.

Ed. 1815. — L, Spalding, Reflex, on Fever, particularly

its Inflammatory Character. New York, 8vo. 1817

A^ Dickenson, Observat. on the Inflammatory Endemic
incidental to .Strangers in the West Indies, 8vo. Lond.
1829. (Has made a judicious discrimination betu^een this

fever and the epidemic injections yellow fever .) — E.Jack-
son, The Hist, and Cure of Feb. Dis. as they appear in
the West Indies among Soldiers, Ike. 2 vols. 8vo. Lond.

1820, passi?n Fournier et Vaidy, Diet, des Sc. Med.

t. XV. p. 248. — J. Allan, On Ardent Fever, Edin. Med.
and Surg. Journ. vol. xi. p. ZX^ . — Macmillan, in Ibid.

vol. X. p. 30 Parson and Wilson, in Ibid. vol. viii.

p. 385— 403 P. Comrie, On Ardent Fever, Ibid. vol.

xiii. p. 165. — Boyd, Dickson, and M' Arthur, in Johnson,
On the Influence of Tropical Climates on European Con-
stitutions, 8vo. 4th edit. 1827. — Hilde7ibrand, Institut.
Med. Pract. vol. ii. p. 190. — iV. Good, Study of Med., by
Cooper, vol. ii. p. 222. 3d edit. — Boisseau, Pyretoiogie,
iVc. p.73. — J. Wilson, Memoirs of West Indian Fevers,

8vo. Lond. 1827 Richter, Die Specielle Therapie, t. i.

p. 117 J. Boyle, On the Topographie and Diseases of

Western Africa, 8vo. Lond. 1834, p. 71. et seg.

XVIII. Bilio-Gastric Fever. — Syn. Febris
Biliosa, Hippocrates, Stahl, Selle, Finke,
Tissot, and Stoll ; Siinochus Biliosa, Galen ;
Febris Gastrica, Baillou, Lentin; F. Gostro-
Hepatica, Hildenbrand ; Febris Cholerica,
Auct. var. ; Fie.vre Meningn-Gastricjiie, Pinel j
Gastrische Fieber, Richter ; Gastric Fever, Gus-
tro-bilious Fever, Bilious Fever, Bilious Con-
tinued Fever, Endemic Fever, Gastric Injiam-
matory or Bilio- Inflammatory Fever.

387. Defin. — Vascular reaction following
chills or rigors and other symptoms of premonition
and invasion, with predominant affection of the bil-
iary functions, and of the digestive mucous surface,
frequently icilh yellowness of the skin, in the severer
cases.

388. This fever is either sporadic, endemic, or
epidemic. — It is endemic in warm countries and
marshy situations among Europeans, particularly
those ;.who have not been long resident in these
parts; and in marshy localities in the summer and
autumn, in temperate climates. — It is epidemic
in some seasons, particularly in autumn when the
summer has been hot, after a wet spring, or after
great falls of rain, or after inundations, and when
great numbers of predisposed persons, especially
from high latitudes, visit such localities. In
these circumstances and persons, it proves the

3R 4

984

FEVER, BILIO-GASTRIC — Description of.

seasoning fever. It is observed chiefly in adults
of the bilious or bilio-sanguine temperaments, and
in persons addicted to spirituous liquors. It is a
very prevalent fever in the countries bordering on
the JMediterranean, in the East Indies, and in
America, and consequently in fleets and armies
in these parts.

389. i. Description. — This fever, in robust and
plethoric persons, approaches severe inflammatory
fever on the one hand, and the more inflammatory
forms of remittent on the other : or it presents a
predominance of the characters of either, accord-
ing to the intensity of the causes and the pe-
culiar circumstances of the aftected. The chief
difference between inflammatory fever and it, de-
pends upon the causes whence they respectively
proceed ; the former arising principally from at-
mospheric vicissitudes and climatorial influence,
in connection with suppressed perspiration ; the
latter chiefly from marsh and vegeto-animal
miasms (see Diagnosis). Its similarity to, and
connection with, remittents, are referrible to the
origin of both in the same causes ; the only differ-
ences between them resulting from the intensity
and concurrence of the causes, and from indivi-
dual predisposition — being differences chiefly of
grade and of type, as shown by Dr. Boyd, and
confirmed by my own observation. That it should
therefore be confounded with these fevers, cannot
be a matter of surprise, and is of little import-
ance as respects the treatment. But when it is
mistaken for the synochoid and adynamic species
with predominant affection of the digestive mu-
cous surface, then the results may be serious.

390. A. Gastro-hilious fever is generally preceded
by lassitude, nausea, or want of appetite ; by dull
pains in the back and limbs ; and by flatulence
and indigestion. Tfhe breath is foetid ; the tongue
is covered by a yellowish raucous coating ; the
mouth is clammy, and the taste perverted ; the
bowels are costive, or relaxed, or irregular ; and the
countenance is pale or somewhat sunk, Thisstate
— the premonitory stage — may continue several
days, the patient not being confined to bed ; but
generally in the morning he is seized with chills
or rigors, preceded by a sensation of cold creep-
ing along the spine. To these soon succeed
severe frontal headach, vertigo, nausea, vomit-
ing, burning heat of skin, restlessness, watchful-
ness, slight anxiety at the praecordia, pain and
oppression in the epigastrium, and in one or both
hypochondria, with more or less soreness, fulness
and tenderness. The eyesare moist and injected,
the conjunctiva often yellowish; the face is
flushed; the breathing oppressed and accelerated;
the pulse full, large, quick, and strong, raiely
hard ; the tongue is clammy, moist, furred, and
yellowish, with a bitter taste in the mouth ; the
thirst is urgent, the breath foetid ; the bowels
are obstinately costive, or loose; the stools bilious,
and the urine scanty and dark. When thestomach
and bowels are inordinately aftected, cerebral con-
gestion very frequently sujjcrvenes at a later period.
As the disease advances, the pulse feels less full,
and is weaker tiian in health. The tiiirst and
anxiety are increased ; and the upper parts of the
body are sometimes covered by a profuse sweat,
whiNt the skin still continues hot.

391. If the attack be very severe, or neglected
at the commencement of reaction, the ])ain of
llie head is aggravated ; and a disinclination to

answer questions, stupor, and insensibility ap-
pear about the second or third day. The eyes
are turgid or inflamed ; a bilious yellow tinge
spreads from the face downwards over the body ;
the tongue is covered by a thick yellow crust, is
red at its sides, and dry and brown in the centre ;
the strength is diminished ; nausea with bilious
vomiting is often distressing ; the pulse becomes
weaker and quicker ; and the patient has an in-
satiable thirst, and desire of cold acidulated fluids.
The urine is very high coloured, voided often, and
produces scalding in passing it. The bowels are
either costive or loose.

392. If the disease has not been mitigated, a
slight remission occurs on the third, fourth, or fifth
day, generally in the morning ; the face and chest
being covered by perspiration, and the temperature
of the surface reduced. But the symptoms are ex-
asperated towards evening ; the tongue becoming
drier and darker ; the epigastrium and hypochon-
dria more painful, tender, and often also tumid
and tense ; the pulse more rapid, constricted, or
weak. The anxiety at the praecordia is now
changed into severe pain, aggravated on pressure,
with oppression and frequent sighing ; the coun-
tenance is sunk ; there is vomiting of putrid or
offensive bile ; the stools are liquid, greenish
brown, foetid, slimy, and occasionally bloody or
dysenteric; the skin is often deeply jaundiced,
and emits a putrid bilious odour. The patient is
now collected, but various adynamic and ma-
lignant symptoms appear from the fifth to the
seventh or eighth day. These are — tremorsofthe
extremities, and of the tongue when held out ;
starlings of the tendons ; pain about the pubes,
with inability to pass the urine ; vomiting of a
dark, glairy matter; difficulty of swallowing;
sometimes swelling and suppuration of the parotid
glands; tympanitic distension of the abdomen; in-
expressive, glassy eyes, dilated pupils ; clammy
sweats, difficult and anxious breathing, and black
tongue. To these succeed delirium, coma, in-
termitting pulse, cold extremities, and death,
sometmies with convulsions. Petechiae, blotches,
and passive discharges of blood from the nostrils,
gums, fauces, &c., are but rarely observed.

393.13. Modifications. — All the above symp-
toms are not present in the same case, nor always
run the same course. In the young, strong, ple-
thoric and unseasoned, in the sanguine and intem-
perate, and in very hot and dry seasons, this dis-
ease approaches very closely to severe inflammatory
fever (§ 354.) with predominant affection of the
stomach and membranes of the brain, or of the
digestive mucous surface generally. But in weak
or elderly persons, and in colder climates and
seasons, it is more mild, and approaches, or even
runs into, some one of the varieties of remittent.
Indeed, it may assume either injlammalorij or
adynamic characters, or present complicalioiis
similar to those observed in that fever, from which
it diflfers merely in type. When animal miasms
and infection are associated with the other causes,
as in crowded transports, ships of war, prisons,
camps, &c., in warm climates, or in hot seasons,
more or less adynamia or depression of vital power,
with contamination of the circulating fluids, is
evinced early in the disease — malignant and
nervous symptoms predominating towards the
close. In such cases, the premonitory and
invading stages are very manifest; reaction is

FEVER, BILIO-G ASTRIC — Don ation — Diagnosis.

985

often low or imperfect, as in the more adynamic
states of remittent, or rather in the malignant
form of fever about to be noticed ; and the type
is perfectly continued. But when it arises chieHy
from terrestrial exhalations, the circulating and
secreted fluids are less vitiated, and it presents
more of the remitting character. When these
causes are very intense, and the predisposition
great, the disease often assumes a very concen-
trated and acute form, runs its course rapidly, and
often passes into the remitting- type, or induces
visceral disease. These violent states of bilio-
gastric fever have been often met by ]\Ir. Boyi.e
and myself in Africa, and by Dr. J. Johnson,
Annesly, and others in the East Indies. This
fever thus may resemble, according to the nature
of the causes — predisposing and exciting, — of the
seasons, of the locality and climate, and of the
epidenjic constitution, either inflammatory, or
remittent fever, or even malignant fever — may
possess more or less of a gastric character in one
case, of a bilious state in another, of an inflam-
matory condition in a third, of cerebral aflTection
in a fourth, of ^n adynamic or malignant form in
a fifth, or a predominance of any two or more of
them. These modifications give rise to the ap-
pellations, gastric, bilious, yellow, gastro-bilious,
gastro-inflammatory, bilious inflammatory, bilious

even an intermittent type. In sucii cases, en-
largements of the spleen, of the liver, of the
pancreas, and even of the mesenteric glands, may
ultimately supervene. — /. Jielapses are more
frequent in this than in almost any other fever,
and are caused chiefly by a too early recourse to
a full or stimulating diet, by irregularities jn
food or drink, by incautious exposure to the
night air or to cold, by vicissitudes of tempera-
ture or of season, and by terrestrial or vegeto-
animal miasms. — The lesiuns observed in J'atul
cases are alogether similar to those found in the
more inflammatory and severe forms of remittent.
395. iii. Diagnosis. — Bilio-gastric (tver nearly
resembles — 1st. Injlammatory fever, in its
milder states ; — 2d. Eemitteut fever, in its se-
vere forms; and, 3d. Epidemic or pestilential
yellow fever. — a. From the frst, it is distin-
guished by premonitory symptoms of consider-
able severity and ^continuance ; by the marked
chills and rigors characterising its invasion ; by
the early occurrence of nausea and bilious vomit-
ing ; by the less continued and violent state of
vascular reaction ; by the copious and early
bilious evacuations and the bilious suffusion of
the skin ; and by the usually longer duration of
the disease. In severe climate or inflammatory
fever, on the other hand, the invasion is sudden,

continued, gastro-meningitic, &c., applied toil by ! and vascular action more or less excited from the

modern writers, and cause it frequently to be
confounded with the severe inflammatory fever
on the one hand, and with pestilential yellow
fever on the other.

394. ii. Duration andTer.mination. — These
depend upon various circumstances — chiefly
upon the exciting causes and circumstances proper
to the patient. — a. When judiciously treated at
an early stage, a favourable change generally
appears from the third to the seventh day, or even
earlier. — b. But when the disease has been
neglected, or aggravated by improper means,
death may take place from the fifth to the eighth
day, preceded by the unfavourable signs just
enumerated (§ 393.). In these, the brain or
its membranes, or the digestive mucous surface,
or all of them, have suffered very considerably,
and are more or less changed. — c. In some
cases, and when it is occasioned by the con-

commencement — premonitory symptoms being
hardly observed. Subsequently the blood un-
dergoes a much more remarkable change than
in gastric fever — the yellow and livid blotches
appearing in the last stage, being very difl^eient
from the bilious suffusion of this disease ; and
the haemorrhage from the mucous surface, the
black vomit, and dissolution of the fluids, &c.,
so frequent in the former, being neither so com-
mon nor so great in the latter. The pain in,
and determination to, the head, is more severe
in the first stage of inflammatory fever, and the
disorder of the stomach much less than in
gastro-bilious fever ; but the a/Tection of the
stomach becomes more violent and unremitting
at an advanced stage of the former than of the
latter.

396. b. Gastro-bilious fever is distinguished
from remittent fever chiefly by its continued or

currence of marsh exhalations with the other ! imperfectly remitting course. In other re-

causes enumerated above, more particularly in
hot climates, or in temperate countries during 1
warm summers and autumns, the inflamma- j
tory action extends to the mucous surface of the I
small intestines and large bowels, the disease
terminating either in enteritis or acute dysentery.
As in the remittent type, so in this, the state of
the secretions, particularly the biliary, and the
nature of the ingesta, concur with the exciting
causes in developing these complications (§237.).
d. The fever may also pass into injiammatinn
or abscess of the liver. This is a frequent com-
plication and termination of the bilio-gastric
fever of the East Indies, and of some other inter-
tropical countries. When abscess forms in the
liver in these cases, dysenteric symptoms are
often superadded. — e. When the disease has
not been entirely arrested, but only mitigated by
treatment, or when it has been mild at the
commencement, and caused chiefly by terrestrial
exhalations, the patient continuing subjected to
their infiueuce, it may pass into a remittent, or

spects there is little difference between it and the
severer forms (§ 230. 232.) of that disease, ex-
cepting that its severity is often greater, and its
duration shorter. Indeed, this is but a variety of
marsh fever, owing its continued and otherwise
modified characters to high temperature and
other concurrent circumstances,

397. As this fever varies from the ardent
seasoning, to the distinctly remittent type, with the
intensity and concurrence of the causes producing
it; and as it may occur contemporaneously with the
pure climate fever, and with the more inflammatory
forms of remittent fever, as frequently observed in
the West Indies and JMediterranean during the
hot months, particularly among soldiers and sail-
ors ; so it is often diflicult to distinguish between
them. I'he chief circumstances, however, which
will fix the attention of the practitioner, are —
the manner of invasion; the distinctness, ob-
scurity, or absence of remissions ; the degree of
excitement characterising the early period, e.s-
pccially as expressed upon the vascular systesu ;

986

FEVER, BILIO-G ASTRIC — Causes — Treatment.

tlie kind of excitement, particularly in respect of
sthenic or asthenic action ; and the state of the cir-
culating fluid, and of the secretions and excretions.

398. c. From epidemic or pestilential yellow
fever, this disease is distinguished — by passing

into the periodic type in many instances, and by
frequently leaving" visceral disease behind it; by
its attacking the same individual oftener than once,
if he have intermediately undergone a change of
locality or climate ; by the more inflammatory or
sthenic character of the period of excitement,
and the much less remarkable change in the
blood and soft solids from the commencement ;
by the headach being confined chiefly to the
temples; by the yellowness appearing early, and
first in the eyes, and being of bilious origin ; by
much less irritability of the stomach in the ad-
vanced stages ; and by its longer duration — ge-
nerally from five to fourteen days. In pestilential
yellow fever, the yellowness of the skin is not fre-
quent, and is of a pale lemon colour ; the face has a
putrid, bloated, or livid hue ; its duration is from
one to five days ; it never passes into the periodic
type, nor leaves visceral disease behind it ; fatal
cases always being attended by the black vomit
at their close. IVIoreover, remittent, inflamma-
tory, and bilious fevers are never infectious, un-
less under peculiarly favourable circumstances,
when tlie latter may assume this character ; but
epidemic yellow fever is remarkably infectious ;
and whilst these are generally benefited by
vascular depletions during the period of excite-
ment, the epidemic malady requires a different
method of cure.

399. iv. The Prognosis depends upon the intens-
ity and concurrence of the exciting causes ; upon
the severity of the attack ; upon the treatment
adopted at the commencement; upon the state
of vascular reaction ; and upon tiie complications
that may arise. — a. It may be favourable, if
the attack be mild or simple, the skin moist, the
vomiting moderate, and the matters ejected con-
sist chiefly of mucous or ingesta ; if the tongue
become moist, the bowels loose, and the stools
bilious ; if the nervous and vital powers be not
much reduced ; and if the yellow suffusion be
slight or slow in its progress. — b. An imfa-
vourable opinion should be formed, if any of the
more dangerous symptoms enumerated above su-
pervene (§ 392.) ; especially if the skin be either
early or deeply yellow, or the sensorial functions
early disturbed ; if the period of exhaustion be
attended by deep redness of the face, dulness of
the eyes, much anxiety, or laborious respiration ;
by a feeble, creeping, or intermitting pulse ; by
very scanty and dark urine ; great pain, tension,
or fulness in the epigastrium and hypochondria;
difficulty of swallowing; tremors of the tongue
or of tlie extremities ; by startings of the ten-
dons; involuntary discharges of fajces, particu-
larly if they be of a black colour ; incessant
vomiting, especially if the egesta be dark, or great
in proportion to the ingesta ; by petechias, en-
largements of the parotids, and coldness of the
extremities.

400. v. Causes. — Gastro-bilious fever is rawserf
chiefly by exhalations from the soil, or from vege-
table and animal mattterundergoingdecom])osition,
in connection with atmospheric heat; by exposure
to the sun ; by the night airs or dews, and the in-
fluence of cold following such exposures or exces-

sive exertion or high ranges of temperature ; by
intemperance and errors of diet or of regimen ; by
excesses in vinous or spirituous liquors ; by great
exertions following inactivity ; by over-eating, or
by a sudden transition from a very poor, to a very
full or rich diet, as in the case of soldiers and re-
cruits ; by anger and other mental emotions ; and by
the causes already enumerated (§ b.). — It most
frequently, however, arises from the concurrence
of two or m.ore of these causes. The influence
of infection in producing it has been doubted ; but
the experience of Drs. Denmark and Boyd, in
ships and hospitals in the Mediterranean, has de-
monstrated its occasional origin in the cause — or
at least the power infection evinces in producing
a severe modification of it.

401. vi. Treatment. — The Mu/?caiio«s are —
1st. To evacuate morbid secretions in the prima
via, and restore the suppressed perspiration, in
the stages of premonition and invasion ; — 2d. To
moderate the vascular reaction attendant upon
the period of excitement ; — 3d. To obviate de-
termination to a vital organ, and mitigate urgent
symptoms ; — and, 4th. To support the vital powers
in the consequent exhaustion. — The^'rsi indica-
tion is best fulfilled before reaction is developed.
At this time an emetic, followed by diluents, by
the vapour bath, or by warm fomentations,
sudorijic drinks, and by warm emollient enemata,
will generally restore the suppressed perspir-
ation, and moderate the consequent reaction. —
Bloodletting is the next important means; but
the utmost care should be taken not to resort to
it before reaction has commenced, or when ex-
haustion is about to supervene. Dr. Denmark
has insisted upon this, and my experience fully
confirms the propriety of the advice. I have
seen this fever most remarkably exasperated,
and almost fatal syncope occasioned, by the ab-
straction of even two or three ounces of blood
during the stage of invasion, before vascular ex-
citement was developed. When this pathologi-
cal state has supervened, depletions should be
energetically and early practised, but with due
regard to the state of the pulse, and to the com-
plications and other circumstances of the case;
and they ought to be aided by cold applications
to the head and purgatives. A full dose (from
10 to 20 grains) of calomel may be given imme-
diately upon the first bloodletting, and afterwards
the tartrate or citrate of soda or of potash may
be taken at short intervals, in the state of efi'er-
vescence, with an excess of the alkali. —As long
as vascular excitement is energetic, antiphlo-
gistic remedies should be cniployed, as recom-
mended above ; and, in addition to these now
mentioned, there are none more deserving of
adoption, than small and frequent doses of the
nitrate of potash and hydro-chlorate of ammonia.
Cold afl^usions, and cold sponging of the surface,
are also useful auxiliaries. When internal viscera
are oppressed, and reaction is not free and open,
the tepid bath, or tepid effusions, will be service-
able.

402. The second indication is to be fulfilled
by local depletions in the first instance, followed
by rubefacients, blisters, and tlie other means
detailed when treating of tlie remittent form of
bilious fevers (m;c § 251, 252— 258.). —The ex-
hanstion in the latter period requires the same
treatment as already advised for this state in the

FEVEH, BILIO-GASTRIC — Treatment.
severer forms of remittent and inflammatory fe-
vers (see § 253, 256, 257.).

403. The mercurial -plan of cure in this fever
has been very strenuously insisted upon by
Chisholm, Denmark, J. Johnson, Boyle,
Boyd, and various other recent writers. They
advise calomel to be given after copious vascular
depletions, with the intention of aft'ecting the
system, and in various forms of combination —
with James's powder or other antimonial pre-
parations, in frequent doses, or in larger quanti-
ties with opium. And they direct the mercurial
unguents to be used externally at the same time,
I have prescribed mercurials with the same in-
tention, to the utmost extent, and in all these
forms in the more concentrated varieties of this
fever in hot climates; but I have not satisfied
myself that they have been actually beneficial
to the extent supposed, even in the cases which
have recovered during or after their exhibition.
I would, therefore, prefer to use it in the manner
J have advised in the severer forms of remittent
(§ 250. et seq.).

404. The propriety of having recourse to
emetics in this fever has been much questioned
by writers, and especially by those of the school
of M. Broussais. They are, in my opinion,
quite inadmissible after excitement has com-
menced. They should be given only in the pre-
monitory and invading stages, as above stated
(§ 401.), but unfortunately the disease seldom
comes under treatment until these have been
superseded by reaction ; and they ought to be
aided, in these periods, by the means men-
tioned (^ 401.) in connection with them. They
are contra-indicated even thus early, if great pain
be felt at the epigastrium, with distension and
tenderness ; and if full and free vomiting have
already taken place.

405. The saline treatment, so remarkably ex-
tolled by Dr. Stevens, in the latter stages of this
and other severe fevers, does not appear to have
been employed to an extent which will v/arrant
an opinion as to its effects. And, although several
years have elapsed since it was so strongly re-
commended by this writer, for these diseases, I
cannot find that any additional evidence of its
efficacy has been adduced. It surely becomes
this physician to furnish further proofs of its
success, and it is morally imperative upon prac-
titioners in warm climates to give it a proper
trial. — It is unnecessary to offer further remarks
on the treatment of this species of fever, as the
observations already made in respect of the ma-
nagement of remittent and inflammatory fever
will in a great measure apply to it; and the more
so, as the severe states of tliese diseases, as well
as of this, although commencing differently and
evincing certain modifications in their early
course, generally present very similar features
in their advanced stages, or when they assume
dangerous complications, and pass into exhaus-
tion of vital power.

BiBLioG. AND Refer. — Avicenna, Canon. Liv. fen. i.
tr. 2. c.35.—Bia7ic/ii, Hist. Hepat. p. 131. — J. Williams,
On Bilious Fevers. Lond. 1752. — J.Grainger, Hist. Febris

AnoinaliE Batava. Ann. 1746-48. &c. 8vo. Ediii. 17')3

Tissof, De Febribus Biliosis, 8vo. Laus. 1758. — Fan Svn'e-
ien. Const. Epid. &c. p. i. — Linci, On Diseases of Hot Cli-
mates, p. 19. — Bellihoii, Von Gallentiebern. Augs. 1772 —
,5to«,Rat. Med. t. i. etii. passim; et De Cognosccnd. et Cu-
pand. Feb. § 340— 37.5.— C.Bi/c/cf, On the Bilious or Yellow
i ever of Jamaica, Svo. Lond. 1772. — G. A. Benelli, Dis-

987

corso Apologetico dplle Febbrn Biliosre, Svo. Bol. 1775

Bmlcnoch, in Mod. Observat. and Inquiries, vol. iv. No. 12.

— Ij. L. Finckc, De Morbis Biliosis, &c. 8vo. Mpg. 1780.

— Appel, De Phlebotomice, imprimis in Febribus Biliosis
recta Administratione. Helmst. 1709. — Domling, Morb.

Gastricorum Acut. Pathologia. Wiceb. 1797. J. P.

Frank, De Curand. Homin. Morbis, vol. i. § 08 Cassan,

Memoires de la Societe Med. d'Eniulation, t. v. p. .39

J. B. Davidge, On the Autumnal Endemic of Tropical
Climates, vulgarly called the Yellow Fever. Bait; 8vo.
17'J8 — Ru'sli,m Trans, of the .Soc. of Philad. vol. ii. ; and
Ed. Med. Comment, vol. xi. p. 170.-0'. Rait, in Ed. Med.

Comment, vol. xiii. p. 313 A". Pearson, Observ. on the

Bilious Fevers of 1797-1799. Lond. 1799.— i?«7,Memorab.
Clin. fasc. iv. No. %. — Spalding, in New York Med. Re-
pos.yol. iii. art. 2. — 7oerrfc«s, in .Sto>7.-, Archiv. b. ii. st,. 2.

— White, Of the Bilious Fever as it appeared at Bath,
Lond. 1802. — Pugriet, Mem. sur les Fievres de mauvais
Charact. du Levant et des Antilles, &c. Lyon.8vo. 1804.

— A. Boyle, On the Endemic Continued Fever of Sicily, in
Edin. Med. and .Surg. Journ. vol. vi. p. 420., and vol. viii.
p. 174 — fK. Irvine, in Ibid. vol. vii. p. 3.33.— Weinhold,
De Inflammatione Viscer. Hypochond. in Febribus Bi-
liosis, §iv. — n. A.G.Bic/iter, Die Specielle Therapie,
&c. b. i. p. 283 — J. Frank, Praxeos Med. Universa; Prae-
cepta, vol. i. p. 2l9. — Den7nark, in Transact, of Medico-
Chirurg. Soc. vol. vi. p.30.—G.A.Ricltter, Darstel.desWe-
sens.der Erkenntniss u. Behandl. der Gastrischen Fieber.
Berl. 18\2. — Tommasini, Sulla Febbre gialla Ame-
ricaoa, e sulle Malattie di Genio Analogo. 1801, Svo. —
Fournier et Vaidy, in Diet, des Sciences Medicates, t. xv.

p. 274 — Alibert, 'Nosologic Naturelle, t. ii. gen. v Rai-

maiin, Handbuch der Speciellen Therapie, b. i. § 139. —
W. Boyd, De Fcbre Minorca?, 8vo. Ed. \S17. — Hilden-

brand, Institut. Medic£e Practicae, vol. iv. p. GSO Meli,

Su le Febbri Billose. Milano, 1822 ; et Su la Condizione

Pathol. delleFebbiiBiliose. Mil. 1824 t. Jo/inson, The

InfluenceofTropical Climates on European Constitutions,
4to. edit. ;;«*«>« — F. G.Boisseau, Pyretologie Physiolo-

gique, &c. 3d edit. p. 130 Schmidtmann, Observat. Med.

t. iii. p. 3-56 J. Annesley and Author, Researches into

the Pathology and Treatment of the Dis. of India and of
Warm Climates, &c. imp. 4to. vol. ii. passim W. Ste-
vens, Observ. on the Healthy and Diseased Properties of
the Blood, Svo. Lond. 1832.— W. Twining, Clinical Il-
lustrations of the Diseases of Bengal, &c. Calcutta, 1832,
f^Yo. passim.— JF. E. E. Conivell, On the Funct. and
Struct. Changes of the Liver, and on Hepatic Disease in
India, &c.8vo. Lond. 183-=),prtM,->». — See also the Refer-
ences to Remittent and Inflammatory Fevers, and
likewise to Pestilential Yellow Fever, as this dis-
ease has been very frequently confounded with them,
ov/ing chiefly to the circumstance of yellotvness of the
skin being one of its chief characteristics ; indeed, this
symptom is more generally observed in it than in the
other fevers just mentioned. The term yellotv fever ought
tobeentirelydiscarded ; as, yellowness being improperly-
viewed as a pathognomonic symptom of one kind of fever,
all others, in which it is a contingent phenomenon, al-
though not more frequently met with in one than in
another, have been confounded with that fever. As re-
spects intermitteiits, their periodicity and exacerbations
sufficiently distinguish them, even although yellowness or
signs of malignancy should arise in their advanced course.
Besides, yellowness is a very indefinite symptom,— it not
only is of various shades, but also arises from very differ-
ent causes ; — it is lurid or tawny in one case, brownish
or mahogany-like in another, greenish in a third, orange-
colour in a fourth, of a lemon tint in a fifth ; and it is,
moreover, either partially or generally diflused, or even
mixed with different colours, as with greenish, livid,
purplish, violet, or reddish blotches. And it may proceed
either from the passage of the colouring parts of the bile
into the circulation, or from incipient dissolution of the
blood, with loss of the vital tone of the capillaries. When
it arises from the former source, especial disorder of the
biliary secretion is presupposed ; in the latter, predomi-
nant affection of the circulating fluids and of the vascular
system. It would be preferable, therefore, to adhere to
the denominations inflammatory, bilio-gastric, and pesti-
lential, as respects those species of fever which most fre-
quently present the symptom in question as the result of
these causes.

Those who have not seen the fevers incidental to inter-
tropical countries, more especially to the West Indies,
Africal, the Mediterranean, and the East, may consider
the distinctions made above not to exist in nature, and
that remittent, bilious, continued, infl.ammatory, and
pestilential fevers are merely modifications and grades of
each other. They may even doubt the utility of the de-
tails into which I have entered, particularly as regards
inflammatory and bilio-gastric fevers ; fur they will
scarcely observe a case of either in temperate countries,
particularly in the severe forms met with in warm cli-
mates, unless in very hot seasons, and in peculiar circum-
stances. But iu those parts of the world to which I have

988

just referred, and in others adjoining them, to which
medical men may proceed to serve, it will be found that
the unacelimated, according to their constitutions, will
he affected by inflammatory fevers of various grades of
severity, in healthy localities and in hot and dry seasons —
with bilio-gastric and remittent fevers, of various forms,
in miasraal situations and sickly seasons, — whilst the
acclimated shall escape the first of these maladies, in the
former of these circumstances, and the second in the lat-
ter, or, if attacked, they shall experience only remittents
or intermittents. The pestilential yellow fever makes no
such distinctions. As already stated, and as will be here-
after shown, its spread is limited only by a low range of
temperature, liy a previous attack, and by circumstances
that circumscribe its infection. Whilst the former fevers
are met with in all warm climates, and occur either spo-
radically or cndemically in them, and are not infectious,
this last appears only on the intertropical shores of the
Atlantic, or parts adjacent, during hot seasons, rages
for a time, and then disappears. Thus, it occurs after
long intervals, prevails sometimes for years, and then
takes its departure, as will be shown in another place.
When we consider the very different constitutions — ori-
ginal and acquired — of those who inhabit European
colonies within the tropics, — when we review the appear-
ances of the new comer, of the old resident, of the Creole,
of the mulatto of various grades, and of the negro, and
take into account the modes of living, the exposures, and
the various other circumstances connected with each
class, and further connect all these with variety of situ-
ation, season, and temperature, — we cannot be surprised at
the very different forms which fever assumes among them.

XIX. Mucous OR PiTuiTious Fever. — Syn.
Fehris Mucosa, F. Mesenterica, Baglivi ;
Morbus Mucosus, Roederer and Wagler;
Febvis Pituitosa, Stoll ; Febbre glutinosa
gastrica, Sarcone ; Fitvre Adenn-me'niitgee,
Pinel ; Fievre Muqueuse, Fr. ; Schleimjieber,
Germ.

406. Cii.\RACT. — Slight febrile reaction follow-
ing chills, liiih mucous evacuations, and pains in
the hack and limbs, and often with slight remissions.

407. i. Symptoms. — Some of the older writers
confoutided mucous fever with influenza, with
catarrhal fevers, and even with bronchitis. But
more recent observers have, with greater propriety,
confined their description of it to tiiat form of
general affection, which is characterised by slight
febrile excitement and nervous depression, with
predominant disorder of the digestive mucous sur-
face, of a sub-acute form, accompanied with mu-
cous or slimy evacuations — admitting, however,
the occasional complication of bronchial irritation
with it.

403. This fever is preceded by general uneasi-
ness, by a sense of heaviness ; or pains in the limbs,
loss of appetite, disturbed sleep, acid or acrid
eructations, and cold or chilliness, which is first
felt in the lower extremities. To these succeed,
marked dislike of food, slight thirst, nausea, some-
times with vomiting of a whitish, transparent, and
viscid fluid of a nidorous or acid taste ; a sense of
weight at the epigastrium, with fulness; flatulent
and colicky pains, with slight tenderness in the
abdomen, and relaxed bowels. The tongue is
usually moist, white, and covered by a mucous
coating, with a sickly or unpleasant taste of the
mouth ; aphthous exudations are occasionally
observed on the fauces and lips ; the saliva is
sometimes abundant ; and the breath is foetid and
heavy. 'J'he evacuations are mucous, more fre-
quent than natural, sometimes tinged with blood,
voided with slight tenesmus, and, in ciiildren,
often with prolapsus ani. In rarer instances, cos-
tiveness, or an irregular state of bowels is observed ;
— mucous diarrhtca and costiveness alternating ;
and, occasionally, worms are voided. 'J'he urine
is either scanty or natural at first, of a citrine

FEVER, MUCOUS — Symptoms.

sits a mucous sediment of a greyish or

brick

colour at an advanced stage. The temperature
of the surface is not much increased, unless'
during the evening exacerbations ; and, to-
wards the acme and decline, a gentle perspir-
ation breaks out, especially in the mornino- and
during sleep. A slight eruption often occurs
during the night, but generally disappears in the
morning. The pulse is feeble* and small, but
seldom much accelerated, unless in the evening
and night. The patient complains of a sense of
weight or of pain in the sinciput and occiput ;
with vertigo upon sitting up ; of confusion of
ideas, and somnolency, without the ability to
sleep ; of depression, sadness, and restlessness ;
of pains and soreness in the hypochondria, in all
the bmbs, and in the joints ; and occasionally of
cougii, noise in the ears, and deafness.

409. ii. The Diagnosis rests upon the circum-
stances connected with the origin of the disease ;
on the appearance of the evacuations ; on the co-
licky pains in the bowels; on the softness, the very
slight acceleration or slowness of the pulse ; on
the little increase of the temperature, and the
humidity of the skin; on the slight degiee of
thirst; and on the very moderate or sub-acute
character of all the febrile phenomena. In its
slighter forms, the complaint is commonly de-
scribed as fever from cold, or as a cold in the
bowels and limbs. In some cases, it presents
either a dysenteric or a rheumatic character ; and
is wiili difficulty distinguished from dysentery, or
from rheumatism in other instances, unless the
history of the disease, and the state of the bowels
and of the evacuations, be closely observed. It
may even pass into either of these affections, or
into others about to be noticed.

410. iii. Duration, Termination and Pro-
gnosis. A. — The Duration of this fever varies
from two to five or six weeks. It often presents
slight remissions, indicated chiefly by the pulse
and skin. The more manifest the remissions, the
longer is its duration, which may be extended
even beyond the latter period. — Relapses are
very common during convalescence ; and are
caused chiefly by errors of diet or of regimen, by
premature exposure to atmospheric vicissitudes,
or to cold and moisture, or to paludal exhalations.
'J'he relapse may assume cither the same or ag-
gravated features, or a purely remittent or inter-
mittent type.

411. ./}. Mucous (ever terminates — 1st, In a re-
turn to health, which most commonly takes place;
and is frequently preceded either by vomiting, or
by a moderate diarrhoea, or by an apiuhous
eruption on the lips, or by a miliary eruption on
the skin, by a geneial sweat, by the urine be-
coming copious and depositing a sediment, or by
a spontaneous salivation ; — 2dly, In the adynamic
state of fever, with predominant affection of the
intestines, and of the brain, or of its membranes ;
— 3dly, In a purely remittent or intermittent
type, or in dysentery, particularly in marshy lo-
calities ; and, in such cases, sub-acute or chronic
disease of one or more of the viscera in the abdo-
men, with or without dropsy, may supervene : —
4thly, In unetjuivocal &ym])toms of rheumatism,
or of peripneumonia; — Gthiy, In death, after
severe, inflammatory afl'cction of the intestinal
mucous surface, attended by obstinate diarrluxa ;

tint, and sometimes passed with pain ; it depo- ] or after excessive nervous exhuuslion, or after

FEVER, MUCOUS —

obscure affection of the brain, or of its meninges,
or of the respiratory organs. — The prognosis is
generally favourable, unless any of the more
severe changes just mentioned present themselves.
This fever seldom terminates fatally when early
and judiciously treated.

412. C. On dissection, the principal lesions are
found — 1st, In the intestinal canal, whieii is
usually greatly distended by a foetid gas ; its
mucous surface presenting inflammatory appear-
ances, consisting of vascular injection, tiiickening,
softening, various alterations of colour, ulcer-
ations, and even gangrene ; — 2dly, In the peri-
toneal covering of the intestines, whicii is either
partially inflamed or altered in colour, the abdo-
minal cavity sometimes containing serum : — -SJly,
In the mesentery, vi'hich often presents lesions
similar to those of the peritoneum, the mesenteric
glands being enlarged, inflamed, or changed in
colour; — ^ 4thly, In the liver and spleen, v/h\c\\
are variously ahered in diflerent cases, but most
frequently congested, enlarged, or granulated ;
the spleen being generally softened, friable, en-
larged— more rarely small and hard; — 5thly,
In the lungs, which are congested or injected,
hepatised, tuberculated, the bronchi being loaded
with mucus and the bronchial glands enlarged ; —
6tldy, In the /)ericarrf(((H!, which sometimes con-
tains a turbid or sanguinolent serum ; the sub-
stance of the heart being flabby or soft. — Morbid
appearances, consisting • chiefly of congestion
and effusion of serum between the membranes
or in the ventricles, are occasionally observed in
the brain. In every instance, the digestive mucous

follicles have been found "enlarged, inflamed in
various degrees, and ulcerated ; presenting the
various lesions, affecting these follicles, described
in the article Ujgestive Canal (§ 36.), the
cfficum, large bowels, and small intestines, being
the parts chiefly diseased,

413. iv. Causes. — This variety approaches bilio-
gastric fever on the one hand, and the enteric form
of synochoid fever, on the otiier. It may occur
either sporadically, endemically, of epidemically ;
and, in either case, it may arise from, or pass into,
fever of a periodic type. It may even run into
dysentery ; and from the severity of the pains in
the limbs attending it, may closely resemble an
attack of rheumatism. Its characters, both con-
stant and contingent, result fro;n the various
circumstances both intrinsic and extrinsic to the
patient, concurring to cause it. These are chiefly
— a. The epochs of childhood and old age ; the
female sex ; the lymphatic, leucophlegmatic, and
nervous temperaments ; prolonged watchings ;
excessive fatigue or indolence ; languid, weak,
delicate, and pale states of frame ; chlorosis, in-
testinal worms, or a cachectic habit of body ; the
debility caused by previous disease, as by agues,
mesenteric obstructions, or by excessive venereal
indulgences. — b. Living in low, humid, cold,
and marshy places; privation of light and of the
sun's rays; the autumnal season, or prolonged wet
and cold weather; want of cleanliness; tiie use of
indigestible vegetables, of unripe fruit, of tainted
animal food, or of unwholesome fisii, particularly
shellfish; of stagnant, marshy, or impure water ;
the privation of accustomed stimuli ; the abuse of
emetics or of purgatives; insufficient nourishment,
&c. The most common of these are cold and
humidity, unhealthy localities, and unwholesome

Causes — Treatment. 989

ingesta. This fever is endemic in the situations
just specified; and it has occasionally appeared
epidemically during autumn and winter, parti-
cularly after much wet.

414. v. Treatment. — Selle, Stole, and J.
P. Frank, looked upon the character of the
stools as the consequence of accumulations of
mucus in the digestive canal, and- have prescribed
emetics and purgatives in order to evacuate them.
Baglivi more judiciously directed vascular de-
pletions, emollients, and mild purgatives. Pinel
first evacuated the stomacii by means of ipeca-
cuanha ; and eiliier continued this substance
afterwards, in weak aromatic infusions, or gave
rhubarb with the tartrate of potash, or with the
hydrochlorate of ammonia, lie occasionally di-
rected three or four grains of the extract of jalap
in an emulsion, as recommended by Uoederer
and Wagleh. Broussais and his disciples,
viewing this fever as a form of primary gastro-
enteritis developed under the influence of cold,
humidity, and bad diet, in persons whose mucous
surfaces are predisposed to inordinate secretion,
and who are liable to sympathetic affections of the
limbs, head, &c., advise a treatment founded on
these views. I'hey believe that collections of
mucus in the prima via are not the cause of the
constitutional disturbance, but are, equally with
such disturbance, produced by the inflammatory
irritation of the mucous surface. There can be
no doubt of the frequent origin of the morbid
secretion in this state, but that it always, or
solely, originates in it, is questionable. Although
inflammation, or rather vascular injection, of the
mucous membranes is one of the constituents of
the morbid condition, there are obviously others
which modify it, or give it a more or less specific
character. Besides, the follicles are more affect-
ed than the mucous membranes themselves ; and
however prominent the affection of these parts
may be, the organic nervous system is manifestly
that which is primarily impressed by the causes,
and which continues longest and most universally
to evince disorder.

415. a. The Jirst intention is to remove the
exciting causes ; and, if the disease comes under
treatment sufficiently early, to endeavour to
arrest its progress, or to shorten its duration, by
the exhibition of an emetic of ipecacuanha, by
the vapour bath, by hot fomentations, and by
warm emollient injections. — b. The second in-
dication is to reduce vascular action, if the disease
be fully developed, or the patient plethoric or
robust, and if febrile excitement be considerable,
by general or local bloodletting, in' moderate
quantity, by refrigerants, by the tepid bath, and
by low regimen. — c. The third intention is to
determine the circulation to the surface, and
derive from the mucous surfaces by means of
Dover's powder, or by ipecacuanha, nitre and
opium, or other diaphoretics ; by the warm bath ;
and by blisters, sinapisms, or warm terebinthi-
nate epithems applied over the abdomen. — d.
The'fourth object is to soothe intestinal irritation
and to correct the secretions, by emollients and
demulcents given by the mouth or by injection ;
and by small doses of blue pill or hydragyrum cum
creta and camphor, with Dover's powder. —
e. The fifth is to evacuate morbid matters from
the intestines, and to prevent their collection, by
the occasional exhibition of mild purgatives aud

990

FEVER, SWEATING — History,

laxative enemata. — /. Siithly, to alleviate urgent
symptoms, or determinations to particular organs
— as to the head, the lungs, or liver — by local de-
pletions, external derivatives, rubefacients; &c. —
g. And, seventldii, to support the powers of life in
the latter period by gentle tonics, light nourish-
ment, and by cinchona or the sulphate of quinine,
especially when the disease presents remissions,
or is disposed to pass into the periodic type, or
into rheumatism, and particularly in humid,
marshy, and unwholesome situations. 1 have
found the following aperient very serviceable
in this form of fever, when the bowels required to
be gently but freely evacuated. Others, how-
ever, in the Appendix (F, 266. 430. 827.), will
be equally useful.

No. 222. R Fotassae Bitart. in pulv. 3 j. ; Potassse Ni-
tratis 3ij.; Confect. .Sennje ., ij ■ ; Syrupi Aurantii 3 j- M.
Fiat Electuarium, cujus capiat Coch. i. vel ij. minima.

BiBLiOG. AND Refer Avicennn, Canon. Liv. fen. i.

tr.ii. C.47. 5.T J.^ocicASj-nopsisnovi Morbi.quemFebr.

Catarrh, vocant, kc. Helms. 1580 Crmise, De Febr. Ca-

tarrhalibus, 4to. Jen. 1676. — C. Piso, De Jlorbis ex Serosa
Collurie ortis, 4to. Lugd. Bat. \7\4. —Bng/ivi, Prax. Me-
dica, 1. i. cap. 5. — I. G. De Huhn, Febr. Cimtin. quae Ann.
1729,Uratislaviaagrassata}sunt,4to. Urat.1731. — Roederer
et rra^/cr, Tractat.de MorboMueoso,&c. Goet. 1762.1783.

— Strac/;, De Febre Pituitosa, Mog. 1781 Knaiis, An-

not. qaa;dam circa Morb. Bil. Mucosum Ann. 1783-4.
Stuttg. grassat. &c. Stuttg. 1786. — Wiebcrs, Discrim. in-
ter Febr. Bil. et Pituitosam, Doering, Tr. vol. i Eis-
ner, Animadvers. in Feb. Pituitosas. Regiom. 1789

J/. .Sto//, RatioMed. vol.iii. p. 141. ; et Aphor. de Cognos-
cend. et Curand. Febr. Sec, edit. 2d. p. 137. — Conshruch,
Hist. Febris Mucosae Ann. 1783-4 Stuttgardiae grassatae.
Stuttg. 1790. — Jacohi, De Febre Pitiiitoso-nervosS, Stuttg.
1782 grass. 8vo. Stuttg. 1793. — Sir oc?/*, in Acta Reg. Soc.
Med. Havn. vol. iv. p. 321 . — Selle, Rudimenta PyretologiiE
•3d edit. p. 262. — Canz, Beschreib. einer Schleimfieberepi-
demie. Tiib. 179-5. — Reil, Memor. Clinic, fasc.i. p. 6. —
Py, De la Fievre Muqueuse, Jonrn. Gen. de Med. t. xix.
p. 229. 1805. — .Sarcone, Hist. Raisonnee des Mai. Ob-
serv. a Naples, par Ballay. Lyon, 8vo. 1804. — Pinel, No-
sog. Fhilosoph. t.i. p. 132. — Hildenhrand, Institut. Med.

Pract. vol.iv. p. 741 Boisseau, Traite des Fievres, &c.

p. 174.

XX. Feveh, Sweating. — Syn. Miliaris Su-
datoria, Sudor Miliaris, Miliaria (from mi-
lium, a millet seed). Sudor, Sudor Anglicus,
Sudor Picardius, Febris Sudatoria, F. Helodes
Sudatoria, Sudatio Febris Helodes, F. Miliaris,
F. Vesicidaris, Purpura alba, Auct. var. ;
Miliaris, Sauvages and Sagar ; Febris Pur-
purata, F. HofFmann ; La Suette, La Suette
Miliaire, La Suette Fpidtmique, Fievre Mi-
liaire, Pujol, Gastellier, Meniere, &c. ; Der
Friesel, Germ. ; Miliary Fever, Sweating Mi-
liaria, Sioeating Sickness.

416. Defin. — After lassitude and general 7tn-
easiness, a sudden attack of febrile disorder, with
7nnst profuse and continued sweat, frequenthj fol-
lowed bq an eruption of miliary vesicles, the disease
occurring epidemically and being infectious.

417. I have preferred the name sweating fever
to that of miliary fever, as sweating is the con-
stant and characteristic phenomenon of the disea.sc,
and is present in the mild as well as in the most
malignant cases ; whereas the miliary eruption is
sometimes wanting in both. This niahuly should
not be confounded with the febrile affections of
lying-in women, attended by sudamina, that have
improjicrly been denominated miliary fever, from
the character of the eruption sometimes occurring
as a symptom of them, during hot seasons and a
too heated regimen. 'J'his is a specific fever, sel-
dom observed in modern times, in this country,
althougli frequently prevailing epidemically in
roany parts of Continental Europe,

418. i. History. — The epidemics which have
been variously denominated, as stated in the Syno-
nymes, have manifestly been modifications of the
same disease, caused by the varying circumstances
connected with its appearance. — The epidemic
sweating sickness, which appeared between 1485
and 1528, and which ravaged England in these and
several intermediate years, was evidently, as sup-
posed by MiM. OzANA.M and Raver, a most vio-
lent form of this malady, in which the sweat was
the most prominent symptom, and the progress
most rapid and acute. But many cases noticed
by BoYER and others, in recent epidemics, were
similarly characterised. — (a) The epidemics ob-
served in France by Riverius, during 1618; in
Germany by Welsch and Laxgius in 1652 ; in
Francfort in 1653; in Augsburg in 1660; in
Bavaria in 1666 ; in Holland by Gruxwae,
in 1666 ; in Hamburgh in 1675 ; in London and
in Edinburgh, towards the end of the seventeenth
century, by Hamilton and Sibbald ; in Saxony
in 1694 ; in Hungary in 1697 ; in Plymouth by
HuxHAM, in 1738 ; in Normandy by Le Pecq-
de-la-Cloture, in 1740; near JMantes by
Quesney, in 1750; in Navarre by Augu.stinis,
in 1755; in Bayeux from 1769 to 1776; in
Piedmont by Allioni, in 1758, and by Dami-
LONio in 1782 ; and in Toulouse and the vicinity
by Gallet du Plessis, in 1781 ; were essen-
tially the same disease. In all these, the fever
was ushered in by chills, horripilations, and
other premonitory and invading symptoms, which
were soon followed by pains in the head, loins,
and limbs; by nausea, flushing, profuse sweat,
dyspnoea, and, about the third day, by a mi-
liary eruption. Numerous other epidemics that
have presented this form of eruption as a pro-
minent symptom, have been described by writers,
who observed them during the two last cen-
turies. But in these it was apparently caused,
either by a too heating treatment and regimen, or
by the neglect of evacuations during the early
stage of the disease ; and it was not always con-
nected with excessive sweat. It was, indeed, in
most cases merely a symptomatic eruption appear-
ing at an advanced period, in a similar manner to
petechia:, &c., with which it was even sometimes
associated. In the epidemics, however, which I
have above enumerated, the eruption was not a
consequence of neglected evacuations, nor of a
heating regimen, for the treatment was generally
depletory and cooling, and it occurred earlier in
the disease, although always preceded by profuse
sweat, which was coetancous with the vascular
excitement, and always peculiar and offensive.
So thick a vapour generally surrounded the sick,
arising from the excessive perspiration, that the
flame of a candle was obscured by it.

419. (b) The epidemic occurrence of sweating
fever in various parts of I'icardy was first noticed
in 1718. Since that time it has frequently ap-
peared in that province, and in other parts of
France; and has more nearly approached, than
the epidemics noticed above, the characters of
the sweating sickness of the 15th and 16th cen-
turies, in respect of the rapidity of its course, the
profuse sweat, and the fre(iuent absence of the
miliary eruption. The sweating fever of Picardy
ajipears to have prevailed more or less in various
parts of this province anfl of Flanders, from 1718
till 1747. In this year it appeared in Paris; and

FEVER, SWEATING — Symptoms.

was described by Bellot, RIalouin, and Boyer.
In various seasons, cases equal in severity to those
of the terrible sweating sickness of the 15th cen-
tury occasionally occurred. These writers ob-
served some that ran their fatal course in fifteen
liours, although more generally death did not
take place until the third, fourth, fifth, or sixth
day, or ever later. When patients passed the
seventh day, they generally recovered. — The most
robust were the most violently attacked ; children
and the aged generally escaped. Irruptions of
this form of the disease occurred in various parts
on the Oise, in 1747 ; at Beauvais in 1750 ; in
several parts of the north of France in 1753 ;
and in the environs of Amiens in 1758. (Mey-
ZEREi, Vandermonde, &c.) The chief pecu-
liarities of these epidemics were a frequent occur-
rence of hajmorrhages, and of severe and compli-
cated cases, often terminating fatally at the end of
one or two days. Robust persons were the most
severely attacked in these as in other epidemics.
Females often experienced menorrhagia in the
course of the disease ; and hjemorrhages occurring
on the third or fourth day were generally fatal.
The sweat was foetid, or putrid, as likewise was
the air expired by the patient. Bloodletting was
employed at the commencement in the more ro-
bust and plethoric ; at an advanced stage it was
most injurious. Emetics, cooling aperients, acidu-
lated drinks, refrigerants, &c. were also pre-
scribed; and at a later period the preparations of
cinchona, the decoction of contrayerva, camphor,
&c. These were found the most successful reme-
dies.— The epidemic of Saint Quentin, in 1768
and 1769, was generally ushered in by slight
chills, rapidly followed by great heat, thirst, pains,
and other symptoms. The treatment just described
was most commonly employed. Since then, several
other irruptions of this fever have occurred, pre-
senting the phenomena about to be enumerated.
'J'hat which took place in 1821, and was ably de-
scribed by M. Rayer, was evidently more asthenic
than those above referred to.

420. ii. Symptoms. — Individual cases of this
fever are very much modified, even during the same
epidemic, by the prominent affection of different
organs in different persons. To this circumstance
is to be imputed its great diversity, as to severity
and character, even in the same family and in
similar circumstances. ]M. Rayer, however,
divides it into two forms, the mild and the malig-
nant ; but it is obvious that intermediate grades
are equally common ; and that most of the malig-
nant or severe cases are rendered such by local
complications. — (a) In the milder form patients
frequently complain of lassitude, loss of appetite,
and pains over the eyes. Sometimes they feel
the gradual accession of fever, and as if a vapour
were extending over their limbs, until it amounts
to burning heat, and more generally constriction
about the epigastrium, for a very short time before
the hot vapour is exhaled in the form of sweat
from the surface. Occasionally persons have
gone to bed apparently well, and have awakened
bathed in sweat, which continued till their reco-
very on death (Rayer). The tongue is covered
with a white, foul, or, more rarely, a yellow fur ;
and the rnouth is clammy. There is more or
less thirst, no appetite, and the bowels are cos-
tive throughout tiie disease. The urine is scanty.
Respiration is oppressed, and the head aches.

991

The pulse is slightly accelerated, but becomes
more frequent at the period of tiie eruption ; and
is commonly full and soft. This state continues
through the second, third, and fourth days ; on
which, but commonly on the third, a slight sens-
ation of tingling is felt, followed by a miliary
eruption on the skin. The eruption appears first
on the neck, and spreads, either rapidly and gene-
rally, or slowly and partially, to the breast, sides,
trunk, and insides of the thighs, legs, and arms.
It may, however, come out suddenly as well as
in succession, and be distinct or confluent. The
vesicles which constitnte it are the size of millet
seeds, diaphanous or pearly, and are easily felt
by the fingers. They are often intermixed with
red papulae ; and more rarely, bullae appear on
some parts of the body. In about two or three
days they dry up, and are followed by a desqua-
mation of the cuticle. — The sweating is much
more constant in its occurrence than tiie eruption
— is always present, is remarkably profuse through-
out the disease, especially before the eruption has
become general, as it afterwards is somewhat
diminished ; and is attended by a peculiar odour,
which Rayer, Schahl, and Hessert compare
to that of rotten straw, and M. Meniere to that
of water impregnated with chlorine, or to that of
the stools of patients in cholera. Le Pecq-de-la-
Cloture says that it has a rotten-sour smell.
The surface is hot, and more or less red. The
sweat, rarefied by the heat, forms a cloud around
the patient, that is condensed, and falls like fine rain
or dew upon the bedclothes. The dyspnoea seems
to depend upon congestion of the lungs and large
vessels, and is referred chiefly to the prsecordia
or to the epigastrium. The headach may be
suborbital or general: it is dull, heavy, and de-
pressing, and seems not to be altogether the result
of vascular determination to, or congestion of, the
brain. In this form, the abdominal regions pre-
sent nothing particular. The symptoms decline
by degrees, and rarely continue longer than four-
teen days ; they commonly disappear about the
eighth or tenth day.

421. (b) The severe, complicated, or malignant
form is generally sudden in its attack as well as
the mild ; but lassitude and want of appetite usu-
ally precede it for some days. The principal
symptoms of invasion are, sometimes chills or
horripilations, and commonly vertigo, violent
headach, nausea, efforts to vomit, flushed coun-
tenance, urgent dyspnoea ; pain in the epigas-
trium, loins, and limbs ; anxiety ; throbbings of
the arteries, and most profuse sweat. Either the
cerebral, or the thoracic, or the abdominal sym-
ptoms predominate in different cases, and give rise
to distinct complications. Where the head is
more especially implicated, delirium, coma, and
convulsions are often present, and soon terminate
life. In these, the patient first complains of
vertigo, severe headach, nausea or vomitino-,
flushed face, injected and starting eyes, epistaxis,
throbbing of the carotids and temporal arteries,
&c., and soon becomes delirious and comatose.
In rarer instances, the spinal chord and its mem-
branes are particularly affected, the patient com-
plaining of painful tension in the course of tiie
spine, with tetanic rigidity or spasms of the vo-
luntary muscles. When the lungs are chiefly
aft'ected, there is often deep-seated pain in the
chest, great dyspnoea, a short and quick respir-

992 FEVER, SWEATING

ation, tlie crepitating rattle, or a blowing noise in
some of the lobes of the lungs, diminished sono-
rousness of the chest, a full andfrequent pulse,
and bloody expectoration or h.-emoptysis, indicat-
ing inflammation or inflammatory congestion of
the respiratory organs. Wlien the digestive
organs are predominantly diseased, the patient
complains of an acute constrictive pain in the
epigastrium, with urgent anxiety, frequent sigh-
ing, a sense of suflfbcation, or of weight in the
chest, and an unusual pulsation in the region of
the stomach. These appear from the commence-
ment, aie exacerbated at intervals, and are most
severe just before the eruption. In others, the
symptoms indicate affection of the bowels, with
constipation ; and in some, severe pains are felt in
the hypogastrium, with scanty, high coloured
urine, and difliculty in voiding it. — 'I'his violent
form of the disease may prove fatal in twenty-four
or forty-eight hours, or in three or four days ; but
it commonly runs its course in from one to two
weeks in favourable cases ; sometimes, however,
extending beyond three weeks. During con-
valescence, debility is its chief consequence,
secondary affections being rare. Those that do
occur, are gastro-intestinal disorders, and the
eruption of boils.

422. c. I'he alterations^/ structure have been
imperfectly observed. — When a fatal result has
been preceded by anxiety, pain, or burning in the
epigastrium, the mucous coat of the stomach and
duodenum has been found much injected. In
the cerebral complication, the brain has been
found congested, the membranes injected, and
the ventricles filled with serum. In the pul-
monary complication, congestion of the lungs,
and hepatization of portions of it, have been re-
marked. Although epidemic visitations of this
disease in France have been frequent in modern
times, and fatal cases very numerous, yet its pa-
thological anatomy has been very imperfectly
investigated. It is evident that death is caused
chiefly by the severity of the complications ac-
companying it.

423 . iii. Diagnosis. — The constant, the profuse,
and the peculiar sweat attending the disease from
the tiine of its development, not only characterises
it, but distinguishes it from all other fevers. The
severity of the complications in the intense form,
especially at the time of attack, and upon the
appearance of the eruption, the character of the
eruption, the epidemic prevalence of the malady,
and its infectious nature, further serve to distin-
guish it. The descriptions of the sweating sick-
7iess by C'aius, Wii.i.is, and others prove tliat it
was a more intense form of this disease than has
been lately observed. The cliaracteristic symp-
toms of the former all exist in the latter; and,
although the eruption is not mentioned in the
sweating sickness, this appears not to have been
a general symptom in recent epidemics. J\I.
J{avfu states it to have been wanting in a great
number of cases, in the epidemic of 1821 ; and
M. Mlnikui; makes a similar lemaik as to that
of 1832.

424. iv. PiiooNOSis. — Sweating fever, as ob-
served in modern times, is a mild disease in its
simple form. l'redon)inanl afl'ection of any inter-
na! organ will remler the prognosis unfavourable,
accr)rdiiig to the severity of such afl'eclion. I low-
ever alarming the symptoms, if tliey decline

— Diagnosis — Treatment.

upon the appearance of the eruption, a favourable
issue may be anticipated. M. Rayer states that,
in 1821, the eruption was independent of irri-
tation of the stomach ; that it was confluent with-
out violent previous pain in the epigastrium or
nausea ; that it did nor always succeed the most
profuse and incessant sweat ; and that it did not
invariably appear in cases where the gastro-in-
testinal disorder was the most remarkable. Death
was often sudden — more unexpected than in the
common eruptive fevers, — and often followed
upon shrivelling of the vesicles. The greatest
number of deaths occurred in 1821, between the
ages of 23 and 33. The mortality in males was
one in thirteen ; and among females, one in
twenty-eight. In the earlier epidemics observed
in Picardy, the mortality was very much greater
than this. It was greatest at the beginning and
decline of the epidemic ; and among bakers,
smiths, and farriers: but was variable in different
townships. The epidemic of 1832 was in many
instances followed by pestilential cholera. The
latter malady often followed the decline of, or
convalescence from, the former, and even occa-
sionally appeared in its course ; the mortality
being thereby much increased.

425. V. Causes. — The theatre of the epidemic
of 1821, was bounded by extensive forests. M,
Rayer states, that the disease is endemic in some
situations ; and that it may occur sporadically
where it has prevailed epidemically. It has been
observed only between 43° and 60° North latitude.
IMoist and shady places, excessive heat, and an
atmosphere surcharged with electricity, seem to
favour its irruption. No age gives immunity
from an attack; but adults and females are most
obnoxious to it. M. Meniere states, that many
of those who had the disease in 1821 were again
attacked, and died of it in the epidemic of 1832,
When once engendered, it spreads by infection,
in the same manner as typhus, scarlatina, and
measles. Unhealthy situations, and the poor in the
vicinity of the place where it firstappeared, suftered
in proportion to their proximity, during these two
epidemics, M, Meniere ren^arks that, of the nu-
merous epidemics which have occurred in France,
and in other countries, since 1718, to the pre-
sent time, there is none which shows its origin,
either in marsh exhalations, or in unwholesome
food.

426. vi. Treatment. — Isolation, temporary
migration, and avoidance of the afl^ected, aie the
only preservative means that can be depended
upon in this malady. — The ?)n7(/ s((i(ei- reijuire
but little aid ; and it is doubtful if medical treat-
ment will either shorten or iilleviate the attack.
In the severer farms, and wliere some inteinal
organ is especially affected, appropriate remedies
ought to be em])loyed to guard it from danger.
If the affection of the head, or of the chest, or of
the digestive organs, be slight, lucal dejiletions will
give relief. If the local complication be severe,
general hlocdlellings, with powerful external and
internal derivatives, as blisters, sinapisms, purg-
atives, &c., will be occasionally used with suc-
cess. But i\l. IIaveu remarks that the cerebral
afl'ection, when severe, is often rapidly fatal, not-
withstanding the repealed abstraction of blood :
and that the nervous phenomena are occasionally
independent of actual inflammation. — After the
eruption, bloodletting is always injurious; and if

FEVER, SVNOCIIOID

it be resorted to at an earlier stage, and in large
quantity, with tlie view oF cutting- short the dis-
ease, it may have a fatal effect, but it never will
produce tiie desired result, \\nien the eruption
tiisappears suddenly, dry frictions, iirticaiioii, si-
napisms, hlisters, and rubefacient liniments, ought
to be employed to solicit its return. Sudarijics
may also be employed in this case ; but they are
seldom useful in other circumstances, as it does
not seem advisable to use means to increase the
sweat. ScAiiL and Hessert found cold bathing
and aspersion of cold water beneficial at an early
stage ; and M. Raver observed the pain at the
epigastrium, and spasm of adjoining parts, pre-
ceding the eruption, to cease after the application
of cold epithems to this region. Emollient caia-
flasms, fomentations, and clysters, will alleviate
abdominal pain, and dysuria; and the general
warm bath, tiie hip bath, and frictions of the sur-
face, will have a similar effect, and promote con-
valescence, particularly if the intestinal or the
urinary canal be disordered. In the more recent
epidemics, ipecacuanha and the preparations of
anti/noHii were given in the first stage, with the
view of rendering the subsequent course of the
disease more mild ; but this practice was found
more injurious than beneficial.

427. Tlie above comprises more than all that
M. Rayer, the historian of the epidemic of 1821,
has advanced respecting the treatment. Tessieu,
BoYEn, and jMenieke, however, state, that full
bloodletting at the commencement is gene-
rally beneficial, and evidently relieves all the
urgent symptoms. Indeed, the epistaxis often
attending the cerebral affection, the ha:moptysis
accompanying the pulmonary congestion, and
the ciiaracter of the gastro-intestinal symptoms,
most obviously demand it. 'I'liey further advise
tepid diluents in moderate quantities ; gentle ano-
dynes to relieve the insomnia generally com-
plained of ; and mild derivatives to favour the
eruption, which, when copious, often alleviates
the internal affections. M. Rayer says no more
of the use of purgatives in this disease, than if
such means were entirely unknown. The writers
who treated the epidemics in the 17th, and earlier
part of the last century, employed them freely,
and were certainly not less successful in their
treatment than he. AI. Menijere advises the
milder kinds to be exhibited in most cases, and
especially when tiie tongue is loaded. When
the pulmonary congestion is urgent, he directs
full bloodlettings and external revulsants ; but
lie judiciously advises the effect of the former to
be sedulously watched during the operation, as a
too careless mode of abstracting blood, or a too
large quantity, may produce instant and fatal
collapse. There is evidently more of congestion
than of inflammation in all the internal compli-
cations of this disease ; and vital or nervous power
is more or less depressed : therefore, although free
depletions are often necessary, they should not be
confided in alone ; but camplior, ammonia, ser-
pentaria, &cc., ought to be exliibited according to
the peculiarities of the case, and conformably
with the principles explained in various sections
of this article. When the eruption appears, means
calculated to suppress it, or even to delay or di-
minish it, should be avoided. Vascular depletions
have been then found injurious, and even speedily
fatal ; and cold applied to the surface is equally

993

dangerous : errors of diet and regimen are likewise

injurious.

428. liegimen. — Patients ought to be deprived
of nourishment of every kind, the first, four or five
days of the disease, or even longer. Diluents of a
mild kind, and tepid, should be given in moderate
quantity. A little veal or chicken broth may be
allowed about the sixth, seventh, or eighth day ;
and the quantity and consistency of the food
gradually increased. Relapses may follow errors
in diet, or consecutive gastro-intestinal disorder
may be induced by this cause. The regimenal
and other means usually required in epidemical
maladies, are necessary in this.
BiiiLioc. AND Refer. — L. Frisius, Sudoris Anglic'

Ratio, Praeservatio, Curatio, 4to. Arg. 1529 S. Richini'

Ue SudatorifE Feb. Cuvatione, 4to. Colon. 1529 J.

Schiller, De Peste Britannica Liber, 8vo. Vo'iX. — J.Bcne-
(liclits, De Novo et prius German, inaudito IVIorbo, quera

Angliciim Sndorem appellant, 8vo. Crac. 15.50 J. Cains,

De Ephemera Britaimica, 8vo. I.ond. 1721 Frncas-

foriiis, DeMorbis Contagiosis.l.ii. cap. 5 Bacodc J'eru-

himio. Hist. Ilenrici VII. ^.h. — Camcraritts, Memorab.
cent. viii. No. 49 — Foresttts, Observ. et Curat. Med.
1. xxviii. p. IBH. — Schen/c, Observ. Med. Rar. fol. Lugd.

UJ44, p. 730 See Casirius, Curdiis, Kcpp/cr, Nidcmon-

tnnus, Neuenaar, P/iri/gius. et Jyirnn;, in llallcr'a Bib-
liotli. Med. Pract. vnl.i. awAn. passim. — Somcrtiis. De
Febribus, l.iv. cap. \^. — Jvncker, De Purpura Alba Ma-
ligna et Benignft. Ilalifi, 1738. — Sn/xwrtWM, Hist. Pur-
puiiB Miliaris Albas curaprimis Argent, et Viciniam in-
festantis. Arg. 1736 — Bellot, An Febri pntrida; Picardi.s
Suette dicta; Sudorifera? 4to. Paris, 1733. — i?a»7.c>-, Ob-

servat. on the present Epidemic Fever. Lond. 1741

Vaiidcrmondc, Journ. de Med. t. xii. p. 354. {The epi-
demic of (hiise in June and July, 17.59.) — Ibid. t. xx. p. 7.
— lioi/er, Mi'thode a snivre dans le Traitement des differ.
Mai. i:pideniiiines,&c. 12nio. Paris, 17G1. (The epidemic
of Bcauvais in \7oO.) — De Angustinis, Observat. circa
Febres Miliares regnantes Mediolani, 1755. Med. 1758.
8vo — Fantoni, De Acutis Febr. Miliaris, iS:c. Nissa,

1702 Fischer, De Febri Miliari Purpura AlbS dicta.

Riga, 1707 — Baraillon, Mem. de la Soc. Koy. de Med.
A. 1770, p. 193. — ile Hae7i, Rat. Med. p. viii. c. 10.—
Tcssicr, Mem. de la Soc. Roy. de Med. de Paris, 4to. t.ii.

p. 4G. (77/t' epidemic of Hardvillicrs in Mai/, 1773.)

Oastcllier, Traiti5 de la Fievre Miliare Epidemique, 12mo.
Paris, \~M. — Pujol, CEuvres, t. iii. p. 2G1. 8vo (The
epidemic of Laiiguedoc in the spring of 1782.) — Tho-

mann, Annaleii ad 1800, p. 259 Kreysig, in Hvfeland,

Journ. dcr Pract. Heilk.l. xii. st.3. p. .59. — Schmid'tmann,

in Uiifelaiid, Journ. der Pract. Arzneyk, b. iii. p. 449

Sleriilterg. in Horn, Archiv. b. v. p. 22. — J.A.F. Ozatiam,
Hist. Mid. des Maladies Epideniiques, &c. 8vo. Paris,

1823, vol. iii. p. G2. 105 Bayer, Sur I'Epideinie qui a

regne dans Ic Departement de I'Oise en I82I. 8vo, Paris,
1822 ; and Treatise on the Diseases of the Skin, by IVillis,

8vo. Lond. 1835, p. 353 Meniire, Archives Gi5n. de

Med. t.xxix. p. 100. (The epidemic of the Department
of the Oise in 1832.) — Hourmann, Gaz. Medicale. Paris,
1832, p. 271. — Pinel-Grandcha??ips, Lancette Frangaise,
t.vi. yi.lCA. — Morcau, Journ. Hebdomad. Sept. 1832.

XXI. Feveh, SYNOcnoiD. — Syn. Synnclms,
Auct. var. ; Enecia Syncchus, Good ; Synochus
mitior, S. Smith ; Common Continued Fever.

429. Defin. — Languor, lassitude, and chills,
followed by vertigo, moderate vascular reaction

and other febrile syinptoms, of a contimied type,
and regular course.

430. This is the most common form of con-
tinued fever in this country. It appears either
sporadically or epidemically. In the latter case,
it is frequently complicated, or characterised by
predominant nfl'ection of some particular viscus
or part, and thence generally assumes a severer
charaQter than in its sporadic form. It often
appears in this latter manner from other causes
than infection ; but, in circumstances favourable
to the generation of an infectious effluvium, this
may become a superadded or a chief cause, or,
indeed, the only cause ; but, in this case, the
disease which results is some one of the moi'e
common forms enumerated under the typhoid

3S

994 fever; SYNOCHOID

species of continued fever. — As, therefore, the
causes of synochoicl, and of these forms of typhoid
fever, are often the same — their intensity and
concurrence producing the more severe states of
disease, as well as giving rise to an infectious
miasm — the view which is about to be taken of
them with reference to the former species, will
very nearly serve also for the latter.

431. i. Description. — Common Continued
Fever occurs in a simple and complicated form,
presenting various grades of severity ; the severe
and complicated states passing into, or becoming
identified with varieties of the adynamic species.
The severe states of common fever have been very
generally imputed to its complications with in-
flammation of internal parts ; but, although its
complications are necessarily severe, yet it may
be equally so without any evidence of local or
predominant affection. This, however, is seldom
the case. — I shall, therefore, first describe the
simple form, and afterwards the more usual
complications and states of severity.

432. A. Simple Continued Fever — Simple
Fever; Mild Synochus ; Synochiis 7nitior — is usu-
ally preceded by the symptoms described above,
as constituting — a. The precursory stage (§ 34.),
especially by lassitude, and a general feeling of
uneasy debility and mental languor. The coun-
tenance is pale ; the features sharpened, dejected,
or anxious ; and the pulse weak and small. — b.
After an indefinite period, varying from two or
three, to several days, irregular chills, rigors or
shivering, commonly alternating with transient
flushings or feelings of heat, are experienced,
with the symptoms characteristic of the period of
invasion (^ 35.). This stage is seldom attended
by any actual coldness of the surface, particularly
after it has continued a short time ; the chilliness
being accompanied by increased heat, constric-
tion, and dryness of the skin. — c. With the
disappearance of the chills, the period of reaction
or of excitement (§ 36.), and all the phenomena
associated with it, supervene. The vertigo, pains
of the head, back, and limbs, and restlessness,
usually present in the preceding stage, are in-
creased in this. The patient complains of mental
confusion and inability ; of general uneasiness
and restlessness ; the countenance becomes full
and fluslied ; the tongue white, foul, loaded, or
furred ; the heat of surface generally rises above
100^, and the pulse and respiration are fuller,^
stronger, and more frequent than natural ; the
pulse being commonly from 90 to 100 or 105
beats in a minute. 'I'he fever is now developed,
and proceeds, as described above (§ 36.), usually
for several days, — its duration varying from two,
three, or four, days to as many weeks, until it either
subsides in consequence of the treatment adopted,
or passes off by means of some critical evacuation
(the period of crisis), wiiich most frequently
occurs on one of the critical days, from the 3d to
the 21st day from the time of invasion, or that in
which chills or rigors were first felt. The stages
of decline and convalescence commonly advance
in th(; manner stated above (§ 41, 42.).

433. 'I'iiis mild form of fever generally termi-
■nales favourably, even when left to nature ; but
it may become complicated in its course, or pass
into a stale of dangerous, or even fatal, exhaus-
tion towards the end of the second week, par-
ticularly in weak, aged, and exhausted persons.

•Description of.

The return of the healthy functions is indicated —
a. by the subsidence of the prominent morbid
actions ; — 6. by the appearance of critical evacu-
ations ; — c. by a quiet and prolonged sleep, out
of which the patient awakens refreshed, and par-
tially restored ; — and, </. by the other phe-
nomena already enumerated (§ 41.), as indicative
of a gradual decline of the disease. The trans-
ition to a severer form of fever is commonly
owing to the occurrenceof a predominant affection
of the respiratory surfaces, or to the change in-
duced in the circulating and secreted fluids, or
to the affection of the digestive mucous surface,
or to the circulation within the head.

434. B. Severe or Complicated Synochoid
Fever — Synochus gravior ; Severe Synochus —
occurs from the same causes that produce the
milder disease, either acting with greater intensity,
or aided by additional circumstances. — The seve-
ral stages may present a more severe affection of
all the functions than has been now described,
without any very predominant lesion of a par-
ticular organ ; but much more frequently some
important viscus betrays increased disorder, gen-
erally of an inflammatory or disorganising kind.
Yet this predominant lesion is not altogether
identical with inflammation — certainly not with
the inflammation primarily affecting healthy per-
sons. It is less acute or intense as respects the
symptoms attending it, more asthenic as regards
the state of constitutional power, and more dif-
fusive and sub-acute in its character, than com-
mon phlegmasia. It partakes of more of the
features of the erysipelatous than of those of
common or pure inflammation. Even when the
local affection is more than usually phlogistic in
appearance, still it is most important to recollect,
especially as respects the treatment, that it is
preceded and attended by a more or less severe
constitutional disturbance, by lesion of the va-
rious manifestations of life, and by a change of
the circulating and secreted fluids, — circum-
stances arising out of the poisonous influence of
the febrile cause, and imparting the peculiar
characters to this affection, — changing it from
the true phlogistic or sthenic inflammatory con-
dition, and determining, accordingly, the con-
sequent lesions (i 50.). Instead, therefore, of
viewing the complication as the cause of the
severity of the fever, we should rather consider
the intensity of the morbid impression made by
the febrile poison, and the resulting consequences,
as the principal source of severity and of local
affection, aided by the predisposed state of con-
stitution, and of the viscus especially affected. —
I shall describe the predominant lesions or com-
plications of synochoid fever, in the order of their
usual succession, and of their frequency.

435. (1. Synochoid fever with predominaiU
njf'ection of the bronchi and lungs. — This is the'
most common, and generally the earliest, com-
plication, although it frequently exists only in a
slight degree. The bronchial surface is often
more or less congested and irritated, and the
structure of the lungs sometimes implicated.
— This complication is not necessarily severe in
proportion to the severity of the fever; but when
It is early present, and its symptoms prominent,
it necessarily aggravates the fever, and super-
induces furtlier complications, l)y impeding the
changes produced in the blood by respiration.

FEVER, SYNOCHOID — Description or.

995

That the respiratory organs, particularly the
bronchial lining, sliould be very frequently af-
fected in fever, may be expected from the nature
of the exciting causes, and the channels through
vvhicii tiiey invade the system, as already ex-
plained (§ 100. et seq.) — the respiratory surfaces
being the parts on which the morbid impression
is generally first made on the frame. — In most
instances, the predominant disorder of these
organs is limited to the bronchial surface ; but,
in others, the substance of the lungs is also con-
gested ; and, in rarer cases, the pleura is at the
same time implicated. During particular seasons
and epidemics, and in some climates more fre-
quently than in others, this complication is very
generally observed. When the bronchial mem-
brane is especially aftected, and the symptoms are
very obvious early in the disease, it has usually
received the name of Catarrhal Fever. But the
affection of the bronchi, especially when the
mucous secretion is not abundant, and still more
frequently that of the parenchyma of the lungs,
is often nearly concealed by the severity of the
cerebral symptoms superinduced by it, or is latent
owing to the altered state of the circulating fluids,
or masked by some other predominant lesion.
This fact, first clearly established by Laennec,
points out the necessity of having recourse to
mediate auscultation, not only in cases presenting
the open symptoms of the pulmonary compli-
cation, but also in those of considerable severity,
and where the sensorium is much disturbed.

436. The bronchial affection is generally not
very remarkable during the first two or three
days ; the patient complaining only of a slight
oppression or constriction in the chest, with ac-
celerated respiration and occasional sighing. To
these succeed fits of dry cough, wheezing, and,
subsequently, the expectoration of a dark viscid
mucus. There is often no cough ; and the
bronchial affection is evinced chiefly by the mu-
cous rhonchus heard more or less extensively
upon auscultation, by the disordered breathing,
and by the matter expectorated. When the mu-
cous rattle is heard extensively, and particularly
if it extend to both lungs, great danget should be
apprehended ; for the changes induced by re-
spiration on the blood being impeded, this fluid
becomes vitiated and induces serious disturbance
of the brain, and of the excreting organs and
surfaces, ultimately passing into structural lesion.
If the affection implicate much of the substance
and vesicular structure of the lungs, the breath-
ing becomes hurried, oppressed, or laborious,
especially after coughing ; and the expectoration
rounded and streaked with blood. In such cases,
the fever is always severe, and attended with
much danger, generally in proportion to the ex-
tent to which the respiratory surface and lungs
are affected. But the danger is not dependent
solely upon the pulmonary affection, but also
upon the consequences which have been just
shown to arise out of it. When, therefore, with
the symptoms now mentioned, the edges of the
tongue and lips are dark or purplish, and the
countenance of a dusk)' hue, or flushed or suf-
fused with a dark red ; when the patient becomes
delirious or comatose ; the pulse very frecjuent,
soft, and feeble ; the abdomen tympanitic, or
inordinately relaxed ; the temperature of the
extremities low, or their motions tremulous ; and

the tongue loaded with a brown or black coat-
ing; consecutive pathological states of great
danger, owing to depressed vital power, and to
contamination of the fluids, then exist.

437, It not infrequently happens, that a
severe bronchial complication attends the early
stage of tiiis fever ; and that, as soon as the blood
is so contaminated, and the cerebral functions
are so disturbed, as to obscure sensibility, and
lower irritability, the bronchial afl'ection becomes
latent, and its more obvious symptoms disappear;
the pathological conditions which it induced being
now most prominent, and proving the immediate
cause of an unfavourable result. If, in sucli
cases, we succeed in removing the morbid con-
dition of the blood, by exciting the nervous
energy and the functions of excreting organs,
the bronchial affection often returns, with the im-
provement in the circulating fluids and in the
nervous functions ; but it also often disappears
entirely with the other affection of important
organs, particularly when critical evacuations
terminate the disease. This return of the bron-
chial affection with the decline of the other
dangerous symptoms, I have remarked in several
cases; but it may generally be permanently
removed by appropriate means (§ 530.). In the
progress of this complication, the expectoration
which was at first scanty and frothy or viscid, or
altogether wanting, is more copious, of a pale
yellow, or yellowish green hue, and gradually
diminishes with the decline of the fever. In some
instances, it becomes so abundant, as the disease
passes its acme, as to favour the resolution of the
inflammatory congestion of the bronchi or lungs,
and thus to prove a salutary crisis, as remarked by
some of the older writers. — When, with dyspnoea
and oppression, there are much uneasiness and
inability to expand the chest, with a short and
quick respiration, active congestion of the paren-
chyma of the lungs should be suspected ; and
if, in addition to these, pain be occasioned on
coughing, and on full respiration, an inflam-
matory state, probably extending to the pleura,
may be dreaded. — In the last stage, the skin is
dusky and cool ; the pulse is feeble and hurried,
more rarely slow and intermittent ; the headach
passes into incoherent wandering, or low mutter-
ing delirium, or coma, but never into violent
delirium. When sensibility is early impaired,
this complication may proceed to extensive or-
ganic change, without having been suspected
during life, owing to the imperfect evolution of
the usual signs, and to the circumstances already
stated (§ 435.). But if the breathing be atten-
tively observed, it will be always found more or
less disordered in these cases ; and if auscultation
be also resorted to, the local affection will not
pass undetected.

438. h. Synochoid fever jcith predominant
cerebral affection. — This complication may ap-
pear early in fever, or at any period of its course.
It may be the only prominent lesion, or it may
supervene on either of the other predominant af-
fections. — It may be only occasionally observed,
or it may characterise particular epidemics ; and
it may, moreover, be slight or sub-acute, or re-
markably intense, and in all the intermediate de-
grees.— In the more slight or sub-acute forms,
it constitutes the Nervous Fever of some writers ;
and, in the more acute and intense grades, the

3S 2

996 FEVER, SYNOCIIOID — DEscnipnoN of

I'hrenitlc or Brain Fever of others. — The former
of these very nearly approach, in their patho-
logical states, the nervous variety of adynamic fe-
ver, denominated Ataxic by Pinel, Neuro-sthenic
by IIiLDENBRAJJD, and Tijphus milior by Cullen.
439. o. Common continued fever, with pre-
dominant cerebral aflection — the Neuro-sthenic
of HiLDENiiRAND — commences, and proceeds
for two or three days, as the simple or mild
form of the disease. Either then, or at an earlier
period, the patient usually complains of pain in
some part of the head, most frequently in the
temples and forehead, or in the occiput, extending'
down the neck. The pain is often constant and
severe, but it is sometimes slight or entirely
wanting ; and it is commonly attended by throb-
bing of the carotids and temporal arteries, and
flushings of the countenance. In those cases
where no pain is felt, even upon shaking the
head, tlie cerebral afiection may not be less ur-
gent and dangerous ; but there is always, in those,
a very early and remarkable giddiness, either with
or without flushing of the face. Occasionally
the pain and giddiness alternate, and the latter
is always distressing when the former is absent.
The expression of the eyes is either heavy and
dull, or morbidly brilliant and animated. The
conjunctiva is generally loaded, injected, and
suftused, in the former case ; and brighter and
more glistening in the, latter. But the eyes are
always more or less sensible to light, the eye-
brows contracted, and lids half closed upon ex-
posure to it. Hearing and the general sensibility
are also more acute. Noises and light inva-
riably increase all the symptoms. The heat of
surface is generally above the natural standard,
especially over the head ; but it is often not
augmented on the lower parts of the body. The
patient is watchful and restless, and the expression
of his countenance indicative of sufiering. In
the less acute cases, the pulse, the thirst, the
appearances of the tongue and of the evacuations,
are nearly as in the simple form ; and tiie sym-
ptoms generally continue, without alteration, for
several days. An important change then oc-
curs. In favourable cases the slumbers, which
were short and disturbed, or attended by a slight
dreamy delirium, become quiet, profound, and
refreshing. In unfavourable cases the pain in
the head changes to a dull, lethargic state, with
a great diminution of the sensibility, and with
increased injection and suft'usion of the eyes.
Delirium, if it have not already appeared, now
comes on, attended by moaning or by incoherent
muttering, during short and interrupted slumbers;
the tongue is loaded, dark, and dry ; and the
thirst is diminished. In from one to three days
the insensibility passes into coma, unless a fa-
vourable alteration takes place ; the pulse be-
comes very (juick, and ol'ten rises to 120 or
upwards; the strength sinks ; and the tongue is
more dry. To these succeed tremors, rolling of
the head on the pillow, tossing of the hands,
picking at the bedclothes, and the other danger-
ous sym])toms consccjuent upon the more acute
states of this complication. ICven when this
unfavourable change has occurred, a stop may
1)0 occasionally put to its progress, although it
generally pursues its onward couise. A more
trari(|uil and protracted sleep ; subsidence of the
delirium, or of the tremors, or of the frequency

of the pulse ; and a cleaner or more moist tongue
commencing at its edges, with an improvement in
the appearance of the countenance, and in the
state of the skin and of the excretions ; are the
usual indications of an arrest of the dangerous
progress of the disease.

440. /8. In the more acute states the cerebral
symptoms are severe, and their progress rapid, in
proportion to the intensity of the local compli-
cation ; the headach or giddiness, the intolerance
of light and noise, and the general sensibility,
being coordinately excessive. The pain in the
back, loins, and limbs is very great ; the skin is
often intensely hot, and pungent, particularly
over the scalp, and is occasionally covered by
perspiration, which is rarely copious or general ;
the eyes are injected and suffused ; the breathing
is frequent and suspirious ; the patient is anxious,
uneasy, and remarkably restless : he rolls the
head, and is wholly without sleep. The pulse is
at first strong, full, or bounding ; but generally
devoid of the hardness characteristic of primary
or pure phrenitis. Sometimes it is oppressed;
and, in the most intense states of complication,
it is often intermittent, slow, or not much above
the natural frequency. Within four or five days,
the pain passes into delirium and insensibility.
The delirium is sometimes violent, and is then
soon follovved by tremors and insensibility ; and
these by subsultus tendinum. The insensibility
increases, and passes into a drowsy lethargy ; the
delirium continuing, but becoming low and
muttering. The patient may still become ob-
servant, and answer when roused ; but coma
supervenes occasionally, with rolling of the eye-
balls or squinting, dilatation of the pupils, and
falling of the eyelids. The tongue is now parched
and brown ; the gums and teeth are covered by
a dark mucous sordes ; the evacuations take place
inconsciously and involuntarily ; the respiration
becomes irregular; the pulse either slow, or re-
markably rapid and feeble, or intermittent; and
life soon terminates.

441. lietwcen these extreme states there is
every grade of intensity, the above symptoms
being variously modified. In some cases the
cerebral afiection is very insidious, and more or
less slow ; in others, open, manifest, and rapid.
In the former it may be indicated only by giddi-
ness and sickness or vomiting; the pulse in the
carotids, and temperature of the head, not being
afTected. In a case of this description, which
lately occurred in my practice (Mr. H. of Fitz-
roy RIarket), all the symptoms subsided instantly
upon bloodletting'. It may thus exist never-
theless, although in a more protracted form, and
present but few of the above symptoms, which,
however, are most frccjuently observed, but not
all of them in the same case. The various
grades of this complication may be further asso-
ciated with considerable bronchial afToction, or
with the disorder of the digestive canal about to
bo noticed. In such cases the predominant
lesion, eilher in the head, the thorax, or abdomen,
frequently obscures the others, until the treatment,
by subduing it, renders them more evident, or until
some one of them requires additional activity.

442. c, Si/noclHiidJcvcr with predominnnt affec-
tion of the digestive mucoas surface. — The
mucous surface of the stomach and intestines is
afl'cctcd more or le.S3 in all fevers, in common

FEVER, SYNOCIIOID — Caus].s.

997

with the rest of the organisation. In the simple
or mild continued fever, it is generally less disor-
dered than in any other. But in tlie more severe
form it isoften prominently deranged, either at the
commencement or at a later period. — a. Tlie
affection of the mucous surfuce of the ftnmach is
sometimes remarkable from the invasion of the
disease. In this case, retchings and vomiting —
symptoms seldom observed in the thoracic and
cerebral complications, particularly the former —
are always present ; and tiie fever has hence been
denominated by many writers. Mild Gustric Fever,
from its very close resemblance to tlie species
described above (§ 392.). There are also pain
and soreness felt in the epigastrium, or in the
left hypochondriutn, and sometimes also in the
right, with tenderness on pressure. The bowels
are generally costive ; the tongue is red at its
sides and point, and loaded with a dirty yellowish
fur ; the pulse is soft, regular, full, sometimes
strong, seldom much above 100 ; and the skin is
hot. This state of disease is often followed by
cerebral affection, and all the characteristics of
that complication ; or it passes into the intestinal
or enteric form.

443. 0. The enteric affection is sometimes
present almost at the commencement of the dis-
ease ; more frequently it does not appear until
a later period ; and occasionally it supervenes
upon either the cerebral or the gastric complica-
tions— aggravating the former, and allaying the
latter of these afiections. — In most cases, it
indicates a severe form of fever, which, at an
advanced stage, is further associated vvith very
marked cerebral disturbance. It cominonly com-
mences with looseness, and with puin and soreness
in the abdomen, especially on pressure. Pain
and tenderness are much less complained of
when this complication occurs late in the disease,
or when the cerebral symptoms are also very
prominent. In cases of tlie early appearance of
the enteric disorder, abdominal pain commonly
ceases as the fever advances, particularly if the
head become also very much affected, even when
the purging and other symptoms are increased.
The tenderness, however, generally continues
much longer. The tongue is at first unusually
red at the sides and point, loaded with a dirty
white or greyish fur, and moist. As the fever
advances, the redness becomes darker and duller,
the surface drier, and the fur browner ; and at
last dark mucous sordes collect on the teeth and
lips. The abdomen is commonly soft and natural,
but is sometimes hard or doughy. 'The pulse is
at first full, and soft, ranging fiom 80 to 100;
but usually becoming more frequent at an ad-
vanced period. Thirst is also present, unless
when the head is much affected, and at the last
stage of unfavourable cases. When this com-
plication does not evince any improvement in the
course of two or three days, it assumes nearly
the same features as characterise the worst cases
attended by cephalic affection (§ 437.).

444. When the enteric affection comes on in
the course of the cerebral complication, it may
pass unheeded, unless the physician is particularly
watchful, and expert in detecting it. In these
cases, sensibility is so obspured, that pain is sel-
dom felt, even upon firm pressure ; and the
bowels are occasionally but little disturbed. The
tongue, however, is red at its point and edges,

1 is covered by a dirty fur, and is dry ; the pulse
I is generally about 110, soft, and small. In both
I these states of enteric disorder, the looseness or
j diarrhoea is the most fiequent symptom. 'i"he
' stools are from three or lour to eight or ten in
' the twenty-four hours ; and are at first feculent,
foetid, dark, and thin. They subsequently be-
I come, in unfavourable cases, watery and of an
ochrey hue, —an appearance imputed by Dr.
Bright to ulceration in the intestines. But this
result is more common in the enteric complica-
tion of adynamic than of synochoid fever.

445. y. The complications of the common
continued fever of this and other temperate cli-
mates, are more frequently associated or mixed,
as Dr. SouTinvooD Smith has very judiciously
insisted upon, than met with singly. In these
mixed affections, however, one or other usually
predominates more or less ; although cases some-
times occur in which it is difficult to say which
is most prominent; or the predominating disorder
of an early stage subsides, and is succeeded or
obscured by another. Occasionally, also, other
complications besides those above specified ap-
pear, even in the same epidemic. — Sore throat,
or injlammations of the fauces, j)huriinx, or oeso-
phagus, or severe affection of the liver, with
more or less disorder of the biliary secretion,
sometimes accompanies one or other of tlie pro-
minent affections above described.

446. ii. Causes. — J. Of the remote causes of
the varieties of continued fevers most frequently
observed in this and other temperate climates,
those which precede the operation of the more
effective causes, which are usually internal as
respects the occonomy, and which, from the cir-
cumstance of their disposing the system to the
operation of these latter causes, have been usually
called the predisposing, require first to be no-
ticed. It is often difficult to determine in what
the disposition to be affected by these forms of
fever consists, and in what manner it is caused.
To say, with many, that it arises from an increased
susceptibility, does not advance our information
one step, and is merely the substitution of one
term for another. Close observation of the cir-
cumstances connected with the origin of these
diseases will show us, that the disposition to be-
come affected with them is not the result of
exactly the same circumstances as favour the
appearance of ardent fever. A depressed or weak
state of vital power, especially as manifested in
the nervous systems, but particularly in that of
organic life, seems to be 'one of the most common
causes of predisposition. This is proved by the
fact, that perfect health, mental activity and
energy, confidence in various means of prevention,
the moderate use of tonics, «S:c., enable the body
to resist the impression of the exciting causes,
particularly infectious and mephitic effluvia ; and
that fear of the disease, despondency, the de-
pressing feelings and emotions, fatigue, increased
sensibility, disorder of the digestive and assimi-
lating functions, &c., are amongst the most
common occasions of these causes taking effect. —
But, although diminir-hed energy of the powers of
life has a marked influence in favouring the oper-
ation of the exciting causes, yet something moie
is required ; and this must be referred to a cer-
tain constitution of frame which is influenced
sometimes in a relative mauuer only by relative

3S 3

998 FEVEE, SYNOCHOID — Causes.

causes, and at other times only by positive
causes, and which often either resists the oper-
ation of the usual causes altogether, or yields
merely to the combined action of a greater or
less number.

447. A much greater predisposition to be
affected by continued fevers exists between the
ages of fifteen and thirty-five, than at any other
period; the forms of fever being generally of a
more inflammatory and acute kind between these
ages, and in the sanguine, irritable, and plethoric
constitutions; whilst persons past the latter of
these ages, and those of a lymphatic, leucophleg-
matic, or melancholic temperament, are more
liable to experience the lower grades of action.
Scarcity, famine, and, consequently, insufficient,
and unwholesome nourishment, among the lower
classes of the community, are the chief causes
of the generation and spread of fevers, especially
those of a simple, low, and infectious character.
AVhatever depresses or exhausts the vital and
moral energies, exposes the body to the impression
of the exciting causes. The circumstances which
produce this effect are fully explained in the ar-
ticle Disease (§ 21. 23. 27 — 36.), and in a pre-
vious section (§ 64.).

448. The disposition, also, which is generated
by certain epidemic constitutions of the atmo-
sphere and season, should not be left out of con-
sideration. A peculiar diathesis seems to be
gradually and generally induced by the epidemic
influence, whatever that influencemay be in respect
of its nature ; and this diatiiesis, or change of the
vital manifestations of the organisation, rapidly
passes into febrile commotion upon the action of
one or more of the exciting causes. The change
thus effected in the diathesis, and increased by
the impression of the exciting causes, may hence
be viewed as the proximate cause, or earliest
pathological state, of the disease ; and to its
continuance or non-continuance after the febrile
action is fully developed, is often to be imputed
the disposition or indisposition to relapse. This
is more particularly the case in respect of the
fevers caused by exhalations from the soil and
from decayed vegetable matters. Infectious mi-
asms— or the effluvia from the bodies of those
in fever — suddenly and remarkably increase the
morbid diathesis ; but when the resulting disease
has been undergone, the morbid diathesis is ter-
minated, and a disposition to a return or relapse is
altogether or nearly lost. Although epidemic
states of the air thus do not favour relapses of
infectious fevers, yet they greatly dispose the
system to a first attack upon exposure to the
exciting causes, when the diathesis has not been
changed by a previous attack.

449. 7}. The exciting causes of continued fever
are upon the whole much better known than the
states of the system wliich dispose to tlieir oper-
ation. Tliey are extremely numerous ; for what-
ever interests the vital energy so as to disturb
generally its manifestations, and to occasion a
morbid reaction, may be an exciting cause of
fever. — It is unnecessary to enumerate even tlie
most influential of tiiem, as they are adduced
with suflicient details, in the articles Disease
(§ 55 — 63.), Endemic iNir-UENCES, Ineection,
and in an early section of this article (§ 65.).
The chief causes of this class of fevers are — 1st.
Those which proceed (a) from the soil; (b) from

its productions in a state of decay ; and (c) from
animal matter undergoing decomposition ; either
of these acting separately, or all of them con-
jointly; — 2d. Animal miasms — (a) from healthy
persons or animals crowded together, or confined
in imperfectly ventilated situations, and without
due regard to cleanliness; (/*) from persons la-
bouring under diseases of various kinds in con-
fined apartments ; and (c) from one or more
persons affected by the disease which the effluvium
propagates; — and, 3d. Changes taking place in
one or more of the various functions, and which
having reached a certain pitch break out in open
fever. Each of these requires a few remarks.

450. a. Emanations from the soil or its pro-
ductions in a state of decay, are most frequently
productive of periodic fevers ; but they occa-
sionally also give rise to continued fever, espe-
cially during certain states of season and tem-
perature, and in plethoric and robust constitutions.
What the conditions are, that occasion the con-
tinued, in preference to the periodic type, cannot
be precisely stated. Extreme ranges of tem-
perature, particularly high grades of it, and humid
states of the air, may have considerable influence,
as is, indeed, often observed in warm climates,
amongst Europeans who have recently removed
thither ; but, in tiiis and other temperate coun-
tries, the continued forms of fever much less
frequently proceed from this source alone, than
is supposed by some writers. In many places,
exhalations from dead animal matter concur with
those proper to the soil and its productions in
causing fever ; and, in this case, the disease
assumes a more continued type and a lower grade
of action ; the circulating and secreted fiuids
being more remarkably vitiated. There can be
no doubt, also, that the particular form and
complication of the fever often depend much
upon the water in common use, upon the nature
of the soil, and upon the exuberance of its pro-
ducts. Water loaded with decaying animal or
vegetable matter; rich, clay, deep, low, and
absorbent soils, &c. ; and the effluvia from pu-
trefying animal matter ; are frequently productive,
particularly when conjoined, of continued fever,
which often assumes a gastric or enteric character.

451. /*. Animal miasms from a number of
persons shut up in small space, in ill ventilated
and crowded apartments, and in low and humid
localities, as in ships of war, transports, jails,
camps, besieged towns, workhouses, &c., will,
in favourable circumstances, so contaminate the
air with animal effluvia as to give rise to fever,
presenting characters of severity in proportion to
the extent to whicii the air is vitiated. Instances
of this kind are referred to in the articles Epi-
demics (§ 12. 17. &c.) and Infection, and are
adduced by PniNGLE, Lind, Mlane, and by most
recent writers on Fever. It is unnecessary to
offer any remarks upon tliis, and the other sources
of animal miasms, whicli act as a poison on sound
persons, and occasion fevers, orupon nf/ec/iou asa
principal cause of the specific forms of the disease,
as they are fully illustrated in that article.

452. c. That changes may take place spon-
taneously in one or more of the functions, and
proceed to tlie extent of giving rise to the worst
forms of fever, appears to be fully proved. The
chief causes of these changes seem to be pro-
tracted or excessive mental anxiety and depression

FEVER, TYPHOID.

999

loss of property, disappointment, wounded pride,
humiliating occurrences, Sec. Tiiese causes,
however, often concur with the predisposition
arising out of disorder of the digestive and assimi-
lating functions, especially when such disorder is
connected with colluvies on the prima via, and
a torpid or loaded state of the biliary organs ; and
are reinforced by exposure to cold, insufficient
nourishment, changes in the usual modes or habits
of life, want of sleep, and exhalations from the
soil, &c.

453. C. Determining iiifluences, <Sfc.— There
are numerous causes which, although often in-
sufficient of themselves to produce continued
fever, are remarkably influential in giving rise to
predominant affection of particular organs, in mo-
difying its form, or increasing its severity. Several
of the exciting causes, moreover, have the power
not only of occasioning the disease, but also of
determining its type, form, and character. This
is the case more especially with the effluvium
proceeding from an infected person. It is im-
portant to attend to these circumstances, more
especially such as determine the nature of the
complications, &c. of fever, as a due reference to
them guides the practitioner to an appropriate
plan of cure. — Epidemic constitutions are most
influential in thus forming the kind and state of
fever (see Epidemics). Next to these are season
and temperature ; climate and situation ; famine ;
the contingencies of war ; employments and avoc-
ations ; habits and modes of living ; mental exer-
tions and moral emotions; and previous disorder
of some one or more of the internal viscera.

454. a. During cold and dry seasons, the more
inflammatory, or sthenic, forms of fever, and pul-
monary complications, are observed. In high
ranges of temperature, and in those conjoined
with humidity, the digestive mucous surface and
liver are inordinately affected, and the period of
increased excitement soon passes into exhaus-
tion, with marked change in the circulating and
excreted fluids, and often in the soft solids. — jS.
Climate, according to its temperature and hu-
midity, exerts similar effects. The situation,
when elevated very far from the level of the
sea, has a similar influence to cold and dry sea-
sons ; but when it is low, confined, or near the
sea, rivers, or lakes, the disadvantage of hu-
midity, and the contingent evils of marsh exhal-
ations, tend to aggravate the type, or to com-
plicate the disease. The quality of the ivater
has a remarkable influence, both in generating
continued fever, and in determining its form ; pu-
trid water, or water containing decayed vegetable
or animal matter, generally causing fever of an
adynamic, gastric, enteric, or mucous character.
— y. Employments and avocations may either pre-
vent or favour attacks of fever. Tanners and
workmen exposed to the fumes of pitch, tar,
chlorine, &c., are rarely affected, even when
fever is epidemic. Persons much exposed to the
open air, and vicissitudes of weather, are most
liable to fever of a sthenic or phlogistic kind, and
to the pulmonary and pleuritic complications. —
8. Habits and modes of living are very influential
and powerful determining causes of fever, even
in this climate. The influence which full and
rich living, and its opposite, poor and unwhole-
some living, exert upon the state of the disease,
has been sufficiently manifested by the epidemics

which have prevailed at various times in Ireland
since the commencement of the present century,
according as they appeared in the poor and ill-fed,
and as they extended to those in easy circum-
stances. In the former, fever usually assumes
the common continued, or the milder adynamic
and typhoid forms, often attended by the pul-
monary complication, or with petechia;, &c., and
frequently passing into dysentery, &c.; in the latter
class it is either accompanied, at an early stage,
with high action, or witli congestion, and pre-
dominant aflx'ction of the head, liver, or stomach.
In persons living chiefly upon fish, it generally
assumes a low and putrid character. Those who
are intemperate, or who have resorted to spirituous
liquors on the invasion of the disease, present es-
pecial disorder of the brain and digestive mucous
surface. — e. Intellectual exertion, mental anxiety,
and other inordinate emotions, may both occasion
a severe fever, and aggravate its intensity, even
when arising from infection ; and, in both cases,
a cerebral or typhoid complication, of a dangerous
kind, is produced. — ^. Previous disorder height-
ens the severity of the disease, and necessarily
determines its predominant features or compli-
cations, although sometimes in an indirect manner.
Thus, it is common to observe bronchitis previous
to, or attending the invasion of, fever, followed
by a remarkable afl^ection of the brain and of the
mucous membrane of the intestines. In this case,
the changes effected by respiration on the blood
are imperfect ; and, consequently, this fluid be-
comes morbid, — disordering first the functions
and ultimately the structure, of the digestive
mucous surface and brain.

XXII. Fever, Typhoid.* — Syn. Adynamic
Fever, Asthenic Fever, Febris Asthenica ; Fe-
bris Contagiosa ; Febris Typhoides ; Typhus
(from Tv(pos, stupor, or tu^oj, to smoulder) ;
Fievre Typhoide, Chomel; Fievre adynamique,
F, nerveux, F. ataxique, Fr. ; Tifo, Ital. ; Der
Typhus, Nervenjieber, Germ. ; Low Fever, Con-
tagious Fever, Infectious Fever.

455. Defin. — After lassitude and general
malaise, imperfect U)r suppressed vascular reaction,
with depressed vital jwwer, manifested especially in
the nervous, vascular, and muscular systems, and
giving rise to changes more or less evident in the
circulating fluids and soft solids.

456. This fever cannot be said to differ spe-
cifically from that last described, although certain
varieties of it present very marked distinctions.
Indeed, the severer forms or complications of
synochoid fever very closely approach, or run
into, certain states of typhoid fever ; the chief
difl^erences consisting in the more sthenic vascular
reaction in the early part of the period of excite-
ment in the former. Even the milder cases of
simple continued fever may gradually assume a
perfectly typhoid state, in the advanced stage.
The distinctions which characterise the following
varieties are results of the circumstances already
shown^(§43.) to deteiraine the forms and compli-
cations of fevers generally — especially of the con-
stitution and habit of body ; of the previous health
and condition of vital organs ; of the nature, in-

* I use the term Typhoid in the same sense as Cul-

LEN and the majority of writers on Fever in this country

since his time. It is, in this sense, nearlj- synon)Tnous

witli most of the names adduced under it,

3S 4

1000

tensity, and concunence of the causes of the
prevailing epidemic ; of the influences operating
after infection or during the early stages, and of
the treatment and regimen then adopted,
i. Mii.D Typhoid Fever. — Syn. Simple Ty-
phoid Fever ; Nervous Fever ; Siinpte Adynamic
Fever ; Regular Typhus ; Slow Nervous Fever,
Huxham ; Tiiphus mitior, Cullen ; Febris ner-
vosa, Knci. ; Languor Punnnicus,
457. A. Tiiis form of fever is characterised
chiefly by great languor and debility ; by giddiness,
dulncss, and confusion of intellect ; by a soft,
feeble, and quick pulse ; and by loss of muscular
power, sleeplessness, and low delirium. It usually
commences with similar preinonitorij siimptoms
(period of infection, Hart.-vian.x) to those above
described. The patient complains of giddiness,
lassitude, uneasiness at the epigastrium, of nausea
and loss of appetite, of alternate chills and flushes,
and of pain in the back and limbs, — the period of
invasion. The chillsare often prolonged, or recur
for two or three days, but seldom, amount to rigor.
The skin afterwards becomes warm, but seldom
very hot — the pericd of excitement, of irritation
(N aiuiann), of re((c?foH(II AUTMANx), of iiifam-
matory irritation (Goeden) ; the pulse frequent,
full, soft, or weak ; the countenance dull, pallid,
and shrunk, or, occasionally, transiently flushed;
the head heavy, confused, and giddy ; the eye
heavy and devoid of lustre ; and the tongue
loaded or covered with a dirty mucus. There
are more or less tlsirst ; a desire of cold, acid
drink ; sometimes pain at the epigastrium, nausea,
and vomiting ; or an irregular and relaxed state
of the bowels ; and offensive evacuations. Pain
of the head is but little, or not at all, complained
of, but that of the back and limbs is felt severely.
Tinnitus uuriutn is generally present. Febrile
uneasiness is great, the restlessness constant, and
the want of sleep continued. — About the third,
fourth, or fifth day, the head is more affected, and
the mind more confused. The respiration is
short and quick ; and torpor, or cwna vigil, is often
observed. Occasional flushes occur in some
cases, while the extremities are cool. The urine
is pale, of a whey colour, or like small beer — oc-
casionally scanty. The bowels are either torpid,
or relaxed, or irregular ; and deliquium, or faint-
ness, partial sweats, tremors, &c. are complained
of, on attempt to sit up. Delirium of a low kind,
or consisting of a muttering incoherence, occurs
about this time ; generally, at first, during the
niL'iil, but subsequently recurring during the day.
'I'he eves become muddy, afterwai'ds suffused or
injected ; and the tongue of a darker hue, dry or
incrufted.

458. From the 7tli to the 9tli, 10th , or 1 1 tli day, or
even later, the delirium degenerates into stupor —
the pi^nod of predon)inanl narcotiim of N aomann —
the nervous stage of JIiedjinhram) — the collapse
of CuM.EN and IIartmann ; the pulse becomes
.small, weak, and very quick, or uneciual ; the heat
of the skin natural, or diminished, or irregularly
distributed ; the hearing dull ; and tremor, the su-
pine posture, coma, and unconscious evacuations,
are soon a(ti-rwards observed. Petechia; sometimes
appear on the trunk, thighs, ike. 'J"he tongue be-
comes brown or black, incrusted and fissured, is
protruded with diliiculty, and the gums and lips
ire covered by a dark sordes. — From about th

FEVER, TYPHOID — Mild Vahieties.

to the character of the epidemic, the peculiarities
of the patient, the severity of the early stages,
and the state of internal organs, a favourable
change very often occurs in all the symptoms —
the stages of crisis and decline, or of recovery,
(Hartmann) — and is announced by a refresh-
ing sleep, or by a warm and general sweat,
or by a gentle, diarrhoea ; followed by subsidence
of delirium, tremor, iScc. ; by the tongue be-
ing moist and clean at its edges, the skin more
natural, and the pulse slower; by returning con-
sciousness ; and by the improved appearance of
the countenance. If these changes do not take
place ; or if the sweats are cold and clammy on
the extremities; or if they, or the diarrhoea, be
unattended by amelioration of the symptoms ; a
fatal change should be dreaded, particularly if
profound coma and great deafness, subsultus
tendinum, or convulsive or spasmodic movements,
difficulty or inability to swallow or to articulate,
hiccup, involuntary evacuations, retention of
urine, tympanitic abdomen, sliding down in bed ;
very rapid, fluttering, or intermittent pulse ; very
black tongue ; and a quick, jerking, laboured
respiration, or other unfavourable symptoms, ap-
pear.

459. B. The symptoms which distinguish this
form of fever.fromthe synochoid are — the greater
prostration of strength from the commencement ;
the mental torpor and confusion of ideas ; the
long-continued chilliness, generally without rigor
or sliivering, at its invasion ; the moderate in-
crease of temperature afterwards, or its natural
grade; the_ pallid and shrunk countenance, ex-
pressive of suffering and debility ; the muddy,
lack-lustre eye ; the torpor, giddiness, and absence
of pain in the head, passing into stupor with
delirium at an early stage ; the quick and small,
or the full, open, and soft pulse, even during the
period of excitement ; the early dryness, and
dark appearance, of the tongue ; the remarkable
foetor of the breath, and of the discharges ; the
supine posture ; the dull, dusky, lurid, or dirty
hue of the surface ; the frequent occurrence of
sloughs in the parts pressed upon, or of erysipelas,
and occasionally of enlargement and inflam-
mation of glands ; and the early appearance of
delirium, with tremor, and other symptoms indi-
cating extreme depression of vital power. AVhen
any of these phenomena occur in synochoid fe-
vers, it is always at a far advanced stage ; the
synochoid thus merely lapsing into the typhoid
form, owing to various contingent influences, or
to predominant afl^ections of particular organs.

400. C. Such are the usual progress and charac-
teristic phenomena of simple typhus ; butit presents
slight modifications, with the activity of reaction
in the early stage, with the affection of particular
organs or of the skin, and with the character of
tiie prevailing epidemic. Wiien the predominant '
affection is either so evident or so influential, as to
modify niateiially the state of disease, certain vari-
eties result, which have been described by authors
as specific or distinct forms of fever, and have
been often connected, in too absolute a manner,
with the peculiar circumstances in which they
were observed, or in which they originated. I
' shall here notice these varieties, with reference
J to the circumstances whence their peculiarities
seem to proceed, and to the various names ini-

fourteeiilii day to a much later period, according l posed upon them from a desire of appearing

FEVER, TYPHOID —Complications

original, but wilh the effect of proving inaccurate
or of causing misapprehension and confusion.

461. ii. Complicated Tvpiioid on Low Ner-
vous Feveh. — A.With predomiiuiiit Ajf'eclion of the
respiratory Organs. — The bronchial surface is the
part chiefly affected, and is rather congested than
inllamcd. The pleura is rarely attacked ; but the
substance of the lungs is sometimes implicated ;
and it then commonly becomes rapidly infiltrated
or condensed, a fatal result quickly superven-
ing-. This complication is often obscure, or even
latent ; but it generally admits of detection
by auscultation, or by attentive observation
alone. Tlie patient sometimes complains of
stricture, oppression, or dyspnoea, but very sel-
dom of pain in the chest. The respiration is
short and hurried, is attended by the mucous
rattle, and with more or less cough. The skin
is seldom hot; at a later period it is cool, or even
cold, in the extremities, and dusky or lurid ; the
cheek is tinged with a dark red, and often assumes
a livid or purplish hue. The pulse is rapid and
weak. The confusion or stupor of an early stage
passes quickly into low, incoherent, muttering,
and coma. The tongue becomes very dry,
black, crusted, and fissured; it cannot be pro-
truded, and articulation is lost. This state may
continue for several days, with unconscious
evacuations, and all the nervous symptoms pro-
minenlly marked ; at last the patient sinks as-
phyxied, the changes necessary to life ceasing to
take place in the blood sent to the lungs.

462. B. Nervous or Ti^phoid Fever ivith promi-
nent Affection oj the digestive mucous Surface — the
Adtinamic Fever of several French writers ; the
Duthiiienterie of M. Bretonneau. — INIany of the
observations made respecting this local affection in
synochoid fever (§ 442.). apply to its occurrence
in typhoid fevers. It is very commonly observed in
large cities, and in circumstances that occasion the
use of water containing animal matter in a state of
decay ; and it commences in a similar manner to
the other varieties of typhoid fever. The sym-
ptoms that usually attend its progress are — a
tumid, tense, hard, or tympanitic state of the ab-
domen, at an early stage of the fever, frequently
without pain or even tenderness on pressure, but
with involuntary stools, and inconsciousness of
their passage at a later period. The tongue is
dry, black, incrusted, and the crust sometimes
fissured ; but it occasionally is dark red, di-y, and
devoid of papillae or fur. The stools are often
ochrey, and more frequent than natural. Dis-
charges of blood, in greater or less quantity,
sometimes accompany them ; but the hiemor-
rhage, and the changes in the mucous surface
occasioning it, may occur without much, or even
any, relaxation of the bowels.

463. C. I'yphoid Fever, with prominent Affec-
tion of the cerebrospinal nervous System — the
Ataxic of PiNEi, — is seldom attended by acute
pain in the head. But heaviness, stupor, con-
fusion, and giddiness are felt severely, and very
early in the attack. The eyes are injected,
suffused, and devoid of lustre.. Delirium appears
early, and frequently becomes more violent than
in mild typhus; the patient attempting to get up,
or out of bed. The scalp is warm, or hot, and
the extremities are often cool. Insensibility and
coma quickly supervene, and are sometimes at-
tended by spasmodic contractions of the muscles

1001

of a limb, or by partial convulsions. Ina-
bility to swallow, retention of urine, and loss
of speech are occasionally observed. Starlings
of the tgndons, relaxation of the sphincters, and
failure of the circulation, occur in the last
stage, and usher in a fatal termination. This
complication is especially characterised by the
early ai)pearance and the severe form of the
symptoms depending directly upon the state of
the cerebro-spinal nervous system.

464. D. Tijplioid or Xervous Fever uilh severe
Affection of several vital Organs — Typhus gra-
vior of CuLLEN and others — is generally charac-
terised by intense disorder of the brain and
digestive canal, with more or less evident affec-
tion of the bronchial surface; delirium being
early, and at first somewhat violent, and soon
followed by insensibility, &c. The pulse is quick
and weak ; the skin is hot, dry, pungent or harsh,
in an early part of the stage of reaction, but it
generally becomes cool, particularly in tiie ex-
tremities, and often discoloured ; respiration is
panting or quick ; the tongue dry and black; the
abdomen tumid, tender, or tympanitic ; and the
stools are dark, offensive, and passed involuntarily
and without consciousness. In tiiis form there is
some degree of reaction, expressed most severely
in the digestive canal and cerebro-spinal nervous
system ; but it is characterised by depression of
vital power, that is soon increased by the ex-
haustion consequent upon the reaction induced in
this state.

465. The vital organs may, however, be se-
verely affected, although excitement be very
slightly, or even not at all, manifested. Such
cases constitute the Congestive Typhus of some
modern writers, — a form of comparatively rare
occurrence, unless accompanied with petechije,and
other symptoms indicating serious changes, not
merely of vital action, but also of the fluids and
soft solids. — In this variety the depression of
vital power is extreme from the commencement,
and such as prevents the developement, and, in
some cases, even the least manifestation, of
excitement. The causes of the disease have
given vitality a shock beyond its powers of
resistance, or of recovery. JMuscular power is
almost entirely annihilated, and the anxiety at
the epigastrium and praicordia is extreme. Re-
spiration is oppressed, and the pulse is quick,
sometimes irregular, intermittent, or even slow,
and always small, weak, and tiiready. The
countenance and eyes at first have an intoxicated
appearance : the former being pallid, occasionally
slightly bloated, or livid and dingy; the latter
being vacant or suffused, and, afterwards, in-
jected, ecchymosed, half shut, or open. The
skin, at an early stage, is warm or harsh ; sub-
sequently it is cool, wltiiered, lurid, and, some-
times, studded with petechia; or vibices; the
extremities being cool, or even cold, and dingy,
or of a leaden hue. The mind is very much con-
fused at the commencement, and soon passes
into, a state of incoherence, delirious mutterino-,
and coma. The patient is unable to protrude the
tongue, owing to deficient power of the muscles
of tiie organ ; and seldom complains of thirst.
The abdomen is tumid or inflated ; the bowels
being relaxed, the stools black and offensive, and,
with the urine, passed unconsciously. The pro-
gress of the disease is usually rapid, and gene-

1002

FEVER, TYPHOID — Comflications.

rally to a fatal termination ; but the premonitorii
stage may be protracted, although severe — the
invasion being sometimes sudden, and resembling
an apoplectic seizure. If the powers of life rally,
recovery may take place ; but it is tedious,
and often attended by various consecutive dis-
orders.

466. E. Of olher Modifications or peculiar States
of Typhoid or Low Nervous Fever. — Various
phenomena beside those already described may
accompany this fever, according to the combin-
ation and intensity of the causes, the previous
health of the patient, and the circumstances
affecting him subsequently to the operation of
the exciting agent. — a. When caused by mental
distress, despondency, &c., this fever presents cer-
tain peculiarities deserving notice. The patient
is dejected, indolent, and incapable of exertion.
He loses his appetite and strength ; he cannot
rest at night, or his sleep is disturbed and unre-
"freshing ; and he complains of headach, and of
many of the symptoms of a common cold. He
is absent, his mind being constantly occupied
with the subject of his misery. His countenance
assumes an anxious appearance ; his healthy
looks vanish ; and his absence of mind often
passes into a state of reverie. After several days,
manifest affection of the brain is observed, with
characters varying with the age, strength, con-
dition, and habits of the patient. In the robust,
plethoric, and in persons addicted to intoxicating
liquors, it is sudden and violent in its accession ;
the headach and despondency quickly passing
into delirium of an active and constant kind — the
patient calling out, or starting up, and attempting
to get out of bed. The pulse is quick, firm, and
oppressed or small ; sometimes soft or irregular.
Muscular power is not so much, nor so early,
reduced as in the other states of the disease, but
there is continual jactitation. In the debilitated,
the aged, or the ill-fed, the cerebral affection is
less violent in its attack, and commences more
gradually, often attended by red or suffused eyes,
or by catarrhal symptoms, or by diarrhoea ; by
delirium, tremor, great prostration of strength,
hurried breatliing, weak quick pulse, subsultus
tendinum, and, sometimes, with a mottled appear-
ance of the surface, in other respects, the pro-
gress of the disease is nearly the same as the more
severe cerebral complications already noticed
(§ 463.), but it much more frequently terminates
unfavourably.

467. b. In some cases the fever is complicated
with sore throat ; and this symptom is occasionally
so severe and early as to resemble an attack of
cynanche maligna. Indeed, cases not infrequently
occur, which fully indicate that the one disease
may pass into the other, under favourable
circumstances in respect of predisposition and
concurrence of the exciting causes ; or, in
other words, that in young persons, in those
predisposed to sore throat, and in cold and
humid states of the air, certain of the exciting
causes of typhoid fever will sometimes occasion
a malignant or putrid inflammation of the tiiroat,
ushered in and attended by this form of fever ;
or they will, in such or similar circumstances,
produce a low fever, in which inflammation of
the throat is a contingent complication, and as-
sumes an asthenic or unfavourable character,
owing to the depressed state of vital power, and

morbid condition of the circulation, in which it
occurs. This complication is observed either as
the most prominent local aflection, or in con-
junction with some other remarkable disorder,
especially with the gastric complication. In
some instances it is very severe ; the pharynx
and upper part of the oesophagus being also
more or less affected, and deglutition altogether
prevented.

468. c. Paralysis may occur, especially in
the cerebral state of this fever ; and, in this
case, the use of one side of the body is gene-
rally lost. If the patient recover from the fever
the functions of the paralysed side are often
gradually restored. This complication may take
place in those cases which commence with pro-
tracted or severe premonitory symptoms, against
which the patient struggles, until he falls down
from exhaustion ; or is suddenly seized, as in a
case of apoplexy — the fever running its course,
as after the usual invasion, with chills, rigors,
vomitings, &c. When the disease is developed
in this sudden manner, it commonly presents
the cerebral character throughout, with delirium,
passing into coma, &c. In a case, however, of
this kind, the cerebral symptoms were subse-
quently slight, and the disease mild.* In some of
the cerebral cases of this fever, the affection of the
mind continues for some days, or even weeks,
after the bodily functions are restored. Instances
may even occur of permanent insanity being the
consequence. But, in all such cases, hopes of
recovery should be entertained until some weeks,
or even months, have elapsed from the disappear-
ance of the fever.

469. F. Relapses and Sequelce. — a. Relapses are
not infrequent alter the mild forms of typhoid fever;
especially when the duration of the disease has been
shortened by the treatment, or its course materially
altered. They are also much more common in one
epidemic than in another. In many instances,
particularly when the procession of the morbid
phenomena has been interrupted by large deple-
tions, or drastic purgatives, the symptoms become
ameliorated for a time, but recur with their previous
severity ; the recurrence being different from a
relapse. — b. This fever, especially its gastric and
enteric states, may pass, or be converted, into
a low or typhoid form of dysentery (see that
article, § 26, 27.), owing to the influence of the
same circumstances that usually cause relapses;
especially premature exposure in early convales-
cence ; the use of too much, or of improper,
food ; the continued operation of the exciting
causes ; a close, impure, and infectious air ; and
suppression of the excretions. — Local ajf'ections,
particularly inflammations, may also appear
during convalescence, arising either from the
above causes, or from atmospheric vicissitudes ;

* A young lady wont some distance to visit nn intimate
friend, delirious in fever ; and having gone into the
rliamber, slic was spnsil)le of a disagreeable odom- upon
tlicciii-lains of till' lied being drawn. She soon al'terwavils
coiiitilaiiicil of slight nausea, iif headaeli, loss of aiipctite,
and general lassitude, 'i'hese .symptoms continued gra-
dually to increase for six days, during which time she
kept about. On the morning of the seventh day she sml-
denly i'ell down without sense or motion. 1 saw her in
this st.atc soon afterwards, and, viewing the attack .as the
result of sudden congestion of the brain, and before I had
learnt the .above iiar'ticulars, I prescribed a moderate
bloodletting, and purgatives. The functions of the brain
soon returned, and the fever ran its course in a milil form,
and without delirium or prominent affection of any organ.

FEVER, TYPHOID

or from whatever may inordinately aflect the
nervous and vascular systems. In these cases
the inflammation is apt to pursue a severe and
rapid course, owing to the unfavourable or de-
bilitated state of constitution in which it occurs.
Bronchitis, often associated with aft'ection of the
substance of the lungs, and inflammation of 'the
mucous surface of the bowels, sometimes with
softening and enlargement, or ulceration, of the
mucous follicles, are the most common diseases
thus contingent on convalescence. Inflammatory
afl^ections of the stomach or liver may also take
place. When the mucous surface of the intes-
tines is the seat of consecutive disorder, the bowels
generally are more or less relaxed, and the stools
are of an ochrey hue, and offensive. In such
cases, the follicles are especially affected ; are
often ulcerated ; and, although they will generally
heal under judicious treatment, perforation of the
intestines and fatal peritonitis may be the result at
a period more or less remote from the disappear-
ance of the fever.

470. G. Of Petechi;e and Exanthematous
Eruptions in Typhoid Fevers. — Nervous or
typhoid fevers may occur sporadically or epidemi-
cally, without any petechial or other eruption ; or
may be attended hy petechiie or vibices in their pro-
gress, and particularly at an advanced period,
or by an exanthematous eruption at an earlier
stage ; or even by both kinds of cutaneous
affection, either successively or almost coeta-
neously. For many years, or in successive epide-
mics, or even in a single epidemic, typhoid fever
may appear in any one or more of the states just
described ; or it may assume either of these forms,
associated with one or other, or with both,
of the affections of the skin just mentioned in a
portion of the cases only; or the affection of the
skin may be one of the most unvarying and chief
characteristics of an epidemic ; and, of the cases
composing such an epidemic, some may be of
the mild, others of the complicated or severe
form ; some may evince more or less reaction or
excitement, others may present depression of the
powers of life and congestion, as prominent phe-
nomena throughout. The above description,
although applicable more especially to the occur-
rence of typhoid fever, independently of any
marked affection of the skin, yet does not the
less apply to the occasional association of the
disease with this affection. Those epidemics, in
which the changes in the skin are very constant
phenomena, sometimes possess other characters,
both in the early and in the advanced stages,
that require an especial notice. Whilst these
changes — both petechial and exa)it!ienjatous —
have been considered by Hildexbrand, Nau-
MANN, FoDERE, Peebles, and other experienced
writers, as indications of specific kinds of fever,
which, in the early stages, may present more or
less either of inflammatory excitement or of de-
pression of vital power; they have been viewed, by
many authors, merely as occasional occurrences,
or as modifications met with only in certain epide-
mics, and not as characteristics of distinct varieties.

471. In trying to solve this question, the same
difficulties present themselves that arise in all
attempts to arrange the different varieties and
states of fever in such an order as the more
constant phenomena may warrant, and as may
conduce to appropriate and successful methods

Exanthematous Eruptions.

1003

of treatment. If I refer to my own observations'
in different parts of the Continent, some time
after the late war, and in various parts of this
country, both before and subsequently, I shall
find — Ist. That petechia: and vibices were
either seldom or rarely seen for several years,
in some epidemics, excepting in the most se-
vere or malignant cases, or when favoured by
a too stimulant treatment, and a too heating
regimen during the early stages ; and that, at
other times, they appeared more frequently in the
advanced periods of the lowest forms of fever, and
even, although much more rarely, towards the
termination of synochoid fever, when antiphlo-
gistic remedies had been neglected in the stage of
excitement. — 2d. That this change, in some epi-
demics, was a very common or even general
symptom, occurring in mild as well as in severe
cases, although presenting very different appear-
ances in each ; and that they were sometimes
observed early in the low states of fever, particu-
larly when caused by unwholesome and deficient
food, by a foul atmosphere, or by infectious mi-
asms. — 3d. That they were very frequently
connected, especially in the plethoric, in the pre-
viously unhealthy, and in persons using much
animal food, with evident change of the circulat-
ing fluids, with predominant disorder of the diges-
tive organs, with a soft, broad, and open pulse,
and with haemorrhages from the intestines, and a
tendency to disorganisation of the mucous surface
of the bowels. — 4th. That an exanthematous rash
or eruption was observed in some epidemics, from
the third to the eighth day of the fever, was quite
distinct from petechiee, generally appeared earlier,
and was, in some cases, either associated with, or
succeeded by, petechia or vibices, or even both. —
5th. That this exanthema was of a reddish colour,
varying in deepness, and rarely passing to a dark
hue ; that it occurred in cases characterised by
vascular reaction in the early stage, as well as in
those of a very low grade — in the mild, in the
complicated, and in the severe; that this eruption
was most probably overlooked in many cases
where it existed ; and that it was very generally
confounded with petechiae, owing to its late ap-
pearance, or to its colour changing, in a some-
what similar manner to petechiaj, with the states

of vital power and of the circulating fluids.

6th. That although the difference between both
these affections of the skin has been insisted
on by HiLDENBRAND aud Naumann, it has
been too widely drawn by them, and without due
reference to the occasional association of both
affections. From these facts, therefore, I am in-
duced to come to the conclusions above stated
{§ 470.) ; and, conformably with the views of the
experienced writers just mentioned, to notice
more particularly the states of fever in which
these changes in the skin are observed, without
considering these states as always constilutino-
distinct species.

iii. Typhoid Fever, with Putro-ady'namic
Characters. — Syn. Putro-adynatnic Fever;
Swoxosjuera ffriweSSvos, Galen; Synochus Pu-
tris, S. cum Putredine, Febris continuu Pu-
trida, Riviere ; F. coutinens Putrida, Selle ;
F. Putrida sanguinea, Vogel ; F. colliquativa
putrefaciens, Quesnoi; F. Hungarica, F. ner-
vosa-putrida, F. asthenica, F. contagiosa ; F.
colliquativa essentialis, Borsieri ; F, Putrida

1004 FEVER, TYPHOID

simplex, Richter ; F. charactere putrido aut
septico, llildenbrand ; F. Petechialis, F. No-
socomialis, F. Castrensis, F. Purpurata ma-
ligna, F. Maligna, F. Carceraria , PestisBellica;
Auct. var. ; F. Continens maligna, IIux-
ham ; Das Fuuljieber, Faulige Fieber, Germ, ;
Fievre grave, F. Maligne, F. Putride, Fr. ;
F. Adynamique, Pinel ; Fehhre Putrida, Ital.;
Morbo Petechiale, Cerri ; Febhre Petechiale,
Rossi ; Febhre epidemica Petecliiale, Bufia; Pe-
techial Tuplius, Camp Fever, Jail Fever, Putrid
Fever, Putrid Malignant Fever, Spotted Fever.

472. Conformably with what I have staled above,
I consider this as a variety merely of typhoid fever,
its especial characteristic — the appearance of
petechiae and vibices — being contingent upon
certain circumstances and causes tending to con-
taminute the circulating fluids, and to destroy the
tonicity and irritability of contractile tissues, and
appearing only as the effect of a series of anterior
changes. Although petechia may occasionally
appear in the advanced stages of other fevers,
particularly those of the typhoid form, yet in
tiiose epidemics which result from famine, war,
unwholesome food, and from air loaded with pu-
trid animal and vegetable matter, or with the
emanations proceeding from a number of persons
shut up in a close atmosphere — causes which are
often conjoined — this symptom is very generally,
if not constantly, observed, and is only one of
the indications of the very serious changes which
liave taken place, not only in the blood, but
also in the soft and irritable structures of the
frame. Infection, either directly or by fomites,
is, however, the chief cause, although cold, hu-
midity, fear of the disease, and the other agents
just noticed, may either generate the fever de
novo, or predispose the system to infection, or aid
its operation after exposure to it. Although cer-
tain epidemics evince a putrid or septic character
at an early period, and thereby justify the appel-
lation generally given to them ; yet this character
is seldom primary, or otherwise than the con-
sequence of suppression or exhaustion of vital
power, the fever commencing in some one of the
forms already described. Indeed, there is no
variety of fever that may not evince a septic or
putrid state — 1st, from the vital depression pro-
duced by the exciting cause ; 2dly, from exhaus-
tion consequent upon vascular reaction ; 3dly,
from the passage of contaminating matters into
the blood ; and 4thly, from these states conjoined.
Hence, when the causes are of a contaminating
kind, and the influences continuing to operate
after infection have a similar tendency, putrid or
malignant symptoms will arise, whether the fever
be synochoid, nervous, typhoid, or gastric, in its
early periods. These fevers are the most prone to
the septic character ; but others, as remittent, in-
flammatory, and bilious fevers, may also assume
it. This particular character may, or may not,
be developed, or may appear at a later or earlier
period, owing to the nature and diversity of the
causes ; to the condition of the internal functions
and of the circulating fluids at the time of attack ;
to the rigidity or tone, or to the laxity of the softer
solids ; to tlie violence or absence of vascular re-
action ; and to the early treatment and regimen.

473. A. I'etec'hial, or putro-adynamic fever ge-
nerally commences with the premonitory and in-
vading symptoms usually observed in other fevers

WITH PUTRO-ADYNAMIA.

of a low grade. When an epidemic presents changes
of a septic or putrid nature, as predominant fea-
tures, the early stages of the fever vary most re-
markably according to the intensity of the causes,
and the state of the patient. The period which
elapses from infection till the manifestation of
the disease ranges from a few hours to five or
six weeks. It is commonly some days, but sufli-
cient evidence has been furnished, in the Irish
and other epidemics, that the longest of these
periods may occur. During the time the disease
thus takes to form, the usual premonitory sym-
ptoms are observed, and increase until chills, horri-
pilations, or rigors are felt. In some instances
the disease commences insidiously, with or with-
out catarrhal symptoms, becoming gradually se-
vere and dangerous. In these it is often difficult
to assign the exact period of attack. Fatal cases
most fiequently begin in this manner, especially
in the plethoric, cachectic, and persons accus-
tomed to full living. In others, after a protracted
and severe premonitory stage and indistinct sym-
ptoms of invasion, the fever proceeds with indica-
tions of imperfectly developed reaction, and soon
assumes a putrid or malignant form. In some
cases, rigors and shiverings sufficiently evince
the period of attack, and quickly give rise to
inordinate reaction, followed by exhaustion and
evidence of change in the fluids and soft struc-
tures. Amongst the most constant of the early
symptoms are — dull pains in the head, occiput,
back, and limbs; universal weariness, soreness,
and loss of muscular power ; confusion of mind ;
pains in the joints and limbs resembling rheu-
matism ; frequent sighing j nausea or vomiting ;
and noises in the ears.

474. The pulse, when reaction is developed, is
full, open, quick, sharp, but soft and easily com-
pressed. Respiration is laborious, suspirious, with
oppression or anxiety at the praecordia and epigas-
trium. Burning heat is often felt internally, and
on the surface of the trunk. When reaction is
either imperfect, or does not take place, the pulse
is slow, or not more frec^uent than usual ; is weak
and compressible, sometimes unequal or intermit-
tent ; and the temperature is little or not at all
increased, or it is unnatural. The tongue is either
loaded and furred, or flabby and covered with a
dirty mucus. Thirst is generally urgent. The
vascular excitement usually continues, in various
grades, from six to eight days ; and as it passes its
acme, or about this period, purplish spots, of the
size of flea-bites, and of various shades of deep-
ness, appear upon the neck, breast, and insides of
the arms and thighs. The pulse becomes more
soft and weak ; sometimes unequal and small.
The tongue is more loaded, and of a darker co-
lour. Thirst is diminished, or is not complained
of ; and the excretions present a veiy morbid
appearance, and an otlensive odour. To these
are added dulness of all the senses, or delirium,
alternating with stupor, difficulty of articulation,
and often also of deglutition, leipothymia, faint-
ness, and treiuors. From the eleventh to the
seventeenth day, but frequently earlier, the ab-
domen becomes tympanitic, if the disease pro-
ceeds uiifavouruhly ;. the petechia; are of a darker
colour ; vibices or blotches appear on the extre-
mities ; profuse frctid perspirations break out
without relief; the posture is constantly supine ;
parts pressed upon (juickly sphacelate ; the tern-

FEVER, TYPHOID — WITH Purno-ADYNAMiA
perature sinks often below the natural standard ;

ico;

and the tongue is now black, fissured, or flabby,
clean, dark red, or livid. Coma; subsullus ten-
dinum ; convulsions; haemorrhage from the bow-
els ; or exudations of a sanious fluid in the eva-
cuations, or from the gums, lips, and nostrils ; also
take place towards the close.

475. A faiourahte change most frequently
occurs from the ninth to the seventeenth day,
and is indicated by profound sleep ; by a warm,
soft, and moderate perspiration ; by turbid urine ;
by natural stools ; and by a brighter colour, or
disappearance of the petechiaj. — Tlie duration of
this fever is seldom longer than twenty-one days ;
but it may terminate on any intermediate day
between the sixth and tvventy-fourtli. A fatal
issue occurs most frequently from the eiglith to
the fourteenth. — Towards the close of an epi-
demic, the usual course is often departed from ;
mild cases of short duration, and relapses, amongst
these especially, being very common. When
mercury has been given so as to aft'ect the mouth, a
crisis is prevented, and convalescence is protracted.

476. B. Modifications. — a. Such is the more
usual course of the disease, particularly as observed
in modern times. But it presents various grades of
severity, and several modifications and complica-
tions. It is in some cases, even in the same epi-
demic, comparatively mild ; yet presenting mani-
fest signs of colliquation, or of a septic tendency,
particularly as respects the state of vital power,
the circulating fluids, and the appearance of the
petechiae. In others, tlie attack is violent from
the commencement, and the symptoms intense ;
diminution of the vital cohesion of the tissues, and
dissolution of the fluids, appearing early and pro-
ceeding rapidly. In many, the invasion is gra-
dual, or much less tumultuous, than in these;
the progress is more insidious, and the results are
not less dangerous. In both, the body undergoes
decomposition soon after death, and the rigidity
usually observed post mortem does not take place.

477. b. When this fever is epidemic, petecliiiE
may appear as early as the third, fourth, or fifth
day from the attack, in mild as well as in severe
cases ; and a white miliary eruption may break
out at a late stage, particularly when the perspir-
ations are copious. Yellowness of the skin, or
purplish colour of the extremities, or enlargement
and inflammation of the glands in the neck or
groins, may occur in an advanced period. Pim-
ples may also appear on the surface, and may
be considered a favourable indication. Although
delirium and insensibility generally follow the
headach of the early stages, yet the mind may
be serene and unaflected throughout — even to
the moment of dissolution. In cases which pre-
sent no distinct sign of invasion, nor of reaction,
but proceed insensibly to a general colliquation
of the fluids and solids, the excretions, both cuta-
neous and intestinal, are generally abundant and
very offensive : the flow even of urine being
sometimes excessive. The tongue is occasionally
natural ; or it is clean and raw like ; or as if
streaked with blood, or with a bloody sanies. An
aphthous state of it, and of the lips, is also some-
times remarked.

478. c. In persons who live fully and luxurious-
ly, particularly if they have passed their thirtieth
year, this fever often proceeds in an insidious
but fatal manner. Such patients do not complain

of pain, or of much uneasiness ; although they
are remarkably debilitated and depressed. Their
manner is somewhat hurried, but their intellect is
clear. The skin is greasy, and covered with dun
petechiaj, sometimes intermingled with white mi-
liary vesicles ; its temperature is low : the coun-
tenance slightly suffused : the eyes glassy ; the
tongue sometimes loaded or crusted, or clean and
moist; thirst is _often absent, and the pulse but
little accelerated. Convulsions are frequent ; and
a fatal termination often ensues, mostly before the
fourteenth day.

479. C. Complications, similar to those already
described, may take place in the early stages of
this disease. — a. The catarrhal, bronchial, and
pulmonary complications are most common in
winter. When the bronchi and lungs are seri-
ously implicated, the respiration is short, hurried,
or laboured ; cough is frequent ; and the sputum
is bloody, rusty, or consists of a dark, sanious
matter, particularly in the latter stages, — h. The
association with cerebral ajjectio)i is very frequent,
particularly in the strong and plethoric, and in
persons whose minds have been much harassed
previously to the attack. These latter seldom
recover from it. In this state the headach is
severe from the commencement : the eyes are
injected or suff"used : reaction is more or less
energetic, and is often attended by epistaxis,
which, however, is never critical. Delirium, in-
sensibility, subsultus tendinum, 6cc., are common
phenomena in the latter stages of unfavourable
cases. — c. Thedigestiie canal and liver are chiefly
affected in summer and autumn ; the fever as-
suming gastric and bilious characters at its com-
mencement, with bilious vomitings, &c., but soon
passing into the putrid state. The enteric and
dysenteric states are also frequent, especially at
later periods of the disease. The enteric is the
most dangerous of the abdominal complications,
particularly when the petechias, or vibices, are of
a dark, or deep purple colour ; the abdomen tym-
panitic ; and the stools are green, livid, or black,
mixed with dark fluid or grumous blood. In
these, fatal hasmorrhages sometimes occur. The
dysenteric state may take place in mild as well as
in severe cases, at an advanced stage; with se-
vere gripings, and dark sanious, bloody, and mu-
cous stools, which are very fcEtid and infectious.
The disease may thus pass into the adynamic
form of dysentery. This change was common
in the epidemics lately prevalent in Ireland, — d.
The complication with inflammation of \\ie fauces
and pharynx, or with putrid sore throat, is some-
times observed, and is to be distinguished from
primary cynanche maligna, by its occurrence in
the course of the fever, or as a contingent aflfec-
tion (§ 479,).

480. D. The sequela: of this fever are sometimes
serious. They consist chiefly of dysentery, chronic
diarrhoea, dropsies and oedematous swellings of one
or more of the extremities, pulmonary consumption,
hepatic obstructions, mania, and other forms of
insanity, abscesses in various parts of the body,
sloughing sores, inflammation of veins, particularly
of those of the extremities, gangrene of the feet,
rheumatic affections, &c. IMost of these result
in great measure from the changes that have
taken place in the blood during the fever ; these
changes affecting the blood-vessels, and organs
most susceptible of congestion. —iJe/ajsies are

l006 TEVER, TYPHOID — WITH

frequeuc in cases of short duration, anJ in those
which have been apparently cut short by active
treatment ; and are generally more dangerous than
the first attack. They are more common in males
than in females ; and towards the close of an
epidemic than at its commencement.

481. £. Diacrjiosis, or the Changes lokich more
especially coxstitute ^Idlignancy or I'uvo-adynamia
in Fevers. — a. The secretions, next after the state
of vital power, indicate incipient dissolution of the
vital cohesion of the blood and soft tissues. — The
nrine has first a more viscid and albuminous
appearance than usual. It is frothy, browner,
and less transparent. If this pathological condi-
tion increases, the urine becomes brown, or dark
brown, clouded, turbid, muddy, and often deposits
a brown sediment. It quickly becomes putrid
or offensive. — The focces are foetid, or have a pu-
trid smell — are dark, fluid, ochrey, or contain
blood. — The sweat is thick, clammy, sometimes
cold, copious, and' always oflTensive ; and occa-
sionally it imparts an ichorous stain to the linen.
— The secretion poured into the mouth is a thick,
viscid, slimy, dirty mucus, of a dark brown co-
lour, that collects over the teeth, edges of the
tongue, and lips.

482. b. The changes observed in the vascular
system are — an open, broad, soft, compressible,
imdulating, or unequal, or a very quick, small,
thready, and irregular pulse ; a more than usu-
ally dark appearance of the superficial veins,
or dark streaks in their course ; and, at an ad-
vanced stage, exudations of dark, dissolved, or
thin blood, or of a bloody sanies, from the outlets
of canals, as the mouth, nostrils, anus, vagina,
&c. — Blood taken from a vein, even previously
to the occurrence of these signs, is very dark,
thin, sometimes of a black purple hue ; and either
does not separate into coagulum and serum, or
coagulates into a soft, pultaceous, or gelatinous
mass, with imperfect separation of the serum.
The fibrinous and albuminous constituents are
deficient ; and, owing to this circumstance, to-
gether with the want of vital power in the vas-
cular system, the coagulum wants cohesion, the
least agitation causing a partial admixture of red
particles in the surrounding serum. — As the dis-
solution of the vital cohesion of the circulating
fluids and softer solids proceeds, tlie colouring
particles of the blood often fall to the bottom of
the vessel, or of the gelatinous coagulum, leaving
the upper stratum, and the surrounding serum,
of various shades — sometimes of a greenish,
purplish, or reddish hue. LANoitisii, Huxham,
ToKDVcE, lIiLDENnnAND, and others, have no-
ticed a peculiar putrid odour of the blood when
taken from a vein. (See Blood, $ 110. el seij.).
'I'his fluid soon undergoes putrefaction after its
removal from the body. It presents, however
various anomalies, in particular cases, or in some
epidemics ; but it seldom evinces very remarka-
ble alterations, excepting as the grosser and more
pal])ab]e results of anterior changes, which, al-
though evidently of a most important kind, admit
not of precise recognition ; nor do those alter-
ations occur until the symptoms indicate depression
of constitutional pov.er, imperfect assimilation
of aljsorbed fluids, and lesion of the depurating
functions. In connection with these changes,
particularly, those of the blood, the tonicity, or
vital cohesion, of the extreme capillaries and

PUTRO-ADYNAMIA DIAGNOSIS.

softer solids are very much impaired, occasioning
thereby further alterations. The functions of
the cerebro-spinal nervous system are often more
or less disordered, as in low nervous fevers ; and
the states of the mucous and cellular tissues, and
of tlie skin, are remarkably altered. The cellular
tissue becomes flaccid, softened, or less coherent,
and consequently slightly tumid ; and hence the
bloated appearance in extreme cases ; or cachectic
fulness of the surface, in the most fatal slates of
the disease. The mucous tissue is discoloured ;
it exhibits a dirty brown, or grey, or livid hue,
with black ecchymosed spots.

483. c. The cutaneous surface is at first merely
dusky or lurid. But as vital power is further
depressed, a bluish, marbled discolouration is
sometimes observed in the shape of veins. Petecliiie
of various depths of shade, from a lively or dark
red, to a purplish or brown colour, appear prin-
cipally upon parts usually covered by the clothes.
They are either alone, or attended by the ex-
anthematous- eruption characterising the variety
next to be noticed (§ 485.), or by dark or pur-
plish spots of various sizes. la some cases, the
skin, especially that of the extremities, becomes
of a dark purple colour. When there is much
heat of surface in the early stage of excitement,
a caustic or morbid sensation is imparted, which
increases whilst the hand remains in contact
with it. When copious sweats follow, a white
miliary eruption, intermingled with petechise, or
vibices also, sometimes is observed. As the tem-
perature is reduced, an unpleasant raw, cadaver-
ous, or cold feeling is imparted to the hand of
the examiner ; and the petechias often become
much darker, or more numerous, or aggregated,
or almost confluent in some parts. In such
cases, passive hiemorrhages, particularly from the
bowels, are not uncommon ; but they may also
occur without much change in the skin. The
integuments readily sphacelate from slight injury,
irritation, or pressure ; and may even be the seat
of sphacelating sores or carbuncles in extreme
cases. — Enlargement or obstruction of the
lymphatic glands, with a tendency to asthenic
inflammation and disorganisation of the surround-
ing cellular tissue, is sometimes seen in the most
malignant cases ; but these changes take place
most remarkably in plague, which has been con-
sidered by many able writers as a modification
merely of this fever — the one disease running into
the other. (See the article on that disease.)

484. d. As to the mmcrfiufe causes of, or pathologi-
cal states giving rise to, the septic or putrid changes
in the fluids and solids, observed more remarkably
in some fevers than in others, even the most ex-
perienced writers are not agreed. There can be
no doubt that these changes should be referred
chiefly to the depressed state of organic nervous
or vital power, and to the consequently imperfect
functions of assimilation, excretion, and depur-
ation, as insisted upon above {§ 10"2.), and in the
article Bi.oon. But the direct introduction of
putrid animal or vegetable matter into the cir-
culation, in considerable quantity, so as to de-
press the vital influence below tiie power either
of salutary reaction or of excreting it through
the cmunctories, will so contaminate the whole
mass of fluids, as to give rise to alterations and
appearances very similar to those just described,
and to many of the more intense symptoms pre-

FEVER, XyPHUS — Pathology.

1007

viously noticed as depending chiefly upon tlie
state of the cerebro-spinal system (§ 479.). The
experiments made by Gaspard, Macendie, and
others (see Lend. Med. Repository, vol. xvii.J, have
proved this fact ; but changes quite as malignant,
as in the fever now being considered, and in
plague and yellow fever, take place without any
very manifest or demonstrable source whence
they could have proceeded. In such cases, nu-
merous facts and circumstances concur in show-
ing that a morbid seminium — an infectious miasm

— proceeds from the bodies of those already af-
fected, and, through the medium of the inspired
air, contaminates the blood as it circulates in the
lungs, and affects the organic nervous influence.
It may also be admitted, that miasms proceeding
from animal and vegetable matter in a state of
decay — from a number of persons breathing the
same atmosphere — from those shut up inclose,
warm, and ill-ventilated places — will produce a
similar effect, and generate a malignant fever de
novo, which will be capable of propagating itself
by means of the emanations evolved in its course.

iv. Typhus. — Syn. True Typhus; Exanthematic
Typhus; Nervous Fever with exanthematous
Eruption; Contagious Typhus; Febris nervosa epi-
demica ; F. nervosa eianthematica ; F. maligiia
cnm sopore, Riviere ; F. Contagiosa ; F. nervosa
petechialis ; F, pestilentialis Europce ; Typhus
Contagiosus exanthematicus, Hildeubrand ; T.
Castrensis, Boerhaave ; T. Gravior, Cullen ;
r, nostras, T. EuroptEus ; T. Communis, T.
Eellicus ; T. Contagiosus, Naumann ; T, Ex-
anthematicus ; Pestis Bellica ; Der Ansteckende
Typhus, Das Ansteckendefieber, Das Exanthe-
matische Nervenjieber, Germ. ; Die Kriegspest,
Hufeland ; Das Fleckfieber, Reuss ; Typhus
Contagieux, Fievre d'Hopital, Fr. : Fievre ady-
namique ataxique, I'inel ; Tifo Contagioso, Ital.

485. This fever is characterised by phenomena
which distmguish it from the foregoing varieties ;

— by catarrhal and gastric symptoms early in the
disease ; by stupor, delirium, or typhomania ; by a
peculiar cutaneous eruption: by more or less evident
affection of the liver ; and by the determinate course
and regular succession of all the febrile changes,

486. True or contagious typhus has been con-
founded with synochoid and nervous fevers, on
the one hand, and with putrid or jnalignayit

fever, on the other. It has been already stated,
that putridity or malignancy not only may
characterise a particular form of fever or cer-
tain epidemics, even at an early period of their
course ; but also, owing to various contingen-
cies, may take place in advanced stages of any
other fever. As the circumstances favouring
the generation and spread of typhus are often
such as also tend to develope those changes
which have been usually named putrid or malig-
nant, and as these changes are frequently ob-
served in the latter stages of typhus — the symp-
toms distinguishing this fever becoming associated
with, or followed by, those indicating the putro-
adynamic state — so has it been often confounded
with other fevers, in which this state has predo-
minated more or less. If we refer to the nume-
rous histories of epidemic typhus recorded by
writers from the close of the fifteenth century up
to the present time, or even to the brief abstracts
furnished by M, Ozanam (Hist, Med, des Mu'

ladies Epidemiqnes, i^r. t. iv. p. 155. ct seq.),
we shall find, that although many of these, owing
to the concurrence of circumstances developing
a putrid or malignant disease, were instances of
fever, either identical with, or very closely re-
sembling, that which I have described as such in
the preceding section ; yet many otiiers — or even
the majority — were true typhus in which the
putro-adynamic state was either early or promi-
nently developed ; the exanthematous eruption
characteristic of typhus being succeeded or ac-
companied by the petechia; indicating the ap-
proach of the septic condition, and being either
mistaken for them, or for an eruption of miliaria.
Owing to this circumstance especially, typhus,
low nervous, and putrid fevers have been very
generally confounded together. The essential
characters of typhus were first distinctly traced
by Sauvages; but Cullex mixed them up with
the symptoms of those forms of low nervous or
typhoid fever which occur sporadically. Even
among modern writers, comparatively few have
made the distinction, excepting Hildenbrand,
FoDERK, Naumann, Peebles, and some others.
True or contagious typhus has not been epidemic
in England for many years ; or, if it have ap-
peared in a few places, it has not extended beyond
them. In Ireland, however, it was extensively
prevalent, particularly in the years 1817, 1818,
and 1819; and in some parts of Scotland since that
time. The fevers most commonly observed in
England, and particularly in London, have been
either synochoid, simple, or complicated ; or low
nervous fever variously associated, and but rarely
displaying a predominance of putrid or septic
characters. During 1836, 7, 8, and 9, this fever
was very prevalent in London, and in several other
places.

487. True typhus, although prone to assume a
septic condition, especially when epidemic, and
appearing under the unfavourable circumstances
about to be noticed, yet may run its whole course
without petechia or any marked putrid symptom.
It may, as shown by Hildenbrand, be simple, or
variously complicated ; and, as remai'ked by Dr.
Peebles, it may be benign throughout, or assume
a malignant character, according to individual
diathesis, the nature of the prevailing epidemic,
or the mode of treatment. It generally presents
itself as an epidemic, is contagious, and runs a
uniform course, unless predominant affection of
some internal organ modifies its course or pro-
longs its duration.

488. It has been shown above, that the pe-
techial affection consists of minute stains or ec-
chymoses, caused by the transudation of blood
from the minute capillaries of the vascular rete
of the skin, owing to the atony of these vessels
and the alteration of the blood ; that it may occur
in the advanced stage of any fever, even of the
more inflammatory or purely eruptive, when con-
verted into an adynamic or typhoid state, by
improper treatment or the peculiar condition of
the pdtient ; and that it is not, in any sense of the
word, an eruption, as it has been very improperly
denominated by some writers. This change in
the skin, which has been viewed as one of the
chief indications of incipient putridity, or of a
septic tendency, is very different from the eruption
characterising typhus. The jjetechice, or cu-
taneous ecchymoses, vary in dimensions from

1008

minute stigmata to large patclies or vihices, and
in the deepness or shade of colour. They very
rarely appear at the commencement, even of the
more putrid or malignant fevers, unless from
peculiar depravity of constitution, or from causes
affecting more especially the circulating fluids —
as impure air, imperfect nourishment, unwholesome
food, or other injurious ingesta.

489. But the exanthema tons eruption attending
true typhus, is as cliaracteristic of it as the erup-
tions of measles or of scarlatina ; and, although
observed by numerous writers, it has been con-
founded with petechiae, with which it is often
associated in the advanced stages of the fever,
or with miliary eruptions. — Hildenisrand gave
a description of it, as it appeared in the conta-
gious fevers prevalent in Ciermany during the
commencement of the present century ; and Dr.
Peebles has recently described it accurately
and minutely, and as he saw it in Ilalyj soon
after the war. His description agrees with my own
observations about the same period. This eruption
appears in the early progress of a fever produced
by human efHuvia, when circumstances occur to
promote them, or to prevent their dissipation.
The animal miasm, whether generated by num-
bers crowded in a small space and confined
air, or proceeding from a person affected by the
disease, should be viewed as a poison, affecting
the human body in a specific manner, and causing
fever with an eruption of a certain form, which
propagates itself by the diffusion of a morbid
effiuvium in the surrounding air, or by its re-
tention in various animal productions or porous
substances when shut up from the air,

490. This eruption usually appears from the
third to the seventh day of the fever, but it may be
delayed till the twelfth or fourteenth day. It is of
a florid, reddish, or reddish pink colour ; disappear-
ing on pressure, but soon returning when pressure
is removed. This circumstance is sufficient to dis-
tinguish it from petechiae. The more exuberant
resembles the measles, and has been mistaken for
them ; but it is more papillar, and rougher to the
touch, being sensibly elevated to the eye ; and,
although sometimes grouped or crowded, it
does not coalesce so much as measles, but each
papilla is more or less separate. It is some-
times vesicular, and followed by desquama-
tion of the cuticle. It is occasionally indistinct,
and may be then overlooked, and it sometimes
approaches more nearly the miliary eruption,
llence it has been mistaken for this eruption in
such cases. It is generally confined to the trunk
of the body, the arms, and thighs, but it may
cover nearly all the body. It raicly extends over
the face or hands. In children, it appears only
upon the trunk, or parts of it, and often scantily.
It is sometimes evanescent, disappearing in one
part of the body and returning in another (1'ke-
Btts.) It may be copious in some cases, and
scanty in others, even in the same family. Owing
to these circumstances, it may escape observation.
It is not liable to recede early in its course ; but
if it disappear fi'om injudicious treatment, or a
faulty slate of the .system, malignant symptoms
are apt to supervene.

491. In some cases, the interstices of the skin
between the papilhe are red or crythenjatous. In
these, there are also increased sufl'usion of the
eyes, redness of the tongue at the point and edges,

FEVER, TYPHUS — DEscEiPTroM of.

redness of the fauces, as in mild scarlatina, and
subsequent desquamation of the cuticle. The
duration of this eruption is from three to five days.
\\ hen the exantheme is slight, it disappears
without leaving discernible marks ; but when it
is exuberant, stains are left in the situation of the
papillffi. If petechiae occur in this fever, they
seldom are observed before the eighth or tenth
day, and then this eruption has usually disap-
peared. When the petechias are earlier, or the
eruption continues longer, so that both exist to-
getiier, they are quite distinct and different in
their appearances ; for the latter is never so dark
or livid as the former generally is, and the pe-
techiae are not attended by the elevation of the
cuticle and roughness characterising the eruption.
The stains left by an exuberant eruption generally
become livid when petechiae are present ; but the
eruption itself does not assume a dark tint, as
long as it retains its papillar form. In the more
malignant cases, and when petechiae appear early
in the disease, the colour of the eruption may,
however, become deeper, or may change with the
alteration in the i^uids and softer solids.

492, A, Description. — True typhus proceeds
in a more regular and determinate manner than sy-
nochoid or nervous fevers ; and presents the several
stages into which I divided fever, when treating
of it generally. — a. The premonitoi-y stage exhibits
the same symptoms as are observed to announce
other fevers, and varies much in duration. Hil-
DENBRAND statcs from three to seven days ; but a
much longer time may elapse from the time of
infection to the occurrence of the stage oj' invasion.
This period is the commencement of the febrile
paroxysms. It begins with a creeping sensation
over the head and back, followed by shiverings,
paleness of the surface, the cutis anserina, inter-
vening flushes of heat, heaviness or giddiness of
the head, and the usual symptoins of this stage, — h.
After a few hours — seldom more than twelve —
the stage of reaction — the injiammatory of Hiluen-
nux'ST), \\\e irritative inflammatory of Goeden —
appears. The pulse becomes full, strong or op-
pressed ; the countenance flushed ; the skin hot
and turgid ; the head confused, heavy, or giddy ;
and the urine scanty and high-coloured. With
these are associated catarrhal or gastric symptoms,
— On the second day of this stage, after a sleepless
and restless night, the heat increases, while the
vomiting and sometimes the nausea disappear.
The weight in the head changes to stupor, often
with tinnitus aurium ; giddiness is augmented,
and the upright posture cannot be borne. The
catarrhal aflection is more developed : the eyes
are red ; the mucous membrane of the nose and
fauces is tumid and red ; deglutition is painful ;
tightness is felt in the chest, often with cough ;
and both hypochondria are tense and painlul.
The patient is averse from exertion, tardy in his
answers, silent as to his complaint, and slow in
protruding his tongue. These symptoms continue
(luring the third and fourtii days. On the latter
of these, an exacerbation takes place, usually
followed by a moderate cpistaxis, excepting in
the milder cases, and generally with relief of the
aflection of the head. From the third to the sixth
day, but sometimes later, the surface of the body
becomes tuigiil and the eruption appears. During
the fifth, sixth, and seventh days, the symptoins
are unchanged, excepting that the catarrhal .li-

FEVER, TYPHUS — Crisis — Complications
faction commonly ceases with the appearance of

100&

the eruption. On the seventh day an evident
exacerbation takes place, followed by a slight re-
mission of a few hours, and introduces a new stage.

493. c. The nervous stage — the status nervnsus
of HiLDENBRAND — bcglns with the eighth day
from the occurrence of rigors. The heat of the
surface is now considerably increased, but the
turgidity disappears. The epidermis is dry,
shrivelled, and brittle ; but pelechiaj or miliaria
are frequently present, and either appear in the
latter part of the preceding stage, or early in this.
The tongue, which was at first clean, and subse-
quently white, rather than loaded or furred, now
becomes parched and shrunk. Thirst is increased ;
but the torpor is often so great that the patient
does not ask for drink. The tightness of the chest
goes off, and the breathing is freer, but more
frequent. The cough ceases, and is often re-
placed by singultus. Swallowing is impeded,
chiefly owing to the dryness of the fauces and
pharynx. The bowels now assume activity — pre-
dominant action being determined to them in
place of the skin. Repeated, loose, foetid stools
occur, attended by slight pains in the bowels, and
by flatulent distension of tiie abdomen, evidently
owing to increased vascular action. The pulse
is variable ; it generally continues full, free, not
very frequent, nor small or soft ; and it often
indicates imperfect reaction or contraction after
the heart's impulse, or seems to be in a state of
constant expansion. The most prominent, how-
ever, of the symptoms in this stage are those re-
ferrible to the sensorium. In the preceding stage
the external senses are impaired, and the ideas
confused. There are sleeplessness, restlessness,
and some involuntary motions. These are all
aggravated or modified in this period. Muscular
power is suppressed by the general torpor of the
nervous system, rather than by debility, as in a
state of intoxication ; but the involuntary mo-
tions, such as tremors, subsultus tendinum, slight
convulsions, or spasmodic affections, are increased.
Difficulty of deglutition, and of evacuating the
urine, is more common ; deafness is increased ;
vision is impaired ; and smell and taste are lost.
The patient dreams without being asleep {typho-
mania), talks deliriously, is occupied with his
internal impressions, and disregards or is unim-
pressed by external objects, or confounds internal
and external perceptions. A single idea or im-
pression usually torments the patient during the
fever, and on recovery there is seldom any recol-
lection of it. This state closely resembles som-
nambulism. With insensibility to external objects,
there is complete loss of the appetites and desires;
the patient wishes and feels nothing, and replies,
when roused, that he is very well. This stupor,
in various degrees, with the supine posture, at
once announces the form of the disease. The
foregoing symptoms continue during the ninth
and tenth days. On the evening of the latter
day a stronger evening exacerbation than usual
occurs, and lasts for a few hours ; and a gentle
perspiration, or some evacuation by stool or urine,
takes place. A sliglit remission follows on the
eleventh day ; but on the twelfth and thirteenth,
febrile heat, and the affection of the nervous sys-
tem, are again increased.

494. d. The period of crisis now generally suc-
ceeds, and without any assistance from art. At

the end of the thirteenth day, a more severe ex-
acerbation than any former one takes place : the
heat is more glowing ; the arteries pulsate more
strongly ; the brain is more affected ; and the
stupor passes into sopor. In twelve hours after-
wards, and on the fourteenth day, the parched
skin shows a tendency to perspiration. In some
a slight epistaxis occurs, with relief to the head ;
tlie nostrils become moist ; the tongue at tiie point
and edges moist, clean, and red ; and perspiration
more copious and general. A free expectoration
olten takes place, especially if the chest has been
affected. When the perspiration is salutary it
is uniform, not clammy, has a peculiar smell, and
occurs during sleep. The stools are now copious,
loose, and offensive ; and the urine plentiful,
muddy, high-coloured, and deposits a copious sedi-
ment. With these changes, or in a few hours after-
wards, the patient seems as if he had awakened
from a dream, or from a state of intoxication; and,
with a return of complete consciousness, all the
severe symptoms abate. A sense of fatigue and
weakness, soreness of the whole body, pale hollow
countenance, giddiness, deafness, and tinnitus
aurium, drowsiness, or frequent inclination to
sleep, tendency to perspire, quick pulse, and ac-
celeration of it upon slight irritation or exertion,
unnatural taste in the mouth, whitish tongue, &c.,
remain for six or seven days after the crisis — these
symptoms gradually disappearing, the tinnitus
aurium last of all.

495. B. Modifications di.x\il complications. — As
in exanthematous fevers, so in this, variations from
the regular type, both in the symptoms and in their
course, are apt to occur, owing — 1st, to the age,
habit of body, previous health, and temperament
of the patient; 2dly, to the prevailing epidemic
constitution, whether inflammatory, bilious, or
tending to the periodic type ; and, 3dly, to the
living, diet, and treatment, and to the unfavour-
able circumstances to which the patient is ex-
posed.— a. The anomalous phenomena observed in
the stage of invasion, are few. The shivering may
be so slight as hardly to be observed ; the fever
seeming to begin at once with increased heat ; or
the rigors may last or return at intervals durino-
some days. — In the period of reaction the modi-
fications are often more numerous and striking.
The inflammatory character of this stage is often
greatly increased ; sometimes as respects the vio-
lence of the general symptoms, but at others with
severe local affection. When the head is the
seat of prominent action, the delirium may be
phrenitic, maniacal, or the stupor may amount to
apoplectic sopor. Inflammation may take place,
either in the lungs, or in the liver, or in the diges-
tive mucous surface, and be so fully developed as
to resemble idiopathic disease of the viscera,
if the previous fever, stupor, tinnitus aurium, and
peculiar eruption, did not establish the difference
between them. — Bilio-gastric affection, also, may
be so prominent as to simulate that form of fever.
But the stupor and typhomania will assist the
diagnosis, should the eruption be so slight as to
escape observation. The nervous character may
show itself prematurely ; especially when the
vital powers are weak, depressed, or speedily ex-
hausted. In these, septic or malignant symptoms
may occur. In some cases, the inflammatory
stage may continue to the ninth or even to the
eleventh day.

3T

1010

FEVER, TYPHOID — Causes.

496. b. In the nervous stage various modifica-
tions are also observed. Local affections may con-
tinue through the greater part of this stage, or may
even first appear in it ; particularly those seated
in the intestines, and implicating especially the
mucous follicles. Diarrhoea, or typhoid dysen-
tery, may thus supervene, and be either slight,
severe, or fatal. The former of tiiese affections
is caused by vascular determination to the intes-
tinal mucous surface, consequent upon the sub-
sidence of the eruption, and by the unhealthy bile
secreted by the irritated liver from the impure
blood circulating in it. The dysenteric symptoms
are owing to the morbid action going on in the
lower part of the ileum, in the caecum, and large
bowels. Lumbrici are sometimes passed. But
the principal and most frequent variations con-
sist in the appearance of numerous petechia; and
vibices, or in their increase or deeper hue, if
they had previously been observed, with several
other putro-adynamic changes. In these, the
nervous symptoms may not be more remarkable
than in milder cases ; or these symptoms may
be very prominent, either with or without the
occurrence or aggravation of the malignant or
septic state. INIiliary eruptions may also appear
m this stage. In the more unfavourable cases
the tongue may be shrunk like a piece of burnt
leather, the heat of surface excessive, the diar-
rhoea exhausting, the distension of the abdomen
great, and pains in the bowels severe. JNIuscae
vojitantes, picking of the bed-clothes, constant mut-
tering, spasmodic aflfections, stiffness or cramps of
the extremities, paralysis of the eyelids or tongue,
horror at liquids, may also occur. A black coating
of the tongue and teeth; foetorof the breath, stools,
and of the body ; dark petechiae or vibices ; ecchy-
moses or bluish patches ; passive haemorrhages,
and even carbuncles, may appear during this
stage, particularly when circumstances concur to
produce putrid or septic changes in the course
of the fever. These severe cases, if they are
not fatal before the fourteenth day, often run on
to the seventeenth, twenty-first, or twenty-eighth
day, and generally end in death.

497. c. Sometimes the prcccrisis on the seventh
day either does not take place, or is not followed
by any alleviation, or is attended by aggravation
of the symptoms. If a decisive crisis take not
place on the fourteenth day, it rarely happens
till the twenty-first ; a crisis between these days
being seldom effective. When death occurs, the
fatal change is either premature or procrastinated.
The symptoms accompanying a crisis are often
variable. Changes in the urine cannot be de-
pended upon. Discharges from the bowels are
often copious, without benefit ; and if they con-
tinue so without alleviation of the symptoms,
or are unnatural, ulceration of the intestinal mu-
cous surface may be dreaded. A critical sweat
is sometimes wanting, the patient recovering
nevertheless.

498. (1. The declitie of the disease may be
protracted, but never shortened ; and attended
by various symptoms, as a continuation of the
stupor, nightly recurrence of delirium, or lingering
affections of some one of the thoracic or abdomi-
nal viscera. A new disease, of an inflammatory
kind, may occur during the stages of decline and
convalescence, or tubercular consumption may
supervene ; and relapses are not infrequent in the

latter period, owing to a fresh infection. — Re'
covery may be retarded by the severity of the
complications, by want of sleep, by errors in
regimen, and by the depressing passions.

499. e. The foregoing modifications refer entirely
to aggravating circumstances ; but some cases
are so slight, that the patient scarcely keeps his
bed — a trifling degree of stupor, with scanty erup-
tion, and occasional pains in the bowels, cori-
stituting the chief complaint. In the more benign
cases a decisive crisis occasionally takes place as
early as the eleventh, or even the ninth, day ;
but relapses are liable to follow if the patient be
exposed to a re-infection.

500. V. Causes. — .(4. Thecauses of typhoid fevers
differ but little from those of the synochoid forms.
— a. The predisposing causes (§ 446.) of both are
the same. Although typhoid fevers most frequently
occur in persons from 15 to 40 years of age, yet
the mortality, in proportion to the number affected,
is much less in this than in more advanced
periods of life. The predisposition to be attacked
diminishes remarkably with advancing age, espe-
cially after 50 : but the proportion of those who
die increases in a still greater ratio. The pre-
disposition also diminishes as we descend from
puberty to infancy, and the mortality diminishes
in a still greater ratio. Thus children and aged
persons are least obnoxious to typhoid and in-
fectious fevers : a somewhat different law here
obtaining from that which characterises the oper-
ation of exhalations from the soil upon the human
constitution ; these latter affecting the young and
old as well as the middle-aged, and renewing their
attacks in various forms, whilst typhus fever seldom
occurs oftener than once in the same person.

501. b. The exciting causes of typhoid and sy-
nochoid (§ 449. et seq.) fevers are often the same,
excepting that infectious miasms, want, and famine,
the various contingencies connected with the ope-
rations of war, and epidemic influences, are most
concerned in producing the severer varieties about
to be described. — The sporadic cases of this fevei',
and which generally present either the milder
form, or most of the nervous character, often
originate in the depressing passions, in changes
from the usual habits and modes of life, or in
exposure to novel influences, physical and moral ;
in weak delicate persons of a lax habit of body ;
in persons imperfectly fed, or reduced by previous
disease, or by exhausting discharges, &c. From
these causes especially proceed the adynamic,
slow nervous, or mild typhoid fevers, often ob-
served in persons who have recently removed info
large cities, or who live in crowded, low, and
ill-ventilated apartments. — The epidemic visit-
ations of typhoid fever are usually of the more
low or severe forms described hereafter.

502. Although nervous and typhoid fevers arise
from animal or infectious miasms, yet they proceed
also from other causes, as shown above (§ 452.
501.) especially mental emotions, and impure air.
The more complicated and putro-adynamic states
of those fevers may be consequent upon other forms
of fever, or upon fevers differently characterised
at the commencement ; but they may also arise
from infectious exhalations, or more immediately
and sporadically from terrestrial emanations, or
from theedluvia produced by animal and vegetable
matters during decomposition, particularly in a
close, warm, and humid air; or from a combina-

FEVER, TYPHOID — Prognosis — Terminations, etc.

tion of causes Loth internal or intrinsic and ex-
ternal, as respects the patient ; and they may
subsequently extend themselves by the infectious
miasms generated in their course.*

503. B. — The chief cause oftrueti/phus has been
already stated to be an animal miasm, generated
either by a number of persons confined in a close
air, or by the disease itself. This miasm contam-
inates tiie air, and infects the healthy frame through
the respiratory organs — either directly as it
proceeds from the morbid source, or indirectly by
means of substances capable of retaining it for a
time, and of giving it out upon exposure to the ! since 1831, has been shown by Drs. Alison and

1011
504. C. — The Causes of both Sijnochoid and Ty-
phoid Fevers aremost active, or abound most, — are
longer retained and more rapidly spread, — in large
cities, or in manufacturing towns, especially in
low-crowded, foul, close, and ill-ventilated parts of
these towns. This fact, already well known, has
been ably illustrated by Dr. Cowan. In the large
manufacturing city of Glasgow, these fevers have
been lately more prevalent than in any other part
of Great Britain. This has been the case since
1815, and more particularly since 1824. A nearly
equal prevalence of these fevers in Edinburgh

air. The causes predisposing to, or counteracting,
infection, are deserving of a brief notice. Infants
and old persons are the least susceptible. Adults,
of delicate habits and melancholy disposition, and
those who dread infection, are most liable to be
attacked. Insufficient or unwholesome nourish-
ment, personal or domestic filth, and bodily fatigue
or mental distress, are very influential concurring
causes. Persons of a lively disposition, those who
use tobacco, and who have no fear of the disease,
most frequently escape. Chronic diseases, par-
ticularly those of the lungs, ulcers, and external
sores or eruptions, are very often preventives.
HiLDENBRAND states, that, in his very extensive
experience, he never saw a consumptive patient
contract the disease. A regular and fully devel-
oped attack seems to prevent a second, for many
years afterwards, if not for ever.

Christison. Dr. Cowan estimates the numbers
of cases of fever in Glasgow in 1835, 1836, and
1837, at 6180, 10,092, and 21,800 respectively,
one-third of which cases was treated in hospitals.
The epidemic prevalence of fevers in Glasgow and
Edinburgh is favoured, beyond what is observed
in the large manufacturing towns in England, by
the much lower living of the poor, and by the want
of due provision for the necessitous in the former
places. The diminished prevalence of fever with
advanced age, remarked upon above, (§,500.) has
been well illustrated by Dr. Cowan in his re-
searches into the statistics of the epidemic of
Glasgow in 1836. He adduces the following table
of the relative population and relative numbers
of cases of fevers at different ages admitted into
hospitals.

Age. 5 to 10.

10 to 15.

15 to 20.

20 to 30.

30 to 40.

40 to 50.

50 to 60.

above CO.

Population
Fevers

25,707
191

21,211
318

20,745
501

38,185
715

26,419
309

18,014
128

11,648
43

10,220
11

According to the observations lately made both
in Edinburgh and Glasgow, the prevalence of
synochoid and typhoid fevers in both sexes appears
to have been nearly equal.

505. XXIII. Prognosis, Terminations, Mor-
tality, and Organic Changes in Synochoid
and Typhoid Fevers.— i. Prognosis. — The prog-
nosis will be influenced by the appearance of any
of those phenomena to which attention has been
directed above (§ 418. et seq.). But in addition to
these, the practitioner will take into the account the

* A gentleman far advanced in age, on ascending tlie
Steps leading to tlie entrance of a chapel in this city, un-
derneatli which the bodies of the deceased members are
buried, was suddenly stiucli by a gush of foul air whicli
issued from tlie grated openings, leading from the place
of burial, on eacti side of the steps. He instantly felt sick
and laint, and after a short time was obliged to leave the
chapel. The following day (Monday), he was confined
to his house ; and complained of aching pain of the back,
limbs, and joints ; of sinking and anxiety at the epigas-
trium and pracordia ; of giddiness, confusion of intellect,
and of chilliness, and great depression. 1 saw him on
Tuesday. In addition to these symptoms, there was
great prostration of muscular power : his pulse was quick,
weak, and unequal, but not above 100 ; his tongue was
loaded w ith a brownish fur. and dry ; his bowels con-
stipated ; his skin dry, harsh, and unhealthy in its aspect ;
his countenance anxious and sallow. The disease pro-
ceeded very nearly as described above (see 473. rf«f^.), and
he died on the eighth day of my attendance, and about the
eleventh from exposure to its cause. His wife, also far
advanced in age, and who had continued to sleep with
her husband during the first three days of the disease,
■was similarly attacked two days afterwards, and three
days before his death. Her symptoms throughout were
entirely snnilar to those of her husband. She also died
on the eighth day of the disease. The bodies of both I
rapidly went on to decomposition, although the weather
was very cold. Disinfecting means were employed as
soon as the nature of the fever was manifested, and no
other person was infected.

previous condition, the age, and the sex of the pa-
tient ; the nature of the prevailing epidemic ; ani)
the influences continuing to operate during treat-
ment. As to the manner in which age should
affect the prognosis from the beginning, some very
interesting facts have been adduced by Dr. Ali-
son, who has given the following table in illus-
tration of the comparative prevalence andmortality
of typhoid fever at different ages, as observed in
his practice : —

Cases

Deaths.

P,

oportions

Under 15

years

- 83

-

- 2 -

.

1 in

41i

15 to 30

_

- 149

•

- 11 -

.

I In

n\

30 to 50

-

- 93

-

- 17 -

.

1 in

51

Above 50

-

- 17

-

- 7 -

-

1 in

24

Of these 342, there were 170 cases of simple or
mild typhus, in which only three deaths occurred;
79 cases presenting prominent affection of the
head, and in these 21 were fatal; 58 cases with
affection of the pulmonary organs, in which 13
vveie fatal; and 35 with abdominal affection, in
which only one death occurred. — From these, as
well as from other data and facts which have
come before every experienced physician, it may
be inferred that the mortality from this fever
increases in an accelerating ratio with advance in
age anc} predominant affection of vital organs. It
is very probable, that the great increase in deaths
at an advanced age proceeds from the circumstance
of the powers of life being then less able to resist
the changes and tendency to death that take place
in the course of the disease, and the contamina-
tion of the fluids and soft solids : and from certain
internal organs having then become highly predis-
posed to serious functional and organic lesions.
3 T 2

1012

FEVER, TYPHOID — Termikations.

506. Typhoid fevere are seldom dangerous to
children in any class of society, although they
are often attacked when the disease is epidemic.
In the upper ranks, and in those accustomed to
live fully and luxuriously, they are very fatal, and
generally assume highly inflammatory states in
the early stages, or septic changes at a later period.
In the epidemic in Ireland, during 1817, 1818,
and 1819, from one fourth to one half of those in
good circumstances, who were infected, died. Of
twelve physicians who were actively engaged in
the treatment of the fever in Cork, eleven were
seized with it, and four died. They are much less
fatal to females than to males ; but pregnant
women often miscarry when they are attacked.
In an equal number of males and of females af-
fected, the deaths may be stated to be in the re-
lative proportion of eleven of the former to seven
of the latter. Persons whose minds have been
very much harassed or exerted previously to in-
fection are in the greatest danger. The putro-
adynamic form, and next to it the low or compli-
cated nervous, are the most dangerous of typhoid
fevers. These fevers, particularly when epidemic
and under circumstances favouring infection, are
extremely fatal to the dark races, and especially
to negroes. The circumstances more particularly
indicative of the prognosis has been fully discussed
above.

507. ii. The Terminations of Synochoid and
Typhoid Fevers vary remarkably, according to
the peculiar features of the epidemic, the locality in
which it prevails, the classes of society which it es-
pecially attacks ; to the age, sex, previous health,
and circumstances of the infected ; to the numer-
ous extrinsic and intrinsic circumstances of the
attacked ; and to the contingent occurrences and
concurrent causes connected with the appearance
of any form of those fevers. — A. Recovery, how-
ever, takes place in the great majority of cases of
these fevers, even when left to nature. Treat-
ment influences chiefly the amount of that ma-
jority, and, unless when very injudicious, not in
so remarkable a degree as usually supposed. The
causes which prevent this issue, are those which,
singly or conjointly, favour a fatal termination ;
and are chiefly, 1st. treatment of the patient in
unfavourable circumstances, as in a foul, close, or
infectious air; 2d. exhaustion of vital power and
of irritability ; 3d. local complications proceeding
to organic lesion; 4th. contamination of the^ir-
culating and secreted fluid ; and 5th. oflficious in-
terference on the part of the medical attendant.

508. 7j. Althougii death is most commonly the re-
sult of these changes, yet D(sce?'a/(/(srase, remaining
after recovery from the fever, and either gradually
disaj)pearing, or becoming more and more fully
developed until life can no longer be sustained, is
sometimes conse(jucnt upon one or other of them.
This is, however, a much less frequent termina-
tion of the fevers proceeding from animal infection
than of those arising from terrestrial emanations.

C. 509. Death is generally caused by two or more
the above circumstances ; seldom of one of them
only, although either may be mainly concerned in
cau-iing it. When death is produced by inflam-
mation of the brain or of its membranes, during
the stage of reaction, or by sim])le or inflammatory
congestion, in this or the subsequent stage, sym-
ptoms of an irritated or inflammatory state of the
brain, passing more or less rapidly into apoplectic

sopor, precede the fatal issue. In these, the blood -
vessels of the brain and membranes are engorged,
sometimes with extravasation of serum, or of san-
guineous serum, or more rarely of blood. The
patient sometimes dies soon after a critical exa-
cerbation, from the sudden occurrence of the
apoplectic state. In this case the brain is only
slightly congested, with little or no effusion of
fluid. In those who die with cerebral affection
in an advanced period of the disease, collections
of ^serous fluid in the ventricles, and between the
membranes of the brain, are frequently found.
Abscesses in the substance of the brain are met
with in rare instances. Hildenerand considers
nervous apoplexy to be the most frequent cause
of death in exanthematic typhus. This only occurs
in the latter days of the disease, preceded by the
symptoms of the nervous stage, a fatal result
taking place suddenly. As it usually happens on
critical days, it may arise from the exacerbation
which then occurs, wholly exhausting the nervous
powers ; particularly as no morbid appearances,
at all adequate to account for death, are observed
on dissection. It differs but little from death by
debility, excepting that the latter mode takes
place gradually and slowly. When debility or
exhausted irritability, the state of the blood, or
lesions of the intestines, cause this termination, the
stupor and delirium generally cease, and the
patient recovers his consciousness just before
death. — Upon dissection, in these cases, no
morbid appearances, beyond slight congestion, or
a somewhat increased quantity of fluid in the
ventricles oral the base of the brain, are observed
within the cranium ; the digestive mucous surface,
and the bloodin the large vessels and cavities of the
heart being most altered. — Medical treatment, if
not very judiciously directed, may be as injurious
as beneficial, by interrupting the regular succes-
sion of morbid phenomena, and preventing those
changes from taking place that are conducive to
recovery. An officious interference may thus be
mischievous, particularly when the disease is reg-
ular or moderate, and no vital organ is very
severely aflfected. JMedical treatment will not
shorten the disease ; we can only expect to con-
duct it to a successful issue, by protecting internal
organs from injury, when they experience the onus
of morbid action, and by resisting the tendency to
death in the last stages.

510. A fatal issue is evidently caused or ac-
celerated, in some cases, by the severity of the
associated disease of the respiratory organs, pre-
venting the necessary changes from being effected
in the blood circulating in the lungs. It proceeds
in others chiefly from the influence of the morbid
blood upon the weakened irritability of contrac-
tile tissues, and particularly of the heart ; and,
in rare instances, from perforation of the intestines
inducing general peritonitis, which soon exhausts '
the remaining powers of life. The lesions of the
digestive mucous surface evidently assist in pro-
ducing this eff'ect ; but in a much less degree than
the depression of organic nervous power and of
irritability, and the deteiiorated state of the
blood, with which they arc intimately connected,
and of vviiich they are important efl^ects. All
these internal lesions evidently commence in the
course, or even not until the advanced stages, of
the disease ; and, when developed, are analogous
to the sphacelated sores and other alterations

FEVER, TYPHOID — Mortality.

•Organic Changes.

1013

which take place in external parts in the more
malignant cases. These internal as well as ex-
ternal lesions depend upon the anterior changes
in the organic nervous power and irritability, and
in the blood ; they present similar characters ;
and, where even the slighter external lesions are
observed, the existence or occurrence of those
that are internal is to be feared. The most con-
stant of these latter are discolouration and dimi-
nished cohesion of the intestinal tunics, distension
of the intestinal tube by flatus, and enlargement
and ulceration of the follicles, with inflammation
or engorgement of the mesenteric glands. There
are various other lesions associated with those;
but they are different in diflferent cases.

511. iii. The RateofIMortai.ity in these fevers,
necesarily difl^ers with the circumstances just al-
luded to. It is obvious that the rate will be high in
hospitals which receive cases at an advanced stage
of the malady, and to which the worst cases are sent.
Not only does the mortality vary with the form of
fever and its complications, with the prevailing
epidemic, with the season, and with the numerous
circumstances predisposing to, and aiding, the ex-
citing causes, but also with the influences which
come into operation during the progress of the
malady. Hence the great dift'erences in mortality
observed by writers in different fevers and epide-
mics. Dr. Alison found the mortality at all
ages, 1 in 9 i; Dr. Christison 1 in 10 in 1837,
and 1 in 6-27 in 1838. Dr. Cowan states the
deaths to have been 1 in 15 in Glasgow during
1835, 1 in 12 during 1836, and 1 in 10 during
1837 ; the rate of mortality in Glasgow and
Edinburgh during this last year being the same.
HiLDENBRAND estimated the deaths in exanthe-
matic typhus at one in 10. Dr. Bardsley ob-
served the mortality in typhoid fevers, in the
iManchesler hospital to vary from 1 in 12 to 1 in
6 3, the average being 1 in 8 \. It has been sup-
posed, that a great increase of deaths from fevers
diminishes the numbers of deaths from other dis-
eases ; but Dr. Cowan has proved, by documents
of what has been observed in Glasgow since 1 813,
that during the prevalence of epidemic fevers in
that city, the mortality from other diseases maybe
greatly increased. In 1835-6-7, the deaths from
fever were 412, 841, and 2180 respectively, and
from other maladies, 7198, 8441, and 10, 270 re-
spectively, constituting, in relation to the mortality
caused by other diseases, 1 in 15"6, 1 in 10, and 1
in 4'7 annually; and to the population 1 in 570,
290, and 116.

512. iv. The Organic Lesions are not confined
to any single viscus, in anyone form of synochoid
or typhoid fever. — a. M. Chomel gives the follow-
ing as the results of a very careful inspection of
the encephalon in 38 cases of typhoid fevers. — In-
jection of the membranes in 4 ; oedema of the
membranes, in 7 ; very slight general softening of
the brain, in 6 ; effusion of serum in the ven-
tricles, varying from a drachm to half an ounce,
in 12 ; numerous red points upon dividing the
cerebral substance, in 5 ; increased density of this
substance, in 2 ; and the normal condition, in 15.

513. /). The mciith, totigiie, and pharytix are
frequently covered with a thick mucus, underneath
which the mucous coat is often not manifestly
altered. ]?ut in some cases this coat is softened,
discoloured, and studded with a few small round
or oval ulcers, most of them not referriblc to the

follicles. The oesophagus occasionally is excori-
ated or slightly ulcerated. The stomach is vari-
ously colotired in its internal surface. It is some-
times pale, most frequently red in various grades,
or purplish or brownish red, occasionally yellow-
ish ; and often the parts of the organ in contact
with the liver and spleen have imbibed the co-
lour of these viscera. — Softening, or diminished
cohesion, of the mucous and submucous tissues,
throughout the greater part of the large curva-
ture, or even the whole of the stomach, is observed
in a large proportion of cases. The softening
seldom extends to all the coats. Sometimes the
mucous tunic is not only softened, but entirely
destroyed, the cellular tissue or the muscular
coat being denuded. It is generally easily de-
tached from the subjacent parts. M. Chomel
found, of forty-two cases, more or less extensive
softening in fourteen. He remarks, that he ob-
served softening of the internal coats of the sto-
mach in the same proportion of fatal cases from
small-pox. — Thickening and great ienidtii of the
mucous coat have also been seen, but not so fre-
quently as softening. Although IM. Louis met
with ulceration of the mucous membrane of the
stomach in four cases, and JNI. Andral in ten, yet
M. Chomel did not find one instance in the forty-
two inspections of which he has given the details.
514. c. The duodemim and jejunitm have oc-
casionally imbibed the colour of the bile or of
adjoining viscera. They are generally of a deeper
red than the rest of the intestines. The ileum is
usually more or less red, with numerous arboris-
ations on the external surface ; but more frequently
the redness is seated chiefly in the mucous coat,
and particularly in the margins of the valvulae
conniventes. In many cases the redness is dis-
posed in zones, between which the three coats of
the intestine present a remarkable pallor. The
redness and injection are not greater around the
ulcerations and tumid patches of agminated fol-
licles, than in other parts. Alterations of colour
are not so common in the large as in the small
intestines, the former presenting chiefly reddish-
brown patches orecchymoid spots, or dirty purplish
or brown-coloured tints. Dark discolouration of the
small intestines, as already noticed (^ 510.) is very
general. Softening of the mucous surface of the
bowels, in the situation of the agminated follicles,
or in the intervals between them, is seldom very
great ; the subjacent cellular tissue more frequently
and decidedly presents this change. Induration is
never observed in the digestive canal after typhoid
fevers. In several cases the mucous coat is re-
markably tumid or thickened, presenting a gela-
tinous aspect, and various shades of colour from
a bright red to a reddish black. This chano-e
varies in extent from two or three inches to as
many feet, but is quite continuous, extending
around the intestine. It is most frequently found
in the ileum, but it may occur in any part of the
small or large bowels. It arises from the infil-
tratiqn of fluid blood into the mucous and sub-
mucous tissues ; for, upon pressing the part, the
blood exudes through the pores, leaving the mu-
cous coat almost in its natural state, IM. Chomel
observed this lesion in seven out of forty-two
cases, and in all these there was hasmorrhao^e,
either from the bowels or into them. He also
remarked it in other diseases, wherein intestinal
haemorrhage had occurred before death.
3T 3

1014 FEVER, TYPHOID

515. d. Since Petit and Bretonneau directed
attention to the almost constant change in the
intestinal inucous follicles in typhoid fever, the
subject has been further illustrated by the re-
searches of Louis, Andral, Bright, Ciiomel,
and others. But, although this lesion is so con-
stant in the low fevers occurring in Paris and
some other parts of France, it is certainly not so
frequent in the same states of fever in this coun-
try ; and, instead of viewing it as intimately con-
nected with the nature of these fevers, I consider
it as only one of several changes superinduced
in the progress of the disease, but one of the most
frequent and important. The first alteration
which these follicles present is enlargement or
engorgement, owing to the formation under the
mucous coat of a yellowish-white matter, slightly
friable, which imparts to the agminated follicles
the appearance of a thickened patch, and to the
isolated follicles that of a pustule. To this state,
which is generally preserved till the twelfth or
fifteenth day, succeeds, in most cases, ulceration,
beginning either in the mucous surface, and ex-
tending to the whitish matter, or in this latter,
which becomes softened and detaches the mucous
coat from the parts underneath. These grades of
lesion in the follicles almost constantly commence
in those nearest the ileo-cajcal valve. From the
eighth to the fifteenth or twentieth day the ag-
minated patches, which have not experienced the
above changes, present a reticulated appearance ;
their mucous covering being of a deeper colour
than natural, softened, partially detached, and
perforated by numerous orifices of enlarged fol-
licles. In proportion as these patches disappear
by ulceration or by sphacelation, the margins of
the ulcers become either more level, evincing a
disposition to cicatrization, or more elevated,
owing to thickening of the submucous and mus-
cular tunics. The ulceration generally extends
in width and depth, and successively invades the
submucous, muscular, and serous coats ; ending
at last in perforation ; but death most frequently
takes place before this last change occurs. Evi-
dence of cicatrization is, in rare instances, ob-
served, when the disease has been of long dur-
ation. Ulceration does not attack all the patches
containing the enlarged glands ; for resolution
sometimes takes place, or absorption of the matter
they contained.

516. e. The mesenteric glands are very generally
more or less changed, especially in connection
with intestinal ulcerations. They are frequently
only enlarged, sometimes softened, and occasion-
ally both enlarged and indurated. In some in-
stances, puriform matter may be traced in the
sanious blood which they contain. They are
usually only enlarged or indurated, or some-
times injected in fatal cases which have not been
of long duration. M. Ciiomel gives the follow-
ing as the results in the 42 cases examined by him :
— Enlargement, with commencing softening and
suppuration in 14 cases, dead from the seventh
to the twenty-fifth day of the disease ; marked
softening in 12, dead from the tenth to the thirty-
sixth day ; redness, enlargement, and induration
in 10, who died after the nineteenth day ; slight
enlargement, with a bluish, purplish, and black-
ish discolouration, in 3 cases, dead after the seven-
teenth day.

517. ll would seem that the mesenteric glands

— Organic Changes.

experience an analogous change to that of the
follicles ; that they become enlarged and softened
about the same period as the follicles ; and that,
if the disease takes a favourable turn, they are
gradually diminished, and assume their natural
state. Suppuration is seldom observed in them,
and ulceration never. The glands nearest the
caecum are those chiefly afTected ; and this is the
part in which the follicles are most frequently
and early diseased. M. Chomel does not think
that ulceration of the follicles is the cause of the
suppuration of the glands, as the latter may exist
without the former. — 1 believe that softening of
the mesenteric glands, with traces of puriform
matter in them, may take place without any neces-
sary dependence upon ulceration of the follicles.

518./. The lesions observed in the other abdo-
minal viscera are seldom such as materially to
influence the termination of typhoid fevers. The
liver is frequently ■ more or less softened. M.
Louis found this alteration in nearly one half of
the fatal cases he examined. It is generally asso-
ciated with softening of other organs, especially
of the spleen. This viscus is enlarged in most of
the fatal cases ; in one half it is increased to about
double its usual volume, or upwards. It is al-
ways also softened — sometimes very remarkably so.
The alterations of these organs seem to have little
or no influence upon the symptoms during life.
The same may be said of the lesions of the mesen-
teric glands. Even the ulcerations found in the
intestines have no determinate relation to the
phenomena referrible to the digestive canal. Di-
arrhoea is not an uniform result of this lesion ;
and pain is seldom complained of unless at an
early stage, or until the peritoneal tunic is perfo-
rated. The ochrey appearance of the stools,
noticed by Dr. Bright, cannot be depended upon
as an indication of this alteration ; and meteoris-
mus, or a tympanitic state of the abdomen, al-
though often attending it, indicates chiefly extreme
depression of vital power, evinced especially in
the weakened irritability or tonicity of the intes-
tinal tunics, throughout the whole tube, render-
ing them incapable of resisting the accumulation
of flatus. jMany of the symptoms referred, by
Continental writers, to organic lesions of the
bowels, originating either in inflammation or irri-
tation, are inseparable from the typhoid states of
fever, and are the expression of the disease on the
whole oeconomy, rather than on this part of it in
particular, 'ihat the aflFection of the digestive
mucous surface and follicles is greater in some
epidemics and countries than in others, and in
large cities than in towns or country places, I am
convinced from observation and the researches of
modern pathologists. That it is more common
in France, especially in Paris, than in En^dand,
is evident from the results of recent incjuiries.
Actual ulceration was found in La Charilt by
I\]. Andual, in 92 cases out of 229 examinations
and only in 16 out of 54, by Dr. Tweedie in the fe-
ver hospital. The proportions, although different,
show the frequency and importance of the lesion,
and the necessity of guarding against its occur-
rence in the course of the disease. IJut the above
changes of the intestines and mesenteric glands are
not confined to typhoid fevers. They often take
place in other fevers, whether bilious or gastric,
mucous, synociioid, &c., particularly in localities
where the water is impure, and when these fevers

FEVER, TYPHOID

lapse into a putrid or typhoid state in their advanced
stages, or when the fluids become deteriorated. Their
frequent occurrence also in hectic is well known ;
and I believe that they would have been found
still more frequently in all fevers, both continued
and remittent, if the intestinal canal had been
more generally inspected in that way in which
only it can be said to be inspected, namely, by
luying it open throughout its whole extent. That
it has been very imperfectly examined in most epi-
j demies, is evident, from the descriptions furnished
! of the morbid appearances, and from the circum-
> stance of it having been very generally overlooked
aslate astheepidemicsdescribed by Hildenbrand
and others early in this century ; and, although
occasionally inspected by some of the writers
upon the epidemic of Ireland, in 1817, 1818,
and 1819, it was not until after the researches of
Broussais, Petit, Buetonneau, Andral, and
Louis, that attention has been generally directed
to it. Waking every allowance for the undue
importance assigned to the lesions observed in
this situation, the propriety of estimating them
correctly, as to their origin and consequences,
must be conceded.

519. g. The importance of the lesions observed
in the respiratory organs has been alluded to. The
epiglottis has been sometimes seen oedematous.
M. CHOiMEL found it ulcerated, with denudation
of the cartilages, in three cases out of twenty which
were carefully inspected. The larynx , especially
its superior aperture, is occasionally also the seat
of ulceration. When ulceration is observed in
either of these situations, it often also exists in
the pharynx, in which it seems often to have be-
gun ; and it is generally found to consist of several
small but deep ulcers, commencing in the form
of pustules filled with whitish purulent matter,
but without any surrounding injection or inflam-
matory circle. — The lungs are often much dis-
eased ; but the alterations of them most frequently
seen, occur only during the last days of life ; and
are referrible to the predominance of physical
over the vital forces, as the disease approaches a
fatal issue. But as congestion of the circulating
fluids occurs in the more depending parts, the
vital cohesion, particularly of the parenchymatous
parts of the lungs, becomes diminished, giving
rise to more or less marked softening of the en-
gorged part. In less frequent instances it is not
only a simple congestion from stasis of the fluids
that is found, but also indications of pneumonia
in the first or second degree. The pneumonia is
sometimes confined to two or three lobules ; in
which case it may have passed into a suppurative
state before death : in other instances it occupies
a whole lobe, but without any signs of suppur-
ation. Qidema, or even emphysema, of parts of
the lungs, is also occasionally remarked. The
bronchi are generally red, or of a livid red, or
violet colour. The lint generally deepens in the
small bronchi, and in the direction of the air-cells.
They also contain some mucus. — M. Chomel
gives the following as the state of the lungs in
42 cases : — Congestion, with or without soften-
ing, in 18 ; hepatisation in the first degree, in 3 ;
hepatisation in the second degree on one side, in
2 ; lobular pneumonia, in 3 : emphysema, in 2 ;
oedema, in 2 : effusion into the pleura, in 2 ; and
the normal state, in 10.
- 520. h. The state of the blood varies much in

— Extehnal Changes. 1015

fatal cases of nervous, putrid, or typhus fever.
Where the putrid, malignant, or septic characters
have been most remarkable before death, the
changes of the blood have been usually the great-
est. — This fluid is commonly dark, black, difilu-
ent ; and but rarely in the state of fibrinous clots.
In a few cases, the blood in the heart and large
vessels assumes the form of black coagula, which
are diflferent from those observed in other acute
diseases. This state is evidently owing to the
absence, or great diminution, of fibrine. The
presence of a gaseous fluid in the blood, espe-
cially in that of the veins, is also evident in some
cases. I have observed this circumstance in
death from other diseases, particularly if asphyxy
was the mode in which the fatal event took place.
(See art. Blood, § 110. et seq.')

521. i. The heart is often softened and somewhat
discoloured. The scftentng of this organ varies
from an almost unappreciable, to a most marked,
degree. In some cases it is so great, that the fingers
may be pushed through the parietes of the ven-
tricles with ease. This diminution of cohesion is
generally observed in cases where the chano-es
in the blood, and softening of the liver and spleen,
have been the most remarkable. Flaccidity, or a
state of softness diflferent from that just men-
tioned, is still more frequent. The flaccidity may
exist without very manifest loss of the cohesion
of the structure ; but it is generally attended by
some degree of the latter, and the softening may
be great, and yet the flaccidity not very apparent,
although this is rare. — The colour of the internal
membrane varies in diflferent cases, and even in
the opposite sides of the heart in the same case.
In some the membrane is red ; in others daik,
brown, or livid : it is often colourless, particularly
when the heart is softened. It never presents
inflammatory appearances, nor the changes im-
mediately proceeding from the inflammatory state.
— The researches of MM. Trousseau, Rigot
(Archives G6ner. de Med. t. xii. — xiv.), and
Chomel (Clinique Med. p. 279.), show that the
redness often found in the aorta, cavities of the
heart, and large veins, in this class of fevers, is
entirely owing to the tinging by, or to imbibition
of, the colouring particles of the blood. Inflam-
mation of the heart, or of its membranes, has not
been observed in any case of these fevers.

522. k. The external changes observed after
death most frequently commence a considerable
time before this event. These consist chiefly of
petechia?, vibices, and blotches, varying as to size,
situation, and depth of colour ; and are to be
ascribed to the extravasation of serum, coloured
with red particles, or of blood itself, into the vas-
cular layer of the skin. Gangrenous eschars, and
sphacelus, are met with chiefly in parts pressed
upon by the weight of the body, as the sacrum,
shoulder blades, heels, and scalp of the occiput,
or in those to which blisters, sinapisms, or other
acrid substances have been applied. But these
changes may occur in other situations, although
rarely, and without these causes, as in the insides
of the thighs ; unusual pressure, or any other
cause, either dissipating or exhausting the remain-
ing vitality of the part, producing these eflfects.
Phagedenic sores or ulcers, and enlargements of
the absorbent glands, are also observed in rare
instances. These sphacelating or spreading ulcers
often commence in the form of pustules or vesicles,

3T 4

1016

FEVER, SYNOCHOID— Treatment of.

which break, leaving a foul sore which rapidly
spreads. Besides these, the usual consequences
of erysipelas are sometimes observed, or the re-
mains of exanthematous and miliary eruptions.
Even emphysema has appeared shortly before,
and has remained after death.

523. V. Patholomcal Conclusions. — The
above exposiiion of the organic lesions, more es-
pecially proceeding from typhoid fevers, suggests
some important considerations, relative not only
to the nature, but also to the treatment, of these
diseases. Few of these changes become apparent
before the seventh day from the invasion when
vascular action has passed into exhaustion, when
organic nervous power and irritability are remark-
ably lowered, the circulating and secreted fluids are
become morbid, and the powers of vital resistance
in great measure overthrown. If inflammatory action
should attack any part, either in this state, or even
at an earlier stage, it will be very different as to its
phenomena, its progress, and its results, from in-
flammation occurring primarily , or in a system whose
vital and physical constituents are not materially
deranged. It is the remarkable affection of these
constituents by the causes of fever, and by the
changes following more directly upon these
causes, that imparts a similar character and ter-
mination to all the lesions now described. The
depressed vital power of the extreme vessels, the
lessened irritability of contractile parts, and the
diminished vital cohesion of parenchymatous and
other structures, heightened by the morbid state
of the blood, are very frequently followed by
gradual softening, infiltration, congestion, or ef-
fusion ; and these often pass into disorganisation
amounting even to sphacelation, or to sphace-
lating ulceration, even without the intervention of
inflammatory action, or of any of its consequences.
Owing to the intimate dependence of the states
of the digestive canal, more especially of its in-
ternal surface, upon organic nervous influence,
the former is involved, in a correlative manner,
whenever the latter suffers. The tonic contrac-
tility of the muscular and serous coats of this
canal is much diminished, the vital cohesion of
its mucous membrane is weakened, the tonicity
of the extreme vessels of this coat is lessened,
and its functions of secretion impaired or other-
wise changed. In this state, it is unable to re-
sist the impressions made by moibid secretions
passing over it. The alterations which had pre-
viously taken place in the organic nervous influ-
ence, in the functions of respiration, and in the
blood, have conjointly given rise to diseased —
usually acrid, or irritating, or septic — secretions
fiom the liver, pancreas, and even also from the
intestinal surface. AVhen we find these secretions
produce spreading or sphacelating sores, as they
often do, in the protected cutaneous surface, we
cannot he surprised at their occasioning analogous
lesions in the more delicate mucous surface of the
intestines, rendered still more delicate and suscep-
tible of lesion by the previous changes just de-
scribed. During the several days of the patient's
life, from the commencement of these changes, or
from the presence of morbid secretions in the in-
testinal canal, absorption will proceed on the di-
gestive mucous surface ; and, notwithstanding the
amount of absorption may be very small, yet we
cannot conceive it possible, that morbid secretions,
cither floating through the intestines, or colkxted

in the follicles, will pass through absorbent glands,
or even into the vessels which run to them, with-
out producing a material change in them. If
these views be just, the inference that depressed
organic nervous influence and irritability, a morbid
state of the blood, and disorder of the secretions,
are concerned especially in causing the changes
of structure observed in the digestive canal, will
be admitted ; and, if admitted, it becomes the
basis of a rational method of treatment. But
these early pathological states induce also those
organic lesions in typhoid fevers, affecting other
internal organs, and even other external parts,
and stamp them all with the same important cha-
racters— characters indicating both a common
origin and a similar tendency, and pointing to the
same principles of cure.

524. XXIV. Treatment of Synochoid and
Typhoid Fevers. — i. Treatment of Synochoid
Fever. — In this fever, as well as in all others
in temperate climates, the indications and cir-
cumstances staled above (§ 123, 124.), as de-
serving of especial attention, should be strictly
observed. The prevailing epidemic, and the
changes that take place in its nature, or cha-
racteristic states of vital action, with its progress
and with the season, should be carefully studied
and made the basis of treatment. Some diflSculty
may occur at first in coming to just conclusions j
but it will vanish with the extent of observation,
especially when diligence has been used. The
chief points to which the attention of the practi-
tioner will be directed, are — the nature and con-
currence of the causes, the extent to which they
may have affected vital manifestations, the de-
gree of excitement or vascular reaction in con-
nection with nervous power, the state of the cir-
culating and secreted fluids, and the nature and
amount of local complications or determinations.
The physician who has studied, in an intimate
manner, the various phases of disordered vital
manifestation, will have little difliculty in recog-
nising the chief characteristics of fever under the
ever shifting circumstances in which tiiey pre-
sent themselves, and in appropriating accordingly
his method of cure.

525. A. The ancients observed carefully the
spontaneous changes which take place in fever,
and conduce to recovery (see art. Crisis) ;
and they were guided, in forming their indica-
tions of cure, by these changes, which they
merely attempted to promote or to imitate.
This mode of practice may be followed in sy-
nochoid fever more successfully, perhaps, than
in any other. Yet it will be belter to combine
with it the more modern indication, of resorting
to such means as may subdue the more urgent
symptoms, and avert contingent danger. «. If the
patient be seen as early as the premonitorq and
ini(idin<:; stages, the impending disease may be
averted by the means advised above (§ 121, 122.)
— more especially by emi-lics, warm diaphoretics,
and the raponv hath. i5ut when excitement has
commenced, the treatment should be antiphlo-
gistic. In this stage we should endeavour, by
a careful examination of the symptoms, to ascer-
tain the existence of local complications ; and,
having determined their absence, the question
will then be as to having recourse to blocdletliiif^.
I have already considered this topic so fully
(§ 128 — 139._) that nothing further need be here

FEVER, SYNOCHOID— Treatment of.

1017

advanced. If the nature of the prevailing epi-
demic, or the degree of reaction, require deple-
tions, the earlier in this stage they are resorted
to the better. But even then they require cau-
tion and discrimination. If the excitement be
slight, and the patient neither robust nor ple-
thoric, and more especially if the causes and
circumstances connected with the origin of the
disease be of a depressing nature, they will be
better withheld.

526. b. The exhibition of emetics in the stage
of excitement was advised by many of the an-
cients, and practised by some of the most recent
writers, although objected to by others. The rea-
son of this difference of opinion is very obvious.
There are states, even of this stage, in which they
will be of service, and others in which they will
be injurious. When reaction is slight — when
the patient is not plethoric, has not experienced
full vomiting, and does not complain of pain or
of tenderness in the epigastrium or hypochondria
— then emetics may be exhibited. 13ut if the
excitement be great, with determination to the
head ; and if the patient have already vomited
freely, and more especially if the symptoms just
mentioned be present, they should not be pre-
scribed. (See § 149.)

527. c. Purgatives, so much decried by Bnous-
SAis, and with some justice as respects several
states of fever prevalent in France, are certainly
of very great service in the common continued
fever of this climate, when employed with a
cautious discrimination. Early in this disease,
calomel, either with or without James's powder,
may be given at night, and a purgative draught
in the morning. At a more advanced stage, calo-
mel, or hydrargyrum cum creta, may be conjoined
with rhubarb. If the stomach be too irritable
to retain the more common purgatives, a full
dose of calomel will generally be retained ; but
its action should be promoted by enemata (see
F. 140. 144.). During the febrile excitement
and when the bowels are sluggish, the stronger
saline purgatives may be given in solution, in
small doses and at short intervals, with refrige-
rants (F. 440, 441.). The remarks already of-
fered upon this subject (§ 150, 151.) will guide
the practitioner as to the choice of purgatives,
and the extent to which they should be pre-
scribed. In this fever, especially, it can never
be injurious to give them to the extent of freely
evacuating morbid accumulations in the bowels,
and of promoting the alvine secretions and ex-
cretions. When the faeces are very offensive,
greater mischief will accrue from allowing them
to remain, even for a short time, in the bowels,
than from too active measures in evacuating them.

528. d. The remarks that have been offered above
respecting refrigerants (§ 139, 140.), diapho-
retics (§ 152.), and diuretics (§ 153.), are en-
tirely applicable to this form of fever. — The cold
ajf'usicrn, which formerly attracted so much more,
and now so much less, attention than it deserves,
is more appropriate in this than in any other
disease. This practice, although resorted to by
the ancients and in Eastern countries, was but
little known in this until it was employed by
Wright and Jacksox. The work of Dr. Currie
on the subject first brought it into fashion ; but
now it certainly has not fashion in its favour.
When the excitement is fully developed, and the

heat of skin above the natural standard, when
there is no sense of chilliness, and when the
surface is hot and unperspirable, the cold affusion
may be employed. Dr. Currie directed water
of the temperature of from 40"^ to 60° or 70°,
and preferred the hours from six to nine in the
evening for its use. In cases of debility the
cool or tepid affusion is more appropriate. I
have resorted to cold affusion over the whole
body, in several cases of fever, in a warm cli-
mate ; but I was not induced by its effects to
entertain a high opinion of it. The affusion of
cold, cool, or tepid water on the head, when this
part is prominently affected, and cold sponging
the surface, are mor i beneficial, and admit of
more general application. Dr. Currie believed
tliat the general affusion had the effect of lower-
ing the pulse and the morbid heat, of inducing
perspiration and sleep, and of cutting short the
fever. I have never seen it succeed unequivo-
cally in producing the latter effects ; but have
remarked that the excitement returned shortly
after its use. In the complication with disease
of any of the thoracic or abdominal viscera, it
should not be used (§ 141.).

529. B. Of the Complications. — a. Predominant
affection of the head has received attention above
{§ 165.). What I have there stated is appli-
cable to this complication of common continued
fever. — Bloodletting is especially requisite, but
its amount, and the mode of performing it,
should entirely depend upon the symptoms and
the stage of the disease. — The cold effusion on
the head, and purgatives, are the next m import-
ance. AVhen the cerebral affection has been
preceded or attended by diarrhoea, purgatives
should be prescribed with caution. Rhubarb
with hydrargyrum cum creta, given so as to
evacuate morbid matters, and promoted by suit-
able enemata (F. 140.), will be then sufficient.
When delirium is the principal symptom, care
should be taken to discriminate accurately the
states of vascular action and of vital power. If it
be unattended by increased heat of scalp, the
pulse being very quick and soft, and the counte-
nance sunk or pale, and especially if it have
followed intestinal disorder, all lowering agents
should be laid aside, and restoratives with opiates,
and mild nourishment in small quantities, pre-
scribed. When fever occurs in persons addicted
to spirituous or other intoxicating liquors, the
cerebral affection is apt to become very severe,
and to be attended with delirium and often with
tremor. In such cases depletions should be used
with caution. If tremor, irritability, &c., ap-
pear, opium, with or without camphor, should be
exhibited. In other respects, -the means advised
in the article Delirium, according to the patho-
logical states upon which it depends, will be here
appropriate. I have repeatedly seen the cerebral
symptoms greatly aggravated by the application
of a blister to the scalp, at a too early stage of
the d.isease. Blisters should be applied prefer-
ably on the nape, but never on the head unless
there be profound coma, or low delirium with
great exhaustion of vital power, as more fully
shown in the articles Coma (j 16.), and De-
lirium (§ 19.).

530. b. The observations already made re-
specting the pulmonary complications (§ 160 — ■
163.) are mostly applicable to those occurring

1013 FEVER, TYPHOID

in this form of fever. — Bronchitis is the most
common affection, and requires the treatment
above advised (§ 161, 162.). When the sub-
stance of the lungs, or the pleura, is nnplicated,
vascular depletions ought to be early practised.
But even in these cases, we should recollect, that
bloodletting must be employed with greater cau-
tion than in mflammations occurring primarily
and in healthy constitutions. It is in this fever
and in its pulmonary complications especially,
that antimonials may be given with greatest free-
dom. After depletions and antimonials have
been carried as far as seems prudent, blisters, or
other external derivatives, should be used. If
the air-passages become loaded with mucus, anti-
mony or ipecacuanha or sulphate of zinc may be
given so as to excite full vomiting.

531. c. Predominant affections of the diges-
tioe mucoiLS surface have already received at-
tention ; and the treatment there recommended
(§ 155 — 159.), is quite appropriate in these com-
plications of this form of fever. — In the gastric
state of disorder, particularly when much pain
and tenderness, with irritability, exist, local de-
pletions should be early employed ; and a full
dose of calomel, given shortly afterwards, will
generally allay what may remain of these sym-
ptoms. Enemata, also, will assist materially
in producing this effect, and evacuate morbid
matters from the bowels. Small, but often re

-Treatment of.

peated, doses of hydrochlorate of ammonia, or of
the nitrate of potash with the carbonate of soda ;
or camphor julep, with the solution of acetate of
ammonia, and nitre or spirit of nitric ajther ; will
afterwards be extremely beneficial. Even in this
form of fever, but still more in the adynamic, we
should be cautious not to be misled by the per-
sistence of pain and tenderness at the epigas-
trium ; or induced to prescribe too frequent or too
large depletions with the view of overcoming
these symptoms. They may never be removed
by these means, however freely employed ; for,
notwithstanding the arguments of Broussais for
their origin in inflammatory action, I believe that
they depend more upon the altered state of the
organic nervous sensibility, than upon increased
vascular action in the stomach.

532. In the enteric com]>Ucation the treat-
ment will depend upon the stage of fever at which
it appears, and the progress it may have itself
made. — Local depletions, external derivatives,
and the other means enumerated above (§ 156 —
159.), are generally necessary. If bloody or
ochrey discharges are observed, especially late in
the disease, the terebinthinate medicines, or the
acetate of lead with opium, as advised by Ur.
Bardsley, will be found the most efficient re-
medies. If the powers of the system become
much reduced, gentle tonics, with the chlorates,
as the infusion of valerian with the chlorate of
potash, and paregoric elixir, will be of essential
service. The following medicines will prove of
great use in earlier stages of this complication,
after local depletions, especially when aided by
external rubefacients and derivatives. In slight
cases, either of them may be given, according to
circumstances ; in the more urgent, both may be
taken alternately, at intervals of tliree hours.
- No. 223. li Soda; carbon. Rr. x. ; I'otassa; NItratis
or. viij. ; Tiiict. (^amphoroE Comp. .5j. ; Mist, ('ampliura.'
(vcl IiiFusi Viil(rri;ina;) .3 X. ; .Syrtipi Auraiitii 3ss. M.
Flat Haustu.t, scxtls horis sumcndus.

No. 224. R Camphoras rasse et subactaegr.ss j. ; Pulv.

Ipecacuanhae Comp. gr. iv. — vj.; Hydrarg. cum Creta
gr. iij — V. , Syrupi Simp. q. s. ut fiant Pilulse ij. vel iij.
sexta quague liora sumendse.

533. ii. Treatment OF Typhoid Fevers. — The
treatment of this class of fevers is the most difficult
in practical medicine. If the physician possess not
just views as to the different and varying states of
vital action, and as to their influence in producing
organic lesion — if he be not enlightened as to
physiological pathology, as well as to pathological
anatomy — if his knowledge of the instruments of
his art be not adequately varied and comprehen-
sive— if his resources be not great and based on
science — he administers to a patient in any of the
forms of typhoid fever, with an equal chance of
doing mischief, or of affording benefit ; and he
may as well adopt his plan of treatment from the
" hazard of the die," as to attempt to reason on
the matter. It is better that the patient were left
to the spontaneous efforts of nature, than that he
should fall into the hands of such a practitioner.
If we look back to the influence of theory and
system in the treatment of these diseases ; to the
importance bestowed on names ; and to the man-
ner in which names have been confounded with,
or substituted for, indefinite and varying entities ;
we shall not be at a loss to explain wherefore it
has often been a matter of difficulty to decide,
whether or not medical interference has proved
beneficial or injurious. This is, however, not an
opprobrium to our science ; but a proof of its dif-
ficulties, and of the ill-founded pretensions of
many of its professors and teachers. In our own
days, we have seen pretensions to which ignorance
gave confidence, and for which professional cant
procured currency, obtain a credence which now
seems surprising, and produce results which the
adequately informed always anticipated. We
have witnessed the promulgation of doctrines, and
of modes of practice, warranted neither by an ac-
quaintance with vital actions, nor by a knowledge
of, or regard to, facts, lead to the most serious
consequences ; and have remarked, moreover, the
power they obtained over those who were either
unwillingor unable to inquire into their truth. But
we have also seen, in the brief space of two or
three years, the illusion vanish before the increas-
ing and spreading lights of pathological and prac-
tical knowledge.

534. The difficulties attendant upon the treat-
ment of this class of fevers depend chiefly upon
the varying states of vital action in their course ;
the modifications and complications they present
in different circumstances and epidemics ; and
the inade(|uate means of discrimination in our
power, between the changes induced by treat-
ment and those taking place spontaneously. — It
is not also from the effects produced upon a few
detached cases, that we can judge sufficiently of
the efficacy of certain remedies; but from the
results in a number — from the rate of mortality
in various circumstances, and in different epi-
demics. Whatever may have been the method
advised by writers — too many of whom have
written from motives wide from those by which
alone they ougiit to have been actuated — we
siiall find, upon close inquiry, that the general
mortality has been such as to demonstrate its
little efficacy, or to show the small superiority
possessed by it over others,

535. The ancients observed the changes which

take place ia the course of fevers with great at-
tention, attributed recovery to the critical evacu-
ations which frequently occurred in their advanced
stages, and did not attempt to interfere with the
efforts of nature as long as the disease pursued a
simple and mild course ; but interposed in order
to accelerate and replace evacuations, when they
did not occur after a certain period, or were in-
terrupted by any circumstance. The cliief fallacy
in this doctrine is, that the evacuation, when it
occurred, was mistaken for the cause of the
amendment, instead of being viewed as the effect,
and as one of the signs by which this change is
often indicated.

536. The physicians who, in modern times,
attributed an important part to putridity of the
humours, recognised merely a portion of the mis-
chief, and that often the most remote and con-
tingent, and mistook, in great measure, both its
origin and nature. They had recourse to cam-
phor, bark, musk, and various preparations, both
vegetable and mineral, possessing antiseptic pro-
perties; and, if they had employed them in ap-
propriate periods and states pf the disease, the
benefit derived from them would have been much
less equivocal. But, mistaking the origin of the
phenomena usually called putrid, they frequently
prescribed these medicines improperly ; and
whilst endeavouring by an early exhibition of
them to prevent putridity, they actually often ac-
celerated or favoured its occurrence.

537. A nearly similar mode of treatment was
advised by Baown, and his once numerous fol-
lowers on the Continent ; but it was based upon
a different doctrine — upon the predominance of the
asthenic diathesis and its consequences. Although
wine, opium, tonics, and stimulants, were recom-
mended by them, in various forms and combin-
ations, with advantage, in certain states of typhoid
fevers, particularly in the latter stages ; yet the
evils resulting from an early recourse to them
were also sufficiently evident, and at last became
manifest even to the disciples of this school.
That this practice, and the modifications intro-
duced by its partisans, did not prove so injurious
in the treatment of fever, especially on the Con-
tinent, as may be supposed, is accounted for by
the circumstance, that depressed vital power, with
septic changes in the fluids in the last stages, cha-
racterised the much larger proportion of fevers
prevalent for several years after its promulgation.
But the appearance of exanthematic typhus in
the north of Italy, at the close of the last cen-
tury, opened the eyes of llazori to the impro-
priety of having recourse to stimulants in its treat-
ment, and laid the foundation for the doctrine
and practice of contni-siimulus. The general
character of the petechial fevers prevalent about
the commencement of the present century in
Italy and Germany, was such as I have deline-
ated in the section on typhus (§ 485.), with more
or less of inflammatory or irritative action in the
stage of excitement ; the exanthematous eruption
in this stage being frequently mistaken for petechia;,
and the appearance of these, and of other ady-
namic symptoms, being favoured by the vascular
reaction which preceded them.

538. The administration of the potassis tartrate
oi antimony in large doses, was the piincipaltreat-
mentemployed by Razori. When the patient was
young and robust, and the disease had not reached

FPVER, TYPHOID— -Treatment Of. 101

the acme of excitement, he directed a moderate
bloodletting at the outset, and immediately
afterwards, four, six, eight, ten, or twelve grains
of tartar emetic, or even more, in solution. He
prescribed this medicine in smaller doses subse-
quently, or substituted for it the kermes mineral,
conjoined with nitre, and in doses of one grain,
or of a grain and a half, every half hour, or hour,
or every two hours, according to the degree of
vascular excitement. He often gave the tartar
emetic and kermes alternately. IlAzoni also
employed purgatives, particularly when the anti-
mony did not act sufficiently upon the bowels ;
preferring neutral salts, manna, and tamarinds,
in large doses, and administering them, in other
cases, in enemata. He enforced a cooling reo-i-
men and severe diet, and allowed only refrigerant
beverages. The success of this treatment is stated
to have been great ; and its propriety, as well as
success, may be admitted, when employed in an
epidemic characterised by high vascular excite-
ment at its commencement, and when adopted
sufficiently early after reaction has taken place,
and in previously healthy persons. But in
other states of typhoid fever, and in the latter
stages especially, the large doses of antimony
here advised appear not, a priori, to be suitable
means. It should, however, be admitted, that
the exhibition of the potassis tartrate of antimony
in the advanced stages of this fever has never been
satisfactorily tried, either in this country or in
France and Germany. That it may be found not
so inappropriate as generally considered, is an in-
ference which the trials made of it, very recently
by Dr. Graves, of Dublin, fully warrant.

539. The pathological tenets lately prevalent
in France have, as M. Chomel states, prevented
the treatment of Razori from being adopted, or
even tried in that country. The doctrine of
Broussais was opposed to this, and every other
means that seemed to its supporters likely to
aggravate the inflammatory action of the digestive
mucous surface, which they supposed to be the
cause of all fevers. If we examine the practical
tenets of this school, we shall find more than one
postulatum assumed as fully established, although
admitting not only of doubt, but even of disproval.
That fever does not depend upon this lesion,
although predominant morbid action in the di-
gestive canal may appear in many cases, and in
some fevers more frequently than in others, has
been already shown. And, granting that this
morbid action is attended by vascular^ injection
of the mucous membrane, it still remains to be
proved that it is the same kind of afl"ection as
inflammation. That it is not the same as primary
and sthenic inflammation, its phenomena and
results, as well as the juvaiitia and Iddeniia,
sufficiently prove. Even granting the doctrine
of Broussais in its fullest range, it still remains
to be demonstrated, that the treatment advised is
that which is the most beneficial, or the most
approf)riate, in the numerous and varying morbid
conditions which fevers assume ; and it, more-
over should be shown, that the means which the
espousers of this doctrine reprobate, are one whit
more prejudicial than those which they laud. In
a class of diseases so varying, and even opposite,
as to their pathological states, as fevers are, not
only in their different forms, but also in the same
■ case at different stages, the success of various

1020

remedies cannot be predicated from doctrinal
tenets. However ingenious the theory, and close
the reasoning, by which we are led to practical
inferences, careful experiment and repeated ob-
servation are necessary to test the character of
any method of cure ; and even were we to adopt
the views of BnoussAis, to these tests we ought
to resort before we should decide between the
efficacy of gum-water and leeches on the one
hand, and that of antimony and purgatives on
the other ; or, indeed, respecting the propriety of
any remedy whatever.

540. The pathological views of Hoffmann,
and the modifications of them by Sauvages and
CuLi.EN, although entirely based upon solidism,
were favourable to rational modes of practice.
These views, in the varying explanations of them
furnished by Heberden, Fordyce, and others,
have very generally guided practitioners in this
country in the treatment of typhoid fevers, until
Dr. Hamilton introduced a modification of the
usual practice, or induced them to have a more
frequent recourse to purgatives than had pre-
viously been ventured upon. That these reme-
dies, especially when judiciously selected and
combined, do not produce the mischievous effects
in typhus which Broussais supposes them to
produce, even when given in cases the most fa-
vourable to his views, I am convinced by expe-
rience, and many of his disciples are at last open-
ing their eyes to the fact. I\IM. Bretonneau,
Andral, and others, more or less partial favourers
of his doctrine, have recently so far discarded the
practical tenets of their school, as to venture on
the exhibition of these medicines ;^ and, as JVI.
Chomel justly remarks, have found that the dread
of them so long entertained is unjust, and that
they may be employed early in many cases of
typhus with great benefit. Where, however,
there is reason to suspect the existence, or even
the commencement, of ulceration, the impropriety
of having recourse to them, unless with the cir-
cumspection and in the manner hereafter to be
mentioned, cannot be doubted. But ulceration
seldom occurs before the twelfth day of the dis-
ease ; and if they have been judiciously employed
previously, I believe that it will very rarely take
place either then or at a later period.

541. The humoral pathology, although super-
seded very generally by solidism, since the days of
HorrMAN, still continued to be partially adopted
by some practitioners in different parts of the
Continent. It has been lately revived in a too
exclusive manner in this country. Amongst those
who have espoused views of this kind may be
mentioned Dr. Stoker, Dr. Ci.anny, and, still
more recently. Dr. Stevens — each of whom has
endeavoured to establish the early predominance
of morbid states of the blood. These views have
been already partially discussed ; and I have
now nothing further to add respecting them, than
that the changes of the blood for which Dr.
Stoker argues, are those which have been above
staled (§ 520.), and which refer merely to its
external appearances. Dr. Ci.anny insi.'its chiefly
on the diminution in typhus of the carbonic acid,
whi( h he supposes the blood to contain in health.
He leconimends the use of fluids, containing or
evolving this gas, as effervescing draughts, Seltzer
water, &c. Kl. Ciio.Mr.L states, that he gave this
practice a trial in the Hotel ])ieu during two

FEVER, TYPHOID —Treatment.

years ; and that, although the cases in which he
employed it were not numerous, they satisfied him
that it did not influence the usual results, and
that he preferred, therefore, to try other means,
the ineflicacy of which had not been so fully
shown. Of the treatment of Dr. Stevens, in
respect of this class of fevers, I entertain similar
opinions to those expressed above (§ 387.). In
two cases of low nervous fever to which I was
lately called, at a period, however, too late to
expect benefit from any treatment, I prescribed
the remedies this writer has advised, but without
any effect.

542. If the rational method of treatment, or
that which is modified according to the form,
state, or stage of the disease, is not much more
successful than that which is dictated in the spirit
of system or of empiricism, it has at least this to
recommend it, — that it brings the results of science
to bear upon existing pathological states, both
vital and structural. Although not admitting so
readily of the usual tests of success as more em-
pirical methods, the experienced physician will
readily forms a tolerably accurate idea of the cir-
cumstances, either promoting or preventing fa-
vourable results. He will make due allowances
for the forms and periods of the disease, the cha-
racters of the epidemic, the influence of season,
and for the numerous circumstances appertaining
to individual cases ; and he will at once perceive
that the means that are beneficial in one epidemic,
or in one form of fever, or in certain cases, will
be most injurious in others. In the present state
of our knowledge, the rational method of cure is
that which is most appropriate to the different
varieties and stages of fever. According to it,
indicatioiis or intentions are derived from a due
estimate of existing symptoms and signs, and of the
pathological conditions evinced by them. Whilst
it comprises every method of cure, and all kinds
of means, it adapts them to the states of the dis-
ease and of the patient. The judicious physician
employs, according to circumstances, remedies
the most opposite ; and, in different cases, or in
different periods of the same case, he has recourse
to sedatives, to refrigerants, to evacuants, to
tonics, to astringents, to stimulants, or to anti-
septics. He neglects no means, but adopts none
exclusively; and while interpreting the value of
symptoms, and inferring the morbid states pro-
ducing them, he endeavours to select and to com-
bine the medicines, whose known operations are
such as are most likely to remove these states, or
to prevent the accession of others usually super-
vening in the course of the disease, and in-
creasing its danger. — I will now proceed to con-
sider— 1st, The treatment appropriate to the
different stages of typhoid fever ; — 2dly , The modi-
fications reciuired by its different forms and compli-
cations ; — and 3dly, Tiie means recommended in
a special manner, and the circumstances or states
of the disease in which they may afford benefit.

543. A. The Treatment afimrpriale to the
stages. — a. In the premonitory stage, and whilst
that of invasion is not fully formed, the future
fever may be checked or prevented by the shower
bath, followed by frictions of the surface; by an
emetic, or by a warm stomachic purgative ; or by
a warm or vapour bath ; or by all these following
in succession ; and in some cases, also, by warm
diluents or diaphoretics ; but this result cannot

FEVER, TYPHOID — Treatment.

1021

be depended upon. — h. When the stage of invasion
is pronounced, bleeding, hot stimulants, &C. are
hurtful, or even dangerous. Tepid and warm
diluents, and the warmth of bed, are the most
suitable means. If vomiting accompany this
stage, it may be increased by tepid and emollient
diluents. If nausea only be complained of, and
if there be little pain, tenderness, or tension, in
the hypochondria and epigastrium, an emetic may
be given, and its action promoted by these means.
— This treatment will generally shorten the chills,
&:c. characterising this period, and favour a re-
laxation of the surface, or the occurrence of mo-
derate reaction.

544. c. In the stage of excitement the treatment
must altogether depend upon the degree in which
reaction is developed, and the manner in which
the brain, the lungs, or the digestive canal, ap-
pears to suffer. If the fever does not present,
early in this state, the characters of low nervous
fever, to their full extent, or those of an adynamic
or of a putrid or septic kind, then a small or
moderate bloodletting may be prescribed ; but
the effects at the time of the operation should be
carefully observed. If the patient be young or
robust, previously healthy and well fed, then a
more copious depletion may be practised, if he be
seen early. Even in the lower states of this fever,
if any of the viscera just named be prominently
affected, a local depletion, either by leeches or by
cupping, may be employed. But if the period of
excitement be far advanced; if the fever be sim-
ple or mild ; if it have passed the tenth day ; and
if it be the true or exanthematic typhus, unat-
tended by inflammatory associations; bloodletting
will seldom be of service, and it may interrupt
the regular and favourable course of the disease,
particularly the latter form of it. In a large
number of cases, in which M. Louis states blood-
letting to have been tried, and in which it appears
to have been indicated, the advantage procured
by it seems to have been slight ; but sufficient to
increase, to a small amount, the proportion of
recoveries, and to diminish the duration of the
disease. — Emetics have been advised also in this
stage ; and, in cases where the chills return
on successive days, or frequently alternate with
flushes, I believe that they will be found of ser-
vice. HiLDENBRAND dirccts them in the first,
second, or third day, or even later ; having pre-
mised a bloodletting in the cases indicating it ; and
prefers a large dose of ipecacuanha, with a grain
of tartar emetic. — Next to emeUcs, purgatives are
of advantage. At an early period, or before the
eighth or ninth day, a full dose of calomel, either
alone or with rhubarb, may be given; or jalap,
with cream of tartar ; and their action promoted
by moderate doses of the neutral salts, or by
manna, tamarind?, &c., according to circum-
stances. These clear away morbid secretions
and mucous sordes, from the digestive surface ;
which, if allowed to remain, would favour the
occurrence of the morbid changes in the intestines.
If, however, the bowels have been much relaxed,
and still continue so, it will be preferable to give
an occasional dose of hydrargyrum cum creta, with
rhubarb, and ipecacuanha, which will promote a
healthy state of the mucous surface, and facilitate
the evacuation of morbid secretions. If the bowels
be only gently open, the circumstance is favour-
able ; but an inordinate action of them must be

moderated by the above medicine, or by others
hereafter to be mentioned, lest intestinal ulcer-
ation and perforation be the ultimate result. At
the same time, care should be taken not to produce
a sudden change or constipation, otherwise the
cerebral or nervous symptoms will generally be
much aggravated, and a tendency to effusion on
the brain be produced. — Diaphoretics, suitable to
the state of the symptoms, either variously com-
bined, or associated with diuretics, may be given
from time to time. Of these, the more refrigerant,
with small doses of camphor, will be most service-
able ; and either some one of those in the Appendix
(F. 431. 436. 440. 818. 865.), or the following,
may be prescribed : —

No. 225. I^ Camphorae rasae gr. ss ^j. ; Potassae Nitra-

tis gr. iij. ; Pulv. Acaciffi gr. ij.; Mucilag. Acacioe q. s.
M. Fiant Pilulae ij. quartis horis sumpndse.

No. 226. R Mist. Camphorae 3 j. ; Liq. Animoniao Ace-
tatis 3j — iij-; Ammoniee Hydrochloratis gr. iv. ; Syrupi
Limonis 3j. M. Fiat Haustus, quarta quaque hord ca-
piendus ; vel interdum, secundis horis, pilulae et haustus,
alternis vicibus, sumantur.

545. d. In the nervous stage the debility is more
real ; irritability is more exhausted, and the senso-
rium more severely and uniformly affected. The
functions of the skin, and frequently those of the
bowels, are also more disturbed than before. The
indications are to support or stimulate the sys-
tem, according to the forms the disease assumes.
— Blisters maybe employed in this stage — seldom
before. They favourably impress the nervous
system, check the tendency to diarrhoea and
affection of the intestinal mucous surface, and
render the skin more perspirable. They are most
serviceable at the commencement of tliis stage ;
and are best applied on the nape of the neck,
behind both ears, or on the calves of the leg. —
Camphor is now one of the best remedies that can
be exhibited. Whilst it promotes nervous power,
it relaxes the skin, and does not increase inflam-
matory action, but rather tends to allay it, parti-
cularly the nervous and cachectic forms of it,
which alone can exist in this disease. It should
be given in larger doses in this stage, more espe-
cially of the malignant or putrid form. From
twelve to twenty grains may be exhibited in the
twenty-four hours. Hildenbrand advises, in the
latter part of this stage, medium doses of cam-
phor ; or one grain every two hours, with an
infusion of arnica and angelica root. He con-
siders that these lessen the stupor, giddiness, and
delirium ; act favourably on the skin ; and prevent
the tendency to diarrhoea. — Emetics are sometimes
beneficial in this stage, when they have been neg-

glected in the previous one, or contra-indicated.

Purgatives are of service only when the bowels
require assistance. They should be given with
the intention of evacuating morbid matters, of
preventing the injurious impression made by such
matters upon the intestinal mucous surface, and
of promoting a healthy action of the abdominal
emunctories. Hydrargyrum cum creta, and rhu-
barb, and the infusion of the latter with the milder
saline substances, in a state of effervescence, are
the most appropriate. These preserve the tone of
the digestive mucous surface, whilst they enable
it to throw off faical collections. Their action
may be occasionally promoted by emollient and
gently laxative enemata. I doubt much the pro-
priety of exiiibiting calomel, or any of the drastic
purgatives, in this stage; and I believe that the
more active neutral salts exhaust the strength

1022

FEVER, TYPHOID— Teeatmen-T of the Complications.

and produce watery stools, in this period, par-
ticularly if they be exhibited in any quantity. It
is iu the common, or synochoid, form of fever, or
at the commencement of this, that they may be
employed. In the latter stages of low fevers,
calomel and cathartics are apt to increase the
intestinal symptoms, or to determine an irritative
action of the bovi'els, liable to terminate in the
lesions already noticed.

546. c. When the disease has reached its acme,
or is approaching the fourteenth day, the treatment
should very much depend upon the predominant
symptoms, upon what has been already done, and
on the effects observed. — If no unfavourable sym-
ptoms are present, mild saline diaphoretics, as
camphor mixture, with liquor ammoniaj acetatis,
&c., or the former with the alkaline bi-carbonates,
and citric acid, or lemon juice, iu efFervescence,and
mild demulcent diluents, are all that are required.
The chief intention at this stage is to favour a
genial perspiration. The temperature of both
medicines and drinks should not be lower than
tepid. If the disease is complicated, particularly
at this period, or is proceeding irregularly, the
treatment must be varied, as wili be hereafter
shown. If a crisis take place, or the more urgent
symptoms gradually subside, the means should
.vary with the degree of vital depression evinced.
Both tonics and stimulants should at first be mild,
in moderate doses, and suited to the state of the
pulse, and of the skin and bowels. At first, a
cold infusion of cinchona, or the decoction, may
be given, with the solution of the acetate of am-
monia, or with either of the alkaline bi-carbonates
and citric acid, in effervescence. The infusion of
valerian may also be substituted for the cinchona,
and given as directed above. — The regimen, diet,
and convalescence, should be managed with strict
reference to the forms and complications of indi-
vidual cases, and as will be hereafter shown.

547. B. The Treatment of the Varieties and
Complications of Typhoid Fever. — a. In the simple

■typhoid, or nervous fever , when it commences as
described above (§ 459.), the period of excite-
ment being characterised by little or slight reac-
tion, bloodletting is seldom beneficial ; or local
bleeding, in a situation indicated by the pro-
minent affection, will only be required. If the
pulse be very rapid, or soft, and open ; if the pro-
stration be great, and the tongue assume a dark
colour; and particularly if this state exist at the
commencement of the disease; vascular depletions
•will be injurious. 'Jlie indications enumerated
above (§132, 133.) will further serve to point out
when they may, or may not, be resorted to. — An
emetic is always of service, particularly if there be
nausea; and if vomiting be spontaneous it should
be moderately assisted, as already advised. — The
bowels should be evacuated early in the disease
by mild purgatives. Those already mentioned
are the most appropriate, or fresh castor oil may
be used. They may be repeated occasionally,
with the views I have stated, but with due caution,
lest they induce too great exhaustion, or favour
the supervention of intestinal disorder. — Whilst
the heat of skin continues, tepid or cold sponging
the surface is grateful to the patient, diminishes
the restlessness, and favours the operation o( dia-
phoretics during the state. — If diaphoresis occur
it should be promoted l)y mild, tepid diluents,
'either simple or medicated, in the manner about

to be noticed. If copious perspirations occur,
especially about the acme of the disease, or at a
critical time, they should not be arrested, unless
they increase the exhaustion, or are attended by
signs of septic deliquescence. — In the nervous
stage the treatment directed above should be era-
ployed (§ 545.).

548. a. Prominent affection or comecuiive in-
flammation of the respiratory organs, in the nervous
form of typhoid fever, recjuires the utmost dis-
crimination on the part of the practitioner, for
its successful treatment. The subject has been
admirably elucidated by Dr. Stokes, in his truly
excellent published lectures on fever. The chest
should be carefully examined by the stethoscope,
in order to ascertain, as accurately as possible,
the state of pulmonary disorder, and to determine
whether the symptoms referred to this organ be
symptomatic, or dependent upon inflammatory
action or active congestion. The able patho-
logist just mentioned remarks that, when the
bronchial surface is chiefly affected, there is much
more lividity of the countenance, than when a
portion of the substance of the lungs is diseased.
This symptom will generally verify the reports
of auscultation. But the treatment will entirely
depend upon the nature of the bronchial affection.
If the dyspnoea and other pulmonary symptoms
depend upon inflammatory irritation, rather than
upon increased secretion from the mucous sur-
face; if there be heat of skin, more or less vas-
cular reaction, and if the patient be young and
robust ; bleeding, general or local, will be neces-
sary, according to the severity of the symptoms
and stage of the disease. If, however, these sym-
ptoms depend chiefly upon a copious secretion
from the bronchial surface, as will beshown by the
stethoscope, bleeding will be most injurious, and
very decided means of an opposite nature will be
requisite, in order to prevent contingent asphyxy.
In this latter case extensive counter-irritation,
the 7nistura ammoniaca, or the decocinm senegee
with camphor, ammonia, the tinctura camphorce
composita, or other stimulating expectorants, must
be resorted to, according to the urgency of the
case, particularly if lividity of the face exist.
When the strength is very much reduced xvine
will also be necessary, with light nourishment.
The temperature of the surface should be kept up.
Dr. Stokes very properly directs the patient to be
enveloped in soft flannel. When the bronchial
affection is more strictly inflammatory, and the
secretion does not interrupt materially the func-
tions of the lungs, anlimonials may follow the
bleeding. But in either case, if the symptoms
referred to this organ, particularly the dyspnoea,
or the cough, become urgent, and be attended by
the tracheal rattle, an emetic of ipecacuanha, or
of sulphate of zinc, should be immediately ex-
hibited. In this state Dr. Graves, whose exten-
sive resources, in matters of difficulty, I have had
fre([uent occasion to notice, has tried the appli-
cation of mo.ias in the course of the eighth pair
of nerves, and the use of the sulphate of quinine
and opium, in enemata; these latter exerting a
powerful influence, in his opinion, in lessening
excessive secretion from the bronchial surface. —
If the substance of the lungs be affected, a single
moderate bloodletting, or local depletions, may
be prescribed, if the patient be robust and the
disease not far advanced. If the bowels be not

FEVETl, TYPHOID — Treatment of the Complications,

materially disorclered, antimonials may afterwards
be given ; but they should be combined with ano-
dynes. Ipecacuanha, with calomel or camphor,
and opium, or extract of poppy, is, perhaps, pre-
ferable in most cases. — Diaphoretics in frequent
doses are always of service, and may be conjoined
Tvith diuretics. After depletions have been carried
sufficiently far, or if the lungs are affected very
late in the disease, blisters, sinapisms, or the ivarm
terebinthinated embrocation, placed on the chest,
and camphor, ammonia, ipecacuanha, or other
expectorants, with hyoscyamus, or extract of
poppy, are the principal means we possess.
When in this complication the skin is cool and
pale, the pulse very weak and small, and the
features collapsed, the warm expectorants, as
polygala, ammoniacum, ammonia, camphor,
the stimulating tonics, and wine, should be given,
according to the peculiarities of the case.

549. B. Predominant affection of the intestinal
mucous surface s\\o\i]d be treated by means similar
to those advised in this complication of synochus ;
and the more especially, as the latter fever, when
thus characterised, either passes into, or is very
nearly allied to, the typhoid form. In the early
stages of this complication a combination of small
doses of hydrargyrum cum cretii, rhubarb, and
Dover's powder, with compound cretaceous pow-
der, given every three or four hours, is generally
of service. If the constitutional symptoms will
permit, and if this affection appear at an early
period of the fever, a local depletion should be
premised, and a blister or sinapism be afterwards
placed upon the abdomen. The terebinthinated
epithem, applied sufficiently hot, and covered so
as to prevent evaporation, if properly managed, is
the most efficacious means — more particularly if
the abdomen be tense, tender, or tympanitic. In
this latter state, an injection with assafoetida, or
with the extract of rue, or with from two drachms
to half an ounce of spirits of turpentine in addition,
will give great relief.

550. In a far advanced stage diarrhcca, espe-
cially if attended by tension, pain, or flatulent
distension of the abdomen, requires great atten-
tion. If the medicines just recommended prove
not of service, the chlorurets, particularly the
chloruret of lime, may be given, with camphor,
and extract of poppies, &c. Mucilaginous injec-
tions, containing syrup of poppies, or laudanum,
or compound tincture of camphor, may also be
administered, and a rubefacient epithem placed
over tiie abdomen. — If hismorrhage from the
bowels occur, it may be ascribed chiefly to ex-
udation from the softened mucous surface, as
shown by the post mortem appearances ; and
acetate of lead with opium, or acetate of morphia,
or extract of poppy, should be exhibited, either in
the form of pill, or with the pyroligneous acetic
acid, in strong camphor julep. The lead has
been recommended, in these cases, by Drs. Bak-
DESLEY, Graves, and Stokes. I have resorted
to it in these several combinations, and have
given it in two or three instances with kr^asote. —
1 have likewise employed, by the mouth, and in
enemata, the spirits of turpentine, which generally
proves the most active remedy of any in such
circumstances. In some hopeless cases it has
succeeded contrary to expectations. In one, how-
ever, that recently occurred to me, although it
arrested the haemorrhage for a time, there was a

1025

return which carried off the patient. If the dis-
ease be far advanced, or the powers of life much
reduced, the turpentine should be given in small
or moderate doses, and its effects carefully
watched. I have also prescribed it in conjunc-
tion with kreosote, the acetate of lead and aroma«
tics, in similar circumstances.

551. y. Prominent affection of the brain may
arise in the course of typhoid fever, either from
congestion within the head, or from the depressed
state of nervous power, unconnected with inflam-
matory action, or even with vascular determin-
ation. This circumstance, long believed by pa-
thologists, has been fully confirmed bylM. Louis,
wlio found, that the presence or absence of deli-
rium has little or no connection with perceptible
organic lesion of the brain. If, however, there
be increased heat or severe pain of the head,
spastic contractions of some muscles, flushed
face, injected eyes, or other indications of active
disorder of the cerebral circulation, particularly
in the stage of reaction, the hair should be re-
moved, and local depletion resorted to. The head
ought to be kept cool, by cold sponging, or lotions.
If delirium be attended by these symptoms, the
same means are required; and, if it be, at the
same time, low, insensible, or muttering, a blister
should be applied to the neck and nape, or be-
hind the ears, or to the calves of the legs, or a
sinapism may be substituted in the latter situ-
ation. Whenever the affection of the head is
connected with increased determination to it, es-
pecially in an early stage, stimulating antispasmo-
dics, as ammonia, musk, or camphor in large
doses, cannot be of service, and may be injurious.
The last of these, however, may be used in small
doses with nitre, and it may be increased accord-
ing to the degree of stupor, and coolness of the
scalp. If the delirium depend upon exhausted
nervous power — if it be attended by stupor ; by
a weak, soft and very quick, or somewhat slow
pulse ; by a moist skin, or copious perspiration ;
or by extreme prostration, particularly after the
eighth or tenth day, or in the nervous stage ; cam-
phor, in doses of from one to three or four grains
every two, three, or four hours ; or the prepar-
ations of valerian, or of serpentaria, or of arnica,
or ammonia, or of ether, or ivine, or opium, may
be severally employed as circumstances will sug-
gest. In other respects, the treatment of this
state, and of sopor and coma, its frequent at-
tendants and sequents, should be directed, as
explained in the articles Coma (§ 16. 19.), and
Delirium (§ 16, 17.). — Rete^ition of urine \s\ery
apt to occur in this state ; therefore, in it especi-
ally, but also in all others, attention ought to be
paid to the circumstance. If an undue accumu-
lation of water in the bladder be detected upon
examining the hypogastrium, it should be imme-
diately drawn off.

552. 5. 7?j the most severe form of nervous fever
(§ 461.), bloodletting is seldom of service, un-
less a| the commencement of reaction, or from
the vicinity of the most affected organ. AVhen
the skin is very hot, tepid sponging, diaphoretics,
external derivatives, and emollient diluents, with
nitre, or small doses of the hydro-chlorate of am-
monia, are the most appropriate. The infusion of
valerian may be given as the disease passes into the
nervous stage, either with the compound tincture,
■ or with camphor, and hydro-chloric etlw, or other

1024

FEVER, TYPHOID— Treatment of the Complications.

stimulants. — HiLDENBRAND advises the arjiica
monlana with camphor, in this state. — If exhaus-
tion increase, and coma come on, these medicines,
or others of a similar kind, may be prescribed in
larger doses, or at shorter intervals ; and a blister
applied to the vertex, or occiput, or to the nape ;
or a large sinapism to the epigastrium, or insides
of the legs. Lalle.mand and Mackintosh have
adduced instances of benefit, in the comatose
stale, from pouring boiling water on the lower
extremities. Musk, the ethers, preparations of
cinchona, or any of the stimulants already men-
tioned, may likewise be tried, in various combin-
ations, in this stage ; or an infusion of green tea
may be given in the usual manner.

553. €. If the disease be sudden in its attack,
or apoplectic, care should be taken to ascertain
whether or not this character arise from weakened
nervous energy of the brain, or from vascular
congestion. When a pale, collapsed countenance
and eyes, weak and small pulsation of the caro-
tids, and coolness of the scalp, indicate the for-
mer, restoratives will be necessary. But, when
there are increased temperature of the head, and
excited action of the carotids, although the coun-
tenance be pale, a small or moderate bloodletting,
local or general, or even a cautious repetition of
it, in young or robust persons, will generally be
required. — The same remarks equally apply to
the occurrence of paralysis. If the paralysis ap-
pear at an advanced stage, even local depletions
may be injurious. In this case, we must trust
chiefly to blisters and other external derivatives,
and to the means already stated (^551.).

554. If, in the early stage of this, or, indeed,
of any other form of typhoid fever, the thirst be
urgent and attended by vomiting, desire of cold
fluids, and heat of skin, stimulants are generally
injurious. If tenderness of the epigastrium ac-
company these, inflammatory irritation, or ere-
thism, of the gastro-intestlnal mucous surface
should be inferred. In this case leeches ought
to be applied ; and cold or iced prinks and saline
medicines, particularly the nitrate of potash, or the
hydro-chlorate of ammonia, frequently exhibited.
A combination of camphor mixture, the solution
of the acetate of ammonia, nitrate of potash, and
spirits of nitric ether, will generally be service-
able in these circumstances. EflJervescing draughts
are productive of little benefit, as the extrication
of fixed air distends the stomach, and either
causes it to react upon, and throw off, its con-
tents, or gives rise to mucli distress and pain. If
irritability of the stomach still continue, a large
blister may be applied over the epigastrium. Dr.
Stokes advises, in the more obstinate cases, the
raw surface to be sprinkled with a small quantity
of the acetate of morphia. I have rarely found
the warm turpentine embrocation fail of removing
this state of disorder, wiien properly employed.

555. C- When singnllus occurs in the stage of
reaction, it is generally connected with the fore-
going state of the stomach, and particularly with
irritation about the cardiac orifice. In tiiis state,
the treatment just advised is tiie most appropriate.
When it appears in the nervous period, or later,
it depends upon exhausted nervous energy ; and
re(iuires stimulants, antispasmodics, and anodynes.
Camphor, ammonia, the ethers, musk, valerian,
opium, and their preparations, variously com-
bined, are the most serviceable!

556. 7j. Diarrhxa is one of the most frequent
precursors of disease of the intestinal mucous folli-
cles ; yet should it not be rashly interfered with,
and still less abruptly arrested, particularly when
it occur early, or at a critical period. I have
imputed the affection of the intestinal mucous
surface in great part to the morbid condition of the
blood ; this surface being one of the channels by
which effete, or injurious materials, pass out of
the circulation during the course of fever. It is
evident, therefore, that if we shut it up without
opening others, the alterations of the blood will
increase, and occasion serious organic changes,
and ultimately a fatal issue. The most rational
procedure, when diarrhoea is an early complica-
tion, is not to interfere with it, unless it become
severe, or continue long ; and then it should be
moderated rather than arrested, and by such
means as will increase the depurating functions
of the skin, the kidneys, and liver, and remove
the irritation excited in the digestive mucous
surface and follicles. The remedies most likely
to produce these effects, are actually those which
have been found most serviceable in this state of
disease. Hydrargyrum cum creta, compound
ipecacuanha powder, camphor, nitre, mild ano-
dynes, variously combined with demulcents,
emollients, aud diluents, are the most generally
of service. In more advanced states of this com-
plication, and in later stages of fever, those medi-
cines which have been already noticed (§ 156.), as
well as some about to be mentioned, may be resorted
to. — When the pulse is small, very frequent, and
weak, and the strength exhausted, diarrhcea must
then be arrested, otherwise it will speedily termi-
nate life. Astringents, opiates, absorbents, re-
storatives, wine, &;c., are all requisite in this
case.

557. 9. Tympanitic distension of the abdomen
may occur early in this fever, and be attended by
thirst, by a desire of warm diluents, by tenderness
on pressure, particularly in the lower part of the
right side of the abdomen, and by diarrhoea.
When these symptoms are present, disease of the
intestinal mucous follicles may be inferred. In
this case a number of leeches, according to the
strength of the patient and stage of the fever,
should be applied, and followed by tiie warm
turpentine embrocation on the abdomen. If
tympanitis and diarrhoea appear late in the dis-
ease— particularly if the stools be foul, watery,
or mucous — ulceration of the intestinal surface
should be dreaded, and the means already ad-
vised (§ 156.) should be resorted to ; or the chlo-
rurets given in the infusion of valerian, or in
emollient vehicles, with camphor, anodynes, &c.
From one or two to four or five drachms of spirits
of turpentine may be prescribed once or twice,
or even oftener in some cases, in a suitable ve-
hicle, if these fail ; or this substance or assafoc-
tida, or extract of rue, with some anodyne, may
also be administered in mucilaginous enematu
from time to time. In most cases of flatulent
distension of the intestines, there is great disposi-
tion to ulceration of the aggregated mucous fol-
licles— if, indeed, it has not already commenced
and both morbid conditions are greatly aggra-
vated by the continuance of the flatulent state.
The intention, therefore, is to procure the dis-
charge of flatus, by means which may at the
same time sheath and soothe the irritable mucous

FEVER, TYPHOID — Treatment of Putho-adynamic.

1025

surface, and restore the lost tone of the capilla-
ries of the diseased part; and, whatever operates
in this way, will be productive of benefit. It is
only by a judicious combination of agents, that
this effect can be attained ; and tiiose just men-
tioned seem the most efficient, especially when
the skin is cool, the pulse feeble, and the prostra-
tion extreme; and, in this state, the more ener-
getic stimulants and tonics, or wine, or opium,
may also be employed, according to the pecu-
liarities of the case. (See § 155—159.)

558. I. The occurrence of perforation of the in-
testines, and consequent peritonitis, should not be
overlooked in the enteric complication, or other
severe forms of low nervous fever. Peritonitis
seldom arises except from this cause, for large
patches of the mucous surface, with Peyer's
glands, may be destroyed by ulceration ; and
yet the peritoneum will be unchanged. When,
however, diarrhoea has been suddenly arrested
early in the disease, by an injudicious use of as-
tringents, general peritonitis and effusion may
result without perforation, and even without ul-
ceration. But this is only one of several bad
consequences which may proceed from injudi-
cious interference. If, in an advanced stage of
fever, and after thirst, diarrhoea, tympanitis, and
great prostration of strength, the patient suddenly
complain of pain in some part of the abdomen,
extending over it, with tenderness, increased dis-
tension, and rapid sinking of the powers of life,
peritonitis has occurred. In this case large doses
of opium, to palliate the patient's sufferings, are
the only means that can be used with any benefit.
— Dr. Stokes, who has very ably elucidated the
subject of peritonitis from this cause, and its
treatment, directs one grain of opium to be given
every hour, or two hours, until a decided effect
is produced by it ; and afterwards at longer inter-
vals. {Dublin Hasp. Rep. vol. v. ; and Dublin
Jour, of Med. vol. i. p. 125.) When effusion
of the intestinal contents into the peritoneal cavity
occurs, the result must be fatal. But when ad-
hesion of the peritoneum to the opposite surface
takes place previously to the perforation, or when
the perforation is speedily followed by a limited
inflammation and etlusion of lymph, recovery is
possible. The formation of coagulable lymph
can hardly, however, be expected in peritonitis
occurring in the course of fever; as the states of
vital action, and of the circulating fluids, are ge-
nerally incapable of producing it.

559. /), Treatment of putro-adynamic fever
(§ 472.). — The phenomena which especially cha-
racterise this variety, may appear either at an
early stage of fever, or at an advanced period, —
they may be the concomitants, or early conse-
quences, of depressed vital energy, and imperfect
powers of reaction ; or the results of vascular
reaction being so great, relatively to the state of
vital influence, as to exhaust both the irritability
of contractile parts, and the tone of the extreme
vessels. In either case, alterations of the circu-
lating fluids, and deficient vital cohesion of the
soft solids, speedily follow, and coexist with these
changes. In conformity with this view, with the
pathological facts stated above (§ 523.), with a
recognition of the characters of epidemics which
have been observed in modern times in different
countries, and with the results of personal observ-
ation, it may be safely inferred, that the treat-

ment of this fever should mainly depend upon
the state of vital action early in the stage of ex-
citement, and the period of the disease in which
the putro-adynamic signs appear ; and that, in a
practical point of view, it will be, therefore, ad-
vantageous to divide this variety of typhoid fever
into_ — 1st. The consecutive putro-adynamic, or that
form which is contingent on more or less manifest
reaction; and, 2d. The primary piitro-udynamic,
or that which is attended by imperfect, or no,
reaction, and in which the characteristic pheno-
mena appear early in the disease. It should,
however, be recollected, that both these forms
may occur in the same epidemic, or that either
may predominate; and, moreover, that the first
or contingent state of putro-adynamia is some-
times met with in all epidemics, whether the fever
be common synochoid, typhoid, or exanthema-
tous, owing to the causes stated above, and with
a frequency relative to the prevalence of these
causes. (§502— 504.)

560. a. The stages of premonition and of invasion
of this variety, are scarcely different in their cha-
racters from those announcing nervous or typhus
fever. The same means as have been advised
above '(§ 543.) may, therefore, be resorted to,
with the intention of preventing the further pro-
gress of disease, or of rendering it more mild. —
When the symptoms of invasion are either indis-
tinct or protracted, the consequent fever is often
rendered much less dangerous than it otherwise
might have been, by the adoption of the measures
already detailed, and more particularly by exhi-
biting an energetic emetic, and by promoting its
full operation by warm or tepid mucilaginous di-
luents. Tepid sea water, or a weak solution of
common salt in a tepid state, has been employed
with advantage, for the purpose either of pro-
moting the action of the emetic, or of producing
full vomiting, when there has been nausea or
sickness.

561. /?. In the consecutive putro-adynamic, or
when the stage cf excitement is more or less de-
veloped,— when the pulse is frequent, full, or
sharp ; the skin hot, and thirst considerable, or
if an internal heat be felt ; vascular depletion may
be practised, but with due reference to the cir-
cumstances of the patient, and to the period which
has elapsed from the time of invasion. So lono-
as the characters of putro-adynamia have not ap-
peared, these symptoms fully warrant a cautious
recourse to depletion ; and in young robust per-
sons, even a repetition of it. — If rigors and shi-
verings are followed by inordinate or tumultuous
reaction, the necessity of larger depletions is ob-
vious. But, even in this case, they should not
be carried too far, or to the extent of producing
syncope ; otherwise, in attempting to avoid the
exhaustion consequent upon excessive action, a
quantity of blood may be withdrawn, too great
for the diminished power of tonic contraction pos-
sessed by the blood-vessels, — the vessels beino-
incapab{e, owing to the loss of their tone, to ac-
commodate themselves to, or contract sufficiently
upon, their contents, when the reduction of these
contents is great, — and thus collapse of vascular
action, and of vital power, may follow.

562. 7. In the ji/'i?)inn/ putro-adynamic, or 'in
cases attended by indistinct signs of invasion, and
by imperfect reaction, we can hardly venture
upon depletion, unless indications of congestion

3U

1026

FEVER, TYPHOID — with Putro-adynamia-

■ Treatment.

or prominent affection of an important organ pre-
sent themselves. In this instance, local deple-
tions, or dry cupping, may be tried. If petechias
appear early in these cases, or if the pulse be very
compressible, very small, or broad and open ; if
the skia be cool, damp, or unnatural, yet not hot ;
if the tongue be flabby, or covered by a dirty
mucus, altliough the fever is evidently not far
advanced, or is very recently passed the stage of
invasion ; then bleeding should not be attempted.
In this case, very different means must be em-
ployed ; and with an energy proportionate to the
prostration of strength attending these symptoms.
If petechiae, or vibices, or blotches, have appeared
on the skin, they will furnish an additional indi-
cation, particularly if they assume a dun, or dark,
or livid colour ; and will indicate the propriety
of having recourse to the tonics, stimulants, and
antiseptics, and the combinations of them, about
to be noticed.

563, 5". laeilherform of thisfever — in thejirst,
after depletions, in the second, after the operation
of an emetic, which should be given at any time
during the invasion, or for three or four days
afterwards — the bowels ought to be freely evacu-
ated, by either of the mild purgatives mentioned
above, and by the occasional use of laxative ene-
mata ; and frequent but small doses of nitre may
be afterwards exhibited in the saline medicine al-
ready prescribed, or of the liydrocJilorute of ammonia
in camphor mixture, or any other suitable vehicle.
These latter are more especially indicated, if
any heat is felt in the region of the stomach, and
if the tongue is red at its edges and point. If
there be increased heat of skin, tepid sponging the
surface with the v.'eak nitro-hydrochloric solution,
or with a mixture of pyroligneous acetic acid,
rose-water, and camphor mixture will prove both
grateful and beneficial. — It is seldom, even in
the primary putro-adynamic, that tonics are pro-
ductive of much benefit very early in the disease.
But, when exhibited with refrigerants, they are
often of great service. The infusion or the decoc-
tion of cinchona, either with the solution of the
acetate of ammonia and nitrate of potash, or
with the hydrochlorate of ammonia, a few drops
of hydrocldoric acid, and sometimes also with hy-
drochloric ether, is the kind of tonic which I can
recommend from experience, as being the most
suitable to an early stage of adynamic fever.

564. It is in this variety of typhoid fever, more
especially, that the (question as to the superior
efficacy of alkaline medicines and of the non-
purgative salines, or of mineral and vegetable
acids, becomes a matter of extreme importance.
Of the latter I can speak from observation ; of
the former I have not yet made sufficient trial
to enable me to form a satisfactory opinion. It
were to be desired that Dr. Stevens, who has
so strongly advocated the use of alkaline and
saline substances in this fever, would furnish us
with that sort of evidence of their efficacy, which
would justify an early and decided recourse to
them ; and that those, who have ample means
furnished them of settling the question at issue,
would at last put it beyond the reach of cavil.
'Ihat these substances are beneficial, at least
several of them, is fully shown by the experience
of successive ages and of numerous writers. 'J'his
is the case in respect of nitre, hydrochlorate of
ammonia, and cliloratc of potash, of the excellent

effects of which I am convinced by repeated
observation. But the superiority of alkaline
carbonates over acids, has not yet been proved.
It is also doubtful, whether or not the benefit
found to result from the former has not chiefly
proceeded from the medicines with which tliey
have been combined. At present we are guided
in some measure by what we know of the physio-
logical action of these substances. The fixed al-
kaline bi-carbonates redden the blood when carried
into it, but they relax the tone of the digestive
mucous surface. Nitre produces a similar change
in the blood, and resists any tendency to decom-
position. Acids constringe the mucous and con-
tractile tissues, impart firmness to the coagulum,
but render the blood more dark than natural.
With these imperfect data, the experience derived
from accurate observation ought to be our chief
guide ; and whether we adopt acids in the earlier
stages of the disease, and alkalies subsequently,
or reverse this order, or even prescribe, in con-
junction with neutral salts, either an acid or an
alkali in excess, much difficulty will be felt in
ascertaining how much is due to either of these
means, and what may be legitimately imputed
to other remedies, with which we may be morally
bound to combine them, in order to render their
beneficial operation more certain. When certain
remedies, which have been particularly recom-
mended in this form of fever, come under review,
these substances will receive further attention.

565. In various states of putro-adynamic fever,
external derimtives will be reciuired, as in the
other varieties. When bloodletting is necessary
at the commencement, they should follow this
operation, particularly when prominent affection
of an important organ exists. As to the choice of
derivatives, little need be added to what has been
already advanced. If blisters be adopted, atten-
tion is sometimes required to prevent spreading or
sphacelating sores. They should, therefore, be
applied only until they cause redness of the sur-
face; when they may be followed by a warm
poultice. Equal care is necessary to prevent
sphacelation of the parts pressed upon in bed, and
the occurrence of foul sores, from the contact of
the morbid excretions, or from both causes con-
joined. The means likely to counteract or remedy

this occurrence have been stated above (§ 166.).

566. s. In the modijications of this fever, no-
ticed above (§ 476.), a decided recourse to the
same inedicines as are necessary in the ad-
vanced stages of the regular form, must be had,
more particularly when signs of coUiquation are
early and prominent. The intention in this case
is to arrest the progress of the changes of the
blood, by supporting the powers of life, and pro-
moting the functions of excretion. If it should
be found possible to correct, in a more direct
manner, the state of the circulating fluids, this
indication ouglit also to be adopted, and tlic means
wliicli operate in this way resorted to. In con-
formity with the former indication, full vomiting
should be induced, if it have not already taken|
place, and a mild stomachic purgative after-
wards given. I'his latter ought to be repeatcdj|
according to the state of the bowels, and the
appearance of the evacuations, which will furnisl^
indications for the employment also of cneniata.J
and indicate such as are most appropriate. In the!
worst forms of erysipelas, and in diffusive inilam-

FEVER, TYPHOID — Exantiiematous — Treatment.

1027

mation of cellular structures, I have found equal
parts of the decoction of cinchona, and the com-
pound infusion of senna, with tartrate of potash,
carbonate of soda, and compound tincture of
cardamoms, an excellent purgative, and I see no
reason against its use in this state of adynamic
fever. After the bowels have been freely evacu-
ated, decoction of cinchona, or a strong infusion
of valerian, with chlorate of potash, and chloric
ether, may be prescribed, according to the severity
of the disease. Of the good effects of the decoc-
tion of cinchona witli the compound tincture,
nitrate of potash, and carbonate of soda, I can also
speak from experience. When the prostration
of strength is extreme, a pill containing two or
tliree grains of camphor should be taken with
each dose of either of these, at short intervals.

567. Other tonics, and different combinations
of them from these now mentioned, will frequently
be productive of great benefit, when morbid ex-
cretions have been evacuated. However specious
the arguments adduced by some writers against
the employment of acids in the putro-adynamic
states of fever, it cannot be denied that good
eff"ects have been produced by them, especially
when exhibited with powerful tonics. The in-
fusion or decoction of cinchona, with hydrochloric
acid, or witli nitro-hydrochloric acids, and chloric
ether (formerly Glutton's febrifuge) ; the sul-
phate of quinine with sulphuric acid, and Hoff-
mann's anodyne ; and pyroligneous acid in large
doses, with camphor, the solution of the acetate of
ammonia, and tonic or aromatic infusions, or the
infusion of serpentaria or of arnica, are the most
energetic, and may severally be tried, according to
the peculiarities of the case. A solution of camphor
in acetic acid was a favourite medicine with many
writers on putro-adynamic fever, and was em-
ployed by them both internally and externally.

568. Dr. Stevens's saline treatment is most
appropriate in this form of fever. He directs
twenty grains of the chloride of sodium, thirty
grains of the carbonate of soda, and eight of the
chlorate of potash, to be given every two or three
hours — or more or less frequently according to
the urgency of the case — dissolved in water, in
the advanced stages. He believes, that when
these salts are prescribed before the stomach has
ceased to perform its functions, they will not irri-
tate the alimentary canal, but will be absorbed
into the circulation and correct its morbid state.
One or two table-spoonfuls of common salt may
also be administered occasionally in a tepid gruel
enema. The strength should, at the same time,
be supported by strong beef tea, or the regimen
about to be recommended.

569. f . If putro-adynamic fever be attended by
predominant affection of any organ, local deple-
tions, followed by external derivatives, will be
necessary, particularly in an early stage of the
fever. — At a later period external derivation,
and the other means advised for the complications
of nervous fever, according to their seat, should be
employed. In this variety, however, a more liberal
use of tonics, conjoined with the antiseptics just
mentioned, is generally required. — When this
or any other form of typhoid fever is complicated
with asthenic inffamn^ation of the fauces or pha-
rynx, or both, the means already recommended
are quite appropriate. In these cases, deglutition
is very difficult, and sometimes impossible. Re-

course to external derivatives, and to injections,
is then urgently required. The action of the
bowels should also be solicited by purgative ene-
mata, unless diarrhoea exist ; and the medicines
that are indicated should be administered in
clysters, and in sufficiently large doses. As the
patient is generally unable to gargle his throat,
advantage will sometimes accrue from syringino-
it with any of the tonic mixtures above prescribed,
or with a solution of the chloruret of lime or of
kreosote ; and if a part, or the whole, or either
of these, should be swallowed, the more benefit
will be derived.

570. 7], If this variety become complicated with
diarrhoea, disorganisation of the digestive mucous
follicles and surface will rapidly take place, if
the treatment be not prompt and judicious. The
means already advised (§ 549, 550.) for thiscom-
pHcalion must be adopted in this case. If the
diarrhoea occurs at an early period, it will
generally be moderated by tonic infusions, with
the nitrate of potash, or with the- hydrochlorate of
ammonia, and the compound tincture of camphor.
A combination of ipecacuanha, nitre, camphor,
and opium, or extract of poppy, will also often
diminish or remove it. If hicmorrhage supervene
from the bowels, these medicines will sometimes
be sufficient to remove it. In more urgent
cases the energetic remedies, previously di-
rected (§ 550.), or the pyroligneous acetic acid,
with camphor and creasote, or turpentine, &c.,
should be prescribed by the mouth, and in ene-
mata. When diarrhoea or haemorrhage charac-
terises putro-adynamic fever, the alkaline car-
bonates will frequently aggravate or perpetuate
it, and render convalescence protracted. In other
respects, the treatment directed for the compli-
cations of nervous fever, and for its last stages, is
also suitable to this ; these stages requiring either
the measures just described, or several of those
about to be noticed, with a more or less direct
reference to the putro-adynamic state, or various
combinations of the substances already enume-
rated (§ 548—555.).

571. c. Treatment of exanthematous Typhus
(§ 485.). — The premonitory and invading periods
of this fever should be treated as recommended
above (§ 543.), with the view of arresting or ren-
dering more mild the procession of morbid pheno-
mena.— a. In the stage of reaction the indications
are — (a) to moderate excessive excitement ; (6)
to guard important organs from the effects of pro-
minent action. — If full vomiting has not occurred
previously, it should be excited by an emetic at
the commencement of this stage, or on the first,
second, or third, day of it. If, however, inflam-
matory signs have become evident, particularly if
the lungs are affected, a moderate bloodletting
should precede the emetic. The eruption, which
generally appears in this period, is usually followed
by slight alleviation of the symptoms, and should
therefore be promoted by mild, tepid diluents,
which may be made either diaphoretic, mucila-
ginous, or acidulous, according to circumstances.
As to bloodletting in this disease it is pernicious
in many, if not in most cases; and not merely in
the nervous, but even in this stage. In the mild
and regular typhus it is superfluous ; but when
a highly inflammatory character marks this period,
or when local action becomes very prominent or
excessive, it must not be omitted ; otherwise the

3U 2

.028 FEVER, TYPHOID — Ex

local affection may run into disorganisation, ami
the nervous stage will be rendered more protracted
or dangerous. The amount, repetition, and mode
of depletion, will depend upon the peculiarities of
the case. — When the bowels are open in this
stage, purgatives, unless of the mildest kind, are
unnecessary. Severe purging is prejudicial, as
it derives from the skin, interrupts the regular
course of the disease, and risks the production of
the enteric complication. Tonics and stimulants
are also injurious.

572. 0. In the nervous stage the disease has in-
duced a state of exhaustion, and the system re-
quires to be supported, and even gently excited.
HiLDENBRAND recommeuds an emetic early in this
period, if it have not been given previously ; and
blisters to be applied, about the seventh or eighth
day, when the nervous stage commences. Camphor,
with the solution of the acetate of ammonia and
7iitre, forms one of the best medicines that can
now be exhibited. The quantity of camphor,
however, should not at first exceed one grain
every two hours, or a grain and a half every three
hours. — Arnica was one of the medicines most
commonly employed in Germany during the pre-
valence of this fever in that country, early in the
present century. IIildenbrand states, that its
operation is stimulant, alterative, and, in large
doses, emetic ; and that it does not promote, but
rather prevents, diarrhoea. In typhus it lessens
the stupor, giddiness, and delirium, and increases
the cutaneous transpiration ; but it is useful only
when the inflammatory character is quite gone.
It should be given in the form of infusion, in a
quantity short of producing nausea. This most
able and experienced writer advises also, in the
course of this stage, the use of volatile stimulants,
especially the infusions of the roots of angelica
and imperatoria, and of the flowers of the calamus
aromaticus.

573. In the typhus epidemic, in the military
hospitals in Vienna and surrounding countries,
during the late war, where it was impossible to
prescribe for the cases individually, the following
plan was pursued by HiLDENimANO, with great
success, in the simple and regular disease : — On
the first day of the fever an emetic was adminis-
tered, and succeeded by diluent diaphoretic de-
coctions. About the seventh day, when the
typhomania and debility were increased, the skin
and tongue dry, and the belly distended, blisters
were put on the calves of the legs, and eight
ounces of an infusion of two drachms of the flow-
ers of arnica, and as much angelica root, with a
little of Hoffmann's anodyne, were given daily,
two table-spoonfuls being taken every two hours,
alternately with camphor powders. — Stimulants,
in this fever, should be prescribed in frequent but
small doses, rather than in large quantities. Cin-
chona and other tonics are superfluous as long as
the disease is mild and regular. But they, toge-
ther with wine, &c., are required, if the putro-
adynamic state appears in this stage.

574. y. If the preceding stages have been pru-
dently treated, and if the disease has been regular
and mild, nothing more is necessary in the way
of medicine, as the period of crisis approaches,
than to ])romote the evacuations attending it ; and,
as the cliief of these is perspiration, mild diluents,
and ihe diaphoretics in common use, or those just
mentioned, arc to be continued. All medicines

ANTHEM ATOus — Treatment.

I should not be abandoned immediately after atj
crisis. Stimulants, however, should be milderyl
and given at longer intervals. Hildenrrani
I advises the camphor and arnica to be given up,
and the infusion of angelica to be continued for
I some time. As convalescence advances, the treat-
j ment should be chiefly dietetic and regimenal.
I 575. S. The irregular forms of tjiphus — the modi-
1 fications and complications — require appropriate
, means, or variations, of the procedure now recom-
mended.— If the infammatory character is violent,
a more activeantiphlogistic treatment is necessary.
I But the existence of deficient power, and the know-
ledge that the nervous stage must follow, should in-
fluence the practitioner. For an inflammatory state
of the brain, or the semi-apoplectic state, bleed-
ing generally and locally must be adopted, to an
amount which the circumstances of the case will
suggest. When the lungs are affected this prac-
tice, aided by antimonials, blisters, and diapho-
retics, is equally necessary. If the inflammatory
state be not entirely removed, and if it is not safe
to bleed more, or if this state be prolonged into the
nervous stage, external derivatives and antimonials
are to be chiefly confided in. The same practice
is applicable to the association of hepatic disease in
this stage. The affection of the intestinal mucous
surface requires the same treatment as was recom-
mended in synochoid and nervous fevers (§ 549. ct
seq.) — Sometimes the gastric or bilious character
predominates, particularly in summer and autumn,
owing to impurities in the prima via, and accu-
mulations of bile in the hepatic ducts and gall-
bladder. Emetics are necessary in these cases
especially, unless there are indications which for-
bid them ; and mild purgatives, in the inflamma-
tory stage — in the nervous, aperient clysters —
should be preferred.

576. £. In the nervous stage various irregularities
often occur. If this character is excessive, or
has taken place suddenly, large and repeated doses
of volatile stimulants are necessary. Camphor,
ammonia, ether, musk, cinchona, serpentaria, wine,
opium, and blisters are severally useful, when ju-
diciously combined. Phosphorus has been recom-
mended for this state, but Hildenerand found it
useless. During this stage a passive, asthenic,
or nervous kind of inflammatory action rnay
occur, particularly in the mucous surface of the
intestines and in the mucous follicles; but it some-
times also affects the brain and lungs. When it
attacks the intestines, there is a painful feeling
excited by pressing the abdomen ; the pulse is
small and irregular or unequal ; the belly is tym-
panitic or tense ; and the stools very frequent and
morbid. For this state a moderate or small local
depletion ; blisters, sinapisms, or hot turpentine
embrocations, followed by warm poultices, over
the abdomen ; camphor, with hydrargyrum cum
creta, and Dover's powder, in large quantities of
mucilage ; or camphor with ipecacuanha, nitre,
and opium ; mucilaginous enemata, with extract
of poppies, (l\c. ; and the other means already inen-
tioned (§ 550.) ; shouhl be chiefly relied upon. If
this form of inflammation, or of inflammatory con- M
gestion, attack the liver, tenderness and fulness in *
tlie right hypochondrium, and jaundice, gencinlly
accompany it, and a very dangerous complication
results. JiOcal depletion is sometimes of use, but
as frequently it is of little service. Mercurials, ex-
cepting, perhaps, the hydrargyrum cum cret;i,are

FEVER, TYPHOID -

still less efficacious. Blisters over the hypochoii-
drium and epigasirium ; frictions with rubefacient
liniments in tliis situation ; rubefacient applications
on tiie insides of tiie thighs ; emollient and aperi-
ent enemata, if the bowels require to be assisted ;
camphor, with nitre, or sulphate of potash, and
anodynes ; diuretics conjoined with mild diapho-
retics ; and the nitro-hydrochloric acid given in-
ternally with the spirits of nitric ether, or used
externally as a lotion or wash ; may severally be
productive of benefit.

577. f. The nervous inflammation of the brain is
indicated by sopor and profound typhomania, and
should be. combated by blisters on the head, by
camphor, by arnica, and the means directed for
this affection in nervous fever (§ 551.). If tight-
ness of the chest and dyspnoea occur in the nerv-
ous stage, congestion of the weakened vessels of
the lungs may be inferred. In this state a small
bleeding, to the amount of four or six ounces, may
be directed in some cases, and followed in all by
blisters on the chest, and antimonials conjoined
with camphor.

578. 7j. If the putro-adynamic character super-
venes and predominates as the nervous stage pro-
ceeds, the debility, equally with the morbid state
of the blood, requires attention. The preparations
of cinchona, either with mineral acid, or with al-
terative neutral salts, large doses of ctimphor, wine,
opium, and the other means directed for tiie va-
rious phases and complications of this condition,
will be rei[uired according to the peculiarities of
indivitlual cases. U diarrhaa or difsentery comes
on in this state, opium in large doses, but at dis-
tant intervals ; warm dilute wine, with spices and
other aromatics ; mucilaginous and farinaceous
liquids, or gruel with common salt, taken in small
quantities but often, and administered in enemata,
with syrup or extract of poppies ; and the other
remedies noticed above (§ 556'.) ; should be pre-
scribed. — If singultus or meteorismus occur, they
should be treated conformably with the principles
already explained (§557.). — Swellings of the
parotids are unpleasant accidents, even when cri-
tical. They should be checked at first by keeping
the bowels moderately open, and cold applications
to them. Iftiiis end be not accomplished, then
suppuration should be promoted by stimulating
poultices ; and the abscess should be early opened,
in order to prevent contamination of the surround-
ing cellular parts. If gangrenous sores appear
in any part, the means directed above (§ 166.),
more particularly the chlorides, creasote, pow-
dered bark, turpentine, &c., eitlier severally, or
variously combined, or in the form of wash,
epithem, or poultice, ought to be promptly and
assiduously employed.

579. iii. Of certain Medicines, Sjc. in Typhoid
Fevers, — a. Anlimoniuls, especially James's pow-
der and tartar emetic, are frequently of service in
the early stages of fever ; the latter for its emetic
operation, and its febrifuge or contra-stimulant
action during excitement ; and the former for this
last effect, in connection with its diaphoretic in-
fluence. The remarks already offered respecting
these medicines (§ 162.) are applicable to the use
of them in the fevers under consideration. It is
chiefly in the early periods, in the more inflam-
matory states, in the pulmonary complications,
and either in aid of, or as substitutes for, blood-
letting, that they should be employed, more par-

• Cehtain Medicines in. 10"29

ticularly the potassio-tartratc of antimony. How-
ever, the results of IIazoiu's practice," and the
recent trials made of this medicine by Dr. Gravis,
in the advanced stage of typhus, indicate the pro-
priety of having recourse to it, at a later period, in
much more liberal doses than have been hitherto
considered safe. This able physician, reasoning
from the good effects of the medicine in delirium
tremens, was induced to resort to it in a case pre-
senting a quick, failing pulse ; a black, dry, tre-
mulous tongue ; tympanitis ; low, muttering deli-
rium ; starlings of the tendons, and nervous
agitation. He prescribed four grains of tartar
emetic, in eight ounces of camphor julep, with a
drachm of tincture of opium — a table-spoonful
to be taken every second hour. The patient
vomited after the second dose ; and, after the
fourth, he fell into a calm sleep, and soon re-
covered. Besides the good eftect of this medicine,
that of vomiting at this stage of fever, as recom-
mended by many of the older writers, is shown by
this case. Dr. Graves refers to other instances
(Loud. Med. and Surg. Journ. vol. vii. p. 541.),
in which tartar emetic and opium produced
decided benefit, in most unfavourable states of
the advanced periods of low nervous fever, and
of exanthematic typhus. The combination of
the potassio-tartrate of antimony with nitre is most
appropriate in the stage of excitement ; but, in the
nervous stage, opium seems indispensable to the
good effects of the antimonj'.

580. b. 0( other antiphlogistic and contra-stimu-
lant means, it is unnecessary to add any thing to
what has been already advanced. The contra-
dictory opinions entertained as to the propriety,
or amount, of depletion are readily explained,
when the various forms of typhoid fever, and cir-
cumstances of the ease, are taken into consider-
ation, in connection with the intentions with which
bloodletting on the one hand, and restoratives on
the other, are resorted to ; and with the fact that
both are very frequently required, not only con-
secutively but even simultaneously. This cir-
cumstance was well known to very many of the
numerous writers on these fevers during the three
last centuries, both in this and in foreign coun-
tries. They well knew and strenuously incul-
cated the fact, even as late as the days of Lea rke,
that, in order to prevent the accession of the
putro-adynamic state, it is necessary to bleed,
and to use other antiphlogistic remedies, with
decision, early in various fevers and epidemics.
And next to bleeding, /litre and the hydrochlorate
of ammonia were held in estimation, for their
efi^ects in lowering morbid reaction at the com-
mencement of typhoid fevers, and in preventing
putridity in advanced stages. Thus, wdiilst nitre
was conjoined with antimonials, ipecacuanha,
small doses of camphor, or with the spirits of
nitric ether, to fulfil the former intention, and to
promote perspiration and the action of the kid-
neys, it was given with tonics and stimulants
to produce the latter indication. The writings of
DeliuS, Hillary, IIaenel, Wood, Razori, and
many others, show us how very little we have
hitherto improved upon their practice in these
fevers. The same remark applies to the use of
the hydrochlorate of ammonia, whose operation as a
refrigerant antiseptic and tonic, ranks it as one
of the best and most generally applicable of the
many remedies employed in fever,
3 U 3

1030

FEVER, TYPHOID — Certain Medicines in.

581. c. As to the use of alvine evacuations, we
have arrived at similar conclusions to those very
generally acted upon during the seventeenth and
eighteenth centuries, but partially lost sight of to-
wards the close of the latter. Tiie good effects of
emetics at the commencement of typhoid fevers
were almost universally admitted, until Broussais
banished them from his code of therapeutics. —
That circumstances sometimes occur, which
either render them unnecessary, or even forbid
them altogether, has been allowed; but very
sufficient evidence has been adduced of their
good effects, more particularly in the periods of
premonition and invasion, and even early in that
of excitement. Many writers of great experience,
especially Cheyne, Tuomy, Stoll, Sandiford,
Reil, Hildenbrand, Hufeland, &c., have ad-
vised them in the advanced stages of these fevers ;
and although they are rarely employed in these
periods by practitioners in this country, I believe
that they will often prove of service even then,
when judiciously resorted to, in exanthematic
typhus. The injurious effects imputed to them
by Marcus, Wendelstadt, Broussais, and
others, are to be referred to the employment of
them in the gastric complication, and in other
circumstances which contra-indicate their use.

582. The operaUon oi purgatives in low fevers is
now well understood ; the indiscriminate use of
them encouraged by the writings of Hamilton
having been checked and tempered by the par-
tial adoption of the views of Broussais. And
yet I believe that the particular state of the in-
testinal mucous surface that exists in these fevers
may be increased by a neglect of this class of
medicines ; and that, when appropriately com-
bined, many of them are calculated to prevent, or
to alleviate, the morbid condiiion which the dis-
ciples of Broussais imagine them to produce. —
A tolerably active purgative early in excitement,
or in the other circumstances above noticed, both
lowers excessive action, and removes morbid ex-
cretions, which, if allowed to remain, would prove
a cause of irritation and contamination to the
frame. In cases, however, where the vascular
excitement is attended by vital prostration, eitlier
early or late in the disease, the use of purgatives
requires much caution. When excitement is
considerable, calomel with jalap, or with rhubarb,
will be given at first with advantage ; but, in
other circumstances, the calomel should be with-
held. When, with excitement, there is consider-
able pulmonary affection the potassio-tartrate of
antimony may be added to the purgative adopted,
as advised by Dr. M'Cormac, and indeed very
generally adopted in practice. r>ut when vital
depression is the predominant feature of the dis-
ease we should be as cautious in the use of
purgatives, as in having recourse to bleeding.
Tlie evacuation of the serous portion of the blood
by means of the former, is nearly e(iually de-
pressing with the latter operation. In the ad-
vanced stages, and especially wiien putro-ady-
namic signs begin to appear, the blood-vessels,
owing to the loss of a great portion of their tonic
contractility, cannot accommodate themselves to
the evacuation of much of tlieir contents, in what-
ever way it may be effected ; for the column of
blood in the vessels is no longer presented to the
contraction of the ventricles in that state ol'
tension whicli favours its healthy circulation. If

the bowels, however, require the aid of a purg-
ative, during a state of prostration, it ought not
to be withheld ; but it should be so selected, as to
produce no greater evacuation than may appear
requisite, and be so combined as to leave a tonic
or salutary impression upon the digestive mucous
surface. In such cases, equal parts of the com-
pound infusions of gentian and senna, or an in-
fusion of cinchona and rhubarb, or the compound
decoction of aloes, or rhubarb and carbonate of
soda, or the purgatives already mentioned (§ 150.
151.), or some of those prescribed in the Ap-
pendix (F. 180, 181.205.216.252.433.), may
be resorted to. In the putro-adynamic form,
and in the advanced states of typhoid fever, purg-
atives ought to be always combined with tonics
and aromatics. They should never be given,
excepting very manifestly required ; and then in
moderate doses, and combined as now advised, par-
ticularly when there is diarrhoea, or evacuations
of blood, or meteorismus. However, rhubarb, or
turpentine, in small or moderate doses, with aroma-
tics, will often be of much service in such cases.

583. d. There are several stimulants of great
use in low fevers ; and which, owing to their pe-
culiar or febrifuge operation, may be given with
great benefit in that state of excitement which is
attended by vital prostration, as well as in more
advanced stages of the disease. Of these the
most applicable and beneficial is camphor. This
substance is most generally adopted ; and has
received the encomiums of most writers on typhoid
fevers and more particularly of Riverius, Stole,
Ferro, Home, INIarcus, Tiiomann, Gebel, Reil,
SciiLECEL, Horn, and Hildenbrand. I have
prescribed it not only in these, but also in pes-
tilential, exanthematic, puerperal, and common
continued fevers ; and am satisfied as to its good
effects; either when exhibited alone, or when com-
bined with other appropriate medicines, and given
in proper doses. In the stage of exciletnent, the
dose, and the medicines which should be asso-
ciated witii it, should have reference to the state
of vital power, to the mildness or severity of the
disease, and to the nature of the prominent affection
or complication. In this stage, particularly if
vital power is not much lowered, it may be given
in frequent doses of half a grain, or a grain, with
a weak solution of the acetate of ammonia, or in
a mixture witii it and spirits of nitric ether, or with
nitre ( F. 494. 496.), or with hydro-chlorate of
ammonia (F. 431.), orwitli aniimonials (F. 493.).
or with any two or more of these. It may be
also exhibited in some circumstances, with ad-
vantage conjoined with calomel. If vital power
is much depressed in this stage the dose of the
campiior may be increased, and the antimonial
or the calomel omitted, or given merely at the
outset. In some one or other of these com-
binations, it will j)rove of benefit, whatever com-
j)lications tiie fever may present. As the disease
passes into tiie 7iervous stage, and more espe-
cially as this stage passes into extreme exhaustion,
the dose of cam))hor siiouJd be increased, and it
may then Ijc conjoined witii tonics, various stimu-
lants, antiseptics &c., as arnica, cinchona, ser-
])cntaria, valerian, angelica, opium, sulphate of
(juinine, the chlorides, musk, aromatics, &c.,
according to the period and peculiarities of the
disease. JNlany of the best writers in Germany
prescribe it, early in tiie nervous stage, with

FEVER, TYPHOID — Certain Medicines in.

arnica, or with acetic or citric acid. IIaute-
siERK, Callisen, Ludwig, Bonnevault, Frank,
Jaegersciimidt, and Hufeland direct a solution
of camphor in acetic acid to be taken internally,
and used externally, early in most states of typhoid
fever. ^V'iththe pyroligneous acetic acid, the cam-
phor may be conjoined with still greater benefit.
The inflammatory state of any organ, supervening
in the course of typhoid fevers, does not contra-in-
dicatethe use of camphor, if given appropriately to
the degree of vascular action and of vital power.

584. Arnica has been very much employed in
Germany in low fevers, and in the nervous stage
of typhus, yet it has not received a satisfactory
trial in England nor in France. Stole, Fischer,
Collin, Ferro, Mercier, Frank, Riciiter,
Hecker, Hildenbrand, and other high autho-
rities recommend it, generally as directed above
(§ 572.). QuENTiN prescribes an infusion of it
with valerian. The flowers and the root are most
commonly employed, and usually in the form of
a weak infusion (F. 222, 223.).

585. In the low nervous form of typhoid fever,
as well as in the nervous stage of exanthematic
typhus, or in that stage and state of the disease
for which the German physicians prescribe arnica,
valerian may be employed with advantage. JMat-
TH.Ei, Frize, Reil, TnojiANN, and others recom-
mend it. I have given an infusion of it in several
cases, and mad« it the vehicle of other medicines,
particularly the chlorate of potash, camphor,
the alkaline carbonates, serpentaria (F. 269,270.),
&c. It is indicated in such states of fever as re-
quire a gentle tonic and stimulant of the nervous
influence, especially when the nervous symptoms
are prominent, although the head be cool and the
pulse weak. In these circumstances it may be
conjoined with camphor, tonics, &c.

586. Serpentaria root was praised by Frize,
Stole, Reil, Marcus, and others, in the ad-
vanced stage of low fevers, and in the circum-
stances just mentioned. It is still used, when
the skin is cool or the pulse is weak, and when
warm stimulating tonics are required. It is most
serviceable in the form of infusion, with aromatics
and tonics (F. 262. 416. 826.). Angelica root
was recommended by Reil ; imperatoria root,
by Hoffmann ; and the root of calamus aromaticus
by Hildenbrand. They are very rarely em-
ployed in this country, although they are of
service, particularly in the form of infusion, as
vehicles for other medicines, and on account of
their warm, diaphoretic, and stimulant effects.
They may be employed variously combined with
each other, or with camphor, tonics, &c. ; and
are indicated in the same circumstances as re-
quire the use of arnica, viz. in the low nervous
and putro-adynamic states. Their infusions are
good vehicles for tonics, the chlorates, or alter-
ative salts. I have sometimes prescribed them
with chloric acid and chloric ether, or with the
chloride of sodium and chlorate of potash.

587. e. Cinchona and other tonics have been
praised by IIuxiiam, Lind, Langrish, Grant,
Westpiial, Sims, Vallisneri, Casson, Fou-
dyce, and most of the writers on fever during the
last century, and by many contemporary authors ;
whilst others have attributed more or less mis-
chief to their use. When the various forms of
typhoid fevers, their complications, and the very
different pathological states in tlie successive stages

1031

of their course, are considered, this contrariety of
opinion is easily explained. When the nervous
stage has appeared, and when the putro-adynamic
state is pronounced, whether early in tlie disease,
as in the putrid or septic variety, or in the ad-
vanced stages of the nervous and exantliematous,
the preparations of cinchona and the sulphate of
quinine, are the best tonics that can be selected,
both for the permanence of their action, and for
their influence in arresting the disposition to col-
liquation that pervades the fluids and soft solids
of the frame. In the early states of the disease,
and where the propriety of having recourse to
tonics is a matter of doubt, the infusioii of bark,
with the solution of the acetate of ammonia, and
spirits of nitric ether, or the decoction if cinchona
with nitre and hydro-chlorate of ammonia ( F. 437,
438.), will generally prove serviceable.

588. f. The propriety of having recourse to acids
in the states of low fever just alluded to has re-
cently been disputed ; and if the effects produced
by them on the blood be considered, as shown by
the experiments of Friend, Eller; Gianella,
Haller, &c., and as stated in the article Blood
(§ 135, 136.), rational doubts of their salutary
influence may be entertained ; yet the experience
of most writers is in favour of them, particularly
in fevers of a low character. Spangenberg,
HuxHAM, Langrish, Wood, Mursinna, Row-
ley, BoYER, Rademacher, Sciilegel, Horn,
FoRDYCE, Bang, Millar, Frank, Hufeland,
&CC .recommend the mineral acids, especially the
liydrochloric in the circumstances mentioned
above. From a careful observation of their effects
in many cases, I believe that they will prove bene-
ficial in some cases, and injurious in others, ac-
cording to the period and state of fever, and the
mode of prescribing them. If they are given
before the blood has become materially altered,
and the vital energy much exhausted, but after
requisite vascular or alvine evacuations have
been carried sufficiently far — whilst the skin is
still warmer than natural, and whilst the pulse is
broad, open, and compressible, the mineral acids,
with tonic infusions, will generally be serviceable.
In this state the infusion or decoction of cinchona
may be given with hydrochloric acid and chloric
ether ; or the sulphate of quinine, with infusion
of roses and sulphuric acid, or also with sulphuric
ether. When the prostration is considerable,
this latter may be the more energetic medicine. In
more doubtful cases, particularly when the heat
of surface is great, the infusion of cinchona or of
valerian may be given with the nitrate of potash,
or with the nitrate of soda, a few drops of nitric
acid, and the spirits of nitric ether ; and when
the skin is cooler, either of these infusions, or some
one of the others already mentioned, may be pre-
scribed with equal parts of the nitro-hydrochloric
ncid and the tincture of serpentaria.

589. In the treatment of typhoid fevers it should
never be forgotten that the state of the circulating
fluids depends chiefly, if not entirely, upon that of
the ot-ganic nervous influence, and that agents
which apparently deteriorate the blood may yet
be of use by administering to this influence. The
carbonic acid gas was supposed by Jansenn,
FoRTiER, and Percival, to act as an energetic
tonic, when taken into the digestive canal ; and
they therefore directed the use of those fluids
which contain it most abundantly j and even

3 U 4

1032 FEVER, TYPHOID —

advised it to be thrown up the rectum. A similar 1
practice was lately recommended by Ur. Clanny, |
with the view of supplying the blood with this
substance. But M. Ciiomel has shown the
inefficacy of this practice (§ 538.). The acids
which have appeared to me most serviceable in
the early period of the adynamic, nervous, or
putro-adynamic forms are the hydro-chloric and
the pyroligneous acetic, particularly when given in
the decoction of bark (F, 388.), or in either of
the warm stimulant infusions mentioned above.
When the nervous or putro-adynamic states are
far advanced ; when the temperature is low, and
the skin lurid or discoloured ; I believe, that
whatever benefit follows the use of mineral acids,
depends chiefly upon the salutary efforts of nature,
or the substances prescribed at tlie same time.
In the state just mentioned, the more energetic
tonics and stimulants, in conjunction with cam-
phor, the chlorate of potash, opium, wine, &c.,
are much more deserving of confidence. Besides
cinchona and sulphate of quinine, other tonics,
as cascarilla, calumba, gentian, &c.,maybe used ;
but they are inferior to bark ; and ou^ht to be
given ciiiefly in conjunction with substances
appropriate to the peculiarities of the case. The
willow bark has been recommended by Otto,
ScHLEGEL, White, and Hufeland, but it does
not appear to be equal to cinchona.

590. g. The chlorates, 6)C. — The chloride of po-
tassium (muriate of potash) was first employed,
under the name of digestive salt, by Sylvius;
and, owing to its febrifuge properties, it afterwards
obtained the appellation of febrifuge salt of Syl-
vius. It was given in doses of from one to two or
three drachms : and, although its action is stimu-
lant, aperient, diuretic, and antiseptic, it has
seldom been used in modern times. It is of
service in the low stages of fever, and when there
is evident change in the circulating and secreted
fluids ; but it is inferior to the chlorate of potassa.
in these states. This latter salt was recommended
by Gaiinett and some other writers, but at no
time has it been generally used. I have pre-
scribed tlie chlorate of potash in several diseases,
since 1819, and consider it a valuable medicine,
especially in the advanced stages of typhoid
fevers. When excitement or vascular reaction is
about to pass into the nervous stage, and when
inflammatory determination has been removed,
either of these salts, but- tlie latter especially, will
be prescribed witii benefit. 'J'iie chlorate may
be advantageously conjoined with tonics and
camphor ; or it may be given in doses of five or
seven grains every two or three hours, in tonic
infusions, or in larger quantities at longer in-
tervals.—A solution of chlorine, or of chloric
<thcr, or of both, may be used in the same states,
for wiiicii tlie chlorate of potash or the cliJorides
are lierc recommended.

591. The chloride of sodii(7n, or common salt,
although sometimes used, in various forms, but
commonly as an aperient and anthelmintic, by
the older writers, has recently been seldom re-
sorted to, cxce[)ting in enemata, in tlie treatment
of low fevers. Formerly jmlrldili/ was much
insisted upon as a ciiaracteristic of certain states
of fever ; for, owing to the intensity and con-
currence of the exciting causes, to the treatment,
and to tiie influences in operation through the
course of the disease, these ciianges of the fluids

Certain Medicines in.

and soft solids, which, although not strictly pu-
trid, yet somewhat resemble it, or even approach
it, were common occurrences in the course of
the inflammatory as well as of the adynamic
varieties. These changes, inasmuch as they con-
sist, in some measure, of an incipient dissolution
of the vital cohesion of the tissues, and of the
healthy condition of the fluids, quickly passing,
with the disappearance of life, into manifest de-
composition, were not altogether inappropriately
termed putrid ; and, for want of a more suitable
name, they may still retain the denomination.
With the modern disuse of this term, and from a
disbelief of the possibility of putridity taking place
in a living body, the operation of medicines in
preventing or counteracting it was denied. Thus
an antiseptic property was denied to medicines,
although it could not be doubted that many sub-
stances had the power both of averting and of
remedying the changes usually termed putrid.
This power was imputed to their influence upon -
the nervous system, particularly the cerebro-spinal
part of it. I have, however, shown at other places,
by experiments performed by myself and others,
that numerous substances are quickly conveyed
into the circulation, where they directly change the
state of the circulating fluids and secretions, and
afl^ect the organic or ganglial nervous influence.

692. Conformably with this view, the older
opinion as to the operation of antiseptics on the
living, as well as on the dead body, — that certain
substances prevent or counteract the changes .
usually denominated putrid or septic, — seems well |
founded. There can be no doubt that the circu- J
lating fluids are contaminated or altered in tlie
course of fever, owing to the superabundance of
certain constituents, and the loss of others necessary
to the continuance of health. The impeded tunc- '
tions of the lungs, the skin, liver, and kidneys, in
tile early stage of the disease, will occasion the
former of these changes, and the stop put to the
functions of digestion and assimilation — to the
sources of supply — will produce the latter.
That the chloride of sodium is necessary to the
healthy state of the blood, cannot be doubted ; it
therefore follows that the privation of it, for a
number of days, during the treatment of feveis,
will materially favour the morbid condition which
the fluids assume in the advanced stages. But as
other substances, as the chlorate of potash, hydro-
chlorate of ammonia, nitrate of potash, and nitrate
of soda, act on the blood and on the economy in a
similar manner to the cliloride of sodium, although .
not so beneficially, universally, and permanently
as this last, which lias been so bountifully supplied
by nature, we arc enabled to account for the be-
nefit derived from the use of tiiem, in the ad-
vanced stages of fever, by writers in the sixteentli
and seventeenth centuries. It seems very pro- .
bable, that the common salt taken so abundantly
with our food, after having produced the eflecls
arising from its neutral state, is decomposed by
the nervous or vital influence, or by the elec-
tricities circulating through the frame ; and tiiat
each of its constituents performs ulterior ofliccs
in the economy, that are necessary to the con-
tinuance of health, and enters into new combi-
nations, ])roduce(l by the actions of the rcspccli\e
organs, in the circulating anil secreted fluids.

5!)3. ]f this view be just, the insuflicientsupiily,
or the privation, of tliis salt in the eaily stages.

FEVER, TYPHOID — Certain Medicines in
whilst the discharge of it continues by the excre

1333

tions, in either its neutral or its decomposed states,
will cause a deficiency of it in the blood in the
advanced periods of fever, and will give rise to
further changes both in the circulating and in
the secreted fluids. In conformity with this
opinion, a modification of the medical and
regimenal treatment, usually recommended in
typhoid fevers, should be adopted. It is not
improbable, that the evils resulting from a total
privation of a substance so necessary to the
healthy discharge of the functions, as the chloride
of sodium is, would have been more generally ma-
nifest in these diseases, if other substances, acting
somewhat similarly upon the blood and on the sys-
tem, had not been commonly employed in the treat-
ment of them. I have been led, by the antiseptic
properties of certain medicines, to have recourse,
in the latter stages of low fevers, to the most ener-
getic of them, particularly the nitrate of potash, the
chlorate of potash, the hydrochlorate of ammonia,
camphor, and the terebinthinates, cinchona, &c.
in various combinations, either with each other,
or with difierent stimulants and tonics,, with the
view of exciting the nervous influence, of support-
ing the powers of life, and of counteracting the
changes, frequently terminating in a dissolution
of the vital crasis and cohesion of the fluids and
soft solids. But in fevers, which are charac-
terised by excessive action at the commence-
ment of excitement, and by extreme exhaustion,
loss of irritability, and depravation of the fluids,
in the latter stages, a too early recourse to some
of these medicines may increase the morbid action,
and aggravate local determinations ; while a too
cautious reserve of them, either as to quantity or
as to the period of fever, may allow the diseased
changes to proceed without interruption to a fatal
issue. It is, therefore, imperatively required of
us, that we should determine, by attentive ob-
servation, both the exact period in which medi-
cines of this description should be commenced
with, and the particular substances that should
be first employed. As respects the kinds of (ever
just alluded to, as well as those forms which are
either nervous, or more uniformly putro-adynamic,
at earlier stages, we are at no loss for means,
which are both refrigerant and antiseptic, and
which may be employed from the commence-
ment, either when excitement is most excessive,
or when it is entirely absent, if due care be taken
in the mode of prescribing them. By this early
attention, particularly in putro-adynamic and
inflammatory putrid fevers, to those means which
may best preserve the fluids from the changes they
are apt to undergo, especially when these fevers
are left to themselves or injudiciously treated, the
advanced stages are rendered much more mild
and even manageable. The more refrigerant of
the substances, formerly termed antiseptics, as ni-
trate of potash, nitrate of soda, hydrochlorate of am-
monia, (kc., wdien duly administered in the early
course of fever, and combined with or followed
by those which are more stimulant and tonic, as
camphyr, cinchona, chlorate of potash, arnica, iS:c.,
as exhaustion and signs of putro-adynamia ap-
pear, will generally prevent the more dangerous
changes in the fluids from taking place. The liu-
drochlovafe of ammonia is now seldom used inter-
nally, although Hon MANN, Jacob, Barchusen,
LoESECKE, TissoT, Werlhof, Monro, Hirschel,

Hillary, M'Causland, Gmelin, and others,
have recommended it highly in putro-adynamic
fevers. I have frequently employed it ; and Ur.
CoNWELi. has found it of great service in the
fevers of India, Sciimiot prefers it in such cases
as are attended by diarrhoea.

594. About the time when M. Labarraque
discovered the chlorinated soda and lime, cases of
fever of a putro-adynamic or malignant form
were frequently occurring in an institution to
which I am consulting physician. I had made
trial of various methods of treatment, but found
camphor, in large doses, variously combined, and
aided by other means according to the pecu-
liarities of the case, the most successful of any.
Shortly afterwards, M. Labarraque's process
for preparing these chlorides was published at
Paris; and as early as 1825 I procured them from
Mr. jMorson, for the use of this, and another in-
stitution, to which I was physician. I employed
them internally, in enemata, and externally, and
as disinfectants ; and the results were such as
have induced me to have recourse to them ever
since, in the various circumstances and diseases
in which I have recommended them in this
work. The chlorinated soda is a valuable medi-
cine in all the typhoid forms of fever, when judi-
ciously prescribed. It may be given early in the
putro-adynamic variety, when excitement is im-
perfect or low, and the skin discoloured, or pe-
techia; are appearing, and continued throughout
the disease. 13ut when vascular reaction is con-
siderable, or local determination prominent, par-
ticularly in the nervous and exanthematic varieties,
this substance should be withheld, until these
states are subdued, or about to lapse into the
nervous stage. — At first it ought to be prescribed
in small doses, so as not to oftend the stomach —
in from ten to fifteen drops of the solution, as
prepared by Labarraque, every three or four
hours in camphor julep or in an aromatic water.
As the disease passes into a state of exhaustion cr
of manifest putro-adynamia, or when there are a
lurid skin, low muttering delirium, stupor, meteo-
rismus, black sordes on the tongue, teeth, &c.,
the supine posture, inconscious offensive evacu-
ations, petechia, blotches, a disposition to gan-
grene in parts pressed upon, coma, «Scc., it should
be given in larger doses, or more frequently, and
in tonic infusions or decoctions, or with camphor,
serpentaria, or other stimulants and tonics. I
have seen it productive of great benefit in such
cases ; but it should be commenced before these
symptoms appear, and be persisted in, as its good
efTects are seldom manifest in less than three or
four days, or more; and it should not supplant
the use of wine, opium, suitable nourishment,
and other means which the stage of the disease
and peculiarities of the case may suggest. It
should also be frequently administered in enemata •
and the surface of the body ought to be often
sponged with a stronger solution of it in warm
water, with the addition of camphor. M. Cno-
jiel'- has lately given the chlorinated soda an
extensive trial ; and he states that it has proved
more successful in low fevers than any other
means, when perseveringly employed. Dr. Gravis
has also recently employed it, and has found it
extremely serviceable. It acts, first, on the
tissues with which it is brought in contact, as a
gentle stimulant and antiseptic ; and is inost pro^

1034

FEVER, TYPHOID — Certain Medicines in.

bably partially decomposed in the digestive organs,
and reduced to the state of common salt. In this
state it is carried into tlie circulation, where it
supplies the waste of this substance that has taken
place in the early stage of the disease.

595. The chlorinated lime, in doses of one or
two grains, may be also employed with great ad-
vantage. When exhibited in solution, it will be
preferable to commence witli half a grain every
hour, or with a grain every two hours, gra-
dually increasing the quantity as the stomach
may tolerate it. It is best adapted to the more
extreme cases of putro-adynamia, and especially
to those attended by urgent diarrhoea and meteo-
rismus. In these it may be conjoined with caiii-
phor and other stimulants. It was employed by
Dr. Reid, of Dublin, in low fevers and in dys-
entery, a few months after the period of my
having first had recourse to the chlorinated soda.
It may be prescribed in the same circumstances
and combinations as the latter ; but is not so gene-
rally appropriate, nor does it admit of so early, or
of so prolonged, an exhibition.*

596. !i. Alkalies and alkaline carbonates have been
employed in various states of typhoid fever, and
frequently with service. The sesqui-curbonate and
other preparations of ammonia have been very
generally resorted to when diffusible stimuli have
been required. In the early stages of these fevers,
the sesqui-carbonate may be used, with advantage,
to make a neutral saline mixture with the pyro-
ligneous acid, and either the alkali or the acid
may be given in excess, or the mixture may be
taken whilst effervescing. The preparations of am-
monia are most useful in the nervous and exanthe-
matic varieties of typhoid fever ; and in con-
junction with camphor, or with tonic infusions, in
the nervous stage. In the putro-adynamic state,
they have seldom appeared to me to have any
good effect, unless combined with these or other
tonics.

597. The sesqui-carbonate of soda and bicarbon-
ate of potash are seldom used unless to form neutral
citrates or tartrates, and to obtain the fixed air
given out during the combination. The advan-
tages of this latter are, however, by no means con-
siderable ; but the salts themselves are of service,
by supplying, in some respects, the place of that
commonly employed. The carbonate of soda has
been occasionally used, and is recommended by
Dr. Stevens as an ingredient in his saline pow-
ders. In the more adynamic slates of typhoid
fevers, or in the intestinal complications, the car-
bonate of soda should be given in a tonic infusion

* Dr. Reip mentions an important fact illustrating the
cause of putro-adynamic fevers, — a cause which exists to
a greater extent than is supposed, especially in large
cities although in a much less degree tlian in the instance
ahout to be adduced. At Valladolid, during the war in
Spain, tlie palace of the" Holy Inquisition" wasapixjjnted
for the barracks of a British regiment. Under tlie co-
lonnade was a well, from which water could bo drawn into
tlie uppermost stories. This water had a swecti.-li de-
cayed taste ; but, for the want of better, the soldiers used
it both for drinking and cooking. No other regiment in
tlie garrison was so uuhcaltliy; and the prevailing <lis-
case was putrid fever, of which there was not tlie sliglitest
fymptom in any [of the other regiments. At last the
reason was discovered : skeletons were found in the well,
and several were observed with pieces of the llesh adhering
to the bones. If the chlorides of soda or of lime had been
then known, or if that which had been long jireviously
recommended been employed, the mortality from this
U-vuT, and from jiutro-adynamle dysentery, would not
hav<' been bo great as it proved during tlic I'eninsular
campaii;ua.

or decoction, with camphor, and with opium, or
extract of poppy, or compound tincture of camphor,
to prevent it from relaxing the digestive mucous
surface, and from increasing the diarrhoea. Un-
less it be thus combined, or conjoined with the
chloric salts, which Dr. Stevens directs, it may
not only aggravate the affection of the bowels, but
also favour relapses, or cause the disease to pass
into the dy.senteric complication. An acetate of
soda, formed by pyroligneous acid, with an excess
either of the acid, or of the alkali, according to
the state of disease, and taken whilst effervescing,
or afterwards, appears to me, from the few cases
in which I have had an opportunity of using it,
to deserve a more extensive trial.

598. The salts employed by Dr. Stevens, viz.
the chloride of sodium, the carbonate of soda,
and the chlorate of potash, cannot be supposed
to act, even upon the digestive organs, in the
states in which they are prescribed, without un-
dergoing some change from their mutual action,
and from the fluids with which they mix. Indeed,
the results may be assumed to be chlorates of
soda and of potash, and carbonate of soda, taking
the proportions of the individual salts into con-
sideration. When these salts are taken into the
stomach during the middle and latter stages of
typhoid fevers, the passage of at least a portion of
them into the circulation may be expected, and
the loss of the saline ingredients of the blood in
the early stages, argued for above (§ 592.), will
be supplied. Upon this principle, and for tlie
reasons there stated, this method deserves a more
extensive trial than it has hitherto obtained ; and
when the nature of the salts, and the modes of
iheir operation, are considered, it does not seem
to difl^er materially from that by means of the
cldoride of soda, first adopted by myself. — There
are certain points upon which Dr. Stevens very
strongly insists, and which are partly contra-
dicted and partly confirmed by former observers :
these are — 1st, The superabundance of acid in the
excretions; 2d, The influence of all acids in ren-
dering the blood dark and grumous; and, 3d,
The mischief produced by them in the latter stages
of fevers. ]\ow, without disputing the accuracy
of the first statement, although a "confirmation of
it is required, I will admit the tru^h of the second ;
for it agrees with my own experiments, and with
those performed by writers early in the last cen-
tuiy, to whom I have referred in the article
Blood (§ 135.). That acids will be injurious in
the latter stages of fever, seems a rational infer-
ence from these experiments, in connection with
the dark and morbid state of the blood at that
time ; and yet numerous writers have recom-
mended them, and adduced proofs of their good
effects even in the most malignant states of remit-
tent, continued, and exanthimatous fevers. The
muriatic or hydrochloric, citric, and pyroligneous
acids have been severally eiujiloyed in these states,
and found of service ; but they have also fic-
([uently failed. That the blood is black and dis-
solved in scurvy cannot be doubted, yet the ad-
vantages derived from citric acid have been great,
unless some remarkable delusions as to the causes
and treatment of this disease have existed * j and

* From several opportunities of observation, I am of
opinion that scurvy has been often confounded with
putro-adynamic lev(-r ; that both diseases formerly pro-
cucdcd from the same causes, and often occurred simul-

FEVER, TYPHOID — Ceiitain Medicines in.

1035

such actually appears in some measure to have
been the case. The trutli, however, seems to
be, that whilst pathologists have lately been
occupied exclusively with the living solids, Dr.
Stevens has concerned himself only with the
blood, and kept too much out of view the influ-
ence of life, especially as manifested in the or-
ganic nervous system, upon both the circulating
and secreted fluids.

599. As far as my own observations enable me
to form an opiuion as to the respective merits of
these acids, and of tiie alkaline carbonates and
salts, I conclude — 1st, That the acids may be
of service early in fever, whilst vascular excite-
ment is considerable, although vital power may
be weak ; that they seldom will be injurious in
this period, as long as the skin continues warmer
than natural, and the blood preserves its colour;
and that but little confidence should be placed
in them when the surface is at, or below, the
natural temperature, or materially discoloured,
unless they be conjoined wiUi substances calcu-
lated to excite the powers of life. 2d, That the
carbonates of soda and potash, the solution of
chLn-ine, and the chlorides, are preferable in the
middle and latter stages, more especially when
the blood appears inorbid, the skin discoloured,
and the excretions ofl'ensive ; but that the sub-
carbonates should not be trusted to in the last
stages of typhoid fevers, unless conjoined with
substances calculated to support the vital en-
ergies ; and that, at this period, chlorine, the
chlorates, and chlorides, should be preferred, as
being more tonic, stimulant, and antiseptic
than the carbonates. 3d, That the sulphate of
soda, the phosphate of soda, and the sulphate of
magnesia, are severally of service in the stage of
excitement, when they may be given, at first so
as to act gently on the bowels, and afterwards in
small doses, as refrigerants or alteratives ; and
that the chlorate of potash, the citrates, and ace-
tates may likewise be employed with the latter
intentions. And, 4th, That circumstances may
occur, in which it will be advantageous to exhibit

taneously in the same camp, array, fleet, or ship ; that
the causes were chiefly putrid water, mouldy and adul-
terated bread, diseased and unwholesome flesh, vegetable
and animal exhalations, insufficient nourishment, and
the depressing passions ; and that the protracted use of
salted provisions of a good a.uality was but little concerned
in producing either of these diseases. During the seven-
teenth and eighteenth centuries, trading vessels were pro-
visioned as cheaply and as sparingly as possible, and fleets
and armies were provided hy contractors who enriched
themselves and those who passed their supplies at the ex-
pense of the lives of thousands. Bread which was ac-
tually nauseous ; the flesh of animals dead of epizootics ;
provisions which had been either salted for years, or
nearly half putrid ; numbers sleeping in a small space
and in imperfectly renewed air ; the constant evaporation
from the too frequently washed decks ; water kept in
wooden casks until it became blackish, inky, stinking, and
nauseously putrid; were causes of fever often in protracted
and simultaneous operation. I have never been in a ship
in any other capacity than as a passenger ; but some of my
voyages have been long, and have afforded me occasions
of witnessing, even at the commencement of thenineteenth
century, the existence of some of these causes. For
many years matters have been altered, especially in the
navy. The mutiny at the Nore ; the advance of know-
ledge ; the stricter attention to the supply, preparation,
and quality of the provisions ; the preservation of water
iu iron tanks, and some other subordinate circumstances ;
have done more to banish putrid fevers, dysentery, and
scurvy from our fleets, than the use of citric acid or any
other antiscorbutic or antiseptic ; and I have no doubt
that the prevention of these causes, and the general adop-
tion of the chlorides, will be found the most certain
means of preventing and of curing these diseases.

the neutral salts with either an acid or an alkali,
as the chloride of sodium, with a vegetable acid,
as prescribed by Morgan ; or witii soda, as ad-
vised by Stevens ; or to prescribe saline sub-
stances with an excess of either of their consti-
tuents, as the chlorates with an excess of acid or
of alkali.

600. 1. Opium, (5fc. — Much difference of opinion
has existed as to the propriety of giving opium in
typhoid fevers. But when we find Svpeniiam,

POLIDORI, RoLFINCK, SciILEGEL, Van HoVEN,

Hobie, Horn, JMarcus, Latham, Stokes,
Graves, &c. favourable to the practice, the
grounds of dissent from it ought to be carefully
examined. There are circumstances and states
of fever which forbid its use, but there are others
which as imperatively require it ; and I believe
that the objectors err grievously in not discrimi-
nating between them, and in not studying either
the conditions which contra-indicate it, or the
modes of exhibiting it in the cases that would be
benefited by it. Sydenham considered that it
prevented coma or stupor, when given after vas-
cular and alvine evacuations had been judiciously
employed. Odhehus, Gilchrist, Home, and
Graves combined it with antimonials ; and the
propriety of the practice cannot be doubted, in
the circumstances in which they employed it.
In the present day, the indications for the exhi-
bition of opiates have been so ably stated by two
accomplished physicians — Dr. Latham and Dr.
W. Stokes — that whatever I may advance as to
this subject must in great measure be an echo of
their observations. When the disorder of the
sensorium outruns the other symptoms ; when by
venesection or topical bleeding, or by alvine
evacuations and refrigerants, tiie general and
local symptoms are relieved, but the delirium
still continues ; when to this state are added,
tremors, subsultus tendinum, and unrestrained
evacuations ; when there has been at first hio-h
vascular excitement, and large evacuations have
been required to guard the brain or other organs
from mischief, and wild delirium has followed ;
if the patient has previously been in a delicate
or nervous state ; if he has been addicted to an
excessive use of spirituous or vinous liquors, par-
ticularly Ihe former; if the habits of the patient
and his occupations have been such as to inordi-
nately excite and exhaust the sensorium ; or if
tiie anxieties, the toils, or the debaucheries of
life have previously injured the health, and more
especially the state of nervous energy ; — in these
several circumstances should opiates be resorted
to, in the advanced progress of typhoid fevers,
and of .synochoid fever that has passed into the
nervous or typhoid state. On most of these. Dr.
Latham has insisted with great precision and
force ; and I entirely subscribe to the value of
his remarks. Dr. Stokes remarks, that three
circumstances call for the use of opium in fever :
1st, Where there is persistent watciifulness ; 2d,
Where an inflammatory condition of the brain has
existed, and been subdued, but delirium or other
nervous symptoms still remain ; 3d, Where an
excited state of the sensorium exists without heat
of scalp, or remarkable throbbing of the arteries
of the head ; and to these I may add a fourth,
AVhere there are much relaxation of the bowels,
unrestrained evacuations, tremors, watchfulness,
or delirium, or subsultus tendinum.

1036 FEVER, TYPHOID —

601. The viode of exhibiting opiates is some-
times of great importance. In many cases, one
or two grains of solid opium may be given, either
alone, or with camphor and nitrate of potash.
The combination with camphor is to be preferred,
when there is much adynamia, and no inflamma-
tory determination to the brain. AVhen the bowels
are very remarkably disordered, ipecacuanha may
be added to these. 'I'he acetate of morphia is
often superior to pure opium, when given in doses
of from a quarter to half a grain, with camphor,
or wiih aromatic spirits, or warm spices, as Cay-
enne, &c. : particularly in cases of extreme pro-
stration. The hydro-chlorate of morphia may be
preferred, if the chlorates are also prescribed.
Opiates are sometimes of service when exhibited
in small mucilaginous enemata. Hildenbuand,
who is averse from the use of opium in the exan-
thematic typhus, unless under circumstances
manifestly indicating it, very justly remarks that,
when it is determined upon, it should be given
in a full or large dose, once or twice repeated
after a proper interval, rather than in small and
often repeated doses.

602. Other itarcotics may be prescribed in cer-
tain states of typhoid fever, but they are not so de-
serving of confidence as opiates. The extracts of
poppy and hyoscyamus are occasionally useful, par-
ticularly when opium disagrees ; but even in such
cases, the acetate of morphia, prescribed as just
directed, will be of service. Breua praises bella-
donna in the states of fever indicating the pro-
priety of having recourse to opium. Tiiis narcotic
is sometimes useful in the delirium attendant on
erysipelas of the scalp. Mr. ]3lackett (^Lond.
Med. Repos, vol. xix.) recommends it in similar
circumstances. It seems deserving of trial in the
states of nervous fever mentioned above, and in
the nervous stage of exanthematic tj'phus.

603. k. The use ojivine and of some other stimu-
lants requires much discrimination. It has been
supposed by some writers, that wine is contra-
indicated where there are delirium ; a dry, black,
or red tongue ; red or suffused eyes ; or much
lieat of surface. This is partly true ; but one,
or even more, of these symptoms may be present,
and yet wine vvill prove of great benefit. Indeed,
wine may be exhibited in the same circumstances
as" require the use of opium. When the delirium
is of the kind above stated (§ 600.), and is accom-
panied with the same phenomena, &c. — when
the state of the tongue is the result of extreme
adynamia, inflammatory determination having
been subdued — when the suffusion or redness of
tiie eyes is the result of want of sleep, and is at-
tended by a cool scalp — and when the heat of
skin exists chiefly on the trunk, and is attended
by indications of putro-adynamia — then wine
will be given with benefit, and it is even indicated.
'J'his subject has been very ably canvassed by
some contemporary writers, particularly by JJrs.
Wii.soN, Piiii.ip, Alison, Guaves, SroKi s, and
TwEEDiE, wiiose experience gives weight to their
opinions; and they very nearly concur with me
in the pro[)riety of exiiibiting wine witli due prc-
ciution even in these circumstances, as well as
in otliers which are Ie-;s doubtful. — Gii.ciinisi-,
J[i:isuAM, IlAr.i.H, \Vi;nsei,, Uaim-es, IM a riii.i.i,
lIuir.i.AM), lIoiiN, and others, even notice tiie
indu'^ncc of wine in reducing the heat of skin,

Certain Medicines in.

in fevers tending to putro-adynamia, and my own
experience confirms the observation.

604. The indications for the exhibition of wine
in the typhoid states of fever may be reduced to
the following : — (a) When the patient has been
proceeding favourably, and the pulse suddenly
becomes weak, very soft, or irregular ; the skin
cool or damp ; the countenance collapsed ; and
the strength prostrated; — (h) When the patient
complains of a feeling of exhaustion, and expresses
his wish for wine or support; — (c) When vital
depression occurs unexpectedly or suddenly, or
without any evident cause ; — (d) When the de-
pression is owing to injudicious depletions, or
excessive evacuations, or to the depletions or
other means required to subdue inflammatory
determinations at an advanced stage, or to pro-
tracted or excessive diarrhoea, or to haemorrhage
from the bowels, or from any other part; — (e)
When, with these symptoms, the abdomen be-
comes tympanitic, and the exhaustion increases; —
(./ ) ^^' hen the delirium is low, muttering, and con-
stant, and attended by tremors, or subsultus tendi-
num ; the surface, and particularly the scalp,
being cool, the pulse soft, weak, or small, and
the posture supine ; — (g) When petechias or vibices
of a dark hue, and other signs of putro-adynamia,
appear ; the scalp being cool, and the action of
the carotids not materially excited ; — (h) If early
convalescence be slow, unattended by local af-
fections of an inflammatory tendency, and owing
chiefly to debility ; — (/) If, with one or more of the
foregoing indications, or with a soft pulse, moist
tongue, or cool skin, in the latter stages, it be as-
certained that the patient has been addicted to
spirituous liquors, or to wine in excess ; — (k) and
if the character of the epidemic be of :i low kind,
and if the early excitement be attended by weak
vital resistance, and soon pass into exhaustion
— then the propriety of having recourse to wine
or other active stimulants, with requisite precau-
tions, cannot be disputed.

605. The kind of wine, its quality, and its
quantitij, are deserving of particular attention. —
Old sherry, Madeira, and white hermitage, of
the best quality, should be preferred. The red
and acid wines are most apt to disagree ; yet port
and red hermitage are useful in some cases, par-
ticularly when diluted, and conjoined with aro-
matic spices, in the form of negus. Navieii re-
commends champagne ; but it is suitable only
to the stupor or coma attendant upon an extreme
state of adynamia. — The] quantity of wine given
in the twenty-four hours should depend upon se-
veral circumstances; but it may vary from four
or five ounces to sixteen or twenty. Ur. Baie-
MAx thinks that it should not exceed a pint; very
much larger quantities have, however, been given
with benefit ; but these are only the exceptions
from the general rule. Regard ought to be had
to the age and previous habits of the patient, as
well as to the state of the disease. Young per-
sons are readily excited, and should take only the
smaller quantities. Older patients, and those
especially who have been habituated to much
wine, or to spirituous liquors, often require the
full amount just named. 'I'he use of it ought
always to be commenced in small quantities, and
increased as the indications may guide the
l)ractitioner. In all cases, it should either be

FEVER, TYPHOID —

diluted, or given in the patient's food; and the
effects carelully watclied. — Dr. Twef.die justly
observes, that, if the patient relishes the wine, if
he is tran([uilli?ed by it, and if there is a gradual
and steady improvement in the symptoms, with-
out any marked excitement after it has been
taken, benefit will result from it. On the other
hand, if the pulse or heat of the skin are much or
quickly raised by it ; if the face becomes flushed,
and the patient restless or incoherent ; wine is
either improper, or the quantity has been too
great. If after having been stimulated, he soon
lapses into the previous state of exhaustion, or
seems weaker^ from each successive dose, no ad-
vantage will be obtained from it. When wine
has produced the desired effects, it should be
gradually withdrawn,

606. Other fermented liquors, particularly
when bottled, and even bramli/, have been used,
in the circumstances indicating the use of wine.
I have employed bottled stout with benefit. It
is an excellent vehicle for the carbonate of soda or
of potash, or for small doses of the hydro-chlorates,
or for both conjointly, and is most appropriate
to tiie advanced stage of putro-adynamic fever.
Spruce beer, ginger beer, and Seltzer water,
may severally be employed, and in a similar
manner. Brandy ought to be much diluted,
and is best suited to those who have been habi-
tuated to spirituous liquors. In cases attended
by a protracted or colliquative diarrhoea, and ex-
treme prostration, the brandy should be burnt,
and given in some thin sago or arrow root.

607. Yenst has been frequently recommended
in typhoid fevers. Dr. Stokf.ii considers, that it
may be given in all the stages in which it can be
retained by the stomach, even when the existence
of inflammatory complications prevents the use
of other stimulants ; and that it is generally easily
taken alone, or with any other niediciae, or in
any vehicle that may be deemed advisable. In
the worst forms of typhus, when it is most needed,
he states that it is rarely rejected, but, on the
contrary, is much relished ; and that it is mode-
rately laxative, often superseding the use of purg-
atives. If it prove not sufficiently aperient, he
gives a little tincture of jalap in it ; and if the
bowels are too much relaxed, a few drops of
tincture of opium are added to each dose. It
appears to Dr. Stoker to correct the morbid
contents of the alimentary canal, and the con-
sequent symptoms of putrescence ; petechia and
black tongue being more effectually removed by
it than by any other means. He has, therefore,
substituted it for bark and wine, when they could
not be employed on account of inflammatory
symptoms, and has conjoined it with them when
there was no such counter-indication. He pre-
scribes the yeast in doses of two table-spoonfuls
every third hour, with an equal quantity of cam-
phor mixture. If administered in enemata, three
times the above dose may be employed. Dr.
Stokeh, whose experience of this treatment has
been long and most extensive, observes, that in-
stead of increasing the tendency to tympanitic
distension, by promoting fermentation, as may be
objected, it actually prevents the accession of this
symptom ; and that, in the most obstinate instances
of typhoid tympany, he has found enemata of
y east and assafoetida"^the most efficacious remedies.

Ceutain Medicines in. 1037

COS. Other stimulants require little attention.
Musk has been recommended by the I'hanks, Ge-
UEf., Gmelin, RIarcus, Honx, SroKEn, and others
in cases of true adynamia — of extreme prostration,
witii much affection of the sensorium. It may be
prescribed in the same circumstances as admit of
the use of wine. Thomann, however, found it quite
inefficacious. It should be given in large doses fo
be of any service — from ten to fifteen grains, with
camphor or ammonia, or other medicines which
the peculiarities of the case will suggest. Phos-
phorus and phosphoric acid have likewise been
employed. They do not appear to possess any
claims to particular notice ; but may be injurious
if loo liberally or inappropriately administered.
I have seen benefit derived from the infusion of
green tea, when the stupor or coma has been
great ; and I believe that strong coffee has some-
times proved useful in similar stales. It has been
recommended by Za.mbelli and Grixdel. The
warm spices, especially capsicum, are often of
service, and may be given in considerable doses
iu the latter stages of typhoid fevers, but chiefly
as adjuvants or corrigents of other remedies. The
spirits (if turpentine are frequently productive of be-
nefit, when prescribed insmall doses, witharomatics
or spices ; but a large dose may be attended by
very serious consequences, when exhaustion is ex-
treme. It is an excellent medicine in enemata,
with castor oil, chloride of sodium, or other purga-
tives when the bowels require to be opened ; and
with assafffitida, or extract of rue, when there is
much tympanitic distension. Substances of a
similar kind, or the usual carminatives, have been
directed in enemata by Thomann and IIufe-
LAND,din order to remove this symptom ; but the
injection just recommended is the most certain in
its effects. The means noticed above (§ 158.)
may also be resorted to. When there is hemor-
rhage from the bowels, these are generally effica-
cious. If they fail, a solution of the acetate
of lead, in pyroligneous acid with the addition
of kreosote, may be thrown up in any vehicle
which the peculiarities of the case may require.

609. Many practitioners are averse from giv-
ing stimulants or tonics in typhoid fevers, from a
fear of thereby aggravating or inducing inflam-
matory determinations. But even where the
nervous inflammations noticed above (§ 495.) mav
be presumed to exist, and particularly in an ad-
vanced period of these complications, a judicious
use of stimulants is actually necessary. It is a
well known fact, and well expressed by Dr. W.
Stoker, that, at a certain period of inflammatory
affections, stimulants become antiphlogistics : and
this is more especially the case in respect of these
affections, when they occur in the course of fevers.
The nervous energy is then depressed, irritability
is most remarkably impaired, the fluids changed,
and the whole constitution incapable of manifest-
ing the phenomena, or of developing the lesions,
constituting true or sthenic inflammation and its
consequences. A spurious or asthenic state of
action only, quickly passing into disorganisation,
can possibly take place in these circumstances ; and
it can be remedied solely by stimulating and an-
tiseptic means. These facts are frequently placed
before our senses, and demonstrated by the treat-
ment found most beneficial, as well by that most
injurious, in malignant sore throat.

1038

FEVER, TYPHOID— Certain Medicines in.

610. I, Various external means have been sug-
gested for typhoid fevers. Some of the most ser-
vicecble of them have already been noticed. The
cold affusion over the general surface is very
rarely admissible in this class of fevers ; but ap-
plied to the head only, it is often of manifest ser-
vice, when the determination to the encephalon
in the early stage of excitement is great, or when
the delirium is high or maniacal, or attended by
increased heat of the scalp, and excited action of
the carotids. In these cases it lowers morbid
action remarkably, and procures sleep. Tepid
bathing and sponging are favourably noticed
by BnocKLESBURY, Wolff, Jackson, Halle,
Brandis, and others. Tepid or warm sponging
with a solution of the chlorides, or of the nitro-
hydro -chloric acids, or of camplior in pyrolig-
neous acid, are deserving of general adoption.
Tepid or warm aromatic baths, or sponging the sur-
face with infusions or decoctions of aromatic plants,
have been employed by Marcus, Horn, Harles,
and DupiN. Kerksig advises warm aromatic
embrocations to be placed over the abdomen,
when there is diarrhoea or meteorismus. — The
use of blisters has been sufficiently noticed.
They may be applied over, or near, the affected
organ, when the affection consists chiefly of con-
gestion, or impaired action. In other circum-
stances, they may be used as derivatives. This
remark is applicable to the use of sinapisms, and
to the warm turpentine embrocation. Callisen
recommended boiling water to be used as a blister
and derivative ; and the idea has been adopted
by some recent writers. One of the most bene-
ficial external means that can be employed, is a
liniment, consisting of the compound camphor
liniment, with soap and Cayenne. This may be
rubbed gently but assiduously over the hypo-
chondria, or insides of the thighs, twice or thrice
daily. 1 have occasionally resorted to this treat-
ment, for upwards of twenty years, and often
with great benefit. Several of the liniinents pre-
scribed in the Appendix may be used ; but the
Cayenne should be added, particularly when
sensibility and consciousness are impaired. —
Dry cupping may also be tried as a derivative,
during the early or middle stages of the disease. In
the putro-adynamic state it is seldom admissible.

611. iv. As to the Prophylactic Measures that
may be resorted to in typlioid fevers, it is unne-
cessary to add any thing to what is stated above
(§ 117. et seq.y, and in the article iNrEcxiox.
I'he means there recommended are quite appli-
cable to these diseases.

612. v. The Diet and Regimen in typlioid fe-
vers are particularly deserving of attention. Both
ought to be suited to the stage and form of the
disease. — a. In the early period of excitement, the
air should be pure, dry, cool, and without any
current. Tlie apartment should be large and
open, the bed without curtains, and the air re-
newed, without exposing tiie patient to any chill.
Barley water, fresh whey, rice gruel, or common
gruel, with a little salt, when the excitemcut is
low, or when thirst is not mucii complained of,
may be employed as the usual beverage. The
temperature of the drink, and of other ingesta,
should be tepid or somewhat above it. If bron-
chial or catarrhal symptoms arc present, warm,
mucilaginous, and mild diaphoretic drinks should
be allowed. Jt is improper in this stage to at-

tempt to excite perspiration by warm coverings.
If stupor is present in this stage, the external
senses may be stimulated, and neither light nor
noise need be excluded.

613. b. In the nervous stage, the air of the
apartment should not be too cool ; and the bed-
clothes ought to be warmer. An uniform tem-
perature, and the purification of the atmosphere,
must be always attended to. A cold, moist air,
and currents of air, during this stage, induce
diarrhoea, bronchial or pulmonary congestions,
or other dangerous complications ; whilst a too
warm, close, and impure air, particularly when
breathed by a number of persons, favours the
development of putro-adynamic changes. The
greatest cleanliness is requisite. Neglect of
this produces gangrenous sores and ulcers, par-
ticularly where pressure is made, or slight bruises
have been inflicted. The tongue should be
scraped, and the teeth and mouth washed with
salt and water, or gargled with them or with the
chlorides, if the patient can do so. Tiie hair may
be cut off in the early stage ; but the removal
of it in this may be injurious, if the adynamia is
extreme, and the scalp cool at the time.

614. In the nervous stage, bland, very digesti-
ble, and fluid nourishment may be allowed. Tiie
drinks should be mucilaginous, and gently warm.
Whatever food or drink is used, whether gruel,
thin arrow-root, &c., or weak animal soups,
broths, beef tea, &c., should contain the usual
quantity of salt, for the reasons stated above
(§593.). If the treatment by the chlorides, &c.
is adopted, this becomes a matter of less import-
ance. Fruit tends to produce diarrhoea, and is
seldom admissible. Wine, as advised above, is
generally required, particularly when this stage
passes into extreme prostration ; and may be
given in the nourishment adopted, or in soda
water. Seltzer water, &c., diluted with warm
water, or with tepid fresh whey. If brandy be
used, it may be given in the same vehicles, or in
weak black tea, in a state of much dilution. In
the true typhus, stimulating the external senses is
more necessary in this stage than previously ; and
it is often beneficial, as Hildenbrand and Nau-
MANN advise, to rouse the patient's moral senti-
ments and affections, and to disperse his fugitive
and chaotic ideas, by recalling former associ-
ations and objects of affection or of ambition. In
extreme cases, however, tiie physical powers
should be excited at the same time as the moral ;
otherwise the latter will be appealed to in vain.
In a case of putro-adynamic fever, in which I
took great interest, these united means proved
successful in rallying the energies of life, under
peculiarly unfavourable circumstances. During
an expected crisis, a greater warmth of the bed-
clothes is proper, and warm whey or other appro-
priate fluids should be given to encourage salutary
evacuations (§ 167.).

615. c. During the abatement of the disease, the
importance of diet and regimen increases, as
treatment by medicine is now gradually aban-
doned. Nourishing food of easy digestion, taken
in small cjuantities ; pure air, and wine in some
cases, are generally required ; but these should
be strictly prescribed as to kind, quantity, and
frequency, according to the peculiarities of tiic
case. As convalescence becomes established, the
animal broths and soups may be succeeded by a

* FEVER, TYPHOID

little solid animal food, of tlie lightest kiad. The
dangers to be appreliended during recovery have
been fully stated above (§ 168)., their causes
assigned, and the means of preventing- them
pointed out (§ 169.). Little further is, tlierefore,
now required. But it will be most useful to re-
collect, that the management of convalescence
should have some reference to the particular form
and complication of the disease. In the exan-
thematic typhus, the danger of consecutive disor-
der is the least, particularly if it have run its
course regularly and terminated by crisis. After
low, nervous, and piitro-adynamic fevers, aflec-
tions of the brain, liver, bowels, lungs, and me-
senteric glands, are not unusual, particularly
when tlie patient has been prematurely exposed
to changes of weather, to irregularities of diet,
&c., and when the treatment has been injudicious,
during early convalescence, or too soon relin-
quished. In all the varieties, the risk of these affec-
tions is increased by the complications which the
fever presented ; the organ which was prominently
deranged remaining longer weak, or more suscepti-
ble than others of being disordered by excitation
or by injurious agents. Therefore, incases where
the predominant' disorder has been expressed on
tlie encephalon, particular care should be taken
to preserve the sensorial functions from early ex-
citement or irritation, or undue exercise. Where
the respiratory organs have been much affected,
premature exposure to cold, or to changes of tem-
perature, &c. ought to be guarded against ; and
where the digestive organs have manifested the
onus of morbid action, the return to a full or
stimulating diet should be long delayed, and the
most digestible food only ougiit to be taken, and
in moderate quantity. (See further on this sub-
ject, § 167 — 170. ; and art. Debility, § 36 — 46.)

I BiBLioG. AND Refer. — Hippocrates, De Blorbis, 1. i.
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la FiC'vre des Hopitaux, Krc. 8vo. Paris, 1811. — Nysten,
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I'aris, 1812, p. 137. — G. L. Wedeiiiajer, Comment, de
Febri Petechi.ali. Giit. W\2. — Zamhelli, De Vi Febri-
fuga; Faba; Arab, sen Coffea;, fie. 8vo. \'i(n. Isl 1. — A'.
Accrbi, Dottrina Teorico-pratlea del Morbo Petecchiale,

8vo. Mitano 1811 //. A. Goeden, Ueber d. Natur u.

Itehandlung des Typhus. Berl. ISU.- /■*. Kulbany, Be-
merk. ii. d. Ansteckenden Typhus, der im J. 1809, 1810,
In Presburg herrschte. Presb. 1811 — G. Rasori, Storia
della Febbre Petechialc di Genova, 8vo. Mihino, 1812.

— /'. A'. Ilartmiinn, Theorie <1 Ansteckend. Typhus u.
Beincr Uiliandlung. Wien. 1812. — Frank, Acta Insti-
tut. Clin. Viln. Ann. ii. 11.28. ;et Interp. Cliu. vol.i. j).222.

— C. Roux, Traite des Fievres Adynamiques. Paris,

1813. — MarcussM Roscklauh, Ueberden Typhus. Bamb.

1814. — E. Horn, Erfahr. ueber die Heil. d. Ansteck. Ner-
venfieb. Sec. 8vo. Berl. 1814. — J. Bischojf; Beobacht.

neb. d. Typhus u. d. Nervenfieber, &c. Prag. 1814

J. F. Ackermann, V. D. Natur. d. Ansteck. Typhus, u. d.
Methode die Krankh. Heidi. 1814. — t\ 1'.. Hufeland,

Ueber die Kriegspest alter u. neuer Zeit. Berl. 1814

G. IVedeynieyer, Ueber d. Erkenntn. u. Beliandl. d. Ty-
phus in sein Regul. u. Anomal. Verlaufe. Ilalbers. 1814.

— A'. /•'. Becker, Ueber d. Erkenntn. u. Heil. d. Petechial-
fiebcr. Gcitt. 1814. — G. JUrg, D. Nervenfieber im J.
181.3, cS.c. Leips. 1814. — G. A. Richter, Med. Gesch. d.
Belagerung u. Einnahme d..Pest. Torgau u. Beschreib.
d. Epidemic, welche daselbst in d. J. 1813, &c. Berl.

1814 Stcinheim, Ueber d. Ansteck. Typhus im J. 1814,

in Altona. Altona, 1825. — J. V. von Hildenbrand, Ueber

den Ansteckenden Typhus, &c. Wien. 1825 R. Calvert,

Reflexions on Fever, 8vo. Lond. 1815 W. Stoker, A

Treatise on Fever, 8vo. Lond. 1815 H. A. Goeden,

Geschiehte des Ansteck. Typhus in Vier Buchern. Bresl.

1816 Bompard, Descript. de la Fievre Adynamique,

8vo. Paris, 1815. — J. //. Hernandez, Essai sur le Typhus,
&c. 8vo. Paris, \>i\G. — D. J. Dickson, in Lond. Med.
and Phys. Journ. vol. xxii. p. 99., vol. xxviii. p. 446.,

vol. XXXV. p. 490., et vol. xxxvi. p. 130 JF. Kidd, in

Edin. Med. and Surg. Journ. vol. xiv. p. 144 A. Duncan,

in Ibid. vol. vii. p. 431., et vol. xiv. p. 529 G. Tom-

masini, Delle Febbri Contag. e delle Epid. Constituzioni.
liologn. 1817. — J. Armstrong, Practical Illustrations of
Typhus and other Febrile Dis. Lond. 1817. — Douche,
Hist, d'une Fievre Nerveuse, Putride, &c. 8vo. Strasb.
1819. — V. Ab. Hildenbrand, Institut. Pract. Medic, t. iv.

— E. Percival, Practical Observat. on the Treatm. Pa-
thol, and Prevent, of Typhus Fever. Lond. 1819 F.

Barker and T. Cheijne, An Account of the Rise, Progress,
and Decline of the Fever lately Epidemical in Ireland.
Lond. 1821. 2-vo\s. —J. Frank, Prax. Med. Univers^-e
Prfecepta, &c. part. i. vol. ii. (2d ed.) passim. — Chomel,
Nouveau Journ. de Med. t. iii. p. 284. (Lcesio nulla post
mortem.) — Dechenaiix, in Ibid. t. iii. p. 329. {Liesiones
primarum viarum.) — J'an der Keer, in Journ. Univers.
des Sc. Med. t. xxxi. p. 129. 257., t. xxxii. p. 5. (Licsiones
infeb. adyn.) — Barbier, Reflexions sur les Fievres, 8vo.
Paris, 1821. — Raikem et Bianchi, Nouveau Journ. de

Med. t. iii. p. 344. — Recamier, in Rev. Med. t. i. p. 192

,/. Armstrong, in Med. Intelligencer, Slay, 1822. — F. J. /'.
Broussais, Examen des Doctrines Medicales, &c. (3d
ed. 3 tomes, 1825.) Paris, 1826. — G. Cerri, Osservazioni

intornoal Morbo Petecchiali. Milano,8vo. 1817 L. Porta,

Mem. sulfa Pecchia. Lodi, 1817. — T. Bateman, A suc-
cinct Account of the Contagious Fever, &c. 8vo. Lond.
1818 J. Yule, Observat. on the Contag. Fever preva-
lent in Edin. 8vo. Edin. 1818. — D. Rotondo, Rapporto
sulla Febbre Petechiale dell' Anno 1817, 8vo. Nap. 1818.

— E. Hale, History of the Epid. Spotted Fever in 1814,
8vo. Boston, 1818. — R. Graham, Practical Observations
on Continued Fever, 8vo. Glasg. 1818 — fl'. Brown, At-
tempt to estimate the Power of Medicine in controlling
Fever, 8vo. ed. 1818. — F. Buffa, Fatti ed Osservazioni
sulla Febbre Epid. Petecchiali, 8vo. Firenz. 1819. —

— S. Lassis, Recherches sur les Causes des Maladies
Epid. appellees Typhus, 8vo. Paris, 1819. — //. Clutter-
back, Observat. on the Prevent, and Treat, of the Epi-
demic Fever, 8vo. Lond. 1819 J. Crampton, Med.

Report of the Fever Department in Steevens's Hospital,
8vo. Dubl. 1819. — n'. 0. Porter, Remarkson the Causes,
X:c. of the Epidemic commonly called Typhus Fever, 8vo.
London, 1819 A. Rossi, Brevi I>umi sul Tifo Conta-
gioso, 8vo. Vicenza, 1819. — D.J. H. Dickso7i, Observat.
on the Prevalence of Fever, and on the eminent Utility of
Houses of Recovery, 8vo. Bristol, 1819. — E. Percival,
Practical Observat. on the Treatment, itc. of Typhus
Fever, 8vo. London, 1819. — D. G. Palloni, Comment.
sul Morbo Petecchiale dell' Anno 1817, 8vo. Livorno,
1819. — .B. Welsh, On the Efficacy of Bloodletting in the
Epid. Fever of Edin. 8vo. Edin. 1819. — G. Tasca, Pato-
logia Nosologica sulla Febbre Petecchiale, Svo. Nap.

18)9 .7. ('. i'richard. History of the Epidemic Fever of

Bristol, 8vo. Lond. 1820. — G. AV))-, Memoir concerning
the Typhus of Aberdeen, in 1818— lit, 8vo. Aberd. 1820.

— jr. llarly. Ilistor. Sketcli of the I^pid. Fever of Ire-
land during 1817—19, 8vo. Dubl. 1820. — ,4. F. Chomel,
De I'Existence des FiOvres, 8vo. Paris, 1820; et Des

Fievres et dos Mai. Pestilentielles, 8vo. Paris, 1820

//«/«<7^(«;, Trans, of Alcd.Cliirurg. Soc. of Edin. vol.i. p.29fi.
fOffiiir ill pro/iiigatiitgjei'er.) — //. Omodei, Del Gov<'rno
Polito-medico del Morbo Petecchiale, con un Prospetto
Compar. della Febbre Petecchiale, die ha regnato l^pid.
nella Lombardia nel 1817, 1818, 8vo. Mailand, 1822.—
Proudfonl, in Edin. Med. and Surg. Journ. vol. xviii.

p. ,374 Graham, in Ibid. vol. xiv. p. 534 Holmes, in

Ibid. vol. xiv. p. .534 Hunter, in Ibid. vol. xv. p. 234.,

vol. xvi. p. 313.— //. Edmonston, in Ibid. vol. xiv., and

vol. xix. p. 226 F. E. Accrbi, Dottrina Teorico-pratica

del Morbo Petecchiale, A;c. Mail. 1822. — Bring, Prin-
ciples of Pathology, p. 104. — y. Ii. I'ark, The Pathology

FIBROUS TISSUE — Morbid States of.

1041

of Fever, Svo. Lond. 1822. — (7. Andral, Cliniquc Meili-
cale (t. i. Fieui-cs), Svo. Paris, 1823.— J. J5. Monfalcon,
Essai stir les Fi^vres Adyn.imiqufS et Ataxiques, 8vo.
I, yon. 1823. — N. Smit/i, A Practical Kssay on Typhus

I'ever. New York, 1824 /•'. E. Fodere, Lei^ons sur les

I'.pidemios, t. iii. p. 370. et seq., et t. iv. p. 100. ct scq. —
Oianam, Hist. Med. des Maladies Epideraiques, t. iv.

)). \hh. et scq J. Black, A Comi)ar. View of the more

Intimate Nature of Fever, .S:c. Svo. Lond. 1826 Brc-

tunncait, De la Dothinenterite. Paris, 182.5. — Trousseau,
Archives Gener. de Med. t. x. p. 07. 169. ; et Rigot, Ibid.

t. xii. et t. xiii G. Bakker, Epid. qua; An. 1820 Ur-

bem Groningara adflixit, in brevi Conspectu posita.
(ironing. 1826. — Sandwil/t, On the Fever Epid. at Brid-
lington, 1818-19, and Lond. 1820, in Jo/mson's Med. and
t hir. Rev. vol.ii. p. 203. ; Med.-Chirurg. Kev. July, 1819,
p. 58.; Ibid. vol. i. p. 39. — Grattan and Crampton, in

Trans, of Irish CoU.^of Phys. vol. i. p. 433 Percival, in

Ibid, vol.i. p. 243. — H. Marsh, in Dubl. Hosp. Reports,
vol. iv. p. 454. — Fixeau, Rev. Med. t. i. 1824, p. 185. ( The
epid. of Paris in 1823.) — Neumann, Journ. des Progres
des Sc. Med. t. v. p. 111. (Of ulceration of the intest. in
typhoid fever.) — Vacquie, Revue Med. t. iv. 1825,p.475. ;
et Journ. Comp. des Sc. Med. for July, Aug. and Nov.
1825. (Of lesions of abdont. viscera in putrid fevers.) —
Leuret, Sur le Dothinenterite Epidemique, in Archives
Genir. de Med. t. xviii. p. 101. 453. — it. Gcndron, in
Ibid. t. XX. p. 127. 285. 361.590. — Mayor, in Ibid. t. xix.

p. Oil Arch, in Ibid. vol. i. p. 137 Brctonneau, in

ibid. t. xxi. p. 57 Louis, in Journ. Hebdom. de Med.

t. i. p. 578. — Lobstein, Repert. Gener. d'Anat. et Phys.

t. ii. p. 342 Rasori, Rev. of his Work in Med. and

Pliys. Journ. vol. xliii. p. 08. 155. — Onwdei, his Work

rev. in Journ. Univers. des Sc. Med. t. xxiii. p. 09.

Tommasini, in Archives Gen. de Med. t. vi. p. 126. ; and
Med. Gazette, vol, v. p. 520. — J. Burne, A Practical
Treatise on the Tj'phus or Adynamic Fever, Svo. Lond.
1828. — F. A. Popkeu, Hist. Epid. Malig. Anno 1820 Fe-
veriB ObservatJB. Brem. 1827. — Alison, in Lancet, No.
337. p. V>5y). — Bayle, Revue Med. t.ii. 1820, p. 89. (Putro-
adynamic fever— experiments with the blood.) — M. Good,

Study of Medicine, by Cooper, vol. ii. passim Bright,

Reports of Medical Cases, &c. 4to. Lond. 1827, p. 178. et

passim Jf. Stoker, Pathol. Observat. parts i. ii. and iii.

On Continued Pever, &c. Svo. Dubl. 1829-30. — /".T. -J.
Louis, Recherclies sur la Maladie connue sous les Noms
de Gastro-enterite, Fievre Putride, Typhoide, &c. 2 torn.

Svo. Paris, 1829 S.Smith, Treatise on Fever, Svo.

London, 1830. — ^. Tweedie, Clinical Illust. of Fever,
Svo. 1830. ; and Cyclop, of Pract. Med. vol. ii. art. Fever.

— M. E. A. Naumann, Handb. der Mcdicinischen Cli.
nique, b. iii. Abth. i. passim. — JV. Stevens, Obscrv. on
the Healthy and Dis. Prop, of the Blood, Svo. Lond. 1832,
p. 103.^^//4on, in Ed. Med. and Surg. Journ. vol. xxviii.
p. 237. ; and Outlines of Pathology, Svo. Ed. 1834, p. 205.
et passim. — R. Millar, Lectures on the Contagious Ty-
phus Epid. in Glasgow, &c. in the Years 1831 and 1832,
Svo. Glasg. 1833. — Elliotson, in Medical Gazette, vol. x.

p. 145. ; and in Lancet, vol. xvii. p. 206. 463 iV. P.

Detvees, Practice of Physic, Svo. Philad. vol. i — Craigie,
Clinical Reports on Fever, Edin. Med. and Surg. Journ.

vol. xl. p. 257 Law, On the Use of Wine in Fevers,

ibid. vol. xxxiii. p. 82. — R. Graves, Lectures, in Med. and

Surg. Journ. vol. iii. iv. vi. and vii. passim F. Boott,

Memoir of the Life and Medical Opinions of J. Arm-
strong, and an Inquiry into the Facts connected with
the Forms of Fever attributed to Malaria, &c. Svo. 2 vols.
Lond. 1833-34. — A. F. Chomel, Lemons de Clinique Mi-
dicale, &c. par Genest, Fievre Typhoide, Svo. Paris, 1834.

— IV. Stokes, in Lond. Med. and Surg. Journ. vol. vi. et vii.

passim R. Graves, in Ibid. vol. vi. et \ii. passim; and in

Dublin Journ. of Med. and Chem. Science, vol. viii. p. 136.

— J. H. Peebles, On Petechial Fevers and Petechial Erup-
tions, Edin. Med. and Surg. Journ. vol. xliv. p. 356 //.

M'Cormac, An Exposition of the Nature, Treatment, and
Prevention of Continued Fever, Svo. Lond. 1835.

Fever, Puerperal ; see Puerperal Diseases.
Fever, Scarlet; see Scarlatina.
Fever, Yellow; see Pestilences,
FIBROUS TISSUE — Alterations of the.
Classif. — Special Pathology — Morbid
Structitres.
l.i. Of the Fibrous Syste.m generally. —
A. The Fibrous System consists — 1st, 0( Jibrous
membranes — membraniz JibroscB — as the perios-
teum, the cerebral and spinal dura mater, the
fibrous capsules, the sheaths of tendons, apo-
neurotic expansions, the sclerotica, the capsule
of the corpora cavernosa penis and of the cli-
toris, &c., the tunica albuginea, and the mem-
branes proper to the spleen and kidneys ; — 2dly,

0( fihnnts cords in whicii tlie fibres are formed
into fasciculi — organa Jibrosa fascicularia. —
Several of the former should be viewed as com-
pound structures; as the dura mater, the tunica
albuginea, the fibro-synovial sheaths, &c. ; but
the hbrous tissue constitutes their chief basis.
With the exception of the fibrous membranes of
a few glandular organs, it is easy to demonstrate
that all the fibrous structures are connected to-
gether, and that the periosteum is the centre and
basis of connection. This tissue consists of
whitish, or greyish, shining, satiny, fibres of
great fineness and strength. These are inter-
woven in various directions, in the first division
of this tissue; and are placed parallel and very
close to each other, in the second. Their cohe-
sion is very great. Hence the fibrous tissue is the
strongest in the body. Although it must be
inferred to possess vessels and nerves, yet neither
have been actually traced into it. That it is
endowed with vital properties cannot be de-
nied; but it manifests them obscurely in health,
but often very remarkably in the course, or as a
consequence, of certain diseases. Its physical
properties are most perfect when the powers of
life are energetic, and are much impaired when
these are depressed or exhausted. During pro-
longed debility, and in cases of extreme vital ex-
haustion, the cohesion of this tissue is diminished,
and laceration or extension of it fakes place with
less violence. During constitutional disorder, or
contamination of the system by specific maladies,
and in the scrofulous or gouty diathesis, it often
becomes the seat of morbid action, and then
evinces vital properties in a most evident
manner. Injuries and irritations of this tissue,
particularly when the vital functions are impaired
or disordered, are often the source of the most
violent and dangerous affections. — The fibrous
tissue, however, is, with the exception of the peri-
osteum and the capsules of joints, not very prone
to disease ; and, even when these are aflfected, a
scrofulous or syphilitic taint has been the cause.

2, B. Leaving out of consideration the con-
genital alterations of this tissue, I will briefly
notice those changes of it which are usually the
result of disease. — a. Fibrous parts are seldom
thinner than natural,, or atrophied. — b. Thickening
is much more frequent, and is evidently the result
of slow inflammatory action. — c. They may
also be expanded or distended by morbidly in-
creased bulk of the organs which they envelope.
We occasionally meet with this change in the
fibrous coverings of the spleen, kidneys, articular
capsules, dec. When the expansion arises from
the accumulation of fluid, it is generally attended
with thinning ; and then, in some cases, the dis-
tension is chiefly in one part only, in the form of
a sac, or is irregularly elongated. But the ex-
pansion may also be conjoined with thickening,
as when it has proceeded from the changes con-
sequent upon an inflammatory state of the con-
tained parts in which the fibrous envelope itself
had participated, as in diseases of the spleen, &ce.
— (/. The articular ligaments and capsules, how-
ever, are frequently elongated and expanded
without any internal change, and merely from
diminished tone or vital cohesion — in some cases
so much so, as to give rise to dislocations. — e.
Fibrous parts may be also ioo short or too narrow.
Morbid contractions are observed in tendons and
3X

1042

FIBROUS TISSUE — Morbid States of.

ligaments, and are generally the result of inflam-
matory irritation consequent upon great extension,
cramp, &c. — f. The changes of colour met with
in this structure are generally associated with
change of organisation, excepting in jaundice.
The morbid colours most frequently observed, are
various shades of yellow, seldom brown, and
rarely black, as in melanosis.

3. C. The continuity of this structure is some-
limes destroyed ; but generally from wounds,
sudden extension, as in dislocations, and external
violence of any kind. Continuity may likewise
be destroyed by purulent collections, by tumours,
and various morbid depositions between its fibres ;
but there is here, with a few exceptions, rather
an expansion of the structure than actual breach
of continuity. Incised wounds of this tissue heal
in general with tolerable ease, in a healthy state
of the system. But this is by no means the case
when the habit or constitution is in fault, or when
there is obvious disorder of the stomach and liver ;
and the difficulty is still further increased if the
injury is attended with loss of substance, or when
the tissue is lacerated. In these latter, the con-
tinuity of structure is in some measure supplied
with cellular tissue, which becomes very dense by
degrees, but never altogether tendinous. Hence
the disposition to rupture or dislocation that ex-
ists so long, and indeed ever after such acci-
dents. The chief exception to this is presented
by the periosteum on some occasions, where it
seems to have been quickly restored,

4, D. The teiture of fibrous parts is changed
generally by infiammation and its effects. But
this disease is not frequent in fibrous structures,
excepting the periosteum, the articular ligaments
and capsules, and tlie dura mater. — In all these
parts, however, it more frequently follows ex-
ternal injuries, than arises spontaneously. When
it is spontaneous, it is almost always merely
a concomitant of other diseases of a constitu-
tional kind, such as scrofula, syphilis, gout, and
rheumatism. The inflammation of this struc-
ture is rarely of an acute kind, excepting in some
forms of gout and rheumatism ; and in these the
inflammatory state is consequent upon, and sub-
ordinate to, a morbid condition of the organic
nerves, rather than identical with that which is
caused by external injuries, or which assumes
the phlogistic character. These specific forms
neither pass through the same phases, nor termi-
nate, as common phlogosis. The inflammation,
also, proceeding from the scrofulous and syphilitic
taint possesses the characteristic features of those
specific diseases.

5. a. The course of inflammation is much
more fre<juently slow ; and often the phenomena
are so indistinct, as to be overlooked. The
changes thereby induced are generally co-ordinate
with the activity and degree of the inflammatory
action. Redness, in various degrees of depth,
and attended with different states of vascular
injection, is usually present. In some cases,
there is a diffused rose-red, especially when the
inflamed tissue has access to the air. In others,
more or less large and numerous red spots or irre-
gular streaks are observed. In many, the inflamed
j)art has a more or less yellowish colour ; and if it
be naturally glistening, this appearance is entirely
lost. Afier chronic, or often-repeated attacks of,
inflammation, other discolourations are sometimes

remarked — the parts being either dark grey,
brownish, livid, or even blackish.

6. b. Swelling is seldom remarkable in inflamed
fibrous structures. But if the inflammation con-
tinue long, or if it recur frequently without com-
plete resolution, fibrous organs, or the cellular
tissue surrounding fibrous structures, are gene-
rally greatly swollen, and their boundaries indis-
tinct, wiih a gelatinous fluid infiltrated into the
adjoining texture, giving it a reddish, soft, and
oedematous appearance. When the intensity of
the inflammation is very high, it runs tediously
into suppuration ; the swelling and oedematous
infiltration of the adjoining cellular substance at
first increases, whilst the fibrous tissue wastes,
the effused fluid, at various points, afterwards as-
sumes a puriform appearance, increases, is con-
centrated, and at last more or less destroys this
structure, the swelling at the circumference of
the part becoming somewhat diminished.

7, E. Ossijication is frequently observed in
the fibrous structure, particularly in the ligaments
and dura mater, and less frequently in the peri-
osteum, the tendons, the fibrous membrane of the
spleen ; and but rarely in the other parts of this
system. It is to be viewed as a consequence ge-
nerally of slow inflammation, and occurs in differ-
ent forms : as in some cases only the fibro-carti-
laginous base of bone is deposited in plates or
roundish flat prominences ; more frequently phos-
phate of lime is secreted either in distinct spots or
small masses surrounded by a circle or plexus of
vessels, or in the form of splinters, or, lastly, in
larger masses, involving the fibrous tisssue equally
throughout. If tiie articular ligaments undergo
this change, they are then usually shortened,
occasioning stiffness of the joint, or more or less
complete anchylosis, according to the extent of
the ossification. An earthy mass, less resembling
bone than chalk or gypsum, consisting principally
of the urate of soda — gout tophus, — is often de-
posited in the ligaments, in the neighbouring apo-
neurosis, and periosteum of one or several joints, in
gouty persons, at first in a soft state, but gradu-
ally becoming hard, and often in large quantity, '
9. F. Sphacelation, or gangrene, rarely occurs
as a termination of inflammation. It is met with
primarily in those fibrous parts which are well
supplied with blood-vessels, viz. the periosteum,
dura mater, fibrous envelope of the spleen, &c. In
the tendons, aponeurosis, and articular ligaments,
it very rarely occurs primarily, excepting when
tiiey are exposed to the air by wounds or ulcers, in
which case they often are destroyed and exfoliate,
together with the surface of the bones and carti-
lages. Fibrous structures, however, are often
attacked with mortifications in conjunction with,
or in consequence of, gangrene of the adjoining
parts. Anthrax sometimes extends to and de-
stroys fibrous tissues ; and when mortification
attacks a limb, the articular ligaments participate
so entirely, that a spontaneous separation often
takes place at a joint. Exjoliution of tendons may
occur in whitloe, or during suppuration from punc-
tured or poisoned wounds, as in dissection, 6cc.
I have seen three such instances. Fungus haima-
iodes seated in fibrous parts is not rare.

9. G. Adventitious productions are but rarely
observed in the fibrous system. — a. Encysled
tumours seldom form in it, if we except those
bursal tumours which occur on the tendinous

FIBROUS TISSUE — Morbid States of.

1043

sheaths and articuhir capsules, and partly between
the tendinous fibres of the aponeurosis, and espe-
cially on the elbow-joint and knee-cap, and which
have their origin in the mucous bags placed in
these situations. — b. Tubercular formations are
equally rare in fibrous parts. Scrofulous deposits
are, however, occasionally found in the dura
mater and periosteum. — c. Sarcomatous and
fungous tumours are more frequent in fibrous
structures, particularly in the periosteum. Fun-
gous growths on tiie tendons are more rare, as are
the sarcomatous swellings upon the articular liga-
ments. — d. Carcinoma, or cancer, does not occur
primarily in this system, but attacks it secondarily
equally with other parts.

10. //.The changes observed in the contents o(
cavities formed by fibrous membranes are fre-
quently marked and important. Morbid collec-
tions, as a watery serum, a gelatinous fluid, puri-
form matter, blood, &c., are not infrequently
found in the aponeurotic sheaths surrounding or
separating- the muscles in the cavities of joints.
The si/novia also varies exceedingly ; sometimes
it is deficient in quantity, so much so as to occa-
sion stiffness, creaking or a peculiar noise of the
joint. IMore commonly it is in unusual quantity,
particularly in all inflammatory states of the
synovial membrane, but occasionally without any
distinct inflammation, as in the knee-joint, in
rheumatic, rickety, or syphilitic subjects. Some-
times the effusion exists to such a degree that the
joint is more or less swollen, or even dislocated, or
its use prevented. This local state of disease has
usually been called dropsy of a joint, hydrops
articulorum, hydrarihus meliceria. The synovia is
occasionally turbid, reddish, watery, albuminous,
gelatinous, &c., as well as increased in quantity.

11. J. Substances adventitious to the situation
have occasionally been found in the cavities of
joints. — a. Blood is rarely observed; but — b.
Pus occurs more frequently, it either having been
produced within the joint itself, from an acute
inflammation of the synovial membrane, and of
the bony cartilages and ligaments forming the
joint, or having made its way into the cavity from
without. I have, however, seen cases where pus
has rapidly collected in one or more joints after
phlebitis, or after the absorption of this fluid from
other and distant parts. It has been supposed
that the pus, in such cases, has been secreted or
deposited in the cavity of the joint, as it has
passed into the circulation from the situation
where it was primarily formed, without previous
inflammation of the joint itself. But the presence
of this morbid secretion in the blood may have
excited inflammatory action of the synovial mem-
brane, rapidly passing into the suppurative stage.
In most of such cases, the parts containing the pus
have been found eroded, and have presented other
changes usually consequent upon inflammation,
even when vascular injection has been absent.
The question is, whether such changes have taken
place previously or subsequently to the secretion
of pus in the joint ? That the more advanced of
them are consequent upon the production of this
fluid may be admitted ; but that inflammatory in-
jection and action preceded, and ([uickly produced
the purulent collection, seems most probable.

12. c. Cartilaginous concretions, which havegrown
from the inner or expanded surface of the synovial
membrane, by necked appendages, and been sub-

sequently broken oft^, are occasionally found in
tiie cavities of joints, either entirely loose, or
attached to them by thin threads. They are at
first soft, then mostly cartilaginous, sometimes
partly cartilaginous and bony ; more rarely alto-
gether bone ; usually rounded, but occasionally
flattened or angular; and varying much as to
size and number. Lieutaud has adduced in-
stances of quicksilver having been found in the
cavities of joints ; but such occurrences must
have been rare, and are now never observed.
(See art. Periosteum.)

13. ii. Inflammation of the Fibrous Struc-
ture OF THE Joints may occur primarily in this
part, or extend to it from the lining synovial mem-
brane, which, like other serous membranes, in-
flames readily, and in which the inflammation of
joints most frequently commences. Inflammation
of joints, implicating their fibrous structures, gene-
rally arises from external injuries, from metastasis
of inflammation from other parts, from pus or
morbid secretions absorbed into the circulation,
from syphilis, gout, rheumatism, &c., and occa-
sions reddening, swelling, softening, &c. of the
synovial membrane. If the inflanmration be not
resolved, there is a consequent secretion into the
cavity of the joint, sometimes of a fibrinous lymph
occasioning anchylosis, but more frequently of a
puriform matter, or of a fluid, which, after being
retained there, assumes a puriform character, and
which often softens or erodes the cartilaginous
coverings of the heads of the bones. Frequently,
also, inflammation of joints commences in the fine
membrane lining the cartilages, or in the articular
extremities of the bones themselves. This com-
monly occurs from the scrofulous and syphilitic
taints, and gives rise to the Caries articulorum
centralis vel interna, of Rust. When the disease
originates in the synovial membrane or bones,
the fibrous, fibro-cartilaginous, and even the
bony parts of the joints themselves, are sometimes
co-affected. This is especially the case, when the
causes act violently on the joint, and aftect equally
all the tissues composing it, as after a violent in-
jury, such as a penetrating wound, compound dis-
location, or fracture extending into it. In all such
cases, an acute and progressing general inflam-
mation of the joint takes place, on which anchy-
losis, abscess, or caries, are usually consequent.

14. A. In the scrofulous and rheumatic, how-
ever, a more undecided and chronic state of
inflammation occurs, either spontaneously or from
injuries, occasioning changes in the joints, which,
according to their extent, seat, and symptoms,
have been called 7norbus coxaritis, hip disease,
claudicaiio or lameness, luxatio spontanea or spon-
taneous luxation, fungus articulorum, articular

fungus, white swelling, S^c, However, with all
these names, it is essentially the same disease.
The joint is more or less remarkably swollen,
less moveable than in the healthy state, and
always somewhat bent. The swelling is, at cer-
tain parts, hard, firm, elastic; at other parts,
mor^ doughy, or even obscurely fluctuating. The
integuments, to the last, even when sinuses are
formed, remain unchanged, although sometimes
slightly varicose, with a hardened state of the
subjacent cellular and adipose tissues. The
muscles surrounding the joint often appear pale
and, together with the adjoining cellular sub-
stance, infiltrated with lymph. The articular
3X2

1044 FLATULENCY — Causes.

ligaments are more ov less swollen, of a dull hue,
frequently without any distinct fibres, hardened in
some parts and softened in others, and often con-
solidated with the surrounding cellular structure.
They are also whitish in some patches, and in others
discoloured, generally converted into a mass con-
taining minute cavities filled with lymph, a
gelatinous fluid, or ichorous pus. The internal
articular ligaments, the cartilaginous coverings of
the bones, and the synovial membrane are entirely
or partially destroyed. The bones either prima-
rily or secondarily aflfected are, in a greater or less
deo-ree, inflamed, softened, swollen, and become
internally carious ; or they are but little swollen,
tolerably hard, yet superficially eroded, or de-
stroyed by caries. Owing to this carious state of
the heads of the bones, whether attended with
swelling or not, dislocation takes place. The ar-
ticular cavity contains at first a large quantity of
thickish, albuminous-like, often a pale reddish,
synovia ; and, in later stages of the disease, if the
joint be more or less destroyed by suppuration, a
thin, frequently foul-smelling, pus, mixed with
blood, cartilage, and cartilaginous fragments,fill up
entirely or partially the cavity of the joint ( Otto).

BiBLioG. AND Refer.— i. Alterations of Fibrous

Structures in general Bariholinus, De Diaphrag.

Struct. Nova. Paris, 1676 Morgagni, Ue Sed. et Caus.

Morb. Epist. Ixiii. s. \^.— I'esUngius, Observ. Anatom.

Epist.xv Walter, Mus. Anatom.vol.i.p.l44 — Hoernigk,

in Haller's Disput. Med. Pract. t. vi. p. iii. — Lieutaud,
Hist. Anat. Med. t. ii. xi.m. — BacherachI, De Morbis
Ligamentorum.lT.W.— //uAn, De Rite Cognoscendaet Cu-
randa Systematis Fibrosi InBammatione. Halae, 1826.—
Bauer, in Archives Generates de Med., March and April,
1823. — 5oj/f)-, in Ibid., April, 1823. — 7F«/<f»-, Museum
Anat. vol. i. \i. Mi. — Acrel, Chirurg. Vorfalle, b. ii.

p. 380 Lavernet, Journ. de Med. Contin. vol. ii. p. 248.

— Lloyd, Treatise on Scrofula and its Connection with
Diseases of the Spine, &c. Lend. 1821. — Go/j;, De
Morbis Ligamentorura, &c. Hala?, 1798, p. 32. etseq.—
Wilson, Lectures on the Structure of the Skeleton, &c.
Lond. 1820. — Otlo, Selt. Beobachtungen, h. ii. p. 32.
No. W. — Chomel, Sur le Rheumatisme. Paris, 181.'5. —
Villerme, in Rev. Med. t. v. p. as.—Crui'eil/iier, Essai sur
I'Anat. Path. t. ii. p. 73.— M'Lellan, in Philadelph.
Monthly Journ., &c. Nov. 1827, p. 'AbG. — Hozvs/iip, in
Trans, of Med. and Chir. Soc. vol. viii. p. 9.5. — Delpech,
Chirurg. Clinique de Montpellier, vol. i. pn.<f«/>« — Lee
Fearn, in Med. Recorder, vol. xii. art. \. — Corniih, in
Lond. Med. Repos. vol. xvii. yi. 200— Nees, in Hufeland's
Journ. d. Prak. Heilk. vol. xvi. p. 180.— W. Wallace, in
Transact, of Associat. of Dubl. Phys. vol. v. — Fourcroy
and Vauquelin,in Annal.du Mus. d'Hist. Nat. t. i. p. 93.,
t. ii. p. 201., t. iv. p. 329. — Ehrmann, Compte rendu des
Trav. Anatom. &c. Strasb. 1827, p. 22. — LoJi7fi«, in
Ibid. 1824, p. 16.

ii. Alterations of the Fibrous Tissues op Joints.

, /I, Monro, primus, in Ed. Med. Essays and Observat.

vol. iv. p. 242. — Lieutaud, Histor. Anatom. Medica,

vol. iii. p. 93. Park, On Dis. of Joints. Lond. 1783. —

Curtinann, De Morbis Articulorum, &c. Giess. 1797.—
Enckelmnnn, De Fungo Articulorum, 4to. Arg. 1749 —
Mliller, De Fungo Articulorum. Gott. 1780 — Ford, On
Disease of the Hip Joint, Jic. Lond. \TJi. — Palletla,
Exercit. Pathol, vol. i. p. 30 — 58. ; et De (Maudicatione

Congenita. L. R- 1787 Crowther, On Disease of the

Joints, &c. Lond. 1808 Sprengcl, in Bust's Magazine,

f. d. ges. Heilk. b. ix. part. ii. p. 301. — Nicolai, in Ibid,
b. xxii. part. i. p. 3. — Ford, Observ. on Dis. of the Hip
Joint, &c. 8vo. I,ond. \H{{). — Dupuytren, in Repert.
C.iuer. d'Anatomie Pathol. .Vc. vol. ii. part. iii. p. l.'iO. —
B.C. Brodie, Pathological and Surg. Observat. on Diseases
of Joints, &c. Lond. 1818. _ (iuicst, De Morbis Articu-
lorum. Halae, WM'>. — (iciss, De Morb. Articnlor. &c.

HaliE, 1826 Margot, Archives Generales de Med. May,

1826. — 0«(', Selt. IJeobach. part. ii. p. i'i. — Taaks, De
Hydrope Articulorum, 8vo. Berl. IWlh.—Crnvcilhier , in
Nouv. Hiblioth. Mcdicale, Janv. 1827 — Laennec, in Diet,
lies Sciences Mudicales, t. iv. p. Va. — l). Cruigie, Ele-
ments of Gener. and Patholog. Anat. p. .'■>12. — J. /■'.
Meckel, Man. d'Anatomie (Jent-r. et Patholog. \c. par
.louidan,ikc. t. i. p.383.— //. /K. Otlo, Compend. of Hum.
and Comp. Pathol. Anatomy, by J. F. South, 8vo. Lond.
1831, p. '.^29.

FLATULENCY. — SvN.*v(ra, •I>yo-»).7'7«(no,'.(/as;

Flatus ; Flatulentia ; A'^rijiuxus, Sauvages.

Pneumatosis Ventriculi, et Pn. Enterica, J, P.

Frank. Pneumatosis, Chomel. Limosis Flatus,

Good. Flutuosite, Fr. Die Bl'dhung, Win-

digheit. Germ. Flato, Ital.

Classif. — 1. Class, Disease of the Digestive
Function; L Order, Affecting the Di-
gestive Canal (Good). I. Class, I. Or-
der (Author, in Preface),

1. Defin. — An undue formation and accumu-
lation of air in the stomach or intestines, with fre-
quent rejection of it.

2. It is of some importance to ascertain the
source of the flatus which is often formed so
abundantly in the digestive canal. John Hunter
first supposed that air is sometimes exhaled from
the blood by the vessels of secreting surfaces;
and, if we view merely the results of the experi-
ments of JNI. Edwards upon respiration, and the
absorption and exhalation of various gases, by
the lungs, in connection with the secretion of air
into the swimming-bladder of fishes, this opinion
will appear not ill-founded, even independently
of the support it derives from pathological observ-
ation. In such cases we have reason to infer
that it is not air, as it exists in the surrounding
atmosphere, that is thus exhaled, but its consti-
tuent gases. The experiments performed by MM.
Gerardin, Magendie, and Chevreul have
thrown much light upon the question as to the
source of the gases found in the digestive canal,
as well as upon their composition ; and have
shown, that they are partly exhaled from the di-
gestive mucous surface. — It would appear, from
the researches of these writers, that they consist,
in the stoniavh, of nearly three parts in four of
azote, the fourth part being oxygen and carbonic
acid ; and, in the intestines, of carbonic acid,
azote, carburetted hydrogen, and hydrogen, in
various proportions. It may, therefore, be inferred
that the air which collects in the digestive canal
is derived from three sources: — 1st, From the
common air swallowed with the food ; — 2d. From
the changes or decomposition of the ingesta, and
of the contents of the canal generally ; — and, 3d.
From the occasional exhalation of gaseous fluids
from the mucous surface during certain states of
local and constitutional disorder. The oxygen
found in the stomach, amounting to eleven parts
in a hundred, is most probably derived from the
first of these sources. It is, however, either ab-
sorbed from this situation, or combines with other
substances, as none is found beyond the pylorus.
The azote and carbonic acid may be attributed
partly to the last source ; whilst a portion of bolh,
and the whole of the hydrogen and its compounds,
may be assigned to the second. — The air, which
is generated so rapidly, and eructated so fre-
quently, during acute inflammatory diseases, par-
ticularly in gastritis, hepatitis, &;c., must be ex-
haled from the irritated mucous surface, inasmuch
as there is no other source existing in such cir-
cumstances to which it can be attributed, espe-
cially when the constant vomitings, and frequent
evacuations from the bowels, have left nothing in
the prima tia capable of furnishing the enormous
quantity of air which is often ejected.

3. Flatulency, since the time of Cult.ev, has
been very generally viewed as a symptom of dys-
pepsia and of other diseases. Hut I agree with
•Sauvaces, Good, and several other writers, in con-

FLATULENCY — Causes,

sidering it (o be occasionally a primary disorder.
Whether it be idiopathic or symptomatic, its phe-
nomena, and the disorders consequent upon it, are
different according to the part of tiie alimentary
canal in which the flatus is generated or confined.
I shall, therefore, treat of this affection, Jiist, as
respects the stomach and oesophagus — Flatu-
lentia ventrimli ; and, secondlt/, with reference
to the intestines — Flatulentia Intestiiioruni. But
although it may be seated in either the stomach
or the bowels more particularly, it very frequently
exists in both at the same time.

4. I. Flatulency of the Stomach will be
considered at this place — (a) in respect of its idio-
pathic occurrence ; (6) as a symptom of other dis-
orders ; and (c) with reference to the disturbances
it tends either to induce or to aggravate. — A,
Primary or idiopathic Jiatulency of the stomach is
met with chiefly when the stomach is empty, or
after the process of digestion in this viscus is com-
pleted ; and is seldom associated eitlier with im-
paired appetite, or diminished powers of digestion.
It is most troublesome in the morning before
breakfast, or during long fasting ; or when an
unusually protracted period has elapsed between
meals. In such cases, the flatus often rises into
the oesophagus, producing mucii uneasiness and
often distress, owing to its excretion being pre-
vented by the spasmodic constriction of the upper
part of this tube. In swallowing also the more
solid ingesta, the bolus meets the flatus in the
oesophagus, and is interrupted or impeded in its
passage to the stomach. In such circumstances,
a conflict sometimes arises between the descend-
ing ingesta and the ascending flatus, and a very
painful spasmodic dysphagia is thereby induced,
until the eructation of air gives relief and allows
the transit of the bolus into the stomach. In this
form of the disorder, the air most probably is ex-
hated, at least in great part, from the internal
surface of the organ. In other respects the pa-
tient's health is not deranged, and the functions of
digestion, defa;cation, and assimilation are regu-
larly and perfectly performed. In other instances,
slight defect of organic nervous power, owing to
sextial indulgences, or to sedentary occupations,
is the only pathological state to which this aflec-
tion can be imputed.

5. B. The remote catises of flatulency are the
nervous and hypochondriacal temperaments ; and
all the influences and habits which depress or ex-
haust the energy of tiie organic nervous system,
or lower the tone of the digestive canal, especially
sedentary occupations ; excessive mental exertion
and anxiety ; venereal indulgences ; intemperance
in eating and drinking ; the ingestion of cold fluids,
particularly when the body is overheated; ex-
posure to a cold air, or to cold in any way, whilst
the stomach is empty, or whilst fasting ; neglect
of the functions of the bowels ; tlie use of bulky
or flatulent vegetables, or of fruits prone to un-
dergo fermentation, especially cucumbers, melons,
salads, &c. ; irregularities of diet ; and previous
or existing disease. — Fast eating, and imperfect
ma'jtication, often give rise to flatulency, by the
quantity of air which is generally swallowed on
such occasions, and by the imperfect or slow di-
gestion which usually results.

6. C. Sumplomotic fiatulency of the sUmach
is extremely common. — (a) It is almost a con-
stant attendant upon in^igeition ; — and (/') often

104&

accompanies general debility . -~ (c) It is also
frequent in hypochondriasis and melancholia ; —
and ((/) in the numerous forms of hy>.teria. In this
last, the flatus often rises into the oesophagus ; and
whilst the reaction of the coats of the stomach
propels it into this tube, spasmodic constriction of
the part just below the pharynx confines it for a
time, and causes a distressing feeling of suffoca-
tion, &c. — (e) Flatulency is an almost constant
symptom of injiammatory and organic affections
of the stomach. — (f) It generally ushers in an
attack of gout ; — and (g) it both precedes and at-
tends asthmatic affections. — (h) It is a common
phenomenon of all the functional, inflammatory,
and organic diseases of the lirer ; and is very cha-
racteristic of accumulations of bile in the gall-
ducts and gall-bladder, anAoi torpor of the biliary
organs. — (i) Itoften, also, occurs in thefunctional
and injiammatory disorders of the bouels, and
sometimes in affections of the other abdominal
viscera. — (k) It not infrequently even accom-
panies chronic diseases of the brain; — and (I) the
adynamic and malignant forms of fever,

7. D. The phenomena usually characteristic of
flatulency vary somewhat with the diseases of
which it is a symptom. In the course of diges-
tion, flatus escapes with or without noise, and
often with an acid, bitter, nidorous, or foetid
odour. Sometimes it is without either odour or
taste ; and at other times it retains the smell and
flavour of the ingesta. When constriction of the
cardia, or of the lower part of the oesophagus,
prevents eructations, or when the coats of the
stomach are so weakened, or so over-distended,
as to be incapable of reacting sufliciently, (i/m-
pn?!i«(c fulness of the epigastrium and hypochon-
dria, with a painful sense of distension, or severe
gastrodynia, frequent respiration, and heavy pain
or oppression in the lower parts of the chest, are
generally complained of. If eructations occur,
especially for some hours after a full meal, acrid
or rancid matters, or portions of undigested food,
are frequently regurgitated at the same time, and
impress the palate and pharynx with an acrid and
irritating sensation, or produce an unpleasant,
dry cough, by affecting the epiglottis and larynx.
Cardialgia is then often associated with tiiis sym-
ptom, or precedes the eructations. When flatu-
lence precedes or attends organic lesions of the
stomach, or obstructions of the liver or pancreas,
the symptoms caused by, and associated with, it
are often severe. Disordered action of the heart,
anxiety, hiccup, gastrodynia, &c., being not un-
commonly observed.

8. E, The disorders induced or aggravated by
flatulence of the stomach, are various indifferent
habits and constitutions. When the stomach is
much distended by flatus, and especially when
the oesophagus admits and retains lor a time the
air in its lower part, the feeling of oppression,
dull pain, and the other symptoms just mentioned,
are much increased. I'he actions of the dia-
phragm are impeded, and the regularity of the
circulation through the cavities of the heart is in-
terrupted by the pressure of the over-distended
organs. Hence the intermissions and irregularities
of the pulse, the sense of anxiety, flutterings,
feeling of suflbcation, and palpitations, so often
associated with, or consequent upon, affections of
the digestive organs. Whytt attributes incubus
to flatulence of the stomach, and, I believe, very

3X3

1046

FLATULENCY — OF the Intestines — Causes.

justly. In delicate, nervous, and hysterical
females, various symptomatic disorders, besides
those now stated to arise directly from this cause,
are often experienced. The modes of dress, par-
ticularly the very strait corsets used by this sex,
aggravate the disorders consequent upon flatulent
distension. — Severe pains of the leftside, conges-
tions of the lungs, or of the brain, headachs,
convule^ions, faintness, vertigo, and several ano-
malous complaints, often thus originate, not only
in females, but also in males, especially those
who are sedentary, hypochondriacal, and debili-
tated. In this class of persons more particularly,
the pressure of the distended stomach prevents
the due action of the bowels, and either impedes
or interrupts the passage of ffccal matters from
the ciECum, along the transverse arch of the colon.
— Thus costiveness, and functional disorders
of the caecum and large bowels, are occasioned,
and are often followed, by displacement of parts
of the colon, and by inflammatory and organic
lesions. — It is obvious, that an aggravation of
disorder will be occasioned by flatulence, where
any of these affections already exist.

9. F. Infants are very liable to flatulence, par-
ticularly when their natural food is taken too
greedily, or when it disagrees and becomes acid
on the stomach. In some cases, a portion of
air may be swallowed by sucking ; but, however
occasioned, the eructations that occur are often
accompanied by the regurgitation of a consider-
able portion of the ingesta. Flatulence is, how-
ever, most distressing and injurious when it affects
infants brought up without their natural suste-
nance, or during the period of weaning. In them,
acidity of the prima via, watery diarrhoea, or cos-
tiveness, or both alternately, morbid offensive
evacuations with severe griping pains, and emaci-
ation, terminating not infrequently in marasmus
and mesenteric disease, are often observed.

10. IF Fl-ATULENCE OF THE INTESTINES may

be either primary or idiopathic, or syniptnmatic,
but most frequently the latter. — A. The prinutrii
form of intestinal flatulence is evidently itself but
a symptom, if we trace the disorder up to its ori-
gin, or but one of the various phenomena result-
ing from debility of the digestive canal— -from
deficient energy of the ganglial nervous system.
In this form, however, the flatus is either expelled
from time to time, per anum, or accumulates and
gives rise to borborygmi or to tympanitic disten-
sion of the abdomen ; but these symptoms seldom
become very urgent in this state of the disorder,
unless some other aflection supervenes. '1 he
bowels are generally costive, sometimes irregular ;
and the secretions poured into the digestive canal,
both from its own surface and from the collati-
tious organs, are deficient, and occasionally even
morbid ; the flatulence and imperfect functions
of these parts being the almost coi'taneousettects
of the impaired influence of the organic nervous
system. 'J'he air which collects in this part of
the digestive tube is to be ascribed chiefly to alter-
ations of its contents, and to exhalation from the
mucous surface. — This form of flatulence may
continue long without any other material disorder,
excepting slight debility, want of activity, cos-
tiveness, &c. ; and it may occasion, in a short
time, some one of the various serious diseases
about to be noticed.

i\. ii, Sympiomalic intestinal Jiatulence is a

common complaint. It is a frequent result of
costiveness, or imperfect digestion in the bowels,
particularly in the duodenum and ca;cum ; and of
a deficient or morbid secretion from the intestinal
mucous surface, and from the liver. When the
quantity of air collected is great, colicky symp-
toms, obstinate constipation, and irregular action,
or atony of the muscular fibres of the intestines,
are the usual consequences. The coats being
unable to contract regularly, or sufficiently to
expel the air, or obstructions being opposed to the
ejection of it, various effects of a serious kind often
result. Portions of the bowels react with m.uch
violence upon the distending cause, whilst other
portions are distended until the contractile power
of the muscular coat is almost altogether lost.
Thus spasmodic constriction in one part and
paralytic distension in another are produced ;
and the organic sensibility of the nerves of the
canal are remarkably excited or altered. Flatulent
colic is the consequence ; and if this be not re-
lieved, intus-susceptions, ileus, or inflammation
of a portion of the bowel, may ultimately super-
vene. If, in addition to imperfect or morbid
secretion, the tone of the muscular coat is still
further reduced — when its power of reacting upon
the collection of flatus is lost more generally or
completely, meteorisimis or tympanitis will be
produced, and the abdomen will be tense, painful,
or tender, and the faecal evacuations either alto-
gether suspended, or interrupted, and hard or
scybalous.

12. Intestinal flatulence is a most common
symptom in hysteria, and is in it generally indi-
cated by borborygmi, in injtamynations of the
bowels, in dysentery, in functional and organic
affections of the citcum, in hepatic disorders, espe-
cially bilious colic, in the colic from lead, and in
the bowel complaints of children. It is very
frequently met widi in the advanced stages of
typhoid fevers ; and, as I have shown, it is one
of the indications of extreme adynamia with pre-
dominant affection of the bowels. IIippocuates
remarks (Coac. Pr(€not. l.i. 46.), that inflation
of the abdomen, without rejection of the flatus,
is a dangerous sign ; and the accuracy of the
opinion must be admitted. In low fevers, the
accumulation of air is often extremely great ; and
whilst it is an indication of danger, it tends to
increase it by impeding the functions of respir-
ation and circulation, aswell as by exhausting the
vital tone of the intestines.

13. C. Inflation of the bowels, particularly of
the colon, gives rise to various symptomatic dis-
orders, wlien it reaches a considerable height ;
and it not infrequently occasions the same affec-
tions as arise from flatulence of the stomach.
Respiration and circulation are both often de-
ranged by this cause ; and congestions of the
veins and sinuses of the brain consecutively in-
duced. Hence vertigo and headachs often follow
a sense of o])pression in the cliesi, and nrcgularity
of the heart's action. Hypochondriacal and
hysterical symptoms are always aggravated by
collections of flatus in the bowels ; and these
latter are favoured by costiveness. Hence the
advantages resulting in these diseases from the
use of stomachic of tonic aperients, — 'J'he colon
may be also partially displaced, and adjoining
parts injuriously j)resscd upon by collections ol'
flatus in tiie large bowels.

FLATULENCY — TnEATMENx.

1047

14. III. Although flatulency very often is
limited to either tlie stomach or bowels, present-
ing the pathological relations just explained, yet
it also frequently extends almost simultaneously
to both, or affects one or other more or less pro-
minently. In this case, the effects produced by
it will vary accordingly, and depend upon the
degree in which it exists. — Flatus, moreover, is
generated in other situations, as in the uterus, in
the urinary bladder, and even in the shut ca lities,
but in very rare instances, particularly as I'espects
the latter of these. In these parts, it is either
exhaled from the vessels furnishing the secretions
poured out on their internal surfaces, or developed
in consequence of the changes which these secre-
tions undergo during their retention. The form-
ation of air in serous cavities is never, I believe,
observed, excepting as a result of inflammatory
action in some part of their surface that has given
rise to a secretion of a sero-albuminous fluid ; and
it is not improbable that the air is produced by
the partial decomposition of the albuminous por-
tion of the secretion. These occurrences are
more particularly noticed in other places.

15. IV. Treatment.— ^. In the primary states
of the disorder, attention to diet, and gentle tonics,
with mild aperients, will generally restore the
healthy functions of the stomach and intestines
in a short time. If much distress be experienced
from the retention of tiie flatus, the addition of
n carminative spint or oil, as those of anise-seed,
pimenta, nutmeg, or cardamoms, to the above, will
give relief; but the frequent use of heating spices
may be injurious in other circumstances, particu-
larly if the complaint depend upon chronic in-
flammatory action of the digestive mucous surface,
as is frequently the case. The practice of reject-
ing the air, either upwards or downwards, should
not be indulged in, for, although momentary
relief is thereby obtained, an increased disposition
to generate it is produced, and the evil augmented.
It is only when air collects to the extent of pro-
ducing much disorder, that its expulsion should
be procured. — In this case, any of the numerous
carminatives in common use may be given, if
they be not contra-indicated by the presence of
inflammation. In some such instances, however,
the more energetic of them may be exhibited with
advantage in enemata. The extract of rue, or any
of the essential ails, may be thus prescribed. —
HuFELAND and others advise warm dry aromatic
epilhems to be applied over the abdomen m these
cases; and Thunberg recommends the cajuput
oil to be rubbed upon this part, or to be given
internally, when the state of the circulation and
of the animal heat indicates the propriety of ex-
hibiting carminatives. — Charcoal, as suggested by
J. P. Frank, and magnesia, if not the most effi-
cacious, are among the safest means that can be
used. The same may be said of camphor, and
the terehinlldnates, and the plants which owe
their efficacy to either of these principles. The
trisnitrale of bismuth is often of great service,
particularly when conjoined with small doses of
ipecacuanha and hyoscyamus.

16. Whenever flatulency of tlie stomach or
bowels is unconnected with inflammatory action —
when the pulse is soft or weak, or not increased in
frequency, when the abdomen and hypochondria
are not painful on pressure, when the tongue is
moist, or pale, and not red at its edges, and when

there is no unusual thirst — then carminatives,
antispasmodics, stimulants, and tonics, combined
with one another, and with absorbents and ape-
rients, will give relief; and they may be either
given by the mouth, or administered in enemata.

— liut even in these cases, our chief dependence
should be placed upon suitable tonics, with the
use of the cold salt-water bath, and attention to
the secretions and excretions, for the cure of the
complaint. — If an attentive view of the case
suggests the existence of inflammatory irritation
in any part of the alimentary canal, the nitrate
of potash, and the cac/)OKa(c of soda or of potash
with demulcents or emollients, and weak camphor
mixture, will be most appropriate. In these
cases external derivatives, gentle frictions of the
abdominal surface with warm rubefacient lini-
ments, as recommended by Wuytt, the appli-
cation of hot terebinthinate embrocations or epi-
thems, or fomentations as used by Darwin, will
be of great service. When the complaint is con-
nected either with slight inflammatory action, or
with imperfect secretion, especially of bile ; or
with botli, as observed in numerous instances ;
deobstruents, and mild j)urgatives, wiW be required.
In such cases, the blue pill, or Plummer's pill, or
the hydrargyrum cum creta, ought to be given at
bedtime, with soap, ipecacuanha, and tai'axacum.

17. B. Flatulence in infants or young children
ought to be treated chiefly by appropriate food
and regimen, and by mild purgatives. Magnesia
\n dill-water, or m Jennel-water, ox m anise-seed-
water, will frequently give relief; but an altera-
tive, as the hydrargyrum cum creta, will generally
be required on alternate nights. The warm or
tepid bath, followed by frictions of the abdomen
with some warm liniment ; enemata with a little
common salt, and some carminative water ; and
an occasional dose of castor oil, with warm
clothing, and pure dry air, will also be productive
of benefit.

18. C. In the more decidedly symptomatic
states of the complaint, the treatment should be
chiefly directed to the disease on which it depends.
But in these states it is generally most urgent,
and hence requires the adoption of means calcu-
lated to procure immediate relief. If those al-
ready described, employed according to the pecu-
liarities of the case, prove inefficacious, it has
been recommended by Reich, Pamard, Tiiilow,
and Piorrv, to draw oft', or to facilitate the escape
of, the flatus, by a siphon, or by the introduction
of a flexible hollow tube into the rectum. In most
instances of difficulty, I have found the terebin-
thinates with aperients, enemata with either spirits
of turpentine of extract of rue, and tereliinthinate
embrocations or liniments applied to the abdo-
men, succeed in procuring the expulsion of the
flatus, by exciting the action of the muscular
fibres of the canal. — WHien this complaint de-
pends chiefly upon debility, and is associated with
other disorders proceeding from this source, the
means advised in the articles Colic, Costive-
NEss, and Debility, according as it may present
more or less of the features of either, should be
prescribed ; and diet and regimen ought to receive
due attention.

BiBLioG. and Refer Hippocrates, XIi^i Nsuff-an,

Opera, vol. i. Vandcr Linden ed — Ca'/ius Aureliaims,
Morb. Chr. 1. iii. c. 2 A'cthts, Tctrab. iii. serm. i. c. '27.

— Paultis JEgineta, 1. iii. c. Z^. — Foyer, Consider. Fla-

3X4

1048

FOETUS — Diseases

tuum. Lips. 1529.— r. Kcnlmann, De Exlialat. Fumos.
et Flatuosis, &c. 4to. Hala', \b^\. — ZacHtus Lusitanus,

Med. Prin. Hist. 1. i. hist. 37 Otisson, De Ventricvilo et

Intcstinis, tr. ii. c. 2-5 P. Cambaltnify, I'neumatologia,

4to. Paris, 1747. — J. S. Carcnt De Aerisliigressu in
Ventiiculum ejusque Ciiculo, Svo. Meil 1759. — tr. £.
Zeviani, Trattado delFlato a Favoie degl' Ipochondriaci,
4to. Veron. 17G1.— U'/n/l/, Works, by his Son, p. 57().
699. I've. (Contains many just observations.)— F. J.
Schrocder, Medicina Flatuum, et Morbor. exinde Pullu-
lantium, 4to. Marb. 1 773. — A'^/n/i/t-r, Amoenit. Exot.
p. 5S9. ( According to tlic Jiipitncse, flalvlencc is the cause
of all diseases. It is conunoii among t.'icm, and thenatio7is
of most Eastern countries, trho indulge f recti/ in the use of
hot ipices and ot/ier carminatives, in order to expel it.) —
G. karttrgi, LeMalattic Flatuose. Napoli, 178G — Vogel,
in llufeland. Journ. der Prak. Arzneyk. b. vi. p. 14.—
Thilotc. in Ibid. b. ix. st. ii. p. \. — Hufeland, Bemerk.
iiber Blattcrn, &c. p. "ibX. — Reich, in Jouni. der Erfin-
dungen, st. x. p 95.-7^. P. Pamard, Dissert, sur quelques
Effets de I'Air dans nos Corps, et Descript. d'une Syringe |
Pneumatique. Avign. 1701.— T/nin/jerg, De Oleo Caje-
puti. Upsala;, 1797 — J. P. Franh. De Car. Horn. Morb.
1. vi. pars i. p. 52.— Vidal, Sur le Oaz Animal consideri5
dans les Maladies. Marseille, ISW.—Jicnaiildin, in Diet,
des Sc. Med. t. xvi. p. IG.— Chotnel, in Diet, de Mede-

cine, t. xvii. p. 18G M. Good, Study of Med. by Cooper,

vol. i. p. 173.

FOETUS — Diseases OF THE.

Classif. — General Pathology.

1. The fcrtus is liable to a greater number of
diseases tiran has generally been supposed. Some
of these, together with the lesions of the foetal
appendages, have been noticed in the article
Aboktion, § 10. As these diseases occasion
various malformations, congenital alterations,
abortions, or even the death of the foetus, a brief
enumeration of them will be useful in various
points of view, bat particularly as indicative of
the sources, in which several maladies of infancy
originate.

2. i. The Causes of foetal disease are, as respects
the mother — violent or prolonged mental emotions ;
imperfect or unwholesome nourishment ; excessive
fulness or deficiency of blcod ; a morbid state of
this fluid, produced by food, medicines, or dis-
ease ; alteratives, as mercury, &c., in large doses,
or too long continued ; attempts at procuring abor-
tion ; the use of strait corsets ; injuries, falls, or
blows on the abdomen ; a cachectic slate of con-
stitution, particularly the syphilitic and scrofulous
taints; constitutional or other diseases, as eruptive,
periodic, or continued fevers, tubercular consump-
tion, &:c. ; drunkenness and venereal exces.ses
during pregnancy ; a laborious life, or inordinate
physical exertion, and previous lesions of the
ovaria, uterus, or foetal appendages. The chief
causes as respects the father, are, predisposing
only, with the exception of the sypliilitic or scro-
fulous taints. There is every reason to believe
that, if tiie father is aged, or debilitated, or suffer-
ing from constitutional or local disorder, asociated
wftli .sexual exhaustion, at the period when im-
pregnation is effected, the foetus will be weakly
formed, and thereby predisposed to disease, es-
pecially when tiie motlicr is exposed, during utci-o-
gestulion, to the more energetic causes, or to those
just enumerated.

3. ii. 'I'he i)he(ises observed in the foetus, cither
consetpient upon one or more of the above causes,
or occurring without any assignable cause, are —
1st. As respects the ccrclini-spinat sijstem — cfi'ii-
sions of fluid in the ventricles, or in the spinal
canal, or iH^wTcn the membranes, giving rise to
hydrocephalus, sjiina bifida, imperfect or arrested
lonnalidu of ])ortions of the brain or spinal cord,
to inflammatory congestion of the membranes or

OF THE — Causes.

of portions of the brain or cerebellum (Lobstein),
with spasmodic contractions of the limbs, &c. ; —
2d. As regards the thoracic viscera — inflam-
mation and suppuration of the thymus gland
(Veron) ; tubercles in the lungs, in the early
stages (Billard, Langstaff, and myself), and in
a state of softening (Husson); inflammation of
the substance of the lungs, and of the pleura ;
dropsy of the pleural cavities; hydro-pericardium,
and malformations of the heart ; — 3d, As respects
the abdominal viscera — inflammation, and even
ulceration, of the internal surface of various parts
of the alimentary canal ; tubercles in the liver
(HooGEVEN,HussoN),inthe mesentery (Oehler),
and in the spleen (Billard); inflammations of
the liver (Bracket, Veron); of one supra-renal
capsule (Andral), of the peritoneum (Desor-
MEAux, Veron), of the small intestines (Bil-
lard) ; dropsy of the peritoneal cavity in various
degrees (Duges) ; enlargement of the mesenteric
glands; accretions of the peritoneum, and of seve-
ral viscera, from chronic inflammation (Andry,
and myself) ; retention of urine, and excessive
distension of the bladder, ureters, and pelves of
the kidneys, from obstructions to the discharge
of it in the liquor amnii (Sandifort, Moreau,
Ph. PiNEL, A. Cooper, Chaussier, Duces,
&c.) ; rupture of the bladder (Duces); lesions
of the kidneys, and other parts of the urinary
apparatus (Kuvsch, Hoffmann, Wrisberg,
A'rolik, Boetschler, Denis, Boivin, &c.) ;
and obliterations of canals, and occlusions of their
outlets, as of those of the alimentary canal, and
of the urinary and generative organs ; — 4th. As
respects the general frame — intermittent fevers,
small-pox (Deuttel, &c.), and other eruptive
fevers (Anury) ; syphilis, and jaundice (Hey,
Andry, Baumes, &c.) ; — and, 5th. As regards
external parts — malformation of the palate,
mouth, and lips; dislocation of various joints,
and even of the hip joint (Dui'uvtren, Chaus-
sier, IN orth); contractions of muscles; fractures,
gangrene, &c. of the limbs (Joerg) ; hardening
of the cellular tissue (Uzembezius, Mauri^eau,
STRATroiiD, &c.) ; anasarca, and oedema of one
or more limbs (Gardien, Duces, Andry, &c.) ;
hydi-ocele (Andry); various tumours and na;vi ;
and several affections of the skin (Goeckel,
Ledel, Oehler, Chaussier, Andby, &c.).

4. My limits prevent me from remarking upon
these ; but it may be mentioned, that MAunif eau
was born with the small-pox ; and that jaundice
may arise in the foetus — 1st, from the same causes
as induce it in the adult ; and, 2dly, from jaun-
dice in the mother. M. Duces mentions that a
lady was subject, during pregnancy, to colic and
jaundice from biliary calculi ; and, in four in-
stances, the children were born deeply jaundiced.
I attended, some years since, a lady in tubercular
consumption, who was delivered, in the seventh
month, of an emaciated and very small foetus,
that died a few days afterwards. On examination,
the lungs were founded loaded with tubercles, and
the mesenteric glands enlarged. M. 'Jonnele
found an enormous fungoid tumour (fungus hx-
malo(tes) on the right side of the head of a ffftus ;
and M. VoisiN, a polypus adhering to the poste-
rior part of the palate. — The existence of worms in
the bowels of the foetus has been asserted by some
writers, and denied by others. The evidence is not
sufliciently conclusive cither one way or another.

FUNGOID DISEASE— Description-.

1049

5. iii. The Death of the Fatus may take place i
from the greater number of these diseases, or from
lesions of the placenta, umbilical cord, or mem-
branes (see Abortion, § 10.). Altiiough tliere
are numerous exceptions to the rule, the more
vigorous the foetus, the stronger and more lively
■will be the sensations of its movement. It is
evident that the existence, antl far less the nature,
of the foetal malady cannot be ascertained before
delivery ; yet, in some instances, it may be sus-
pected, from what is known of the causes. An
attack of ague in the foetus is usuallj' made mani-
fest to the mother; but does not generally cause
abortion. The feebleness and slowness of the
foetal movements, after the fifth month, are indi-
cations of impaired strength of the foetus, which
should not be overlooked. The total cessation of
motion ; a feeling of uncomfortable weight gra-
vitating to the side on which the patient lies, and
of general uneasiness and coldness in the lower
part of the abdomen ; flaccidity of the abdominal
parietes subsequent to a certain degree of teifsion;
foetor of the breath, pallor of the countenance,
lividity of the eyelids or surrovinding circle, and
flaccidity of the breasts, generally denote the
death of the fcetus ; and when tlie pulsation of
the heart cannot be heard on auscultation, this
event may be inferred with certainty.

BiBLioG. AND Refer Deuttel, De Morbis Fcetum.

Hala?, 4to. 1702. — Hoogcven, Tractatus de Foetus Huniani

Morbis, 8vo. L. B. 1784 Bawnes, Traite de I'lctere, ou

Jautiesse des Enfans, 8vo. Paris, 180G Stewart, Trans.

of Med. and Chirurg. Society, vol. v. p. 144 — Latvrence,

in Ibid. vol. v. p. 165 Iley, Ibid. vol. vii. p. .530 — Chaus-

sici; in Diet, des Sciences Med. t. xvi. p. 50., et t. xxxiv.

p. 232 Mvrat, in Ibid. t. xvi. p. 49 I'eron, Nouv.

Biblioth. Mt'dicale, July, 1826, p. 301. — .Brac^t^, Journ.

Gener. de Med. Jan. 1828 Desormcaux, Diet, de Med.

t. XV. p. 396 Lvbsfem, Repert. d'Anat. &c. t. i. p. 28—

141. — Stratford, Journ. des Progies des Sciences Med.

t. xvii. p. 266 /'. Anclri/, in Ibid. t. i. N. S. 130.— Rossi,

in Ibid. t. iv. p. 119. — tonneli, in Ibid. t. xiv. p. 251.—
Jiresc/iet, Diet, de Med. 1. 1. — Allonncau, Nouv. Biblioth.
Med. t.ix. p.383.— (ifo/. Suint-Hilaire, Archives Gener.
de Med. t. ix. p. 41. — Kilian, in Ibid. t. xvi. p. 564. —
Dvpvytrcn, in Archives Gen. de Med. t. xiii. p. 83., et
t. xvi. p. .562.; et Repert. Gen. d'Anat. iVc. t. ii. p. 131.
(Congenital luxation 0/ fi'tnur.) — P. S. Denis. Recherches
Patholog.sur Plusieurs Maladies des Nouveaux-nes, 8vo.
Commercy, 1826.— C. Billard, Traite des Maladies des

Enfans Nouveaux-nes, &c. 8vo. Paris, 1832, 2d edit

A. Colson, Archives Gen. de Med. t. xviii. p. 24. — Carus,
in Ibid. t. xvi. p. 444.— f'elpeau, in Ibid. t. vi. p. 135. 403.
584., et t. XV. p. a-ia. — A.Dusi's, Diet. Med. et Chirurg.
Prat. t. viii. p. 290.

FUNGOID DISEASE. — Syn. Hamato-cere-
briform Disease; Milt-Uhe Tumour, JMonro.
Soft Cancer, Auct. var. Spvngoid Iiif animation.
Burns. 3IeduUaru Sarcoma, Abernethy. C«?--
cinoma ipongiosum,\onng. Fungus Httmutodes,
Hey, Wardrop. Fungoid Disease, A. Cooper.
Fungus Medullaris, JNIaunoir. Matiere ctre-
hriforme, Auct. Gall. Carcinome moti et Spon-
gieux, Roux. Tumcur Enctjihaloide, Laennec.
Fongus ISIeditUaire, Lobstein. Curcinus Spongio-
sus, JM.Good. Carcinome Sanglante, Cancer moa,
Fr.Der Blutschswamm,GcTm. Bleeding Fungus.

Classif. — 3. Class, Sanguineous Diseases;
4. Order, Cachexies (Good). IV. Class,
IV. Order (^Author, in Preface).
1. Defin. — A tumour, or tumours, consisting
of a lehitish, ptilpii, brnin-like substance ; generalli/
soft, circumscribed, elastic, or obscurely Jiuctu-
ating ; giiing rise to large vascular growths,
uhich bleed profusely : always connected with con-
stitutional vice; contaniijiating the frame, and
terminating fatally .

2. i. Description. — This is the most malig-
nant formation to which the body is liable. When
it appears covered only by the integuments, and
has not yet acquired considerable bulk, the surface
of the tumour which it forms is smooth, generally
equal, and not discoloured ; it is commonly soft
and elastic, and communicates to the touch an
obscure sense of fluctuation. When removed
from the body, the hjematoid tumour is generally
circumscribed, and more or less rounded : iu fre-
quently possesses a capsule of condensed cellular
membrane. — A. M, Laennec has divided the
disease into — 1st, the encysted ; 2dly, the irregular
and non-encysted ; to which he has added, 3dly,
the interstitial impregnation of organs by the cere-
briform substance. This last is not mentioned by
Mr. Wardrop, who has described this disease
with great accuracy. M. Laennec has never met
with it in the lungs. It may be, therefore, con-
sidered as a rare form of the disease. When
divided, the substance soils the knife, and is com-
posed of an opaque, whitish, homogeneous matter,
resembling, in colour and consistence, the cerebral
pulp. Hence the name, Encephaloid, given it by
the French pathologists. It softens after exposure
for a short time to the atmosphere ; and when the
softer part is washed away, or when the mass is
compressed, a filamentous or fine cellular tissue
remains.

3. B. The consistence of the hwmatoid tumour
varies in different cases, and sometimes indifferent
parts of the same mass — being sometimes more
dense than the firmest brain, at other times as soft
as the brain of a foetus, as the milt of a fish, or
even not much firmer than custard. According
to JM. LoiiSTEiN, the different degrees of softening
is owing to the progress of the disease ; and this
appears to be generally the case. In the frst
stage, or that of crudity, the melanoid tumour has
the consistence of a firm brain, or of the conglo-
bate glands ; in the second, the consistence is less,
being that of the foetal brain ; in the third, it ap-
proaches that of milt or custard .- to these may be
added a fourth, when the tumour is situated ex-
ternally, or near the surface of an organ or part,
viz. thatattended with ulceration and the rapid pro-
duction of bleeding fungi from the ulcerated part,

4. r. The colour of this production varies
sometimes in the same mass. It is commonly of
the colour of the brain ; occasionally portions of
it are redder, and exhibit more of a fleshy ap-
pearance : and in other cases, parts of it resemble
a clot of blood. A\']ien the heematoid mass is
encysted, it is readily detached from its capsule;
and, in the early stage, is often divided into se-
veral lobes, placed closely together, and separated
by an extremely fine cellular tissue, which seems
to convey the vessels for its nutrition. In the ad-
vanced stages, the division into lobes disappears.
The non-encysted form is, however, more common,
particularly in the viscera. The masses consti-
tuting this formation vary from the size of a pea
to tjiat of the head of a fatus at tlie full time.

5. D. I'he medullary structure, although the
general, is not the only, form observed in the pri-
marily diseased mass. Some of tlie fungoid pro-
ductions are composed of distinct parts provided
with cellular capsules, and differing in size, colour,
and consistence. .Some of these parts re?emble
slightly softened glue; others have earthy par-
ticles mixed with the pulpy ceiebriform matter ;

1050-

FUNGOID DISEASE— DEscniPTioN.

many present insulated portions of the colour and
consistence of boiled yolk of egg. As the tumour
increases, the softening and disorganisation cha-
racterising the successive stages of its growth
takes place. Disorganisation generally com-
mences in the central parts : cavities now form
in il, chiefly containing blood ; and, when the
blood is washed away, and the tumour is placed
in water, numerous membranous shreds and
filarilents are seen floating in these cavities.

6. If the fungoid mass is situate near the sur-
face of any internal viscus, discolouration of, and
adhesion to, the part covering it, followed by
ulceration, take place. But the ulcerative pro-
cess, instead of giving rise to loss of substance,
produces a fungous growth, and, as well as when
the tumour forms exteriorly, the increase of bulk,
which had hitherto been slow, now becomes rapid.
The fungus which thus forms is soft, easily torn,
of a dark red or purple colour, of an irregular
shape, and bleeds profusely when slightly injured ;
and differs from the firm dense structure of the
cancerous fungus. It resembles, when small, the
softer kinds of polypous vegetations which form
on mucous surfaces. — When the primary hae-
matoid tumours are situated towards the surface
of the body, they increase in size more rapidly
than when seated internally. They generally
soon lose their uniform round and smooth appear-
ance ; they project very considerably, and at
last become irregular at their surface. Their
consistence diminishes, particularly in the pro-
jecting portions, where the soft elasticity passes
into obscure fluctuation. The veins running over
or from the diseased mass assume a varicose
appearance; an erysipelatous-like redness of the
prominent parts supervenes, followed by lividity,
adhesion of the integuments to the tumour, ulcer-
ation, and soft reddish fungous excrescences. The
growth of the tumour is now remarkably rapid.
The surface of the fungi exudes a thin foetid
sanies, often with blood, wliich is sometimes dis-
charged in great quantity ; hence arose the name

fungus humatodes, which applies only to the ad-
vanced stage of the malady. When the fungus is
very large, its more prominent parts often lose their
vitality, and separate in most offensive sloughs.

7. In some cases the voluntary nerves have
been connected with the diseased mass, and have
participated in the change of structure; but they
have not been found changed beyond the limits
of the tumour. In the eye, the optic nerve is
always changed in structure ; and in a case re-
ferred to by Mr. WAnDnop, the anterior crural
nerve passed into the centre of the diseased mass,
and was so completely lost in it, that it was im-
possible to distinguish between the two structures.
This appearance being general whenever large
nerves enter into the hicmatoid tumour, has led
M. Maunoiii to infer that the cerebriform matter
composing it is nothing else than a morbid accu-
mulation of the nervous pulp. This opinion is
combated by IM. LonsTi.iN, who avers that he
has met with cases in which, particularly in early
stages of the disease, the nerves passed through
the tumour without experiencing any change. I
am, however, disposed to doubt this, at least as
respects the fully developed disease : if they jiass
through, 1 believe, from the dissection of a case
vvhicli occurred to me, lliat they are always
changed, and identified with the morbid mass :

if they pass merely by it, or between insulated
portions of it, no change will be observed.

8. The most remarkable characteristics of this
disease are — 1st, The frequently simultaneous
occurrence of a number of the tumours consti-
tuting it in different parts of the body ; the least
connected with each other, either by structure or
function : and, 2d, That when an apparently
isolated mass of the disease is met with in an ex-
tremity and extirpated, it always soon afterwards
manifests itself in some distant part, either exter-
nally or internally ; the subsequent disease being
even more rapid in its progress than that preceding
it. The simultaneous appearance of the hajmatoid
tumours, or their successive manifestation, al-
though sometimes observed to take place in the
course of the absorbent system, seem not to be
always propagated through this medium ; for, in
the case of the diseased mass appearing first in
one of the lower extremities, the subsequent
occurrence of it may not be in the glands above
the originally affected part, but in some distant or
internal organ, as in the lungs, liver, in an upper
extremity, &c. This was well evinced in a most
remarkable specimen of the disease which came
before me several years since in a lad of about
fifteen ; who presented in all the extremities, upper
and lower, in the parietes of the thorax and ab-
domen, in his neck and head, a number of those tu-
mours, certainly not under fifty. They varied from
the size of a walnut to that of a large orange ;
many of them were of simultaneous origin, and
those which were the latest in appearing did not
occur in the seat of the glands of the absorbents
leading from the primary tumours. A somewhat
similar, and still more remarkable case, in respect
of the great extent and number of the tumours,
both internal and external, I had lately an oppor-
tunity of seeing frequently with Mr. Bushell.

9. Often, however, when the original mass
is advancing through the changes 1 have de-
scribed, the absorbent glands become aflPected
by the disease, and the internal viscera, and the
whole constitution, are contaminated; or, per-
haps, it would be more correct to say that the
original contamination is thereby so far heightened
as to occasion a more general formation of this
diseased structure. When the absorbent system
is affected, ]\Ir. Wardrop states, that usually one
or more glands swell in the vicinity of the pri-
mary tumour, and that this takes place sometimes
at an early period of the disease, and occasionally
not until the primary tumour is far advanced. In
some cases the diseased glands grow to a great
size, whilst in others they are but slightly en-
larged. Occasionally the primary affection makes
little progress, whilst the disease of the glands
advances rapidly. — The structure of the glands
thus secondarily affected is entirely converted into
the cerebriform matter, exhibits a homogeneous
j)ulpy mass, and is contained in a cellular capsule.
Mr. Wahduop has never observed a fungus arise
from the diseased gland.

10. This morbid ])roduction may appear in one
part only, or in several at the same time, or in
distant j)arts successively, 'i'lie tumours which
first appear may be called jirimnry ; those which
occur afterwards, either in the absorbent glands
or in remote parts, may be named cnnseciitii^e.
But the disease may terminate fatally without
any more than a single mass being developed.

rUNGOID DISEASE — Diagnosis and Complications.

1051

Mr. Langstaff has adduced an instance of this.
The primary tumour may be small, and the subse-
quent productions most extensive, or the reverse.

11. There is scarcely any organ or part of the
body exempt from this disease. The extremities,
the mamma;, tliyroid giand, the testes, ovaria,
uterus, tlie lungs, the liver, pancreas, spleen, the
stomach, the intestines, the urinary bladder, pro-
state gland, the mesentery, omentum, the eye,
the brain, the spinal cord, the nerves, the glands,
the heart, the muscular parts of the trunk, the
bones, &c., have all been found affected with
this malignant disease. It seems to commence
in the cellular tissue ; but, as it is developed, the
proper texture of parts to which it extends is either
converted into it, or is absorbed in proportion as
it is increased.

12. ii. PnoGREss and Duration. — a. The
progress of the disease may be divided into four
stages. — In the Jirst, the tumour has the con-
sistence of tiie conglobate glands ; in the second, it
is much softer ; in the third, ihe softening is still
greater, and amounts to a state of semi-liquefac-
tion, and gives the sensation of fluctuation ; in the
fourth, ulceration or vascular fungi arise. — Signs
of general cachexy appear in the second or third
stage, and are very decided in the fourth. — /;.The
duratioti of this malady is generally some months
at least ; and it may continue for two or three
years. In the early stages, it is not usually at-
tended by febrile action, or much pain ; and it
may exist for a considerable time without occa-
sioning emaciation ; but there is always more or
less debility. Acceleration of pulse, and emaci-
ation, appear in the advanced stages, often ac-
companied with efl'usion into the adjoining ca-
vities, particularly when an internal organ is the
seat of the malady, as the liver, uterus, &c. —
In the third and fourtli stages, the vital functions
are very manifestly aflected. The stomach loses
its power, or rejects the ingesta. The patient ex-
periences most severe pain ; and the energies of
life decline. The complexion often assumes a
livid, earthy, or peculiar yellowish hue, or pale
straw colour ; the pulse becomes smaller and
weaker; and at last the patient sinks, generally
without either delirium or insensibility having ex-
isted for any considerable time before death.

13. iii. Diagnosis and Complications. — This
disease was confounded with cancer until the
commencement of this century, when Burns and
Hey first remarked the difference between them.
They are still considered by some Continental
pathologists, and by Dr. Carswell, as varieties
or modifications of the same constitutional ma-
lady ; and there are several circumstances which
both favour and militate against this opinion.
They both occur in similar habits of body and
temperaments ; they often arise spontaneously, or
without any manifest cause, or are traced to the
same exciting agents; they are both dependent
upon constitutional vice, as well as upon perverted
organic action and fecretion in their seats ; and
they both undergosomewhat similar local changes,
and occasion an increasing contamination of the
fluids and soft solids. Moreover, as 1 have stated
in another place (see article Disease, ^ 141 —
144.), and as Drs. Kerr and Carswell have
justly remarked, both may co-exist, or the car-
cinomatoas may pass into the fungoid formation.
Dr. Carswell observes, that numerous examples

might be given of scirrhus, medullary sarcoma,
and fungus hamatodes, as they are commonly
called, originating in the same morbid state, and
passing successively from the one into the other
in the order in which they have been named.
Indeed, these varieties are sometimes met with
not only in tlifl^erent organs of the same indi-
vidual, but even in the same organ.

14. The points, however, of dissimilarity are
very striking, as remarked in the article referred
to (§ 141 — 144.) ; and, notwithstanding these cir-
cumstances, are suflficient to constitute them
distinct diseases. As these points have not been
brought into view by the able writers just men-
tioned, and as they deserve a fuller notice than
I have bestovred on them in the sketch indicated
above, I shall here state them more fully. — a.
There is no relation between the hard, incom-
pressible texture of schirrhus, in which carcinoma
commences, and the cerebriform, elastic, and
soft substance constituting fungoid disease. —
b. Carcinoma commences in scirrhus, which
confounds in one mass all the tissues which it
invades, and often without much increase of bulk,
although with augmented density ; fungoid dis-
ease always consists of a more or less evident
tumour, which seems to destroy every trace of
any other structure. — c. Carcinoma, even in
an advanced stage, when fungous projections
sprout from its ulcerated parts, presents but little
vascularity; whereas the fungoid disease possesses
large vessels and vascular cavities, so that it
derives one of its most common names from this
circumstance.— d. Fungoid disease attacks or-
gans in which true carcinoma has not hitherto
been seen to originate ; as the lungs, the liver,
the brain, the spinal cord, and the nervous
trunks. — e. Cancer affects the aged, fungoid
disease the young ; and the former is attended
with more pain at the commencement than the
latter: — and,/, as, MM. Maunoir, Lobstein,
and Velpeau have remarked, there is something
peculiar in the cachexy attending carcinoma, that
IS not observed tn the fungoid malady ; for it is not
unusual to see persons, labouring under this latter
affection, possessing their natural colour. This,
I believe, occurs most frequently when some ex-
ternal part only is affected, or when the disease
has not invaded the digestive or assimilating or-
gans, or when absorption of the morbid matter has
not taken place to a great amount. In a case now
under my care, the healtliy complexion is pre-
served, and yet neither the able practitioners who
have seen it, nor myself, have any doubt as to its
nature.

15. IM. Lobstein asks, with reference to the
question of the identity of these two maladies,
whether, admitting that true cancer sometimes
gives rise to the fungoid formation, it therefore
follows that this latter is the same as cancer?
JMay there not exist, simultaneously, tuberculous
degeneration of the lungs, fungoid disease of the
livei*, and fibrous tumours in the womb, without
inferring the idefftity of these three morbid form-
ations? Fungoid disease, th'jrefore, appears, from
its vascular relations, from its peculiar structure,
and from its early characters, its advanced course
and terminations, to be a distinct malady, although
it may be consequent upon, or complicated with,
other alterations of structure. \\'hen it occurs
in young subjects, it is always primary, or is not

1052

FUNGOID DISEASE — Causes— Prognosis — Obigin'.

preceded nor attended by the carcinomatous form-
ation. But in persons past the meridian of life,
in whom only scirrho-cancer or carcinoma is met
with, the fungoid structure is sometimes produced
consecutively, or in an advanced stage of it, and
thus occasionally exists as a secondary complica-
tion with that disease, or as one of the advanced
changes of structure consequent upon the consti-
tutional vice. The question, therefore, as to dif-
ference is reduced to this, — that, when fungoid
disease attacks young persons, it is always a pri-
mary and distinct malady ; and that, when it
affects persons advanced in life, it is either pri-
mary, or consecutive of, and complicated with,
carcinoma (see art. Disease, § 141 — 144.). In
a few instances, other morbid formations besides
this have been found associated with the cere-
briform structure, as fibrous tumours, scrofulous
matters, pus, melanosis, hydatids, osseous and
earthy deposits, &c.*

* Besides the distinctions I have Insisted upon above,
Scarpa and Beuaud have adduced others, which I may
liere notice at length. The cerebritbrm or fungoid struc-
ture, when fully developed, is a milk-white pulpy sub-
stance, studded with rose-coloured points — scirrho-cancer
lias the appearance of the skin of brawn, and is traversed
by numerous cellulo-fibrous radii or bands. The former
comprises a number of arterial vessels, that increase with
the softening which it undergoes ; extravasations of blood
take place in its substance ; and the ulceration of its ad-
v.anced stage is accompanied with lijemorrhage, which is
often repeated, and frequently profuse ; — the latter is
nearly deprived of vessels ; sanguineous extravasation
is seldom observed in it ; and the ulceration to wliich it
gives rise is rarely attended by any considerable h<Emor-
rhage. The cerebriform substance is often found in the
veins of the diseased part — sometimes nearly filling
them — and occasionally, also, in those in the vicmity ; —
a similar circumstance is very seldom observed in scir-
rho-cancer. The cerebriform disease attacks primarily
all the systems, tissues, and organs of the body ; the pri-
mary seat of carcinoma is much more limited. The for-
mer attains a great size, is lobulated, and presents a cha-
racteristic elasticity and softness ; — the latter never
reaches a great size, it even sometimes assumes the ap-
pearance of diminished bulk, with increased density, and
has neither a rounded outline nor elasticity. — I'ungoid
tumours frequently co-exist, even primarily, in several
organs — occasionally in considerable numbers ; — carci-
noma is generally solitary. The cerebriform disease
softens into a rose-coloured bouillie ; scirrhus assumes the
form of a. jelly. In their progress to the surface, the first
stretches to the skin, and renders it thinner, without ad-
hering to it ; the second cements itself to the integuments,
which no longer admit of motion, but are firmly attached
to the diseased mass. The progress of ulceration in this
is remarkably slow ; in that very rapid. In the one, the
period which elapses from the commencement of ulcer-
ation is often as long or longer than that which pre-
ceded this change ; in the other, the period subsequent
to ulceration is disproportionately short, and the lesions
consequent iijion it are of a much more acute and violent
charactir, though the pain may be less.

It is in the early stage, or state of crudity, that these
two maladies are distinguished from each other with
greatest difficulty. The fungoid structure has not then
attained the white colour it subsequently acquires. It is
at first semi-transparent, firm, and divided into numerous
lobules. Its vascularity is also not so great as at an ad-
vanced stage, liut, allhdiigh it thus resembles scirrhus,
to conclude from this, that thryare idcnticil diseases, is to
admit that the same lesion will give rise to two kinds of
structure that essentially differ. lUit this stag(M)f fun-
goid disease is vmy short ; and in cases where a number
of tumours are developed in different parts of the body,
they all have the same cerebriform structure. Malig-
naHt disease may, however, present the cumiHicalcd
slates ahov(! mentioned ; the same tumour cDnsisting
partly of the carcinomatous and i)artly of the cere-
briform structure. In addition to these, it may even
comprise other morbid products, disseminated through
it, or collected in one or more places — in one part an
adventitious fibrous tissue, in another a fibro-cartilagi-
nous fonnation, in a third tubercidar matter, in a fourth
multilocular cysts containing various substances — here a
gelatinous secr('lion, there a milky fluid, this a reddish
or bloody matter, that an ossc iius or a cretaceous deposit.
These, as well as the c<.Tel)rirorni products thus accl-
dcntully or occa,ionally coinpi ised in carcinomatous or

16. iv. Causes. — a. The predisposing causes
of fungoid disease are — debility of constitution,
early age, and peculiarity of diathesis. Children,
and persons who have not passed the meridian of
life, are much more frequently affected by it than
persons in the decline of fife. Those of the lymph-
atic and nervous temperaments, of a scrofulous
constitution, of a sallow or pale complexion, and
of a lax fibre, with a flabby state of the soft solids,
and languid circulation, are oftenest its subjects.
As to the influence of sex, suflicient data have
not been furnished to admit of an opinion ; but
the most of several cases which I have seen have
occurred in males. The same may be said of the
influence of climate ; but, like cancer, it seems to
be most prevalent in countries the inhabitants of
which partake largely of animal food. It has
even been supposed that eating much pork pre-
disposes to it. An hereditary disposition to it may
be admitted with more truth. General debility
is, however, its most common antecedent. — /;.
The exciting causes are often unknown. Some-
times an external injury, as a blow or bruise, has
occasioned it, often after a long period. Most of
the cases which I have seen appeared to have
arisen chiefly from a poor and unwholesome diet,
aided by cold and moisture.

17. V. 'i' he Prognosis is extremely unfavour-
able. If the malady is developed so as to admit
of precise recognition, a fatal issue may be delayed
a short time by a tonic or restorative treatment, but
can never be averted. Extirpation, or amputation,
has been attempted, but with no benefit, and often
with disadvantage. Although the diseased part
be removed in this way, its source is sttll in the
constitution, and it soon afterwards is developed
in some other situation, generally in an internal
viscus, the nearest to the seat of the extirpated
part. If it exist also in an internal organ, the
shock occasioned by the operation accelerates its
growth and fatal progress.

18, vi. OniGiN. — Many writers on this dis-
ease, and especially the French pathologists,
suppose that the diathesis in which the disease
originates is connected with the cancerous taint ;
and that the fungoid is only an advanced stage, or
higher grade of carcinoma. MiM. Maunoir and
LonsTLiN are opposed to this view ; and my
opinion, as just stated, coincides with theirs.
Although both diseases are distinct as to the Kind
of action, as to the form of the morbid structure
thiit results, and as to some of the circumstances
in which it takes place, yet the manner in which
they both arise may not be different ; their morbid
actions being similar in some respects, but differ-
ent in others. Hence the alliance occasionally
observed between them ; as in other diseases ge-
nerally connected, but specifically different. 'I'he
opinion, therefore, which I have stated as to the
origin of Cancer (§ 25, 26.), and the remarks
there oflered, are, in part, applicable to this dis-
ease.— Dr. IIoDGKiN has endeavoured to show
that fuii^tis ha'matodes and carcinoma originate
in acystiform serous membrane. 'J'hat they thus
arise in some instances may be admitted ; but I
agree with Dr. Carswei.l in the opinion that
they are often formed independently, and where

malignant tumours, are not the constituents of carci-
noma, but contingent formations consequent upon the
morbid nutrition ami secretion constituting the local dis-
ease.

cysls cannot be detected ; and that, even where
cysts have existed, their formation in the cellulai-
tissue external to the cysts lias been demon-
strated. — The views of JM. Andrai. have been
stated in the article just referred to, and in that
on Disease, § 138. M. CnuvEiLHiEn beheves
that this, as well as some other lesions, are the
results of the deposition of morbid products in the
cellular tissue of organs, the venous capillary
system furnishing these products,

19. Dr. Carsvvell is of opinion that the form-
ation of the fungoid and carcinomatous substance
takes place in the blood, whether it be found in
this fluid alone or in other parts of the body at the
same time ; and he adduces the facts — 1st, That
the morbid substance is found in the vessels which
ramify in these malignant tumours, or in their
vicinity ; — 2dly, That it is found in those vessels
which communicate with the diseased part of an
organ ; — and, 3dly, That it is met with in vessels
having no direct communication with an or^an af-
fected with the same disease. The veins, however,
and venous capillaries, are the only parts of the
vascular system in which the diseased substance
is found — sometimes in contact with the internal
surface of the vein, or occasionally united with it
by means of thin colourless fibrine, or even of
very minute blood-vessels, as in the case of the
cerehriform matter. In the articles referred to,
I have stated that, when this morbid substance is
detected in the blood, it has been absorbed, as
in the case of other morbid secretions ; and the
accuracy of the opinion seems to be supported
by the fact, that it is found only in the veins
and absorbents; but Dr. Carswell believes
that this is not the case, as there are instances
in which the venous blood alone was the seat of
the disease. If such be actually the case, an
obvious difficulty presents itself; but various
sources of deception arise in the course of minute
researches, and mislead even the most careful.
That the blood is early aflected in this and other
malignant diseases, I fully believe ; but that the
cerebriform matter is formed in it, and afterwards
deposited in the parts which are its seats, cannot
be supported by the history and progress of the
local and constitutional affections. If it were
previously formed in the blood, wherefore is it
often deposited only in one situation] — where-
fore is it not excreted by the emunctoriesT —
wherefore does it not always affect a number of
parts simultaneously'! — wherefore is it never
found in the arteries, and so frequently in the ab-
sorbents and veins proceeding from the seat of
disease? — These and other questions that may
be asked, cannot be answered consistently with
this doctrine, I therefore entertain the same
opinion as was stated by me in the articles al-
ready referred to, and believe that, like carcinoma',
it essentially depends upon a debilitated and other-
wise morbid state of the system generally ; and
that the vital actions of the part or parts primarily
and especially affected are depraved — that the
nutrition, organic sensibility, and the secreting
function of these parts are remarkably altered,
and that the morbid product which results is par-
tially absorbed into the circulation, and contami-
nates the fluids and soft solids, sometimes exciting
a similar morbid action in other situations,

20. Conformably with the best ascertained
facts connected with the appearance of the cere-

FUNGOID DISEASE — Treatment. 1053

briform niatter in the vessels, it would seem, that
at a somewhat advanced stage of tlie disease, or
when this structure becomes more or less softened,
the molecules of it pass into the veins and ab-
sorbents leading from the part in which they have
been formed ; that they there sometimes are
aggregated into masses sufl^ciently large to admit
of their recognition ; that, although these masses
are generally found merely in contact with the
internal surface of the veins, they sometimes ad-
here to it by means of the fibrine which collects
around them, as in every other instance in which
a semifluid or partially concrete substance, or a
secreted matter of greater consistence than the
blood, passes into the circulation; and that, when
they thus adhere to the internal surface of the
veins, minute vessels are ultimately developed in
the fibrinous envelope which has been formed
around them. — The principal changes observed
in the blood of those affected by this disease, and
which I have had an opportunity of remarking in
two cases after death, are, an unusual thinness —
a deficiency of fibrine and red particles — a state
of partial anaemia — and imperfect coagulation.
This state has been also remarked by Beclard,
Vei.peau, Andual, and Kerr, whose observ-
ations respecting the presence of the cerebriform
matter, surrounded by a fibrinous envelope, in the
venous blood, fully confirm the view I have taken
of its origin in this situation, and militate against
its primary formation in this fluid. (See articles
Cancer, §26.; and Disease, § 141.)

21. vii. Treatment. — This is a subject on
which much cannot be said with any hope of ad-
vantage. Surgical treatment is of no avail, and
strictly medical means of very little more. What-
ever excites pain, or irritates the local disease,
tends to promote its growth ; and whatever lowers
constitutional power, only lays the system more
open to contamination. The intentions, there-
fore, which we should propose to ourselves', when

entering upon the ti-eatment of this malady, are

1st, to support the powers of life, and thereby to
resist as long as possible the extension of the dis-
ease ; — 2dly, to promote the secretions and

excretions, as auxdiary to the first indication ;

and, 3d]y, to palliate the sufferings of the patient.

22. A. The frst of these is founded upon the
evident and admitted fact that the disease is
dependent upon, and associated with, debility ;
and upon the results of observation ; and the
means which may be employed to fulfil it need
not be materially different from those specified in
the article Cancer, § 29. et seq. Although no
medicine has hitherto proved successful in curino-
the malady, yet new remedies, or novel combin-
ations of those that are old, should nevertlieless
be directed against it. Besides, judicious means
have often prolonged life, or enabled the system
to resist its progress for a time. Conformably
with these views, the preparations of cinchona ;
the sulphate of quinine ; the preparations and
compounds of iron, particularly the ferri ammo-
nio-chloridum, and the tincture of the sesqui-
chloride ; sarsaparilla ; bitter tonic infusions or de-
coctions, with liquor potassae, or the alkaline car-
bonates ; and the preparations of iodine, — may be
severally used, and combined with some one of the
more energetic narcotics, particularly the acetate
or hydrochlorate of morphia, or conium, or bella-
donna, or aconitum. — The preparations of iodine

1054 FURUNCLE, STHENIC

are the most successful of any means I nave em-
ployed, in resisting the progress of this morbid for-
mation. The ioJuret or iodide of iron, and the
iodide of potassium, should be selected, and taken
internally in small or moderate doses. The external
use of iodine is often injurious. In a case of this
disease, affecting chiefly the stomach and some
others of the abdominal viscera, lately under my
care, a combination of the acetate of morphia and
kreosote palliated the urgent symptoms after other
means had failed. In the still more recent case
of a lady from Wales, who came to town on
account of malignant disease of the stomach,
that probably partook of the fungoid character,
from the size of the tumour and other symptoms,
this combination proved serviceable. This lady
had been treated with great discrimination by
]\Ir. Serph of Welshpool. During her stay in
London, the acetate of morphia in a dilute aro-
matic spirit always afforded relief ; but, when
the disease had advanced further, and after her
return home, it had but little effect. Mr. Serph,
therefore, at my request, gave her the following
during the paroxysms of suffering, with great
benefit : —

No. 227. R Morphife Acetatis gr. ij. ; Kreosote 11\
xij. ; Pulv. Glycyrrh. et Pulv. Acaciae, aa q. s. ut fiat
massa asqualis, quam divide in Pil. xij. Capiat unam,
omni hora, urgeuti dolore.

23. When the diseased part appears about to ul-
cerate, and afterwards especially, it should be pro-
tected from external injury or irritation; and if the
bleeding from it be copious, or the discharge of-
fensive, a solution of kreosote in weak pyroligneous
acid or spirits of turpentine will prove the most
efficient styptic and corrigent. The chloride of
lime may likewise be employed. In addition to
the other tonics just enumerated, the chlorate of
potash may be tried in the decoction of cinchona.
If iodine be prescribed, it should be continued
for a long time. The iodide of potassium may be
given in the compound decoction of sarsaparilla ;
with conium, aconitum, or any other narcotic, if
much pain be felt. During the course of treatment,
the secretions and excretions should be regularly
promoted ; and if the bowels be sluggish, their
actions ought to be promoted by a tonic or sto-
machic aperient repeated according to circum-
stances. The other means, which have been
recommended in the article Cancer (which see),
are equally appropriate in this, and other malig-
nant formations.

BiBLlOG. AND Refer J. Burns, Dissert, on Inflam-
mation, vol. ii. p. 302 Iley, Practical Observat. on

.Surgery. Lond. 8vo. 1803.— J. Ahernethy, Surg. Observ-
ations. Lond. 1S04.— S. IVardrop, Observat. on Fungus
Ha>matodps or Soft Cancer, 8vo. ed. 1809. ; and his edi-
tion of the Works of Dr. Baillic, vol. ii. — Lacnnec, Diet,
des Sciences Medicales, art. Enccphaloidcs — A. Monro,
Morbid Anatomy of the Human OuUct, Ike. Kdin. 1811.
— C. Bell, Surgical Observat. part iv. — G. Lnnustiiff, in
'f r.ins. of Med. and Chir. Soc. vol. viii. p. i. — IVardrop,
Earlc, and Laivrence, in Il)id. vols. ili. and viii. — Hodj^ltin,

in Ibid. vol. xv. p. 2(;-'> C. Bell, in Ibid. vol. xii — Koui,

Relation d'un Voyage a Londres en 1814. — Maunoir,
Mem. sur leg Fongus MeduU. et Iloemat. ■ Genfiv. 1820.

Cruvcilhicr. Essai sur I'Anatom. Pathol, t. i. p. 82. ;

and Anat. Pathol. Ike. liv. iv, viii. — BaricUy, Obscrv.
Sing. Fungi Medul. in Cordo, 8vo. Halle, 1821 — Bns-
clicl et Fi:rrus, Diet, de Med. t. iv. — Bcrard et Bfgin,
Diet, de Med. Prat. art. Cancer, t. iv — A. Scarpa, in
Archives Gen. de Med. t. x. p. 277. — Andral, Anat. Pa-
thol, t. i. p. 219 J. A. Recamicr, Recherclnis sur le

Trait, du Cancer, &c. 2 vols. Paris, Hvp. 1829.— /i.
Cooper, Lectures, in Lancet, vol. ii. p. 399.; and Illus-
trations of Diseases of the Breast. Lond. -Ito. 1829.—
J. J. Lobttciti, Trait<5 d' Anat. Pathol, t. i. p. 419 — ii.

-Symptoms.

Home, On the Format, of Tumours, &c. 8vo. Lond
1830.— fF. Kerr, in Cyclop, of Pract. Med. vol. ii. p. 298.
— B. Carswell, in Ibid. vol. iii. p. (3.57. ; and Illustrations
of the Elementary Forms of Disease, fascic. ii. and iii.

FURUNCULAR ERUPTIONS. — Syn. Fu-

runcuLar Inflammations ; Fiiriiiicles. Furuii-
cuii ; Furunculus, Sauvages. Pnyma, Willan,
Good. Thlysis FuruncuLusa, Young.

Classif. — 3. Class, 2. Order (Good). 7.

Order, 1. Genus (Willan). IV. Class,

IV. Order (A%ithor).

1. Defin. — Inflammation of the cellular appen-
dices penetrating the reticular texture of the corion,
arising from disorder of the digestive 07-gans, and
modifed in character by the state of constitutional
power, and the condition of the circulating fluids.

2. The true skin or corion is penetrated by
small conical prolongations derived from the cel-
lular tissue underneath. With'these, the vessels
and nerves proceed to the superficies of the corion
to form the papillar tissue and vascular rete.
VVhen inflammation commences in one or more
of these prolongations, furunculus or Ijoil, hor-
deolum or sty, and anthrax or carbuncle, are the
results ; but in these, the surrounding true skin,
with the subjacent cellular tissue, participate to
a greater or less extent with the progress of in-
flammation. M. Rayer remarks, that, left to
themselves, these affections always terminate ih
the mortification, and subsequent expulsion, of
one or more of the small cellular cones of the
dermal tissue, which are then designated by the
title of cores. This termination is generally
ascribed to the resistance oflered by the fibrous
corion to the expansion of the cone of inflamed
cellular tissue, and to the consequent strangula-
tion of it ; but the cores are probably the con-
densed tissue surrounding the matter which is
formed in the inflamed tumour, and which is
thrown oflP after -this matter is discharged. --It is
even possible, that the inflammation in this affec-
tion commences in the vessels themselves which
accompany the cellular elongations or cones ;
and that the disease is actually a limited angeitis,
or arteritis, of one small branch, the cellular sub-
stance sloughing in consequence of its supply of
blood being cut ott', from an impervious state of
some of the minute ramifications.

3. The varieties of furuncle are generally de-
pendent upon disordered states of the digestive
functions, and the characters which they assume
vary with the states of vital action and of the cir-
culating fluids. When furuncle occurs in a tole-
rably sound constitution, and healthy condition of
the blood, it assumes a sthenic character, and
constitutes furunculus or the common boil, or sty
when it is seated in the eyelid. But, when it
affects the aged or debilitated, or previously dis-
eased, or the cachectic, or those in whom the
circulating fluids are impure, and the vital actions
languid or imperfect, it puts on an asthenic form,
and gives rise to two varieties ; one of which has
been noticed only by M. Guersent and myself,
and which may be caUcd Asthenic]Furuncle ; the
other has been usually named Anthrax or Car-
buncle.

I. Sthenic Furuncle — Boil ; Furuncle; Phyma
Furunculus, Good ; Furoncle, Clov,, Fr. j Die
Beule, Germ.

4. This species is characterised by stnall in.
Jlummuiory swelling of the skin and subjacent eel

J

FURUNCLE, ASTHENIC — DEscniPTioN.

105^

lular tissue ; this swelling being circumscribed,
conical, hard, red, hot, and painful; and termi-
nating in the formation of a small (juantity of
matter, and the expulsion of dead cellular tissue.

5. i. Symptoms, — This affection begins in a
small, hard tumour, most frequently seated on
the hips, buttocks, thighs, back, nape of the neck,
and armpits. The tumour becomes conical,
painful, of a vivid or violet red colour, and
reaches, in a few days, the size of a large walnut.
From the fifth, to the eighth day, it points, the
apex becoming white and soft. It soon afterwards
breaks, and discharges a little sanguineous pus,
the outer part of the slough being exposed through
the small opening. The core or slough is gene-
rally expelled two or three days afterwards, and
the pain then ceases, the swelling subsides, the
cavity left by the core fills up, and, in a few days,
the opening closes, a cicatrix only remaining.
One boil is often followed by others, which follow
a similar course, and attain various sizes. They
may succeed one another more or less rapidly ;
but they are seldom attended by fever, unless
they are large or numerous. When they form in
the perinaeura, or near the anus, difficulty of
voiding urine is often felt. In other situations,
they may affect the lymphatics proceeding from
their seats, and the adjoining glands.

6. ii. Causes. — The application of blisters,
frictions with irritating liniments or ointments,
inattention to personal cleanliness, the use of
sulphureous or alkaline baths, and various ante-
cedent or associated affections, are the usual
causes of this eruption. Furuncle is often con-
sequent upon the decline of, or convalescence from,
fevers, the exanthemata, and inflammatory disease
of the skin ; and it often seems to depend upon
weakness, or chronic inflammatory irritation, of
the digestive organs; or upon the accumulation
of sordes in the prima via. In some cases, how-
ever, it occurs without appreciable antecedent
disorder.

7. iii. Treatment. — But little is required for
this complaint beyond attention to the digestive
organs. Accumulations of mucous sordes and
faecal matters ought to be freely evacuated by an
aperient consisting of equal parts of the com-
pound infusions of 'gentian and senna with a
neutral salt or alkaline carbonate. A bread
and water poultice, or any other soothing and
relaxing application, may be kept on the part.
If the boil be large, and the pain considerable,
the division of the skin, at the most prominent
part, will be of service. When a succession of
boils appears, an emetic- may be given, and its
operation promoted by the infusiorf of chamomile
flowers. The above stomachic aperient may be
afterwards continued daily, or on alternate days.
If the eruption still appears from time to time,
gentle tonics may be prescribed. Dr. Fosbjiooke
recommends large doses of sulphuric acid. Mr.
Copland Hutchinson informed me, that he
found the liquor potassae, or Brandish's alkaline
solution, in any bitter tonic infusion, most benefi-
cial in these cases. The extract of taraxacum
may be added to a mixture or draught of this
kind, and an alterative pill given at bedtime, and
continued for some days.

8. II. Hordeolum — Stye; Phyma Hordeolum,
Good; Sclerophthalmia, '2K\7ipo^6a\iJ,ia; Orgeolet,
Fr. j GerstenlwH, Geim, — is a small injiamma'

tory tumour or boil in the free edge of the eyelids,
most frequentlii near the inner angle of the ei/e.^
It is in every respect a similar affection to furun-
cle, the dift'erence arising entirely from tiie nature
of its seat. It is seldom larger than a grain of
barley, and is generally smaller, as its name indi-
cates.— Its causes, progress, and treatment are in
all respects the same as those of common boil. —
This, and the preceding variety of furuncle, are
most common in young persons, just before or
soon after puberty, and in adults who eat largely
and take much spirituous liquors. — In scrofulous
constitutions, and persons addicted to intemper-
ance, they assume a chronic form. In such cases,
local applications with camphor are of service.

9. III. Asthenic Furuncle. — Atonic Furun-
cle; Furoncle Atouique, Guersent — consists of
a small circumscribed swelling of the skin, in one
or several situations, witli or unthout livid dis-
colouration ; followed by a very small purulent
phlycticna at the sunimit,and by softening, destruc-
tion, and large perforation of the corion under-
neath ; and preceded and attended by much de-
bility and low fever.

10. This affection was described by M. Guer-
sent, in 1823 ; and early in the same year I saw
two cases of it, with IMr. Painter, in a low street
and ill-ventilated apartment in Westminster.
Both occurred in unhealthy children in the same
family, and terminated fatally. The bodies were
inspected after death. Since then I have seen
only three other cases ; but I have met with others
somewhat similar, consequent on the application
of leeches. — All the instances which have oc-
curred in my practice, as well as those seen by
INI. Guersent, were in children much weakened
by previous disease ; or in those affected by gas-
tro-intestinal irritation, or by chronic disorder of
the bronchi, or asthenic inflammation of the sub-
stance of the lungs. There have always been,
both before and after the appearance of this
eruption, well-marked symptoms of adynamia ; and
coma has generally come on before death.

11. i. Description. — This eruption appears
chiefly on the trunk, the lateral parts of the neck,
and insides of the thighs. In the cases which I
have seen, the number of furuncles was consi-
derable — not fewer than five or six ; and, in two
cases, there were about twenty. They commence
in small, circumscribed, and hard swellings, of a
livid tint, but sometimes nearly colourless. At
a further advanced stage, very small purulent
phlyctffinae appear in their summits, that break,
and leave the skin underneath of a greyish co-
lour, softened, and perforated as in common
furunculi. They discharge at first a serous, san-
guineous, or ichorous fluid. The tumours soften
and disappear ; and the perforations of the co-
rion enlarge rapidly, producing, in two or three
days, holes in the integuments, varying from three
or four, to six or seven, or even eight or nine,
lines in diameter. These perforations are perfectly
round,; their margins are not elevated, nor thick-
ened, nor injected ; and they entirely resemble
the holes made by a drill or auger. The cellular
tissue is not thrown off in the form of a core,
but is destroyed by a rapid ulceration, or phage-
denic absorption. The bottoms of the ulcers have
a greyish or sanious appearance, and are nearly
dry. There is no discharge from them, nor have
they any tendency to scab ; and the perforations

1056

FURUNCULAR T^ISEASES — CAnBuxci-E— Pnocni

of tlie integuments frequently proceed down to
the muscles, or aponeuroses, the peculiar struc-
ture of which may often be seen at their bottoms.
The skin forming their margins is pale and some-
what softened, and the cellular tissue immediately
beneath the cutaneous margins is often destroyed
to the extent of one or two lines. — In the variety
of asthenic furuncle following the bites of leeches
in cachectic and debilitated children, which is
the most common, the perforations of the skin are
at first triangular, but their progress is nearly
the same as tiiat of the spontaneous variety, and
as they enlarge they became entirely circular.
The ulceration attending upon the advanced stage
of disease is seldom very painful. Havingreached
the extent just described, it remains stationary
for a longer or shorter time, and in the more un-
favourable cases shows no disposition to repara-
tion. When it evinces a disposition to heal, the
bottom is more moist, somewhat redder, and more
vivid ; the perforated margins of the skin become
more closely connected with the subjacent tissues,
granulations arise and elevate the bottom of the
ulcer, and the perforation is lessened. Thus a
depressed cicatrix is formed, as in other cases
where the skin has been destroyed.

12. In the two cases, in which I had the op-
portunity of seeing the appearances after death,
no attempts at reparation were visible in the ulcer-
ated perforations, which went down to the mus-
cles, as if the part had been removed by an auger.
There was no injection or inflammatory appear-
ances in the margins. The chief alterations were
moderate emaciation, congestion, and injection
of the membranes of the brain, with slight serous
effusion ; congestion of the substance of the
lungs, with limited hepatization in an early grade ;
patches of injection in the digestive mucous
membrane, other parts being pale ; and enlarge-
ment of the mesenteric glands. ]M. Gueissext
has not mentioned the internal lesions he may
have observed ; but those just noticed throw not
much light, upon the affection, and are of frequent
occurrence after other diseases. In most of the
cases I have treated, there has been low nervous
fever, with more or less manifest affection of the
gastro-intestinal surface, or of the head or lungs.
The perforations are always uniform in character,
although varying somewhat in size : they are pe-
culiar ; and are hardly ever modified from the
state above described. They appear analogous
to the perforating phagedenic or atonic ulcers
sometimes seen in the stomach.

13. ii. Treatinent. — The means of cure should
necessarily be directed chiefly to the constitutional
disorder. This should be removed, by the pre-
parations of cinchona ; by the sulphate of qui-
nine ; by the mineral or vegetable acids ; by cam-
phor or ammonia ; by the decoction of bark with
nitre, and spirits of nitric ether ; by the infusion
of valerian or cascarilla with the chlorate of
potash, or chloride of ammonia, and chloric ether ;
by camphor julep with the chloro-sodiac solu-
tion ; or by similar remedies, aided by means
calculated 'to relieve internal complications, as
alteratives, external derivatives, and mild sto-
machic purgatives. Neither leeches nor blisters
should be applied, as the former are liable to mul-
tiply the perforating ulcers, and the latter are apt
to produce sphacelation. The semicupium, how-
ever, with much salt and mustard in the buth

may be used. Removal to a dry, healthy atmo-"
sphere, or to the sea-side, or to an elevated situ-
ation, and light nourishment, are also beneficial.
The most efficacious local applications are, the
solutions of the chlorinated soda or lime, kreo-
sote, the dilute acids, pyroligneous acid with
camphor and kreosote, poultices of powdered
bark, with spirits of turpentine, and the balsams
and terebinthinates, especially Peruvian balsam,
or equal parts of it, or of copaiba, and of turpentine.
III. Carbuncle. — AvQpa^, Hippocrates; An-
tfirax ; Carbo ; Persicus Ignis ; CarbunciUus,
Celsus ; Fhyma AtUhrar, Good ; Charbon,
Fr. ; Karbunhelf Germ.; Furuncular Aitthrar.
i 4. Carbuncle appears in the form of a hard,
painful, circumscribed tumour of a deep red colour,
icith a sensation of burning heat, terminating in
gangrene. M. Rayer states that it is an acute
inflammation affecting simuhaneously several of
the contiguous cellular cones penetrating the re-
ticulations of the true skin. It is not improbable
that the vessels themselves, particularly the arte-
ries, are more or less implicated in the inflamma-
tion.

15. i. Progress. — Anthrax occurs most fre-
quently in the nape of the neck, or above the
nape, on the back, shoulders, buttocks, thighs,
and sides of the trunk. It often commences in a
small tumour, of a few lines in diameter, the apex
of which is sometimes covered with a sanguino-
lent vesicle. In other cases it is much larger from
the beginning, and it then generally advances with
greater rapidity. As it spreads, so it becomes
more prominent and penetrates more deeply ;
and, in seven or eight days, it is often as many
inches in diameter. Its colour deepens to a violet
or bluish tint, and it is hard throughout, until
the cellular tissue of the central parts passes into
gangrene. Its base afterwards continues to spread,
the circumference remains hard, and the centre
softens, and fluctuates very obscurely. The heat
is still burning, the pain is tensive, and both are
now referred chiefly to the base of the tumour.
When left to itself, the skin covering the anthrax
becomes thin and soft after some days, and is
perforated in several places. It then discharges
a little bloody pus, or ichorous matter with small
shreds of mortified cellular tissue. It occasion-
ally sphacelates to a much greater extent, and
its surface becomes dark, black, and insensible.
For some days afterwards, new perforations are
formed, through which whitish sloughs of cellular,
substance are passed. The openings enlarge or
run into each other; give passage to a thick san-
guinolent matter ; and sometimes emit a foetid
odour. The sloughs are at length detached, the
discharge increases and becomes thinner, and the
pain and heat diminish. When the destruction
of the integuments is considerable, the superficial
fascia are often denuded, eroded, and even per-
forated— the surrounding skin being livid, bluish,
thinned, and partially detached from the parts
underneath. If a favourable change in the part
takes place, granulations appear ; and a cicatrix,
which is always irregular, depressed, and puck-
ered, and continues long dark, or brownish red, is
formed, partly by the ulcerated surface, and partly
by the union with it of the loose flaps of skin.

16. The constitutional symptoms are generally
severe, and often precede the local lesion. In-
deed, anthrax rarely occurs excepting in habits

FURUXCULAR DISEASES— Carbuncle—Treatment.

1057

of body evincing more or less cachexy, with san-
guineous pletliora, and disorder of the digestive
functions. For some days before its eruption,
the patient complains of anorexia and increased
disorder of tliese functions, and of lassitude, chills,
or shiveringi. Witii tlie developement of the
tumour, the febrile commotion increases, and
presents the usual concomitants of inflammatory
fever. If sphacelation take place, or if the ul-
ceration be protracted, the attendant fever assumes
gradually an adynamic character; and in delicate,
old, or very cachectic persons, it is nervous or
ailvnii^'c from the commencement.

'7. \'arious inlemal affections may also be
complicated with the external disease. Conges-
tions or inflammations of the liver or of a portion
of the lungs, enlargeuient of the spleen, and
gastro-intestinal disorders, are the most frequent
associated complaints. When anthrax is seated
in the neck, cerebral symptoms are often present.
If it occur in the lateral or anterior parts of the
neck, dyspnoea, cough, headach, and even serious
affections of the larynx or trachea, are experi-
enced. If it take place in the parietes of the
ciiest, the most severe pleuritic and pulmonary
symptoms sometimes supervene, from the extension
of the inflammation internally to the pleura, and
thence even to the lungs. \Vhen it attacks the
abdominal parietes, peritonitis has even occurred
in a similar manner. Anthrax may also be asso-
ciated with some other external eruption, espe-
cially with the common furuncle, which may
either precede or accompany it.

18. ii. Causes. — Anthrax is most common in
spring and summer, according to M. IIayer.
It is certainly most frequent in persons past the
meridian of life, and in females about the total
cessation of the menses. High, rich, or gross
living, with insufficient exercise, and a full, gross
habit of body, predispose to it, and even more
directly produce it. — Cau>=es which derange the
digestive and biliary functions, the application of
acrid or stimulating matters to the skin, neglect
of personal cleanliness, and the bites of insects,
most commonly excite it. It is often a sequela
of small-pox, measles, and typhoid fevers ; and
it is a common attendant upon plague, and some-
times even appears in the latter stages of the
putro-adynamic form of typhoid fever.

19. iii. Diagnosis. — Carbuncle is to be dis-
tinguished from the common boil, by the latter
having only a single opening, and being smaller
and more conical ; and by several occurring in
succession. The former, on the contrary, is
broader, less acuminated, is perforated by several
openings, is darker, and more gangrenous, and
is generally single when occurring as an idiopa-
thic disorder. x^ccording to Dupuvtren and
Raver, however, anthrax is a tumour formed
by the conglomeration and confluence of se-
veral furuncles. Carbuncle has very generally
been confounded with malignant pustule, or aa-
thracion. The latter belongs to a different order
of affections of the skin ; and is described, as
well as distinguished from anthrax, in the article
Pustules.

20. iv. Treatment. — This should be com-
menced with the exhibition of an emetic, the
operation of which may be promoted by a tepid
infusion of chamomile flowers. A full dose of
calomel and James's ponder should afterwards be

given, and the free action of the bowels promoted
by 2)urgatives. — Whenever the pulse is strong,
full, or hard, bloodletting, according to the age
and habit of the patient, is requisite, particularly
early in the disease. — Leeches ought also to be
applied around the base of the tumour, and the
bleeding from their bites encouraged by tepid
fomentations. A repetition of the local depletions
may be required even oftener than once. — Di-
aphoretics, with the potassio-tartrate of antimony
and opium, if the pain and burning be very severe,
should afterwards be given, and the bowels kept
open by the occasional exhibition of a purgative.
W'hen the attendant fever is of a low form, or when
gangrene has taken place, and suppuration con-
tinued for some time, especially when the patient
is aged, of a cachectic habit, or is addicted to
intoxication, or is greatly debilitated, the decoction
of cinchona, with the alkaline carbonates ; the
sulphate of quinine vf'iih camphor; tonic infusions
with hydro-chloric acid and chloric ether ; and the
means advised in putro-adynamic fever, should
be prescribed, with light nourishment, wine, &c.

21. The local treatment should consist chiefly
of refrigerant applications in an early stage of the
swelling. Compresses moistened with equal parts
of pyroligneous acid and rose-water, to which
some camphor has been added, should be con-
stantly applied from the commencement. They
generally relieve the pain and burning heat. If
the inflammation still proceeds, a crucial incision,
completely across the swelling, and down to its
base, as advised by Dupuytren and Rayek,
should be made. This will give instant relief by
the loss of blood, and by removing the strangu-
lation of the vessels and cellular tissue. It also
averts gangrene, facilitates a healthy suppurative
action, and hastens granulation and recovery.
The actual and potential cauteries formerly ad-
vised, are now rarely employed. Several American
writers recommend the application of blisters over
the swelling — the discharge from the surface fa-
vouring a return of healthy action in the diseased
part.

22. When anthrax is complicated with any of
the internal affections indicated above (§ 17.),
the treatment ought to be decided and appropriate
to the morbid associations, as the progress of the
complication is generally rapid, owing to the
unfavourable state of constitution giving rise to
this kind of local disease. — During convalescence,
sulphureous baths, and the aperient sulphureous
mineral waters, with strict attention to the func-
tions of the digestive organs, and to diet and
regimen, are usually productive of benefit. I
have found the following medicines of service,
when the patient cannot resort to suitable mineral
waters.

No. 228. R Infusi Sennse Comp., Iiifusi Gentianse Co.,
aa 3 vj. ; Sods Carbon, gr. xij. ; Spirit. Ammon. Arom.
.3ss. ; Tinct. Cardamom. Co. 3j. M. Fiat Haustus, al-
ternis noctibus sumendus.

No. 229. PotassaB Bitart. in Pulv. 5 j-; Sulphuris Pras-
cipitati 3iij.: Confect. Senna? 3ij.; Syrup. Zingiberis q.s.
ut fiat Electuarium molle.cujus capiat Coch. j. raiaimum,
hora somni quotidiS.

BiBLiOG. and Refer. — i. Furuncle Celsus, De Re

Medica, 1. v. ch. 28 Bichat, Anat. Generate, t. iv.

p. 087 Fosbrooke, in Edin. Med. and Surg. Journ. vol.

xviii. p. 64 — Daynac, Rev. Medicate, Sept. 1829, p. 416.
— Rayer, Theoret. and Pract. Treat, on Diseases of the
Skin, by R. Willis, p. bi2.—Lassus, Patliol. Chirurg. t. i.
p. 16. — Richerand, Nosogr. Chir. t. i. p. 123.— W. Gib-
son, Institutes of Surgery. Philad. 8vo. 1824, vol. i

Chelius, Handb. der Chir. b. i. p. 74 — M. Good, Study of
3 Y

FURUNCULAR DISEASES — Carbuncle — Bibliography.

1058

Med. by Cooper, vol. ii. p. 350. — i^. G. Boisseau, Noso-
graphie Organique, t. iv. p. 91 — J. Green, Pract. Com-
pend. of Dis. of the Skin, Lend. 1835, p. 268.

ii. Asthenic Furuncle. — 6f2<p)st'«<, in Archives Ge-

nerales de Medicine, t.i. p. .336 I find, upon reference to

the London Medical Repository , for July, 1823, p. 32., that
I described this eruption in the London Medical Society,
at the commencement of that year ; and that soon after-
wards M. Guersent's paper respecting it appeared in the
Archives. It was thus noticed, for the first time, almost
simultaneously by this physician and myself.

iii. Carbuncle Celsus, lib. v. sect. 28. — ^. Tosi, De

Anthracse seu Carbunculo Tractatus, 4to. Venet. 1576.
— C. P. De Herrera, De Carbunculis Animadvers. 4to
Pintia;, 1604. — T. B. Mitchell, New York Med. and
Phys. Journ. 1815, vol. ii. p. 64. — J. B. Beck, in Ibid.
1823, vol. ii. p.37. — Z). llosack. Essays on Various Sub-
jects. N. Y. 1824, vol. ii. p. 2b6. — A. Cooper, Lectures
Lancet, vol. i. p. 245 — Sanson,\n Diet, de Med. et Surg
Prat. t. iii. p. id. — Marjolin, Diet, de Med. 2d edit.
Paris, 1833, art. Aiithrax — Dupuytren, Lemons, Lancette
Fran(;aise, Mars, IHZ'i. — Bayer, Opus cit. p. 549. — /?

Coates, in Amer. Cyclop, of Pract. Med. vol. ii. p. 29 J.

Green, Opus cit. p. 270,

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The STUD for PRACTICAL PURPOSES and PRACTICAL

MEN ; A Guide to the Choice of a Horse for Use more than for Show. By Harry Hieover.
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RECORDS of the CHASE, and MEMOIRS of CELEBRATED

SPORTSMEN. By Cecil. With T;vo Plates by B. Herring. Fcp. Svo. 78. 6d.

BLAINE'S ENCYCLOPAEDIA of RURAL SPORT

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Colonel HAWKER'S INSTRUCTIONS to YOUNG SPORTS-

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London : LONGMAN, BROWN, GREEN, LONGMANS, and ROBERTS.

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